Not looking too hot - advice?

[Perlkrys]

Hi everyone,

I have been lurking this site for awhile, but this is my first post. I had double jaw surgery to correct an underbite and crossbite (maxilla advanced 5mm, mandible rotated 5mm) four weeks ago and things aren't looking too great. I have a follow up with the surgeon tomorrow morning, and would love any advice you have to give about addressing these issues. Are these legitimate concerns? Am I crazy? Should I push for a re-do or seek out another surgeon entirely?

I've brought up my concerns the last few visits, and so far he's been very dismissive. I brought up the off-center midlines and was told the bones were moved to their correct positions, and not to worry about the cupid's bow (my upper jaw lined up with my face before, and now looks pretty off and slanting away from my face.. actually the whole bottom half of my face seems to be slanting to one side). I believe my upper jaw should have been slightly advanced, and my lower slightly set back, but because he only advanced the upper, my upper lip is looking extremely long and strange. My surgeon countered this by telling me my lip was too short before the surgery (pretty sure it was already on the average to long side). It doesn't look TOO BAD with my mouth closed, but with lips at rest half of my upper teeth show. Whoa buddy. My surgeon says females should show more teeth, but I'm pretty sure this is extreme. The surgical plan was not to lower my maxilla, but it sure seems a heck of a lot lower. My whole bottom face feels very prominent now, and I can see in the X-rays he flared out the backs of my jaw which is making my face bow out strangely on the bottom. I also have lip incompetence now and can't imagine being able to chew food with my lips sealed.

There are some other concerns I have about the orthodontic setup prior to surgery (top incisors are flared out, bottom teeth strangely extruded which isn't great for the long-term stability of my teeth, which is why I had the surgery in the first place). I think these issues could be fixed with orthodontics but may compromise my new bite. For example, if my upper teeth were unflared I would have an underbite again!

I'm pretty disappointed after preparing for two years and going through the hell of surgery to have extremely sub-par results, but even more frustrated that the surgeon seems adamant about admitting no wrong.

Anyone else been there? Words of wisdom? Oof.

My pre-surgery face for reference:






Notice the off-center midlines and crazy slant up and to the right?:

[emanresu]

In the second photo your teeth seem centered, but in the third and fourth photos it seems like there’s some asymmetry, so it’s hard to tell. When determining a patient’s midline, it seems surgeons have to use some amount of subjectivity, as faces often aren’t perfectly symmetrical, so it very well could be true that your cupid bow isn’t an accurate reference point, but, again, it’s hard to tell. I definitely see a bit of a cant though. Regarding vertical placement, I think your teeth are in an ideal position.

If your teeth are too flared, it may indicate that you needed premolar extractions to make room for your other teeth, but that’s generally considered pretty aggressive and surgeons try to avoid it when possible. I also think teeth are supposed to have a bit of a flare (how much though, I’m not exactly sure). It’s hard to tell without a profile shot and x-rays, but I think you have a nice face and wouldn’t benefit much from extractions both from an aesthetic and functional standpoint, as a bit of extrusion isn’t really a concern for stability.

If I were in your shoes, I’m not certain I’d go through surgery again to correct what seems to be a minor cant and asymmetry issue, as it’s really not that noticeable, but that is your decision to make. However, I would probably see another surgeon to see what they think of your results as they’ll be less biased, just for some peace of mind.

Sorry I can’t be of more help, I’m just learning this stuff as I go.

[GJ]

It's really hard to tell from those photos. They're small and at different angles.
My gut reaction was (I'm sorry to say) the same as yours, though, that you seem to have looked better before the surgery.

[jawguy123]

At only 4 weeks post-op you still have a lot of swelling. I wouldn't be so quick to jump to the conclusion that you look worse than you did before the surgery. Many people look very, very different at 6 months post-op than they did at the 4 week mark.

Personally, I don't think your asymmetry in itself at all would warrant another surgery. I believe a study showed that cants less than 4 degrees were unnoticeable by laypeople, and your midline doesn't look that off. That said, it's hard from the pictures you posted to judge the tooth show at rest. Around 3.5mm is very normal in women. Are the bottom of your teeth showing in the third picture? If so, your tooth display doesn't look excessive by any means to me. That said, it's hard to tell from the pictures if your jaws are in a satisfactory position.

Regarding revision, from what I've read, I believe revisions can be performed up to 6 weeks after the first surgery using the original cut. If you wait past that point, you'll probably have to wait 9ish months to get a revision (since the bone has to heal). That said, if you don't completely trust your surgeon, I wouldn't get a revision with him anytime soon. Given all your concerns about the orthodontics, you don't want to rush into a revision, because you're then setting yourself up for a third surgery. I would, however, get a second opinion as soon as you can; if you've expressed your concerns to your surgeon, there's no harm in seeing another and saying "I'm concerned about X, Y, Z... what are your thoughts?"

I really think that if you wait for swelling / soft-tissue to settle there's a chance (not sure how much -- hard to tell with the limited pictures) you'll be happy with the result. If not, lots of people have successfully pursued revision with great results. One particular study showed a vast majority of (the study's author's) patients who underwent a second orthognathic surgery for purely cosmetic reasons were pleased with the outcome. Anecdotally, many seem to find the second recovery easier than the first.

Also, I'm really not convinced you'll need a revision -- I'm just giving you this information for the peace of mind that if you do end up wanting to go down that road, it's completely doable and you're not alone.

[kavan]

4 weeks is too soon to tell.

[Perlkrys]

Thanks very much everyone for the replies. I am trying to be patient, as I know swelling can distort your face for awhile. I've always been self conscious about my lower jaw, which seemed to me to be very long, and was pushing for the movement to be split between the two jaws. He was pretty dead set on just advancing the upper, and I found out today that he also advanced the lower by a few mm, which he did not tell me he was going to do beforehand. After voicing my concerns that my jaw would be too prominent with just the maxillary advancement, it seems pretty bizarre to me he would also advance the lower jaw without my consent. I also found out today that he performed a VY lip advancement, which to my understanding lengthens the upper lip (while also keeping your nose from flattening?).

I showed him the cant and what looks to be a pretty extreme yaw in the xrays today, and he sort of brushed if off saying my "bite looked fine". At the moment I'm currently only touching on one side of my mouth and one side of front incisors. Perhaps this can be fixed with orthodontic finishing?

I'm hoping once swelling goes down my nose will relax and take up some of the space my upper lip is currently occupying. Does anyone have experience with this? Was the lengths of your lip and nose one month post-op significantly different than 6 months down the road? It is encouraging to hear at least one person thinks thinks the vertical placement is correct.. maybe it's just a change I'll need to get used to?

For anyone who had revisions, would you recommend doing a second opinion consultation as soon as possible, or waiting until the soft tissue relaxes so the surgeon has a better understanding of where your facial features lie? If the VY lip advancement permanently lengthened my upper lip (which currently looks pretty Lurch-y), I guess I would have to consider a lip tuck or something along with lefort 1 impaction. I sort of feel like I've given up one problem (a sub-par bite and slightly recessed maxilla) for a host of others?

Here are some links to photos that are a bit bigger and hopefully clearer to see. Thanks so much for your support & advice. <3

my current face:
https://s33.postimg.cc/s06quu6sv/IMG_0965.jpg
https://s33.postimg.cc/l9q9lebxb/IMG_0966.jpg

pre-op xray:
https://s33.postimg.cc/gnp3gik8v/IMG_0967.jpg

post-op bowed out lower jaws (from unplanned advancement) and slanted midlines:
https://s33.postimg.cc/ranyigqtr/IMG_0964.jpg

this one shows a bit of the yaw and the cant, right side of jaws is higher than left:
https://s33.postimg.cc/9x8m72pdb/IMG_0963.jpg

[GJ]

You look attractive in those photos.
Give yourself time to adjust to the new face.

PS. That is not cool he did procedures without your consent. Which surgeon?

[Perlkrys]

Hi GJ, I'll PM you.

[jawguy123]

Just to repeat myself, at 4 weeks you still have significant swelling.

VY lip advancement

I think a V-Y closure is very commonly done with maxillary movements. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847014/. I wouldn't be too concerned about this.

For anyone who had revisions, would you recommend doing a second opinion consultation as soon as possible, or waiting until the soft tissue relaxes so the surgeon has a better understanding of where your facial features lie? If the VY lip advancement permanently lengthened my upper lip (which currently looks pretty Lurch-y), I guess I would have to consider a lip tuck or something along with lefort 1 impaction. I sort of feel like I've given up one problem (a sub-par bite and slightly recessed maxilla) for a host of others

I don't think it would hurt to consult with another surgeon now (especially if you feel you aren't getting straight answers from your current doc). However, I think it's very likely they'll say to come back at the 6ish month mark if you still aren't happy, given how much swelling you currently have.

[Perlkrys]

Thanks Jawguy!

[PloskoPlus]

VY plasty is used to maintain the vermilion show. It won't lengthen the lip. Although some surgeons believe vy is a placebo. What you see is a consequence of your tip rising and the upper jaw being more forward.  If you had an alar cinch, it should relax over the next 2 months and the nose tip will drop a little.
P.S.
Your surgeon sounds like a dick.

[Perlkrys]

Update: hallelujah, maybe?

I snapped this photo today, and it’s the first in which I’m sort of starting to resemble myself a bit again (except for the new lower mega-jaw, but surgery changes your face, ok, got it). The crazy lip situation is still there but mellowing, and my nose is starting to point in the right general direction. Midlines and canting are still bananas.

https://s33.postimg.cc/9lqslmbpr/9_A92_E1_A2-890_D-4530-_A6_BC-740_E48_E92178.jpg

My concern is looking at my gums it seems like I’m still totally a class III skeletally, and it’s just barely working because my incisors top and bottom are all flared out like crazy to overcompensate (not at all comfy bite-wise).

But worse, I feel over the past few weeks that my bite has been slipping even more into class III.. my lower braces seem to stick out more than the uppers now and front teeth are getting closer to edge to edge. Is this a thing that can happen? My bands are basically non-existent (a dinky one on each side for “support”). Anyone else experience something like this prior to ortho finishing? 🤔

[GJ]

In general, when women look sultry they look good, and the leaning into the camera gives a sultry vibe, so that could be biasing the result.
But I do think you look good there.
The best thing to do, for accuracy, would probably post the before and after taken by your doctor. These usually look like mug shots and will show the worst case scenario.

[Perlkrys]

In general, when women look sultry they look good, and the leaning into the camera gives a sultry vibe, so that could be biasing the result.
But I do think you look good there.
The best thing to do, for accuracy, would probably post the before and after taken by your doctor. These usually look like mug shots and will show the worst case scenario.

Never underestimate the power of a good camera angle!
My surgeon didn't take any before photos. Hmm..

[GJ]

Never underestimate the power of a good camera angle!

Oh yeah, I think the online dating world exists solely because of good camera angles.

My surgeon didn't take any before photos. Hmm..

Well that's convenient. "Compared to nothing...you look great!"