Solution to Nasal Widening Post Lefort?

[jusken]

I've heard many people suggest doing a rhinoplasty(weir excision, etc) to address the widening.  To me, this is obviously incorrect.  If the tissue on your nose wasn't too wide to begin with, then I think this is a critical error to seek out this solution.  Seems like because a Lefort 1 simply moves a section of the jaw, it always creates a small discrepancy near the nose.  The ideal solution would actually bend the maxilla - this is ignoring feasibility of course.

After a very simple and successful plate removal procedure following my double jaw surgery, my nose still looks a little flared.  I guess it's not a huge deal, but with how easy the plate removal was, I basically have an idea that might work for the rest.  Why not just shave down a little bit of the bone under the nostrils?  The procedure would basically be the same as the plate removal (in fact the surgeon already shaved down some bone under the plates), with only a little bit of downtime especially compared to an external incision.  The only question is how much, and whether or not a surgeon would be willing to do it.

I'm going to consult with a local surgeon about this next week and see if it's possible.  Any thoughts or knowledge on this?

[molestrip]

The maxilla is egg-shell thin. If you shave it down, then you'll just have a hole in it. Typically the ANS will be shaved to avoid broadening of the nose. Alar Cinch can also be used. Sorry but there isn't a great solution to this problem. Fortunately, the existing solutions work well most of the time.

[jusken]

The maxilla is egg-shell thin. If you shave it down, then you'll just have a hole in it. Typically the ANS will be shaved to avoid broadening of the nose. Alar Cinch can also be used. Sorry but there isn't a great solution to this problem. Fortunately, the existing solutions work well most of the time.

Hey thanks for the reply molestrip.  What's the ANS?  Anything involving shaving sounds like the right answer.

Alar cinch demonstrates a severe misunderstanding of the problem in my opinion.  This is not a real solution, and I can't imagine any other outcome other than some weird distortion of the nose (or, as I suspect, little or no real difference).

The problem the Lefort 1 creates is an unnatural stepoff that doesn't mimic natural bone growth.  Unfortunately it's right under the base of the nose.  Instead of being a smooth slope, there's going to be more of a step where the bone fuses together.  This pushes the base of the nose too far forward and, in turn, makes the nostrils look flared.  I just drew over a quick image I found on the google to quickly demonstrate this:



Anything else simply isn't correct and unnatural.  The problem is excess bone, not excess soft tissue.

[Nataliepryor]

I am having the cartlidge reduced either side of my nose, which I think will decrease the flared look.

[jusken]

ANS is the anterior nasal spine.  The ANS rotates the tip and pushes it out when moving the maxilla.  Arnett mentioned shaving the nasal spine so that it helps with rotation but, widening can't be helped and it's more to do with what it's resting on (upper jaw). The widening isn't as noticeable if you have a large nose or a high vaulted nasal cavity with a depressed paranasal region.  In a sense, moving the maxilla would only be matching the projection (the make or break of the monkey lip).


By the way, the alar cinch isn't good for long term results.  It's also uncomfortable.

The widening could be eliminated if the whole nasal cavity was moved too.  Only moving the lower portion of the nose loses the support on top, thus- flaring issues at the base.

27F: Cool thanks.  Shaving the nasal spine seems very close to what I'm suggesting here.

I've bolded a sentence that I think would be a catastrophe.  If the nasal cavity was moved too, your whole nose would be just too far forward.  I know it would be for me.

I'm certainly not an expert on these matters, but I've anaylzed the s**t out of my facial growth.  Also, analyzed the hell out of 3D data I've collected of my skull after the surgery.  A Lefort 1 is a very linear movement.  To truly reverse this retrognathic development, the movement would probably have to be a curve, anchored at the nasal base.  I made a fast and silly sketch of this:



Still, as with the previous pic I made, shaving that linear stepoff would come close enough to solving the problem (if you aren't destroying the bone there in any way by doing so).


Natalie: I personally would never alter the soft tissue of my nose.  I wish you luck though if that's what you think will make this better.  My nasal base is just slightly compressed after the surgery because of the bone movement.  I'd rather do nothing than not address this.

[jusken]

Wouldn't that cut go right through your tooth roots?  Anyway, I don't think a single linear movement can ideally solve a growth problem like this.

As far as the shaving is concerned, we'd be talking like ~1mm maximum.  Though yeah, we're talking a remodeling of bone - which might take some skill as to not remove too much or in the wrong way.  Maybe I'll take a look at the 3D model I have and what would have to be done exactly.

[terry947]

The pic that you drew is basically a CCW rotation? Nasal widening isn't a big deal, actually in most cases it looks better cuz now the nose has something to sit on.

[jusken]

The pic that you drew is basically a CCW rotation? Nasal widening isn't a big deal, actually in most cases it looks better cuz now the nose has something to sit on.

Sorry it's a bit simplified.  #2 is a Lefort 1 with CCW rotation and advancement.  #3 is an imaginary, but perhaps ideal procedure, where the bone is bent into position based on a curve.  This would allow more gradual changes near the nasal base, instead of a linear change just like everywhere else.

For me, and many cases I've heard about, the nasal widening isn't ideal.  My nose does look better from profile, but the widening is slightly off.


27F: Yeah okay, I see what you're saying.  I was literally looking at the exact location of the cut you drew.  If it was slightly below the nasal base, that might actually improve some cases.   But, looking quickly a skull for reference, the traditional Lefort 1 does create a much simpler separation as it cuts right into the nasal cavity (just trying to look at the justification).

[buzzhead]

I just had bimax done two and a half weeks ago.  My maxilla was brought forward and dropped cw with grafting.  I know that my nasal spine was not shaved and I did not have an alar cinch as my surgeon said it never looks right.  But I did not notice any widening or flaring of my nose.  I think that how tissue reacts to movements is really individual specific depending on pre existing bone formation and types of movements made.  Maybe bringing my maxilla forward AND down mitigated the nose effects.  I will verify my movement measurements at my next appointment with the surgeon.  Also, in my youth, I had previous orthodontic work done where 4 bicuspids were removed (two upper two lower) and front top incisors brought back.

[jusken]

buzzhead: yeah, bring the maxilla down would be a big difference.  Bringing it up naturally would tip the nose and cause the prior supporting structure to now be pushing it forward.  If anything, a downward movement would cause the exact opposite scenario. 

To me, this is just further evidence for shaving to be the ideal solution - returning that nasal base support closer to its previous shape.

[molestrip]

You're on to something with the step function but wrong about the solution. Adding a curve to the step wouldn't solve the problem. You need a method of replicating what the original growth would have been, that is moving the whole face forward, more closer to the maxilla but going all the way up to the forehead. The increased nasal support often helps with narrow noses but it's hard to know where the maxilla should have been. In MMAs, it's often brought too far forward even. Shaving of the ANS is just to prevent tipping, which is largely a problem for men. But, men tend to have wider noses anyway so aesthetically not a problem. The S-MMAs tend to be disasters but otherwise, I think people tend to tolerate the nose changes fairly well. People just aren't that sensitive to these changes.

[jusken]

You make some really good points molestrip.  For me personally though, I'm not going to be pursuing a huge laundry list of things to correct all of my bad facial development.

I actually think my nose is one of my better features, of which I feel there aren't many.  Since I have such a narrow face, the flaring right at the base of my nose looks weird to me especially when I move my nose a lot(speech, expression).  If this was alleviated slightly (or just partially reverted back to the way it was), I think I'd be totally content with it.  It just looks slightly pushed forward right at the very base.  I had my maxilla AND nasal base moved up and forward, so it's no surprise this is the case.

I absolutely wouldn't be surprised at all if most patients who had a Lefort 1 that advanced both up and foward had similar complaints.

[molestrip]

We're gambling with our lives here and even a small risk is too much considering what's at stake. Aiming for perfection is a recipe for disaster.

[jusken]

We're gambling with our lives here and even a small risk is too much considering what's at stake. Aiming for perfection is a recipe for disaster.

I couldn't agree more.  I've been getting increasingly more cautious lately and lowering my expectations to match this sentiment.

That said, I will still do research from time to time to see if a simple solution exists.