lots of questions about jaw surgery for cosmetic reasons

[beautyislife]

I have a lot of questions and this seems like the place to ask. Hopefully these aren't too repetitive to what else is on the forum, I tried to do research on my own.

I have seen 4 surgeons (two local, Gunson, Zarrinbal) for their advice. I'm just not sure who to go with and what to do. Every surgeon has said functionally there will be little benefit and it would mostly be for cosmetic purposes and to help my airway. Personally I like the way I look when I jut my jaw forward and I do really like the upper lip curvature look (mine is flat).

Dr. Gunson's plan was to do CCW with 6mm forward movement for my upper jaw and 10mm for my lower jaw. Dr. Zarrinbal mentioned he would do jaw surgery + chin wing + additional upper jaw stuff to help with the nose area and smile lines or he said just a chin wing and camouflage the upper jaw area, but no mention of it being a CCW movement and no mention of advancement measurements. I sent both my questions but I believe they are being fed up with how many questions I have.

Anyway, here are questions I hope to get answered and understand a bit more with.


1) I have recessed cheeks and a flatter mid face. With Dr. Gunson's plan I would get HA paste on my cheekbones, but if I don't go with him, what can happen? Would my mid face look flatter and my cheeks too recessed after jaw surgery?

2) Is getting chin wing and jaw surgery together wise? I don't want a massive amount of advancement. Would this even be stable? Seems like a lot of work on the jaw.

3) I have dark circles and lack of support near my eyes. Dr. Z said jaw surgery would help with this, but if skin is being pulled, would it help? Seems like my eyes would be more deficient with soft tissue. Does this impact the tilt in anyway?

4) Does jaw surgery remove the hollow cheek appearance? I like this look, but am nervous doing bi-max will fill out the area and make it impossible to have this.

5) I notice a lot of fat near the cheek/face area, when I pull my skin up, it looks a lot better, like a face lift. Does this get worse with jaw surgery? It seems like fat pad removal would be necessary?



I am worried about which doctor to go with. I don't like the idea of HA paste and they are very expensive in Santa Barbara. I sent my measurements and renderings to Dr. Z for his advice to see if he would do CCW and similar advancement. He said we could also see if I can do surgery without braces which is nice because it would be a full year with braces if not. Ultimately I would like a good result and not to wait a long time.

Here are some images: https://imgur.com/a/irRO8jJ

[GJ]

1) I have recessed cheeks and a flatter mid face. With Dr. Gunson's plan I would get HA paste on my cheekbones, but if I don't go with him, what can happen? Would my mid face look flatter and my cheeks too recessed after jaw surgery?

From all reports, HA doesn't do much at all. If you're doing CCW rotation, then your midface might appear further back, especially in profile. Ask for a morph for some idea. Also, just envision the movement. You should be able to get an idea of what it will look like by just thinking about how the jaws are moving.

2) Is getting chin wing and jaw surgery together wise? I don't want a massive amount of advancement. Would this even be stable? Seems like a lot of work on the jaw.

I'm not sure. Genio and jaw surgery at the same time preferred over two separate surgeries. Since a chin wing is essentially a glorified genio, it's probabyl fine to do them together assuming good planning. But, ask the surgeon.

3) I have dark circles and lack of support near my eyes. Dr. Z said jaw surgery would help with this, but if skin is being pulled, would it help? Seems like my eyes would be more deficient with soft tissue. Does this impact the tilt in anyway?

There was a guy here years ago who said his eyes looked more recessed and darker after surgery. He was obsessed with it. I haven't really seen anyone else comment one way or the other. In general, if you're giving more support by moving things forward, it should help. CCW is not purely forward, though, so it complicates the matter. The teeth will be more forward, but imagine it rotating on a pivot point -- the back of the maxilla will actually recess and move down a bit. Is this noticeable? Possibly. It depends on the person's overall structure.

4) Does jaw surgery remove the hollow cheek appearance? I like this look, but am nervous doing bi-max will fill out the area and make it impossible to have this.

I've heard and seen mixed things on this, and again, I think it depends on the person and degree of CCW.

5) I notice a lot of fat near the cheek/face area, when I pull my skin up, it looks a lot better, like a face lift. Does this get worse with jaw surgery? It seems like fat pad removal would be necessary?

From personal experience and reading others' stories on here, it got worse. I haven't seen anyone say this issue got better. Fat pad removal has a very bad reputation around here. Lazlo and "Jay" had it done and said it was a net negative.

[beautyislife]

Thank you for the quick response.

I'm guessing there's no good way to "mimic" what one could look like in relation to how the midface/cheek area is affected? Does jutting the jaw forward and moving the upper lips forward not somewhat help to give an idea? I have asked for a morph, but it doesn't ever show any changes to the mid face region, people just pull the jaws forward in those images.

That is also very unfortunate to hear about the fat/excess look near the cheeks. Seems to me like a facelift would be the only applicable solution, but I don't want a facelift at 25.


Would surgeons be able to give some idea? Especially after meeting in person to the questions/concerns that are more specific to the person? I am hoping they can at least say how some of these things would turn out.

[beyondconfusedtbh]

Just to add to GJ's response:

HA is really only ever used to augment a tiny amount, usually in the 1-2mm range. That said, the user 'ForeverDet' got HA paste on his cheekbones as part of his surgery with Dr. Gunson. He was content with the results overall but complained of prolonged (~2yrs) swelling on one side of his face as a result.

SOME people have also reported that HA reabsorbs causing imbalances further down the line.

If anyone has any insight regarding soft tissue ('cheek fat' as op called it) distribution post op I'd love to hear it. I suspect however that the trauma caused by surgery is the culprit. GJ, could you expand on the changes you observed?

[GJ]

I suspect however that the trauma caused by surgery is the culprit. GJ, could you expand on the changes you observed?

Mostly that the smile line area got worse. Some of this could be natural aging, but my family and myself all have good genetics in that area, so considering that and all the cases I have seen (i.e. others' results where they lost support), I think it's the surgery.

This makes some sense mechanically:

1. If you rotate the jaws CCW, the area near the smile lines actually recesses as the middle/back of the maxilla move down. The tissue can bunch up in that midface area without proper support. This is why they use the HA paste. If the face becomes shorter and rotated, the tissue has less support without a forward movement to offset that.
2. If you rotate the jaw CW or move it linearly, you create the opposite problem and the tissue might pull downward.

Now is that how it plays out in the flesh? Kind of. Based on my own experience, observation, and the fact surgeons admit this issue and try to use bone grafts or HA paste to offset it. This is also why Class III cases almost always have a combination of both jaws moved, even though just moving one would fix the problem. The reason is if they move the lower jaw back too much there is bunching of skin under the neck. So, tissue does react to the movement.

[GJ]

I'm guessing there's no good way to "mimic" what one could look like in relation to how the midface/cheek area is affected?

Not really. The best thing is to understand the mechanics of the movement and how the tissue will follow those new angles. Then you can imagine what the issue will do.

Would surgeons be able to give some idea? Especially after meeting in person to the questions/concerns that are more specific to the person? I am hoping they can at least say how some of these things would turn out.

The surgeon can answer these questions, but IME they will just downplay the changes. They are thinking big picture, and you are thinking small picture. So, there's a conflict there. You'll be reassured if you ask the questions, but that doesn't mean you'll like the outcome.

All this said: people do have the surgery and look better, skin looks fine, etc. It really depends on the movements, quality of your soft tissue, underlying bone structure, etc. If you have good tissue and/or underlying bone, you can get away with more. It's also possible you simply wouldn't care about any changes because the other benefits are worth the sacrifice. This is all case by case, and yet we're trying to speak in generalities.

[kavan]

The difference regarding any comparison between Gunson and the other doctors is that the Gunson contour diagram is something  that we can SEE. We can't see 'what Dr. Z told you' (or what other doctors told you for that matter) in TERMS of questions that ultimately resolve to asking; 'Which one will make you look better?' What we can deduce in so far as what the others told you, we deduce that from something we can SEE. On the G diagram, the airway is increased, the profile contour is improved but there is no salient functional (bite) issue. So what we see from the G diagram cross references with every surgeon the benefit to function is little and most of it would be for cosmetics and airway. So, in terms of 'telling you something', they all told you right.

We can't SEE any visuals as to what Z told you. The best we can do is cross reference what he told you in terms of the G diagram that we can SEE. If he told you he could do a lower jaw advancement with a chin wing, well that's similar to what we see on the G diagram (lower jaw advance with genio) with the exception that a chin wing is a type of glorified genio. (ref question #2).  No mention of rotations or measures just resolves to no visuals from Z.

If you know you have recessed cheeks and kind of a flat midface, then G's suggestion of HA GRANULES (G uses granules to affect a shape contour where as HA 'paste' is something used more to fill in dents.) is a good one because flat midface area could look more RELATIVELY recessed via bi-max advancement. (ref Q #1). Your not liking the idea of HA or the expense of G is a different issue than whether or not G's suggestion was a good one. It was.

Dark circles could be a function of not so great sleep from a smaller airway. We see on the G diagram, the airway is BIGGER. So, if Z told you jaw surgery would help with the dark circles, it's probably due to the airway expansion via jaw surgery. But again, a thing were we can only cross references what Z says with what we SEE from the G diagram. Lack of support near your eyes is probably due to not a lot of midface support, something that G told you could be addressed via the HA. But again, your not liking the idea of HA or expense involved with carrying out a CLEAR CUT PLAN is a different issue. (ref Q #3)

Questions #4 and #5 disregarded. If someone NOTICES a lot of fat near the cheek area then that is INCONSISTENT with having hollow cheeks.

Conclusion: Based on G's contour diagram the profile is improved and his suggestion for HA to the midface area is consistent with your mentioning that area is recessed. Based on what Z told you, we can't really go any further than cross referencing what he tells you with what we can see on G's diagram. There is not enough information on Z's plan to tell you if his plan or 'vision' for you is any better than G's.

[beautyislife]

Thank you for the insight. I will see if Dr Z can provide any imaging and more specific information about movements.

[beautyislife]

One more question - does anyone have insight or extra material on how harvesting bone from the ilac crest turns out long term?

[beautyislife]

Can someone help me decipher these measurements?
https://imgur.com/B8rQKmw

[Dogmatix]

Can someone help me decipher these measurements?
https://imgur.com/B8rQKmw

You have counter clockwise rotation of the maxillomandibular complex. Posterior down grafting of 4mm, no A-P advancement of the maxilla, but rather 1mm back for ANS.
Because of the rotation, the chin have about 10mm advancement while the maxilla stays. 10mm of the chin tells that the surgeon probably thinks you have a retruded chin, that could benefit from being advanced. You probably have a specification in the document telling you if there's a geniplasty included as well.

Do you mind telling who the surgeon is, and posting a profile picture to see your profile?

[kavan]

They look like they come from Alfaro and would come from a VSP where the patient would get a VISUAL of the proposed changes. Did you get a visual?

[beautyislife]

You have counter clockwise rotation of the maxillomandibular complex. Posterior down grafting of 4mm, no A-P advancement of the maxilla, but rather 1mm back for ANS.
Because of the rotation, the chin have about 10mm advancement while the maxilla stays. 10mm of the chin tells that the surgeon probably thinks you have a retruded chin, that could benefit from being advanced. You probably have a specification in the document telling you if there's a geniplasty included as well.

Do you mind telling who the surgeon is, and posting a profile picture to see your profile?

Alfaro. Interesting, there's no linear advancement of the maxilla?

I can share profile pic via pm, prefer not to post on here if that's ok.

They look like they come from Alfaro and would come from a VSP where the patient would get a VISUAL of the proposed changes. Did you get a visual?

Yup, Alfaro. I have the visual: https://imgur.com/X1xem1P

[Dogmatix]

Alfaro. Interesting, there's no linear advancement of the maxilla?

I can share profile pic via pm, prefer not to post on here if that's ok.



Yup, Alfaro. I have the visual: https://imgur.com/X1xem1P

Well, you see pretty well what is going on in your visualisation and how the maxilla moves.
If you want to understand exactly, the easiest way is to learn where the landmarks are. Those which are most interesting is ANS, PNS, POG, and then the others of course also, but those give the big picture.

Here is a good schematic of where the points are found.
https://goo.gl/images/n9fC6M

On your table, ANS is moved A-P -1.1mm, which means it's moved back 1.1mm horisontally, etc. The incisors come forward slightly about 1mm with the rotation, which you also see in your table, upper incissor tip forward 1mm.

Please share your picture in private message if it's ok for you.

[kavan]

Alfaro. Interesting, there's no linear advancement of the maxilla?

I can share profile pic via pm, prefer not to post on here if that's ok.



Yup, Alfaro. I have the visual: https://imgur.com/X1xem1P

So, that's CCW with chin elongation. That's what all the measures together add up to as the whole picture.