How does my surgeon's plans look?

[scramfranklin]

I ideally want the best aesthetic result (and functional, and I realize those won't always align) I can possibly get... is this it? I know to an extent, it's just "what I want, and what is doable", but I think many users here have a better aesthetic eye than myself and the average person. Would you recommend any changes? Why or why not?

https://imgur.com/a/2Qyx52l

[kavan]

I ideally want the best aesthetic result (and functional, and I realize those won't always align) I can possibly get... is this it? I know to an extent, it's just "what I want, and what is doable", but I think many users here have a better aesthetic eye than myself and the average person. Would you recommend any changes? Why or why not?

https://imgur.com/a/2Qyx52l

 There are some 'WTF' things about the presentation such as taking photos of FOLDED photos and the nose contour in the X ray looking different from the contour in the photo.

But TBH, the biggest WTF is I've never seen such a bad ceph tracing. The soft tissue contour tracing looks like either a 6 year old made it or the doctor has a shaky hand...and what type of retarded software is the guy using anyway where he can't generate a ceph displacement diagram with the proposed changes overlayed to the before...OR.. could it be that's the 'best' he can do. I'd be concerned the doc had some brain to hand movement disorder.

The occlusal plane is INCREASED via  CLOCKWISE rotation whereas a better doctor could have DECREASED the OP via CCW posterior downgraft and achieved more 'horizontally' oriented maxilla advancement and in turn could have achieved more lower jaw advancement that can be had with an OP decrease when an OP increase is not really 'needed' to maximize aesthetics.

Regarding the 'aesthetics', it looks like crap. I'd recommend a change in doctor.

[scramfranklin]

Eek. Thank you Kavan. Well that is very worrisome. He is a really well regarded doctor from what I have read about him, and I know he wanted CW rotation of the maxilla due to my unsteep occlusal plane (and I think because I have a brachyfacial, short type face). He said my occlusal plane was sloped downwards.

The fold in the picture was just how it was mailed to me, but I noticed the nose as well. I definitely have some thinking to do.

[GJ]

This is Richard Joseph's plan, correct?
I think he's one of the best surgeons I've ever seen (just based off his website -- have no experience with him).

That planning does look primitive. Maybe have that plan run by a surgeon who uses more advanced software, or just get a second consult.

The occlusal plane is INCREASED via  CLOCKWISE rotation whereas a better doctor could have DECREASED the OP via CCW posterior downgraft and achieved more 'horizontally' oriented maxilla advancement and in turn could have achieved more lower jaw advancement that can be had with an OP decrease when an OP increase is not really 'needed' to maximize aesthetics.

Since he has a short lower third, CW rotation isn't uncalled for. If you CCW rotate such a short lower third you could wind up with a Popeye look.

It's somewhat of a tough case because CCW rotation will likely look bad (too short), and CW rotation isn't going to address occlusal angle. It looks like his thought process is to move it CW to address the short lower third, then use the genio (-1.1mm) to reduce any unwanted length that creates. It's not a bad idea, IMO, but I am biased against CCW rotation on short faces.

I think a second opinion from a surgeon is in order. Maybe you can setup and email consult with Gunson, but keep in mind he likes heavy rotation. Relle might be a better fit for this case. See if you can email consult him.

[kavan]

This is Richard Joseph's plan, correct?
I think he's one of the best surgeons I've ever seen (just based off his website -- have no experience with him).

That planning does look primitive. Maybe have that plan run by a surgeon who uses more advanced software, or just get a second consult.

Since he has a short lower third, CW rotation isn't uncalled for. If you CCW rotate such a short lower third you could wind up with a Popeye look.

It's somewhat of a tough case because CCW rotation will likely look bad (too short), and CW rotation isn't going to address occlusal angle. It looks like his thought process is to move it CW to address the short lower third, then use the genio (-1.1mm) to reduce any unwanted length that creates. It's not a bad idea, IMO, but I am biased against CCW rotation on short faces.

I think a second opinion from a surgeon is in order. Maybe you can setup and email consult with Gunson, but keep in mind he likes heavy rotation. Relle might be a better fit for this case. See if you can email consult him.

Well, a CCW with posterier downgraft would push down his jaw angles and allow more advancement of the lower 1/3rd of the face just like bracios with short lower '1/3rds' can have when they also have more advancement to the 'short' lower 1/3rd. They have compact 'square' faces which is normal and OK for a bracio. So, a short lower '1/3rd' is normal for a bracio to have and it's not as if his OP is that 'flat'. It's about 8 or so in the before diagram where as about 4 or below 4 is too flat as outside the norm even for a bracio.

So, yes, the CCW would make him look more bracio but it would also be consistent with what a bracio could have and what he could get--MORE ADVANCEMENT to to the lower 3rd--than can be had by CW-ing it in hopes of making him look less bracio or more dolio. CW to make the lower 1/3 longer LIMITS the advancement that he could have as a bracio that OTHER bracios DO have; the 'square' look when they have a more advanced lower '1/3'.

That sloppy ceph diagram is about the worse I've ever seen and the morph presentation is sloppy too. However, I don't know if that's due to the doctor or due to taking a photo of both at different camera angles. The linear distances between the horizontal lines are longer in the before.

ETA:  I think what he did was an improvement and looks like an honest prediction as far as the morph goes and maybe that's just the extent that the aesthetics will reach given your start point. So, looking like more improvement would be had by plastic surgery aimed at addressing the overly obtuse neck.

[kavan]

There are some 'WTF' things about the presentation such as taking photos of FOLDED photos and the nose contour in the X ray looking different from the contour in the photo.

But TBH, the biggest WTF is I've never seen such a bad ceph tracing. The soft tissue contour tracing looks like either a 6 year old made it or the doctor has a shaky hand...and what type of retarded software is the guy using anyway where he can't generate a ceph displacement diagram with the proposed changes overlayed to the before...OR.. could it be that's the 'best' he can do. I'd be concerned the doc had some brain to hand movement disorder.

The occlusal plane is INCREASED via  CLOCKWISE rotation whereas a better doctor could have DECREASED the OP via CCW posterior downgraft and achieved more 'horizontally' oriented maxilla advancement and in turn could have achieved more lower jaw advancement that can be had with an OP decrease when an OP increase is not really 'needed' to maximize aesthetics.

Regarding the 'aesthetics', it looks like crap. I'd recommend a change in doctor.

OK, maybe too harsh to say change in doctor.  See if another doctor can kick up a different plan. Maybe see if you can get an on line eval by Gunson based on your cephs.

[scramfranklin]

Thanks Kavan. I am going to get a consult done with Gunson and and see what he thinks. It will probably be this surgeon or Gunson in that case.

[scramfranklin]

This is Richard Joseph's plan, correct?
I think he's one of the best surgeons I've ever seen (just based off his website -- have no experience with him).

That planning does look primitive. Maybe have that plan run by a surgeon who uses more advanced software, or just get a second consult.

Since he has a short lower third, CW rotation isn't uncalled for. If you CCW rotate such a short lower third you could wind up with a Popeye look.

It's somewhat of a tough case because CCW rotation will likely look bad (too short), and CW rotation isn't going to address occlusal angle. It looks like his thought process is to move it CW to address the short lower third, then use the genio (-1.1mm) to reduce any unwanted length that creates. It's not a bad idea, IMO, but I am biased against CCW rotation on short faces.

I think a second opinion from a surgeon is in order. Maybe you can setup and email consult with Gunson, but keep in mind he likes heavy rotation. Relle might be a better fit for this case. See if you can email consult him.

Thank you. It is, and I agree a lot of his results look very good. I'm going to consult Gunson and see what he has to say. I'm not familar with Relle, but I will look into him!