Re: Dr Hernandez Alfaro

[Dogmatix]

It's like anything else. OUTPUTS are a function of INPUTS. So results are to outputs as starting point is to inputs.

Every heard the adage: 'You can't make a silk purse out of a sow's ear.' ? It's like that and I DON'T mean this as insult to how the patients looked before. I mean it to convey the adage relates to outputs are a function of the inputs and results are a function of the start points.

For example, something like an extremely high mandibular plane angle can't be made much lower even with CCW and the person will still have a high MP after CCW and advancement BSSO. These surgeries are to balance bites and aesthetics so that both are improved.

IMO, I think the people who have significant problems with both the bite and aesthetic deviations from the norm will be the happy ones with their results and will like them despite some minor trade-offs that some of you MAGNIFY when looking at the results. . (Pretty obvious they are happy given they volunteer their photos to be used.). Others just looking at the RESULTS (and maybe judging from perspective of 'lack of perfection' or not being transformed into a model) or who just can't figure out, or worse yet, VOID of the concept that results depend on the start point, perhaps should not even be pursuing maxfax surgeries for 'aesthetics alone'.

*applauding*

I'm sorry if I sometimes come off as judging a result or person, which is never the case or purpose. But however, looking at cases, picking them apart and understanding what is possible, why the outcome is what it is etc is at least  important for me. If I could'nt have such discussion, I think it would be very easy for me and others to go in with unrealistic expectations. If you don't understand that any other solution would cause bad trade offs and why, it's easy to judge a surgeon, or even worse, your own result as bad. Just as you say,  'You can't make a silk purse out of a sow's ear'. I think looking at plans and results, twisting and turning them and understand the surgeons thoughts is good for understanding, at least for me. My state of mind when looking at my own case is not so much that I'm afraid of trade offs, but more to not understand them, and ensuring there is not a better solution available. One example is e.g that I'm glad that these discussions have educated me enough to turn down if I'd get a plan that didn't contain ccw.

[Dogmatix]

Why do both results have noticeable asymmetry? The second one in particular has a good deal of asymmetry.

Is it just that bimax exposes this (meaning they had it prior to surgery) or is it movement via surgery first?

With the above being said. I didn't look at the frontal.picture that accurate before, but as you say, there is assymetry on the chin. Surgery first give less predictable result than surgery last, but I don't see how that can reflect on the horizontal assymetry on the chin, also given that there was a mentoplasty included that probably could've addressed it.

[kavan]

*applauding*

I'm sorry if I sometimes come off as judging a result or person, which is never the case or purpose. But however, looking at cases, picking them apart and understanding what is possible, why the outcome is what it is etc is at least  important for me. If I could'nt have such discussion, I think it would be very easy for me and others to go in with unrealistic expectations. If you don't understand that any other solution would cause bad trade offs and why, it's easy to judge a surgeon, or even worse, your own result as bad. Just as you say,  'You can't make a silk purse out of a sow's ear'. I think looking at plans and results, twisting and turning them and understand the surgeons thoughts is good for understanding, at least for me. My state of mind when looking at my own case is not so much that I'm afraid of trade offs, but more to not understand them, and ensuring there is not a better solution available. One example is e.g that I'm glad that these discussions have educated me enough to turn down if I'd get a plan that didn't contain ccw.

Thanx. No need to say 'sorry'. My comment was a general one and not targeted to you. It's a long thread with many posters which does have some people on it who appear to be just looking at 'aesthetics alone', not looking at the over all improvement and don't give a second thought to input vs. output.

ETA: the long thread that this started as in 2017 has been split into 2 separate threads.

[PloskoPlus]

Complaints about post-op asymmetry are a common amongst jaw surgery patients.  The standard explanation is that advancement magnifies any existing asymmetry.  However, in the examples posted, the asymmetry is barely noticeable pre-op and striking post-op.  Is this really something that everyone contemplating jaw surgery should simply be prepared to accept?  I am not so sure.  What if someone has really bad asymmetry to start with?  What the hell should they expect? 

Honestly I'm less and less impressed with Alfaro.  Maybe I would have also grown unimpressed by other big names, had they put as up as many cases on their website as he has.  But I distinctly remember one of his showcases, where the patient had clearly misaligned dental midlines post-op. That is simply unacceptable as leaving a patient with a decent bite is the absolute minimum competency that a surgeon should be able to demonstrate. I already know what his apologists will say - "that was most likely surgery first with post-op ortho yet to take place", etc., etc.  Whatever the case, a surgeon with attention to detail would not post such a result with literally hundreds to choose from.  It just strikes me as sloppy.  The other explanation - "that really is his best" is even worse.

Many people cannot stomach revision and simply put up with their "OK" result, which gnaws at them for the rest of their life.  It's not a great place to be.  This is not even taking into account the fact that most surgeons often refuse to revise their own work, let alone that of others.  Therefore, one should be as hard on the surgeon as possible.  Yet I see people exhibiting Stockholm Syndrome symptoms before they've even been "kidnapped".  I know this, because I've been there myself.  I ignored all the warning signs and excused my surgeon's arsehole behaviour from well before surgery to more than a year post-op.  At least the arrogant prick left me with a decent bite.

[JourneyToSerenity]

From a purely aesthetically perspective, I can understand the reservations some may have of him, Estela, whose pictures now seem to have been taken down, had quite prominent asymmetry in her post-op pictures.

https://www.instagram.com/p/BqZwsoPlaEP/

Is another case where he seems to have a prominent mentolabial angle despite having mentoplasty.

Still, it would be wise to remember that only a select few of those who consent to share their pictures are seen by us, the public. Those patients may also be entirely focused on the functional aspect of the surgery rather than addressing any aesthetic concerns. Most of the prominent surgeons commonly mentioned on here seem to be the most skilled and reputable of all maxillofacial surgeons. There may well be an element of, Alfaro, overselling himself, however, from my consultation he never seemed that way inclined, and unlike most maxillofacial surgeons I’ve met, at least he wasn’t trying to leave me in a worse or similar functional state by omitting certain procedures.

[Dogmatix]

From a purely aesthetically perspective, I can understand the reservations some may have of him, Estela, whose pictures now seem to have been taken down, had quite prominent asymmetry in her post-op pictures.

https://www.instagram.com/p/BqZwsoPlaEP/

Is another case where he seems to have a prominent mentolabial angle despite having mentoplasty.

Still, it would be wise to remember that only a select few of those who consent to share their pictures are seen by us, the public. Those patients may also be entirely focused on the functional aspect of the surgery rather than addressing any aesthetic concerns. Most of the prominent surgeons commonly mentioned on here seem to be the most skilled and reputable of all maxillofacial surgeons. There may well be an element of, Alfaro, overselling himself, however, from my consultation he never seemed that way inclined, and unlike most maxillofacial surgeons I’ve met, at least he wasn’t trying to leave me in a worse or similar functional state by omitting certain procedures.

There is no question that Alfaro "knows stuff". I've read some of his papers and by doing that you understand that he is involved in research and have an interest in doing good surgery (not obvious for all surgeons). In some of his papers on the soft tissue plane, he refers to Gunsons previous research, so he is also aesthetically interested.

On the case you posted, I always try to think what I would've done differently and what I would've want to displace differently if it was my face. Because sometimes it is as Kavan said, you have to work with what you have. With the prominent mentolabial angle, I suppose you mean that it points a bit up. There is a bit lack of soft tissue support under the chin, and maybe it was that it was chosen to turn the chin up a bit to maximize the support. I don't know, I'm just speculating what the option would be. Also that the pointing up is a bit of an illusion because of the soft tissue that is not going horizontally. I did a photo edit test and stretched some of the soft tissue under the chin, and it was clearly beneficial, meaning I can understand if the surgeon chosed to try to do as much as possible for soft tissue support.

In the picture below I've done nothing but removing some soft tissue between the throat and chin. In my opinion it's a great result, if there was something that could be done to improve, it's some procedure to have the skin stretched.

https://imgur.com/3XkzfCm


On the asymmetric case that is now removed(available on google cache). My take was that it seemed noticable over advanced in a way that would make me hesitant and assymetric on the chin. Over advancement I can't really comment on, since it maybe was motivated if the indication was sleep apnea. But the fact that they advertise themself with short surgery time, and use this as a meassurement of how good they are, then they can't leave an assymetric genioplasty. I mean, as far as I'm concerned I don't care if I have to spend 24h in the surgery room, just get it right.

[kavan]

From a purely aesthetically perspective, I can understand the reservations some may have of him, Estela, whose pictures now seem to have been taken down, had quite prominent asymmetry in her post-op pictures.

https://www.instagram.com/p/BqZwsoPlaEP/

Is another case where he seems to have a prominent mentolabial angle despite having mentoplasty.

Still, it would be wise to remember that only a select few of those who consent to share their pictures are seen by us, the public. Those patients may also be entirely focused on the functional aspect of the surgery rather than addressing any aesthetic concerns. Most of the prominent surgeons commonly mentioned on here seem to be the most skilled and reputable of all maxillofacial surgeons. There may well be an element of, Alfaro, overselling himself, however, from my consultation he never seemed that way inclined, and unlike most maxillofacial surgeons I’ve met, at least he wasn’t trying to leave me in a worse or similar functional state by omitting certain procedures.

You can take a 'purely aesthetic perspective' when judging a fine work of art, for example a sculpture in a museum. But you can't when it comes to altering 'flesh and bone'. It's not as if they are working with clay where judgement based on 'aesthetics alone' has much direct relation to what they are doing and what they're working with. It just resolves to FLAW FINDING. Not the best perspective to take when critiquing a doctor's work. Better perspective is how things work.

Not meaning to be an apologist for Alfaro here but the 'spot the flaw' you mentioned--the prominent mentolabial angle-- is a trade-off associated with CORRECTING his salient aesthetic problems. CCW, which he probably got to correct his main issues, rotates the jaw up and out which sets the pogonian point higher. If his 'mentoplasty' was a sliding genio which it probably was because they also use SG to give more of a CCW look in long face cases, that also sets the pogonian point higher on the chin. Both together, can close in on the lip to chin curve because the pogonian is moving out and up and hence closer to the lip.

[kavan]

There is no question that Alfaro "knows stuff". I've read some of his papers and by doing that you understand that he is involved in research and have an interest in doing good surgery (not obvious for all surgeons). In some of his papers on the soft tissue plane, he refers to Gunsons previous research, so he is also aesthetically interested.

On the case you posted, I always try to think what I would've done differently and what I would've want to displace differently if it was my face. Because sometimes it is as Kavan said, you have to work with what you have. With the prominent mentolabial angle, I suppose you mean that it points a bit up. There is a bit lack of soft tissue support under the chin, and maybe it was that it was chosen to turn the chin up a bit to maximize the support. I don't know, I'm just speculating what the option would be. Also that the pointing up is a bit of an illusion because of the soft tissue that is not going horizontally. I did a photo edit test and stretched some of the soft tissue under the chin, and it was clearly beneficial, meaning I can understand if the surgeon chosed to try to do as much as possible for soft tissue support.

In the picture below I've done nothing but removing some soft tissue between the throat and chin. In my opinion it's a great result, if there was something that could be done to improve, it's some procedure to have the skin stretched.

https://imgur.com/3XkzfCm


On the asymmetric case that is now removed(available on google cache). My take was that it seemed noticable over advanced in a way that would make me hesitant and assymetric on the chin. Over advancement I can't really comment on, since it maybe was motivated if the indication was sleep apnea. But the fact that they advertise themself with short surgery time, and use this as a meassurement of how good they are, then they can't leave an assymetric genioplasty. I mean, as far as I'm concerned I don't care if I have to spend 24h in the surgery room, just get it right.

CCW points up the pogonian point more and sliding genio for more of a CCW effect (for long face case) also points it up more. So both narrowed the lip to chin curve on that guy. But both were needed to correct his salient aesthetic problem.

[Dogmatix]

CCW points up the pogonian point more and sliding genio for more of a CCW effect (for long face case) also points it up more. So both narrowed the lip to chin curve on that guy. But both were needed to correct his salient aesthetic problem.

Yes, so this was in some way what I was getting at. If this pointing up is what JourneyToSerenity was getting at, I couldn't really see the problem. First I don't think it's pointing up noticeable, but also if I would've thought that, it's a natural part of the rotation that was needed in this case. The alternative would be less ccw, or maybe some clockwise compensation on the genio, but that would give other trade offs on the over all perspective. So as I concluded, for me this is also a good result and I think the patient should be very happy. If there was anything I could see it was to stretch the skin a bit, which is not a max-fac problem from this point as more advancement would get too much.

I'm not here to neither defend nor criticise a surgeon. But if there are doubts on a case, and all we have is a profile picture without x-rays or a comment from a surgeon, I think it's fair to judge in favour of the surgeon as there may be things we don't know. That's why I'm very carefull when commenting on the over advancement on the other case. Based on what I know, I can't judge such thing, I can only do the "clay" analysis as you may call it. Which is also why I think it's a shame surgeons don't put up more info on each case. If all they advertise is the aesthetics, this is what they're gonna get comments on.

[kavan]

Yes, so this was in some way what I was getting at. If this pointing up is what JourneyToSerenity was getting at, I couldn't really see the problem. First I don't think it's pointing up noticeable, but also if I would've thought that, it's a natural part of the rotation that was needed in this case. The alternative would be less ccw, or maybe some clockwise compensation on the genio, but that would give other trade offs on the over all perspective. So as I concluded, for me this is also a good result and I think the patient should be very happy. If there was anything I could see it was to stretch the skin a bit, which is not a max-fac problem from this point as more advancement would get too much.

I'm not here to neither defend nor criticise a surgeon. But if there are doubts on a case, and all we have is a profile picture without x-rays or a comment from a surgeon, I think it's fair to judge in favour of the surgeon as there may be things we don't know. That's why I'm very carefull when commenting on the over advancement on the other case. Based on what I know, I can't judge such thing, I can only do the "clay" analysis as you may call it. Which is also why I think it's a shame surgeons don't put up more info on each case. If all they advertise is the aesthetics, this is what they're gonna get comments on.

I agreed with your observations which is why I 'bolded' the parts that referred to pointing up .  I also agree with what you're saying here as to judging.  Some judgments are made in presence of GAPS where person might not know the reason why something looks a certain way. But ya, docs should put up more info as to what they did.

[JourneyToSerenity]

On the case you posted, I always try to think what I would've done differently and what I would've want to displace differently if it was my face. Because sometimes it is as Kavan said, you have to work with what you have. With the prominent mentolabial angle, I suppose you mean that it points a bit up. There is a bit lack of soft tissue support under the chin, and maybe it was that it was chosen to turn the chin up a bit to maximize the support. I don't know, I'm just speculating what the option would be. Also that the pointing up is a bit of an illusion because of the soft tissue that is not going horizontally. I did a photo edit test and stretched some of the soft tissue under the chin, and it was clearly beneficial, meaning I can understand if the surgeon chosed to try to do as much as possible for soft tissue support.

In the picture below I've done nothing but removing some soft tissue between the throat and chin. In my opinion it's a great result, if there was something that could be done to improve, it's some procedure to have the skin stretched.

https://imgur.com/3XkzfCm

I think you've misunderstood me, i'm purely talking about the mentolabial labial angle. Bare with me, I'm hopeless at explaining this succinctly. Hope this helps a little:

https://i.ytimg.com/vi/AGCtU_uuIdA/maxresdefault.jpg

In this lady's pic you can see the fold to anterior lip angle is roughly 45 degrees, but due to the chin point being roughly in line with the fold, her fold isn't prominent/deep and looks quite nice.

Now, if you go back and look at the gentlemen's profile on Alfaro's instagram, you'll see that his fold to anterior lip is quite steep, too, in both pre and post op pics, but due to his fold to chin point being roughly in line in his pre-op pics, the fold isn't prominent/deep. However, in his post op pics due to his SG, the fold to chin point isn't no longer roughly in line, due to it being brought forward, and up, now the fold looks a lot more prominent/deep, which now looks like this - <.

I'm curious to know if there's anything that can be done to prevent it from looking like that as I don't find it aesthetic at all.

You can take a 'purely aesthetic perspective' when judging a fine work of art, for example a sculpture in a museum. But you can't when it comes to altering 'flesh and bone'. It's not as if they are working with clay where judgement based on 'aesthetics alone' has much direct relation to what they are doing and what they're working with. It just resolves to FLAW FINDING. Not the best perspective to take when critiquing a doctor's work. Better perspective is how things work.

Not meaning to be an apologist for Alfaro here but the 'spot the flaw' you mentioned--the prominent mentolabial angle-- is a trade-off associated with CORRECTING his salient aesthetic problems. CCW, which he probably got to correct his main issues, rotates the jaw up and out which sets the pogonian point higher. If his 'mentoplasty' was a sliding genio which it probably was because they also use SG to give more of a CCW look in long face cases, that also sets the pogonian point higher on the chin. Both together, can close in on the lip to chin curve because the pogonian is moving out and up and hence closer to the lip.

Personally, I don’t see what there is to like about his profile apart from his open mouth posture being removed. Maybe i'm being harsh as this case hits closer to home as I suffer from the same open mouth posture, so I'm probably more critical.   In his after pics, he looks like he has a mentalis strain when his lips are 'shut', much more visible from the frontal pics, although, it's still hard to see the extent of it due to his facial hair.

By bringing the pogonian up and outwards, like you've said, you naturally increase the mentolabial angle. Is there anything a surgeon can do to give support to what I presume is the Basion[?], to prevent the fold from being as prominent/angled?

[kavan]

I think you've misunderstood me, i'm purely talking about the mentolabial labial angle. Bare with me, I'm hopeless at explaining this succinctly. Hope this helps a little:

https://i.ytimg.com/vi/AGCtU_uuIdA/maxresdefault.jpg

In this lady's pic you can see the fold to anterior lip angle is roughly 45 degrees, but due to the chin point being roughly in line with the fold, her fold isn't prominent/deep and looks quite nice.

Now, if you go back and look at the gentlemen's profile on Alfaro's instagram, you'll see that his fold to anterior lip is quite steep, too, in both pre and post op pics, but due to his fold to chin point being roughly in line in his pre-op pics, the fold isn't prominent/deep. However, in his post op pics due to his SG, the fold to chin point isn't no longer roughly in line, due to it being brought forward, and up, now the fold looks a lot more prominent/deep, which now looks like this - <.

I'm curious to know if there's anything that can be done to prevent it from looking like that as I don't find it aesthetic at all.

Personally, I don’t see what there is to like about his profile apart from his open mouth posture being removed. Maybe i'm being harsh as this case hits closer to home as I suffer from the same open mouth posture, so I'm probably more critical.   In his after pics, he looks like he has a mentalis strain when his lips are 'shut', much more visible from the frontal pics, although, it's still hard to see the extent of it due to his facial hair.

By bringing the pogonian up and outwards, like you've said, you naturally increase the mentolabial angle. Is there anything a surgeon can do to give support to what I presume is the Basion[?], to prevent the fold from being as prominent/angled?

He doesn't look like he has 'mentalis strain' the after frontal (nor the after profile photos). He looks like he's showing how much tooth show he has when his mouth is slightly open and also that he can close his lips with ease (on profile).  Logic would dictate that the before frontal photo was to show an EXCESS of unattractive tooth show. Hence it should follow that the after photo was to show it's correction.

The only 'mentalis strain' I see here is mental strain. Like more of a thing where you are straining too much via bandying about medical terms. Easy enough to say; 'Chin strain' or ' The fold between the chin and the lip.', or 'the chin to lip angle'. If you can say it that way, it demonstrates observation and/or just knowing the med terms are from ancient latin roots and translate that way into English.

There's no 'increase' to the chin to lip ANGLE. When the angle becomes LESS, it's DECREASED.

ETA: It all depends on what problem you want to fix; an extreme maxillo-facial deviance from the norm or the problem of finding flaws after an extreme maxfax problem is corrected.  I'm sure the patient in the photo wanted to correct the former. He can easily address his decreased chin to lip angle with some filler if it bothers him and get some plastic surgery to sharpen his chin to neck angle.

[JourneyToSerenity]

He doesn't look like he has 'mentalis strain' the after frontal (nor the after profile photos). He looks like he's showing how much tooth show he has when his mouth is slightly open and also that he can close his lips with ease (on profile).  Logic would dictate that the before frontal photo was to show an EXCESS of unattractive tooth show. Hence it should follow that the after photo was to show it's correction.

The only 'mentalis strain' I see here is mental strain. Like more of a thing where you are straining too much via bandying about medical terms. Easy enough to say; 'Chin strain' or ' The fold between the chin and the lip.', or 'the chin to lip angle'. If you can say it that way, it demonstrates observation and/or just knowing the med terms are from ancient latin roots and translate that way into English.

Cheers, Kavan. With a mentalis strain, the chin area becomes a lot more ‘puffy’, his sg definitely portrays that look. On the second slide photo, it seems clearly evident, at least to me.

There's no 'increase' to the chin to lip ANGLE. When the angle becomes LESS, it's DECREASED.

ETA: It all depends on what problem you want to fix; an extreme maxillo-facial deviance from the norm or the problem of finding flaws after an extreme maxfax problem is corrected.  I'm sure the patient in the photo wanted to correct the former. He can easily address his decreased chin to lip angle with some filler if it bothers him and get some plastic surgery to sharpen his chin to neck angle.

Agreed, it does become decreased, however, I meant to say the angle becomes more acute and thus looks more 'harsh/unnatural'. Is there any way to change it surgically rather than an implant/filler? I'm clutching at straws here, but is it possible to do a sliding genio and then slightly rotate the poigonion downwards?

[kavan]

Cheers, Kavan. With a mentalis strain, the chin area becomes a lot more ‘puffy’, his sg definitely portrays that look. On the second slide photo, it seems clearly evident, at least to me.

Agreed, it does become decreased, however, I meant to say the angle becomes more acute and thus looks more 'harsh/unnatural'. Is there any way to change it surgically rather than an implant/filler? I'm clutching at straws here, but is it possible to do a sliding genio and then slightly rotate the poigonion downwards?

With mentalis strain which applies to the strain of closing the lips, the strain is to the front of the chin in the area of the mentalis muscle. Sometimes that is visible via an orange peel appearance when the person is straining to close the lips. It has NOTHING to do with LAXITY under the chin. As to 'puffiness' on the side view, you are clearly confusing SUB-MENTAL FULLNESS with 'chin strain'.

You are also confusing your problem list which includes lip incompetence, airway issues and long face with a request to make it those WORSE whether you know that or not.

So, yes, it is possible to have a sliding genio where the chin slides backwards instead of forwards where the pogonian goes downwards. Just make clear to the doctor that you would RATHER the surgery make your long face and chin strain/lip incompetence WORSE and it's quite OK with you if your airway increase can't be maximized in the process and that you would rather have those things made WORSE than accept a possible acute angle lip to chin groove. Why? Because a backwards and down pogonian orientation is actually ASSOCIATED with chin strain/lip incompetence, a longer looking face and sometimes, airway issues.

 Your critique of the Alfaro patient's appearance reflects confusion as to the difference between chin strain/lip incompetence and sub mental fullness. Your targeted focus on his acute lip to chin groove and need to avoid such a possibility reflects you only understand how things look but not how things work. It might not be prudent to undergo surgery if you are unwilling to accept a possible trade-off of an acute angle lip to chin fold that is often done in a genioplasty aimed at CORRECTING the things YOU have such as; chin strain/lip incompetence, long face and helping to improve airway issues.

If you are considering Alfaro for your surgery, you should make clear to HIM just how disturbing that patient's out come is to your keen aesthetic sensibilities. Although he might not have time to explain the relationships I've explained here, he would be in a position to determine 'mutual candidacy' if he knew how unwilling you were to accept a possible trade-off associated with correcting the problems you have, (which I looked at via the first post you made). Presently, your strong aesthetic protestations of that patient's outcome, (acute angle lip to chin fold) including but not limited to confusion as to how things work could preclude the doctor from offering surgery to you when the surgery needed to correct what you have:

("- Lip incompetence corrected
- Removal of Gummy smile
- For my lower lip to roll upwards and look normal instead of drooping
- I have a long face, want to shorten the height of the face
- To improve my breathing + increase airways")

would be the same/similar type of surgery the Alfaro patient had.

Moral of story: "The lady doth protest too much, methinks"

END OF STORY.