Alar/Base Widening Post Jaw Surgery

[jusken]

I've been scouring through these boards to see what people generally feel about their nose width post jaw surgery.  I've mentioned this problem many times in regards to my case, as my nose has been widened quite a bit beyond my inner canthal distance.  I've tried removing the hardware under my nose and then just dealing with it for a while (it's been about 5 years or so since my double jaw surgery).  It just doesn't look right to me.

So I'm prepped to get a couple opinions from specialists on this matter, but also wanted to get the general feeling about rhinoplasty dealing with this.  It seems like alar width reduction isn't a very popular operation to show before afters online.  Mainly rhinoplasty galleries include lots of dorsal hump / tip work.  So, is the scarring just too much of a tradeoff generally?  Can a sill reduction alone hide the scars better and be preferable?  These are questions that I'll ask, but I also feel that doctors just don't have to be totally honest about the statistics on these things.

Has anyone here addressed this or know someone who has and has been satisfied with the outcome?

[kavan]

Not a specific suggestion of which doctor to go to but here's a link with some coverage as to base reduction.

https://www.drhilinski.com/rhinoplasty-tutorials/nasal-base

Here's a professional article with references to other doctors in the bibliography.

https://academic.oup.com/asj/article/22/3/289/183689

and another

https://www.semanticscholar.org/paper/Nasal-base-reduction-by-alar-release%3A-a-laboratory-Gruber-Freeman/8fe6b34838797e1de5e1d82b03190c52c15118fa

[Lazlo]

frankly i can almost always see the scars from this procedure a mile away. and if you're a man you can't wear thick foundation or make-up to try and hide it.

[GJ]

I've been scouring through these boards to see what people generally feel about their nose width post jaw surgery.

I don't like the changes to my nose either, but I'm not even sure what happened. It only looks slightly wider, but something about it looks off. The nostrils also look to be flared more after surgery.

Didn't Gunson do your original surgery?

[jusken]

I don't like the changes to my nose either, but I'm not even sure what happened. It only looks slightly wider, but something about it looks off. The nostrils also look to be flared more after surgery.

Didn't Gunson do your original surgery?

Yeah Gunson did the surgery.  I should clarify that looking at my old pictures my nose was slightly outside of my inner eye vertically, so the change isn't huge - but enough to make it look too wide to me now (it looks compressed).  I notice this change with a lot of post jaw surgery pictures of patients, but probably depending on how wide your face is, this change can appear more minimal I think.

With me, my nostrils used to hang further down.  With the jaw surgery, the base they sit on is higher up now and further forward.  This has resulted in a straighter profile, but also a vertically compressed nose and more flared looking.  When I look from the bottom, it's clear the nostrils aren't disproportionately flared, simply everything is wider (base + nostrils).  The look isn't natural to me, even though the total width increase was probably only 1mm per side, maybe slightly more.  It's clear that the nose is best left to naturally grow into the correct place if you can help it!

[kavan]

Can you clarify whether this arose in the process of having CCW advancement to maxilla and also how many mm your maxilla was advanced out.

[jusken]

I had CCW yes, it's standard with Gunson.  I apologize, but I don't know which terms here mean what.  My ANS was 2.6 and my PNS was 3.4.  Are either of those relevant?

[GJ]

It could be your ANS wasn't tripped to make up for it being more forward.

[kavan]

I had CCW yes, it's standard with Gunson.  I apologize, but I don't know which terms here mean what.  My ANS was 2.6 and my PNS was 3.4.  Are either of those relevant?

Here's a 'snip' from one of Gunson's displacement proposals.

A-P direction when positive conveys the 'pure' horizontal advancement of ANS and PNS

The Vert(ical) direction for ANS conveys whether ANS moved up or down. In this one it's 0

A PNS where the vertical has a POSITIVE sign means the PNS was moved down (which is the CCW) for this reading.

I'm wanting to know ANS A-P on yours, ANS Vert on yours, PNS A-P on yours and PNS Vert on yours.

[jusken]

Ah, okay I'll just add a snippet of my movements then.

[kavan]

Ah, okay I'll just add a snippet of my movements then.

Also mention if you got a multi-segment Lefort.

[jusken]

I had the BSSO + LF1 if that's what you mean, yeah.

[GJ]

The LF1 can be multi-segment. They cut it into (usually) three pieces and widen it. Did you have that?

[kavan]

I had the BSSO + LF1 if that's what you mean, yeah.

Ah, okay I'll just add a snippet of my movements then.

OK, that tells me your ANS moved UP (1.9mm) in the vertical direction and your PNS moved DOWN (3.7) in vertical direction for the CCW aspect of it. Can you confirm if you had anterior impaction AND posterior downgraft ?

Also, was this 'single' lefort 1 or was it SEGMENTED? For example IF he had to cut the lefort into 3 pieces to move around the upper front teeth separately from the 2 adjoining upper sides (multi-segment Lefort 1), although I can't go through all the scenarios where they might do that, one of them is to give more WIDTH so that the back upper teeth occlude well with the back upper teeth to the mandible like when there is some narrowness to the transverse maxilla.

Short and sweet, no matter what the multi segment lefort 1 was for, that is IF you got one, it would tend to putting a 'stretch' near the nasal base. Also, since L1 brings the nasal base FORWARD, it's going to look wider to you because it's MORE in the foreground.

So, let's say you did NOT get a multi segment L1 and just 2.6mm horizontal advancement of ANS with 1.9mm impaction to anterior maxilla. That's enough for your nasal base to LOOK wider to you whether you look at in the mirror or take a photo of it. It's because the 'forward' advancement (and yes, even with CCW) brings the nasal base forward and puts it more in the foreground even though it might not be 'technically' wider.

However, IF you did get a multi-segment L1 which usually increases the transverse direction (width between the right and left side of the upper back teeth), that's something that veers toward a STRETCH to the nasal base to make it 'absolutely' or 'technically' wider.

I know someone who went to Gunson who got LESS nasal base advancement than you (but MORE CCW via posterior downgraft) than you BUT he also got the multi-segment L1 to increase the transverse width so the side teeth would meet better with about the 14 mm advancement of the B point he got and he got the very WIDE nasal base with BOTH. Although Gunson didn't prepare him for that, I DID so he knew what to expect. But he was OK with it and I think people can be OK with something like that when they know what the trade-offs can be ahead of time.

[jusken]

Cool, thanks for the breakdown kavan.  Yes, I remember Gunson talking to me about the multi-segment LF1 and the risks associated with it - so he did perform that.

I'm very confident that there is a fundamental problem with changing the shape of the nasal base - a nose adapts to a recessed maxilla and becomes longer, etc.  This is a fairly obvious trade-off, I simply wasn't totally prepared for it going into it.  Certain movements would clearly make a more unfavorable change, but in any case you're left with essentially a smaller space for the nose.  This would produce a favorable change if you have a very narrow nose for instance or a wide face where such a small width increase is relatively less significant.   Given all the jaw surgery cases I've seen, many people get a 'divergent' nasal shape - a slightly wide and flared look.

I'd change it 100% if there were no other trade-offs...  but that seems unlikely here.