Alar/Base Widening Post Jaw Surgery

[Post bimax]

You would also have to reverse the BSSO that went with the LF1.

Yeah I'm aware.  I'm just planning at some point to consult with Gunson to see if I was over-advanced and was/am a candidate for CCW-r.  My hope is that he would be able to do a (partial) setback of both jaws plus ccw-r to maintain similar projection of the mandible.

I know the trade-offs with the nose can occur even with ccw and even with smaller movements.  My question is just whether or not the LF1 portion of the setback would reduce the magnitude of those tradeoffs or if the flare is CAUSED by advancement but cannot be REVERSED by setback.

From some of the literature I've read, the amount of nasal flare is correlated with the amount of advancement (about 1:2), which seems about right in my case.  My guess is the nasal 'tilt' would be reduced by a setback, but nostril flare seems harder to 'put back in the box'.  But that's just intuition.

[jusken]

In theory, but I've seen this happen with CCW a lot, too.
So it's something more complex. Might be the starting point with your nostrils, too. If they're a little flared to begin with, maybe you're just screwed no matter what way things move.

Edit: it looks like Kavan already touched on this above. Next time someone consults with Gunson maybe ask the exact reason why it happens even with CCW.

I've talked to Gunson about it, but I didn't press too much.  He stated confidently that in his cases the nose doesn't change by more than 1mm, but mine did.  I think this is a bit of an overconfidence issue and he mostly avoided it.

If you think about it just logically, CCW has the potential to cause an issue near the base of the nose.  The rotation creates space higher up but nearer to the teeth is rotating forward and up.  My nose flares out just at the bottom base  - so this is congruent with this line of thinking.  When you pair this with forward positioning, I can see where you inevitably get issues.

My thinking has changed over the years.  I'm starting to think that especially in correcting long facial growth like mine, this is one of the trade offs you're left with through no real fault of the surgeon (although Gunson did over-promise in this regard).  It could be said that I just have excess 'ala' because of that facial development.  If this is true, it highlights how narrow the current methods are in addressing the problems associated with facial development - and how dubious it is to be recommended for aesthetics alone.

[PloskoPlus]

Yeah I'm aware.  I'm just planning at some point to consult with Gunson to see if I was over-advanced and was/am a candidate for CCW-r.  My hope is that he would be able to do a (partial) setback of both jaws plus ccw-r to maintain similar projection of the mandible.

I know the trade-offs with the nose can occur even with ccw and even with smaller movements.  My question is just whether or not the LF1 portion of the setback would reduce the magnitude of those tradeoffs or if the flare is CAUSED by advancement but cannot be REVERSED by setback.

From some of the literature I've read, the amount of nasal flare is correlated with the amount of advancement (about 1:2), which seems about right in my case.  My guess is the nasal 'tilt' would be reduced by a setback, but nostril flare seems harder to 'put back in the box'.  But that's just intuition.

You have to keep in mind that Posnick does not believe in alar cinches. (Wolford does. He thought that mine snapped too early. He would do another one in a revision. When I told him that I'd just seen a big name rhino surgeon who said that he's never seen them work, Wolford replied that when done properly they certainly do work.)

[Post bimax]

You have to keep in mind that Posnick does not believe in alar cinches. (Wolford does. He thought that mine snapped too early. He would do another one in a revision. When I told him that I'd just seen a big name rhino surgeon who said that he's never seen them work, Wolford replied that when done properly they certainly do work.)

Yeah, I’m aware of this as well. The research I mentioned was for cases where no alar cinch was performed. I saw some studies suggesting the cinch does help but I know there is controversy about this.

[kavan]

Yeah I'm aware.  I'm just planning at some point to consult with Gunson to see if I was over-advanced and was/am a candidate for CCW-r.  My hope is that he would be able to do a (partial) setback of both jaws plus ccw-r to maintain similar projection of the mandible.

I know the trade-offs with the nose can occur even with ccw and even with smaller movements.  My question is just whether or not the LF1 portion of the setback would reduce the magnitude of those tradeoffs or if the flare is CAUSED by advancement but cannot be REVERSED by setback.

From some of the literature I've read, the amount of nasal flare is correlated with the amount of advancement (about 1:2), which seems about right in my case.  My guess is the nasal 'tilt' would be reduced by a setback, but nostril flare seems harder to 'put back in the box'.  But that's just intuition.

Your photos show that you already had some nasal flare. Seen by the large nose holes and how the alars spread out with a smile. Your cephs show that your ANS-PNS was already in a few degrees of CCW orientation and you've heard from one person who went to Gunson and who got CCW without even THAT much advancement, that he got a wider nose base. I think your first step would be to go back to Posnick in time to get the plates REMOVED (sometimes they can kick up inflammation) and being that he's also a PS, ask him to reduce the nasal base which is usually done by removing a wedge section from the alars similar to what they do with 'ethnic rhino'.

[Post bimax]

Your photos show that you already had some nasal flare. Seen by the large nose holes and how the alars spread out with a smile. Your cephs show that your ANS-PNS was already in a few degrees of CCW orientation and you've heard from one person who went to Gunson and who got CCW without even THAT much advancement, that he got a wider nose base. I think your first step would be to go back to Posnick in time to get the plates REMOVED (sometimes they can kick up inflammation) and being that he's also a PS, ask him to reduce the nasal base which is usually done by removing a wedge section from the alars similar to what they do with 'ethnic rhino'.

I haven’t seen many b/a pics for any of Posnick’s rhinos so I don’t know how good he really is at them considering he specializes in maxfax and academia. Apparently reducing  tilt/flare is a difficult procedure to get right and there are a few top PS in the DMV area with large galleries and extensive public reviews, so that seems like a better option. It’s hard to say whether plate removal would make a difference at all imo. But I’ll ask anyway.

I do still want to at least consult Gunson to get his opinion before doing anything as I want to make the decision to either go through with or avoid a revision with full confidence. Btw what are you getting approx for my OP angle? Maybe I’m doing it wrong

[GJ]

I've talked to Gunson about it, but I didn't press too much.  He stated confidently that in his cases the nose doesn't change by more than 1mm, but mine did.  I think this is a bit of an overconfidence issue and he mostly avoided it.

Yes, I've had that same convo with him. I'm not sure why he says it when there are clear cases of widening, but it's better to under promise in that regard. My guess is he's trying to put the patient's mind at ease and thinks he can do 1mm, but it doesn't always happen, so might at well admit it can be bad.

If you think about it just logically, CCW has the potential to cause an issue near the base of the nose.  The rotation creates space higher up but nearer to the teeth is rotating forward and up.  My nose flares out just at the bottom base  - so this is congruent with this line of thinking.  When you pair this with forward positioning, I can see where you inevitably get issues.

Yes, agree with the mechanics.
I don't think A/G trim the ANS, either? Anyone know? If done that could help, in theory.

[kavan]

Yes, I've had that same convo with him. I'm not sure why he says it when there are clear cases of widening, but it's better to under promise in that regard. My guess is he's trying to put the patient's mind at ease and thinks he can do 1mm, but it doesn't always happen, so might at well admit it can be bad.

Yes, agree with the mechanics.
I don't think A/G trim the ANS, either? Anyone know? If done that could help, in theory.

That helps when the upper lip is TETHERED to the base of the nose. Here's a link where a rhino doc shows what tethering looks like. http://www.facialsurgery.com/ClkoffTPgt3_2011_09_03bh.html

Here's another photo of what is meant by this TETHERING.

But if a person doesn't actually have THAT, cutting down or cutting off the nasal spine would be removing support to the nasal base and that might make the tip rotate down and create a very sharp acute nose to lip angle.

[kavan]

Yes, I've had that same convo with him. I'm not sure why he says it when there are clear cases of widening, but it's better to under promise in that regard. My guess is he's trying to put the patient's mind at ease and thinks he can do 1mm, but it doesn't always happen, so might at well admit it can be bad.

Because they consider it a GOOD functional thing, especially for breathing when the nose holes get bigger.  It's one of the functional 'perks' of CCW. So, it's not something you'd be avoiding by getting CCW. But he down plays that part because he over plays the 'increased aesthetics' part.


 Wolford mentions it outright on one of his pages and mentions it within the context of CCW being great for increasing the airways.  Nose holes are  airways too, you know.

Dr. Wolford says:

As the maxillary and mandibular complex is advanced forward in a counter-clockwise direction the overall facial balance is improved, the oropharyngeal airway opens and the nostrils are widened; all to improve the airway.  Our studies have shown that with the first 10 mm of advancement, the oropharyngeal airway opens up 65-70% of the amount of mandibular advancement.  With 10 to 15 mm of advancement, the oropharyngeal airway continues to open, but at a lesser percentage of the amount of mandibular advancement of only about 55-60% of the mandibular advancement.  When the mandible is advanced greater than 15 mm, the oropharyngeal airway continues to open, but only about 40-45% of the amount of mandibular advancement.

ref= http://www.drlarrywolford.com/orthognathic-corrective-jaw-surgery/

[april]

Post Bimax - So if Posnick does not believe in alar cinches, did he still do one on you?

I don't think A/G trim the ANS, either? Anyone know? If done that could help, in theory.

I've been wondering about this.

I just assumed they did do ANS shaving, because in some of the A/G before & afters I've seen online, their patients' noses don't seem to significantly upturn in profile view. They maybe slightly upturn, but no dramatic ski slopes/piggy noses you sometimes see with other surgeons. It looks more controlled.

But then again, what I'm seeing in before & afters might just be an illusion - where upturning is occurring but it doesn't look as obvious due to other changes such as better lip curve etc.

Jusken - besides the alar base widening, did you have significant tip upturn?

[Post bimax]

April- No, I don’t think so. If he did he didn’t tell me but I never asked and it’s not standard with him. I didn’t even know about it at the time.

[jusken]

Post Bimax - So if Posnick does not believe in alar cinches, did he still do one on you?

I've been wondering about this.

I just assumed they did do ANS shaving, because in some of the A/G before & afters I've seen online, their patients' noses don't seem to significantly upturn in profile view. They maybe slightly upturn, but no dramatic ski slopes/piggy noses you sometimes see with other surgeons. It looks more controlled.

But then again, what I'm seeing in before & afters might just be an illusion - where upturning is occurring but it doesn't look as obvious due to other changes such as better lip curve etc.

Jusken - besides the alar base widening, did you have significant tip upturn?

I don't think my nose upturned much if at all, but did become straighter in profile and more in line with my hump (more forward?).

ANS shaving might help with the upturning in some cases, but I don't think it would work for flaring unless in some rare cases.

[tonebame]

That helps when the upper lip is TETHERED to the base of the nose. Here's a link where a rhino doc shows what tethering looks like. http://www.facialsurgery.com/ClkoffTPgt3_2011_09_03bh.html

Here's another photo of what is meant by this TETHERING.

But if a person doesn't actually have THAT, cutting down or cutting off the nasal spine would be removing support to the nasal base and that might make the tip rotate down and create a very sharp acute nose to lip angle.

Hi kavan, this is my first post so sorry if I seem ignorant.

What would you say is the best way for a patient to reduce the amount of upturning of the nose on a big maxillary advancement (underbite)?

Would cutting down the nasal spine downturn the nasal tip (which i want)? Even at the cost of bigger alar base, that is preferable since I can just do an alar base reduction which is alot simpler than a surgery to fix a pignose

Thanks kavan. Need some experts on this matter and truly appreciate it.

[kavan]

Hi kavan, this is my first post so sorry if I seem ignorant.

What would you say is the best way for a patient to reduce the amount of upturning of the nose on a big maxillary advancement (underbite)?

Would cutting down the nasal spine downturn the nasal tip (which i want)? Even at the cost of bigger alar base, that is preferable since I can just do an alar base reduction which is alot simpler than a surgery to fix a pignose

Thanks kavan. Need some experts on this matter and truly appreciate it.

This is an old thread, a long one and one that applied to the original poster. My advice is start your own thread if you're seeking collective advice targeted to you.