MMA relapse, now 7 weeks PO. How to proceed?

[kavan]

Regarding the nose changes: https://imgur.com/gallery/bfnppEG
Barely any, but the surgeon employs some special suture technique.

Perhaps alar cinch which they use to prevent excess widening.

[InvisalignOnly]

I think you managed to remain remarkably calm and rational in the circumstances. I can't give any advice but wish you well and hope the revision will be successful and you will be happy with the final outcome.

[Dogmatix]

If it were me, i would step back and wait a couple of weeks before making this decision. I have no medical background but its my understanding that the temporalis muscle and other muscles of the jaw atrophy after a BSSO so I wonder how your strong jaw muscles caused this problem.  And if so how are the dealing with the muscle pull as you go into another surgery? I would want to know the reason for the cant as well. You dont want to have to get a third surgery if this is not exactly the right correction for you.

According to Arnett, “early relapse is mostly caused by movements at the osteotomy site (osteotomy slippage) or temporomandibular joint sag and is usually called surgical displacement. Two different types of force vectors interact with healing bone fragments. On one side, the stretched paramandibular connective tissue (skin, sub cutis, muscles and periosteum) tends to deviate the tooth-bearing fragment into its original position; on the other side, osteosynthesis hardware, in some cases skeletal suspension and the condyle if seated into the fossa tends to stabilize the fragments. Disharmony of these forces occurs in case of inappropriate fixation and/or wrong peroperative condylar position>” The more your tissues and muscles were stretched, the greater the risk of an early relapse.

If there is no harm to you in giving yourself a little bit of  time to fully understand the recommendations, the risks and the benefits and to understand how this strong muscle pull will affect an area that will now have been operated twice in a short period of time, then i would step back and not make a rush decision.  There  are only a handful of surgeons in the USA that would perform such a large advancement.

I know you have your reasons to be skeptical and are caught in a bad situation. But I wouldn't advice to wait and would very much appreciate if the surgeon want to deal with things as soon as possible if it was me. It's not a rush decision, the dice is cast and this is more a situation to get back on the path that is already decided. It's mentally draining to be in a situation of uncertainty. Yes, there are questions that needs to be asked in order to make the right decision, but I think asking the questions and deal with the situation now will be better than staying in this bubble of uncertainty and anxiety. Your situation is different where you have complications and as I understand don't have a good offer on the table. In this situation the surgeon, patient and this board of experts (JSF approved stamp) agree on the problem and that it can be fixed.

[PloskoPlus]

IMO you look significantly better. Did your tooth show change significantly? I have a big fleshy nose. The advancement did widen it a little bit, but I’m not bothered by it. In general those with fine thin noses, nostrils get the worst deal. Furthermore, anterior downgrafts spare the nose a little compared with other movements (impaction and advancement being the worst). 

[jawsandsleep]

IMO you look significantly better. Did your tooth show change significantly? I have a big fleshy nose. The advancement did widen it a little bit, but I’m not bothered by it. In general those with fine thin noses, nostrils get the worst deal. Furthermore, anterior downgrafts spare the nose a little compared with other movements (impaction and advancement being the worst).

I most definitely dont look much better. My tooth show increased to about 1mm at rest. I feel like my nose was mostly spared.
However, an anterior downgraft + a CCW rotation is going to increase vertical face length. If youre starting with a long face type like I do, this should be taken into consideration. I am seeking a chin reduction at some point.

[GJ]

I am seeking a chin reduction at some point.

How much of your movement was chin?

[jawsandsleep]

I think you managed to remain remarkably calm and rational in the circumstances. I can't give any advice but wish you well and hope the revision will be successful and you will be happy with the final outcome.

Thank you, I appreciate the kind words. I guess its human nature to just move on with life. I was devastated, but I do think I have some hope left.

If it were me, i would step back and wait a couple of weeks before making this decision.

I have been postponing the revision for two weeks already to clear my head a little. At this point I am considering getting the mandible back thus restoring function and improving aesthetics. I am definitely not fully informed, but if the mandibular set back is indeed a smallish procedure as the bones arent fully formed, then it would be preferable to walking around in my currernt state.
I will have to trust my surgeon on this one.

Why I have decided to get the mandibular setback: https://imgur.com/gallery/NdBw6tm
I believe there is only so much a Lefort I can do without disrupting the harmony of ones face. I have gained fullness in my midface and my lips and its a significant improvement. Notice how the are below the eyes remain in their hollow position. At this point, I have to ask myself: What do I have to gain from advancing the maxilla even more? I am a long face type patient which means there are many related deficiencies leading to this phenotype. When you see a person with notable forward growth, it usually is accompanied by other features which cannot be easily achieved by surgery (cheekbones, infraorbitals, etc.)
A CCW lefort is already an optimized approach as it provides more favorable changes to the lips and takes care of my sleep apnea.

[jawsandsleep]

How much of your movement was chin?

anterior downgraft of about 5mm + rotating the mandible forward have increased facial length. The genioplasty has done almost nothing and only moved the chin a few mm in the horizontal plane.

Basically, what I am trying to say: anterior downgraft moves down the chin, ccw rotation of a cw rotated chin brings it into a more vertical position, thus adding to the vertical length. Both these things have significantly lengthened the lower third and I am not able to passively close my lips.

[april]

IMO you look significantly better. Did your tooth show change significantly? I have a big fleshy nose. The advancement did widen it a little bit, but I’m not bothered by it. In general those with fine thin noses, nostrils get the worst deal. Furthermore, anterior downgrafts spare the nose a little compared with other movements (impaction and advancement being the worst).

Are you referring to the morph? Original pics were deleted I think.

[kavan]

anterior downgraft of about 5mm + rotating the mandible forward have increased facial length. The genioplasty has done almost nothing and only moved the chin a few mm in the horizontal plane.

Basically, what I am trying to say: anterior downgraft moves down the chin, ccw rotation of a cw rotated chin brings it into a more vertical position, thus adding to the vertical length. Both these things have significantly lengthened the lower third and I am not able to passively close my lips.

Na...CCW rotation to the extent you implied you had that via a posterior downgraft brings the chin FORWARD up and out with the CCW posterior downgraft rotation and can do so with little or no genio. You better check your records as to WHAT displacements you had lest you make a decision not knowing what means what. Also, when still in the process of requesting advice or 'explaining' the actual results, those photos should REMAIN up there during duration of active discussion. Morphs are no substitute for removing the photos you entered to query for feedback.

[kavan]

Thank you, I appreciate the kind words. I guess its human nature to just move on with life. I was devastated, but I do think I have some hope left.

I have been postponing the revision for two weeks already to clear my head a little. At this point I am considering getting the mandible back thus restoring function and improving aesthetics. I am definitely not fully informed, but if the mandibular set back is indeed a smallish procedure as the bones arent fully formed, then it would be preferable to walking around in my currernt state.
I will have to trust my surgeon on this one.

Why I have decided to get the mandibular setback: https://imgur.com/gallery/NdBw6tm
I believe there is only so much a Lefort I can do without disrupting the harmony of ones face. I have gained fullness in my midface and my lips and its a significant improvement. Notice how the are below the eyes remain in their hollow position. At this point, I have to ask myself: What do I have to gain from advancing the maxilla even more? I am a long face type patient which means there are many related deficiencies leading to this phenotype. When you see a person with notable forward growth, it usually is accompanied by other features which cannot be easily achieved by surgery (cheekbones, infraorbitals, etc.)
A CCW lefort is already an optimized approach as it provides more favorable changes to the lips and takes care of my sleep apnea.

I'm very conversant in morphing and know what the 'no nos' are. What you did was take your after which showed your mouth area being very open. You morphed that. I see the SEAM to the morph where part of shortening your chin involved also shortening the MOUTH OPENING to your after.  Act of 'grabbing' THROUGH the open mouth area to shorten the chin. That's a NO NO in morphing. So, good luck if you think that a morph that CUTS through your mouth area to shorten both your chin and the mouth opening illustrates what's possible to do during surgery. Better have your surgeon take a close look at that morph and the SEAM in there showing where you cut through to shorten both mouth opening with the chin which ISN'T even a morph of your before surgery photo yet morphs an after surgery photo WITHOUT the actual after surgery photo beside it. Yup. Good luck on acting on information based on that and let us know how that works out for ya.

[GJ]

You have to converse with your surgeon then follow your gut. There are issues such as your ethnicity and how you relate to your face at play here, and so nobody can tell you how to objectively quantify something so subjective. People gave their opinions. I'd take them as just that and then follow your gut after speaking with your surgeon.

I don't know if this helps at all, but I feel your anxiety and pain. It's a bad situation and wish you the best.

[PloskoPlus]

Are you referring to the morph? Original pics were deleted I think.

I guess it was the morphs.

[PloskoPlus]

I most definitely dont look much better. My tooth show increased to about 1mm at rest. I feel like my nose was mostly spared.
However, an anterior downgraft + a CCW rotation is going to increase vertical face length. If youre starting with a long face type like I do, this should be taken into consideration. I am seeking a chin reduction at some point.

What was your pre-op tooth show at rest?  1 mm at rest is good for a man.

[april]

How are you jawsandsleep, any updates?