Genioplasty - yes or no?

[kavan]

Ok, so I set down with a mirror today and tried to work out what I want. I want to look as close as possible to how I look in the first picture that I'm attaching to this post (obviously, without the ridiculous looking mentalis strain because here I'm forcing my lips to close - this is a selfie without any 'special effects').

So, I want the lower part of my jaw / chin to come a bit forward and upward. At this point I have absolutely no idea if this is surgically possible. The second picture shows my teeth / jaws as they are now.

What I DON'T want is: tooth extraction, flat face, long face, long and sad looking philtrum, 'man-like' lower jaw, protruding chin.

Now I just need to find out if this is at all possible or not, and if so, who would be the best person to do it.

Well, if you recall what I said in my early prior post, I mentioned that there are plenty of people walking around with a facial imbalance where having one can 'blend in'. Also there are those who are 'attached' in some way to their imbalance where they will mourn the loss of an imbalance once it is improved. What I can tell you from the frontal view (and your statements) is that it looks like you have an imbalance BUT you are attached to it and quite possibly enough that you would find something 'wrong' with an improvement even if it made something 'right'.

I'm not going to do a full or complex analysis here. Just a basic one having to do with proportional division of '1/3rds' to describe the basic imbalance.

1: Your lower '1/3rd' is shorter than the 2 upper 1/3rds.

2: The shortness can be isolated to the lower jaw.

3: There is also narrowness to the lower jaw area relative to the prominence of the cheeks (yellow diagonals).

Since BOTH the shortness of the lower jaw area AND it's narrowness is a direct function of the lower jaw RECEDING into the background, better balance would be achieved by bringing it MORE into the FOREGROUND. In terms of aesthetics, a better FRAME for the upper 2/3rds and the 'long' distance from the base of the nose to the (red) line that passes through the closing of the lips would be one that brought the lower jaw (and chin) area MORE into the foreground. In terms of surgery to do that, it would relate to a BSSO and possibly some chin augmentation. That would be in addition to reducing the Vertical Maxillary Excess via anterior impaction of the maxilla.

The issue here is that you have an imbalance that can be seen from the front which could be improved by giving you a wider and longer 'frame' to the lower '1/3rd' of the face. BUT you are ATTACHED to it. So, if a doctor corrected that imbalance, you would probably have what is called 'locus of identity' issues which is when one is ATTACHED to an imbalance and mourn it's loss once it's corrected. That is to say, attributing the imbalance to looking 'feminine' would very well result in your attributing correction of it to looking 'masculine' or 'protrusive'.

So, you would have to find a surgeon who is more 'sensitive' to your attachment to your imbalance than one that is honed into optimizing or maximizing aesthetic balance.

[GJ]

In that photo there appears to be a yaw, too.
This is difficult to address.

Agree with Kavan's analysis. To me your face looks short in all the photos posted, and it's most likely due to the lower third being shorter. Impacting and shortening that even more might be very bad. That's what I was trying to warn against. It's possible it would look good, though. Honestly, I can't envision it. But my gut in shortening an already short face is tread lightly. 

[kavan]

In that photo there appears to be a yaw, too.
This is difficult to address.

Agree with Kavan's analysis. To me your face looks short in all the photos posted, and it's most likely due to the lower third being shorter. Impacting and shortening that even more might be very bad. That's what I was trying to warn against. It's possible it would look good, though. Honestly, I can't envision it. But my gut in shortening an already short face is tread lightly.

Well, my analysis involves both a BSSO and chin displacement along with the impaction to address the VME.

Impaction is done to reduce VME. But after the impaction, the lower jaw can have some auto rotation to swing forward and up somewhat. THEN, after THAT, if it's brought MORE forward (more into the FOREGROUND with a BSSO, it will 'cast' WIDER in frontal view and a little longer to offset both the narrowness to the lower '1/3rd' and the shortness. The chin, itself, could also be brought more into the foreground with a forward and down displacement (oblique genio but not sliding) to further balance the relatively short lower 1/3rd. An oblique genio would tend to work (yes, it elongates) because you'd also be WIDENING the areas beside the chin by the BSSO bringing lower jaw more into foreground and also because some elongation would be needed to offset the length of the labial ledge area or what you call the 'philtral' area. That is because the lower 1/3 is further subdivided into 1/3rds where a LONGER distance between where the lips close and the base of the chin would be needed to offset the long distance between subnasa and the closing of lips.

Some of the shortness to the lower 1/3rd is directly attributed to the recession of the mandible as is the narrowness. But the other shortness that the eye picks up is due to the excess length of the labial ledge area (long upper lip) which could be offset by the oblique genio (genio that brings forward but also elongates for which a bone buttress material needs to be put in between the cuts).

The CCW impaction that WOULD address the VME could also make her lower 1/3rd cast shorter IF done as SINGLE JAW surgery. But doing BOTH the BSSO and oblique genio WITH IT would tend to give better balance and most certainly offset imbalance that could arise from SINGLE (upper) jaw surgery.

[GJ]

Yeah. But since she doesn't want a masculine jaw, that rules out BSSO unless it's extremely conservative. BSSO with rotation would give her an "anchorwoman jaw." She can get some of that rotation and projection via the impaction, and it would be mild (likely keep some femininity) and with less risk to her nerves. If it's not enough, rotate the chin forward and down as well, as you mentioned, in a follow up procedure. I don't see her coming out of it remaining feminine with BSSO, though, and I don't see her face as overly narrow -- it looks within norms. But I admit, this is a really hard case due to the shortness of the lower 3rd, and I can't envision the end result of double jaw on her. So, maybe what you recommend is the correct plan. I'm skeptical she even needs surgery so I have bias here. Best thing is to probably get three plans from surgeons with a good reputations, and then post those plans.

[kavan]

Yeah. But since she doesn't want a masculine jaw, that rules out BSSO unless it's extremely conservative. BSSO with rotation would give her an "anchorwoman jaw." She can get some of that rotation and projection via the impaction, and it would be mild (likely keep some femininity) and with less risk to her nerves. If it's not enough, rotate the chin forward and down as well, as you mentioned, in a follow up procedure. I don't see her coming out of it remaining feminine with BSSO, though, and I don't see her face as overly narrow -- it looks within norms. But I admit, this is a really hard case due to the shortness of the lower 3rd, and I can't envision the end result of double jaw on her. So, maybe what you recommend is the correct plan. I'm skeptical she even needs surgery so I have bias here. Best thing is to probably get three plans from surgeons with a good reputations, and then post those plans.

A BSSO doesn't patently give a female a 'masculine jaw'. Not if it's done in accordance to guidelines for females which DIFFER from guidelines for males where the male jaw is absolutely more forward and wider than the female jaw.  However, the PERCEPTION of a 'masculine jaw' could arise from an ATTACHMENT to the jaw being recessed or retrusive as it is. That is to say if she's attached to the (faulty) concept of: 'A recessive jaw is therefore feminine.', that's the type of attachment that would result in the PERCEPTION of it looking 'masculine' EVEN IF the BSSO was conservative and done in accordance with guidelines for female (recessive) lower jaws.

 Her jaw looks recessive from the front because it RECEDES into the background. (Because it is recessive.) If that's hard to 'see', the profile view shows it better. It's recessive RELATIVE to her upper 2/3rds which are more in the foreground.

So, the reason not to get a surgery wouldn't be because a BSSO would make her look more 'masculine'. The reason not to get a surgery would be because she IDENTIFIES with the imbalance or does not perceive as imbalance. 'Rotating' her chin forward and down (it's not a rotation, it's a linear diagonally downward displacement) in the ABSENCE of a BSSO (that would also visually widen the lower face somewhat) could look like a pointy chin in the absence of also bringing the lower jaw more in the foreground.

Basically, my eye 'sees' the imbalance of the front. But as I said in one of my earlier posts on this string, there are plenty of people walking around with jaw imbalance and enough so there is no impending 'need' for each person having one to have surgery to correct. Some people want to maximize or optimize correction of imbalances and some don't.

Let's just say that the face in the photo has an imbalance to the lower 1/3rd that would veer toward better balance by the displacements I mentioned. However the PERSON who possesses the face would have to WANT to DETACH from the imbalance to justify surgery. If instead, they are ATTACHED to the imbalance and don't want to detach, then no surgery at all would be the conservative choice.

[InvisalignOnly]

Dear Kavan and GJ, I am so grateful to both of you for the long analysis, and also this was the first time I felt I could actually understand everything you wrote so I'm feeling a bit more in control of the whole process. I will read it all a few more times and try to process it. The German doctor I spoke to was trying to explain stuff about the 1/3 measurements but it was difficult to follow on a video call, I understand it much better now.

I have video consultations coming up with Dr. A in Spain and Dr. D in Belgium within the next 3 weeks, and a couple of others (UK, France). I doubt that I will get detailed plans from them though - at least the ones I spoke to so far said they had to see me and get measurements done to be able to prepare a detailed plan, even though someone has just asked if I could get a full face CBCT done here and send it to him so I'm in search of a hospital that can do that where I live. Will post updates.

[InvisalignOnly]

Update: so I had a few more consultations and only have one more scheduled, with Dr A in Spain. So far there are two surgeons I am seriously considering and as usual, they have quite different views on how to fix my face.

Dr D from Belgium is confident that I need Le Fort 1 plus BSSO and genioplasty. He says all three are needed and in addition, he also suggested paranasal augmentation with medpore plus PEEK cheek bone augmentation (all in one operation). It never crossed my mind before to use any implants but he sounded quite convincing.

The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.

I stressed it to him that I'm worried about nasal changes and looking older after Le Fort 1 and he kept saying and included in his written recommendation as well that all things considered, the Le Fort would give me the best aesthetic result.

Now there is a British surgeon I've been talking to that made a great impression on me, and he told me that it would not be a good idea to touch my maxilla at all and I would get the best and safest outcome from orthodontics, mandibular advancement and / or genioplasty. He says that my gummy smile is not bad at all and I am getting to that critical age when my upper lip will start 'sinking' and I will be happy I have a gummy smile and tooth show. Which sounds great and I would be so glad and relieved to avoid Le Fort 1, on the other hand though, I cannot imagine ever being happy about my tooth show as honestly, it is just way too much and if I get it 'corrected' by orthodontics, my teeth will still be visible, only they will be inclined backward.

Right now I am really in two minds, both plans are really tempting to me in different ways. I feel very comfortable with the British surgeon, he was very honest with me about the risks and did not try to 'sell' me anything, quite the opposite in fact. He is well qualified and experienced and was very confident saying just moving the lower part forward would be a great improvement and we would avoid the risks associated with messing with the maxilla. His plan is lower risk, but potentially also 'lower gain'.

If Dr D's plan works out, I believe I would end up looking a lot better than now, and probably better than if I go with the British doctor's plan. On the other hand there are a lot more things that can go wrong, medically and aesthetically. It really is like gambling. Does anybody think the plan of moving the lower part only (with or without genio) can actually be a good one, including from the aesthetic point of view?

[kavan]

Update: so I had a few more consultations and only have one more scheduled, with Dr A in Spain. So far there are two surgeons I am seriously considering and as usual, they have quite different views on how to fix my face.

Dr D from Belgium is confident that I need Le Fort 1 plus BSSO and genioplasty. He says all three are needed and in addition, he also suggested paranasal augmentation with medpore plus PEEK cheek bone augmentation (all in one operation). It never crossed my mind before to use any implants but he sounded quite convincing.

The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.

I stressed it to him that I'm worried about nasal changes and looking older after Le Fort 1 and he kept saying and included in his written recommendation as well that all things considered, the Le Fort would give me the best aesthetic result.

Now there is a British surgeon I've been talking to that made a great impression on me, and he told me that it would not be a good idea to touch my maxilla at all and I would get the best and safest outcome from orthodontics, mandibular advancement and / or genioplasty. He says that my gummy smile is not bad at all and I am getting to that critical age when my upper lip will start 'sinking' and I will be happy I have a gummy smile and tooth show. Which sounds great and I would be so glad and relieved to avoid Le Fort 1, on the other hand though, I cannot imagine ever being happy about my tooth show as honestly, it is just way too much and if I get it 'corrected' by orthodontics, my teeth will still be visible, only they will be inclined backward.

Right now I am really in two minds, both plans are really tempting to me in different ways. I feel very comfortable with the British surgeon, he was very honest with me about the risks and did not try to 'sell' me anything, quite the opposite in fact. He is well qualified and experienced and was very confident saying just moving the lower part forward would be a great improvement and we would avoid the risks associated with messing with the maxilla. His plan is lower risk, but potentially also 'lower gain'.

If Dr D's plan works out, I believe I would end up looking a lot better than now, and probably better than if I go with the British doctor's plan. On the other hand there are a lot more things that can go wrong, medically and aesthetically. It really is like gambling. Does anybody think the plan of moving the lower part only (with or without genio) can actually be a good one, including from the aesthetic point of view?

'intrusion' usually refers to jamming the teeth up into the aveolar part of jaw bone via appliances to do so. Since a Lefort 1 is mentioned, it probably refers to impaction. In essence addressing too much upper front teeth show and also some protrusion. Sounds like that part addresses part of your face that bothers you most. BSSO and genio would address lower jaw/chin retrusion. He could be up-selling the implant suggestion. Would depend on how convincing he was vs. your own observations. The paranasals could be to potentially offset changes to the nose base by pushing back the maxilla in light of your apprehensions.

As to British doctor, you can lose some lip support when the teeth are pushed backwards. The upper lip can look longer if it's inclined along a vertical plane. Diagonal flare out of upper teeth makes it look shorter from the front.

[april]

Hoping Dr A will help clear things up because there doesn't seem to be too much consensus on what should be done. Have all these consults been these online/phone consults, or have you seen any in person?

The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.

I could be wrong, but if he wants to move things backwards then it sounds like he may think you have bimaxillary dental protrusion (which you may have - your teeth are pretty protrusive!!). What is a alveolar segment osteotomy for the lower jaw - did he explain? Will it move your teeth back or forward?

I came across this video, could alveolar segment osteotomy be something like this on lower jaw? https://youtu.be/ddIXs2eZCaM (although I have no idea how that'd work on you specifically, so I might be way off)

[kavan]

Hoping Dr A will help clear things up because there doesn't seem to be too much consensus on what should be done. Have all these consults been these online/phone consults, or have you seen any in person?

I could be wrong, but if he wants to move things backwards then it sounds like he may think you have bimaxillary dental protrusion (which you may have - your teeth are pretty protrusive!!). What is a alveolar segment osteotomy for the lower jaw - did he explain? Will it move your teeth back or forward?

I came across this video, could alveolar segment osteotomy be something like this on lower jaw? https://youtu.be/ddIXs2eZCaM (although I have no idea how that'd work on you specifically, so I might be way off)

Yes. That's what it is.

[InvisalignOnly]

Hoping Dr A will help clear things up because there doesn't seem to be too much consensus on what should be done. Have all these consults been these online/phone consults, or have you seen any in person?
What is a alveolar segment osteotomy for the lower jaw - did he explain? Will it move your teeth back or forward?

These recent consults have been over Skype (they got my x-rays and several photographs beforehand and saw me on video) but over the last twenty-odd years, I also consulted surgeons and orthos in person and it was my experience that they always tell me different things (bimax, top jaw surgery only, bottom only, pull teeth from top, from bottom, from both, do nothing, get a chin implant, etc. etc. - I got told all these in person before). I think the issue is that whatever is done, I might lose some of my good features along with the bad, at least that's the impression I get. I'm in the process of trying to get CBCT done and will try to arrange some personal consultations before finalizing plans but right now I can't travel because of my work.

Re: alveolar segment osteotomy, yes he explained very well and showed it to me on a model. My lower front teeth are currently proclined and instead of asking me to wear braces for several months to straigthen them, he is planning to extract teeth during / just before the operation and reposition the six lower front teeth so they'll be straight and in a different position. It's pretty much what you see in the video you posted, but only in the lower jaw. He would also bring the lower jaw forward along with it, plus do a genio.

[Dogmatix]

These recent consults have been over Skype (they got my x-rays and several photographs beforehand and saw me on video) but over the last twenty-odd years, I also consulted surgeons and orthos in person and it was my experience that they always tell me different things (bimax, top jaw surgery only, bottom only, pull teeth from top, from bottom, from both, do nothing, get a chin implant, etc. etc. - I got told all these in person before). I think the issue is that whatever is done, I might lose some of my good features along with the bad, at least that's the impression I get. I'm in the process of trying to get CBCT done and will try to arrange some personal consultations before finalizing plans but right now I can't travel because of my work.

Yes, this is a good insight.
Some things are absolute when designing a treatment, and some things are opinions, preferences etc. Treating narrow airways is absolute, you can see them on the x-ray and after surgery you can do a new scan and see what you achieved. Oclussion of the bite is also absolute, you can see if the bite fits and if the function is good etc.

There can how ever be several configurations that yield such results and when having aesthetic concerns it can be very subjective. The more degree of freedome you add to your treatment, the more configurations are possible. Doing treatment with only braces don't have so much degree of freedome, you're limited to tha plasticity of the alveolar bone. Extracting teeth, cutting the jaws, segmentating the jaws, implants and so forth opens a lot of posibility to different configurations. It is also as you say,  you can never come with a picture of someone else and say you want to look like that. You bring the bone structure and tissue and the surgeon will do the best they can figure out and it will be some trades.

Hopefully all proposed treatments meet the absolute surgey goals. Good function. Some surgeons are very restrictive and won't do anything more than what's absolutely necessary. They know about the risk of complications and every cut adds complexity and risk. Also it's often a requirement within the health care system that they only offer to treat the diagnosis and to do it in a cost efficient way even if a more fancy and aesthetic pleasing solution is possible. On the other hand there are more bold surgeons who seem to always do double jaw surgery and segmentations.

I don't answer a lot of question, but on the other hand you didn't ask any question. But just confirm that jaw surgery is not an easy fix and you need to go through the proposals you got and try to figure out what makes sense to you. Is it an option to not do anything? Yes/no? Can you isolate your concern in a way where an implant would solve your concern? Etc and try to narrow down where you're heading. Hopefully that can narrow it down to understand what you want. You need to be confident before signing up for something like this, it's a long and big process.

A lot of us reject extractions categorically, but also the most common extraction case is alternative treatments to overbite to avoid surgery when it's motivated. I don't know what it looks like in your case, but look into so it really make sense before extracting teeth.

Lastly. I saw you wrote in another thread that you look significantly different from the norm. It's a scientific fact that anyone is unable to evaluate their own appearance objectively. I think you can ask anyone in here and they'll tell you that they have the worst case. If we were able to swap cases on the forum, the need for surgery would probably go down.

[Dogmatix]

The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.

Suggesting surgery first give the impression of wanting to get you into and out of the surgery room as soon as possible. Orthodontic preparation always give most predictive result. If the teeth are already in a good position, it shouldn't need much adjustments any way and it wouldn't fall under the surgery first approach. SF differs from normal protocol in the sense that the anticipated movements are scheduled after the surgery instead of before. If there are no anticipated movements, then it's just surgery. First anticipate that there is a switch in order from conventional treatment and switching the order can affect the predictability and it's ultimately the orthodontist that decides when it's sensible sending you to surgery, as they're the ones that are handling the case after.

[InvisalignOnly]

There can how ever be several configurations that yield such results and when having aesthetic concerns it can be very subjective.

Hopefully all proposed treatments meet the absolute surgey goals. Good function.

Lastly. I saw you wrote in another thread that you look significantly different from the norm. It's a scientific fact that anyone is unable to evaluate their own appearance objectively. I think you can ask anyone in here and they'll tell you that they have the worst case. If we were able to swap cases on the forum, the need for surgery would probably go down.

Thanks so much for your thoughtful response! The thing is, I do not have any functional problems - I wonder how many people on this forum really do? I can eat and speak completely normally, several of my teeth meet at the back and I do not have any pain anywhere. I started having breathing problems recently but I do not have any proof that this is related to my jaws / bite, or that jaw surgery would address that issue.

At this stage, I mostly just want to get surgery to improve my looks. I do not 'subjectively' feel ugly or anything and I get a lot of positive feedback from people about my current looks, but it's a fact I look different, something like an older version of the girl in the article with the teeth sticking out: https://www.daytonfacialsurgery.com/procedures/jaw-surgery/. I definitely do not think my case is really bad or the 'worst', but I definitely have the kind of class 2 bite that is quite noticable to a lay person, especially because of the vertical maxillary excess.

At the same time I'm quite worried about any surgery making my looks worse, not better, on top of all the potential complications, pain, numbness and so on. For example the 'after' pictures of this particular girl look horrifying to me and this is not the first time I see a really bad result for this type of surgery (and I am sure that the really bad ones never make it to the internet so I can only imagine how common it is for people to end up looking worse than before). Anyway, I really don't know what to do.

[InvisalignOnly]

Suggesting surgery first give the impression of wanting to get you into and out of the surgery room as soon as possible. Orthodontic preparation always give most predictive result. If the teeth are already in a good position, it shouldn't need much adjustments any way and it wouldn't fall under the surgery first approach.

He said I'd need braces for about 6 weeks in total, mostly during and after surgery. I had braces several years ago and have straight teeth. I believe that wearing braces before the surgery is a relatively new practice and they originally used to do surgery first and then braces, and that's still the case in some countries, especially in Asia. I might be wrong but I personally feel that in many cases Western doctors are really overdoing it with the orthodontics. We can read about several cases on forums where people had braces on for years before surgery and things still went wrong - anyway, just my two cents.