Genioplasty - yes or no?

[Dogmatix]

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.

I often use quotes around words like "need" and "normal". There are a lot of norms on everything that can be meassured on a person. Actually, if you calculate the probability of being inside the norm on many enough meassurements, it's more normal to not be. Norms are calculated by taking the mean value of a random population and looking at the standard deviation. A standard deviation is where 68% of a random population fits. The probability for a random person to be within +-one standard deviation on 2 unrelated measurements, is 0.68^2 = 46%. More probable to not be. Sometimes you use +-2 standard deviations that is 95% or other cut off, but you get the point. However, meassurements when looking at a specific area are not unrelated. If there's a big enough imbalance in the jaws the values are correlated.

It also depends what you mean with need. People lived before surgery was available. There are different clinical criterions when surgery is covered by health care system or insurances. It effectively treats OSA, bite problems can lead to decay in different ways. I personally think aesthetic concerns can be as valid as any as long as you understand the surgery. Aesthetics is definitely one thing that adds up for me when deciding, but also function and aesthetics are often correlated. What is considered aesthetic is normally when things look healthy. Hopefully most surgieries meet the objective of why they're carried out and I don't know who is to judge what is needed except the person having the surgery.

If you don't think the girl on the top on the link you posted have a great improvement, you shouldn't get into jaw surgery. I can't tell if it's the best plan, but a significant aesthetic improvement.

[Dogmatix]

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.

This article have a good summary of orthognatic approach and how it has evolved.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314839/

Presurgical orthodontic preparation was uncommon for patients requiring orthognathic surgery until the 1960's. The patients' and clinicians' desire for optimal esthetic and occlusal results led to the most common current treatment approach presurgical orthodontic decompensation of the occlusal relationships and attainment of normal dental alignment. The disadvantage of having orthodontic interventions both before and after orthognathic surgery include a long treatment time of 7–47 months, dental caries, gingival recession and root resorption.[1,2] Other complications associated with preoperative orthodontic treatment are temporary worsening of facial appearance and masticatory discomfort. When a patient refuses surgery after all the preparations have been made, the results can be catastrophic. Ever since the first orthognathic surgery procedure was performed by Hullihen in 1848, many new techniques and methods have been introduced.[3] As shown by Kondo and Aoba the limits of orthodontic treatment alone to severe malocclusions are broadening, but the underlying skeletal imbalances remain.[4,5] Brachvogel et al.[6] in 1991 proposed concept of “surgery-first and orthodontics second” with the goal of reducing some of the disadvantages and inconveniences of presurgical orthodontics. He claimed that the normalized surrounding soft tissues (lips, cheeks and tongue) settled teeth into better positions after surgery, facilitating remaining orthodontic tooth movement and reducing the total orthodontic treatment period.

Nowadays, the concept of surgery-first followed by orthodontic treatment is applied to orthognathic surgery cases in orthodontic centers in Korea, Japan and Taiwan. This concept and technique are called “surgery-first-orthognathic-approach” or “surgery-first approach” (SFA).

In modern treatment it has definitely been the most common approach with orthodontic preparation and only few cases with surgery first. The article says that before 1960 they apparently did it but then switched to the normal approach of orthodontic preparations. Now it has started to come back again, with all technology and stressed society we live in. Surgery today is more advanced and they can predict a lot better with digital models etc than they could 1960. But the fact remains, doing surgery first includes making assumptions and guessing, while orthodontic preparation aims to have the teeth in final position so the surgeon have no excuse to find the occlusion. Even with surgery first, they bond the braces before surgery if they gonna use braces after, so they can use it as anchorage for elastics and guidance during surgery.

[kavan]

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.

If you can't make a decision about maxfax and instead be in a state of perpetual indecision the more consults you go on, then what stops you from just ISOLATING the part that directly addresses the bimax protrusion? You could get the same segmental osteotomy on the UPPER jaw to reduce protrusion there too. Also maybe a little bit of the upper segment, which is excess alveolar process, could also be reduced vertically instead of getting the entire lefort to push that area backwards along with suggestion of paranasals to help support the nose area that can change a bit from that. If they can't reduce the alveolar excess with that (which I think they can), then you can get excess upper tooth show reduced by reducing the length of the teeth (shaving them down).

That would allow you to look at your face with the KEY areas that bother you GONE and later decide if you wanted the other things maxfax could do or if you just wanted to leave stuff alone.

[InvisalignOnly]

You could get the same segmental osteotomy on the UPPER jaw to reduce protrusion there too. Also maybe a little bit of the upper segment, which is excess alveolar process, could also be reduced vertically instead of getting the entire lefort to push that area backwards along with suggestion of paranasals to help support the nose area that can change a bit from that. If they can't reduce the alveolar excess with that (which I think they can), then you can get excess upper tooth show reduced by reducing the length of the teeth (shaving them down). That would allow you to look at your face with the KEY areas that bother you GONE and later decide if you wanted the other things maxfax could do or if you just wanted to leave stuff alone.

I had no idea this was an option! Sounds great to me, will start doing more research in this direction. I am now getting to the point where I kind of understand what my dilemma is - the 'teeth sticking out' bothers me the most but the classic solution to that - Le Fort 1 - is what scares me most about the surgery. So I'll have to see if there's an alternative, will definitely look into what you suggest here.

[InvisalignOnly]

If you don't think the girl on the top on the link you posted have a great improvement, you shouldn't get into jaw surgery. I can't tell if it's the best plan, but a significant aesthetic improvement.

I am not going to start an argument about this but I showed those photos to two of my friends just to check whether it's just me and they both agreed she looked terrible after the surgery; I honestly don't think many people would say it was an improvement in any ways, let alone 'significant', with the obvious asymmetry, horrific witch chin, weird nose area and so on. I don't think that my opinion on this is a reason for me not to have jaw surgery, however, as I have seen many before and after pictures where people had a great improvement but this was definitely not one of those.

[PloskoPlus]

I had no idea this was an option! Sounds great to me, will start doing more research in this direction. I am now getting to the point where I kind of understand what my dilemma is - the 'teeth sticking out' bothers me the most but the classic solution to that - Le Fort 1 - is what scares me most about the surgery. So I'll have to see if there's an alternative, will definitely look into what you suggest here.

AFAIR, botox can be used to reduce gum show.

[InvisalignOnly]

AFAIR, botox can be used to reduce gum show.

Thanks for the tip! I actually tried that once before and it did work to an extent. Also, it was suggested to me to try lip fillers in my upper lip to make it heavier and cover more teeth (my upper lip is quite thin). I decided to leave both botox and fillers for the time being while I'm doing consultations so that doctors can see what I naturally look like, but my back up plan is just camouflage orthodontics, botox and fillers (in case I decide not to go through with the surgery).

[InvisalignOnly]

Even with surgery first, they bond the braces before surgery if they gonna use braces after, so they can use it as anchorage for elastics and guidance during surgery.

Yes, Dr D said they'd put on braces just before surgery, then use them after surgery to finalize the bite.

[ben from UK]

If you don't think the girl on the top on the link you posted have a great improvement, you shouldn't get into jaw surgery. I can't tell if it's the best plan, but a significant aesthetic improvement.

I noticed you have a strange taste before. The girl went down at least 1 point due to longer philtrum, upturned nose with visible nostrils and long pointy chin. She's still not ugly cause she had a good base, but this was not a succesfull procedure imo. Only her sideprofile was improved, but profile is overrated. Some people change the front of the face negatively, only to improve a minor profile flaw.

By fhe way, I'd like to see more female surgeons to see if they are better than men. Too many male surgeons fck up too much. Most of the times females are more precise and you need precision with this. But maybe it turns out women aren't better cosmetic surgeons and then we can close that chapter.

[InvisalignOnly]

I noticed you have a strange taste before. The girl went down at least 1 point due to longer philtrum, upturned nose with visible nostrils and long pointy chin. She's still not ugly cause she had a good base, but this was not a succesfull procedure imo.

I am not saying she is ugly, what I'm saying is she looks worse after the surgery instead of looking better. I can't quantify it as in it's one point or two or three, but compared to herself she looks worse, which is a devastating result when you go through serious surgery like this mainly to make yourself look better. Of course, she still looks nice in the after picture compared to a lot of other people, but not compared to her previous self. Even though, as you say, she had a good base so I'd have expected her to look way better after.

[kavan]

I noticed you have a strange taste before. The girl went down at least 1 point due to longer philtrum, upturned nose with visible nostrils and long pointy chin. She's still not ugly cause she had a good base, but this was not a succesfull procedure imo. Only her sideprofile was improved, but profile is overrated. Some people change the front of the face negatively, only to improve a minor profile flaw.

By fhe way, I'd like to see more female surgeons to see if they are better than men. Too many male surgeons fck up too much. Most of the times females are more precise and you need precision with this. But maybe it turns out women aren't better cosmetic surgeons and then we can close that chapter.

I think Dogmatix is just telling her that her reactions to the outcome are enough where she shouldn't get surgery. It doesn't matter whether he likes it or not or what his tastes are. What matters is her reaction to it is sufficient information for him to tell her; 'then don't get jaw surgery'.

[kavan]

I had no idea this was an option! Sounds great to me, will start doing more research in this direction. I am now getting to the point where I kind of understand what my dilemma is - the 'teeth sticking out' bothers me the most but the classic solution to that - Le Fort 1 - is what scares me most about the surgery. So I'll have to see if there's an alternative, will definitely look into what you suggest here.

he video certainly showed BOTH areas of the bimax protrusion being addressed via the segmental osteo. Here's a link to the maxillary one:

https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAx8jfULsh0VAdAsNSU!/?approach=&bone=CMF&classification=95b-Maxilla%2C%20Sagittal&contentUrl=srg%2F95b%2F05-RedFix%2FP400-SubapicOst%2F03_AntMaxOst.enl.jsp&implantstype=Subapical%20(Block)%20osteotomy&method=Maxillary%20prognathism&redfix_url=1340280307204&segment=Orthognathic&showPage=redfix&soloState=lb&step=3&subStep=11&treatment=

[Dogmatix]

I think Dogmatix is just telling her that her reactions to the outcome are enough where she shouldn't get surgery. It doesn't matter whether he likes it or not or what his tastes are. What matters is her reaction to it is sufficient information for him to tell her; 'then don't get jaw surgery'.

Yes. I think this discussion is way out of line and below anything I can participate in. Imagine if this beautiful girl were to come and read some of these comments, where we don't even have all the records to know anything about the situation. It also demonstrates not being able to understand the complexity of surgery and I see a big risk getting into this, if this is how the outcome is being evaluated.

[InvisalignOnly]

Yes. I think this discussion is way out of line and below anything I can participate in. Imagine if this beautiful girl were to come and read some of these comments, where we don't even have all the records to know anything about the situation. It also demonstrates not being able to understand the complexity of surgery and I see a big risk getting into this, if this is how the outcome is being evaluated.

Funny how nobody objected on other threads where everyone was going on and on about how jaw surgery and implants made some guys' faces less attractive than before, illustrated with real people's photos. Maybe it's because most posters there were male, it's ok for them to say another guy looks worse after surgery, but if I point out that a woman looks objectively worse, then I'm the problem and don't understand the 'complexity' of the surgery etc.? OK, I will drop it and keep my opinion to myself from now on.

[Dogmatix]

Funny how nobody objected on other threads where everyone was going on and on about how jaw surgery and implants made some guys' faces less attractive than before, illustrated with real people's photos. Maybe it's because most posters there were male, it's ok for them to say another guy looks worse after surgery, but if I point out that a woman looks objectively worse, then I'm the problem and don't understand the 'complexity' of the surgery etc.? OK, I will drop it and keep my opinion to myself from now on.

I'm not a moderator or have any obligation to object any where, I only represent my self and don't read every discussion on the board.
I have no problem discussing aesthetic preferences and different opinions of what they want. Continiously judging someone elses result as "terrible", "horrific", "weird", "She looks so so so f@cked up" etc is not a constructive discussion and just disrespectful. A constructive discussion would resolve to asking about the result, if it would be possible to handle it in an other way and try to understand the displacements and tradeoffs being made. You also jump back and forth between "having very, very serious second thoughts" and argumenting that you don't. With all respect, I just don't think you're ready for this, there's a very big chance you'll wake up after surgery being devestated and psychologically in big trouble.