bimax vs bsso

[kavan]

In my opinion, his occlusal plane is (looks) steep enough that only a bimax will be able to achieve the optimal result.  If he will ultimately get a bimax, I think he should do that first since CCW rotation will impact the nose independent of any ANS shaving.  My fear is that he gets a good rhino and then has to revise it because the bimax changed his nose.

Also, I feel as though jaw surgery will set the 'canvas' for his face to which the rhino can be tailored.  I.e, I think he should get the jaw in the right place first and then detail the nose to fit his new face.  The nose will play little role in BSSO planning whereas the jaw might impact aesthetic planning for the nose.

Edit: UNLESS the OP is happy with the morph from the rhino doc, which is a perfectly acceptable face.

A protrusive ANS if NOT cut down during the surgery would tend to limit maxilla advancement even if only a few mms were needed in the process of CCW rotation and BSSO advancement. That is to say, it could pose a limit of 0 maxillary advancement which in turn would limit mandible advancement.

Thing is if it's cut down during the surgery, OTHER rhino techniques would have to be used with it, lest resultant nose aesthetics would not look good.

See my post on here about the TVL used in planning a bimax CCW surgery.

The top CCW docs are not known for rhinoplasties. Just for some adjustments to compensate for maxillary advancements. There was a case a few years back where Alfaro did a rather significant CCW posterior downgraft BIMAX advancement which looked great EXCEPT for the NOSE. He had to remove part of the ANS to get the jaw balance. But the nose tip drooped down with that and the nose suffered. It was a situation where Alfaro was not really versed in doing the rest of the rhinoplasty that would have had to go with the ANS cut down.

Moral of story: An ANS cut down had to be done for the BIMAX advancement (and that was WITH CCW downgraft). But he, a top maxfax, didn't do the rest of the rhino needed with the ANS cut down.

IMO, a 'good' maxfax probably would cut down his ANS during the bimax CCW surgery. But I'm not too sure that they would be good at doing all the rhino techniques with that to make the nose good. I tend to think that a maxfax would have an easier time balancing the jaws if they didn't have to worry about thier limitations to do a good rhino along with balancing the jaws.

[Post bimax]

A protrusive ANS if NOT cut down during the surgery would tend to limit maxilla advancement even if only a few mms were needed in the process of CCW rotation and BSSO advancement. That is to say, it could pose a limit of 0 maxillary advancement which in turn would limit mandible advancement.

Thing is if it's cut down during the surgery, OTHER rhino techniques would have to be used with it, lest resultant nose aesthetics would not look good.

See my post on here about the TVL used in planning a bimax CCW surgery.

The top CCW docs are not known for rhinoplasties. Just for some adjustments to compensate for maxillary advancements. There was a case a few years back where Alfaro did a rather significant CCW posterior downgraft BIMAX advancement which looked great EXCEPT for the NOSE. He had to remove part of the ANS to get the jaw balance. But the nose tip drooped down with that and the nose suffered. It was a situation where Alfaro was not really versed in doing the rest of the rhinoplasty that would have had to go with the ANS cut down.

Moral of story: An ANS cut down had to be done for the BIMAX advancement (and that was WITH CCW downgraft). But he, a top maxfax, didn't do the rest of the rhino needed with the ANS cut down.

IMO, a 'good' maxfax probably would cut down his ANS during the bimax CCW surgery. But I'm not too sure that they would be good at doing all the rhino techniques with that to make the nose good. I tend to think that a maxfax would have an easier time balancing the jaws if they didn't have to worry about thier limitations to do a good rhino along with balancing the jaws.

Ok, I see what you're saying.  I didn't think about the relationship between the ANS and TVL with regard to planning.  In the cases with prominent ANS then, it might be preferable to perform the rhino first and then bimax based on the new ANS position.

Alternatively, I suppose it's possible to ask the maxfac to plan the procedure around where the ANS 'should' be after the rhino (blue line on your diagram).  Presumably this could make the final nose result more predictable by having the detail work done after the bimax movement.  This assumes OP actually wants a bimax and would also require close coordination between the maxfac and rhino surgeon.

[kavan]

Ok, I see what you're saying.  I didn't think about the relationship between the ANS and TVL with regard to planning.  In the cases with prominent ANS then, it might be preferable to perform the rhino first and then bimax based on the new ANS position.

  Yes. That's what I'm saying.

Alternatively, I suppose it's possible to ask the maxfac to plan the procedure around where the ANS 'should' be after the rhino (blue line on your diagram).  Presumably this could make the final nose result more predictable by having the detail work done after the bimax movement.  This assumes OP actually wants a bimax and would also require close coordination between the maxfac and rhino surgeon.

That could leave the maxfax result looking terrible if they had to advance the maxilla. So could cutting the ANS during the surgery and telling him to get a rhino later.  He could be stuck with about a year's worth of very WONKY face.  He could get the rhino first and tell the doctor to give him a neutral to slightly downwardly rotated tip position. In that way, if the bimax includes a few mms forward advance to maxilla, the tip won't take on an overly upward rotation of the tip.  A neutral tip position and also a slight downward rotation of tip is within normative nose. But the rhino should not have upward tip rotation because then any advancement of maxilla will have that veer toward a less than optimal aesthetic for the nose.

[Post bimax]

That could leave the maxfax result looking terrible if they had to advance the maxilla. So could cutting the ANS during the surgery and telling him to get a rhino later.  He could be stuck with about a year's worth of very WONKY face.  He could get the rhino first and tell the doctor to give him a neutral to slightly downwardly rotated tip position. In that way, if the bimax includes a few mms forward advance to maxilla, the tip won't take on an overly upward rotation of the tip.  A neutral tip position and also a slight downward rotation of tip is within normative nose. But the rhino should not have upward tip rotation because then any advancement of maxilla will have that veer toward a less than optimal aesthetic for the nose.

That's true.  i was just considering what might be optimal for the final result.  I'm sensitive to the impact of the LF1 on nose appearance given the changes I had, even though my LF1 advancement was far beyond anything OP should consider.  It's one of the risks maxfacs should inform their patients of, but often don't.

[kavan]

That's true.  i was just considering what might be optimal for the final result.  I'm sensitive to the impact of the LF1 on nose appearance given the changes I had, even though my LF1 advancement was far beyond anything OP should consider.  It's one of the risks maxfacs should inform their patients of, but often don't.

I totally agree. They should tell them about the nose changes.

[lsubuilder]

Just had a consult with Alfaro. He was great answered all of my questions. He wants to do a bimax with ccw rotation. I asked about the prominent nasal spine. He said not to do anything and that he would cut below it so it would not be an issue. Also said he would do surgery first and theres a chance i dont need braces after at all since my bite is fine. 1.5 hour surgery time is crazy fast compared to here. Just waiting to see what the prize is on that. I have a consult with Gunson next week as well.

[Post bimax]

Just had a consult with Alfaro. He was great answered all of my questions. He wants to do a bimax with ccw rotation. I asked about the prominent nasal spine. He said not to do anything and that he would cut below it so it would not be an issue. Also said he would do surgery first and theres a chance i dont need braces after at all since my bite is fine. 1.5 hour surgery time is crazy fast compared to here. Just waiting to see what the prize is on that. I have a consult with Gunson next week as well.

Refer to reply #30 on this thread.  You need to be very careful about letting the maxfac entirely handle nose modifications.

[lsubuilder]

Yes i am concerned about that. He said my nasal spine looks prominent because my jaws are so recessed compared to it. He would cut around it and move everything else. Does that make sense to you? Ive never heard that before

[Post bimax]

Yes i am concerned about that. He said my nasal spine looks prominent because my jaws are so recessed compared to it. He would cut around it and move everything else. Does that make sense to you? Ive never heard that before

Sorry- I misread your earlier reply.  I thought you were saying he said not to worry and that he would cut it down.  That's what happens when you skim.

Typically the lefort 1 cut is above the ANS.  I'm not sure how he's going to do that.

[lsubuilder]

Its possible i misunderstood what he said. I will have to ask him again if i go forward

[Post bimax]

Its possible i misunderstood what he said. I will have to ask him again if i go forward

Here's a diagram of the standard lefort1 fracture: https://medicine.uiowa.edu/iowaprotocols/facial-fracture-management-handbook-lefort-fractures

As you can see, the fracture is above the ANS.  I'm not familiar with a lefort fracture that would leave the ANS in place.

[lsubuilder]

Thats what i thought. I told him i was worried about that moving forward and making my nose worse. Which is when he said he could cut around it. Ill have to get him to clarify.

[kavan]

Just had a consult with Alfaro. He was great answered all of my questions. He wants to do a bimax with ccw rotation. I asked about the prominent nasal spine. He said not to do anything and that he would cut below it so it would not be an issue. Also said he would do surgery first and theres a chance i dont need braces after at all since my bite is fine. 1.5 hour surgery time is crazy fast compared to here. Just waiting to see what the prize is on that. I have a consult with Gunson next week as well.

That's an admission that Alfaro can't do the rhino which would need to go with an ANS cut if he removed it during the surgery which is what I was saying in response #30.

[kavan]

Yes i am concerned about that. He said my nasal spine looks prominent because my jaws are so recessed compared to it. He would cut around it and move everything else. Does that make sense to you? Ive never heard that before

Your nasal spine 'looks' prominent because it IS prominent and your jaws would look LESS recessed by comparison if you had a deprojection rhino.

[kavan]

Thats what i thought. I told him i was worried about that moving forward and making my nose worse. Which is when he said he could cut around it. Ill have to get him to clarify.

Such a 'clarification' would show up in a surgical displacement diagram and READ OUT where the read-out section for the maxilla, under the category of 'ANS' displacements in the horizontal direction read ZERO, 0, nulla, ninch.