bimax vs bsso

[kavan]

From looking at your contour in the FLESH, it looks like you have an Anterior Nasal Spine that sticks out too much. Because the upper lip looks to be 'tethered' to an area at base of nose that is too far out which is a type of contour associated with the ANS* being too far out.

FRom looking at your ceph it looks like the green dot I marked as ANS COULD BE where your ANS is. I'm not entirely sure of 'exact' location which is why I put a question mark (?) to it. But what I've pretty sure of is that you have a prominent ANS, which gives appearance that your maxilla is overly forward. But it isn't. That is to say, you don't have an overly high SNA angle but the LOOK of the area looking too far forward relative to the lower jaw is most likely attributed to a very protrusive ANS.

The ANS can be CUT DOWN during a bimax surgery along with other rhinoplasty type adjustments. So, that very possibility will SHIFT you towards bimax and to a maxfax that has more tools in his tool box than the one you consulted with already.

As to exact location of ANS on your ceph, you would need to get a tracing of your ceph where dots were placed over the exact points.


*NOTE: ANS is abbreviation for Anterior Nasal Spine but NOT the angle formed by the landmark points; 'S', 'N' and 'A'. ANS is also a landmark point.

[lsubuilder]

Thanks for the advice everybody. I’m going to get consults with the surgeons mentioned. I’ve had a consult scheduled with randy Sanovich in Dallas but it got pushed back because of the virus. I don’t know much about him he was recommended by a friend. I unfortunately have to drive out there. Working on a consult with Gunson but his office wants a doctors referral which I don’t have.

I will definitely mention the ans. Always hated that and was told I’d need a rhinoplasty before I knew my jaws were the issue. Would be great if I could get that tethered look fixed. Maybe the surgeon I went to figured I didn’t need the upper jaw moved forward because of that?

[kavan]

Thanks for the advice everybody. I’m going to get consults with the surgeons mentioned. I’ve had a consult scheduled with randy Sanovich in Dallas but it got pushed back because of the virus. I don’t know much about him he was recommended by a friend. I unfortunately have to drive out there. Working on a consult with Gunson but his office wants a doctors referral which I don’t have.

I will definitely mention the ans. Always hated that and was told I’d need a rhinoplasty before I knew my jaws were the issue. Would be great if I could get that tethered look fixed. Maybe the surgeon I went to figured I didn’t need the upper jaw moved forward because of that?

That could have been a factor if he wasn't braced to do the rhino techniques that might have to be done when the ANS is cut down.

[PloskoPlus]

Thanks for the advice everybody. I’m going to get consults with the surgeons mentioned. I’ve had a consult scheduled with randy Sanovich in Dallas but it got pushed back because of the virus. I don’t know much about him he was recommended by a friend. I unfortunately have to drive out there. Working on a consult with Gunson but his office wants a doctors referral which I don’t have.

I will definitely mention the ans. Always hated that and was told I’d need a rhinoplasty before I knew my jaws were the issue. Would be great if I could get that tethered look fixed. Maybe the surgeon I went to figured I didn’t need the upper jaw moved forward because of that?

Another surgeon worth considering.

https://profilesofs.com/steven-sullivan

[kavan]

I also will add that what you have going on with the (suspected) EXCESS of the ANS is most certainly in rhinoplasty land. It would tend to explain why a rhinoplasty doctor told you the problem was with your nose. It's because it plays a significant role in making your upper jaw LOOK too far forward and thereby, RELATIVELY making the lower jaw look too far backward. So, it's not a thing where the problem is to your jaw/s INSTEAD of your nose. It's more of a thing where who ever does the jaw surgery will also need to be very competent in rhinoplasty.

As to the doctor you consulted with who wanted to do single jaw BSSO, it just seems unlikely that his overall preference (for a patient population) is single lower jaw surgery. That is to say, it doesn't make much sense to me that a maxfax would have much of a practice if he didn't perform BIMAX surgery. It's more likely he recognized his limitation in RHINOPLASTY but also recognized single jaw surgery would help improve the convex profile. Similarly, the rhino doctor, before that, saw that a rhino would improve your profile.

Advice from consults is usually limited to what's in the doctor's toolbox where they just look for the stuff they CAN do. For the most part, they don't evaluate in terms of what's in other doctor's tool boxes.

Your nose would need to be DEPROJECTED and cutting down the ANS is just part of that. Hence, a  rhinoplasty and a good one is an important part for aesthetic improvement which is more likely to be in a rhino guy's 'tool box' than the maxfax guys. So, I wouldn't rule out consulting with rhino doctors also.  Here's a link to a tutorial on ANS rhinoplasty. It has photos on how big the ANS can be.

http://www.facialsurgery.com/ClkoffTPgt3_2011_09_01bh.html

[lsubuilder]

I actually had a consult with dr denenburg for a rhinoplasty. He was great to talk to an recommended de projection. Would it be better to look into a rhinoplasty before or after jaw surgery? Or should I look for a surgeon that would do both at the same time?

[Post bimax]

I actually had a consult with dr denenburg for a rhinoplasty. He was great to talk to an recommended de projection. Would it be better to look into a rhinoplasty before or after jaw surgery? Or should I look for a surgeon that would do both at the same time?

Personally I feel as though these procedures should be done separately, although they are often performed jointly. Performing them simultaneously adds an extra layer of risk because the soft tissue changes are less predictable. More moving parts at once means more room for error. Rhino should come second.

I’m currently pursuing a revision and feel as though I need a rhino to address some of the side effects of my original surgery. But in addition to financial reasons, I’m delaying the rhino until a year minimum after my revision in order to have a more predictable result. Realistically it will be several years though because this stuff is so expensive.

[kavan]

I actually had a consult with dr denenburg for a rhinoplasty. He was great to talk to an recommended de projection. Would it be better to look into a rhinoplasty before or after jaw surgery? Or should I look for a surgeon that would do both at the same time?

I would isolate nose to rhino guy. Most likely first and separate given that area needs a lot of time/attention to it. Max fax nose work is often just some minor adjustments. The de projection will give better balance and you would be in a better place to isolate the lower jaw BSSO only if you wanted. It shouldn't preclude bimax either, later down the line if you wanted that instead. All those 'big names' given to you do surgeries where prior surgeries have already been done.

[lsubuilder]

This is the morph dr dendenburg sent me. It does help my profile. Ill bring it up in the consults I get. Sounds like I do need that first then I’d hate to get a bimax and it looks even worse lol. Just more money lol

[kavan]

This is the morph dr dendenburg sent me. It does help my profile. Ill bring it up in the consults I get. Sounds like I do need that first then I’d hate to get a bimax and it looks even worse lol. Just more money lol

That's consistent with my thoughts on the matter where that alone does make LESS the how much the lower jaw looks to be recessed. That is to say, WITHOUT the nose being addressed, it makes maxilla protrusion LOOK like MORE than it is and mandible retrusion also look MORE than it really is via RELATIVE comparison. Basically, the nose is giving too much of an OPTICAL ILLUSION as to the extent of the jaw imbalance. With the nose out of the way first, the conservative choice would be the single BSSO offered to you.

ETA: A nose a good rhino guy can do (and Dennenberg can be considered such) might not be something you can expect the maxfax to do.

[GJ]

OP, I personally don't think you need a nose job. But if you decide to go that path, I'm going to PM you some info on a lead in your area who is excellent.

[lsubuilder]

One last question. If I end up having bimax with ccw as some have suggested i need, would that make the nasolabial angle worse or better if i leave out any rhinoplasty work?

[Post bimax]

That's consistent with my thoughts on the matter where that alone does make LESS the how much the lower jaw looks to be recessed. That is to say, WITHOUT the nose being addressed, it makes maxilla protrusion LOOK like MORE than it is and mandible retrusion also look MORE than it really is via RELATIVE comparison. Basically, the nose is giving too much of an OPTICAL ILLUSION as to the extent of the jaw imbalance. With the nose out of the way first, the conservative choice would be the single BSSO offered to you.

ETA: A nose a good rhino guy can do (and Dennenberg can be considered such) might not be something you can expect the maxfax to do.

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.

[Post bimax]

One last question. If I end up having bimax with ccw as some have suggested i need, would that make the nasolabial angle worse or better if i leave out any rhinoplasty work?

CCW will improve your nasolabial angle, but it will not fix the 'tethered' look without intervention at the ANS.

[kavan]

Thing is, you stand to get more facial balance 'relief' from having the ANS cut down than you would with jaw surgery alone without that. The jaw to jaw balance brought about by maxfax whether you get the single BSSO or the BIMAX with CCW stands to NOT look like good facial balance (soft tissue contour) if the ANS is not cut down.

The ANS cut down is a 'deprojection rhino' and they just can't lop it off without doing other rhino adjustments along with it which are best done by a nose guy who demonstrates they are familiar with managing protrusive ANS and doing so to also improve overall aesthetics of nose.

For those of you on here who are familiar with Gunson's TVL line for the CCW, you would know that the Gunson TVL passes through WHERE the BASE of nose MEETS the UPPER LIP. I've drawn one in GREEN on his ceph. (His S-N line/plane is actually parallel with plane of photo. So looks like he's close to the type of head rotation they want.) NOTE how the line suggests ALOT of maxilla advancement and of course mandible advancement with that for the lips to 'kiss' a bit past the line and the chin point to line up with it.  Now, WITH THAT, try to VISUALIZE how his nose to lip angle would look with the maxilla brought forward so the lips are close to that line. If you can't visualize what that could look like, I can tell you it would look BAD. THAT'S WHY I called the GREEN TVL a FALSE one. It's because his protrusive ANS gives a FALSE reading of where the TVL should be placed as guideline to displace both maxilla and mandible.

The BLUE TVL is adusted to (approximately) WHERE that line should pass through the BASE of the nose where it meets the upper lip. So, the BLUE adjusted TVL is a better aesthetic guideline with reference to a Gunson type CCW posterior downgraft rotation BIMAX. However, for the TVL to pass through where the base of then nose meets the lip, the ANS would need to be cut down.

So, it's not a thing where he needs a rhino just for nose aesthetics. But rather he needs one because the ANS would need to be cut down for good JAW SURGERY aesthetics where the situation is one where cutting ANS down will require other alterations of nose best done by a rhino guy.