Is a recessed maxilla causing the issues in my face?

[almtsb]

I’m 26M. I used to look normal as a kid, but around when I hit puberty at age 13, I started to look really old for my age and developed this “creepy pedo” type look to my face. I think these angles capture it best:

Current: https://imgur.com/a/emUmYQ7
Age 15: https://imgur.com/a/oMB8MhG
Age 10: https://imgur.com/a/iVNaHsN

I’ve been having a tough time finding any before & after pics online of similar cases. This is the only one I found, and it looks like a dramatic improvement (believe she was operated on by Dr Raffaini in Italy, but not certain):  https://imgur.com/a/e01nejT

I am optimistic since the issue completely disappears in blurry photos, or photos taken under certain lighting conditions, or when I just wear a mask for the coronavirus:  https://imgur.com/a/B9hFHSG

Lateral ceph, pano, intraoral, CBCT:
https://imgur.com/a/BY9Wpck
https://www.youtube.com/watch?v=spzU-gYyawg&feature=youtu.be

I consulted with several orthodontists, jaw surgeons, and plastic surgeons (Gunson, Walline, Ting, Yaremchuk, Taban, etc.).

Based on the X-rays and what the orthos told me, it looks like I have a “hypodivergent” facial type (vertically deficient maxilla with deep overbite and near horizontal occlusal plane : https://imgur.com/a/owIlDOh as opposed to long midface with steep occlusal plane)

Most of the jaw surgeons said I would look better after bimax but they didn’t really answer my specific question regarding the aged appearance. Gunson didn’t want to talk about any aesthetic benefits at all. He said I should get the jaw surgery to fix my small airway and any aesthetic benefit I get would just be an added bonus, but that I shouldn’t come into it expecting any improvement. I kind of doubt if a Lefort 1 will help since oftentimes I see the patient's nasolabial folds get worse after the advancement, not better.

Yaremchuk said the aged appearance is caused by deficiency in the upper midface so it would not be addressed by a Lefort 1, and recommended implants. He directed me to his website for before & after pics of similar patients, but over there was not able to see any similar cases. The closest before case I found was this guy, but in his case the nasolabial folds actually look deeper after getting the implants and IMO he doesn’t look any better: https://imgur.com/a/5wnZOd7

During my consult, I showed yaremchuk the picture of the girl operated on by Raffini. He said she probably had some combination of Lefort and lower jaw surgery, midface and jaw implants, cheek lift, aggressive rhinoplasty, lip lift, and upper blepharoplasty.

This week I am consulting with Eppley and Sinn. I read of one guy on this forum who had Sinn give him a modified Lefort 3 which is why I am interested. If anyone here could give specific insight as to what issue in my jaws or face is causing the aged pedo like appearance it would be helpful.

Also anyone know where I might find a 3D model of what a normal guy’s maxilla should look like (with naturally straight teeth). That way I can compare to mine and see where the deficiency is. I’ve found some 3D skull models online but they look too perfect, almost unrealistic, as though they were created by an artist rather than straight from a CT scan.

[Post bimax]

Your arches look ridiculously narrow.

Who gave you that CEPH morph?  Tbh it looks pretty good, though the lip contour seems fudged. Really hard to believe the soft tissue at your ANS won't come forward even with that bit of CCW rotation.

The girl in the picture you posted had some lip filler, some kind of face/eye lift, major rhinoplasty, better lighting, makeup and head posture.  I'm not even sure what kind of implants/genio/JS she got because it's hard to tell from that one image.  So really, that's not helpful for you.

Just looking at you, seems like you need CCW or linear bimax with an 'out and down' genio to account for your short chin.  Hard to say since your OP looks flat already.  Don't know if you would look any 'younger', but you would probably look better.

[GJ]

Nice job hoarding the Costco paper towels.

Yeah your arch is super narrow. That looks uncomfortable.
Your "current" photo looks bad; like we can see the deformity very clearly there. But I think that's the lighting. You shot it under the most unflattering lighting and the worst angle to show something like that. But it does show something is wrong.

Cursory look at your records I see narrow arches, a deep bite, and an overall deficient structure (both maxilla and mandible) that could benefit from both a linear and CCW movement. To me this justifies surgery. Get at least three opinions. And ask what they plan to do to address the narrow arches.

[kavan]

GJ and Post Bimax. Thanx for giving the guy some advice. You guys must have the patience of a saint to keep open 9 separate links/tabs to look at someone's photos when the poster elects NOT to put ALL of his photos on the SAME LINK and describe them on that link but instead expects people to open 9 separate links to give him feedback. For that reason, I PASSED on this one.

[almtsb]

Thanks everyone. @Kavan my bad, I should have posted everything in one link.

@Post Bimax, the morph was done by Walline at LACOMS. Good eye, the ANS moving forward would also push the lip forward in theory. Not sure why Walline didn't include that as part of the morph.

I just consulted with Dr Sinn and Eppley yesterday. Sinn seemed to be more knowledgable in terms of aesthetics than either Gunson or Walline. He pointed out some issues in Walline's plan for me and recommended LJS with some kind of bone grafts from the taken from ocean that he could place in my midface area to address the deficiency. He told me he also does an "infraorbital rim advancement" (which I think people on here refer to as a modified Lefort 3) I thought it was pretty cool, but a little too extreme in my case. Also told me to be weary of ANS reduction as it would increase the hump on the top of my nose.

Eppley was helpful too. He said a Lefort 1 would improve my nasolabial folds, but not by much. I'd need 7 to 10 mm forward movement to get a noticeable improvement. Better option in my case would be a cheek lift and midface + infraorbital rim implants.

[kavan]

ALL the doctors are going to suggest to you what THEY do as to fit you into what ever their default surgery is. The decision at hand would be WHO'S default do you best fit into.

For starters, if your back teeth area is angled inward (which looks to be the case) and THAT contributes to the narrowness to the upper arch, the plan should include a 3 piece lefort which can be done along with CCW rotation and also bringing the maxilla forward. Such a plan would also include the BSSO. But due to your NOT having a high mandibular plane angle (MPA) and being slightly on the side of being a low angle patient, the genioplasty would need to be a 'down and out' one and not a sliding genio. (Because CCW-r would DECREASE your MPA and a sliding genio would decrease that more.)

From the displacement diagram on the https://imgur.com/a/BY9Wpck LINK, that looks to be a suggestion for CCW-r and perhaps a 'down and out' genio (not a sliding one). So, that looks like it could be on target, especially if the suggestion also includes 3 piece lefort. Looks in the venue of what Gunson does (although it might be another's displacement proposal).

I think you would benefit from bimax: CCW-r (via posterior downgraft), 3 piece lefort, the BSSO that goes with that and either no genio or one that displaces down and out. But not a sliding genio. That does look to be in the venue of Gunson or another who does similar. You look to fit into THAT basic 'default' than Sinn's and Eppleys.

Keep in mind, you can always get the stuff Sinn does (modified L3 and coral onlays) after the bimax base surgery is done. Likewise with what Eppley offers.

No idea where suggestion of ANS reduction came in for YOUR specific case

[Post bimax]

Thanks everyone. @Kavan my bad, I should have posted everything in one link.

@Post Bimax, the morph was done by Walline at LACOMS. Good eye, the ANS moving forward would also push the lip forward in theory. Not sure why Walline didn't include that as part of the morph.

I just consulted with Dr Sinn and Eppley yesterday. Sinn seemed to be more knowledgable in terms of aesthetics than either Gunson or Walline. He pointed out some issues in Walline's plan for me and recommended LJS with some kind of bone grafts from the taken from ocean that he could place in my midface area to address the deficiency. He told me he also does an "infraorbital rim advancement" (which I think people on here refer to as a modified Lefort 3) I thought it was pretty cool, but a little too extreme in my case. Also told me to be weary of ANS reduction as it would increase the hump on the top of my nose.

Eppley was helpful too. He said a Lefort 1 would improve my nasolabial folds, but not by much. I'd need 7 to 10 mm forward movement to get a noticeable improvement. Better option in my case would be a cheek lift and midface + infraorbital rim implants.

This makes sense.  Another user here had a morph from Relle (also at LACOMS) that had a similar misrepresentation.  It seems to me surgeons in that practice are more conservative with CCW rotation and make up for it on the CEPH contour via manipulation or some very generous software projections.  FWIW Relle has very positive reviews despite this.  I don't know about Walline.