Dr. Fialkov - Sliding Genioplasty - Toronto

[EPN]

Hi all,

I consulted with two major surgeons in Canada, being Dr. Wittenberg in Vancouver and Dr. Fialkov in Toronto.

Both said complete different things.

Dr. Wittenberg uses Gortex strips over the step off because he said it won’t look continuous and blend properly, he does a great job with them. Dr. Wittenberg uses Twlight anesthesia, lines up your chin during the surgery to what he thinks looks best. Doesn’t use a plate, just one screw. He’s confident I’ll need gortex to my labiomental fold. He claims without Gortex strips my face will look narrow and not ideal for a male.

Dr. Fialkov doesn’t use any materiel other than a plate and screws after moving your chin forward, he claims the step offs created won’t be noticeable. Dr. Fialkov partners with an orthodontist who takes many different x rays and determines where your chin should ideally be to the exact millimetre. He does so under general anesthesia. Dr. Fialkov mentions my labiomental fold will look natural, if he wants he would take bone from my hip, but really says it’s not needed in my case.

I am leaning toward Fialkov.

Here are my x rays, I’m interested to hear how much movement you think I’ll need, or any experiences or advice.

https://imgur.com/a/DQgNVcN

Thank you very much.

[eastcoastian1]

Hi all,

I consulted with two major surgeons in Canada, being Dr. Wittenberg in Vancouver and Dr. Fialkov in Toronto.

Both said complete different things.

Dr. Wittenberg uses Gortex strips over the step off because he said it won’t look continuous and blend properly, he does a great job with them. Dr. Wittenberg uses Twlight anesthesia, lines up your chin during the surgery to what he thinks looks best. Doesn’t use a plate, just one screw. He’s confident I’ll need gortex to my labiomental fold. He claims without Gortex strips my face will look narrow and not ideal for a male.

Dr. Fialkov doesn’t use any materiel other than a plate and screws after moving your chin forward, he claims the step offs created won’t be noticeable. Dr. Fialkov partners with an orthodontist who takes many different x rays and determines where your chin should ideally be to the exact millimetre. He does so under general anesthesia. Dr. Fialkov mentions my labiomental fold will look natural, if he wants he would take bone from my hip, but really says it’s not needed in my case.

I am leaning toward Fialkov.

Here are my x rays, I’m interested to hear how much movement you think I’ll need, or any experiences or advice.

https://imgur.com/a/DQgNVcN

Thank you very much.

Your jaw looks quite small. Neither recommended jaw surgery?

[EPN]

Your jaw looks quite small. Neither recommended jaw surgery?

Both did not recommend jaw surgery due to my bite being okay.

[kavan]

Given the fact that you have a ceph that shows both your bone and soft tissue profile, either doctor would be in the capacity to make a calculation of where your chin should be. But the 'exact' mm is not set in stone. There is some leeway or 'wiggle room'.

In general, wiggle room for the CHIN displacement doesn't need to be 'exact' to the last mm because it does NOT involve changing the BITE. So, even if the doctor made a highly exact calculation to the last mm of how he would move the chin BONE, if he went on 'auto-pilot' and stuck to the exact calculation for the chin BONE to be moved, it could imply he's not allowing himself the wiggle room to 'eyeball' the SOFT TISSUE response to the bone displacement calculation. Eyeballing the soft tissue response to the displacement of the chin BONE is basically the act of an aesthetic judgement of what would look good on the patient which is possible to do during a surgery because after they make a cut to the bone, they can move the chin complex in accordance with where the soft tissue (the profile you see in the MIRROR) would look good. Soft tissue response to bone movement is not as 'exact' or exactly predictable as is the calculation for the bone movement.

In fact a basic aesthetic guideline of where your (male) chin should be is pretty straight forward (assuming you have elementary geometry and math under belt). You drop a vertical tangent to the outer most curvature to the lower lip. The (soft tissue of the) chin should be about 3 degrees behind that line (on the average). The wiggle room comes in where it could be moved to touch the vertical drop down line IF that would look good (aesthetic eyeballing against a calculation). To over simplify, the first step is to drop a straight line vertical from the lower lip where the chin should be a little behind that line but not really in front of it. That's the first step in a basic chin evaluation.

The next basic step involved with planning out a SLIDING genio involves choosing the angle of inclination the CUT to the chin has with the horizontal plane. The genio cut is basically a diagonal one that's inclined 'X' degrees away from the horizontal plane. What 'X' should be depends on both vertical (upward to shorten) and horizontal (outward) displacement components that are optimal given the patient. For example if one wanted to minimize how much a sliding genio could make the chin (vertically) shorter and maximize how much it could bring the chin (horizontally) outward, the cut would be LESS away from the horizontal plane than it would be if you wanted to minimize the horizontal displacement and maximize the vertical shortening. To over simply this, there is a RANGE as to the ANGLE of the CUT that can be made/adjusted for a sliding genio.

So, if one doctor is telling you that the sliding genio will give you a step-off where he needs to blend that in with gortex and the other one is telling you that you wont' get a step-off, it just means they ANGLE the cut differently. So, the doctor predicting a step-off would be using a higher angle cut than the one not predicting a step-off.

Since it looks (to me, from looking at your ceph) that you would want to MAXIMIZE horizontal outward displacement vector of the chin and MINIMIZE vertical shortening displacement vector, I'd opt for the lower angle cut (ball park about 10 deg for sliding genio) UNLESS, you thought your chin was longer than you liked it and wanted to see it shorter.

So, IF you wanted more shortening of the chin along with some outward horizontal advancement, the gortex would cover the step off and also more gortex could be used to advance the chin further outward,like an implant does. Gortex can be used for additional augmentation and since it can be placed LAYER BY LAYER, it yields itself to adjustments that can be made during the surgery that look good to the eye. In that case, you would choose the doctor who does that.

 On the other hand, if you were totally averse to having anything other than your own bone used in a surgery and wanted to maximize horizontal (outward) displacement and mimimize vertical (upward/shortening) displacement of the chin with NO HELP from ANY material (eg. layer by layer gortex) used to fine tune further adjustments that could be made during the surgery, then you would choose the doctor who doesn't do it that way.





 

[EPN]

Given the fact that you have a ceph that shows both your bone and soft tissue profile, either doctor would be in the capacity to make a calculation of where your chin should be. But the 'exact' mm is not set in stone. There is some leeway or 'wiggle room'.

In general, wiggle room for the CHIN displacement doesn't need to be 'exact' to the last mm because it does NOT involve changing the BITE. So, even if the doctor made a highly exact calculation to the last mm of how he would move the chin BONE, if he went on 'auto-pilot' and stuck to the exact calculation for the chin BONE to be moved, it could imply he's not allowing himself the wiggle room to 'eyeball' the SOFT TISSUE response to the bone displacement calculation. Eyeballing the soft tissue response to the displacement of the chin BONE is basically the act of an aesthetic judgement of what would look good on the patient which is possible to do during a surgery because after they make a cut to the bone, they can move the chin complex in accordance with where the soft tissue (the profile you see in the MIRROR) would look good. Soft tissue response to bone movement is not as 'exact' or exactly predictable as is the calculation for the bone movement.

In fact a basic aesthetic guideline of where your (male) chin should be is pretty straight forward (assuming you have elementary geometry and math under belt). You drop a vertical tangent to the outer most curvature to the lower lip. The (soft tissue of the) chin should be about 3 degrees behind that line (on the average). The wiggle room comes in where it could be moved to touch the vertical drop down line IF that would look good (aesthetic eyeballing against a calculation). To over simplify, the first step is to drop a straight line vertical from the lower lip where the chin should be a little behind that line but not really in front of it. That's the first step in a basic chin evaluation.

The next basic step involved with planning out a SLIDING genio involves choosing the angle of inclination the CUT to the chin has with the horizontal plane. The genio cut is basically a diagonal one that's inclined 'X' degrees away from the horizontal plane. What 'X' should be depends on both vertical (upward to shorten) and horizontal (outward) displacement components that are optimal given the patient. For example if one wanted to minimize how much a sliding genio could make the chin (vertically) shorter and maximize how much it could bring the chin (horizontally) outward, the cut would be LESS away from the horizontal plane than it would be if you wanted to minimize the horizontal displacement and maximize the vertical shortening. To over simply this, there is a RANGE as to the ANGLE of the CUT that can be made/adjusted for a sliding genio.

So, if one doctor is telling you that the sliding genio will give you a step-off where he needs to blend that in with gortex and the other one is telling you that you wont' get a step-off, it just means they ANGLE the cut differently. So, the doctor predicting a step-off would be using a higher angle cut than the one not predicting a step-off.

Since it looks (to me, from looking at your ceph) that you would want to MAXIMIZE horizontal outward displacement vector of the chin and MINIMIZE vertical shortening displacement vector, I'd opt for the lower angle cut (ball park about 10 deg for sliding genio) UNLESS, you thought your chin was longer than you liked it and wanted to see it shorter.

So, IF you wanted more shortening of the chin along with some outward horizontal advancement, the gortex would cover the step off and also more gortex could be used to advance the chin further outward,like an implant does. Gortex can be used for additional augmentation and since it can be placed LAYER BY LAYER, it yields itself to adjustments that can be made during the surgery that look good to the eye. In that case, you would choose the doctor who does that.

 On the other hand, if you were totally averse to having anything other than your own bone used in a surgery and wanted to maximize horizontal (outward) displacement and mimimize vertical (upward/shortening) displacement of the chin with NO HELP from ANY material (eg. layer by layer gortex) used to fine tune further adjustments that could be made during the surgery, then you would choose the doctor who doesn't do it that way.

Wow. I really appreciate your detailed response.

That makes sense regarding the chin movement not needing “exact” measurements, but it’s interesting that one surgeon says he will eyeball then movements during the surgery and the other wants measurements to get the “ideal” aesthetic profile for a male. Dr. Fialkov basically said he will show me the ideal chin and I can pick if I want it larger or smaller horizontally and said in my case I don’t need vertical. This is after the orthodontist he partners with examines my xrays.

I also never thought about the angle of the cut, I suppose surgeons don’t typically go into this type of the detail for the average patient. I will bring it up and see if Dr. Fialkov would go into further detail.

I would be okay with either surgeon, including using gortex from Wittenberg or my own hip bone grafts IF it was required.

If Dr. Fialkov believes he can produce a balanced surgical result utilizing only my own chin bone, I think this is best for me, financially and less things to go wrong.

Here is an example of a patient of Dr. Wittenberg - https://imgur.com/a/sDVj44H - great results. Dr. Wittenberg doesn’t say anything about his movements.

And here is an example of Dr. Fialkov - https://imgur.com/a/7j1adml - I would consider my chin projection similar to this patient. This is a 12mm horizontal movement and a few mm vertical with a hip graft to his labiomental fold.

If I remember correctly, Dr. Fialkov mentioned I’d likely be in the 8mm horizontal range.

Again, I really appreciate your response and time you put into it. I will bring up your points with Dr. Fialkov.

[kavan]

Wow. I really appreciate your detailed response.

That makes sense regarding the chin movement not needing “exact” measurements, but it’s interesting that one surgeon says he will eyeball then movements during the surgery and the other wants measurements to get the “ideal” aesthetic profile for a male. Dr. Fialkov basically said he will show me the ideal chin and I can pick if I want it larger or smaller horizontally and said in my case I don’t need vertical. This is after the orthodontist he partners with examines my xrays.

I also never thought about the angle of the cut, I suppose surgeons don’t typically go into this type of the detail for the average patient. I will bring it up and see if Dr. Fialkov would go into further detail.

I would be okay with either surgeon, including using gortex from Wittenberg or my own hip bone grafts IF it was required.

If Dr. Fialkov believes he can produce a balanced surgical result utilizing only my own chin bone, I think this is best for me, financially and less things to go wrong.

Here is an example of a patient of Dr. Wittenberg - https://imgur.com/a/sDVj44H - great results. Dr. Wittenberg doesn’t say anything about his movements.

And here is an example of Dr. Fialkov - https://imgur.com/a/7j1adml - I would consider my chin projection similar to this patient. This is a 12mm horizontal movement and a few mm vertical with a hip graft to his labiomental fold.

If I remember correctly, Dr. Fialkov mentioned I’d likely be in the 8mm horizontal range.

Again, I really appreciate your response and time you put into it. I will bring up your points with Dr. Fialkov.

Assuming BOTH can look at your ceph, BOTH should be in the capacity to plan the angle of the cut and the horizontal and vertical displacements. Again, the vertical displacement in a sliding genio is UP. It is NOT down. Also, an orthodontist is not really needed to examine your X rays for a SOLE genioplasty if he/she has already confirmed your 'bite is right'. Orthos come in when planning surgery for the ENTIRE jaw/s.

Looks like this dr. F is a PLASTIC SURGEON and NOT a maxfax. So, no wonder he has to have an ortho examine your X ray and plan out a chin surgery. Although some plastic surgeons can do genios, they usually also have some background in maxillo facial surgey and they DON'T need an ortho to plan your surgery from your ceph. OK.
Also, if he's going to show you some pictures of ideal chins and you can pick smaller or larger horizontally, that's a QUALITATIVE choice and not one of 'exact' measures. As to showing you pictures of 'ideal chins', well that's on SOMEONE ELSE. Tell the doc who wants to show you that to produce a displacement proposal based on YOUR OWN chin. Dr. F does NOT perform jaw surgery as does a MAXFAX surgeon whereas maxfax docs perform genios all the time with jaw surgeries. Hence, the maxfax (Dr. W) would have more experience and all the training/planning capacity than this PS, Dr. F.

It was sounding like a choice between a plastic surgeon who can't evaluate a sliding genio on his own WITHOUT help from the ortho and one who just wings things on the table. However, Dr. W is a maxfax surgeon and that's a whole lot better than a plastic surgeon who needs some ortho to evaluate your ceph and plan a bone cutting surgery for you. It can also be assumed that Dr. W, being a maxfax surgeon who performs double jaw surgery in addition to genios would be able to plan out a chin surgery for you based on your ceph. So, I don't think it's all winging on table and eyeballing with him and instead more likely a plan from your ceph and fine tune alterations on the table given how the soft tissue envelope responds to the advancement.

[Lazlo]

i've consulted with fialkov. very solid surgeon with a solid rep. genio should be a breeze for him.

[EPN]

Assuming BOTH can look at your ceph, BOTH should be in the capacity to plan the angle of the cut and the horizontal and vertical displacements. Again, the vertical displacement in a sliding genio is UP. It is NOT down. Also, an orthodontist is not really needed to examine your X rays for a SOLE genioplasty if he/she has already confirmed your 'bite is right'. Orthos come in when planning surgery for the ENTIRE jaw/s.

Looks like this dr. F is a PLASTIC SURGEON and NOT a maxfax. So, no wonder he has to have an ortho examine your X ray and plan out a chin surgery. Although some plastic surgeons can do genios, they usually also have some background in maxillo facial surgey and they DON'T need an ortho to plan your surgery from your ceph. OK.
Also, if he's going to show you some pictures of ideal chins and you can pick smaller or larger horizontally, that's a QUALITATIVE choice and not one of 'exact' measures. As to showing you pictures of 'ideal chins', well that's on SOMEONE ELSE. Tell the doc who wants to show you that to produce a displacement proposal based on YOUR OWN chin. Dr. F does NOT perform jaw surgery as does a MAXFAX surgeon whereas maxfax docs perform genios all the time with jaw surgeries. Hence, the maxfax (Dr. W) would have more experience and all the training/planning capacity than this PS, Dr. F.

It was sounding like a choice between a plastic surgeon who can't evaluate a sliding genio on his own WITHOUT help from the ortho and one who just wings things on the table. However, Dr. W is a maxfax surgeon and that's a whole lot better than a plastic surgeon who needs some ortho to evaluate your ceph and plan a bone cutting surgery for you. It can also be assumed that Dr. W, being a maxfax surgeon who performs double jaw surgery in addition to genios would be able to plan out a chin surgery for you based on your ceph. So, I don't think it's all winging on table and eyeballing with him and instead more likely a plan from your ceph and fine tune alterations on the table given how the soft tissue envelope responds to the advancement.

Thanks.

Very valid points to consider.

Dr. Fialkov’s ortho does tracing to show where ideally the chin should be, then partners with Dr. Fialkov, I believe this is where Dr. Fialkov goes over the movements with you, and if one wants a disproportionate large chin etc, you can discuss that with him. Being put under general anesthesia also puts me at ease compared to twlight with Dr. W.

Dr. W won’t say a word about movements in mm, just says he will line everything up during surgery. Like you mentioned, I’m sure he goes over xrays first. Just makes me a little nervous I don’t have much of a say in the results, but more trust in the surgeon. Sliding genioplasty is Dr. W bread and butter procedure without a doubt. If I hadn’t researched as deep as I did, I would be going with Dr. W without a doubt.

I suppose I can’t really go wrong with either for only a sliding genioplasty.

[EPN]

i've consulted with fialkov. very solid surgeon with a solid rep. genio should be a breeze for him.

Thanks. Any particular reason it ended at only a consultation? Agreed, SG is one of this main procedures.

[kavan]

Thanks.

Very valid points to consider.

Dr. Fialkov’s ortho does tracing to show where ideally the chin should be, then partners with Dr. Fialkov, I believe this is where Dr. Fialkov goes over the movements with you, and if one wants a disproportionate large chin etc, you can discuss that with him. Being put under general anesthesia also puts me at ease compared to twlight with Dr. W.

Dr. W won’t say a word about movements in mm, just says he will line everything up during surgery. Like you mentioned, I’m sure he goes over xrays first. Just makes me a little nervous I don’t have much of a say in the results, but more trust in the surgeon. Sliding genioplasty is Dr. W bread and butter procedure without a doubt. If I hadn’t researched as deep as I did, I would be going with Dr. W without a doubt.

I suppose I can’t really go wrong with either for only a sliding genioplasty.

Well, glad I was helpful in adding some points. Ultimately, choice is up to you.

[IconVillage]

Fialkov was on my shortlist of surgeons for my sliding genioplasty. Heard good things about him. Wittenburg has mixed reviews however.

[EPN]

Fialkov was on my shortlist of surgeons for my sliding genioplasty. Heard good things about him. Wittenburg has mixed reviews however.

Did you pick another Canadian surgeon? Curious who if you’re willing to share.