thoughts..?

[Movebone]

Hi All,

Was wondering if anybody could comment on what to do about the bunched up soft tissue around my mouth. I keep hearing contradictory things about the effects of maxillary advancement, some say that it leads to more puffiness, which I can hardly afford, while others say that it helps support the soft tissue . Its really difficult to visualise where the upper jaw should be positioned, as its a fairway ahead of the mandible so it might be an illusion but is it possible its not recessed? I have a large nose and a long philtrum aswell inspite of the flat midface so am additionally worried about those tradeoffs of advancement.

Also can anybody weigh in on whether the optimal maxilla position would change based on whether one was interested in going for the full silicon treatment after Bimax (orbital, malar,ramus,chin)?

PS how f**king useless are orthodontists, with my f**ked face, four seperate orthos still refused to refer me for a cbct scan, or even refer me to a surgeon!
'blah blah blah, very good ortho work, I don't see a problem' idiot...

anyway attached some pics and thank for input!

https://imgur.com/a/guOFAXr

[GJ]

CCW should make the philtrum area a bit more concave, and usually the orthodontics for that procline the teeth, which would also give support/concavity. In theory. Soft tissue is "unpredictable"...

CCW rotating both jaws would also fix your mandible, and you might only need a small genio after the movement. IMO that would be the best route. It's probably worth the negative tradeoffs provided you go with someone reputable who can control the nose widening, etc.

[kavan]

There is nothing inherently or generally contradictory about L1 advancement supporting soft tissue and having bunched up soft tissue around the mouth. NOT in the sense that the area will become puffier. IF the problem is bunched up soft tissue, than the L1 advancement will give more 'face space' for better distribution of it. IF the problem is a peri-oral fat mound, which some people have, the LI advancement won't make it 'go away' but won't make it puffier either. Having BOTH isn't a counter-indication (against getting) a L1 IF that's needed in process of bimax surgery giving better balance to jaws.

However, there will be some LIMITATIONS of how much of a L1 someone can have. In your case, the long philtral area and the large nose to lip angle would be the limiting factors. Not bunched up soft tissue or a peri-oral fat mound. That large angle could open more with maxillary advancement because the more the advancement the the more the nose to lip angle gets exaggerated. Although 'bucking out' the front teeth more helps close the angle a little, the orientation at the base of the nose is going diagonally upward and that's what would be going forward more with maxilla advancement. So, the long lip and large nose to lip angle is going to limit the amount of maxillary advancement you can have, lest that problem area get more exaggerated.

There also looks to be another limitation as to the NET CCW rotation from CCW downgrafting. Your ceph reveals, MINIMAL tooth show. So, the downgraft might also involve downgrafting the FRONT maxilla (a CCW POSTERIOR DG is just the back part) and that would decrease the NET CCW rotation. A higher NET CCW rotation allows for more of a BSSO advancement (as does more maxillary advancement). So, a higher net CCW rotation could require a surgery to REDUCE excess length of the long philtral area. In fact, some surgeons (ones who do the large down grafting) might want that in order to MINIMIZE maxilla advancement and also maximize the net CCW-r from a down graft.

So, this looks like somewhat of a complex case, that YA, would resolve to a surgeon who does the DOWNGRAFTING and CCW. But you'd want one who's associated with plastic surgeons to do the lip lip lift. I see you getting SOME improvement with the CCW bimax surgery and of course, chin advancement. But I don't see you getting a short conCAVE upper lip out of it or much of a dramatic 'Wow' factor out of it.

Enclosed is my basic study from which I formed my opinions.

[Movebone]

Thanks alot for the replies and the ceph analysis. I tried to do something similar once and gave up when after, much and careful deliberation, I was forced to randomly mark the point 's' and draw up a long list of useless measurements lol.

Interesting that the peri-oral soft tissue isn't necessarily adversely affected by L1, more 'face space' is exactly what I would wanna achieve to stretch those damn chipmunk cheeks!!

In regards to the nose-lip angle would shaving the ANS or other rhinoplasty techniques aimed at rotating the tip down help facilitate a larger BSSO? Looking at realself, surgeons seem quite confident that they can reduce an obtuse angle, though I'm not sure if that in-itself directly relates to more L1 advancement.
It also seems a liplift is more a requirement than the 'cherry on top' that I thought. Fun!! especially when you read all the negativity towards the procedure on this board, but say, if I was to get the scar, wouldn't that also eliminate the nose widening as an issue as a sill excision would blend quite nicely into the bullhorn...I might be getting carried away here ..but it seems these adjunct soft tissue procedures could theoretically help to get more BSSO?

Kavan, I've attached a result I think is quite good for the starting base. Do you think something like that is possible?

[kavan]

Thanks alot for the replies and the ceph analysis. I tried to do something similar once and gave up when after, much and careful deliberation, I was forced to randomly mark the point 's' and draw up a long list of useless measurements lol.

Interesting that the peri-oral soft tissue isn't necessarily adversely affected by L1, more 'face space' is exactly what I would wanna achieve to stretch those damn chipmunk cheeks!!

In regards to the nose-lip angle would shaving the ANS or other rhinoplasty techniques aimed at rotating the tip down help facilitate a larger BSSO? Looking at realself, surgeons seem quite confident that they can reduce an obtuse angle, though I'm not sure if that in-itself directly relates to more L1 advancement.
It also seems a liplift is more a requirement than the 'cherry on top' that I thought. Fun!! especially when you read all the negativity towards the procedure on this board, but say, if I was to get the scar, wouldn't that also eliminate the nose widening as an issue as a sill excision would blend quite nicely into the bullhorn...I might be getting carried away here ..but it seems these adjunct soft tissue procedures could theoretically help to get more BSSO?

Kavan, I've attached a result I think is quite good for the starting base. Do you think something like that is possible?

When ever the ANS is cut down, other rhino techniques usually need to go with that and become within the venue of a good rhino doc and not defacto to the maxfax. I just didn't see the same type of nose to lip 'tethering' in your ceph as I've seen in other people's. But it could be possible that a rhino aimed at derotating the tip and also deprojection of it (which might include altering the ANS) could help mitigate the limitation the area poses to maxillary advancement, as would shortening the long lip. Bullhorn LL is NOT one where the sills are removed. What a rhino and LL could do is allow them a little more leeway in the maxillary advancement and net CCW rotation which, in turn allows for more of a BSSO. But it doesn't prevent the advancement from widening the nose base. It just give a better base line such that advancement doesn't exaggerate your present problem.

As to your attachment of someone else's photo, I don't address questions about expectations based on someone else's photo and don't 'cross engineer' Gunson's patient photos to predict what another can expect for themselves from them. I could BUT I don't bother to do so because it's quite clear Gunson has elected NOT to elaborate on what the patients in his photos got. So, not my task to fill in information as to what Gunson left out.

The guy in the photo certainly had his soft tissue envelope well distributed. But BECAUSE Gunson does not really elaborate on what was actually done on the cases he presents, nor are before and after CEPHS included in his presentation, I'm not up to the task of relating the PARTICULARS of what that patient got to your specific situation, nor anyone else's.

I've actually posted about that before some time back in response to an entry about Gunson's new case photos. My GRIPE was that they were ABSENT of elaboration of what the patients had done. Although there is nothing inherently 'wrong' about his not elaborating on specifics of what the patients had done, CLEARLY, they are there for people to consult directly if they want to know whether or not what one patient in the photo cases is possible for them.  I'm not going to GUESS cross engineer it against questions here wanting to know if they can expect similar.

[Rodin]

https://pubmed.ncbi.nlm.nih.gov/17618145/

Have wondered whether its possible to perform a L1 without cutting above the nasal spine. Apparently it is, but I have no idea how possible it would be to find a surgeon to do it or if there are negatives. This is the only article I've found and the sample size was 5.