Surgery scheduled having second thoughts, please provide opinions

[jawsurgery202005]

Long time follower but only recently just joined the community

Summary: Prev had a sliding genioplasty done 2 years ago with implant placed into the labiomental region (surgeon strongly recomended this as he said my labiomental fold otherwise would have been too deep). Since the surgery I had pain in the area of the graft, original surgeon said it was in my mind. Consulted lots of surgeons afterwards, universal consensus was it was the graft

Fast forward to present day, a plan was made (New surgeon) to remove the graft, partially reverse the genioplasty (surgeon thinks prev slightly overdone) + for optimum aesthetics recomended a Bimax with downgrafting due to short face (ie. lack of tooth show on full smile) as well as infraorbital rim implant due to negative vector/recessed midface. As far as occlusion goes, no issues there, never had braces. I trust this new surgeon as he has come off as very genuine and down to earth but am quite hesitant due to previous bad experience.

I was due to have this all done but now am concerned this is all overkill/will be too much too fast. Wondering what the community generally thinks my face would need if anything to provide a better facial balance that would not look overdone

Currently thinking of just doing the graft removal and seeing how bad the fold will be and then consider the revision genio +/- bimax at a later date if not satisifed w how things look post graft removal. I know my midface/infraorbital area is truly terrible but am scared the implant might lead to issues later down the road but am concerned if I leave the infraorbital implant out and go forward w the bimax then I might overall look worse then I presently look due to the midface looking relatively even more recessed due to the jaw movement.

Sorry for the overly long post but I'm really hoping to get some objective responses from people who know their maxilofacial stuff

Thank You!

Link to photos updated: https://flic.kr/s/aHsmRzpsM7

[kavan]

photos don't show

[jawsurgery202005]

I've updated the link, should work now, thanks

[kavan]

The chin work looks fine and normal. But if it hurts, then just remove the graft if it's been determined it's the graft to the chin groove that's the culprit to pain. But keep the genio. The groove can be made less with filler after you get the groove graft out.

There is enough tooth show for the smile and it does not look like you have 'short face' as to get a drop down to the maxilla. You could get away with NO bimax. Just keep the chin genio and fill in the groove later with filler.

I don't opine on negative vector in absence of seeing the eye area which is needed for the sagittal evaluation of NV other than to say it usually goes with subperiosteal midface lift to resuspend the cheeks over the oribital rim implant and is most certainly NOT something that needs to be done at same time as bimax. 

[Gadwins]

[...]

There is enough tooth show for the smile...
[...]

What is your definition of enough tooth show or what do you mean for the smile, just for this case? I ask this question, because I thought a litte bit of the upper gums should be visible.

[InvisalignOnly]

I know my midface/infraorbital area is truly terrible

No it's not. I can't comment on the rest of your post but you have a totally normal looking face as is, there's nothing 'terrible' about any part of your face at all. It's your body, you do whatever you think is right but objectively, your midface (or any part of your face) does not look bad as it is now.

[kavan]

What is your definition of enough tooth show or what do you mean for the smile, just for this case? I ask this question, because I thought a litte bit of the upper gums should be visible.

What is this...the Nth time I address someone ELSE'S post and you interject needing a 'definition' of how my feedback to another adapts to YOUR thoughts on something.

I've been through this before with you on other strings. I just forget what 'N' is. Let's see, I give a response to an OP in which my feedback is ADAPTED to the CONTEXT of what the OP expresses are his/her concerns and then YOU interject needing an adaptation to your understanding of things.

It's like I told you before on other strings, if you have thoughts on the matter, then use them to DIRECTLY address the OP concerns within the context of what the OP's concerns are. So if you have thoughts about his smile and what it should look like in terms of gum show then you adapt your thoughts on the matter into a definition of 'x' mms of gum show and adapt in what ever terms you have as to YOUR CONTEXT of what his smile should be as to justify to HIM why he should adapt to your understanding of how much gum show you think he should have go forward with a bimax surgery in pursuit of chasing x mm of extra gum show.

[jawsurgery202005]

No it's not. I can't comment on the rest of your post but you have a totally normal looking face as is, there's nothing 'terrible' about any part of your face at all. It's your body, you do whatever you think is right but objectively, your midface (or any part of your face) does not look bad as it is now.

Thanks it seems any bimax intervention would only yield minimum benefits then. I thought becuase of the thin upper lip, prominent labionasal folds, lack of tooth show (note the pics in the link are me at a maximum smile I would not be able to smile any harder if I tried), slight negative canthal tilt and mild scleral show (I know that's not visible as I didn't post a full face pic) indicated a short/underdeveloped midface. But it's interesting to see that others don't seem to think there is much midface deficiency so perhaps its a question for me to reassess my expectations

[jawsurgery202005]

The chin work looks fine and normal. But if it hurts, then just remove the graft if it's been determined it's the graft to the chin groove that's the culprit to pain. But keep the genio. The groove can be made less with filler after you get the groove graft out.

There is enough tooth show for the smile and it does not look like you have 'short face' as to get a drop down to the maxilla. You could get away with NO bimax. Just keep the chin genio and fill in the groove later with filler.

I don't opine on negative vector in absence of seeing the eye area which is needed for the sagittal evaluation of NV other than to say it usually goes with subperiosteal midface lift to resuspend the cheeks over the oribital rim implant and is most certainly NOT something that needs to be done at same time as bimax. 

Thanks for the reply Kavan
My pics provided were me at a maximum exaggerated smile so perhaps I should have posted what my normal smile looks like however if jaws don't seem recessed enough then that alone seems to nulify the justification for a bimax in the context of normal occlusion. Regarding negative vector I know I had not provided orbital views however even if negative that also doesn't seem like something a bimax would correct so thank you for pointing that out

Just out of curiosity how do you tend to measure short face b/c the following link are examples of people treated for short face via maxillary downgrafting and clockwise rotating however when I look at their befores measuring lower face to mid face they don't appear short. In fact it was this webiste that initially "tipped" me off to thinking I had a short face growth pattern as many of the initial descriptors (ie. thin upper lip, chubby cheeks growing up but then flat cheeks in adulthood and lack of tooth smile) sounded like me.

https://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/

I attached a photo of my normal smile into the album, curious if this changes your thoughts regarding my smile

Thanks for your time

[kavan]

Thanks for the reply Kavan
My pics provided were me at a maximum exaggerated smile so perhaps I should have posted what my normal smile looks like however if jaws don't seem recessed enough then that alone seems to nulify the justification for a bimax in the context of normal occlusion. Regarding negative vector I know I had not provided orbital views however even if negative that also doesn't seem like something a bimax would correct so thank you for pointing that out

Just out of curiosity how do you tend to measure short face b/c the following link are examples of people treated for short face via maxillary downgrafting and clockwise rotating however when I look at their befores measuring lower face to mid face they don't appear short. In fact it was this webiste that initially "tipped" me off to thinking I had a short face growth pattern as many of the initial descriptors (ie. thin upper lip, chubby cheeks growing up but then flat cheeks in adulthood and lack of tooth smile) sounded like me.

https://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/

I attached a photo of my normal smile into the album, curious if this changes your thoughts regarding my smile

Thanks for your time

My response to you was in reference to the context and concerns you expressed in your initial post. At NO TIME did you mention in your opening post what you express after the fact here, a prior concern about lack of gum show when smiling nor short face. You expressed neither impelling desire for more tooth show nor any problem that you had with your present tooth show. What you expressed were second thoughts about having the full blown surgery suggested to you INCLUDING the bimax. Taking what YOU expressed were YOUR concerns, I adapted my advice to it which was that your could 'get away' with no bimax surgery and that ORIS don't need to be placed during a bimax surgery.

So, if you had actually expressed a concern about short face and/or lack of approx 2mm GUM show when smiling was actually bothering you, my response would have differed. Not to mention that given that was a major concern of yours prior (in the absence of revealing it was), your doctors suggestion to drop down the maxilla for more tooth show and to address short face should have been INTUITIVELY OBVIOUS.  But your concern was in the direction of having 2nd thoughts about surgery which is in the direction of can you get away without going through with the bimax (and at same time with ORIS). So, with reference to that, my answer is YES, you can.

Let me make this clear. If the original poster does NOT include all of the issues he/she is concerned about in the initial post and chooses to OMIT them, it's not my task to re-adapt my feedback with reference to your LATER introducing here that you had this concern about short face/lack of tooth show ALL ALONG. Just out of curiosity, if that article and also lack of gum show when smiling was a primary concern of yours, why did you elect to OMIT mention of it in your initial post. Rhetorical question that you need to ask YOURSELF. But now that you have expressed it's a primary concern, it's now YOUR task to resolve what's in the article to your surgeon's advice and your decision to go toward his suggested surgery or move away from it.

 

[InvisalignOnly]

it seems any bimax intervention would only yield minimum benefits then

I don't know whether the benefits would be minimal or significant; nobody knows, as jaw surgery is such a gamble plus it's quite subjective what you, the surgeon, or random other people would consider a big or small aesthetical benefit in your case. All I am trying to say is that you already look fine / normal; this is not a clear cut case like some Class 2 or 3 cases where everyone that looks at you for the first time notices that there is something different or 'wrong' about your face. You already look fine as is, so I can see why you are having second thoughts about getting major surgery. There is a chance you would like your face a lot better after surgery but there is no guarantee, so it's up to you if you are willing to take that risk. Did the surgeon show you a picture of the projected outcome / what you would look like in the after? Did he show you before-after photos of previous patients with similar issues?

[eastcoastian1]

Honestly, didn’t look like you needed any surgery and it doesn’t now. I’m chalking this up to body dysmorphia.

[jawsurgery202005]

I don't know whether the benefits would be minimal or significant; nobody knows, as jaw surgery is such a gamble plus it's quite subjective what you, the surgeon, or random other people would consider a big or small aesthetical benefit in your case. All I am trying to say is that you already look fine / normal; this is not a clear cut case like some Class 2 or 3 cases where everyone that looks at you for the first time notices that there is something different or 'wrong' about your face. You already look fine as is, so I can see why you are having second thoughts about getting major surgery. There is a chance you would like your face a lot better after surgery but there is no guarantee, so it's up to you if you are willing to take that risk. Did the surgeon show you a picture of the projected outcome / what you would look like in the after? Did he show you before-after photos of previous patients with similar issues?

Yeah I agree, its very subjective which is why i figured I would try and get some objective opinions from others who don't have a monetary benefit. I always thought my midface looked a bit flat and that when i smiled i didn't have as nice of a smile as others despite have  naturally straight teeth but to your point the vast majority of people I have seen with really "good" changes are those with obvious issues like overbites and underbites so I suspect I would benefit more from first taking some time to really think about if my issues really are even issues at all worth addressing rather then assuming they just are for which the responses here have helped make me think this. My surgeon who proposed the bimax does have very good looking results that look natural but the vast majority are again pateints who have occlusional issues, so another reason I think it best to just take some time to reflect and only focus on the current discomfort that needs to be addressed. Hopefully removing the graft resolves the issue and doesn't cause the labiomental fold to deepen too much. 

[GJ]

I'd simply remove the graft and see how it feels. Because you got a really good result from just a genio. You should keep it where it is if the pain goes away.

[jawsurgery202005]

I'd simply remove the graft and see how it feels. Because you got a really good result from just a genio. You should keep it where it is if the pain goes away.

Yeah I'm strongly leaning that way now
Thank you!