Poor aesthetics after BSSO

[alanda]

Hey everyone 
I would like to ask what you think about my case.
I am after BSSO (retrognathism), and apart from all health aspects (problems with jaw joint, badly folding teeth), I have reservations about aesthetic issues.
At the beginning of the treatment, it was found that my nasolabial angle was too large. Before the surgery, the orthodontist stated that she would persuade the surgeon to perform the BSSO, not DJS, because according to her it is unnecessary.
However, now I can see, when the swelling is completely gone, that, especially when smiling, the maxilla gives the impression that is too much behind. Without a smile it is a little better, but the face appears "flat". In my opinion it does not look good and an adjustment should be made.
I told that my orthodontist, and she thinks it could actually be better, but I should be glad that nothing fell apart and I regained feeling (what kind of argument is that anyway?!).

What do you think?

I attach some photos. I can also insert an x-ray if needed

[kavan]

MAXFAX surgery, whether it's single or double jaw does not always come with the option of making everything aesthetically ideal.


I would ask whether or not the BSSO alone improved what (an advancement) BSSO is meant to improve; correction of LOWER JAW recession. I would assume the BSSO improved your lower jaw. If my assumption is wrong and the BSSO did not improve lower jaw recession, please show the before photo.

The aesthetic issue/complaint here resolves to seeing something on your face that was ALWAYS THERE that the surgery was not planned to change (or to make worse). I mean I'm hard pressed to critique the outcome of a single jaw surgery (BSSO) that can be assumed to have corrected/improved a recessive lower jaw BUT to critique on grounds that it it didn't change the upper jaw when there is QUESTION whether or not you would have liked the outcome IF the upper jaw were also advanced.

You've gotta realize that you are saying (or rather what I'm hearing from what you say) is that the aesthetic issue with the outcome of the surgery is  that DID NOT IMPROVE the part where NO surgery was done.  To further 'translate' what you are saying and want me to critique is something like this: 'I had a lower jaw surgery that IMPROVED/CORRECTED my lower jaw recession and now, I don't like the part that was ALWAYS THERE which the lower jaw surgery did NOT CHANGE.'

What we need to agree on here is the obvious: A surgery aimed at improving ONE PART doesn't doesn't always make the WHOLE 'ideal'. For a surgery to ONE part to kick up something close to 'ideal', all of the OTHER parts have to be close to ideal to begin with. So, what you are seeing (and not liking) is a common phenomenon: When something is corrected, it makes it easier to notice a part (or parts) that was/ were ALWAYS THERE; the phenomenon of seeing a 'change' in something that was NOT changed.

I agree that you don't have the 'ideal' aesthetic outcome. But I don't conflate that with; 'poor aesthetics after a BSSO' because the  LOWER JAW looks to be within a good aesthetic range.

As I see it, your aesthetic issue was a non-ideal START POINT; overly obtuse NLA that would have become more obtuse with maxillary advancement. It would not have become LESS obtuse (decreased NLA). So, I think your ortho was concerned that maxillary advancement could make the overly obtuse NLA  larger.

Refer to the line diagram where the NLA is 'ideal' and the whole profile becomes 'ideal' when ONLY the lower jaw recession is corrected. The thing about the 'ideal' NLA in the contour diagram is it fits into an angle and is not a curve where as yours is a curve but one they use to measure the NLA.

A better aesthetic would be one where your NLA was either DECREASED or even remained the same but fit into an angle in the process of bringing your upper jaw (and upper lip) more forward, which in turn, would have brought your front teeth more forward. So, what you are NOT seeing here which I THINK you would LIKE to see is either a DECREASED NLF with more 'poofyness' or 'pout out' to the UPPER lip for the SOFT TISSUE contour in addition to the front teeth being more forward or yours just to fit into an angle like the one in the line diagram I provided. However, NLA is usually increased with maxillary advancement. So, I can't really tell you maxillary advancement would have decreased the NLA for a 'better' aesthetic. I can tell you that your ortho opted for the maxilla not to be brought forward out of concern that the large NLA would have been increased.

So, ya, I can see that the optimal or 'ideal' aesthetic is not there with the outcome. But I think you need to see that you didn't start with an ideal NLA for that to happen. You started with a 'too large'that could stand to INCREASE with upper jaw (and base of nose advancement). It would not have stood to decrease to be within the ideal.

All I can do here is explain the judgement call they made and the most likely reason they elected NOT to advance the upper jaw. I can't really 'critique' them on the grounds that they elected NOT to INCREASE your NLA in a circumstance where a decrease to it would not have occurred with maxillary advancement.

That said, who's to say whether or not you would have liked an outcome where the maxilla was also advanced. However, if you think you would like the upper lip to come more forward in soft tissue contour, along with the front teeth coming more forward (via maxillary advancement), then you would have to have some way of being sure you would  like or would not mind a TRADE OFF of even a LARGER NLA that would go with that.

Note: Illustration included with this post. Also, a separate post below this where I get your CURVED contour to fit into the same angle.

Edited.

[kavan]

To my above post, I add; 'Large NLA take 2'.

It might be possible to have the SAME NLA with the maxilla brought forward a little. But for the contour change to fit into the angle. For example IF some maxillary advancement straightened out the CURVE to the upper lip to be flush with the (lower red) line and rotated the nose tip up to be flush with (upper red) line, the same angle or even a little increase of it might not be that bad or even look better. My reasoning here is that bringing out the maxilla can straighten the curve to the upper lip and also rotate the lower tip of the nose upward. Geometrically speaking, a CURVE is NOT an angle. But that's basically how they measure an angle from a Nasio labial CURVE such as yours.

So, it would depend on IF you thought the CURVE CONTOUR CHANGE I got to fit into the SAME angle was an improvement and also IF they thought they could achieve that.

Enclosed is 'Large NLA take 2' morph which you could show to your ortho or maxfax to ask if that would be possible to do.

[alanda]

Thank you so much for your comprehensive response and dose of information!

You've gotta realize that you are saying (or rather what I'm hearing from what you say) is that the aesthetic issue with the outcome of the surgery is  that DID NOT IMPROVE the part where NO surgery was done.  To further 'translate' what you are saying and want me to critique is something like this: 'I had a lower jaw surgery that IMPROVED/CORRECTED my lower jaw recession and now, I don't like the part that was ALWAYS THERE which the lower jaw surgery did NOT CHANGE.'

Yes, exactly, it is true what you write, but I will try to explain what I meant. BSSO improved the lower jaw, while it accentuated what was always there- before the surgery, I didn't pay much attention to my maxilla because, due to my receded lower jaw, it  seemed to protrude properly.

Note: Illustration included with this post. Also, a separate post below this where I get your CURVED contour to fit into the same angle.

I can see from the illustration that, even with the increased/same NLA, it looks better without that "curve".
Aside from the NLA issue, I'm also bothered by the "flat" face, which I feel is just caused by not extending the maxilla.
I'm also adding a photo where I simulated the jaw protrusion and I think aesthetically it looks better.

In the second photo I also add the effect of one of the patients. I think my maxilla looks like this person's before surgery (on the right), and I would like the effect as on the left (i.e. after surgery).

Therefore, I think the decision to have DJS would be the right one.

[kavan]

Lefort 1 advancement brings forward the base of the nose and the lip area. So if parts of the face ABOVE that area are flat to begin with, they can look RELATIVELY flatter when an area directly BELOW them is advanced. Same principle of why your NLA area looked 'off' to you when the lower jaw was advanced.

I don't use other people's photos when advising someone. So, all I will point out is that the photo presentation called 'other patient', the photo on the left has the nose to lip contour fitting into an angle and the whole photo looks AIR BRUSHED. If that side by side presentation is meant to be a MORPH of YOU, I decline or otherwise reject that type of presentation on the basis that a morph presentation must ALWAYS be an alteration done by using the SAME photo; original on the LEFT and alteration of the photo on the right.

[alanda]

I just would like to specify that I used the photos of another patient to indicate what do I mean when I'm talking about "flat face/ retracted maxilla"- due to the fact that I am not an english native speaker and I may not express myself clearly, I wanted to present what I am talking about "graphically" 

I would also like to ask, can you tell me how is it measured that the maxilla is retracted? My guess is that the surgeon does not judge it by eye, but performs a measurement - on a cephalometric image? In a plain face photo in profile?

[kavan]

Usually on a ceph relative to other distance relationships like the lower jaw. Profile.

[alanda]

could you please tell me how to calculate it in a ceph? my surgeon will not do it because I am already a postoperative patient (the new calculation costs $ 2,500), but I would like to calculate it myself to check if the game is worth the candle and it is worth making an appointment with another surgeon

[kavan]

could you please tell me how to calculate it in a ceph? my surgeon will not do it because I am already a postoperative patient (the new calculation costs $ 2,500), but I would like to calculate it myself to check if the game is worth the candle and it is worth making an appointment with another surgeon

I hope you're not asking me to give you personalized tutorial in ceph analysis on the basis your surgeon won't and that you don't even show a  ceph. If that's the case, the answer is NO.

However, if you're just wanting some basic info on ceph analysis, here's a link.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781118925225.app1

There are other links in the EDUCATIONAL section.

[alanda]

Thanks for that article!! Thats exactly just what I needed- detailed but condensed information with graphics I don't understand what you mean by „that you dont even show a ceph”- if the point is that I sound unbelievable, I am sending my ceph in attachment

[kavan]

Thanks for that article!! Thats exactly just what I needed- detailed but condensed information with graphics I don't understand what you mean by „that you dont even show a ceph”- if the point is that I sound unbelievable, I am sending my ceph in attachment

Your question was asked in the absence of showing a ceph. Now that you have one and the article I gave, you can compare yours to the info they provide.