Concerns about planned surgery with dr. Gunson

[tyler93245]

I am having jaw surgery done primarily to treat sleep apnea (AHI 10) aswell as bruxism. Of course the underlying cause is maxillary and mandibular hypoplasia. I have braces on and am preparing for surgery now.

I have consulted with a few jaw surgeons in the US, where I live. Out of the options I have, it seems that Dr. Gunson is one of the few doctors who will perform a posterior downgraft on the maxilla AND is experienced enough to make drastic enough movements of the jaw for all of this effort to be "worth my time". 

His plan seems reasonable and well thought through. CCW rotation of the mandible will be performed up to the point where the front incisor teeth are just below the molars. He explained to me that this is the anatomical limit of a CCW rotation, as placing the incisors above the molars would cause TMJ. From there, he explained amount of CCW rotation achieved will dictate how much maxillary and mandibular advancement will be possible. Basically, a simple multi-segment lefort1 + BSSO + CCW rotation case

I appreciate his plan because he has not presented arbitrary numbers in mm of advancement as a limit to the forwards movement, he has clearly demonstrated that he would be taking me to the anatomical limit of possible forwards growth through achieving as much CCW rotation as possible. For this reason I've chosen him to carry out my surgery.

I have requested that Dr. Gunson put his effort into expanding the airway as much as possible, with aesthetics/ balance being a low priority. My main goal with this surgery is to gain as large of an airway as possible.

My main concern lies here: I understand that as a result of my lower jaw deficiencies, my entire infraorbital plane is also recessed. In advancing the maxilla and mandible, I only stand to accentuate that existing recession. Given that my aim is to advance & rotate the lower jaws as much as anatomically possible, it seems I have extra reason to be concerned about this since I am aiming for results that most other jaw surgeons cannot provide & therefore have not been documented extensively. While aesthetics are a low priority for me, I would like to avoid looking worse as a result of this surgery. It seems that some sort of midface augmentation is required to counteract this imbalance introduced by the advancement of the lower jaws.


Dr. gunson provides patients with a cheekbone augmentation proceedure as an optional part of his jaw surgeries. The HA paste will eventually become part of my bone, and from what I can tell it will avoid the goofy puffed look of implants that comes from silicone lying ontop of soft tissue.  The major benefit for me, however, is that Dr. Gunson would be able to complete it at the same time he would be performing my double jaw surgery. I would avoid the need to have a separate surgery for something I don't want to worry or think about in the first place.

I do have concerns about Dr. Gunson's abilities to complete this midface augmentation, however. I was hoping some of you could chime in since I noticed that atleast one member here has had midface HA paste augmentation done with Dr. Gunson.

Red flags for me include that Dr. Gunson refers to the procedure as 'cheekbone augmentation', which implies he is not addressing the overall recession of the midface but rather only augmenting parts where the zygoma most frontally protrudes. This would obviously cause aesthetic issues if the other areas of recession, mainly the infraorbital rims, are not addressed. Since a 'clockwise' rotated posture of the infraorbital complex is implicit to recession, it seems as though augmenting only the cheekbones would cause a visual appearance of low-set cheekbones and emphasize recession of the infraorbital rims.

The experience of the other individual on this forum who had this procedure with Dr. Gunson seems to exactly confirm this theory.

I am trying to weigh the risks of the HA paste cheekbone augmentation procedure with Dr. Gunson. First and foremost, I would like to know from others who have experience with it that it will atleast not make me look worse. If that is the case, I think I am inclined to accept the shortcomings of the procedure for its convenience. Again, my main goal is simply to avoid looking deformed given my (more) unique request of maximum forwards movement at the cost of aesthetics. I would love to hear the opinions of those who have gone through/ considered this procedure as to whether, in my specific case & for my expectations, this HA paste midface augmentation is worth doing or if I would be safer off (aesthetically speaking) skipping it.

Attached are my photos/ scans for your evaluation. I apologize for the lack of a traced CEPH scan, since my posterior downdraft will be determined by my dental anatomical limits I hope the untraced CEPH attached will suffice.


https://imgur.com/a/RszIo9y
 

[GJ]

Regarding surgery, if you do decide on it some day, I think if Gunson is willing to do a modified lefort 3, then that's the better option over HA, but to my knowledge he doesn't do that.

HA does not have a great reputation here. I know people who have had it done with surgery, and they complain about the look of it. I've seen a few in-person, and I agree something was off, though it's hard to say what was the HA and what was the surgery. It almost seemed in the wrong place, as you say, but it was really hard to tell.

My advice: do more research. I'm not sure where you live, but you can try to meet up with people who have had it done (even if as part of surgery).

What is strange is that you went from surgery for functional reasons where you didn't really care about aesthetics to a purely cosmetic procedure.

[tyler93245]

Regarding surgery, if you do decide on it some day, I think if Gunson is willing to do a modified lefort 3, then that's the better option over HA, but to my knowledge he doesn't do that.

What is strange is that you went from surgery for functional reasons where you didn't really care about aesthetics to a purely cosmetic procedure.

Correct, Gunson does not perform that surgery.

Either way, (This from the ml3 doctor I consulted with) a modified lefort 3 cannot be performed at the same time as a lower jaw surgery due to there being too much uncertainty in the ways the jaws will finally position themselves after they heal. In other words, the experience of the other forum member here who had this surgery without the lower jaws being moved actually embodies the standard for this surgery- not the exception.

I looked into ml3 mainly for the possibility that it could be performed at the same time as a DJS as a superior alternative to other forms of midface augmentation. Since this is not possible, I am not interested in the surgery. The process of getting a second jaw surgery soley for aesthetics would be too inconvenient for me and wouldn't make sense for my personal goals since I am indifferent to aesthetics for the most part. I only mentioned the research I did in this post to clarify as to why the procedure is not an option for me.

Also, to further clarify, my goals are not aesthetic. I am looking into these cosmetic-only procedures because of my specific goal I have communicated with Dr. Gunson. Extreme forwards movement of the lower jaws is likely to create a large amount of imbalance in facial harmony around the orbitals, especially judging by Dr. Gunson's examples of past patients for MMA surgery. My desire is to preserve the harmony I currently have, and avoid looking worse as a result of the DJS. Overall, my biggest goal would be to find an optimal balance of aesthetics and convenience when looking to augment my midface- and the HA paste augmentation seems to be the only procedure which can achieve this balance since it can be performed during the DJS.

HA does not have a great reputation here. I know people who have had it done with surgery, and they complain about the look of it. I've seen a few in-person, and I agree something was off, though it's hard to say what was the HA and what was the surgery. It almost seemed in the wrong place, as you say, but it was really hard to tell.

As such, in the hopes of finding the right balance between aesthetics and convenience, I am willing to accept the shortcomings of this operation because of the fact that it can simply be 'tacked on' to the functional DJS procedure that I have already planned with Dr. Gunson.

Ultimately, If I have the surgery and I come out with a subpar aesthetic result, I will not bother with a revision or additional surgery since I am not concerned enough with aesthetics to bother. I do think, however, that since this HA paste procedure has been offered to me in such a convenient and easy manner by Dr. Gunson, it is worth considering.

I would just like to be sure that I'm not making a grave mistake by accepting this procedure. Mainly, I would like to rule out the possibility that undergoing DJS + midface augmentation with Dr. Gunson would leave me looking worse off than soley having a DJS procedure done with him.

I am hoping some individuals here who have dealt with Dr. Gunson can chime in. I have read their opinions on the HA procedure, and I hope they can elaborate on their experiences more.

Thank you GJ, I appreciate the response.

[GJ]

Ah okay, I misunderstood your comment. I thought you were saying you decided against DJS.

[kavan]

I don't know how much you would need to 'maximize' your air way which factors into the bimax advancement you get. It depends on what your base line airway measure is and how much advancement it would take to bring it to the norm of an ample airway. But just to say the term; 'to maximize' in maxfax refers to minimizing something else. So, with the CCW-r, they want to maximize the horizontal displacement vector while minimizing an unwanted vertical displacement vector or to maximize airway expansion while minimizing unwanted aesthetic sequella. That's what the CCW is about. I'm not sure if you're making a special request to have the largest airway possible like beyond what's ample even if it looked bad on your face. So, in maxfax CCW, when they say they want to maximum airway expansion via CCW, it means they want to MINIMIZE unwanted (and un aesthetic) vertical displacement vectors to get the horizontal displacement vector they want. They can get the same horizontal displacement vector with linear advancement to open up the airways in a person with a very HIGHLY inclined (occlusal) plane (steep OP) but with it, comes the unwanted vertical displacement vector that sacrifice aesthetics. So, with 'maximizing', it relates to 'minimizing' something else as in; 'We've OPTIMIZED or BALANCED. Here's the maximum we've kicked up as a function of minimizing something else.' Not to belabor but best not to be interpreted as requesting; 'Give me the biggest airway possible and I don't care if it's beyond optimal or ample if it looks bad.'

Besides, a lot of advancement will make recession to the upper midface more visible by relative comparison and they can't bulk up the HA granule material that much. You can get about 5mm out of a porex orbital rim implant and maybe 2 or 3 from the HA material. When he says 'cheek', he could mean the cheek complex that includes orbital rim area, maybe assuming most patients won't be bandying the term 'orbital rim'. Just ask him to draw on your face photo the area he's going to augment with the stuff. 2-3 mm is fine if he can frost more surface area of the bone structure with it instead of isolating it to just the zygoma area

[GJ]

When he says 'cheek', he could mean the cheek complex that includes orbital rim area, maybe assuming most patients won't be bandying the term 'orbital rim'. Just ask him to draw on your face photo the area he's going to augment with the stuff. 2-3 mm is fine if he can frost more surface area of the bone structure with it instead of isolating it to just the zygoma area

Yes, asking him to draw it is a good idea. In general, the HA they use is put lower on the cheekbone. Patients sometimes get upset by this because it's not what they're expecting.

[tyler93245]

I don't know how much you would need to 'maximize' your air way which factors into the bimax advancement you get. It depends on what your base line airway measure is and how much advancement it would take to bring it to the norm of an ample airway. Not to belabor but best not to be interpreted as requesting; 'Give me the biggest airway possible and I don't care if it's beyond optimal or ample if it looks bad.'

This is actually precisely what I'm hoping for.

I have yet to see an objective measurement of constitutes an 'acceptable' airway. I have seen certain evidence of airway sizes that way eliminate the issue of sleep apnea, ex. http://www.drlarrywolford.com/tmj-jaw-surgery-diagnosis-treatment/airway-evaluation-tmj-corrective-jaw-surgery/ "The normal anterior-posterior dimension from the posterior pharyngeal wall to the soft palate and posterior pharyngeal wall to the base of the tongue should be 11 mm, plus or minus 2 mm... Accompanying these deficiencies is usually a high occlusal plane angle. A normal occlusal plane to the Frankfort horizontal plane is 8 degrees, plus or minus 4 degrees", however I have never seen a proper explanation for what constitutes a 'proper' airway besides anecdotal experience from doctors who's primary goal it is to 'cure' apnea through elimination of an AHI index. Anecdotally, from my ENT (who was involved in the pioneering of jaw surgery treatment for UARS), I have heard stories of jaw surgeons planning surgeries to provide 'just enough' forwards advancement to eliminate an apnea index- just to have apnea reappear in the patient as they age and soft tissue support in the airway collapses. He communicated to me that there is an overall lack of scientific understanding of the airway by most jaw surgeons, and it is much safer to have aggressive movements done during jaw surgery than to risk being 'under-operated' on and have to repeat the process later on in life. I am not concerned about this issue with Gunson in specific, since he obviously appreciates the art of more drastic movements- however it lays the pretext for my inclination that there isn't necessarily a set airway size that one should hope to achieve, 'more is better'.

On the subject of 'more is better', I do believe there is more to be gained than just an 'acceptable' airway. There are studies which indicate that there could be a linear relationship between airway size and overall airway performance, with no set point at which an airway becomes 'too big' to provide more utility. For example studies on athletes and airway size https://bmjopensem.bmj.com/content/6/1/e000886
http://www.mosessport.com/Relationship_of_Muscular_Strength_to_Jaw_Posture_in_Sports_Dentistry.pdf

My goals, mostly being functional, are directly tied to the size of the airway I can gain (for the most part). Perfect posture, increased athletic performance, and the ability to sleep well in any position/climate all are of great interest to me. Thus, I would accept a subpar aesthetic outcome in favor of a 'beyond reasonable' jaw size- due to my personal opinion that the current scientific understanding of the airway MAY be flawed (not to say I'm smarter than anyone, rather that I have noticed a trend in research that indicates such).

with the CCW-r, they want to maximize the horizontal displacement vector while minimizing an unwanted vertical displacement vector or to maximize airway expansion while minimizing unwanted aesthetic sequella. That's what the CCW is about. I'm not sure if you're making a special request to have the largest airway possible like beyond what's ample even if it looked bad on your face. So, in maxfax CCW, when they say they want to maximum airway expansion via CCW, it means they want to MINIMIZE unwanted (and un aesthetic) vertical displacement vectors to get the horizontal displacement vector they want. They can get the same horizontal displacement vector with linear advancement to open up the airways in a person with a very HIGHLY inclined (occlusal) plane (steep OP) but with it, comes the unwanted vertical displacement vector that sacrifice aesthetics. So, with 'maximizing', it relates to 'minimizing' something else as in; 'We've OPTIMIZED or BALANCED.

I believe this is, exactly, what I discussed with Dr. Gunson (and why I am particularly concerned about midface imbalance given my request for drastic movements from the already drastically- moving doctor). He indicated he would be able to perform a posterior downgraft to my anatomical limit, then perform as much horizontal displacement as my bone structure would allow- up to the limit where the final results may become unstable. I am actually unsure of what exactly that limit is, and I will have to confirm exactly what the limit is with Dr. Gunson. Assuming, however, that the isolated linear horizontal displacement would be equal to or greater than your example of a purely linear advancement "They can get the same horizontal displacement vector with linear advancement to open up the airways in a person with a very HIGHLY inclined (occlusal) plane (steep OP) but with it, comes the unwanted vertical displacement vector that sacrifice aesthetics" then yes, that would precisely encompass my goal. As much rotation and forwards advancement as possible (possibly to my own aesthetic detriment, which I am overall OK with). This would be certainly be past the point of an aesthetically 'balanced' face, however it would mean I would be moving closer to the ideal of an 'optimized' face in the frame of my own goals and opinions.

Just ask him to draw on your face photo the area he's going to augment with the stuff. 2-3 mm is fine if he can frost more surface area of the bone structure with it instead of isolating it to just the zygoma area

That is a terrific idea, I will do so as soon as I get the chance.

Thank you Kavan, I greatly appreciate your knowledge and well elaborated response.

[kavan]

OK, when Wolford says 11mm, he's referring to a diameter cross section since the measure is in millimetres (as opposed to mm cubed for volume).  So, 11mm-13 would be the norm, one they consider ample to increase and improve the airway. They might be able to go a little over that. But consider that if you are going to someone like Wolford or Gunson, not only do they want to increase the airway but they also want to decrease negative aesthetic sequella along with that. They operate on principle of balancing FACE, AIRWAY and BITE which is a reason the Arnett school of thought which Gunson uses is often referred to as 'FAB'. That's one of the reasons people go to Gunson (or Wolford). They are looking for ADEQUATE airway with optimized aesthetics. In fact both are sought out when aesthetics are a key consideration. However, since Gunson's aesthetics DO include more dramatic advancements (when they would look good), perhaps doing so would also kick up a VERY ample airway.

If you really don't care what you look like after a request for 'the biggest airway of all' that exceeds what he would consider as ample to improve your breathing and to kick better aesthetics in the process, then it sounds like you could be looking for the maxfax equivalent of Dr. Eppley who gives patients what they SAY they want when doing what they say they want doesn't always look good. I'm not too sure Gunson is going to go over board with the airway if going WAY BEYOND 'very ample' is going to kick up poor aesthetics. Even IF he did and bimaxed your face WAY BEYOND where it would NOT conform to an improved aesthetic, there would be little way to COMPENSATE for that via improvements to the upper midface. So, if you don't care about the aesthetics of a LOT of OVER ADVANCEMENT to get 'biggest airway of all', you would need to also abandon  care of how (bad) your upper midface could look  when it's left so far behind via RELATIVE COMPARISON.

ETA:

Logically, the following are self negating goals. They are logically inconsistent.  You can't 'avoid ' looking worse as a result of DJS and also willingly accept looking worse if that's the outcome that would go along with a beyond reasonable jaw advancement in the act of going 'toward' a beyond ample airway. You're saying that you want to 'avoid' something yet go 'towards' it at the same time.

My desire is to preserve the harmony I currently have, and avoid looking worse as a result of the DJS.

My goals, mostly being functional, are directly tied to the size of the airway I can gain (for the most part). Perfect posture, increased athletic performance, and the ability to sleep well in any position/climate all are of great interest to me. Thus, I would accept a subpar aesthetic outcome in favor of a 'beyond reasonable' jaw size-.....

[tyler93245]

OK, when Wolford says 11mm, he's referring to a diameter cross section since the measure is in millimetres (as opposed to mm cubed for volume).  So, 11mm-13 would be the norm, one they consider ample to increase and improve the airway. They might be able to go a little over that. But consider that if you are going to someone like Wolford or Gunson, not only do they want to increase the airway but they also want to decrease negative aesthetic sequella along with that. They operate on principle of balancing FACE, AIRWAY and BITE which is a reason the Arnett school of thought which Gunson uses is often referred to as 'FAB'. That's one of the reasons people go to Gunson (or Wolford). They are looking for ADEQUATE airway with optimized aesthetics. In fact both are sought out when aesthetics are a key consideration. However, since Gunson's aesthetics DO include more dramatic advancements (when they would look good), perhaps doing so would also kick up a VERY ample airway.

If you really don't care what you look like after a request for 'the biggest airway of all' that exceeds what he would consider as ample to improve your breathing and to kick better aesthetics in the process, then it sounds like you could be looking for the maxfax equivalent of Dr. Eppley who gives patients what they SAY they want when doing what they say they want doesn't always look good. I'm not too sure Gunson is going to go over board with the airway if going WAY BEYOND 'very ample' is going to kick up poor aesthetics. Even IF he did and bimaxed your face WAY BEYOND where it would NOT conform to an improved aesthetic, there would be little way to COMPENSATE for that via improvements to the upper midface. So, if you don't care about the aesthetics of a LOT of OVER ADVANCEMENT to get 'biggest airway of all', you would need to also abandon  care of how (bad) your upper midface could look  when it's left so far behind via RELATIVE COMPARISON.

Understandable. I definitely do not want the 'eppley' equivalent of jaw surgery. When speaking with Dr. Gunson I did confirm with him that we work towards airway results over aesthetic balance. I did think he was going to be taking me to my anatomical limits with expansion (thus my elusion to 'beyond- reasonable jaw size')- however I will have to confirm with him what exactly his limit was in the horizontal vector after the posterior downgraft was completed (be it anatomy or aesthetics). Either way, I most certainly do not want to be an eppley case. I should clarify, my concern is that he has agreed to focus on the airway as a priority in the F-A-B trio; I want to see what measures I can take to minimize visual orbital recession. Given the patients on his before-after page already seem to have a good amount of imbalance, and I will be on the more aggressive end of the imbalance scale considering the plans I currently have with Dr. G, I would like to do a good amount of research on his HA paste procedure to see if it will help or harm the situation.

I suppose my clarification about my agreement with Dr. G to prioritize A in F-A-B should address my apparent cognitive dissonance. My apologies for not making that clearer. I'm not expecting to look worse, regardless of the lower jaw movements I get. I'm just preparing for an outcome that may be less aesthetic than a standard F-A-B surgery due to my goals. What I do worry may make me look worse is the cheek augmentation in specific (again, my failure to clarify). 

As always, Kavan, your intelligence and thoughts are much appreciated.

[kavan]

Understandable. I definitely do not want the 'eppley' equivalent of jaw surgery. When speaking with Dr. Gunson I did confirm with him that we work towards airway results over aesthetic balance. I did think he was going to be taking me to my anatomical limits with expansion (thus my elusion to 'beyond- reasonable jaw size')- however I will have to confirm with him what exactly his limit was in the horizontal vector after the posterior downgraft was completed (be it anatomy or aesthetics). Either way, I most certainly do not want to be an eppley case. I should clarify, my concern is that he has agreed to focus on the airway as a priority in the F-A-B trio; I want to see what measures I can take to minimize visual orbital recession. Given the patients on his before-after page already seem to have a good amount of imbalance, and I will be on the more aggressive end of the imbalance scale considering the plans I currently have with Dr. G, I would like to do a good amount of research on his HA paste procedure to see if it will help or harm the situation.

I suppose my clarification about my agreement with Dr. G to prioritize A in F-A-B should address my apparent cognitive dissonance. My apologies for not making that clearer. I'm not expecting to look worse, regardless of the lower jaw movements I get. I'm just preparing for an outcome that may be less aesthetic than a standard F-A-B surgery due to my goals. What I do worry may make me look worse is the cheek augmentation in specific (again, my failure to clarify). 

As always, Kavan, your intelligence and thoughts are much appreciated.

OK, I'm glad we established rapport here. Have him give you a contour displacement diagram. It's something where there is 2d contour diagram made from your ceph and another one transposed on it showing the change in profile contour. Although the airway 'advancement' isn't listed on the read out as are the other advancements, the change can be seen on the contour diagram made from the ceph.

[tyler93245]

Have him give you a contour displacement diagram

I believe he gave me one, here it is
https://imgur.com/a/h6JDAUQ
I was unsure of what to make of the meaning of it. It looks like the mandible ends up further back with the maxilla further down(?) I didn't think these would be the final movements of the surgery. Is this something I should bring up with Dr. G?

[kavan]

I believe he gave me one, here it is
https://imgur.com/a/h6JDAUQ
I was unsure of what to make of the meaning of it. It looks like the mandible ends up further back with the maxilla further down(?) I didn't think these would be the final movements of the surgery. Is this something I should bring up with Dr. G?

The profile contour change looks GREAT! The airway on the diagram and change (increase) thereof, I believe is marked by the paired 'S' curves at the gonial angle. The displacement at the posterior mandible and maxilla is not a concern.

[tyler93245]

The profile contour change looks GREAT! The airway on the diagram and change (increase) thereof, I believe is marked by the paired 'S' curves at the gonial angle. The displacement at the posterior mandible and maxilla is not a concern.

That is great to hear. Much appreciated!

[beautyislife]

Regarding surgery, if you do decide on it some day, I think if Gunson is willing to do a modified lefort 3, then that's the better option over HA, but to my knowledge he doesn't do that.

HA does not have a great reputation here. I know people who have had it done with surgery, and they complain about the look of it. I've seen a few in-person, and I agree something was off, though it's hard to say what was the HA and what was the surgery. It almost seemed in the wrong place, as you say, but it was really hard to tell.

My advice: do more research. I'm not sure where you live, but you can try to meet up with people who have had it done (even if as part of surgery).

What is strange is that you went from surgery for functional reasons where you didn't really care about aesthetics to a purely cosmetic procedure.

I agree with this. I had HA paste placed on my cheeks and hate the outcome. It along with not enough advancement are biggest gripes with the surgery. I also don't think it was worth the cost, I would've gone with someone else, but hindsight is always a b****

[tyler93245]

It along with not enough advancement are biggest gripes with the surgery.

May I ask more about this specifically? AKA what you asked of Dr. G/ the aspects he most closely focused on during the surgery (emphasis on advancement vs emphasis on balance)?