Please: Advice on Jaw & Midface Surgery (Pics Inside)

[Luis_McLovin]

Hello all,

Recently, in August of last year, I'd done a hair transplant (HT) as I'd been thinning for some time. I still am aggravated by my deficient face & profile and am seeking a solution. I believe surgery is the means to this. I've been casually reading online across searches and browsing forums without engaging yet and thus here I seek to share my images, my thoughts as to where I need attention. I believe these to be the culprits:

These are first 2 attachments taken before my HT, please note my head is slightly forward in the photos:

Pic 1 and 2

The last photo is ~6 months after HT, though they're taken casually on the phone - whereas first 2 are tripod. Here I am purposefully alternately chin-tucking and more relaxed. Please excuse facial hair, though note growth pattern and shape.

Pic 3

My judgement is I appear to be deficient in the infraorbital and maxillary area, and I am a victim of a downward growth jaw.

My bite is pretty good, no significant overbite, thanks to years of braces as a teen. Thanks to this, I also have a narrow palate, the braces too surely played a role in my jaw development.

As a child I unfortunately was a victim of often mouth-breathing (no longer a serious issue anecdotally), but the damage has been done. I sometimes still wake up with the mouth open, though.

Seems my goinal angle is quite large, maxilla recessed (resulting in slight crook of the nose). From my front profile it is also visible that my jaw angles are assymetric, how my maxilla and mandible on front bite line up is also assymetric (madible is slightly left offset when viewed from front) and, possibly a result of midface assymetry, my left lower eyelid more pursed than the right, even when eyes open.

I have a casual understanding of surgical treatments, such as BIMAX/BSSO/MSDO/SARPE/MSE+FM/DJS/LeFort/IMDO/Genio/ChinWing/SFOT etc. however it is quite a large world of surgery treatments and I am lost as to which may me most appropriate for helping treat a hypoplastic face.

Besides aesthetic, I am also interest in breathing improvements, I've had in 2015 a septoplasty to improve my breathing by reducing turbinates. I still have mediocre breathing and a terrible sense of smell. I can't smell anywhere near as well as anybody! For this motive too I am wanting to understand which options could help improve breathing and improve my cosmetic appearance.

Please, may your thoughts be shared as to what is an appropriate treatment?

[GJ]

A ceph would be more helpful than those photos, but based on those photos I think a mild CCW rotation would be appropriate.

We'd need a ceph to see why you have the asymmetry. Many times it's due to the mandible growing longer on one side, but it could be the yaw. Do you have a cant in the maxilla? It's hard to say how to address it, or if it's even possible to address based on those photos. I recommend reading this:

https://go.digitalsmiledesign.com/hubfs/DSD%20Articles/Articles%20by%20others/Pich,roll%20and%20yaw.pdf

It might explain to yourself why it's happening. Personally, I don't think your asymmetry is very bad, and I wouldn't bother addressing it in a CCW surgery because your face would likely shorten a bit, and it would make it even less noticeable. If elongating the face, the opposite might be true, and it might be worth addressing then.

I also don't think you look bad at all. Look totally normal to me. All issues are mild, IMO.

[tyler93245]

Hard to tell if you are not shaved. If you still have breathing issues, you'd be suited for jaw surgery.

If you want to go about this the "right" way, you will need 2 surgeries. A double jaw surgery, then a midface surgery. You should aim for a double jaw surgery with CCW rotation, plus a modified lefort 3 (which is also done with ccw rotation). The two surgeries cannot be done at once, so you'd be looking at a period of 1.5 - 2 years preparing or recovering from surgery. It's a hard and expensive way to do it, but the only technical "correct" way.

You can also just have a double jaw surgery and use implants/ paste to correct the midface, but the results would be aesthetically inferior. Anecdotally, I've never seen an implant patient who looked natural. You'd have to ask someone else about that if that's your desired route.

There aren't that many good options for the midface at this current time. Either go through a expensive lefort procedure that may leave visual scars around your eyes (depending on surgeon) or go with implants/ paste that may make you look "goofy" or underprojected, respectively.

[kavan]

I don't see anything in your frontal photos that would impel me to advise you to pursue jaw surgery for correction. As to the right side of face (left side of photo) having a wider contour 'ARC' or being more 'volumetric' than the other side, filler to the left side of face (right side of the photo) could be used to arc out the slightly deficient side.

I don't see anything in your profile photos either that would impel me to advise to to pursue jaw surgery and I can't comment on areas covered up with a mustache.

As to infra-orbital rim area, that is NOT 'jaw surgery'. Deficiencies in that particular area are evaluated in terms of 'negative vector' relationships. A negative vector is when EYEBALL is too far forward to the infra-orbital rim area below it. Deficiencies are evaluated by dropping a a straight line vertical dropped down from the center outward projection of the EYEBALL. Negative vector is when infra-orbital area is behind the line. It looks like you have 0 vector relationship where eyeball and infra-orbital rim area just about on same line.

Conservative options for zero vector relationships or even very modest negative vector relationships are often addressed by filler. IMO, surgical options are more justifiable for people with very clear cut negative vector relationships. Yours is not. It's very modest to minor. Those options include orbital rim implants with midface lift (as to recruit cheek flesh higher in order to hide the outline of the implant) or a selective bone cutting surgery sometimes referred to as 'modified lefort 3' to advance the lower orbital rim forward.

Disclosure:

My assistance here is limited to providing you with information as to the (alternative) options that exist which are outside of venue of 'jaw surgery'. It is not with aim to persuade you to have this that or the other one, explain how the surgeries are performed, suggest doctors or to evaluate the risks. I leave that as a matter of self choice and research.

ETA:

Since your post is on the AESTHETIC section of board, my assessment and citing of options refer to the soft tissue contours that I can SEE. As to problems such as breathing issues which could put you in venue of surgical correction via maxfax surgery, those are things I can't evaluate from here. They are best evaluated/explored by consulting with a maxfax surgeon.

[Luis_McLovin]

A ceph would be more helpful than those photos, but based on those photos I think a mild CCW rotation would be appropriate.

...

 Personally, I don't think your asymmetry is very bad, and I wouldn't bother addressing it in a CCW surgery because your face would likely shorten a bit, and it would make it even less noticeable. If elongating the face, the opposite might be true, and it might be worth addressing then.

I also don't think you look bad at all. Look totally normal to me. All issues are mild, IMO.

Hi GJ, much appreciate the impartiality  My initial hunch agrees. Gains from a hypothetical surgery would inadvertently minimise present asymmetry anyway. Truly the focus is the apparent retrusion. To my knowledge, addressing assymetry specifically would be a very involved process, probably intramandibular distractors on each side carefully extended. I agree that there is little to gain there for the surgical effort and cost.

I took some different photos, here I shaved down up my mandible line and trimmed facial hair. The facial hair line to the chin runs along my mandible, felt with an index finger. The soft tissue around is visible and I’m with an upright head posture.

Ultimately though, it is as you write. I read on what cephalogram are following your comment and am going to seek this to properly understand whats underneath the skin. I imagine a max-fasc surgeon conducts it as part of their pre-op assessment. From prior threads on here I reckon Mirco, Alfaro and a few other European surgeons would be worthwhile to solicit their opinion too. I’d need to understand their costs too, as at the present time I afford a budget no more than 20 thousand.

As for breathing complications, following up from my initial post here I downloaded a “sleep recorder” app to see about snore and I was surprised that I no longer snore. I should mention I recently lost 20kg. I am quite pleased with this discovery! Hence I no longer have a justification of worry insofar as sleep breathing, at least, not at this time (I’m in my twenties). I did snore when younger and I was mouth-breathing at night as a child too. I also had extractions as a child, if I remember, 3 separate teeth. Today, I’ve what I’m confident is a class 1 bite (no malocclusion), thanks in part to 3 years of braces. Indeed it is a cosmetic and athletic performance enhancement desire on my part to seek this, improving airway and masculinisation of the jaw.

Time-wise, I am nearing finishing graduate school and could accomodate the weeks of recovery if this procedure were done shortly after graduation, before the responsibility of graduate employment afterwards.

But, I agree, it is mild. I will have to desist this if feedback from surgeons is negative, or if, personally, I felt that the possibility for cosmetic change was trivial given what capital it will cost. Meanwhile, please lets hope otherwise 

[GJ]

I see it, but those photos confirm it's mild. Ceph will help. Remember, too, that if you have thick tissue 3mm of bony movement = about 1mm of soft tissue movement. Thicker tissue can and usually does absorb the movement. Yours looks on the thicker spectrum just eyeballing the photos.

Report back once you have a plan. Don't tell the surgeon what you're thinking in terms of movements because it could bias them to plan around that.

[Luis_McLovin]

I see it, but those photos confirm it's mild. Ceph will help. Remember, too, that if you have thick tissue 3mm of bony movement = about 1mm of soft tissue movement. Thicker tissue can and usually does absorb the movement. Yours looks on the thicker spectrum just eyeballing the photos.

Report back once you have a plan. Don't tell the surgeon what you're thinking in terms of movements because it could bias them to plan around that.

Hi, just a quick update. I’m continued maturing my thoughts on the matter and started soliciting consults.

I’m scheduled to meet with Raffaini and his orthodontic collaborator for an in-person consult on June 15th. My goal remains to expand the airway passages as much as appropriate for the functional benefits (health, stress, chewing, sleeping etc.) and have it reflected on the face too with an outlook to go with the movement.

At the in-person visit they will perform diagnostic imagery. More to see come June 15th

I have an idea of which movement and outcome desired, however of course it is the experts I will meet with whom can confidently say what is possible and willing to do. From my end, I would ideally wish for this similar treatment plan that Paul Ocoeancig from Profilo Surgical does for his patients, which are as follows:

Maxilla:
1. Segmental maxilla split in half
2. Anterior impaction
3. Posterior down graft
4. Anterior advancement
5. Rotation of the maxilla segments outwards at the posterior end for widened bite

Mandible:
1. Bilateral Sagittal split behind the molars
2. Rotate the ramus at the condylar laterally outwards
3. Genio split part-way up mandible front, anterior advancement
4. Remaining mandible front split down front-line
5. Mandible opened outwards to widen, matching new ramus width

Some Photos to help illustrate the movement. Please note these images are not myself and are taken from the Profilo Surgical YouTube profile. The 1st is a before and the 2nd image is an after. Note the increased bigonial width and shortened lower third. This patient had a mandibular widening of 1.47cm and advancement at the chin point of over 2cm.

https://youtu.be/rYIn1q3VOiM?t=4170

[Luis_McLovin]

So I've done a CBCT and I think it speaks for itself. My functional issues, while real, are mild and obviously non-life threatening. My jaw structure is also oddly shaped as its plain to see the irregular development between the left and right sides. I still am interested in a procedure. I just came back from Italy after having seen Raffaini and he's uninterested. I'm seeking Zarrinbal for a telephone consult now that I have CBCT scans to share with him over email.

I would attach the whole archive but I'm limited by the allowed file types. I've included a screenshot.

[InvisalignOnly]

My two cents - please don’t hate me - in my entirely subjective opinion, you should shave the mustache. You would look a lot better overall. Even your mandible looks weaker because of the mustache. I would just shave it off and maybe grow a beard, or maybe not.

[Luis_McLovin]

My two cents - please don’t hate me - in my entirely subjective opinion, you should shave the mustache. You would look a lot better overall. Even your mandible looks weaker because of the mustache. I would just shave it off and maybe grow a beard, or maybe not.

Hi! Thanks on the comment Here’s what I look like recently! I stopped the moustache upkeep because laziness made it easier to simply use a beard trimmer all over XD I’d probably still do a Stache again in the future although the short beard now does suit very well…. And helps hide the asymmetry a bit Ive noticed that I look more “even” if I don’t clean shave. Suffice to say, if you look even clean shaven, you’ve got good structure

[InvisalignOnly]

I honestly think you look great in this latest photo! I wouldn’t mess with jaw surgery.

[Luis_McLovin]

I honestly think you look great in this latest photo! I wouldn’t mess with jaw surgery.

Thank you! I’ve also been recently considering less invasive health/cosmetic procedures - perhaps a MidFace Skeletal Expansion (or MARPE) to widen my dental arches and slightly increase my facial width, zygomatic projection, and get those sweet sweet respiratory health gains.

Perhaps with a combination of SFOT for the mandible arch it could partially correct the deficient asymmetry when repositing the teeth? without bi-max?

I do have mild respiratory issues. My cephalometry/ CBCT revealed interesting details about my nasal structure. Raffaini suggested I see an ENT as he reckons my past septoplasty may have partially failed. So I’m a bit lost as to how best to proceed.

I think I will still see if a MSE procedure (just maxilla lateral procedure) with dental repositioning would achieve my ambitions of better health and outlook. Raffaini also suggested I investigate reconstructive rhinoplasty procedures.

[Luis_McLovin]

Update:

Just had a Zoom call with a British Orthodontist, Dr Sunil Hirani. He works with young adults and children with MSE cases. His technicians are based in France and are directly trained by Won Moon, they make specific MSE appliances based on 3D scans of the teeth and mouth to best fit. Dr Sunil Hirani is interested, but needs to see me in person to further evaluate and perform 3D imaging.

Dr Sunil Hirani also advised that due to my age, 25, 26 this October, I need to be educated and prepared for if MSE fails. To mitigate this he advised that its possible either a corticotomy to facilitate the suture split or a SARPE to loosen the palate and expand with the MSE. I could potentially have the MSE fitted in Britian, fly to meet with a Maxillo who will do this SARPE, with the appliance already installed, and return to Dr Sunil Hirani to begin our treatment of expansion.

Now I am to visit Sunil Hirani for imaging and his decision if to proceed and also to reach out to a maxillo about collaborating together.

[Breakingbad]

I concur with what others have said--you look great. At the same time, your arches are visibly narrow. While I think that this has the potential to significantly affect appearance in a negative way in many cases, I don't think that's the case here. Still, there's no doubt that the effect of having wider arches on your appearance would be positive.

As I understand it, the major difference between the two solutions you had in mind, is that while the Paul Coceancig style bi-max treatment plan might achieve widening at the ramus, non-surgical expansion wouldn't. Aside from that, it seems that expansion would achieve all the other objectives. I don't see a particular benefit that would come from increasing your inter-ramal width. In the last photo you posted, your inter-ramal width looks well proportioned with respect to your interzygomatic and forehead width.

Off-topic, but looking at the Profilo Surgical Youtube video, I'm wondering if you know if rotating the ramus at the condylar laterally outwards is something that Paul Coceancig does as standard for his bi-max patients? I haven't encountered movements like that in the surgical plans I've seen. I wonder why. Could it be that he's the only surgeon who does this frequently?