Preventing upturning (pig nose) after maxillary advancement (Lefort 1 forward)

[tonebame]

Hi guys, I am getting a LeFort 1 with my double jaw surgery to fix an underbite. This is not for cosmetic reasons whatsoever, it's functional, but I'd still prefer the cosmetic side to not botch my nose and facial harmony. The maxillary advancement will probably be something like 8-10mm or more. It will be alot. One of the biggest concerns I have is upturning.

I understand that your nose does widen- and even an alar cinch can't mitigate it that much- that's actually fine by me.

The real concern is the upturning because it gives off a pignose effect- this is one of the most unattractive features for me that I would hate to get- once your nostrils show that much- it practically consumes everyones attention no matter how perfect your other features are- and more importantly it consumes my own attention, I don't want to look like that. I'd take a wide nose anyday over an upturned one. Because it looks better, and also because an alar base reduction is infinitely easier to do than a rhino to lengthen my nose downwards. I have a wider asian nose for context. 

So my question to knowledgeable members are- what's the best way to prevent or mitigate this pignose upturning effect from a big maxillary advancement?

From users like @kavan or @PloskoPlus I have seen very interesting threads. Seems like anterior nasal spine reduction could work? My nose is not tethered like kavan's link, and I can feel my nasal spine definitely inside my nostrils and not in the columella at all whatsoever. And would getting an alar stich be even worse due to it causing more upturn? Can alar stich be removed after 6 months or so as well if I don't like what it did to my nose and would be nose tissue return to normal?


Jesus Christ, I sound insufferable and like such a big whiner already. Sorry for all these questions- I am just compiling everything I intended on saying in 1 post after registering on this forum, hence it's long. Sorry!

https://jawsurgeryforums.com/index.php/topic,7579.msg67070.html#msg67070

https://jawsurgeryforums.com/index.php/topic,3801.msg25664.html#msg25664

tagging them here, apologies

Thank you two very much, I truly appreciate all you guys do. Really thank ya'll!



                    tldr; How to reduce upturning after maxilla advancement? ANS reduction? No alar cinch? Anything else? I don't mind widening of the nose- just mind the upturning.

[GJ]

8-10 mm is a pretty huge movement for just the maxilla. Are you sure that's the appropriate movement, and you don't need some type of rotation? Many times when the movement is that large, rotation is a better option.

Yes. Reducing the ANS could help. But I don't know if it will help a lot with an 8-10mm movement. I think even the most prominent ANS are only 3 or 4mm. To my knowledge the alar cinch only helps with widening, and it doesn't create an upturning, but I sort of get what you're thinking - as you pinch the sides, it might actually move the nose up? Seems like something that makes sense in theory but doesn't really happen. FWIW: I had a 3-4mm movement of the maxilla and ans reduction, and didn't have the pig nose issue. The cinch kept width pretty good, too. Maybe 1.5mm total widening.

[tonebame]

8-10 mm is a pretty huge movement for just the maxilla. Are you sure that's the appropriate movement, and you don't need some type of rotation? Many times when the movement is that large, rotation is a better option.

Yes. Reducing the ANS could help. But I don't know if it will help a lot with an 8-10mm movement. I think even the most prominent ANS are only 3 or 4mm. To my knowledge the alar cinch only helps with widening, and it doesn't create an upturning, but I sort of get what you're thinking - as you pinch the sides, it might actually move the nose up? Seems like something that makes sense in theory but doesn't really happen. FWIW: I had a 3-4mm movement of the maxilla and ans reduction, and didn't have the pig nose issue. The cinch kept width pretty good, too. Maybe 1.5mm total widening.

Hi GJ, thank you for the response and your own story! Now that I know you did ANS reduction, may I ask if your nose projection seems flatter than normal after ANS reduction? Was your ANS in your columella or was it deep inside the nostrils like mine?

Thank you for your statement about the alar cinch. I guess I will keep the alar cinch based on what you said- you understood exactly what I was inferring.
Yeah, I think my surgeon is going to move the front part down vertically (he said clockwise rotation of the jaw- not counter clockwise, is clockwise a thing? only hear of CCW, never CW), because my teeth are also really little show + recessed. Is this called downgrafting? And how can this affect the nose- if I were to put my maxilla more downwards in the front? When I smile I basically can barely see my front teeth.

The 8-10mm was a guess based on my underbite numbers (10mm underbite, maybe more), but I think you know more than me since I hadn't factored in rotations or any of that. 8-10 isn't the official number from my doctor.

Thank you alot GJ.

[GJ]

I'm not sure on the specifics of the ANS. I'd have to look through my notes if I have any on that.

If you're an underbite case, usually that's resolved best by moving the lower jaw back a little and upper forward a little. That way you don't get extreme movements like 10mm of the upper. Also it keeps the lower from having neck flab. These cases usually are linear movements, too, without rotation. So now this is making more sense. Maybe show us this plan when you have it.

[kavan]

1: The orientation of ANS-PNS needs to be observed in a ceph. Profile facing to the right. When ANS is HIGHER than PNS, the inclination will be that of an upward diagonal. That's when 'forward' advancement can upturn the nose. That's because 'forward' advancement of ANS-PNS will be a combination of horizontally outward AND vertically upward because movement is along upward diagonal. If ANS-PNS is basically 'level' or 'horizontal', there is little to no displacement vector of vertically upward. With NO CEPH to observe, no way to tell what your ANS-PNS orientation is. Also, IF ANS is higher than PNS, a CLOCKWISE rotation would help decrease the inclination of ANS-PNS and that would help mitigate the 'upturning' to the base of the nose.

2: It is best to have a surgeon who is CONVERSANT in rhinoplasty techniques. Some  can make a 'V' notch under the ANS to prevent it from going too far forward. However, cutting out a 'V' notch BELOW the ANS usually requires pzeizo electric cutting tools and lots of practice with them. As to actually CUTTING the ANS off, whether it's all or just some of it, AGAIN, the maxfax needs to be converant in rhino techniques because the nose base could collapse down due to no ANS support.

3: If surgeon is not conversant in rhino techniques, it is NOT a good idea to be a 'back street driver' by making requests to him/her to cut down the ANS. You must be poised to pursue a RHINOPLASTY subsequent to the maxfax surgery for such things as de-rotation of the nose base.

4: There is NO 'instructions' you can give to a surgeon who is not conversant in rhinoplasty techniques IF in fact they are needed to mitigate the nose base from going 'upturning'. You need to ESTABLISH IF your surgeon is in that capacity or be braced to pursue rhino subsequent to your maxfax surgery.

[Post bimax]

IMO a maxillary advancement of that degree will almost certainly cause upturning. Also as a word of caution, my first surgeon was also a rhinoplasty surgeon and I still got the ‘pig nose’ as you describe.

[tonebame]

I'm not sure on the specifics of the ANS. I'd have to look through my notes if I have any on that.

If you're an underbite case, usually that's resolved best by moving the lower jaw back a little and upper forward a little. That way you don't get extreme movements like 10mm of the upper. Also it keeps the lower from having neck flab. These cases usually are linear movements, too, without rotation. So now this is making more sense. Maybe show us this plan when you have it.

Thanks GJ. My surgeon stated he would definitely move my lower jaw back yeah, I guess I can expect a smaller maxillary advancement then. I will definitely show the plan when I get it in a few months.

IMO a maxillary advancement of that degree will almost certainly cause upturning. Also as a word of caution, my first surgeon was also a rhinoplasty surgeon and I still got the ‘pig nose’ as you describe.

Hey. It seems pretty likely yeah, based on the amount of reddit posts I've looked at of significant underbites being fixed. Nearly all of them have upturning of their nose if they did significant maxillary advancement. I hope I can mitigate it- if it's not too much upturning I could definitely live with it. If it's a little bit of upturning that's fine. Just pig-like is a no-no. I hope I can get a good result

1: The orientation of ANS-PNS needs to be observed in a ceph. Profile facing to the right. When ANS is HIGHER than PNS, the inclination will be that of an upward diagonal. That's when 'forward' advancement can upturn the nose. That's because 'forward' advancement of ANS-PNS will be a combination of horizontally outward AND vertically upward because movement is along upward diagonal. If ANS-PNS is basically 'level' or 'horizontal', there is little to no displacement vector of vertically upward. With NO CEPH to observe, no way to tell what your ANS-PNS orientation is. Also, IF ANS is higher than PNS, a CLOCKWISE rotation would help decrease the inclination of ANS-PNS and that would help mitigate the 'upturning' to the base of the nose.

2: It is best to have a surgeon who is CONVERSANT in rhinoplasty techniques. Some  can make a 'V' notch under the ANS to prevent it from going too far forward. However, cutting out a 'V' notch BELOW the ANS usually requires pzeizo electric cutting tools and lots of practice with them. As to actually CUTTING the ANS off, whether it's all or just some of it, AGAIN, the maxfax needs to be converant in rhino techniques because the nose base could collapse down due to no ANS support.

3: If surgeon is not conversant in rhino techniques, it is NOT a good idea to be a 'back street driver' by making requests to him/her to cut down the ANS. You must be poised to pursue a RHINOPLASTY subsequent to the maxfax surgery for such things as de-rotation of the nose base.

4: There is NO 'instructions' you can give to a surgeon who is not conversant in rhinoplasty techniques IF in fact they are needed to mitigate the nose base from going 'upturning'. You need to ESTABLISH IF your surgeon is in that capacity or be braced to pursue rhino subsequent to your maxfax surgery.

Thank you kavan, this was extremely detailed. I hope you can look at my cephs and other picture (ambered colored bones? not sure what this imaging type is called)

I was actually considering telling my non-rhino surgeon to shave off my ANS, but per your advice, I agree it's probably best to do a separate rhino with a more qualified person.

Here are my imagings, there are 4 pictures, some showing soft tissue and some showing just the bone.

Thank you so much kavan, please have a look: https://imgur.com/a/fDQp7ZV

[kavan]

Thanks GJ. My surgeon stated he would definitely move my lower jaw back yeah, I guess I can expect a smaller maxillary advancement then. I will definitely show the plan when I get it in a few months.

Hey. It seems pretty likely yeah, based on the amount of reddit posts I've looked at of significant underbites being fixed. Nearly all of them have upturning of their nose if they did significant maxillary advancement. I hope I can mitigate it- if it's not too much upturning I could definitely live with it. If it's a little bit of upturning that's fine. Just pig-like is a no-no. I hope I can get a good result

Thank you kavan, this was extremely detailed. I hope you can look at my cephs and other picture (ambered colored bones? not sure what this imaging type is called)

I was actually considering telling my non-rhino surgeon to shave off my ANS, but per your advice, I agree it's probably best to do a separate rhino with a more qualified person.

Here are my imagings, there are 4 pictures, some showing soft tissue and some showing just the bone.

Thank you so much kavan, please have a look: https://imgur.com/a/fDQp7ZV

Your ANS is below your PNS. You have an overly acute base of nose to lip angle. Your tip is already rotated DOWNWARD. So, with all those things together, I don't think you have to worry about getting an upturned snout like nose because much to most of the advancement would go into increasing the overly acute base of nose to lip angle so it's closer to 90 degrees and you DO need SOME de-rotation of the downward rotated nose tip. Basically, your downward rotated tip in addition to the overly acute nose to lip angle is that of a 'collapsed' nose with VERY LITTLE support from the ANS (because it's too far back to your face because of maxillary recession) whereas the ANS should support it better when it is ADVANCED. Hence, I don't think you have to worry about this. It looks to be within the venue where IF you needed some ANS 'shaving', the modest amount would be within what many maxfax docs can do during the surgery. A problematic ANS case is when someone has what I referred to as base of the nose to lip 'tethering' and a really prominent ANS, in which case they need what's called a 'deprojection' rhino. That is NOT you. You are the opposite of that.

[tonebame]

Your ANS is below your PNS. You have an overly acute base of nose to lip angle. Your tip is already rotated DOWNWARD. So, with all those things together, I don't think you have to worry about getting an upturned snout like nose because much to most of the advancement would go into increasing the overly acute base of nose to lip angle so it's closer to 90 degrees and you DO need SOME de-rotation of the downward rotated nose tip. Basically, your downward rotated tip in addition to the overly acute nose to lip angle is that of a 'collapsed' nose with VERY LITTLE support from the ANS (because it's too far back to your face because of maxillary recession) whereas the ANS should support it better when it is ADVANCED. Hence, I don't think you have to worry about this. It looks to be within the venue where IF you needed some ANS 'shaving', the modest amount would be within what many maxfax docs can do during the surgery. A problematic ANS case is when someone has what I referred to as base of the nose to lip 'tethering' and a really prominent ANS, in which case they need what's called a 'deprojection' rhino. That is NOT you. You are the opposite of that.

kavan, I just want to say thank you so much. You have alleviated alot of my fears- your explanation makes alot of sense and now I know that even if my nose upturns, it probably won't upturn to the point where I would dislike it. I probably don't even think I'll want an alar base reduction anymore either. I'll be fine! Thank you so much for your explanation- it definitely relieved alot of my neurotic thoughts. First the first time in months I am finally looking forward to my DJS. I will keep you guys updated in the future on my progress.

[GJ]

kavan, I just want to say thank you so much. You have alleviated alot of my fears- your explanation makes alot of sense and now I know that even if my nose upturns, it probably won't upturn to the point where I would dislike it. I probably don't even think I'll want an alar base reduction anymore either. I'll be fine! Thank you so much for your explanation- it definitely relieved alot of my neurotic thoughts. First the first time in months I am finally looking forward to my DJS. I will keep you guys updated in the future on my progress.

My nose tipped down a bit pre-op. Post-op it did turn up a bit, but it's minor. Everyone has a different result, and it will depend on many things, but in general your nose should look within normal even if it turns up a little. I'd say brace yourself for a minor change with it turning up a little. It's also possible the tip doesn't turn up, but the nostrils flare. I can't see you having a pig nose based on the records you posted, but I can see some of the changes I'm mentioning. Prepare for them, and if they don't happen, great.

[kavan]

kavan, I just want to say thank you so much. You have alleviated alot of my fears- your explanation makes alot of sense and now I know that even if my nose upturns, it probably won't upturn to the point where I would dislike it. I probably don't even think I'll want an alar base reduction anymore either. I'll be fine! Thank you so much for your explanation- it definitely relieved alot of my neurotic thoughts. First the first time in months I am finally looking forward to my DJS. I will keep you guys updated in the future on my progress.

glad it helped. If you want to see the type of case where the ANS would be problematic to advance forward and where the TETHERING to the upper lip from the nose base kicks up an overly OBTUSE angle (yours is overly acute), look at the IMGUR link found in the following thread. https://jawsurgeryforums.com/index.php/topic,8399.msg77892.html#msg77892