3D CBCT scans and pictures of me - looking for aesthetic advice

[PeterSteiner]

Hello everyone,

I uploaded my 3D DVT scan to Google Drive, I hope that's ok.

Some info about me: 26 yo male, mostly 12-14% bf, yet my face does not reflect that. I also have thick skin and a big nose that pulls a lot of soft tissue outwards in a bad way. 37mm IMW. I have been mewing for 8 years. Interestingly my sutures are still open according to my orthotropic doctor which surprised her.

In general, I find it difficult to smile because I have to make a lot of effort to make my teeth visible, resulting in a non-aesthetic grimace. This can be due to my underbite or other reasons. My underbite also causes pain when teeth come together throughout the day. In addition, my bite is also asymmetrical, which may have led to the asymmetry of my entire face. Unfortunately, I cannot see the origin of my asymmetry. I also seem to have a long midface. Even though I seem to have some sort of forward growth (my SNA is almost 90°?) and like my side profile, I lack serious projection in my midface. I'm not sure how much a CCW in the ANS or PNS would benefit in shortening my midface or affect the projection.

Overall, I would love a more symmetric face, a normal and symmetric bite, a more projecting smile, a shorter midface and more projection in my midface. I heard of terms like high lefort1 ccw, posterior downgraft ccw, anterior downgraft ccw, modified lefort 3 (the more safer version?) to project some parts of the midface more. I would really appreciate some guidance because my issues don't seem to be very obvious. Understanding what has gone wrong in my development would already help a lot!

3D DVT scan: https://drive.google.com/file/d/1yDOSGB_gmr11E--3KlEQiR2l9CEX2i4H/view?usp=sharing
Pictures about me: https://drive.google.com/drive/folders/1vqhf5TF9TCGHFBqtLzOTNdKk8tQ-zwVd?usp=sharing
Little pictures from my scan: https://drive.google.com/drive/folders/1_pFae2Up1i_HZFMH_w1HQa6pOZEV2ERN?usp=sharing

Thanks in advance!!

[GJ]

It looks like your asymmetry is due to the right side being longer than the left. This is likely due to hormones/puberty/issues in the growth phase, though it could be other things. In general that is corrected by shortening that side, as that is more stable then lengthening the other side.

Your bite looks more edge to edge than an underbite. Were you diagnosed with an underbite? Either way the treatment will probably be the same - move the upper jaw foward a few mm and maybe down a couple mm if you need more tooth show. I don't think you'd need any rotation either way. Move the upper foward to clear the underbite/edge to edge bite, down for tooth show, and then probably a genio (forward, maybe up) to compensate for those movements. I don't see why you'd need double jaw. This is bad, though, because most of the un-aesthetic chances from jaw surgery happen from moving the upper jaw, and I think that is the only jaw you probably need moved.

So, I might just try to correct this orthodontically if possible. Has that been ruled out?

[PeterSteiner]

It looks like your asymmetry is due to the right side being longer than the left. This is likely due to hormones/puberty/issues in the growth phase, though it could be other things. In general that is corrected by shortening that side, as that is more stable then lengthening the other side.

Your bite looks more edge to edge than an underbite. Were you diagnosed with an underbite? Either way the treatment will probably be the same - move the upper jaw foward a few mm and maybe down a couple mm if you need more tooth show. I don't think you'd need any rotation either way. Move the upper foward to clear the underbite/edge to edge bite, down for tooth show, and then probably a genio (forward, maybe up) to compensate for those movements. I don't see why you'd need double jaw. This is bad, though, because most of the un-aesthetic chances from jaw surgery happen from moving the upper jaw, and I think that is the only jaw you probably need moved.

So, I might just try to correct this orthodontically if possible. Has that been ruled out?

Hey GJ, thank you for your analysis.

Do you mean the right side from your point of view or mine? As it feels like the left side is longer than the right side from my point of view. Perhaps we mean the same side. It's interesting that one side is longer than the others, I haven't seen it like that before. It might be also the reason, why my bite is off too. Exactly which part of my face would they shorten if they intended to fix that?

Regarding my bite, yes it seems edge to edge. My orthodontist referred to it as "mild underbite", though don't know how true that is.

About moving the maxilla forward and down, in a CW fashion, I think that would lengthen my midface, wouldn't it? I thought of CCW to shorten my midface and to improve my occlusal plane. Is CW really required for teeth show?

I disliked the idea of correcting this orthodontically because I think I generally lack teeth show and have skeletal asymmetries. I am also very dissatisfied with my midface projection. I can't interpret how recessed my midface is but I would love to have more projection there. I am satisfied with my jaw, the main thing that bothers me is the "lack of action" in the midface area.

[GJ]

Do you mean the right side from your point of view or mine? As it feels like the left side is longer than the right side from my point of view.

To me it looks like the right side (from your point of view, left side me looking at it on the screen) is longer, but I could be wrong. Nobody is symmetrical, so this is mostly within normal and just depends how much you want to chase a solution. If it's affecting your bite and things like that, it might be worth the adverse trade offs.

There isn't really a way to lengthen or shorten the midface, only the lower 3rd. You might get the perception the midface is longer or shorter as things move, but in absolute terms it can't really move either way. People with underbites generally do have some midface recession, so again moving the upper jaw forward would probably help with that. I think rotating the complex (both jaws) CCW would actually make that worse. I don't see CCW appropriate for you, but that's just my opinion. You could probably move the chin CCW, but I don't see the jaws moving CCW addressing any of your concerns. I'd think a very small movement of the jaws forward and down (which on net I guess is CW) would make the most sense. It would fill out the midface a bit and get you more tooth show, which seem to be your biggest complaints. The downside of that is your lower third might get a little longer, but that could maybe be balanced out by shortening whichever side of your face is longer or adjusting the chin to compensate.

To me this is not a jaw surgery case, so I'm just speaking in hypotheticals if someone wanted to correct a lack of tooth show and had a class 3 jaw and/or edge to edge bite. I view your case as a compromise where you could probably address some things that concern you, but it might bring up some other things you don't like.

[PeterSteiner]

To me it looks like the right side (from your point of view, left side me looking at it on the screen) is longer, but I could be wrong. Nobody is symmetrical, so this is mostly within normal and just depends how much you want to chase a solution. If it's affecting your bite and things like that, it might be worth the adverse trade offs.

There isn't really a way to lengthen or shorten the midface, only the lower 3rd. You might get the perception the midface is longer or shorter as things move, but in absolute terms it can't really move either way. People with underbites generally do have some midface recession, so again moving the upper jaw forward would probably help with that. I think rotating the complex (both jaws) CCW would actually make that worse. I don't see CCW appropriate for you, but that's just my opinion. You could probably move the chin CCW, but I don't see the jaws moving CCW addressing any of your concerns. I'd think a very small movement of the jaws forward and down (which on net I guess is CW) would make the most sense. It would fill out the midface a bit and get you more tooth show, which seem to be your biggest complaints. The downside of that is your lower third might get a little longer, but that could maybe be balanced out by shortening whichever side of your face is longer or adjusting the chin to compensate.

To me this is not a jaw surgery case, so I'm just speaking in hypotheticals if someone wanted to correct a lack of tooth show and had a class 3 jaw and/or edge to edge bite. I view your case as a compromise where you could probably address some things that concern you, but it might bring up some other things you don't like.

Thanks a lot, your points make sense. Generally, I mainly want to improve my midface aesthetics. Do you think a modified lefort 3 where the nasal area is left behind would benefit me? I've seen such a case and was really impressed by the results.

[GJ]

I'm not sure. Since that's a rare procedure it's hard to say. I think maybe one person (Earl?) ever on this site has had that done. Or it was something like that. We just don't see it enough to comment. I guess in theory it could work, but as you cut higher up you introduce more risk (blindness, surgeons operating on you who do maybe a few of these procedures in their lifetime, etc).

Maybe see if anyone else chimes in on that.

[kavan]

1: On the frontal bone scan the RIGHT side of face would be on LEFT side of photo. Likewise the left side of face would be on right side of photo.

2: The RAMUS of the mandible (vertical part of mandible) MEASURES longer on the left side of scan (face). I observed that by drawing a vertical line from most outer part of ramus starting to where it can be seen below lateral cheek bone and where it meets the top of gonial angle. However, the horizontal distance from gonial angle to gonial angle does not show asymmetry.
Also when observing the body of the mandible the frontal bone scan, the symmetry looked within the norm. That is to say; relative to the frontal bone scan, the entire border of the mandible looks pretty symmetrical.

3: Because the ramus of the mandible MEASURES longer on the left side of the bone scan (face) BUT the whole body and lower border of the mandible, when viewed for symmetry,  shows only very minor asymmetry, which looks within the norm, my observations yielded that the measure of the left (facial) ramus was longer because LESS of the CHEEKBONE (on left side of face) is covering it up. Similarly, the ramus measures shorter on the right side  because MORE of the cheekbone on that side is covering up the upper part of it.

4: The bite looks pretty even on the frontal bone scan. So, doesn't look like a matter of one side of the of the dental arch looking longer/shorter than the other.

CONCLUSION: On the frontal bone scan, the CHEEKBONE on the right side looks more robust than that on the left side in terms of targeting location of asymmetry. So, that could suggest that the PERCEPTION of the JAWs being asymmetrical is an illusion from the cheekbones not being symmetrical with each other. So, consider jaw surgery does not address that area directly.

A photo of my line comparisons drawn on your frontal scan is included.

NOTE: Your frontal photos (self taken) were looked at but not depended on in my evaluation (beard, off poses, etc.). A frontal bone scan is adequate to look at to see where asymmetry could be coming from.

OTHER:

Lack of upper tooth show is addressed by adding a graft to the maxilla during a lefort 1. A graft to kick up more tooth show can be a uniform one of little to no rotation especially so if whole upper dental arch could benefit from more tooth show. More tooth show is also kicked up via advancing the maxilla in addition to grafting it.

An edge to edge bite in addition to a complaint of the upper jaw being recessed would be addressed by bringing the maxilla forward during a lefort 1. So, lefort 1 can address both those issues. (But not a perceived asymmetry to the jaws IF the main asymmetry is coming from an area not changed during jaw surgery, e.g. the cheek bones.)


An illustration is included with this post.

[varbrah]

I had MLF3 w/ Sinn prior to his retirement. Typically the orbital-zygomatic complex needs to be mobilized separately from the LF1 area (different movements/rotations required) so it would need to be two procedures at least 6 months apart.

Judging from your undereye area, either that or midfacial implants would be necessary to correct the deficiency. Alternatively, orbital decompression to decrease globe projection and set your eyes back.

Honestly though, a combination of midfacial augmentation AND orbital decompression would likely be needed to fully round out the eye area. MLF3 maxes out at like +6mm of advancement. That would improve your midfacial soft tissue support significantly,  but from what I’m seeing this  may not be enough standalone to reduce the prominent appearance.

Also - are those CBCT images aligned so along the FH plane or along some other reference plane? Did you happen to do any adjustment there or is the alignment straight from the raw DVT? I’d postpone judgment on vertical asymmetry if not.

[kavan]

Those photos (of another person) don't 'for sure' suggest the changes in them are from the type of modified L3 one poster on here ('Earl') had. Nor do they suggest the person in them had the base of their nose 'left behind'. They suggest maxillary advancement of the Lefort 1 area was included BECAUSE the L1 area (which includes base of nose) is clearly advanced and the drooping nose tip is lifted. However, SINCE a 'whole' and/or most of a Lefort 3  ALSO can include the Lefort 1 area, person in photo may have had much to some of the L3 area advanced given the upper midface area (orbital rims and cheek bones) also were advanced. Keep in mind a 'modified' L3 does not mean the same modifications to it for each person. It just means that the entire L3 was not done. Also, a modified L3 can include moving the L1 area along with it.

I would say, a very salient change in profile perspective relative to the base of the nose area arose from Lefort 1 area being advanced even if the L3 advancement brought the L1 AREA along with it.

As to the person on here (Earl) who had 'modified L3', he knew EXACTLY where to modify it to target what area he needed advanced (orbital rim and cheek area) and he had that AFTER he had double jaw surgery to advance both jaws. His situation was 'prominent eye' (recessive orbital rim area). He did all his own research on that given he had a very clear cut situation where his UPPER midface area was recessive (prominent eye or 'bug eyed').

That said, since the PRECEDENT of pursuing L3 (on this board) was via someone in capacity to KNOW and be sure which part of it was needed for his case and also was able to ferret out a surgeon who would do it and researched all that on his own without having to ask on board; 'Do you think I need an L3?', I hold people wanting to know about mod L3 benefiting them to the same standard of having very good reason to be sure that's the thing for them and enough so that they don't need to seek 'surity'/confirmation from mods here of whether or not it will benefit them.

[GJ]

I had MLF3 w/ Sinn prior to his retirement.

I didn't know that. How did that go?

[varbrah]

I didn't know that. How did that go?

Pretty well, tbh. Huge payoff at the cost of a comparatively milder recovery than DJS - it looks really, really good.

As you'd expect with any osteotomy, the first few days were a pain - relatively easy beyond that, though. Functional impairment was minimal. I was back to comfortably chewing light foods by about day 3, so I was able to subsist nicely on takeout nigiri/sashimi rather than soups or disgusting meal replacement shakes.

Beyond the immediate recovery phase, the largest inconvenience was probably the peri-orbital edema. Obviously with the skin being so thin in that area, even residual swelling can be noticeable. More annoying than anything though and I'd definitely do it again if I had to.

[varbrah]

Probably not too much to read into here nor explain to the OP, tbh 

Thanks to Earl's foundational role in popularizing the procedure -- and piss-poor taxonomical prowess -- "MLF3" has become the default term for the standalone Zygomaticomaxillary component of the Maxillo-Malar osteotomy design / surgical procedure described by Heggie in the 1990s:

https://www.researchgate.net/publication/14939202_The_modified_Le_Fort_III_osteotomy_in_the_correction_of_mid-facial_deficiency_Case_reports

Very safe to assume anyone on the internet using this term is doing so downstream of Earl's misnomer, rather than in referrence to the technically correct procedure.

Not much of a practical distinction exists these days anyway. Heggie's design has been 'preserved', but the overall (MLF3) complex is no longer mobilized as a single unit in a single procedure.

Instead, Heggie's primary innovation (i.e. the method by which the zygomaticomaxillary complex is accessed, segmented, and mobilized) has been stripped out and refined, with the constituent LF1 and Malar osteotomy components mobilized independently across two separate operations -- or the Malar component is simply advanced standalone (i.e. Earl's "MLF3").

[GJ]

Pretty well, tbh. Huge payoff at the cost of a comparatively milder recovery than DJS - it looks really, really good.

Cool! I would be superior curious to see if it you want to email me results. I share nothing.
Feel free to black out eyes, etc, too. Or not, but I am curious having only seen Earl's results.

[varbrah]

Cool! I would be superior curious to see if it you want to email me results. I share nothing.
Feel free to black out eyes, etc, too. Or not, but I am curious having only seen Earl's results.

Sure. I'll try to find/create some comparables - Unfortunately I don't have much to work with since I was just banking on getting my before/after shots from Sinn.

I actually reached out to the clinic some time ago only to learn he had just retired. His office manager was way too pre-occupied with the business unwinding/liquidation to actually get anything done about my photos/records though, lmao. Oh well.

[AnonWillow]

Thanks a lot, your points make sense. Generally, I mainly want to improve my midface aesthetics. Do you think a modified lefort 3 where the nasal area is left behind would benefit me? I've seen such a case and was really impressed by the results.

do you have a link to this case? impressive results.