Asymmetry diagnosis and procedure plan help

[AnonWillow]

From my research I believe I have a small, underdeveloped, and recessed mandible. I have been advised bimax, genio, potential downgraft, CCW, and looking for opinions. As well, I am quite concerned about my midface, cheeks, and nose. I have asymmetry beginning at the nasal base, and believe the tip is very off center as a result. I've included a pic of my face in the second imgur album pre-rhino that should exemplify the midface/zygo deficiency I am speaking of. I feel the right side of my face is significantly more deficient than the left. Potentially want to separate problem statement between lower third/jaw and the rest of my face/maxilla.

Concerns:
- Recessed mandible
- Small mouth/palate + lip structure
- Zygomatic asymmetry/lack of midface support
- Whole orbital region asymmetry
- Eyes at different heights/depths? Whole side of maxilla different depths?


Many angles: https://imgur.com/a/Agc5Mz2
CBCT, Ceph, more pics of just jaw + full face: https://imgur.com/a/QdhLk9i
Videos:
https://streamable.com/09f5rn
https://streamable.com/ontlpv
https://streamable.com/is5enr
https://streamable.com/bedqrm

I can add more content if helpful, looking or any and all advice.

[GJ]

The part of the plan that makes no sense to me is you say they want to do CCW. I was thinking you need either straight linear advancement or even CW rotation. Your midface is long, so lengthening the lower third would balance that out, and frankly the lower third is short. 

Regarding genio, you have a deep labiomental groove as-is, so the genio should be accompanied by grafting of some type (bone, HA) to smooth some of the otherwise harsh shadows you'd get with any advancement of the chin.

You have a unique face. I do think this looks like a surgery case due to the fairly severe underdevelopment of the jaws, the overjet, and imbalance of the facial thirds. The thing is, you could afford to lose some weight, and that's clouding my perception a bit. If you want to be conservative you can maybe get away with BSSO and genio only by closing the overjet surgically. You mention rhino, so if you had that, advancing the maxilla could mess it up, so if that's a concern maybe BSSO/genio only, though you won't get as much advancement.

Do you have apnea or any other major functional problems?

[AnonWillow]

I was diagnosed with sleep apnea at one point, but had a septo at the same time as my rhino and my latest diagnosis determined I didn't have it. Although I still do snore and have sleep problems, not fully convinced it's gone/my breathing is proper. My body fat is ~20%, working on cutting it down but unfortunately my face holds fat poorly. Any thoughts on the midface/zygomatic area? Is there any similar genioplasty cases you know of I can look too that include grafting? Also, any thoughts on the development of the right VS left jaw? The left is seemingly more developed, and I'm having a hard time diagnosing where the difference is(difference in bone volume at the gonial angle, different bone shape, the mandible being deviated more to one side, soft tissue).

[GJ]

I was diagnosed with sleep apnea at one point, but had a septo at the same time as my rhino and my latest diagnosis determined I didn't have it. Although I still do snore and have sleep problems, not fully convinced it's gone/my breathing is proper. My body fat is ~20%, working on cutting it down but unfortunately my face holds fat poorly. Any thoughts on the midface/zygomatic area? Is there any similar genioplasty cases you know of I can look too that include grafting? Also, any thoughts on the development of the right VS left jaw? The left is seemingly more developed, and I'm having a hard time diagnosing where the difference is(difference in bone volume at the gonial angle, different bone shape, the mandible being deviated more to one side, soft tissue).

No, I don't have any photo examples of grafting in the chin.

When you say the left is move developed, is that left from your perspective or mine?

[AnonWillow]

Left side of my jaw(right side of images/video) is more developed I feel. I went and added descriptions to a few of the imgur images to clarify. Appreciate the replies so far, ty.

[GJ]

Left side of my jaw(right side of images/video) is more developed I feel. I went and added descriptions to a few of the imgur images to clarify. Appreciate the replies so far, ty.

Thanks for clarifying. Just want to be sure we're talking about the same thing. The best record to see what is going on with that is the CBCT scan. It looks like the left "body" of the ramus is slightly longer, and there appears to be a "yaw" when you look at the top-down image, though it is cut off so it's hard to be sure. My guess would be those are the reasons.

In the flesh I don't really see it because your face has a lot of fat that masks the bone structure.

I'm not positive, but I think that's what is going on. Maybe let some others chime in.

[kavan]

I'm electing to focus on first things first which is the jaw to jaw relationship. Anything that is not the actual maxfax surgery (such as areas ABOVE the places the jaw surgery doesn't change), are things to address at a later time (after the maxfax surgery). So, my focus will be on what I can see as an actual PROPOSAL for you, in particular the ceph displacement diagram included in https://imgur.com/a/QdhLk9i link.

The ceph displacement proposal SHOWS an excellent IMPROVEMENT of the soft tissue profile and that proposal CORRELATES with what you have already been told/suggested. Visually, it COMMUNICATES the following:

1: CCW rotation (around the ANS point) which is something that will allow for MAXIMIZING the amount of lower jaw advancement and MINIMIZING the amount of upper jaw advancement. So, the 'forward' advancement of the upper jaw is less than the advancement of the lower jaw.

2: The advancement that could be called 'linear' is (directly) to the CHIN. The chin is displaced in a 'down and out' vector. So with that there is both forward advancement (to ADVANCE the chin) and downward displacement (to VERTICALLY ELONGATE). That type of genio which I call a 'down and out' genio often includes a graft to be sandwiched between the moved chin segment to fill in the GAP.

Those are the salient displacements the displacement diagram SHOWS you along with what should be obvious as a resulting greately IMPROVED profile balance. Hence, the displacement diagram pretty much CONFIRMS the suggestions you relayed you were told:

..... I have been advised bimax, genio, potential downgraft, CCW.

I have no 'questions' about that advice because I can SEE (and interpret) the visual (ceph displacement diagram) that depicts similar advice.

So, my advice is to target your focus on the actual CEPH DISPLACEMENT PROPOSAL to actually OBSERVE the proposal is a great improvement and re-assess all your other aesthetic concerns which the maxfax surgery doesn't change..e.g. orbits, excess facial fat, at a later time.

[kavan]

I am including here an Asymmetry ANALYSIS based on the frontal skull bone scan. As with bone scans, the left side of the photo is the right side of the face and the left side of the photo is the right side of face and each side was marked on the front bone scan. A diagram and basic explanation is included with this post.

Wording to illustration/diagram is as follows:

I use a straight forward method to take a look at asymmetry. All it takes is very elementary geometry and and basic observation skills.

The FRONT skull scan gives all the information we need to look at as to where the asymmetry could be coming from.

1: Landmarks through which a (red) vertical line should pass through are used to divide the FACE into 2 parts. Landmarks through which (green) horizontal lines should pass through are looked at to check for vertical asymmetry of the facial bones. The FACE bone area is vertically symmetrical. For example, one side is not vertically longer or shorter than the other.

2: Next, we check for horizontal asymmetry, the extent of it to see where the asymmetry is coming from and whether or not it's coming from a place that can be corrected via surgery.
That's done by MIRRORING each side of the face.2a: RIGHT side is mirrored. 2b. Left side is mirrored.

OBSERVE: The RR mirror symmetry is much WIDER than the LL mirror symmetry. The bulk of where the asymmetry is coming from is to the right side of the SKULL bone/s which is/are WIDER than on the left. So, the widths of the face bones would not be same on each side and the width to the right side of face will be MORE than that to the left due to width of side of the skull bones affecting growth pattern of either side of face.

The 'bad' news is that it isn't something surgery is going to correct as to make all symmetrical (width wise). But the 'good' news is that at least by KNOWING that, it spares you from chasing all types of different surgeries in pursuit of width symmetry.

[AnonWillow]

Thanks for this. Chance that the CT scan isn't at the perfectly straight frontal angle? That is the best still I am able to obtain from the DICOM files though. It seems like if the deviation between that side was that large it would be much more apparent in more pics. I may be wrong. Is there some variation of implants/osteotomy that would help alleviate a wider right side in this case?

[kavan]

The red vertical line passes through the landmarks it's supposed to pass through; center of nose (hole) and between the central incisors. So, if you turned the skull either way, you would most certainly not have symmetry. That should be intuitively obvious.

You wanted to know about where the asymmetry was coming from and I showed you where it was coming from. Again, it's coming from a place where IF you kept 'chasing your tail' to correct asymmetry, you would still have asymmetry.

The frontal asymmetry does not preclude you from getting a good improvement though from the suggested plan you were given (profile contour change diagram).

Thanks for this. Chance that the CT scan isn't at the perfectly straight frontal angle? That is the best still I am able to obtain from the DICOM files though. It seems like if the deviation between that side was that large it would be much more apparent in more pics. I may be wrong. Is there some variation of implants/osteotomy that would help alleviate a wider right side in this case?

[AnonWillow]

Would any kind of maxillary expansion(MSE or SARPE) be advised?

[kavan]

Advised for what? I've already advised against chasing asymmetry by showing the frontal asymmetry is coming from a place that surgery isn't aimed at correcting. But do ask your doctor same question.

[AnonWillow]

https://imgur.com/a/cpVUs93

Any opinions on this latest surgical plan? (upper/lower jaw movements, downgrafting, genio, etc).

Note the soft tissue scan used is a bit old with higher bodyfat, and also the nose is extremely deprojected from wearing a masking during.

I am still curious if my upper arch shape could be improved, seems very pointed. I am not sure exactly I'm desiring, something like the canines/premolars being more visible from the front. Maybe it is palatal width.