Surgical plans and projections, advice?

[fiveoneoh510]

Hi all! Yet another prospective patient here with questions about surgeons and surgical plans before setting a surgery date. Would love to hear any feedback that you have!

Info:
- 38/m in US with sleep apnea (AHI 35), unable to tolerate CPAP
- Had BSSO+genio with Bloomquist in 2016 mainly to treat open bite, unaware of sleep apnea at the time. Recovered well, minimal paresthesia in chin area
- Planning MMA early next year, have consulted with: Walline, Gunson, Bobek, Kasey Li, Alfi, Alfaro
- All suggested DJS + CCW rotation; Li suggested doing an Inverted-L to avoid the screws from the previous BSSO, he doesn't do them though and nobody else suggested going this route.

Imaging:
- Ceph, pano, front/side photos: https://imgur.com/a/99sbLUP

Treatment plans:
- Walline and Gunson, see here: https://imgur.com/a/5mRnwJ8
- Gunson also suggested adding cheek augmentation to avoid a hollow look after advancement
- Bobek: ~10mm pog, 5-7°ccw
- Alfi: +10mm mx1, 3-5° ccw
- Li: +10-12mm pog, ~6°ccw
- Alfaro: +9.5mm mx1, +19mm pog, 12° ccw (not seriously considering — seems like it's way too much)

Thoughts:
- If I'm going through this again, I'd like to maximize the airway benefit but also achieve a harmonious and aesthetically pleasing outcome. I'm generally pleased with my current appearance and don't really want to look too drastically different or chimp-like
- Each surgeon suggested slightly different movements and this has made it hard to choose
- Leaning towards Walline/Lacoms, but the simulation seems a little weird to me (see below). The movements are in the ballpark of others, though, it's within my budget, and patients seem generally satisfied on groups/forums, for whatever that's worth.

Questions:

- Something about Walline's projection is bothering me, it seems like I'm jutting out my chin... I know that's the point of the surgery, but maybe it's too far forward? Or perhaps the "after" image doesn't show horizontal changes to the base of the nasal area that may occur when the maxilla advances, making it seem deficient relative to the mandible? I know these morphs are notoriously inaccurate and maybe I'm being too critical. What do you think, does it look weird to you?

- I'm having a little trouble reading Gunson's plan from the inclinations, but it seems like it's very similar to Walline's. During the consult he mentioned 7°CCW, +8-9mm mx1. From the plans linked above, do you see any significant differences between his plan and Walline's?

- Alfi, like Alfaro, apparently performs the surgeries very quickly with a piezo and custom guides, which he says would minimize nerve damage and improve recovery vs other surgeons. Since this is a revision and I'm old(er), I am of course concerned about lasting nerve damage. What do you think, should this be a big consideration?

- Any other advice on picking from the surgeons and plans above? Is there more information that I should them for?

[GJ]

Are you dead set on this? I think you're playing with fire and will likely turn your world upside down with another surgeon. e.g. nose will widen, rotation given you already look really good is very questionable, etc. I get it's for function, and if you need it you need it, but I'd try anything before messing with what you have.

[kavan]

.......
- Something about Walline's projection is bothering me, it seems like I'm jutting out my chin... I know that's the point of the surgery, but maybe it's too far forward? .....

- I'm having a little trouble reading Gunson's plan from the inclinations, but it seems like it's very similar to Walline's. During the consult he mentioned 7°CCW, +8-9mm mx1. From the plans linked above, do you see any significant differences between his plan and Walline's?

- Alfi, like Alfaro, apparently performs the surgeries very quickly with a piezo and custom guides, which he says would minimize nerve damage and improve recovery vs other surgeons. Since this is a revision and I'm old(er), I am of course concerned about lasting nerve damage. What do you think, should this be a big consideration?

- Any other advice on picking from the surgeons and plans above? Is there more information that I should them for?

The main difference between Gunson's plan and Walline's is that Walline's plan has your jaw (with the chin) advanced more. So that would be what is 'bothering' your eye. That is matter of aesthetic preference and I think your 'eye' is telling you Gunson's plan is more to your aesthetic liking. As to trouble reading the tech specs of a readout; 'inclinations', it is the CONTOUR PROFILE diagram which  SHOWS all of the tech specs visually. Gunson's contour profile proposal is relative to a 'True Vertical Line' he chooses which reflect an aesthetic. This TVL passes through the base of the nose and you see it in his contour diagram proposal. You can see the lips projecting a tad passed it and the chin 'kissing' the line. This TVL is parallel to the VERTICAL plane of gravity and also the vertical plane of the picture/diagram. Now, if you take Walline's proposal and draw Gunson's TVL through it so it passes through the base of the nose as does Gunson's, you will see that Walline's proposal has the chin going more FORWARD to the Gunson TVL. So, that is what is meant by 'aesthetic preference'. Hence, which one YOU prefer is YOUR choice. Both are within good aesthetics. As to Alfaro, his aesthetic preference leans more toward the jaw/chin advancement going beyond Gunson's TVL.

Based on what you have said here which I have picked up on as 'aesthetic preference', in particular 'something bothering you about chin..out too far..', your preference leans away from Walline's aesthetic (and also would lean away from Alfaro's) and hence leans more toward Gunson's contour proposal.

[fiveoneoh510]

Are you dead set on this? I think you're playing with fire and will likely turn your world upside down with another surgeon. e.g. nose will widen, rotation given you already look really good is very questionable, etc. I get it's for function, and if you need it you need it, but I'd try anything before messing with what you have.

Thanks for putting that out there, I’m quite worried about messing up my life with this too.  I’ve been mulling this over this for a couple of years now, though, and while I’m very hesitant to do it, it seems like it might be worth the risk. The sleep apnea is severe enough that it’s really cutting into my quality of life, not to mention the health risks of leaving it untreated. I’ve consulted with sleep surgeons and discussed other options like a UVPPP, turbinate reductions, hypoglossal nerve stimulators and oral appliances,  etc., but it seems like the success rates are not great (or not a good fit for my case) and recovery would be similar, so even the ENT surgeons have suggested going the MMA route first, given that it seems like a skeletal issue is contributing the most to the apnea in my particular case.

Good points about nasal widening and potential over rotation. The surgeons above all said they do alar cinches as part of the surgery and said the widening should be minimal, but I suppose even a couple mm can make a big difference.

Rotation-wise, I wonder if the head posture (and stubble) in my photos might be a little skewed upwards (ccw) making my lower third seem less recessed. I definitely don’t want to end up with a reverse smile or overly rotated jaw though.

[fiveoneoh510]

The main difference between Gunson's plan and Walline's is that Walline's plan has your jaw (with the chin) advanced more. So that would be what is 'bothering' your eye. That is matter of aesthetic preference and I think your 'eye' is telling you Gunson's plan is more to your aesthetic liking. As to trouble reading the tech specs of a readout; 'inclinations', it is the CONTOUR PROFILE diagram which  SHOWS all of the tech specs visually. Gunson's contour profile proposal is relative to a 'True Vertical Line' he chooses which reflect an aesthetic. This TVL passes through the base of the nose and you see it in his contour diagram proposal. You can see the lips projecting a tad passed it and the chin 'kissing' the line. This TVL is parallel to the VERTICAL plane of gravity and also the vertical plane of the picture/diagram. Now, if you take Walline's proposal and draw Gunson's TVL through it so it passes through the base of the nose as does Gunson's, you will see that Walline's proposal has the chin going more FORWARD to the Gunson TVL. So, that is what is meant by 'aesthetic preference'. Hence, which one YOU prefer is YOUR choice. Both are within good aesthetics. As to Alfaro, his aesthetic preference leans more toward the jaw/chin advancement going beyond Gunson's TVL.

Based on what you have said here which I have picked up on as 'aesthetic preference', in particular 'something bothering you about chin..out too far..', your preference leans away from Walline's aesthetic (and also would lean away from Alfaro's) and hence leans more toward Gunson's contour proposal.

Thanks a lot for that explanation, that makes a lot of sense. Also good to hear that both plans make aesthetic sense. From the numbers it looks like Gunson would advance the maxilla (measured at the ANS) 3mm vs 4.5 for Walline and the chin would advance 10mm vs 12.2mm if I interpreted it correctly.  Walline also seemed to be fairly flexible with movements, so if I do continue with him I might see about opting for slightly less advancement (hope it wouldn’t negatively affect the airway impact too much, though).

[kavan]

Thanks a lot for that explanation, that makes a lot of sense. Also good to hear that both plans make aesthetic sense. From the numbers it looks like Gunson would advance the maxilla (measured at the ANS) 3mm vs 4.5 for Walline and the chin would advance 10mm vs 12.2mm if I interpreted it correctly.  Walline also seemed to be fairly flexible with movements, so if I do continue with him I might see about opting for slightly less advancement (hope it wouldn’t negatively affect the airway impact too much, though).

Well, as I said, the contour diagram is a visual of the numbers. Hence, the numbers are the quantitative data used to 'draw' the diagram. Anyway, ya, from the displacements at the ANS and chin point, you see there is a relationship as to Walline's advancement being somewhat more than Gunson's.