General Category > Aesthetics
Opinions on my plan
Dex1816:
Hi,
I was hoping to get some opinions on the surgical plan I've been given, as it prescribes some very large movements:
. 23mm lower
. 11mm upper
. CCWr 5 degrees
I have recently learned about the risk of 'chimp' look which, as I understand it, is a combination of too much advancement of the upper jaw causing a protrusive upper lip and unfavorable nose changes, as well as the fact that large advancements in general risk an uncanny look in that they leave the rest of the midface too far behind. I have attached some lateral before and afters.
The main point of contention for me seems to be that the surgeon wants to bring the bones to the tip of the nose bone rather than the nasion, and I'm fearful this would leave me with an unnatural and protrusive look. Note that while I have been identified as having a small airway and at risk for sleep apnea in the future, I do not have any severe problems as of yet. The reason I am having surgery is mostly for an aesthetic change. I have also considered cheek implants or a zygomatic osteotomy in the future to correct any drastic discrepancies if that makes a difference.
Any thoughts would be much appreciated. Thanks!
Dex1816:
And a soft tissue before.
kavan:
The decision should be based on whether or not you like the proposed changes in the after soft tissue profile. Hearing or reading about 'uncanny' or 'chimp' looks is neither here nor there unless the visual of the proposed changes look like that (which they don't). Although soft tissue changes are not entirely predictive, when a surgeon uses a high tech program to show/design the bony displacements (which he has done), and also gives you a SOFT TISSUE change profile with it, that is going to be MORE applicable your specific potential outcome than other people's outcomes.
Dex1816:
--- Quote from: kavan on May 25, 2024, 05:14:43 PM ---The decision should be based on whether or not you like the proposed changes in the after soft tissue profile. Hearing or reading about 'uncanny' or 'chimp' looks is neither here nor there unless the visual of the proposed changes look like that (which they don't). Although soft tissue changes are not entirely predictive, when a surgeon uses a high tech program to show/design the bony displacements (which he has done), and also gives you a SOFT TISSUE change profile with it, that is going to be MORE applicable your specific potential outcome than other people's outcomes.
--- End quote ---
Thanks for your comment, Kavan.
What you say makes sense, I guess I'm just concerned that the soft tissue simulation, rather than just being not entirely predictive, won't be very predictive at all, as I've heard a few horror stories. The surgeon did say the upper lip and nose base would have a "better" appearance in real life than was seen in the simulation.
Most of my concerns stem from what I've read about regarding an optimal aesthetic ideal. The vast majority of plans utilize Arnett's True Vertical Line, or something very similar, to bring about a pleasing profile, with a line also dropped down from the soft tissue nasion representing where the upper incisors should come to make for an attractive face. My plan far exceeds this classic measurement.
I've also had difficulty deducing what chimp lip actually is and what causes it. From what I can tell, it mostly occurs from linear advancement around the ANS. I do need some more support around the base of my nose, but then again, I've also read the risk of chimp lip can be worse if you have an obtuse nose-to-lip angle like I do prior to surgery. In the image attatched, the linear advancement results in the feared fullness of the upper lip and nose, where CCWr does not. From what I can tell from my plan, I seem to be having a combination of both linear and CCWr.
Just having some pre-surgery nerves I guess! If my result looks like the simulation, I'll be very happy. I just hope it does.
kavan:
The primary culprit behind 'chimp lip' is the linear advancement which is sometimes done for sleep apnea surgery, when someone's bite is right such that both jaws can be advanced equally as ONE COMPLEX to correct the apnea. The term 'linear' advancement refers to along the line of orientation or angle of inclination the maxilla already has relative to a horizontal plane. So, linear advancement implies NO ROTATIONS are done which could be done for advancement to take place over a more aesthetically favorable orientation. For example, when insurance is paying for the surgery, they prioritize the extent the mandible needs to be advanced to correct the airway. But the maxilla has to 'go along with the ride' by the same amount WHETHER OR NOT it would look better when advanced LESS. In general, what a good handful of these 'chimp lip' cases have in common is that the advancement takes place over an UNFAVORABLE inherent orientation of the jaws and no rotations are done to mitigate over advancement. So, what ever amount the lower jaw needs to be advanced to OPEN THE AIRWAY is going to be the same for both jaws and in terms of 'aesthetics', yes, that could resolve to 'over advancement'; the type that is associated with chimp lip. However, linear advancement does not predict that someone will get a chimp lip out of that.If the person just happens to have a favorable rotational orientation to the jaw complex and just happens to need BOTH jaws advanced EQUALLY by the same amount the airway needs to be open, then the aesthetic outcome would tend to be favorable.
In order to PREDICT chimp lip or some uncanny valley result, the ORIENTATION of the maxilla along with a lot of other factors would have to be taken into account. It should be inherently obvious that an actual PLAN you get from the surgeon is a better source of information than people warning you about 'chimp lip'. You don't know what they are taking into account (and they probably don't know either) or if they are in the capacity to predict that your maxillary advancement will result in unfavorable nose changes. For all we know, they could be looking at sleep apnea (insurance) cases and drawing conclusions from that.
Again, what other people say base on cases/people OTHER than YOURS/YOU in terms of unfavorable predictions are neither here nor there as being reliable sources of information directly applicable to you and most CERTAINLY NOT more reliable than a displacement proposal that actually SHOWS you a good approximation of the profile contour change.
You have a displacement proposal right in front of you. Do, you see anything about it that depicts or predicts 'chimp lip' ('monkey muzzle')? Yes___ No___
Is the maxillary advancement the SAME as the lower jaw advancement? Yes___ No___
So, what is it about this plan that looks anything like a 'monkey muzzle' that could substantiate warnings you might have read/heard about?
As to your concern that the surgeon wants to bring your maxilla out further than the nasion, the surgeon is taking into consideration the hooked 'stick-out' you have to the bony nose bridge. So, that resolves to a good aesthetic judgement with aim of giving you a better stream lined 'slope' to the nose. The slope of the nose bridge is somewhat high due to the hooked bony 'stick-out' of the nose bone.
In closing, there is NOTHING in your plan that warrants WORRY about monkey muzzle or unfavorable nose changes providing you OPEN your EYES and LOOK at it.
ETA: If the depiction doesn't show the upper lip angling outward and the teeth don't angle outward in the bone model, no assumption can be made that the teeth would angle outward with a smile.
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