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Opinions on my plan

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Dex1816:

--- Quote from: kavan on May 26, 2024, 10:36:06 AM ---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.
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If I understand what you've said: chimp lip mostly occurs when only linear advancement is used and no CCWr.

When CCWr is used, is linear advancement also employed? or does the CCWr replace the need for linear advancement? I cannot really tell from my plan. If the former is true, isn't there still a risk of chimp lip given that a linear movement is still taking place? Not necessarily relating this to my plan, just interested.


--- Quote ---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?
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--- Quote ---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.
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I agree I've gotten too in my head about what are ultimately layperson's interpretations that cannot hold a candle to the calculations of a surgeon, and that what I've heard is clearly not a wholly accurate representation of reality.

To answer your question, nothing about the proposed plan indicates chimp lip, of course. My fears are related to its accuracy regarding those soft tissue changes; surely anyone who has suffered from chimp lip has also gotten a highly sophisticated 3D plan, that presumably did not show these aesthetic problems before surgery as then they assuredly would've been altered.

While as you say, this problem seems characteristic with insurance sleep apnea cases, what about the people who go to top surgeons like Alfaro and Alfi and report to coming out over advanced/with protrusive lips? Shouldn't their 3D plans have shown this would be the case?


--- Quote ---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.

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I see, that aesthetic choice makes sense. If the attractive norm is to have the maxilla at the nasion, though, is there not a risk that I'll look a little strange with my teeth way out there?

Thank you for taking the time to write such a detailed reply. It has been very reassuring despite the fact I clearly still have a lot to learn about this procedure.

kavan:

--- Quote from: Dex1816 on May 26, 2024, 04:45:39 PM ---If I understand what you've said: chimp lip mostly occurs when only linear advancement is used and no CCWr.

When CCWr is used, is linear advancement also employed? or does the CCWr replace the need for linear advancement? I cannot really tell from my plan. If the former is true, isn't there still a risk of chimp lip given that a linear movement is still taking place? Not necessarily relating this to my plan, just interested.
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Linear advancement is a term where there is NO rotation done.  The rotation changes the line of advancement for both jaws. But just because both jaws are advanced along a more favorable 'line' does not make it a thing where maxilla is CCW and the mandible is linear. The ccw done to the maxilla is such that the mandible is also rotated along with it.  If you want to discuss horror stories of chimp lip risks, discuss them with those who relayed them to you. You asked for opinions on your PLAN. So, no more engaging me in opinions about what ever horror stories you read from who knows where.


--- Quote from: Dex1816 on May 26, 2024, 04:45:39 PM ---I agree I've gotten too in my head about what are ultimately layperson's interpretations that cannot hold a candle to the calculations of a surgeon, and that what I've heard is clearly not a wholly accurate representation of reality.

To answer your question, nothing about the proposed plan indicates chimp lip, of course. My fears are related to its accuracy regarding those soft tissue changes; surely anyone who has suffered from chimp lip has also gotten a highly sophisticated 3D plan, that presumably did not show these aesthetic problems before surgery as then they assuredly would've been altered.

While as you say, this problem seems characteristic with insurance sleep apnea cases, what about the people who go to top surgeons like Alfaro and Alfi and report to coming out over advanced/with protrusive lips? Shouldn't their 3D plans have shown this would be the case?
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Excuse me but I didn't offer to opine on plans of other people you gleaned your fears from that I can't see. So, don't expect me to opine on something that is not a PLAN I can SEE. Hows about you put up a post in the emotional support section asking for 'OPINIONS ABOUT MY FEARS' if that's what you need validated.  Again, I am responding to a post that reads OPINIONS ABOUT MY PLAN.


--- Quote from: Dex1816 on May 26, 2024, 04:45:39 PM ---I see, that aesthetic choice makes sense. If the attractive norm is to have the maxilla at the nasion, though, is there not a risk that I'll look a little strange with my teeth way out there?
--- End quote ---

The nasion norm would apply more to someone who doesn't have a hook like stick out to the nose bone. I explained why the surgeon made that aesthetic judgement call and he gave you  predictive visuals to refer to.


--- Quote from: Dex1816 on May 26, 2024, 04:45:39 PM ---Thank you for taking the time to write such a detailed reply. It has been very reassuring despite the fact I clearly still have a lot to learn about this procedure.

--- End quote ---

You're welcome but if I had known ahead that all of this advice would be dominated by your need to have fears addressed found who knows where, I would have passed on it.

Dex1816:

--- Quote from: kavan on May 26, 2024, 06:01:23 PM ---Linear advancement is a term where there is NO rotation done.  The rotation changes the line of advancement for both jaws. But just because both jaws are advanced along a more favorable 'line' does not make it a thing where maxilla is CCW and the mandible is linear. The ccw done to the maxilla is such that the mandible is also rotated along with it.  If you want to discuss horror stories of chimp lip risks, discuss them with those who relayed them to you. You asked for opinions on your PLAN. So, no more engaging me in opinions about what ever horror stories you read from who knows where.
--- End quote ---


--- Quote ---Excuse me but I didn't offer to opine on plans of other people you gleaned your fears from that I can't see. So, don't expect me to opine on something that is not a PLAN I can SEE. Hows about you put up a post in the emotional support section asking for 'OPINIONS ABOUT MY FEARS' if that's what you need validated.  Again, I am responding to a post that reads OPINIONS ABOUT MY PLAN.
--- End quote ---


Those are fair points, I apologize for skewing the topic in that direction when I asked for help with my own specific take.

As I understand what you've written: CCWr denotes the advancement of both jaws. I take it, then, looking at my own plan, that after such a rotation has taken place, the mandible is then moved even further forward in a linear direction to achieve the rest of the large movement (along with the genioplasty, of course), as presumably CCWr alone couldn't amount to 23mm of advancement. In this way, as the mandible 'went along for the ride' during the rotation, the opposite would be true during the portion of the operation where the mandible was further advanced -- that the maxilla would also be advanced in a linear fashion after the portion of the operation where the whole complex was rotated. Is this correct?



--- Quote ---The nasion norm would apply more to someone who doesn't have a hook like stick out to the nose bone. I explained why the surgeon made that aesthetic judgement call and he gave you  predictive visuals to refer to.
--- End quote ---

I have attached an image of my current x-ray with another filter. I take it where I've drawn the blue arrow is what you mean by 'hook like stick out'?

I can see how advancing everything to such a point would have this favorable change at the nose, my concern is that it would be at the expense of something else. For example, to have your jaws that far forward from the nasion, wouldn't one need appropriate forward growth in all other areas to match it and have it look normal? (cheek bones, brow ridge, etc).

On the soft tissue plan, it looks good, but I would worry that when I smile, my teeth would look like they jutted forward in an uncanny manner far past the rest of my face.

The surgeon did also said I have a hanging columella, which I assume is due to a lack of support under the nose.

kavan:
CCW-r is based on the rotation of a TRIANGLE constructed from points/landmarks on the maxillary mandibular complex. The concept behind it is that when this triangle is ROTATED, the lower vertex of the triangle advances in a forward direction. So, if point A is ANS of maxilla, point B is PNS of maxilla and point C is the outermost chin point (pogonian), the rotation has it that point C is moved forward via the ROTATION and also that the rotation alters the linear path  the maxilla and mandible can be advanced along. A rotation isn't a linear movement in itself but it changes the orientation of the linear paths moved/advanced along just like rotation of triangle ABC changes the orientation of the linear paths within the triangle.

Enclosed is a diagram of a rotated triangle.

Maxfax NOMENCLATURE has it that the term 'linear advancement' is reserved to describe forward advancement of the whole triangle with NO rotation of it. For example for point C to move forward, point A would also need to be moved forward and along the orientation of line/path AB. So, in both examples using a triangle as reference, advancement is always along a linear path. But the term 'linear advancement basically means forward displacement of the whole triangle along what ever inherent orientation line AB of it has. So, if point C of a triangle is to be advanced forward, point A also has to go along with the ride where as with the ROTATION of the triangle, point C gets a free ride and point A can stay where it is (when it's the rotation point).

After the TRIANGLE is ROTATED, in which case the lines that form it are re-oriented, advancement along the changed paths takes place. So, if point C was to be advanced 'a lot', point A would also need to be advanced but not as much as point A.

Now as to FEARS or concerns about displacements made to your Max-Md triangular complex, a fear or undue concern about point A of the triangle advancing 'too much' could result in an outcome of point C not being advanced enough. Conversely, a fear/concern about point C being advanced 'too much' could result in point A not being advanced enough. If the fear is both being advanced 'too much', it could result in under advancement.

The Max-Md triangular complex looks to be in good aesthetic balance. That is what the bony displacement model shows and also what the soft tissue displacement prediction shows. So, you need to think about it in terms of the MM TRIANGLE on which CCW along with the advancements that can go with it is based. Although the displacement proposal, visual thereof doesn't predict ahead of time whether you will like the outcome or not, it's what you have to base your decision on and more reliable than basing your decision on fears. Also, no one here, including my self can give you a better prediction of the outcome than the visual you were given was or predict whether or not you will like what you see in the mirror. So, if you want to make a decision based on fears of this or that extent of advancement being 'too much' or will 'look funny' or won't look as good as the prediction itself --what ever--you can do that if you want (on your own time) and ask the surgeon for LESS advancement based on those fears/concerns. But if you want to make a decision based on fear, you also need to consider 'what if' your decision requesting a change of plan is a faulty one

In closing, you are assuming the predicted outcome is erroneous or could be. There is NO absolute certainty that it is an exact prediction of an outcome, whether or not you will like it even if it is or whether or not you DO like it as it is depicted. IMO, it's an OPTIMAL outcome. But since your fears lead you down a path of 'what if' it is an erroneous prediction or you might not like it even if it's 99% predictive, then your choices resolve to no surgery at all in the event the prediction does not guarantee the outcome it shows or a choice of which direction you would rather err on; under or over advancement. As to 'what if' the prediction of the outcome is in error in some way, there is also the 'what if' your assumption that it is in error in some way is in error.

There is no ABSOLUTE CERTAINTY to be guaranteed here and NO BETTER predictions to be made here than the one you got already. It's inherently a decision made under uncertainty.

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 given that the orientation of the teeth support the upper lip.

ETA: If the bone model SHOWS you both the jaw advancement and the rest of the scull with it, no assumption can be made that it's out of proportion with the rest of the scull.

Dex1816:
This was a very sobering post, Kavan, and your explanations of CCWr via demonstration with the triangle were very informative -- thank you.


--- Quote from: kavan on May 27, 2024, 02:56:56 PM ---Enclosed is a diagram of a rotated triangle.
--- End quote ---

So:

. CCWr rotates the triangle on a fixed point. It still ultimately results in forward advancements, but the terminology 'linear advancement' refers to:
. The entire triangle (all points) moving forward as a unit

What I'm still uncertain about is whether or not in a plan like mine, both of these different movement patterns are taking place -- that first the triangle is rotated as much as is favorable, then it is linearly advanced to bring the maxilla to the final planned 11mm (where the rest of the mandibular advancement takes place via genioplasty).

The reason I ask is that I take it only so much advancement can be brought about by the CCWr because eventually, you'll end up at a 0-degree occlusal plane.

Regarding the theoretical problem of chimp lip, if the entire amount of advancement of the upper and lower jaws could be accomplished with CCWr alone (with the rest of the pogonion taken care of by genioplasty), the risk of chimp lip would surely be very small, as the ANS area associated with the upperlip/under nose fullness would rotating downwards. Hopefully I have this understood correctly.


--- Quote ---There is no ABSOLUTE CERTAINTY to be guaranteed here and NO BETTER predictions to be made here than the one you got already. It's inherently a decision made under uncertainty.
--- End quote ---

What you have expressed regarding the inherent uncertainty involved aligns with what I have been going through in my own head; whatever decision, it ultimately devolves to something of a leap of faith. I cannot verify that the changes I might wish to make to the plan -- being a non-expert -- would translate to a more favorable result, nor can I guarantee that the soft tissue predictions I've been provided are wholly accurate either.

That said, I have been attempting to resolve some of this anxiety by learning about the well-established attractive norms. For example, it is well-established that for the incisors to line up with the soft tissue nasion is considered attractive, so even if I did opt to dial the advancement of the maxilla down to meet this metric, I would hope I would be in a relatively 'safe' position as to have a favorable outcome (i.e to not be under advanced). The same goes for tried and tested criteria like the True Vertical Line. I appreciate your earlier comments that the individual nature of my own situation must take precedence over cookie-cutter values, however.

Having spoken to my surgeon, they are very willing to make changes based the concerns I have about being advanced beyond what I consider aesthetically pleasing, but you're right -- I have to have something of a solid basis for doing so, and it's difficult to know how much is based on fear and objective reality.

For example, I have attached a publicly available before and after from another patient my surgeon operated on. When this was posted on another public forum, many people said the result was excellent, and many also said they thought the person's jaws were now too big and that their upper lip area had become too protrusive (these were large movements of 18mm at the mandible and 8mm at the maxilla, with CCWr, If I recall -- she is around 5 weeks post op in those images).

As I puzzled the images myself, I went back and forth. It is no doubt there is a great improvement overall, but is there also credence to the notion that she may have been more balanced with slightly less advancement? Perhaps. And there in lies the subjective element of all this that I'm never really going to get a definitive answer to.

As you say, I'm not going to get any better prediction than with the displacement models the surgeon can provide, so it may make sense for them to design a 'dialed back' alternative and then compare them to reach the ultimate conclusion. They said we could design two separate plans.

You have expressed this is likely an optimal plan/likely outcome and made well-founded points as to why. I just now have to make a decision on which direction this 'leap of faith' is going to go.

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