Happy to hear your opinions

[VainVanVeen]

Hello everyone,

I've recently started seeking different maxfacs and thus far, i've seen one. I have a meeting next month with another one.

My face has always bothered me : I have a weak short chin (lacking in height and in my opinion, width) coupled with big lips (I don't hate them), which makes the problem look worse in my opinion. I've been sporting a beard which, when it's "put" well (often luck), hides my chin, gives structure and more height to my face. It gets tiring to always try to get the beard right and to mostly depend on it.

I also think I generally lack definition : both my mandible and my maxilla look puny to me, they lack robustness. I have the same problem with my zygomatic bones. If we add up all of this together we end up with a short face that lacks definition, as if the soft tissues are not stretched enough, all around.

The meeting with the maxfac, he trained under a well regarded maxfac in sweden, left me with a couple of interrogations

First off, he mentionned that my bite (I've had orthodontics treatment younger) and jaws were both in good positions despite a slight asymmetry. He mentionned they were both just a tiny bit behind.  About my maxilla, he mentionned two things : I have close to no tooth show while my lips are slightly open, and my maxilla is a little bit short. He said he couldn't do much moving around the jaws because of my lips : he warned me about the chimp look. This surprised me because what my face lacks possibly the most seems to be height, which if im not mistaken, would be a CWr and not a CCWr in the event I need Bimax. I've always understood, perhaps wrongly, that the chimp look is mostly a CCW problem. My philtrum is also pretty concave and not flat, which puts another interrogation about his chimp look claim.  About the genioplasty, he mentionned he wouldn't be able to advance it a crazy amount (10mm) because of the moon chin look. Again, I'm curious about this claim.

Near the end of the meeting, he said he could probably help me : I have another meeting scheduled next month, he decided this to give me some thinking time.

Other things he mentionned : the possibility of plastic surgery. Now I've heard about bone erosion and the likes, I'm not thrilled about it, but I'm not completely closed to the idea either if it would be better for my case. He also did say something about removing some of the fat under my neck and chin (which I always took as lack of bony support with possibly thick soft tissue) and around my cheeks, which also lack bony support. If I do anything about my cheeks, I'm already aware implants are inevitable. I want to do something about my lower third first before anything else.

I have a ceph that I'll link here : https://imgur.com/a/z5G7G1U

So I think that's it. Excited to hear all of your opinions

If you need more infos, no worries I'll add what's missing 

Thanks in advance  !

[GJ]

You could probably lose any fat under your neck and chin by just exercising and save yourself the risk of a surgery there.

This is probably not a jaw surgery case, to be clear. But if you want jaw surgery, my first impression was either a linear advancement or a CWr. Your upper lip/philtrum looks flat, and then your lip curves. So he's probably concerned with the chimp look because of the part higher up. I kinda agree. Hard to say. You generally get about 1mm of soft tissue movement for 3mm of bone. So, you can think how that might turn out. I can't visualize it.

[VainVanVeen]

Thank you for answering !

About the fat, I've already tried. I could probably be a little bit leaner (as I've already been), but I'm already pretty lean (I know most people say this and it's easy to say) : this is the only part of my body that's mostly like this.

I see what you mean about the philtrum, the lip curve was throwing me off. Thanks for the observation.

Do you think advancing the chin and giving it some height would be a good idea, like a kind of middle ground procedure ? Is the labiomental fold a worry here ?

Thanks again

[GJ]

Thank you for answering !

About the fat, I've already tried. I could probably be a little bit leaner (as I've already been), but I'm already pretty lean (I know most people say this and it's easy to say) : this is the only part of my body that's mostly like this.

I see what you mean about the philtrum, the lip curve was throwing me off. Thanks for the observation.

Do you think advancing the chin and giving it some height would be a good idea, like a kind of middle ground procedure ? Is the labiomental fold a worry here ?

Thanks again

To me that's a good compromise (in theory), but only if they can fill the groove with something (HA, bone, etc) to tame the shadow. You already have a deep groove, and a genio might make a step there in addition to a deeper groove. Your tissue looks thick on that ceph, so I'd think you'd need a bigger bone movement to move that soft tissue. Probably like 6mm of bone to get 2 or 3 of soft tissue? I'm not sure exactly, obviously. But ask about all that and how they'd fill the groove/shadow, and also ask if it would create any step off.

[VainVanVeen]

From the documents they gave me about the genioplasty, there is mention of titanium plates but nothing about paste or the likes. I asked them if they could do the type of genioplasty where they widen the chin by cutting and putting a bone graft in the cut, they said no. So I'm not certain about them using something for the groove except the plates and screws. In any case, I'll ask them.

[GJ]

From the documents they gave me about the genioplasty, there is mention of titanium plates but nothing about paste or the likes. I asked them if they could do the type of genioplasty where they widen the chin by cutting and putting a bone graft in the cut, they said no. So I'm not certain about them using something for the groove except the plates and screws. In any case, I'll ask them.

You might want to go on more consults, too.

[kavan]

My guess would be Double jaw advancement with clockwise rotation around the ANS point. CW-r around the ANS point will bring PNS up, push the chin point backwards and down. Soft tissue of the lips will go backwards and soft tissue at chin will go backwards and down. So, with the CW-r, it tends to reduce the type of 'stick out' you have with the lips. It also increases your LOW Mandibular plane angle and sets the chin point downwards so it doesn't look so short. CW-r is backwards and down and that is the best rotation to have (in your case) for the double jaw advancement.

[VainVanVeen]

Thank you for your thoughts Kavan !

I have more to say but time's short and I'm in the middle of writing a paper for university. I'll come back to your comment when I'm done with my essay.

[kavan]

Thank you for your thoughts Kavan !

I have more to say but time's short and I'm in the middle of writing a paper for university. I'll come back to your comment when I'm done with my essay.

In the event I'm not around, I'll provide some more info that could explain why the guy hesitates to offer surgery. I'll also provide a diagram having to do with rotations.


1: The angle of inclination the lower incisor has with the border of the mandible looks to exceed 95 degrees. It's not uncommon for prior ortho to get 'bite rite' by flaring out the upper and lower incisors which might contribute to the lip 'stick out'. I don't remember the exact angle but just to say the maxfax docs like it to be near range of 90 to 95 degrees and not overly obtuse. So, maybe he doesn't want to pluck a pre-molar which would be needed to get the lower incisor with in the range of inclination they like it to have when doing an advancement.

2: Although the lip 'stickout' is made less and re-orients to rotate down and backward with CW-r, lack of tooth show along with complaint of lower face too short would require an OVERALL down graft (one to the entire maxilla) with net CW-r. Thing is that an overall down graft to ELONGATE the maxilla is not something all surgeons do (advanced skill set is needed). Just sayin' for short lower '1/3rd' and lack of upper tooth show, a down graft that spans the entire maxilla is needed. So, you would have to establish if he actually does them. By the way, an overall maxillary downgraft to increase the height of lower face can have net CW-R, net CCW-r or 0 net rotation if length of it is uniform throughout span of maxilla. When the front of it is longer than the back of it, it's net CW-r and when the back of it is longer than the front, it's net CCW-r. But no matter the rotation, what the grafts have in common is LENGTH added to lower 3rd of face. Monkey muzzle (chimp lip) has more to do advancing over an unfavorable rotation when they advance both the jaw and maxilla equally where they have to advance the maxilla TOO MUCH to because they DON'T do a CCW-r in a person who could need that in order to have the mandible advanced more than the maxilla. So, it's more of a matter of an equal advancement of both jaws in people who start with an unfavorable inherent rotation of the jaws which is not changed (via rotation) before hand. So, chimp lip is neither directly associated with CW-r or CCW-r pe se. It's directly associated with MORE advancement of the maxilla than a person might need when a doctor advances both jaws equally (linear advancement) to get a large mandible advancement and the maxilla goes along with the same ride.

3: Another thing that needs a graft of sorts is a genio that goes in the direction of downward and outward. It makes a bone GAP than needs to be filled in with a graft. So, maybe he doesn't do the type of grafts other docs do

4: Depending on how much you conveyed to the doctor that your bone structure was not as 'robust' as you would like,maybe he thought you were expecting too much from maxfax surgery. Bimax/double jaw surgery will do nothing for cheek bones. Although they can vertically elongate the maxilla for a longer lower 'third' of the face, they can't make the jaw bone itself more robust. That is to say, it doesn't actually make a vertically short mandibular body longer or more 'hefty'.

All that said, I think it could be a combination of your expecting to get a more 'robust' bone structure from maxfax surgery and also, possibility of pre-molar removal and also a question of whether or not he performs the type of BONE GRAFTING techniques associated with maxilla elongation and also a type of genio that goes down and outward also needing bone grafting. Like it sounds more in that direction than in direction of getting 'chimp lip'. I'm not predicting whether you could or could not get chimp lip. Just saying, I don't think that possibility is the salient reason for his being disinclined to encourage surgery.

[VainVanVeen]

Thank you for all this information Kavan. Would have replied sooner, but searching for a roommate sucks a lot of energy out of you.

I don't think I emphasized too much my complaint about the lack of robustness : I mentionned it in passing about my lack of "definition" and clearly stated I knew it would mostly be an "illusion" anyway. (Giving the appearance of more robustness by giving more height to lower third of my face, thus stretching the whole thing.) I think your guess about his reasons could be it : lack of skillset needed would not surprise me, being overall too conservative for a case like mine (which I understand completely, i'm aware it's not an easy one), etc..

Thank you for the explanation about CW and CCW in relation with "chimp lips". It's, I think, clear to me.

You mentionned my case would benefit (I assume aesthetically since we're in that category) from CW rotation around the ANS point, which is backwards and down. If I understand correctly, backwards and down would give more space for the soft tissue to stretch and give more height to my whole face, which would give more of an overall visual structure to the lower part of my face. Would the genio be down and back too, or would it be down and forward (to kinda elongate) ? About the stickout of my lips, it doesn't really bother me, but if it's a symptom of the aesthetic deficiency of my lowet third, I don't mind it changing at all

About tooth show, just want to specify (in the case I wasn't clear) when I lightly open my mouth, i have little to no upper tooth show, but when I smile, no problems. I guess that is because my ortho flared my upper teeth out during my treatment long ago ?

Thank you again for your answer Kavan

[kavan]

Thank you for all this information Kavan. Would have replied sooner, but searching for a roommate sucks a lot of energy out of you.

I don't think I emphasized too much my complaint about the lack of robustness : I mentionned it in passing about my lack of "definition" and clearly stated I knew it would mostly be an "illusion" anyway. (Giving the appearance of more robustness by giving more height to lower third of my face, thus stretching the whole thing.) I think your guess about his reasons could be it : lack of skillset needed would not surprise me, being overall too conservative for a case like mine (which I understand completely, i'm aware it's not an easy one), etc..

Thank you for the explanation about CW and CCW in relation with "chimp lips". It's, I think, clear to me.

You mentionned my case would benefit (I assume aesthetically since we're in that category) from CW rotation around the ANS point, which is backwards and down. If I understand correctly, backwards and down would give more space for the soft tissue to stretch and give more height to my whole face, which would give more of an overall visual structure to the lower part of my face. Would the genio be down and back too, or would it be down and forward (to kinda elongate) ? About the stickout of my lips, it doesn't really bother me, but if it's a symptom of the aesthetic deficiency of my lowet third, I don't mind it changing at all

About tooth show, just want to specify (in the case I wasn't clear) when I lightly open my mouth, i have little to no upper tooth show, but when I smile, no problems. I guess that is because my ortho flared my upper teeth out during my treatment long ago ?

Thank you again for your answer Kavan

I'm sorry, it looks like I put a lot of time into this one, left info in anticipation I might not have time later down the line and now your full case/circumstance really isn't fresh in my memory.

Anyway, any rotation around any point is selected in accordance of changing the orientation of the facial 'triangle' so advancement can take place over a more favorable inclination. The rotation itself, doesn't change the length of anything just like if you rotate a TRIANGLE, the length of any of the sides don't change. So, I can't speak of anything getting 'stretched out'.

CW-r around ANS point would most likely be chosen for someone with short face and lips sticking out because with the rotation, the lip area goes backwards and the chin point goes backwards and down. But the rotation itself does not make things 'longer'. What it allows for (when CW) is a 'steeper' diagonal path to advance 'forward' on. 'Forward' along a downward diagonal path is a combination of horizontally outward and vertically down. (Remember your high school basic physics of vector displacement). So, for someone who needs more elongation, a path is chosen that is somewhat 'steeper' than someone who doesn't.

For example, with the jaw advancement, the 'forward' displacement is both horizontally forward and vertically down. So, any elongation comes from the advancement, not the rotation itself. What the rotation does is to allow advancement over along a more favorable inclination path.

ROTATION is an entirely different geometrical 'operation' than advancement.

The genio advancement would not be down and back. The matter here is that a ROTATION would set the chin point down and back and the rotation would result CHANGING the angle of ORIENTATION of the path the chin is going to be advanced 'forward' on. The chin point moves in the direction of the BSSO. If more elongation is needed and needed to be done to the chin in a separate genio, the direction of the type of genio to select would be one that is   is horizontally outward and vertically down and not one that is horizontally forward and vertically up.