BSSO or Bimax? Surgery Soon

[emanresu]

Hello JSF, it's been a while. My surgery is finally approaching (1.5 weeks), and my surgeon sent me a document with two options, but I'm having difficulty deciding.

Images, with bonus GIF at the end: https://imgur.com/a/mIpvBZK

Lower jaw w/ genioplasty would net me 14mm of advancement. Including upper jaw would provide an additional 3mm. I'm on the fence, because I feel like it makes sense to advance the jaws as much as possible since I'm already going under the knife. But having an additional surgical movement for the sake of 3mm perhaps seems a bit excessive.

Another concern is that upper movement would likely upturn and widen my nose even more, worsening my already existing aesthetic issue there. I've looked up prices, and an alarplasty costs about 2.5k, so I could address the nose widening down the line, but correcting the upturning is going to involve a rhinplasty, a significantly more expensive procedure with a higher rate of poor outcome.

I have a call with my surgeon tomorrow, and to mitigate undesirable soft tissue changes, I think I'll ask if he can do the following:

• Reduce the forward movement of the upper jaw from 3mm to 1mm–1.5mm
• Counterclockwise rotation with posterior downdraft for a rotation of 5–6 degrees
• Reaffirm that I want the anterior impaction to be as small as possible

These changes would have it be closer to the plan Gunson made for me. Photos are several years old, but it's the last one in the gallery here: https://imgur.com/a/xdHuNHk

If he is unable to do this (and I'm not sure why, as I originally went with this surgeon because he said he could go CCW w/ posterior downgraft), I would feel a lot more comfortable with the upper movement. But as it stands, between the '3mm-upper-plan' vs 'lower-only' plan, I'm leaning towards the latter. What do you think?

[GJ]

I'd avoid touching the upper jaw if it's possible (to avoid issues with the nose widening). You're better off sacrificing a little advancement on the lower to not touch the upper. The bite looks edge to edge in all those images so that's a concern.

[emanresu]

Hey GJ, thanks for the response! Avoiding upper jaw surgery if possible was the way I was leaning as well.

However, in a twist of fate, I spoke with my surgeon this morning and it turns out the advancement amounts are less than he originally mentioned: only 9mm for lower+genio vs 12mm for DJS. I'm leaning towards DJS now, as I feel the advancement would otherwise be too small given my lower third issues.

It also seems like he wants to do linear advancement of the upper jaw instead of CCW like I originally wanted. It's only 3mm though, so I guess I'll just have to hope the unavoidable upturning isn't too severe. Somewhat interestingly, he said the cartilage in my nose suggested it might be more resilient to upturning, but also at one point said "I cannot guarantee how much the nose will change, but I can guarantee the nose will change." Doesn't instill too much confidence as far as potential unwanted changes go, but I certainly appreciate the honesty on his part.

[kavan]

NOTE: IMGUR blocks my seeing all the images by putting up videos of girls making disgusting confections that look bloody brains. So,limited feedback from me to queries dependent on IMGUR links.

I managed to copy a document called Plan (alpha) Triple Jaw; the (read-out) DISPLACEMENT PROPOSAL as to look at it while I post my response. I also got a quick look at your face. By the time you see my post, I will have deleted the displacement read-out proposal of plan alpha triple jaw. But I have the following to say about it:

'Triple Jaw': WTF??? there are only 2 jaws; upper and lower. The correct terminology for the surgery is DOUBLE JAW SURGERY with GENIOPLASTY.

ANS: The 3mm displacement is purely horizontal which is not too much of a 'bad' thing. For example, doctors who do the CCW via posterior downgraft often want to set the displacement vector of the ANS to pure horizontal line because the unfavorable nose base aesthetics can arise from displacement over a DIAGONAL line. The read out tells you the 3mm are in A-P direction and there is 0 down-up movement. So, displacement is purely horizontal. There is NO 'UP' (or 'down') vector component of your read-out chart. So, nothing in it that conveys IMPACTION or a turn UP to the nose.

As to the nose base getting a little wider, a good maxfax will do something called an 'alar cinch' to mitigate that. As to the foregone conclusion that 'all noses will look worse' after maxillary advancement, it's usually a KNEE-JERK one because all noses don't look worse after maxillary advancement. It depends on the angle of inclination the nose base is advanced over.

The possibilities of an unfavorable aesthetic outcome to the nose can increase when advancements are very large and also over an unfavorable inclination of the maxilla. But to keep it simple, it's mostly a problem for people who START OUT with good nose aesthetics or would OTHERWISE NOT have needed nose correction before any jaw surgery. So, personally, I fail to see the reasoning behind 'risk avoidance' of possible nose sequella when your start point for the nose is that you would benefit from some nose improvement (rhino) whether or not you had jaw surgery and also when the angle of inclination the 3mm advancement is taking place over is ZERO.

A decision to KEEP your nose AS IS resolves to a decision to forfeit the extent of the lower jaw advancement you could get in a circumstance where the  lower jaw recession is the GREATER of your aesthetic problem. So, right there, acting on knee jerk RISK AVERSION that your nose base could get a little wider blows your chances of getting a good jaw advancement when the jaw recession is the BIGGER aesthetic problem. So, the nose will REMAIN an aesthetic problem in its own right if you choose to keep as is and also forfeit getting a good lower jaw advancement to do so. Keep nose as is (via no maxillary advancement) = possibility of under correction of lower jaw. I mean if you want to look better, BOTH your nose and lower jaw need to be corrected. So when you forfeit the extra jaw advancement you could have to keep the nose the same, you're still left with a nose needing correction but also under correction of lower jaw. I don't know where the logic of that type of decision comes from. Probably none of my business. Just sayin' it would not be my own.

NOW, BACK TO THE READ OUT CHART.

1: The doctor who claims you have 'THREE' jaws (just LOL) doesn't list the PNS on the chart. When CCWA-r via posterior downgraft is in the cards the PNS point (posterior nasal spine) is listed with a downward movement. So, there is no information on that.

2: Look at the POG POINT part of your chart. The displacement at the POG point tells you what the final advancement of the lower jaw (including the chin) is. The A-P direction is the HORIZONTAL displacement which is 11.4mm and the 'up/ down' part tells you, the chin point is going vertically up a little. It's also implicit that the advancement at the POG point is a function of the A-P advancement to the ANS point of UPPER jaw. So, the displacement read-out chart conveys that a purely horizontal advancement of the ANS, allows for the POG point to be advanced 11.4 mm horizontally and .6mm vertically upward. So, NO IDEA where you come up with a lower jaw advancement of '14mm'.
 
3: There is NO anterior impaction on the (alpha) Triple Jaw displacement read-out. The ANS section of your displacement proposal reads 0= NO upward movement of the ANS. So, NO IDEA where you conclude any anterior impaction to remind the surgeon you want 'minimum' because the chart read 0.

4: The KEY points to understand on a DISPLACEMENT PROPOSAL chart are: ANS, PNS and POG and the 'up' and 'down' measures of those things. ANY movement along a DIAGONAL path will have both a VECTORIAL vertical (up or down) and horizontal displacement (A-P direction). If the displacement path is purely horizontal there will be NO=0 vertical upward or downward displacement.

In closing, I don't see any basis for the conclusions you are coming up with,  and it's not clear you understand the very basics of what the displacement chart is conveying when you think it's telling you you are getting an impaction that your doctor needs to 'minimize' where 0 impaction can be read from the read out or 14mm lower jaw advancement from it when the pog point doesn't convey that or that your nose will be 'upturned' when the read out lists a 0 upward vectorial displacement of the nose.

[emanresu]

Hey kavan! Thank you for putting it so plainly. (Also that’s regrettable about the brain confections…)

For example, doctors who do the CCW via posterior downgraft often want to set the displacement vector of the ANS to pure horizontal line because the unfavorable nose base aesthetics can arise from displacement over a DIAGONAL line.

So, personally, I fail to see the reasoning behind 'risk avoidance' of possible nose sequella when . . . the angle of inclination the 3mm advancement is taking place over is ZERO.

This is a very interesting insight I hadn’t heard before. The common belief often touted is “maxilla moving forward = nose widening and upturning”. But understanding how the direction of movement does (or does not) cause change is appreciated, thank you.

As to the nose base getting a little wider, a good maxfax will do something called an 'alar cinch' to mitigate that.

The surgeon confirmed in our initial consult that he does indeed use an alar cinch. He mentioned that it doesn't prevent all widening, so my concern was regarding widening my already wide nose. On that note...

A decision to KEEP your nose AS IS resolves to a decision to forfeit the extent of the lower jaw advancement you could get in a circumstance where the  lower jaw recession is the GREATER of your aesthetic problem. So, right there, acting on knee jerk RISK AVERSION that your nose base could get a little wider blows your chances of getting a good jaw advancement when the jaw recession is the BIGGER aesthetic problem. So, the nose will REMAIN an aesthetic problem in its own right if you choose to keep as is and also forfeit getting a good lower jaw advancement to do so.

I think these are tough words that I needed to hear. I realize my nose is also an issue, but my thinking was that opting for a slightly less optimal jaw surgery plan might prevent it from getting even worse. If it did worsen, it could push the issue over the edge, making rhinoplasty feel unavoidable, while right now, my nose might not be “bad enough” to justify surgery and could still be lived with (although, from what I'm gathering, it seems like my current nose may be even worse than I initially thought).

It seems like not going all the way with this jaw surgery is a lost opportunity, and perhaps I should figure out a way to make this rhinoplasty happen. (Maybe I'll start with an alarplasty, a minor procedure that's cheap and done under local anesthesia, while I save up for a rhino if the alaraplasty improvements prove insufficient.)

NOW, BACK TO THE READ OUT CHART.

1: The doctor who claims you have 'THREE' jaws (just LOL) doesn't list the PNS on the chart. When CCWA-r via posterior downgraft is in the cards the PNS point (posterior nasal spine) is listed with a downward movement. So, there is no information on that.

I spoke with the surgeon today, and it seems like he's hesitant to do the original CCW w/ posterior downgraft plan unfortunately. He did mention there'd be some CCW rotation with the lower jaw too though.

So, NO IDEA where you come up with a lower jaw advancement of '14mm'.

Yes, sorry for the confusion. The 14mm vs 17mm values were what the doctor had told me originally, but it seems these values changed when it was put into this visualization software. I shouldn’t have assumed the values stayed the same, and should’ve checked the document closer.

So, NO IDEA where you conclude any anterior impaction to remind the surgeon you want 'minimum' because the chart read 0.

Again, this is an issue that arose due to me just assuming things were the same based on the conversation I previously had with the surgeon a few months ago, very sorry about that.

Overall, it seems like my concerns with the surgeon’s proposal are unfounded, so I think I will be proceeding with this 'Triple Jaw' () plan. He mentioned he could also increase the genioplasty from 5mm to 6–7mm, so I’ll probably do that too. Thank you as always kavan, I hope you realize how much of an impact this has had on my decision-making. Much appreciated!

[kavan]

Hey kavan! Thank you for putting it so plainly. (Also that’s regrettable about the brain confections…)

This is a very interesting insight I hadn’t heard before. The common belief often touted is “maxilla moving forward = nose widening and upturning”. But understanding how the direction of movement does (or does not) cause change is appreciated, thank you.

The surgeon confirmed in our initial consult that he does indeed use an alar cinch. He mentioned that it doesn't prevent all widening, so my concern was regarding widening my already wide nose. On that note...

I think these are tough words that I needed to hear. I realize my nose is also an issue, but my thinking was that opting for a slightly less optimal jaw surgery plan might prevent it from getting even worse. If it did worsen, it could push the issue over the edge, making rhinoplasty feel unavoidable, while right now, my nose might not be “bad enough” to justify surgery and could still be lived with (although, from what I'm gathering, it seems like my current nose may be even worse than I initially thought).

It seems like not going all the way with this jaw surgery is a lost opportunity, and perhaps I should figure out a way to make this rhinoplasty happen. (Maybe I'll start with an alarplasty, a minor procedure that's cheap and done under local anesthesia, while I save up for a rhino if the alaraplasty improvements prove insufficient.)

I spoke with the surgeon today, and it seems like he's hesitant to do the original CCW w/ posterior downgraft plan unfortunately. He did mention there'd be some CCW rotation with the lower jaw too though.

Yes, sorry for the confusion. The 14mm vs 17mm values were what the doctor had told me originally, but it seems these values changed when it was put into this visualization software. I shouldn’t have assumed the values stayed the same, and should’ve checked the document closer.

Again, this is an issue that arose due to me just assuming things were the same based on the conversation I previously had with the surgeon a few months ago, very sorry about that.

Overall, it seems like my concerns with the surgeon’s proposal are unfounded, so I think I will be proceeding with this 'Triple Jaw' () plan. He mentioned he could also increase the genioplasty from 5mm to 6–7mm, so I’ll probably do that too. Thank you as always kavan, I hope you realize how much of an impact this has had on my decision-making. Much appreciated!

As to the nose, I'm glad you took no umbrage with my 'straight talk'. Anyway, even if a CALIPER measure was little wider to the nostril area, you would be looking at it via relative visual comparison of a better lower face frame. So, by relative comparison, you might not see much of an unfavorable change in the mirror. That is to say, your nose change might not dominate your frontal facial VISAGE post bi-max and chin advancements as much as it does now. But still a 'wait and see' and there is wait time as to when you want to 'fix' it.

[emanresu]

As to the nose, I'm glad you took no umbrage with my 'straight talk'. Anyway, even if a CALIPER measure was little wider to the nostril area, you would be looking at it via relative visual comparison of a better lower face frame. So, by relative comparison, you might not see much of an unfavorable change in the mirror. That is to say, your nose change might not dominate your frontal facial VISAGE post bi-max and chin advancements as much as it does now. But still a 'wait and see' and there is wait time as to when you want to 'fix' it.

Ah very interesting, I hadn’t really considered how a larger nose could in all likelihood look proportionate with a larger lower third (or, at least, camouflage it). I’ll try not to hold out too much hope for my subpar nose, but I will certainly keep all this in mind for some sense of comfort over the coming weeks. Thank you again!

[kavan]

 

Ah very interesting, I hadn’t really considered how a larger nose could in all likelihood look proportionate with a larger lower third (or, at least, camouflage it). I’ll try not to hold out too much hope for my subpar nose, but I will certainly keep all this in mind for some sense of comfort over the coming weeks. Thank you again!