Kindly asking for feedback on my surgery plan

[Mitochondria947]

Hello everyone.

I am kindly requesting your thoughts on my proposed surgery plan.

I was diagnosed with class II malocclusion, mandibular retrognathia, crossbite, and I have functional breathing disturbance during sleep (especially when sleeping on back). However, aesthetics are also a concern. Public speaking is part of my job, and so I would also prefer the surgery to achieve neutral, or perhaps even positive aesthetic result.

I have been in invisalign for 18months. In December I had a 3d plan constructed with my surgeon, who actually requested that I do further decompensation. Therefore, I am now undertaking a final 16 weeks of orthodontics until the position of the teeth are set to be ready. We will do another plan and he said that this may add ~1mm to the final BSSO.

The surgery will be private, with a well-known surgeon in Germany who has extensive experience with posterior downgraft.

Here is the preliminary plan:

- Custom plates

-Lefort 1
9mm total advancement
1.8mm anterior impaction
Posterior downgraft (6 degrees CCW rotation)

- BSSO
10.4/12mm one side
12mm other side

- Optional genio (he proposed a small reduction)

Total advancement at pogonion ~13mm

I have attached my profile pictures, along with proposed movements.

Unfortunately I tend to naturally adopt a forward head posture, and my CBCT was taking in prone position without any control for my head posture.

My potential concerns (based on very limited understanding):

My nose is already mildly upturned, and my nasolabial angle is obtuse due what what appears to be a prominent ANS. I am slightly worried that such a large advacement of the maxilla may lead to significant upturning of the nose and worsening of an already obtuse NLA. I discussed this with the surgeon, and he offered either a subspinal lefort 1 (a modified cut below the ANS), or ANS/nasal contouring.

My thinking is that a subspinal lefort 1 may help to equalize the "tethering" effect by advancing all of the other surrounding tissues anteriorly. So the ANS remains in the same position, but no longer appears prominent.

However, this (may?) bring with it a secondary concern - which is the potential for development of a "chimp-like" upper lip.

RE the movement of the MMA complex as a whole, does this look over-advanced?

And finally, my chin is already quite prominent (although posteriorly set back). With autorotation of the mandible, the chin is set to come forward and down. My question is whether a reduction, or perhaps some vertical lengthening would be best.

I am honestly confused, don't have anyone else to discuss this with, and this forum has been a goldmine of extremely useful information over the years. It seems like the best place to ask these questions.

Thanks for taking the time to read, and apologies for the lengthy post.

[Mitochondria947]

I forgot to add. Here are my profile photos where you can see me smiling

[GJ]

To me, those movements seem way to extreme giving your starting position. You look good as is, yet 13mm and 2mm of impaction (I'd be worry about zero tooth show, which is extremely aging). I think you might go from a more elegant look, which you have now, to a more neanderthal look. PM me with the surgeon who proposed this, as it seems much to extreme.

[Mitochondria947]

To me, those movements seem way to extreme giving your starting position. You look good as is, yet 13mm and 2mm of impaction (I'd be worry about zero tooth show, which is extremely aging). I think you might go from a more elegant look, which you have now, to a more neanderthal look. PM me with the surgeon who proposed this, as it seems much to extreme.

Thankyou. I PM'd you the surgeon's name.

On those profile photos I am jutting my head forward (which I think I do unconsciously). Apologies. I don't know if they are the most accurate.

I have attached some other photos which include me attempting a more "normal", straight head posture. Do they change your opinion in any way?

[GJ]

That still seems extreme to me, although I do see what you mean.
I would think 8-10mm with CCW just looking at it. Maybe others will chime in with an opinion.

Have you consulted with multiple surgeons? I would definitely consult with at least three. Some have preferences that they work into their plans. I got your surgeons name on PM and don't know anything about him.

[Mitochondria947]

That still seems extreme to me, although I do see what you mean.
I would think 8-10mm with CCW just looking at it. Maybe others will chime in with an opinion.

Have you consulted with multiple surgeons? I would definitely consult with at least three. Some have preferences that they work into their plans. I got your surgeons name on PM and don't know anything about him.

I consulted a well-known surgeon (A) in the early stages based in Barcelona, prior to doing orthodontics. He gave a preliminary suggestion for simple BSSO.

However, I personally suspected I may be a bimax candidate. I later consulted another well-known surgeon in Rome who suggested Bimax with CCW.

I started orthodontics, but since read some very bad reviews and experiences with that particular surgeon. Several reports of people receiving substandard aftercare and then being ignored despite surgical complications, etc.

The surgeon I am currently in discussions with has one of the best reputations in Germany, but does not advertise his services and is not well-known outside of that country. However, I do agree that it would be good to get some more opinions.

Thankyou

[Mitochondria947]

Out of curiosity, I supplied ChatGPT with my side profile pictures and my proposed surgery movements.

I gave it the precise measurements, and asked it to generate an image of the after-surgery result.

I then superimposed the 3D plan which I received from my surgeon, and I was very surprised at the ChatGPT's accuracy. It tracks very closely with the plan.

Furthermore, the estimated "after" picture does not look over-advanced in my opinion. I have attached the images.

I understand that these 3D plans are not 100% accurate. However, I'd be curious to hear anyone else's opinion on this.

Thankyou

[GJ]

If you get a result like that, it would be great.

Personally, I would not trust ChatGPT with something like this. It's reading from all different textbooks and approaches, likely averaging them, and then on top of it, it's also trying to please you. Seriously. This thing wants to be everyone's best friend. Haha. Sometimes you can get more realistic answers by telling it you want it to be brutally honest and not your friend. Lol.

I'd be curious to hear a surgeon's opinion on the GPT results, though. What you should do is go on a few more consults. The standard is three before a surgery.

[Mitochondria947]

I had a consult with another surgeon, although decided to go with the original surgeon and plan.

Surgery was 2 weeks ago.

I am still very swollen, but here are the results so far (10 days post-op)

Swelling along the jawline has come down a fair bit, although it is still tight and puffy around the upper lip, nose area and cheeks.

 

[Mitochondria947]

The file was too large, so I have to write another post.

Here are the current results at 2 weeks post-op

[GJ]

That looks like a really nice result.

[Mitochondria947]

Finally hit one month!

I can still breathe much better. My lower jaw wants to return back to it's original position at night, but hopefully elastics can address that over time. My bite is currently stable

Swelling around the mandible and submental area has improved a LOT since then. Currently, most of the swelling is sitting around my nasal/paranasal area. The nose is still a little swollen, and my cheeks/inner malar area are definitely still very puffy.

I currently have no pain. The worst thing at this point is the inability to eat solid foods. I can't chew (obviously), and am getting sick of eating slop. I am mostly drinking milk with whey protein and collagen, along with a laundry list of supplements.

The surgeon I went to was Dr Tobias Ebker in Berlin.

Overall, I am super happy I did it, despite that first week being absolutely brutal.

I have attached befores to this post with my full face. I figure there's no point censoring/doctoring it at this point.  Because of file size limitation, I will post the afters in the next post.

[Mitochondria947]

Here are the results at 4 weeks post-op

The swelling has come down faster than I thought. Like I said, it remains puffy at the maxilla cut (paranasal area and cheeks), but for the most part it is low. I have been doing an extensive supplement and peptide protocol, including several other interventions, which I believe probably helped.

I hadn't come across any mention of Tobias Ebker on this forum, and testimonials are scarce elsewhere online. He doesn't market himself, yet is considered an expert in posterior downgraft. I am pleased I chose this surgeon, because aside from the obvious improvements in function, I am quite pleased with the aesthetic result so far.

Hope this helps someone in the future!

[GJ]

Yeah insanely great result. The surgeon must be stoked, too.