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Thank you for your detailed reply and your time. I've looked into the topic again and think I understand it better now.

I know that the Roof of the hard palate is also the floor of the nose. The floor therefore remains connected to the maxilla even after the Lefort 1 cut, which completely separates the upper jaw from the skull in DJS.

The maxilla is then moved forward (like the mandible), because of the DJS. If only that were to happen, it is maybe possible (the odds are higher) that the expansion of the whole nasal cavity after the surgery could be achieved by turning on the turn key of the expansion device (the exact name of the expander my surgeon uses is "GNE").

Because in this case, the maxilla is (simply put) only moved horizontally. It was not moved down in a downgrafting procedure, which would have created a gap that would have had to be filled with material (such as natural bone). The vertical distance between the skull, maxilla, hard palate and everything that goes with it remains the same.

But in my case, the posterior maxilla would be downgrafted by 3-4mm, to achieve a CCW-Rotation. This gap is then filled with material, probably natural bone. This means, that the maxilla and the skull would be "connected" again.

Back to the topic of the hard palate. The hard palate is both, the floor of the nose and the roof of the mouth. For this reason, the floor of the nose would also be expanded with the expander device in the weeks after the surgery, because this area is not affected by the Lefort 1 Cut. The hard palate isn't cut horizontally in the middle or anything weird like that, which would separate the floor of the nose and the roof of the mouth.

In my eyes, the problem is, that the floor of the nose with the area of ​​the nasal passage, which lies under the Lefort Cut, is only a very small part of the nasal passage. I have attached 3 pictures where you can see a skull example showing how my surgeon does the DJS with CCW and downgrafting. In the picture of the front view, I marked in red the area of ​​the nasal passage that I think would be expanded.

In order for the expansion to affect the whole nasal cavity, the expansion would have to involve the bones to the left and right of the large main part of the nose cavity, which lie above the Lefort cut.

I drew the areas in green. I know that good expansion (like EASE+MSE) also has an effect up to the cheekbones (which is why many people have a optically wider face after) and that the lower nasal cavity expands more than the area at the top between the eyes. It's just a rough sketch.

To have an impact on these essential areas in green, the pressure of the expansion would also have to affect the areas where the Lefort cut with the downgrafting took place.

The problem I see is stability. Because the expansion by turning on the turn key (sorry for my bad english, i dont know how to articulate it different) of the expander device happens in the weeks after the surgery. After what I read in the testimonials (but I'll ask him myself also) of the people, who did the expansion with my surgeon the same way i described it (putting in the device shortly before the surgery, then DJS, then expansion in the weeks after), the expander device only remains on the palate for a total of 4 weeks after placing it there on the surgery day.

I know that's a very short timespan for a expansion device to stay in the mouth and I'm not 100 percent sure if my surgeon would actually do it that way. I will clarify it later, but what is clear is that the actual expansion takes place shortly after the surgery.

During this period, the entire jaw is still very unstable due to the DJS. The whole thing is held together with plates, which are removed after 6 months when the bones have grown well together again. This includes the area where the Lefort 1 cut and the downgrafting took place.

In my opinion, it is therefore unlikely that the expansion would affect the areas above the Lefort cut, which would result in the majority of the nose cavity not being expanded (since it lies above the Lefort cut).

Ron from Jawhacks talks in his Youtube-Video "How MSE Works" about the DOME-Procedure (min 5:40). He explains that the sutures that connects the maxilla with the zygoma (cheek bone) are cut on both sides. This is done so that the pressure, which is created by the expansion, isnt transferred to the cheekbones. So the resistance of the cheekbones decreases, which simplifies the expansion.

However, this has the consequence that the optical changes that you get through an expansion like EASE+MSE (in which the suture between the maxilla and zygoma is not cut) cannot be achieved, because these are accomplished by pushing the zygoma/cheek bones outwards (which does not happen in the DOME, because of the cuts).

I have to admit that it is based on Rons Video not entirely clear to me whether the zygomas will be cut completely (which would be quite invasive, which I cannot really imagine) or whether incisions will only be made to weaken the areas, not to cut them completely.

In Rons Interview "Pt 3 - Dr. Vaughan Compares SARPE, DOME and MSE", Dr. Vaughan says (min 5:53), that the cuts, which are made in a normal SARPE (without DJS or something like that of course) are similar to the cuts made in a DOME. The difference is the places where the cuts are made, with SARPE the cuts are made in the area like those of the Lefort 1 cut, while the DOME cuts are like i said in the sutures between the maxilla and the cheekbones. There are also cuts made in the suture of the palate, but thats not the point here.

At min 5:35, Dr Vaughan says that the SARPE cuts are less invasive (and therefore also the DOME ones, because he says they are basically the same), which also overlaps with what I heard about the SARPE cuts in the Lefort 1 area, that they are just incisions and not a complete cut of the bone like the Lefort 1 Cut in a DJS. This complete cut must be made in a DJS in order to be able to advance the Maxilla.

With this background, in my opinion it now appears that even incisions (not complete cuts) as with DOME reduce the chance that the areas after the incisions (with DOME the cheek bones, with SARPE the bones above the Lefort 1 cutting area) get changed/influenced by the palate expansion.

By this logic, SARPE procedures would admittedly reduce the chances of significantly improving nasal breathing. I know that there are still people who have improved nasal breathing after the SARPE procedure and also Dr. Vaughan says in the interview that he and Dr ting use SARPE and DOME to primarily improve nasal breathing, which doesn't make complete sense to me. But I think that it is simply the case with incisions that they reduce the chances of improved nasal breathing through a SARPE, but that its still possible, that the nasal cavity above the Lefort incision areas can be expanded. Correct me if you think different or i get something wrong.

Referring to my case, where not only incisions, but a complete cut is made with Lefort 1 (+ the downgrafting and the added bone material, which makes it even more less likely) I think it is very unlikely that the expansion shortly after the DJS would improve my nasal breathing (in a significant amount).

Sorry for the long article. This is just my perspective and how I see everything, you're welcome to share your perspective.

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!

Hello everyone, I have a question regarding SARPE + MMA and can't find an answer to it. You would help me a lot if you answered this question. And sorry for my bad english btw.

I'm planning to have MMA surgery this year with CCW and downgrafting to get my sleep disorder under control. I saw that the surgeon im planning to do the surgery with, sometimes does a SARPE in the same surgery as the MMA. The MARPE would be placed on the palate by an orthodontist a few hours before the surgery.

I think that expanding the nasal cavity in addition to enlarging the upper airway through MMA makes sense because, because on the one hand, I am recessed and have an underdeveloped lower jaw, but I also have a narrow palate and have the typical empty gaps on the left and right when I smile.

So for me it's really about breathing better through the nose, thats why i would do SARPE additionally. But according to my understanding, it is impossible to expand the nasal cavity if an MMA surgery was performed at the same time.

Because in MMA with downgrafting and ccw with lefort 1, the maxilla is completely separated from the skull and then repositioned further down and forward, what creates a gap between the skull and the maxilla, which is why everything is held together with plates. Due to the Lefort cut, only the floor and the very lower part of the nasal cavity is still attached to the maxilla, the larger part of the nasal cavity is now just attached to the skull.

As far as i know, during a normal SARPE without MMA, the surgeon simply cuts the palate down the middle to ensure the split, and also makes a few Lefort 1-like incisions to weaken the overlying bone area to facilitate expansion later. Then the Marpe application is turned up little by little in the weeks after the surgery, which expands the palate.

The difference between these lefort 1 cuts in a normal SARPE in comparison to a SARPE with MMA is, that the maxilla is still connected with the skull, because the maxilla isnt repositioned further down and forward, so there is no gap through an mma-advancement. So in a normal SARPE the expansion still impacts the nasalbreathing, because the maxilla is still connected to the skull.

So is it right, that the expansion of the palate doesnt improve the nasal breathing in the scenario with SARPE+MMA at all? Because then, the expansion would only affect the maxilla and not the nasal cavity due to the gap. I would then just do the MMA and see, if my sleep problems get solved through just increasing the upper airway. If its not enough, i would wait, until the bone heals completely and then after maybe 2 years expand my palate with mse+ease or something like that. What do you think of that?

Thank you in advance.

I'm not seeing the issue. You look good.

No I do not. I have marionette lines around my mouth. Do you think I have enough bone left in chin for chin wing osetomy?

Does anyone know a Toronto maxillofacial surgeon that does revisions? I've been denied by several that won't even see me because I had past jaw work done.