jawsurgeryforums.com
General Category => Aesthetics => Topic started by: some1afterall on April 27, 2018, 01:33:06 PM
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I had a recent consult that included the surgical plan of CCW maxilla rotation, slightly forward and up (1-2 mm, small movements). My question is how will this affect my lips and philtrum? After my first jaw surgery, which included CW rotation, my philtrum lengthened and my upper lip kinda hangs above my incisors. I was told CCW rotation will move my upper lip into a better position where my upper lip is supported by my incisors. Would this then create a fuller upper lip and shorter philtrum?
What would be some of the unwanted aesthetics that come with CCW rotation? Further nose widening?
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I had a recent consult that included the surgical plan of CCW maxilla rotation, slightly forward and up (1-2 mm, small movements). My question is how will this affect my lips and philtrum? After my first jaw surgery, which included CW rotation, my philtrum lengthened and my upper lip kinda hangs above my incisors. I was told CCW rotation will move my upper lip into a better position where my upper lip is supported by my incisors. Would this then create a fuller upper lip and shorter philtrum?
What would be some of the unwanted aesthetics that come with CCW rotation? Further nose widening?
Let's see, your history is that you started with a 'horsey' GUMMY SMILE and convex profile. The surgery you got CORRECTED your gummy smile. Yet somehow you think the surgery you got prior included CW rotation and now want to know some unwanted effects of CCW. See if you can figure out which is used to correct gummy smile, CW or CCW so you have some clue as to the rotation direction you had in the first place.
Although your original complaint was that your face looked 'too long' to you in frontal, for the most part, the surgery you got addressed your prior CONVEX profile. The apparant perceived excess length to the face in frontal was attributed to the chin genio, the 'whys' of which explained to you. Gotta wonder if that info was processed.
Now comes a question for a new appearance problem as to whether or not revision max fax will make a thin lip fuller and a philtrum shorter. STOP. THINK. If this is something you are considering TO do that as with THAT objective, that particular objective is more predictably obtained via lip augmentation and lip lip lift.
Quite frankly, I consider giving any further information on this matter an exercise in futility. Reason being is that you haven't shown much ability to process or 'digest' information that was given to you or that you had already.
If I'm wrong here, I'll eat Lazlo's shorts.
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I had a recent consult that included the surgical plan of CCW maxilla rotation, slightly forward and up (1-2 mm, small movements). My question is how will this affect my lips and philtrum? After my first jaw surgery, which included CW rotation, my philtrum lengthened and my upper lip kinda hangs above my incisors. I was told CCW rotation will move my upper lip into a better position where my upper lip is supported by my incisors. Would this then create a fuller upper lip and shorter philtrum?
What would be some of the unwanted aesthetics that come with CCW rotation? Further nose widening?
The lip doesn't change length with jaw surgery... However, when the teeth are too vertical, so is the lip and a vertical lip LOOKS longer (especially if the upper jaw was advanced). I have the same problem. AFAIK, CCW will roll up the lip and make it look shorter.
P.S. Was it Gunson?
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I have 10mm of lip incompetence now (worse after jaw surgery,now upper AND lower tooth show at rest). I don’t think a lip lift would help. I’m obviously unhappy with my jaw surgery results, therefore I’m consulting with a few of the best surgeons in the field. What happened to freedom of speech? Isn’t that what the internet and this message board are about? Am I not posting a question about jaw surgery aesthetics in a jaw surgery aesthetics board?
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Kavan,
I think you're unduly harsh. 10 mm of lip incompetence is not a cosmetic issue... It's a bad functional outcome.
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Kavan,
I think you're unduly harsh. 10 mm of lip incompetence is not a cosmetic issue... It's a bad functional outcome.
Oh...was I responding to any mention of a 10mm lip incompetence?? I don't think so. She brought it in later. Look at the mention of the 10mm and when I made my post. I was responding to her information processing abilities. Can you explain for her how she got CW rotation in the first surgery when the first surgery was to reduce a gummy smile.
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The first surgery was for an anterior open bite and retrognathia.
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And I thought I was posting in the aesthetics board?
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Oh...was I responding to any mention of a 10mm lip incompetence?? I don't think so. She brought it in later. Look at the mention of the 10mm and when I made my post. I was responding to her information processing abilities. Can you explain for her how she got CW rotation in the first surgery when the first surgery was to reduce a gummy smile.
My guess is posterior impaction to fix the open bite was greater than the anterior impaction (if there was any), so the net rotation was CW. Anyway, I don't know what the original surgeon told the OP. I wouldn't overestimate the intelligence of most surgeons.
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My guess is posterior impaction to fix the open bite was greater than the anterior impaction (if there was any), so the net rotation was CW. Anyway, I don't know what the original surgeon told the OP. I wouldn't overestimate the intelligence of most surgeons.
That's a good explanation as to a possible net CW rotation based on a guess she got more posterior impaction than anterior. But then again CCW (anterior impaction) is done to correct gummy smile. But it would be preferable if she could better clarify what she got.
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I assume this is the surgical plan proposed by Dr Gunson? I don't think you ever mentioned your lip incompetence before. Would that be a result of your surgery with Dr. O'Ryan? There are other members here that were operated by her and ended seeking revisions elsewhere. One of them got her revision with Dr. Karas, who you mentioned before.
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When in doubt, I'd trust Gunson over a lesser-known surgeon.
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I managed to get the pre and post op profile X-rays. So... what's the verdict? I'm working on getting the surgical notes.
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I assume this is the surgical plan proposed by Dr Gunson? I don't think you ever mentioned your lip incompetence before. Would that be a result of your surgery with Dr. O'Ryan? There are other members here that were operated by her and ended seeking revisions elsewhere. One of them got her revision with Dr. Karas, who you mentioned before.
I think the poster 'Lyra' is the person in this blog who had a bad experience with a Felice O'Ryan. http://www.confessionsofametalmouth.com/my-doctors.html
Found her string here: http://jawsurgeryforums.com/index.php?topic=4481.msg44042#msg44042
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Lazlo,
I don't think you've misunderstood the whole situation.
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Lyra had her original surgery with Dr Felice O'Ryan at Kaiser Oakland. Her revision was done with Dr Nestor Karas in Walnut Creek.
I also had my original surgery with Dr Felice O'Ryan at Kaiser Oakland. My results weren't as bad as hers, but I still have lip incompetence/strain, left TMJ pain, and my face looks even longer post surgery. If I could go back in time I wouldn't of had surgery at all.
Right now I am consulting with many surgeons and trying to read and educate myself so that I don't go in blind if I decide to go through with a revision. Right now revision surgery looks like either 1) a total upper and lower revision with small CCW rotation and forward movement + a genio revision with reduction in vertical length OR 2) genioplasty revision alone with vertical shortening and removal of bsso hardware and smoothing of some of the side notches leftover.
I may not go through with any revision - but right now I'm doing my due diligence.
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Lazlo,
I don't think you've misunderstood the whole situation.
Wait I just reread her post and pics, its a little confusing. She had a consult with Gunson and analysis but didn't have any surgeries done by him it seems. She only had the consult to analyze if there were any mistakes made. Is this correct Kavan?
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Wait I just reread her post and pics, its a little confusing. She had a consult with Gunson and analysis but didn't have any surgeries done by him it seems. She only had the consult to analyze if there were any mistakes made. Is this correct Kavan?
Lazlo,
I did NOT say anything in my post to her about Gunson. No idea how you drew that conclusion.
My first post to her in this string was out of frustration where despite my reading through her over 40 posts, I was unable to put the 'WHOLE' of her situation together due to the presentation of it which I found too confusing. For example, in past posts she mentioned she was satisfied with the function of her bite and in a NEW one in this string it was lip dysfunction. Presentations where some info is conflicting or there is absence of 'hard' info in the history and/or timing gaps of when info is presented makes it hard for me to help someone.
None the less, as of RECENT, she has presented some HARD info (the CT scans) which give me more information that I can (eventually) help with.
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This is why I think surgeon did CW rotation. Philtrum lengthened, no change in angle, if anything it seems steeper. Keep in mind there is a genioplasty that is helping somewhat with projection.
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Surgical movements aside, you can see that in your before ceph your maxillary incisors were proclined, holding up your lip.
In the post-op ceph they now look upright. This can cause the lip to look longer just as PloskoPlus has said.
Is your top lip thinner now too? This s**t happened to me with just braces.
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@ April, yes totally. I’ve thought about the effect the open bite, proclined teeth had on my upper lip area. Maybe the longer philtrum is just par for the course (unfortunately).
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OK, now that you present the 'hard' info (the X rays), this certainly yields more information than 'speech'in so far as what I could put together based on your past many posts. For example, your first post emphasized the gummy smile and 'horse face' which stuck in my memory the most where such would be corrected via CCW anterior impaction. Also, it was only recent you mentioned lip DYSFUNCTION (lip incompetence) where as prior, you said your function was fine. So given that there is the presence of more 'hard' info where that was once absent, I'm happy to share some feedback with you.
Indeed, those cephs make it's much clearer that the maxfax did a net counter clockwise rotation in addressing the anterior open bite. The change in orientation of the ANS-PNS is there to see. You were used to seeing your upper lip somewhat hoisted outward via the outward inclination of the upper front teeth which will make it look shorter from frontal view. So, some CCW done in a revision surgery would give better support to your lip. But since the way you liked it before any surgery was a function of how flared out the front teeth were with the anterior open bite, I can't predict if doing so will kick up what you were used to seeing in the mirror prior but rather suggest you don't count on that.
In so far as CCW to the maxilla revision which he suggests, the mandible will rotate by pretty much the same degree the CCW to the maxilla is (approx). However a FEW degrees doesn't compensate for a very high angle mandibular plane.
As far as predictions go with regard to the chin, in particular with Gunson getting the chin to appear shorter in frontal, which he does to compensate for apparent longness of the face, he probably would want to redo the chin via a diagonal cut where it's slid upward where one vector of displacement that way is vertically SHORTER and the other is horizontally projected. IMO, that would look better on you and the right thing to do to help lip incompetence; strain in getting your lower lip to move up to close with the upper.
All in all, I think Gunson has a good capacity to IMPROVE on that prior doctor's surgery, give you better upper lip support, decrease the apparent excess length coming from the chin area and also make it easier for you to close your lips. But I don't think it's going to 'return' you to what you liked seeing in the mirror from ONLY the FRONTAL view which I mention in the event that's what you want to see it doing.
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Thanks for your lengthy reply.
My teeth are straight now, my bite is pretty closed, about a 1mm overjet. Honestly, I knew I strained to close my lips but I didn’t realize exactly how much incompetence I had until my consult with Gunson where he had me fully relax my mouth, jaw and lips, which resulted in 10mm of upper and lower tooth show.
I knew the aesthetics weren’t what I had thought they would be, as I felt like my face looked longer and my lips seemed thinner, especially my lower lip after the genioplasty. I’m starting to see that jaw surgery isn’t the miracle surgery I thought it would be, I’m still stuck with my genetically imposed limitations, but there is something to say about facial bone structure. I have strong cheekbones and I think balanced facial proportions and less strained lips would do me a solid.
The X-rays and professional pre/post op photos are useful because I’ve come to realize that many of my personal pre-surgery photos were from flattering angles.
I’m consulting with another surgeon tomorrow then hope to meet with Relle in the future.
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Thanks for your lengthy reply.
My teeth are straight now, my bite is pretty closed, about a 1mm overjet. Honestly, I knew I strained to close my lips but I didn’t realize exactly how much incompetence I had until my consult with Gunson where he had me fully relax my mouth, jaw and lips, which resulted in 10mm of upper and lower tooth show.
I knew the aesthetics weren’t what I had thought they would be, as I felt like my face looked longer and my lips seemed thinner, especially my lower lip after the genioplasty. I’m starting to see that jaw surgery isn’t the miracle surgery I thought it would be, I’m still stuck with my genetically imposed limitations, but there is something to say about facial bone structure. I have strong cheekbones and I think balanced facial proportions and less strained lips would do me a solid.
The X-rays and professional pre/post op photos are useful because I’ve come to realize that many of my personal pre-surgery photos were from flattering angles.
I’m consulting with another surgeon tomorrow then hope to meet with Relle in the future.
Why are you going to consult with yet another surgeon? Your aesthetics have improved and your bite is good/perfect.
Have you become addicted to surgery or something?
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Lazlo,
I did NOT say anything in my post to her about Gunson. No idea how you drew that conclusion.
My first post to her in this string was out of frustration where despite my reading through her over 40 posts, I was unable to put the 'WHOLE' of her situation together due to the presentation of it which I found too confusing. For example, in past posts she mentioned she was satisfied with the function of her bite and in a NEW one in this string it was lip dysfunction. Presentations where some info is conflicting or there is absence of 'hard' info in the history and/or timing gaps of when info is presented makes it hard for me to help someone.
None the less, as of RECENT, she has presented some HARD info (the CT scans) which give me more information that I can (eventually) help with.
Kavan, I was just asking if Gunson had operated on her. Then I realized I had misread her post and she had only had a consult with Gunson. I was asking you to confirm since you ostensibly would have known the thread much more intimately having posted it yourself.
So please b*tch, don't hate the playa, hate the game.
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Why are you going to consult with yet another surgeon? Your aesthetics have improved and your bite is good/perfect.
Have you become addicted to surgery or something?
I’m consulting with more than one surgeon to see if they all agree on a revision. It’s not like I want to spend $$$ and get braces again and go through jaw surgery again, but if Gunson thinks I have a case than it’s worth looking into.
Things don’t feel/look right to me. Sometimes are better than others.
Far away with good makeup some angles look nice. I don’t know, jaw surgery is an f’k up thing for a lot of people to get into.
I want to hear your story, Lazlo.
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I think my husband is tired of hearing me b*tch about my jaw so it feels nice to share the company of others that are going through this s**t.
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Kavan, I was just asking if Gunson had operated on her. Then I realized I had misread her post and she had only had a consult with Gunson. I was asking you to confirm since you ostensibly would have known the thread much more intimately having posted it yourself.
So please b*tch, don't hate the playa, hate the game.
Oh, OK. Thanx for clarifying. I guess there was a lot of confusion going on.
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Thanks for your lengthy reply.
My teeth are straight now, my bite is pretty closed, about a 1mm overjet. Honestly, I knew I strained to close my lips but I didn’t realize exactly how much incompetence I had until my consult with Gunson where he had me fully relax my mouth, jaw and lips, which resulted in 10mm of upper and lower tooth show.
I knew the aesthetics weren’t what I had thought they would be, as I felt like my face looked longer and my lips seemed thinner, especially my lower lip after the genioplasty. I’m starting to see that jaw surgery isn’t the miracle surgery I thought it would be, I’m still stuck with my genetically imposed limitations, but there is something to say about facial bone structure. I have strong cheekbones and I think balanced facial proportions and less strained lips would do me a solid.
The X-rays and professional pre/post op photos are useful because I’ve come to realize that many of my personal pre-surgery photos were from flattering angles.
I’m consulting with another surgeon tomorrow then hope to meet with Relle in the future.
I was initially thrown for a loop due to the verbal emphasis on 'gummy smile' and long or 'horsey face' in your description in other posts as that being the main reason for your surgery (in which CCW, anterior impaction used to correct). That and the convex profile and bite which were corrected. So, yes. It was the presentation of the before and after cephs (at a later time) that made things more clear to me that the surgery prioritized the open bite as the main focus of correction. Hence, net rotation was CW used to close an open bite which is also visible in the before/after X rays.
So, now, it's even more clear that one aspect you LIKED about your original smile and the philtrum contour that looked visually shorter was due to the EXTENT of the open anterior bite, where the philtrum was oriented diagonally to project shorter. Closing the anterior open bite, (which the prior surgery did indeed correct), came with trade-off of your philtrum being oriented along with the front teeth on a more vertical plane which made it look longer. Also, the genio which was not the type where the chin is slid upward along a diagonal cut (where doing so makes it look vertically shorter and horizontally advanced) was not the type to visually compensate for 'longness' seen from frontal.
What you need to clarify/reconcile in your own mind is your 'attachment' to the aspects of your face that you LIKED but were contingent on the PROBLEMS you got corrected, eg. you liked but missed the way the extent of the open anterior bite made your philtrum look shorter and how the extremely convex profile with a lot of chin recession made your chin look shorter too. Hence, a surgery aimed at addressing and making less the TRADE-OFF you got from the anterior bite being corrected (like Gunson's proposal for some CCW to do that) and also the chin correction he would do, won't also bring back what you liked seeing in the mirror in frontal view given what you like seeing in the mirror in front view was directly related to what any surgeon would want to correct but not to 'return' to you.
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I really think surgeons and orthodontists need to better inform their patients of the trade-offs. This all makes complete sense in hindsight - once the problem has been deconstructed - but when signing up to ortho & surgery most wouldn't be aware at all of the potential soft tissue changes.
In every consult I've been in I have only ever been asked about what I DON'T like -- not once have I been asked what I DO like.
Granted I haven't consulted with Gunson, and I know he likes to maintain aesthetics.
If I had been told prior to signing up to ortho that my upper lip would become thinner, longer and cover more teeth, I think I would've walked away because I liked my fuller upper lip and smile. Yes it's ridiculously obvious now that it's exactly what happens when you make teeth more vertical, but it didn't even cross my mind until it was too late.
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I really think surgeons and orthodontists need to better inform their patients of the trade-offs. This all makes complete sense in hindsight - once the problem has been deconstructed - but when signing up to ortho & surgery most wouldn't be aware at all of the potential soft tissue changes.
In every consult I've been in I have only ever been asked about what I DON'T like -- not once have I been asked what I DO like.
Granted I haven't consulted with Gunson, and I know he likes to maintain aesthetics.
If I had been told prior to signing up to ortho that my upper lip would become thinner, longer and cover more teeth, I think I would've walked away because I liked my fuller upper lip and smile. Yes it's ridiculously obvious now that it's exactly what happens when you make teeth more vertical, but it didn't even cross my mind until it was too late.
I remember, over 11 years ago, when I first consulted with a maxfax about getting my jaw advanced where at the time, I didn't know I had a deep bite, he asked me what did I like best about my face and I told him' 'my NOSE'. He told me the rotation he would have to do to advance out my lower jaw would be rotating my nose upward and it seemed at the time, his implicit assumption was that I would NOT like that look because my nose was great which is probably why he asked me what I liked best about my face. That said, I KEPT my maxfax deformity because I did not want to alter my nose.
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If I may ask, did you pass on surgery back then only? Or have you never gone through with any procedure?
I'm curious since you seem to have dedicated a good amount of time (maybe money) to gathering knowledge in this field..
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didn't get it.
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I’ve consulted with Gunson, Karas, and Deschamps-Braly. I’m paranoid now after thinking of going through another major surgery, paying top $$$, many months of recovery and ending up with an unsatisfactory result. Gunson is supposed to be the best with aesthetics, right? But I’ve heard even he has bad results ;(
Days like today I think I look pretty normal and maybe the minor jaw pain and lip incompetence might be ok when considering risk/reward. If maxillary advancement and ccw rotation makes my nose even wider or with more nostril show I’d be bummed and if my philtrum got longer with even less the upper lip unsupported I’d be hiding in a closet.
Maybe I should just get a rhinoplasty. Anyone heard of good ones in the Bay Area? I like Dr Behmand in Walnut Creek’s results.
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I’ve consulted with Gunson, Karas, and Deschamps-Braly. I’m paranoid now after thinking of going through another major surgery, paying top $$$, many months of recovery and ending up with an unsatisfactory result. Gunson is supposed to be the best with aesthetics, right? But I’ve heard even he has bad results ;(
Days like today I think I look pretty normal and maybe the minor jaw pain and lip incompetence might be ok when considering risk/reward. If maxillary advancement and ccw rotation makes my nose even wider or with more nostril show I’d be bummed and if my philtrum got longer with even less the upper lip unsupported I’d be hiding in a closet.
Maybe I should just get a rhinoplasty. Anyone heard of good ones in the Bay Area? I like Dr Behmand in Walnut Creek’s results.
I think you have to isolate what bothers you most and to resolve to either full blown revision bi-max, isolated CHIN correction or plastic surgery help. Although Gunson could give better lip support via the CCW and advancement so your philtrum is on a 'diagonal' plane and not a vertical one that makes it look longer to you, you should discuss possibility of trade-offs to the nose base with him and inquire if a trade off at the nose base would also make the rest of your nose look better. At most, I would suggest getting his PLAN for you, his ceph displacement DIAGRAM and to LOOK at what he's going to do to the CHIN. In the event you sought out an ISOLATED genio, you would want to consider the TYPE on Gunson's plan.
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I’ve consulted with Gunson, Karas, and Deschamps-Braly. I’m paranoid now after thinking of going through another major surgery, paying top $$$, many months of recovery and ending up with an unsatisfactory result. Gunson is supposed to be the best with aesthetics, right? But I’ve heard even he has bad results ;(
Days like today I think I look pretty normal and maybe the minor jaw pain and lip incompetence might be ok when considering risk/reward. If maxillary advancement and ccw rotation makes my nose even wider or with more nostril show I’d be bummed and if my philtrum got longer with even less the upper lip unsupported I’d be hiding in a closet.
Maybe I should just get a rhinoplasty. Anyone heard of good ones in the Bay Area? I like Dr Behmand in Walnut Creek’s results.
Dr. Relle, but he's in LA. Gunson and him would be my recommendations for California based surgeons.
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I have Gunson’s ceph, it did include 5mm chin shortening.
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He said ccw and small maxilla advancement would better support lip/philtrum but I wonder for what trade off from the frontal view.
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Image does not show.
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Maybe this worked?
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Yes. that one worked.
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Looks like a substantial revision. Did he give you a table of movements as well?
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Maybe that's this?
Maxilla A-P Vert
ANS -0.5 -2.3
PSN -0.1 +6.6
Mx1 tip +5.1 -3.4
Molar MB cusp tip +3.6 +2.8
Mandible A-P Vert
Md1 tip +5.5 -4.6
Molar MB cup tip. +5.5 +1.5
B point +10.0 -3.2
Pog +9.5 -8.1
Genioplasty -3.3 -4.2
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Looks like a substantial revision. Did he give you a table of movements as well?
Indeed very substantial with posterior downgraft for the CCW and the chin shortening.
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I didn’t realize it was such an involved plan. Sounds like I should do some more reading and research. Does it seem like a risky/unstable surgical plan? He didn’t say anything about that during the consult.
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He did tell me he would take about 5mm off the chin (with the genioplasty) and we had a total of 10-11mm to make up for (with the lip incompetence).
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Is this a typical Gunson surgical plan? CCW and down grafting?
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I can't opine in terms of 'risk'. Only the doctor doing the surgery can give you a better idea of risk relative to in HIS hands.
The plan is 'typical' in the sense that he would do a significant posterior downgraft for the type of CCW needed to maximize the the extent of the lower jaw advancement and to also shorten the chin so the face does not cast as 'long' or 'too long' in frontal view. He also gives more 'flip' to the upper lip with the change in angle to the front teeth which tends toward more support of it as he told you and also to visually shorten the philtrum. Observe the diagram and you should see that.
It is best to cast your focus on observing the contour changes that can be seen on the displacement diagram and not get caught up in isolated numbers because all the isolated measures associated with the displacements are part of the WHOLE contour change which is seen outlined in red. Hence, better to hone one's powers of observation when there is a contour diagram to observe than to get caught up (and perhaps eventually confused) by all the different measures for each thing to be displaced.
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Can you post a larger image of the ceph or email it to me?
It's small on my monitor. From what I can see you are still 10mm recessed. This is typical of unskilled surgeons who don't understand rotation.
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Yes, he did talk about improving the lip/philtrum area.
I trust that Gunson is a more skilled surgeon than the one who performed my original surgery.
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Okay much easier to see now.
You can see the entire complex is rotation CCW. So as the lower jaw swings forward and up, the upper jaw the upper jaw is rotating along an invisible fulcrum. Basically the back of the upper jaw comes down, and the front moves sightly up (this might move forward, too depending on the bone and how the teeth are placed).
In general, I'd say prepare for a larger lower jaw, shorter face, and with regard to your question about the philtrum area, I'd guess that area gets more "sunken" in. That isn't a guarantee to happen, but as the upper jaw rotates you could theoretically lose some support there. This is why Dr. Gunson grafts the area. Almost everyone I have spoken with says those grafts don't do much. But then again, we can't see those patients without the grafts to compare. In poor lighting that shows depth of lines in the face you might notice a worsening in the smile line region, IMO. The lip support should improve.
Overall, it should be an improvement over the current situation, but likely will have a few issues mentioned above that you have to weigh. There are also the increased risks of revision to consider.
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By grating, you mean onlay HA grafts?
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By grating, you mean onlay HA grafts?
Yes.
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Yes.
I've seen him put them over the plates... Surely that'd make any revision a lot harder.
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Okay much easier to see now.
You can see the entire complex is rotation CCW. So as the lower jaw swings forward and up, the upper jaw the upper jaw is rotating along an invisible fulcrum. Basically the back of the upper jaw comes down, and the front moves sightly up (this might move forward, too depending on the bone and how the teeth are placed).
In general, I'd say prepare for a larger lower jaw, shorter face, and with regard to your question about the philtrum area, I'd guess that area gets more "sunken" in. That isn't a guarantee to happen, but as the upper jaw rotates you could theoretically lose some support there. This is why Dr. Gunson grafts the area. Almost everyone I have spoken with says those grafts don't do much. But then again, we can't see those patients without the grafts to compare. In poor lighting that shows depth of lines in the face you might notice a worsening in the smile line region, IMO. The lip support should improve.
Overall, it should be an improvement over the current situation, but likely will have a few issues mentioned above that you have to weigh. There are also the increased risks of revision to consider.
Thanks for your reply. In regards to CCW and perceived negative aesthetic outcomes:
Things I don't like right now are long flattened philtrum, long chin, lack of lip support.
Things I do like amount of tooth and gum show when I smile, strong cheekbones.
I definitely am hesitant to move forward with a surgery that could possible age me. I have genetically downturned eyes with creased eyelids and lots of crows feet at 32, so aging of smile line area sounds meh.
Also I'm not sure what you mean by philtrum area "hollowed", I thought that CCW would help create more supported lips and a shorter more attracted, slightly curved inward philtrum... more like (
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I've seen him put them over the plates... Surely that'd make any revision a lot harder.
If I decide to go through with this surgery it will be my last time.
So the other angle would be what about just fixing the genioplasty? It doesn't fix everything but it would be a big winner in the aesthetics department as my long chin is the thing I dislike the most. Dr Deschamps Braly in SF will do a vertical reduction genioplasty with upward angling... ughhh... maybe I can just find someone to take the plate out.
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Thanks for your reply. In regards to CCW and perceived negative aesthetic outcomes:
Things I don't like right now are long flattened philtrum, long chin, lack of lip support.
Things I do like amount of tooth and gum show when I smile, strong cheekbones.
I definitely am hesitant to move forward with a surgery that could possible age me. I have genetically downturned eyes with creased eyelids and lots of crows feet at 32, so aging of smile line area sounds meh.
Also I'm not sure what you mean by philtrum area "hollowed", I thought that CCW would help create more supported lips and a shorter more attracted, slightly curved inward philtrum... more like (
If you observe the diagram and how the lips relate to the upper teeth, it shows less upper teeth show.
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If you observe the diagram and how the lips relate to the upper teeth, it shows less upper teeth show.
... At rest.
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The CCW rotation will create (optically) more posterior jaw height and width making your face look more oval. This, together with shortening genioplasty should make the face less long and more balanced. Since you have lip incompetence and this plan should address it, it's probably worth pursuing. But at the end of the day, you have to make the call. The alternative of just a 10 mm reduction genioplasty doesn't sound great to me. You will end up complaining that your lower third is now too small. But then again, I'm not a fan of genioplasties. They are overdone 90% of the time because most surgeons are incapable of creating enough lower jaw advancement. Genioplasty should be just the icing on the cake, not half of the cake.
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I’m going to follow up with Dr Karas. He ordered my a 3DCT TMJ work up to further evaluate my case. He’s less bells and whistles than Dr Gunsom, but he did a great job with Ashley’s (Lyra) complex case and I liked him a lot. Great listener, seems cautious and thorough. I’d like to get a better feel for what his surgical plan would entail.
Plosko-thanks for your feedback. You’re probably right. After all this I’m not a fan of genioplasty’s either. I liked my pre-genioplasty cover up face much better. In retrospect, I should’ve never gone back for the genioplasty add on.
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so aging of smile line area sounds meh.
Also I'm not sure what you mean by philtrum area "hollowed", I thought that CCW would help create more supported lips and a shorter more attracted, slightly curved inward philtrum... more like (
Well there is no guarantee it would age you. Soft tissue issues are unpredictable, as we're told over and over.
I didn't say the philtrum would hollow. Just that it might be sunken, especially in certain light. Think about it: if the upper jaw rotates CCW that means everything that is up front is now moved more posterior. This could mean the midface area near the smile lines. I've seen people with sunken smile lines after CCW. Again, it is unpredictable and has to do with their starting point, soft tissue thickness, etc. Many variables. But it is something to weigh as possible.
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Well there is no guarantee it would age you. Soft tissue issues are unpredictable, as we're told over and over.
I didn't say the philtrum would hollow. Just that it might be sunken, especially in certain light. Think about it: if the upper jaw rotates CCW that means everything that is up front is now moved more posterior. This could mean the midface area near the smile lines. I've seen people with sunken smile lines after CCW. Again, it is unpredictable and has to do with their starting point, soft tissue thickness, etc. Many variables. But it is something to weigh as possible.
IMO, that's infinitely preferable to a vertical or (worse) convex philtrum.
Before my surgery I asked if I'd end up with a chimp like convex lip. The surgeon, in his usual patronising manner, dismissed the question: "6 mm of bone advancement turns into 3 mm of soft tissue advancement". Anyway, "by their deeds you shall know them". I ended up with a monkey lip anyway. Unfortunately I only saw his before and afters after my surgery. All his patients got the monkey upper lip. I've seen so many cases of chimp lip, that it's basically a given that if you don't have a flat occlusal plane to begin with and the surgeon doesn't do CCW, you WILL get a chimp lip. It's guaranteed. Sorry for venting... I'm just absolutely sick of needing facial hair to cover up this mess.
Provided this surgery goes well (no relapse, bite or joint issues), this surgery could be a big net win.
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What did Dr. Karas suggest to you? I got a referral to his office after Lyra suggested I speak with him over my "ailment".
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But then again, I'm not a fan of genioplasties. They are overdone 90% of the time because most surgeons are incapable of creating enough lower jaw advancement. Genioplasty should be just the icing on the cake, not half of the cake.
Very accurate. I know of several people, myself included, who's genios are basically there to mask a steep angle/help with projection.
Not only is it less than ideal aesthetically, but it can bring about functional problems aswell.
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Very accurate. I know of several people, myself included, who's genios are basically there to mask a steep angle/help with projection.
Not only is it less than ideal aesthetically, but it can bring about functional problems aswell.
Yes. Relle told me many surgeons use it to mask surgical problems (e.g. not enough rotation, etc).
What functional problems do you have?
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Hello friends, thank you much for all of your responses. We've created quite a lively discussion now, haven't we?
Ah yes, the chimp lip. I remember post surgery I looked like a Who, from Whoville. I think naturally if CCW is supposed to better support the upper lip, the philtrum groove should deepen/curve inward, like a (, which is a positive thing.
Dr Karas was great. He was soft spoken and listened intently to what I had to say. His exam was thorough, he ordered more imaging studies. He seems conservative, cautious. Since I was rushed into my first surgery only on "Don't worry, I do this all the time" to my many questions and concerns, I like the slow, cautious approach heading into a revision. I need the reassurance that I'm not jumping into something head first without testing the temperature.
I'm having quite a bit of TMJ and neck pain + headaches, both Gunson and Karas recommended mouth guards and/or PT to try to get that under control-something Kaiser Oakland NEVER suggested. Nope. They wanted to slap braces on me and take me to the OR, even though TMJ pain is only improved with orthognathic surgery in like 10% of patients.
Anyways, we'll see. At this point I'd say my revision is 25% function 75% aesthetics, but best believe anyone who has had a sub par jaw surgery knows that when you look bad after such a major surgery it affects your health and wellbeing - how you feel about yourself affects your health. Pyschosomatic.
So in the name of health I move forward. If anything exciting happens I'll let you'all know.
GJ what's the verdict? Are you going to make a $10/month forum subscription fee? $20/annual maybe?
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Yes. Relle told me many surgeons use it to mask surgical problems (e.g. not enough rotation, etc).
What functional problems do you have?
Even IF or when it's not to mask surgical screw ups (like not enough CCW), sometimes, even with enough CCW, the mandibular plane can just be too high an angle and to give appearance of more CCW, the chin is slid upward and outward.
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What does one do if one needs CCW for the lips/philtrum, but can't really afford to lose much tooth show?
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Maybe both anterior and posterior downgrafts, with the posterior one being larger (amounting to ccw)? You might also need your jaw/s set back?
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Yes. Relle told me many surgeons use it to mask surgical problems (e.g. not enough rotation, etc).
What functional problems do you have?
If I close my bite it's not long until I feel tension/pain in my joints. This is not due to genio, but the fact I suspect my jaws were over-advanced (which can cause tmj).
In order to give me a 10 mm maxillary advancement, a pair of premolars were extracted. This made my teeth show and lip support worse pre-op, and post-op the teeth show is not as good as it was before braces and I still don't have much lip support when smiling. I think it's due to a lack of vertical growth, though. I don't show any upper teeth, ever. It overall doesn't feel natural.
For reference, when I smile all you can see are my lower gums and a bit of lower teeth.
One thing that stood out post-op was how incredibly less comfortable my chin area was. My lower lip is smaller and feels like it's being pushed inward constantly. I know scar tissue and plates could be a case, but it seems like a direct consequence of a (more so) steep mandibular angle plus the chin being too long. It's uncomfortable and slightly painful.
Last but not least, where my soft tissue sits now doesn't quite add up with my bone structure and, if I smile/laugh for an extended period my nasal base area and septum begin aching. I also can't tell if some of the additional pain I experience when smiling comes from muscles or not.
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If I close my bite it's not long until I feel tension/pain in my joints. This is not due to genio, but the fact I suspect my jaws were over-advanced (which can cause tmj).
In order to give me a 10 mm maxillary advancement, a pair of premolars were extracted. This made my teeth show and lip support worse pre-op, and post-op the teeth show is not as good as it was before braces and I still don't have much lip support when smiling. I think it's due to a lack of vertical growth, though. I don't show any upper teeth, ever. It overall doesn't feel natural.
For reference, when I smile all you can see are my lower gums and a bit of lower teeth.
One thing that stood out post-op was how incredibly less comfortable my chin area was. My lower lip is smaller and feels like it's being pushed inward constantly. I know scar tissue and plates could be a case, but it seems like a direct consequence of a (more so) steep mandibular angle plus the chin being too long. It's uncomfortable and slightly painful.
Last but not least, where my soft tissue sits now doesn't quite add up with my bone structure and, if I smile/laugh for an extended period my nasal base area and septum begin aching. I also can't tell if some of the additional pain I experience when smiling comes from muscles or not.
The idea of extracting upper teeth to create a bigger underbite to make more advancement possible sounds insane. What was the justification?
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If I close my bite it's not long until I feel tension/pain in my joints. This is not due to genio, but the fact I suspect my jaws were over-advanced (which can cause tmj).
In order to give me a 10 mm maxillary advancement, a pair of premolars were extracted. This made my teeth show and lip support worse pre-op, and post-op the teeth show is not as good as it was before braces and I still don't have much lip support when smiling. I think it's due to a lack of vertical growth, though. I don't show any upper teeth, ever. It overall doesn't feel natural.
For reference, when I smile all you can see are my lower gums and a bit of lower teeth.
One thing that stood out post-op was how incredibly less comfortable my chin area was. My lower lip is smaller and feels like it's being pushed inward constantly. I know scar tissue and plates could be a case, but it seems like a direct consequence of a (more so) steep mandibular angle plus the chin being too long. It's uncomfortable and slightly painful.
Last but not least, where my soft tissue sits now doesn't quite add up with my bone structure and, if I smile/laugh for an extended period my nasal base area and septum begin aching. I also can't tell if some of the additional pain I experience when smiling comes from muscles or not.
Could it be that they did the wrong type of genio on you? Maybe you needed one (if you really needed one at all) where they reduce the height a bit while still adding projection. I think Kavan said the same thing above.
Now OPs post has been hijacked, haha.
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GJ what's the verdict? Are you going to make a $10/month forum subscription fee? $20/annual maybe?
I'm really not sure, but I guess I better decide soon. I like donation models because not everyone has 10/month or 20/year. The problem with it is nobody wants to give anything unless you force them. This is human nature, so I don't blame them, but it is a disappointing trait.
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Hey I wanted to give you guys an update on my revision process. I've been given two revision plans with some similarities, some differences.
Gunson proposed a plan of maxillary and mandibular advancement, with CCW, some posterior maxilla down grafting and about 5mm vertical reduction of chin.
Karas proposed a plan of maxillary and mandibular advancement and "we'll have to figure out what to do with the chin problem" as we get closer to the surgical date.
I think because Gunson has a substantial track record with consistently good aesthetic outcomes and he had an idea to address my "chin problem" right out of the box I'll end up working with his team.
Any thoughts?