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Hi Kavan, thank you for the reply.

Thank you for the insight regarding the 3/4 view - I will ask Dr Ramieri to send other images at a better angle in order to assess it better.

From the side profile view, do you think it looks like a substantial improvement in your opinion?

Dr Alfaro was sure he could do surgery and advised me to get scans done of my teeth and a plan done with and without surgery which cost me 500 euro. After I asked a few questions he seemed to change his mind, maybe he thought I was annoying or pedantic. He also didn't seem to notice the asymmetry to the same degree Ramieri did.

I will update following my next consult! Cheers

Well, you don't really need a 'substantial' improvement. However, it does show an improvement.

I think a large piece of the puzzle in all of this is a presumed likelihood of me developing sleep apnea when I get older. I originally perused jaw surgery for aesthetic concerns, and it was only later that I learned people with my sort of profile usually have very small airways and so are at risk for sleep apnea. From what I have been told, it is an inevitability that I will have issues when I get older due to soft tissue laxity, and so that has been a large reason for the size of the advancements in my plan.

The balance between a sleep apnea focussed plan and an aesthetic one seems to be causing something of a discordance between my surgeon and I. As I understand it, those treated for severe sleep apnea theoretically require to be advanced as much as possible as is within the boundaries of safe advancements, and this doesn’t necessarily correspond to the most ideal aesthetic outcome.

Having questioned the aesthetic risk of over-advancement and asked about the plan being dialled back somewhat, my surgeon agreed to do so but reiterated that in his professional opinion, this would not be congruent with adequate treatment to best open up my airway — that this would be a trade off I would have to accept.

Given that I don’t currently have any sleep problems and as I say, am here in the first instance to fix some deep insecurities about my face, it’s difficult for me to assess all of this from a standpoint of clarity. I’m sure the proposed plan would open up my airways more than a more conservative one, but is it really necessary? At the same time, I see this study referenced a lot: https://pubmed.ncbi.nlm.nih.gov/12377834/
Having assessed a huge amount of data, they found airway narrowing was almost always at its worst at the base of the tongue, and even for sleep apnea cases, every case I see seems to be moved 7mm as a maximum in the upper jaw.

As has already been discussed at length, however, all I have is the displacement models above as my best guide, and this is always going to be a leap of faith. I also recognise I have no where near enough knowledge on the topic to be assessing the situation myself, but of course it’s also the case that no surgeon is infallible, either.

Yes, i also thought that a CCW with posterior downgraft really lengthens the nasal passage, making the overall nasal cavity larger.

I wrote to someone on Reddit about it, he said that, in a posterior downgraft, the nasal passage is getting longer due to the bone structure (more in the back, because no anterior downgraft), but the soft tissue, which forms the nasal floor in addition to the bone (hard palate), doesnt changes the position.

Because in comparison to the bone, the soft tissue is not moved down because the soft tissue is A attached to the anterior part of the maxilla and B attached to the pterygoid plate, which in most cases is not influenced by a Lefort 1.

To put it simple, if you look into your nose starting frontal from the nostrils, first comes the anterior part of the maxilla, then the posterior part and then the pterygoid plates. The posterior part is in the middle, and because the soft tissue is connected at the beginning (anterior maxilla) and at the end (pterygoid plates), the soft tissue remains in the same position, because its stretched between A and B.

But that would mean that in the posterior part of the nasal cavity you can push the skin/soft tissue down 7mm (with a 7mm posterior downgraft) until you touch the bone.

According to your understanding, how tightly is the soft tissue (like here on the nasal floor) connected to the bone? Basically it's true that only the bone is moved and the tissue is stretched, but you can feel it in your nose, it's really just a very thin layer of skin on the floor. I can't imagine this 7mm being stretched. It has to tear apart.

As to 3/4 view:

The head pose (to the right) should be turned somewhat more to the left for the full 3/4 view and visa versa.

When I used to morph people to show improved contour changes, my requirement was that the 3/4 view for the ogee curve was to pose without the nose getting in the way and for both eyes to show. Basically, the head pose needed to conform with the artistic principles of how to draw a human head in 3/4 view. If not, the person's actual ogee curve is not completely in the field it needs to be viewed in and subsequently alter it. Your pose has the eye area blacked out and the nose in the way.

I see what you mean by the curve contour below the nose making it look somewhat like an underbite. It could be an artifact (type of hiccup in soft ware program). But just to say, it's a problematic perspective to view the true 3/4 perspective and also to morph it from. See if you have the option for him to show you from a true 3/4 perspective. If not, show him what you're seeing and ask if that particular perspective kicked up a 'hiccup'.

Anyway, the SALIENT perspective to look for an underbite contour is the PROFILE perspective. A maxfax guy is usually going to make sure the profile posture of the head is right (correct) for that one and software predictive programs have an easier time with those.

As to Alfaro, I think he's 'straight out' with it in the sense that you really don't 'need' surgery. Like you could 'survive aesthetically' if you didn't have any. He's also straight out with it to say on the morph proposal that it depicts the direction he's going in.

I think Ramieri might be a better choice for you especially IF he let's you play with the design program to show what you like. But I think the profile and frontal perspectives are the better ones to base your decision on rather than the 3/4 perspective which is not exactly a 'true' 3/4 pose.

Hi Kavan,

thanks for the response. Here is a picture of my simulation which shows the two downgrafts

Then it would have to do with combined or competing rotations.