jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: mediumdrinkofwater on November 17, 2022, 02:41:27 AM
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Referenced Case:
https://www.instagram.com/p/Cf_oWZ-tUWF/
I have wondered for a while what exactly was done to this patient, since I myself am interested in a modified cw-aproach, without horizontal movement, to adress the gonial angles.
So I asked Dr.Brusco in respect to the aforementioned case, which he documented on instagram, and he wrote back the following:
DR.B:
"The movement in this case involved mainly a slight anterior shortening and centering associated with a lateral outwards flaring of the wings to achieve the best possible symmetry. The gaps were filled with an autologous bonegraft.
My thoughts now:
What does he mean by anterior shortening, how does that look like from the side-view?
Also, is it just me or has the front view not changed at all from the picture? However, the x-rays clearly display that the angles were laterally flared out extensively. Maybe the beard is covering up the change?
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What I can see in In this case other than the obvious is that left mandible was shortened at the angle which was longer or let's say more pronounced. https://imgur.com/a/IS0G4oJ
I don't know if this is what he meant by anterior shortening since I would expect anterior to be at the chin.
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So shortening is basically bone shaving?
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So shortening is basically bone shaving?
No i just said what I can observe. I don't think this is what he meant tough.
Shortening is making something shorter by any means.
Still not happy with your CW result?
EDIT: https://www.facebook.com/161961044428233/posts/581844712439862/?flite=scwspnss
-- This is a funny result I saw recently. :P
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Wow, that after-profile looks terrible.
The only thing I’m unhappy with are the somewhat blunted angles from the front view, so it’s either a side wing for me or I call it a day. Either way is fine for me at this point
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I remember when I looked at your post op pics i thought you look good. Solid wide jaw i believe. What do friends and family say?
If you want objective feedback some pre/post pics would help.
If either way is fine then call it a day.. 8)
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What I can see in In this case other than the obvious is that left mandible was shortened at the angle which was longer or let's say more pronounced. https://imgur.com/a/IS0G4oJ
I don't know if this is what he meant by anterior shortening since I would expect anterior to be at the chin.
Anterior shortening would apply to the front of face as to shorten the chin and or to adjust for symmetry at the place where they cut through the chin. They don't shorten it from the bottom or anything like that. But when they make a cut that goes right through the chin, they have option to remove some bone area at the cut if some adjustments in that regard are needed. I think they can also use the little bone fragments or 'chips' to jump start the osteogenisis process to the posterior area of the jaw.
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Anterior shortening would apply to the front of face as to shorten the chin and or to adjust for symmetry at the place where they cut through the chin. They don't shorten it from the bottom or anything like that. But when they make a cut that goes right through the chin, they have option to remove some bone area at the cut if some adjustments in that regard are needed. I think they can also use the little bone fragments or 'chips' to jump start the osteogenisis process to the posterior area of the jaw.
Ah that makes sense, thank you.
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Anterior shortening would apply to the front of face as to shorten the chin and or to adjust for symmetry at the place where they cut through the chin.
Interesting, thx!
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Wow, that after-profile looks terrible.
Why is it terrible? The chin looks to be in the right place, but there should have been some grafting of the groove - is that the part you think looks terrible? It could probably be fixed with a graft still if the patient wanted it.
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Ah that makes sense, thank you.
If you look closely at the frontal bone scan, you can see the shape of the cut to the chin. The bone scar of chin cut is kind of straight horizont below the lower central incisors and it angles down to form sort of a notch below the the nerve holes. So, below the initial cut they make is where they can shorten areas of the chin and/or 'anterior mandible' to adjust for symmetry if needed. It's not uncommon for areas to the central chin and or the anterior mandible (areas beside the central chin) to be a little long or off center. So, when adjustments to symmetry and/or excess length are made to the anterior aspect of the mandible (central chin and area beside it), it avoids asymmetry from the chin being carried through the rest of the cut below (inferior to) and beyond (towards the posterior direction) the nerve holes.
Now, beyond and below the nerve holes, they continue the cut to the back of the jaw and they want the areas released from the cut to be as symmetrical as possible. Basically, they have to PRY areas and PULL down to flare out and lengthen the posterior jaw angle area. Prying away and pulling down are 2 FORCES that could snap the bone if they are also coupled with the need to apply them unequally to adjust for asymmetry at the back of the jaw line. Also, if they have to pry out a LOT to get a large flare out. So, ability to apply those forces to both sides of the jaw segment, somewhat equally, is enhanced by addressing what ever adjustments needed to the anterior mandible (central chin and beside it) to cut down on asymmetry/excess length coming from that area so it does not carry through to the segments they need to pry out and pull down beyond (posterior to) the anterior mandible. In this particular case, I think that is what the doctor was dealing with and describing when he mentioned anterior shortening and centering associated with lateral outward flaring. Like not too much shortening or alteration to the anterior mandible but just what was needed to safely pry and pull at the posterior mandible.
The (frontal) increase in width is an improvement yet is subtle. But that is understandable because too much prying and pulling to effect a more dramatic flare out can be a recipe for an unwanted snap when done in an initial surgery.
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I have read your reply.. learned something new!
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Why is it terrible? The chin looks to be in the right place, but there should have been some grafting of the groove - is that the part you think looks terrible? It could probably be fixed with a graft still if the patient wanted it.
Yes, I was referring to the strong mento-labial fold mainly. It looks very artificial, non-natural imo. I thought this kind of thing was avoided with chin wings?
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Yes, I was referring to the strong mento-labial fold mainly. It looks very artificial, non-natural imo. I thought this kind of thing was avoided with chin wings?
It is not avoided because of the chin wing but because the cut at the chin goes further up (like a shield) and the space behind is filled with bone graft or alloplastic material. Other method is something that is called chin visor.
Shield: https://www.instagram.com/p/CRV1mBpJCH_/?utm_source=ig_web_copy_link
In short: Basically just add volume above the chin.
I mean could also be achieved with filler.
Unrelated but this is the best cw result i have ever seen: https://www.instagram.com/p/Ced2dXLoh8C/?utm_source=ig_web_copy_link
... I've posted a video where they show what was done to him if you want to know.
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Unrelated but this is the best cw result i have ever seen: https://www.instagram.com/p/Ced2dXLoh8C/?utm_source=ig_web_copy_link
... I've posted a video where they show what was done to him if you want to know.
Agree, very nice result! Same technique as with the other person (long cw). It’s really baffling how every result looks completely different than the next one. Can you post the link of the vid? I would like to see the X-ray (if available).
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Agree, very nice result! Same technique as with the other person (long cw). It’s really baffling how every result looks completely different than the next one. Can you post the link of the vid? I would like to see the X-ray I’d available
When he says "long cw" he means the cut goes all the way back through the angles and "short cw" not through the angles. Some of the "long cw" results had the mandibular border segmented in 2 and then widend.
Video: go through my post history
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It is not avoided because of the chin wing but because the cut at the chin goes further up (like a shield) and the space behind is filled with bone graft or alloplastic material. Other method is something that is called chin visor.
Shield: https://www.instagram.com/p/CRV1mBpJCH_/?utm_source=ig_web_copy_link
In short: Basically just add volume above the chin.
I mean could also be achieved with filler.
Unrelated but this is the best cw result i have ever seen: https://www.instagram.com/p/Ced2dXLoh8C/?utm_source=ig_web_copy_link
... I've posted a video where they show what was done to him if you want to know.
Yes. An 'add on' to the procedure that's referred to as either a chin 'shield' of chin 'visor'.
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Yes, I was referring to the strong mento-labial fold mainly. It looks very artificial, non-natural imo.
Kavan, do you know what besides grafting at the time of surgery can mitigate this? Is it possible to graft after, to fill in the LM groove, without detaching the mentalis? He could definitely benefit from that.
And what is the cause of this in the first place - is it an angle issue? The chin goes straight out. I wonder if it was tilted down a little if it would mitigate this type of look?
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Kavan, do you know what besides grafting at the time of surgery can mitigate this? Is it possible to graft after, to fill in the LM groove, without detaching the mentalis? He could definitely benefit from that.
And what is the cause of this in the first place - is it an angle issue? The chin goes straight out. I wonder if it was tilted down a little if it would mitigate this type of look?
I said it in reply #`16 in this thread. An 'add on' to the procedure that's referred to as either a chin 'shield' of chin 'visor'. It's been discussed here before. Might be worth a search. It involves a certain way of cutting that allows for filling in the grooved area. Basically, if a step-off that would show a sharp and deep groove between the lower lip and chin can be predicted to happen from the advancement of the chin a type of cut and back fill behind it can be used that will fill in that groove with part of the chin bone and back fill behind it.
ETA: I originally referred to my post which was #17 in the thread but requests for removal of things changed post # 17 to #16.
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You can also fill the labiomental fold/groove area with a lipofilling procedure (fat grafting to the deep chin fold) I have seen it a few times on a Instagram video of a Austrian Surgeon(he does a lot of fat grafting). It looked nice and balanced and according to him it's permanent after everything has settled down.
Filler is also an option, but it's not permanent and i never have seen it before.
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Im actually considering a side Wing After my Chin Wing. My mp is optimal now and I don’t require any further horizontal advancement, yet my gonal angles are somewhat blunted from the front view.
I have picked up, that a side wing would address this, by cutting a part of the posterior mandible border and placing it further back, effectively increasing the mandible border length. The new gap between both segments would be filled with a new hip graft. Is this correct so far?
My main concern would be bone resorption of the new graft. I have read somewhere on this forum, that hip grafts are only meant to work as sandwiches between bones, such as in the prior example provided by dr.B, and not as buttress, filling a gap. Is there any literature on this? Maybe kavan knows something…
Also, What would happen if the new graft gets resorbed? Do the two segments just move back into their old position?
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A second chin wing addresses blunted jaw angles and the gap between the segments are filled with a hip graft. (bone buttress). A bone buttress is part of 'sandwiching' the cut bone segments. It's the 'meat' of the sandwich whereas the bone segments are the 'bread' of the sandwich.
Resorption would/could be some but in range of minor minor. The part they take from the hip (illiac spine) is strong type of bone (cortical) and not type that gets porous (spongy bone).
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How exactly does this procedure enhance the jaw angles? Does the jaw angle sitting in a more posterior position than before automatically enhance the gonial angle from the front? Or would it require extra flaring of the segment, which would be a seperate set of movements in the same surgery?
Ideally, I would like to tell my surgeon to do this operation without extra flaring of the jaw angles, since there is a risk of them breaking off, due to elasticity issues. I hope that alone would get the job done, and "undo" the previously blunted jaw angles.
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You said you just had forward movement without any drop down.
So if you move part of the segment back this aspect could look like before surgery but with part of your mand. border more advanced.
Almost as if you had a genio with a cut beginning more posterior in the first place.
In this case it would not enhance the angles but just restore them.
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You said you just had forward movement without any drop down.
So if you move part of the segment back this aspect could look like before surgery but with part of your mand. border more advanced.
Almost as if you had a genio with a cut beginning more posterior in the first place.
In this case it would not enhance the angles but just restore them.
Exactly.
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You said you just had forward movement without any drop down.
So if you move part of the segment back this aspect could look like before surgery but with part of your mand. border more advanced.
Almost as if you had a genio with a cut beginning more posterior in the first place.
In this case it would not enhance the angles but just restore them.
It is possible that there may or may not have been some drop down, but it will have been very minor.
The restoration of the previous position of the angles, will provide an improvement over the current gonial angles if I’m not mistaken? The question is do more posterior positioned angles favour the genial angle from the front view and why is this the case?
Would the end result not from a cosmetic perspective be more comparable with a bsso rather than a genio, since more of the mandible has been advanced?
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Just a note:
Reply #21 from me on this thread was meant to clarify some questions/confusion you stated in Reply #20 .
There is nothing in your (present) response that followed that demonstrates feedback to your questions furthered much understanding on your part when a return response is a new set of different or more questions.
Likewise with your response to Tomasjohn who also clarified one of your questions. Your response is just a different set and or more questions, none of which demonstrated that you 'digested' the prior info given and none of which were questions about info given.
The salient and very BASIC thing to be understood here (and I'm not sure if it is) is that an additional chin wing (side wing) surgery can put back your posterior jaw angle where it was prior if the initial one ended up blunting by bringing the whole bottom border of the mandible forward.
How exactly does this procedure enhance the jaw angles? Does the jaw angle sitting in a more posterior position than before automatically enhance the gonial angle from the front? Or would it require extra flaring of the segment, which would be a seperate set of movements in the same surgery?
Ideally, I would like to tell my surgeon to do this operation without extra flaring of the jaw angles, since there is a risk of them breaking off, due to elasticity issues. I hope that alone would get the job done, and "undo" the previously blunted jaw angles.
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Just a note:
The salient and very BASIC thing to be understood here (and I'm not sure if it is) is that an additional chin wing (side wing) surgery can put back your posterior jaw angle where it was prior if the initial one ended up blunting by bringing the whole bottom border of the mandible forward.
Yes, I do understand this, but I think I have a hard time visualizing how this will look like. For example, how exactly would a setback of the posterior segment effect the anterior segment cosmetically. What exactly is the cosmetic tradeoff is basically what im trying to figure out?
Im guessing you would also need an xray to give more specific advice. I will provide more information to my case in due time.
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Yes, I do understand this, but I think I have a hard time visualizing how this will look like. For example, how exactly would a setback of the posterior segment effect the anterior segment cosmetically. What exactly is the cosmetic tradeoff is basically what im trying to figure out?
Im guessing you would also need an xray to give more specific advice. I will provide more information to my case in due time.
No one here can visualize and describe to you how you would look other than to tell you that if you like everything about the change except the blunting of the back angles, a secondary procedure (side wing) can place them further back without changing the other stuff done prior. We haven't been looking at your face daily in the mirror as you have in order to visualize that for you.
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the following cw-patient "could" be comparable to my case. He had a minor advancement and very little drop off:
https://www.instagram.com/p/BkDw1OoBQvo/?hl=en
Do you guys think he would benefit from the discussed side-wing procedure, where the jaw-angles are set back? Would that alone restore angularity to his face?
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the following cw-patient "could" be comparable to my case. He had a minor advancement and very little drop off:
https://www.instagram.com/p/BkDw1OoBQvo/?hl=en
Do you guys think he would benefit from the discussed side-wing procedure, where the jaw-angles are set back? Would that alone restore angularity to his face?
I think you need to develop your ability to observe what's there to observe before asking questions that demonstrate lapses in that ability and trying to get answers here about how someone elses case relates to yours.
The ceph shows that he got a DROP DOWN to mandibular chin wing segment (which means entire segment including the chin). The posterior jaw angle is moved down VERTICALLY and not moved horizontally to blunt there. The chin is also dropped down vertically. If the segment were moved horizontally, you'd see blunting of the jaw angles which are not seen in the ceph X ray.
It's very OBVIOUS from the ceph X ray that he doesn't need to have his jaw angles 'set back' BECAUSE they were not brought forward in the chin wing procedure to blunt them. Your questions are based on not observing that.
Try to practice and hone better observations skills if you need to compare your case and what you specifically had to someone else. It's an important base to have.
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Okay fine, he got some drop-down as well.
The seph was made from a diagonal angle, which might distort visibility of the actual movement made.
The link again for reference: https://www.instagram.com/p/BkDw1OoBQvo/?igshid=YmMyMTA2M2Y=
I think it’s quite evident that there was horizontal movement from the second picture, which shows the b/a from side profile and front view. I’m not sure how you are concluding that the jaw angles were not moved forward and that there is no blunting, since the picture from the front clearly shows a more roundish and less angular face.
I see the following here: drop down + horizontal advancement of the whole segment.
So the question remains, would he benefit from setting back his jaw angles.
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The referenced case has been discussed before. The outcome was not only a function of CW, he had more done. See this reply: https://jawsurgeryforums.com/index.php/topic,7780.msg78404.html#msg78404
Impossible to say if he would benefit from simple setback because more complications could occur like stepp-off etc.
It is clearly different for every case.
If you could benefit from such a set-back can only be judged after a concrete plan has been made by a surgeon. Then we could comment on this plan.
You would make most progress by doing this:
1) See surgeon (I would go back to original surgeon) and explain what you want any why
2) Get an answer how he would do it and why
3) Get feedback here and assess by yourself
4) Act or change plan
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..The seph was made from a diagonal angle, which might distort visibility of the actual movement made.
Keeping in mind that your questions were relative to the ceph of oblique perspective,'which might distort visibility of the actual movement made'. When that's the case, it calls into question why you expected it to yield an answer to the question of 'would he benefit from moving his jaw angles back?'. It's a demonstration of seeking answers to distorted questions which might yield distorted answers.
The link again for reference: https://www.instagram.com/p/BkDw1OoBQvo/?igshid=YmMyMTA2M2Y=
I think it’s quite evident that there was horizontal movement from the second picture, which shows the b/a from side profile and front view. I’m not sure how you are concluding that the jaw angles were not moved forward and that there is no blunting, since the picture from the front clearly shows a more roundish and less angular face.
So, now your question seeks out an answer to front and side views that you fail to link in your response and you're 'not sure' how I didn't see blunting from an oblique ceph your questions were based on.
From the ceph you introduced, I saw no telltale signs of an extent of horizontal movement that would yield blunted angles. So a question of 'should he move them BACK' can't be answered when a ceph used to ask the question doesn't show the jaw angle segment was moved forward.
I see the following here: drop down + horizontal advancement of the whole segment.
So the question remains, would he benefit from setting back his jaw angles.
To me, your questions resolve to demonstrations of using a faulty foundation to ask them and it's like trying to build on a foundation of sand to answer them. So, I leave you to your OWN observations. IF your observations are correct on what ever you use to base them on, you can use them to answer your own questions.
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The referenced case has been discussed before. The outcome was not only a function of CW, he had more done. See this reply: https://jawsurgeryforums.com/index.php/topic,7780.msg78404.html#msg78404
Impossible to say if he would benefit from simple setback because more complications could occur like stepp-off etc.
It is clearly different for every case.
If you could benefit from such a set-back can only be judged after a concrete plan has been made by a surgeon. Then we could comment on this plan.
You would make most progress by doing this:
1) See surgeon (I would go back to original surgeon) and explain what you want any why
2) Get an answer how he would do it and why
3) Get feedback here and assess by yourself
4) Act or change plan
I saw no 'set forward' in the ceph the OP introduced to pose a question about a set back. If a set forward could not be seen from that perspective, it would require a ceph of profile to contend that it was. So, the 'impossibility' of answering his question is found in the way he poses it.
Also, when a person asks a question based on whether AN ENTIRELY DIFFERENT PERSON would look better (with this or that) and seeks that kind or answer to apply to himself, it's a red flag for a distorted question in which the OP might distort the answer if he applies to himself. For example, an answer of: 'He would look great by doing that (what ever 'that' happens to be) might be a good answer about the OTHER PERSON. But if the OP asking it is using another person as a PROXY for answering what the OP should do, it's a red flag and best not to answer it. People wanting to know if THEY would look good based on a proposed CHANGE to what ANOTHER person had or could have are best prompted to show THEIR OWN photos.
Your response pointing out 'impossibility' was a GOOD ONE and so were your suggestions as to how he should proceed.
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Okay, I will consult with my surgeon first. Thanks for the advice!