jawsurgeryforums.com
General Category => Aesthetics => Topic started by: ditterbo on January 08, 2017, 02:23:51 PM
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If one has a very dolichocephalic skull pattern, retrognathia, very mild maxillary retrusion, no anterior maxillary excess, basically no ramus, and lastly, a mandibular plane angle of 40 degrees, how would bimax w/CCW rotation be of much aesthetic benefit over camouflage procedures like SG, implants, or chin/side wings? I'm describing myself but this may be the case of other 'borderline' people. Because like if you can't impact the anterior maxilla, then how are you benefiting from the CCW rotation with just a posterior downgraft alone for the rotation? Your mandibular plane angle won't change much at all. People say the biggest aesthetic benefit of bimax is from CCW and not straight forward advancement. Sure straight forward advancement helps, but can't that be masked with plastic surgery? In fact I'm already considered 'well compensated' by some with a 12mm chin implant and rhinoplasty, both I did before realizing I had retrognathia.
For instance, Gunson's plan for me is no maxilla anterior impaction, but about a 10mm posterior downgraft. 15mm lower jaw, 2mm upper jaw, and 3mm SG. That gets me 6mm more at the pogonion vs my current profile before you consider a less than perfect surgery, which could easily get me back to within 2-3mm of my current chin. Also my mandibular angle plane would barely change. It'll be 5 degrees better if that. That's due to the lack of maxilla anterior excess to impact, which would then let the lower jaw come up and reduce the MPA.
So if I were to get bimax hoping for it to be my last surgery with a ~2 point looks gain, I think I'll come out very disappointed.
The benefits of CCW, as I understand it, is to shorten the face thereby helping fill in the mid-face and getting you a more naturally forward-growth pattern looking jaw. You get this by BOTH posterior maxilla downgrafting AND anterior maxilla impaction for the full CCW rotation. One without the other significantly reduces the aesthetic potential of a textbook CCW movement. Great I don't have a gummy smile to start with, but that means bimax won't do much more than this chin implant is doing for me already. My jaw angle will still be steep and probably not anymore defined because it's so narrow and seriously dolichocephalic.
Counter argument is if you look below average anyways, then you'll need bimax just to get a 'normal' face to only then improve upon vis-a-vis PS. So then you're looking at bimax followed by a face full of implants or osteotomies as you see fit. As I stand now without any nagging medical issues to also address with bimax, I don't want use bimax solely as a cosmetic 'gateway' surgery to the actually helpful cosmetic ones. Without medical problems, it may be 'close enough' to augment what I already have and call it a day. Probably just fix my nose, think hard about a side wing + ZSO from Dr. Z, and be done.
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I looked basically exactly like you before. Was also pretty 'borderline'.
I had bimax with anterior impaction to achieve CCW rotation, except had no gummy smile like you.
HORRIBLE IDEA.
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I looked basically exactly like you before. Was also pretty 'borderline'.
I had bimax with anterior impaction to achieve CCW rotation, except had no gummy smile like you.
HORRIBLE IDEA.
Why do you regret your surgery? Did the bimax w/ CCW rotation not do anything?
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Why do you regret your surgery? Did the bimax w/ CCW rotation not do anything?
I'm proposing a full CCW rotation can't be achieved when you don't already have a gummy smile. It requires impaction of the anterior maxilla to get the full aesthetic benefit of both absolving the gummy smile AND just as importantly, decreasing the sharp mandibular plane angle (if you have one like me).
He didn't have a gummy smile but still got full CCW. If I'm understanding this rotation correctly, he probably got a great aesthetic improvement until he opens his mouth and reveals almost no teeth. Not sure but maybe the loss of maxilla in the front could have messed up some other areas due to less support.
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I'm proposing a full CCW rotation can't be achieved when you don't already have a gummy smile. It requires impaction of the anterior maxilla to get the full aesthetic benefit of both absolving the gummy smile AND just as importantly, decreasing the sharp mandibular plane angle (if you have one like me).
He didn't have a gummy smile but still got full CCW. If I'm understanding this rotation correctly, he probably got a great aesthetic improvement until he opens his mouth and reveals almost no teeth. Not sure but maybe the loss of maxilla in the front could have messed up some other areas due to less support.
I'm not a guy, but that's precisely what happened. I got a very strong jaw now (as a female, not sure how I feel about this), but no upper tooth show at all, while my lower teeth are visible up to the gumline.. As well, the impaction does seem to have caused a loss of support in the midface even though I had a slight forward movement to supposedly mitigate that.
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we have a little simular situtation mb u remember. same head shape(long) only my upper third bigger than you, fu*k balding
what is ur plans and what are you doing now. i forgot my jaw problem for 2-3 month cuz that stress last year and genetics made me balder so fast.
i did a consult and still cant decide. doc didnt say anything %100. He said ''looks like ccw but mb genio and if u dont want them,then just braces''.
i really want your surgery before after photos and then want to decide mine :D. i have same problems with you plus giant head
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we have a little simular situtation mb u remember. same head shape(long) only my upper third bigger than you, fu*k balding
what is ur plans and what are you doing now. i forgot my jaw problem for 2-3 month cuz that stress last year and genetics made me balder so fast.
i did a consult and still cant decide. doc didnt say anything %100. He said ''looks like ccw but mb genio and if u dont want them,then just braces''.
i really want your surgery before after photos and then want to decide mine :D. i have same problems with you plus giant head
0 plans, no ones told me otherwise that bimax is more than just a gateway procedure to get actual appearance improving surgery. Particularly for my case where I think I've probably already gained 90% of the improvement you can reasonably expect after an actual bimax case (not talking projections where relapse and soft tissue thinning isn't accounted for). Going through my recording again from the Gunson consult, Gunson's medical reasoning for bimax is quite dubious, basically ludicrous IMO.
He claims I wear my back teeth out more due to my lower jaw moving forward to form my habitual bite (can't get an ortho or dentist to agree on that), my teeth are almost in their natural position, incisors are where they're supposed to be, my airway is fairly large with smallest point being 186mm. but "you've already experienced the pitfalls of camouflage treatment and the unintended consequences" "every issue taken in isolation isn't needing jaw surgery, but diagnostically, it's worth it" - Gunson.
I don't know if it's good or bad that I went the PS route over bimax. The "only" downside to the PS is my smile is now tight and slightly asymmetric. Bimax could've traded off a lot more functionality and sensation for nearly the same results. I dono anymore, venting a bit and frustrated with this lack of clear reasoning to do bimax. Too many variables and unknowns. My chin implant can start drilling into my bone in 2 years and then I'll all of a sudden need to do something.
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You don't need any impaction at all to achieve ccw rotation if your gum show is already good. Just posterior downgrafting.
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You don't need any impaction at all to achieve ccw rotation if your gum show is already good. Just posterior downgrafting.
But then you need A LOT of it. And it would have to be porous ha.
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You don't need any impaction at all to achieve ccw rotation if your gum show is already good. Just posterior downgrafting.
See the surgical plan I posted from Gunson at start of thread. It's almost 10mm of a posterior downgraft but it barely changes my mandibular angle. So what's the aesthetic improvement in that CCW? If I'm lucky, someone like Posnick, who prefers much milder CCW, would advance my jaws with just enough CCW to keep my current long face. Gunson's posterior downgraft is severe enough to actually shorten it but not by much at all considering where I'm starting from.
I've either hit the ceiling in what I need to know with bimax in my case (doubtful) or the veteran forum goers aren't taking much interest in this thread. Has anyone seen before/after of others with the same skull pattern and slanted off ramus?
I might make new profile shots. Something about the ones Gunson made of me I just can't reproduce at home. Might just be my heads held higher.
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See the surgical plan I posted from Gunson at start of thread. It's almost 10mm of a posterior downgraft but it barely changes my mandibular angle. So what's the aesthetic improvement in that CCW? If I'm lucky, someone like Posnick, who prefers much milder CCW, would advance my jaws with just enough CCW to keep my current long face. Gunson's posterior downgraft is severe enough to actually shorten it but not by much at all considering where I'm starting from.
I've either hit the ceiling in what I need to know with bimax in my case (doubtful) or the veteran forum goers aren't taking much interest in this thread. Has anyone seen before/after of others with the same skull pattern and slanted off ramus?
I might make new profile shots. Something about the ones Gunson made of me I just can't reproduce at home. Might just be my heads held higher.
I was pro surgery wrt your case before... Now I'm not so sure. Maybe had you not had all that camouflage work to begin with. (BTW, The dipping upper lip after rhinoplasty is surprising . I know the muscles may be effected, but not too that extent.)
IMO, what seems to affect your looks the most from the front is the rather long midface. Since that's mostly the nose, I'm not sure what can be done about that.
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I was pro surgery wrt your case before... Now I'm not so sure. Maybe had you not had all that camouflage work to begin with. (BTW, The dipping upper lip after rhinoplasty is surprising . I know the muscles may be effected, but not too that extent.)
IMO, what seems to affect your looks the most from the front is the rather long midface. Since that's mostly the nose, I'm not sure what can be done about that.
I thought I linked it but here's Gunson's plan: http://i.imgur.com/xFym2lf.jpg
The upper lip affect is probably from the columella strut graft used in the rhino to project the tip. I'd like to revise my nose but I'm holding out while running this bimax decision to the ground. But ya the long face thing is hard for to work out. It gets worse as I lose fat in my mid-face with aging + immediate upper cheek hollowing caused by the rhino. I took a pulse oximeter test overnight, at home, and I don't have sleep apnea. The sleep study test probably diagnosed mild apnea while I was forced to sleep on my back per protocol.
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Longer midface is OK provided you're tall.
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That's a big rotation. Whether the translates into a big change in how you look... I don't know. I suspect that it will. Just for reference his revision plan for me had much smaller net changes everywhere... Probably why he felt it was not quite worth it in my case.
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Not tall, 5' 9". I think the long face affect is amplified by my hanging columella / retracted nostrils...
It's a big posterior rotation, requiring the 2 or 3 piece lefort to accomplish (forgot which he selected), but I don't see how this would be much improvement over the current chin implant. I see the rotation improving the gonial angle very slightly, which would also improve my mid-face slightly, but that's it. Slight enough I'm afraid I would look no different except to those closest to me.
Also, from this forum, sounds like his HA approach does hardly anything helpful for the mid-face and is a waste of money.
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Why is a long mid-face ok if you're tall?
Less incongruent. Everything is long, face is long. In fact it's almost accepted - tall, long face. At any rate it's much better than the combination of short height, long midface. And when people look up to you, it looks shorter.
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What if I went chin wing + ZSO? I probably will lose a few mm in the chin but other than that... it still leaves me open to bimax or implants later on, right?
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You're only borderline considering you already had a large implant placed. I agree you should have had jaw surgery to begin with and you were not borderline. The MPA isn't that interesting to me because it's just a measure of the amount of excess vertical growth you got but not a measure of deficiency, it's purely aesthetic. The occlusal plane is way more interesting to me and you've got a pretty steep one, that's why Dr Gunson wants to downgraft it so much. Unfortunately, he can't downgraft it too much without creating a discontinuity in the jaw line since he can't touch the ramus which is why he needs to advance both jaws. Doing that will create an imbalanced face though so it's a game of tradeoffs. I think he has a pretty good plan here, especially if it removes that foreign body from your chin. You had a really small airway before that will cause problems soon if not already. You've also got an arch form deformity that he can surgically fix which will improve the health of the teeth long term. Pretty narrow nostrils and lots of volume missing under the eyes.
Basically, you were a moderate to severe case before the implant/rhino surgery and it only looks minor now. You still have some health problems that surgery can address. I think you look ok now but you'll look a little better after. I'd want the surgery in your case and shame on the plastic surgeon for not recommending it to you the first time. And yes he knew better!
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lots of volume missing under the eyes.
How can you tell this? He blocked out is eye area. Looks OK to me though.
The long midface is OK if you have a wider jaw to balance it. I think a CCW rotation would achieve this somewhat. MMA + CCW will give you the advancement and lower third increase you're looking for while also improving your airways (which, from your first pre-op photo, looks pretty severe)--you say you don't have sleep apnea now but your risk will increase as you age, as I'm sure you're aware. If I were you that's what I'd do and then *maybe* look into a chin wing / implants after that's all done. Unless you personally prefer a strong-jawed look, I think you'll be pretty balanced without them though.
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You're only borderline considering you already had a large implant placed. I agree you should have had jaw surgery to begin with and you were not borderline. The MPA isn't that interesting to me because it's just a measure of the amount of excess vertical growth you got but not a measure of deficiency, it's purely aesthetic. The occlusal plane is way more interesting to me and you've got a pretty steep one, that's why Dr Gunson wants to downgraft it so much. Unfortunately, he can't downgraft it too much without creating a discontinuity in the jaw line since he can't touch the ramus which is why he needs to advance both jaws. Doing that will create an imbalanced face though so it's a game of tradeoffs. I think he has a pretty good plan here, especially if it removes that foreign body from your chin. You had a really small airway before that will cause problems soon if not already. You've also got an arch form deformity that he can surgically fix which will improve the health of the teeth long term. Pretty narrow nostrils and lots of volume missing under the eyes.
Basically, you were a moderate to severe case before the implant/rhino surgery and it only looks minor now. You still have some health problems that surgery can address. I think you look ok now but you'll look a little better after. I'd want the surgery in your case and shame on the plastic surgeon for not recommending it to you the first time. And yes he knew better!
Arch deformity - My upper palate or both are narrow? An ortho said my lower is fairly narrow, but no mention of the upper and that's been the extent of it. To tjaar & molestrip regarding my airway, that ceph you saw is with my jaw properly seated in the joint. My jaw's subconsciously jut out 2-3mm to form my bite. My AHI rating is 10, from a sleep study, and my airway, per Gunson's analysis, is 186mm. My nose is basically no use for normal breathing, despite the prior septorhino. The nose cavity looks to me like it was narrowed from the surgery. Neither did surgery correct the long nose affect which is piling onto the long midface problem I have.
My jaw & midface are naturally super narrow. I am concerned that without some widening and advancement type surgery on the mid-face, correcting the jaws alone won't help much aesthetically. BTW when people say they had their jaw advanced "x"mm, are they referring to the total at the pogonion or the literal jaw cut and forward movement? If I look at straight advancement, Gunson moves my maxilla forward just 2.8mm and my mandible only 8.8mm. People here have said 15mm mandible advancements make the big aesthetic difference, and people with 12mm or less tend to be disappointed. But then Gunson rotates my mx1 tip a whole 8mm and rotates posterior down 9.6mm, which are both on the large end of the spectrum. But isn't 8.8mm of a jaw cut not nearly enough for sleep apnea treatment, let alone aesthetic treatment? Gunson said his plan would treat even severe sleep apnea, but his big movements are really in the CCW area rather than straight advancement. The latter of which I thought treats sleep apnea. Am I following this right? I checked with Dr Gary Warburton and his rough cut surgerical plan would halve Gunson's movements by 50-60%, which gives me some perspective for sure.
I think the area below my eyes and just above the apple of my cheeks have significantly hollowed out from the rhinoplasty. I presume that's the area molestrip was referring to? I suppose I'd need to see either Yaremchuk for a full head of implants post bimax, or Dr Sinn for a modified LF3 post bimax, and/or Dr Z for a ZSO and/or chin wing post bimax. It's so much easier just doing nothing honestly, ugh.
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bimax is the only way to achieve anterior projection of the jaws, and rotation if you need it (you probably do).
Nothing else can achieve this. Ive looked.
Implants are exceptional at providing width and contours etc, but they are extremely limited in anterior projection, in fact the only anterior projection they can provide is at the chin point which will look odd if the rest of the mouth area is recessed.
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Its probably why so many implant results look lackluster. In fact I think that is the key difference between people who get good outcomes vs the ones that don't: the people who achieve good results with mandible implants already have adequate projection and normal planes, so adding some bulk to the jaw is fine. On the other hand, people with recessed jaws and steep almost downward growth, still have this odd look after implants.