jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: tyler93245 on April 12, 2021, 09:11:20 PM
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I am very curious to know if there is any "tribal" knowledge on this site on the efficacy of a multisegment lefort 1 vs an MSE treatment in expanding the nasal passage.
Both surgeries apparently do provide an increase in the nasal passageway volume, but exactly how much is not necessarily well documented between the treatments.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750828/#b4
https://escholarship.org/uc/item/2c05r669
Look at the attached image of a real MSE treatment. The change in nasal airway size seems drastic in comparison to what one would gain from a simple split of the maxilla at the lefort 1 level. I am left to wonder how MSEG lefort 1 surgery can even compete + if this may contribute to jaw surgery relapse if the nasal passage is not properly addressed.
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Here is a good lecture on why MSE isn’t all it’s cracked up to be: https://m.youtube.com/watch?v=vsqs8KAqSzE&t=32s
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Although I don't have time to read and evaluate the articles you cited, the photo of the MSE looks like something someone would get for a significant expansion to the middle part of the bone structure. The piriform aperture has become incredibally WIDER. The holes visible in it could be the nasal passages. I'll assume they are if you're sure the photo is showing that is so.
The 3 piece Lefort 1 would certainly not expand the whole midface bone structure as you see in that photo. But I do think that people with very very WIDE piriform apertures (who would also have a very WIDE nose base with that) would have no problem breathing in air from their nose. However, the rest of the airway, the part that is expanded via the maxfax surgery towards that aim, IF that's the problem, might not get expanded with that.
Which surgery to pursue would depend on where the airway is narrow.
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Although I don't have time to read and evaluate the articles you cited, the photo of the MSE looks like something someone would get for a significant expansion to the middle part of the bone structure. The piriform aperture has become incredibally WIDER. The holes visible in it could be the nasal passages. I'll assume they are if you're sure the photo is showing that is so.
The 3 piece Lefort 1 would certainly not expand the whole midface bone structure as you see in that photo. But I do think that people with very very WIDE piriform apertures (who would also have a very WIDE nose base with that) would have no problem breathing in air from their nose. However, the rest of the airway, the part that is expanded via the maxfax surgery towards that aim, IF that's the problem, might not get expanded with that.
Which surgery to pursue would depend on where the airway is narrow.
Yes, those holes are the entrance to the nasal passage.
I'm not sure about the width of my passages- but what I do know is my nose stuffs up at night, making it much more difficult for me to breath. Sometimes I'll wake up and air won't even be able to move through one of my nostrils, at all. I had a septoplasty which was supposed to fix this, however it did not do much. My ENT did not seem to think further treatment was possible, but it seems MSE helps alot. https://jawhacks.com/blog/mse-86-days-84-turns-expansion-complete
I'll be speaking to my maxfac about this. I have a MSEG lefort 1 planned, however I'm unwilling to take risks with my results so I'm now heavily considering delaying my surgery to go through a course of MSE (unless my maxfac can provide information that my nasal passage will be sufficiently expanded with a MSEG lefort 1) and then simply having a normal lefort 1 movement instead of a multi segment one.
I imagine a DJS would be fairly useless if I still have these nasal breathing issues so I'm concerned about the lack of information there seems to be on this. It seems that using MSE as a means to expand the nasal passageway is very novel, however MSE is a very tested/safe treatment and it's not hard to realize why it would be so effective for nasal breathing. I'll take the "safe" route regardless.
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Yes, those holes are the entrance to the nasal passage.
I'm not sure about the width of my passages- but what I do know is my nose stuffs up at night, making it much more difficult for me to breath. Sometimes I'll wake up and air won't even be able to move through one of my nostrils, at all. I had a septoplasty which was supposed to fix this, however it did not do much. My ENT did not seem to think further treatment was possible, but it seems MSE helps alot. https://jawhacks.com/blog/mse-86-days-84-turns-expansion-complete
I'll be speaking to my maxfac about this. I have a MSEG lefort 1 planned, however I'm unwilling to take risks with my results so I'm now heavily considering delaying my surgery to go through a course of MSE (unless my maxfac can provide information that my nasal passage will be sufficiently expanded with a MSEG lefort 1) and then simply having a normal lefort 1 movement instead of a multi segment one.
I imagine a DJS would be fairly useless if I still have these nasal breathing issues so I'm concerned about the lack of information there seems to be on this. It seems that using MSE as a means to expand the nasal passageway is very novel, however MSE is a very tested/safe treatment and it's not hard to realize why it would be so effective for nasal breathing. I'll take the "safe" route regardless.
I looked at the link you gave and it was kind of weird because I recognized, word for word, something I said on this board prior which was: "Since the roof of the mouth is the floor of the nose"... It's like I never heard a surgeon say it that way and when I said it exactly that way on JSF years back, I said it in the absence of hearing it said that way anywhere else. I digress.
TBH, I don't know a whole lot about the MSE but clearly, the photo you showed was something that expanded the whole middle 1/3rd of the face. So, from my perspective, the MSE expansion device looks very much like something that can be used when the AESTHETICS it could/would kick up are on target with what the person wants to achieve and most likely does have a very favorable 'side effect' of better nasal breathing for someone who might not even be getting it for that specifically.
But prior I just wanted to point out the parts of the airway/s that are opened up with the multi segment bimax would be to different parts of the airway and which parts are the issue to your particular situation are indeed best explored with the doctor.
I took a quick look at the video 'the dude' linked to and the doctor on there was saying the MSE opened in a cone shape way as to not reach all the way to the PNS. But of course, one interested in having the MSE would be more inclined to watch the whole thing than my quick look.
Not that I can argue in favor or against on the above statements I made. But I do agree you should discuss with the surgeon to see if the surgery (already planned for you?) can be adapted to include the device, called off if no adaptation OR maybe establish if it's something you could have afterwards.
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why would you ever want to expand your nose that much? it will look horrible horrible horrible. it will not be worth the widened arch or increased breathing capability.
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Take a look at this device:
https://facialsculptureclinic.com/en/surgery/orthognathic-classification/upper-jaw-too-narrow-smile-distrator/
This is what you want. With this device you get at least 2mm of bone expansion for every 1mm at the level of the teeth. The spidery looking "hyrax" expander used in MSE supposedly isn't even half of that. So just by using this device you will get twice the expansion you otherwise would have because eventually the upper arch becomes wider than the lower arch and your bite will be too compromised to expand anymore. Even better is that because this doesn't touch the teeth you can leave this device in while you are doing braces which saves time and prevents relapse from wanting to remove it too soon. It probably hurts less too because moving teeth is always painful. The "hyrax" device seems completely obsolete to me. I can't see any reason to use it when this is available. If you want more tooth movement, use this device instead and give yourself a better nasal airway and a broader more attractive midface as a bonus.
Here are a couple of examples to show what this does for the face. You can just imagine how much better these people breath through there nose with an extra 10mm of space in there. If you look close at the first case you can see the base of the nose is wider just from this even before the second jaw surgery.
https://facialsculptureclinic.com/en/case/jaw-surgery/too-narrow-upper-jaw-smile-distractor/168/
https://facialsculptureclinic.com/en/case/jaw-surgery/too-narrow-upper-jaw-smile-distractor/227/
Now notice in the first link at the top of the post they traditionally make three cuts in the adult jaw when they do palate expansion: one on each side of the upper jaw like with the Lefort surgery and one down the suture in the middle. The cuts on the side aren't required. There are sutures elsewhere on the skull that will absorb the stress from the expansion. Do it this way and it's a much less invasive surgery. Probably expands the face elsewhere too a little that way. You can even just do so called micropunctures along the suture and a little bit of "bone scoring" elsewhere making it a remarkably noninvasive surgery.
Kasey Li does this and I'm sure some other things too and calls the whole thing "EASE:" https://www.sleepapneasurgery.com/surgical-solutions-for-adults-ease/ Dr. Li by the way is an absolutely incredible surgeon and just all around good person.
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Take a look at this device:
https://facialsculptureclinic.com/en/surgery/orthognathic-classification/upper-jaw-too-narrow-smile-distrator/
[...]
One orthodontist told me, that there were cases, such this device just drilled itself further into the jaw sideways. I don't know, if there are any real studies about this scenario.
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This is what you want. With this device you get at least 2mm of bone expansion for every 1mm at the level of the teeth. The spidery looking "hyrax" expander used in MSE supposedly isn't even half of that. So just by using this device you will get twice the expansion you otherwise would have because eventually the upper arch becomes wider than the lower arch and your bite will be too compromised to expand anymore. Even better is that because this doesn't touch the teeth you can leave this device in while you are doing braces which saves time and prevents relapse from wanting to remove it too soon. It probably hurts less too because moving teeth is always painful. The "hyrax" device seems completely obsolete to me. I can't see any reason to use it when this is available. If you want more tooth movement, use this device instead and give yourself a better nasal airway and a broader more attractive midface as a bonus.
Here are a couple of examples to show what this does for the face. You can just imagine how much better these people breath through there nose with an extra 10mm of space in there. If you look close at the first case you can see the base of the nose is wider just from this even before the second jaw surgery.
https://facialsculptureclinic.com/en/case/jaw-surgery/too-narrow-upper-jaw-smile-distractor/168/
https://facialsculptureclinic.com/en/case/jaw-surgery/too-narrow-upper-jaw-smile-distractor/227/
Now notice in the first link at the top of the post they traditionally make three cuts in the adult jaw when they do palate expansion: one on each side of the upper jaw like with the Lefort surgery and one down the suture in the middle. The cuts on the side aren't required. There are sutures elsewhere on the skull that will absorb the stress from the expansion. Do it this way and it's a much less invasive surgery. Probably expands the face elsewhere too a little that way. You can even just do so called micropunctures along the suture and a little bit of "bone scoring" elsewhere making it a remarkably noninvasive surgery.
Very interesting and insightful. Thank you for this response.
I never noticed the differences between MSE types, I'll queue myself in now.
The fact that this type of expansion can be done with braces on is very convenient since I've already had my braces placed a month ago.
My understanding is that the horizontal Lefort style cuts used in SARPE prevent the whole maxilla from expanding because those cuts absorb the expansion rather than letting the whole maxilla split, so they are to be avoided.
Do you have personal experience with MSE?
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Very interesting and insightful. Thank you for this response.
I never noticed the differences between MSE types, I'll queue myself in now.
The fact that this type of expansion can be done with braces on is very convenient since I've already had my braces placed a month ago.
My understanding is that the horizontal Lefort style cuts used in SARPE prevent the whole maxilla from expanding because those cuts absorb the expansion rather than letting the whole maxilla split, so they are to be avoided.
Do you have personal experience with MSE?
From the link 'the dude' gave https://facialsculptureclinic.com/en/surgery/orthognathic-classification/upper-jaw-too-narrow-smile-distrator/ it shows that particular doctor uses a cut for that SARPE device as you say such that the whole maxilla does not get expanded in the process. But from the diagram shown, the cut looks to be at the level where the expansion would be also be to the base of the nose which seems to be where you want the expansion.
Same doctor has another case on there ('the dude' gave link to that). It's of a woman that had the 'smile expander' device (the SARPE device that particular doctor uses) and her midface area is noticeably wider. Yet he also has her down for cheek augmentation via HA. But how much one can augment the cheek area with HA is kind of limited and her midface expansion looks to be more than what would arise from HA alone. So, I'm WONDERING if the doctor didn't make the same cut shown in one of his diagrams to limit the expansion in her case such that the SARPE expansion could extend to also expand her midface area. Like, clearly, I can see why the L1 cut would be used to PREVENT the forces of expansion to extend upward to the rest of the anterior midface. But I don't see why it couldn't be used without the L1 scoring to EXTEND the forces of expansion HIGHER to the midface.
In any event, there looks to be quite an assortment of devices to expand the palate. Here's a link I found: https://en.wikipedia.org/wiki/List_of_palatal_expanders. There are probably even more than that.
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[...]
Same doctor has another case on there ('the dude' gave link to that). It's of a woman that had the 'smile expander' device (the SARPE device that particular doctor uses) and her midface area is noticeably wider. Yet he also has her down for cheek augmentation via HA. [...]
If you mean this woman https://facialsculptureclinic.com/en/case/jaw-surgery/too-narrow-upper-jaw-smile-distractor/227/ , then it is just bad photo presentation. Even her forehead is noticable wider and her ear to ear distance is also larger. I don't think, that you can widen the forehead.
She also looks a bit more up in the after pictures (right one). I am comparing the first pictures, where she is not smiling and is looking directly into the camera.
At least, what I saw in some painting programs, when I tried to compare the distances.
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If you mean this woman https://facialsculptureclinic.com/en/case/jaw-surgery/too-narrow-upper-jaw-smile-distractor/227/ , then it is just bad photo presentation. Even her forehead is noticable wider and her ear to ear distance is also larger. I don't think, that you can widen the forehead.
She also looks a bit more up in the after pictures (right one). I am comparing the first pictures, where she is not smiling and is looking directly into the camera.
At least, what I saw in some painting programs, when I tried to compare the distances.
Says you (who measures 'ear to ear distance when the after photo HIDES the ears) whom I didn't post to and don't wish to hear from. Kindly stop trolling my posts.
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You can see her accesoires, what is part of her ears, and I gave two references, just to be sure.
I just outline a statement of you, which could be wrong and everybody can make their own oppinion and you don't have to react to it.
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I spoke to Dr. Gunson about this recently.
"Some ENTs claim that more nasal airway expansion is possible with MSE vs jaw surgery, but there is no research to prove this". (Not his exact words)
He pointed out that since a MSEG lefort 1 cut (or atleast the one he performs) is made slightly above the nasal base, the airway is indeed expanded.
Up to this point, though, I've found no opinions on which procedure is better at expanding the nasal base.
It seems there is not much knowledge on which procedure provides the best outcome in expanding the nasal passageway. This seems to be a novel field of ENT research that not many have looked into.
Geometrically, atleast, MSE does seem like a clear winner in this aspect.
It's very unlikely I'll skip out on some sort of MSE treatment at this point. MSE is not possible after surgery and I am unwilling to jeopardize my airway results. Regardless of what the research may say at this point, MSE seems like a "no risk" proceedure (in the fact that jaw surgery can be performed after it). I'll likely put my planned jaw surgery date on hold after I consult/ plan with a few specialized ENTs. It seems like the foolproof "safe" route to take.
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MSE is not possible after surgery.
Absolutely no reason you cannot do MSE after jaw surgery.
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Absolutely no reason you cannot do MSE after jaw surgery.
That's the first I've heard it's possible.
Regardless, Dr. Gunson told me himself it was not possible and I need to work under his guidelines.
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That's the first I've heard it's possible.
Regardless, Dr. Gunson told me himself it was not possible and I need to work under his guidelines.
I would guess you need to have upper plates removed to do so so it complicates things
But if you need it done definitely get it done before, it'll make the bite more precise.
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Absolutely no reason you cannot do MSE after jaw surgery.
I appreciate your confidence, with seeing-is-believing, please does there exist an anecdotal account of this treatment path? I’m considering jaw work but am unsure if I wish to do MSE I need to do before or after and I’ve yet to find hard assurances.
Is there a past treatment profile of a person?
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I appreciate your confidence, with seeing-is-believing, please does there exist an anecdotal account of this treatment path? I’m considering jaw work but am unsure if I wish to do MSE I need to do before or after and I’ve yet to find hard assurances.
Is there a past treatment profile of a person?
https://m.youtube.com/watch?v=vsqs8KAqSzE&t=32s
15 minute mark
Edit:
I am just saying it is technically possible, not that it’s a good idea. If you are doing jaw surgery without braces I don’t see why the order matters at all. If you are getting braces for jaw surgery it would be silly not to do the palate expansion first since you’ll need braces a second time otherwise. I was thinking more like if you are doing jaw surgery and already pretty far along and expect a pretty good outcome, don’t feel like you are making an irreversible mistake by not expanding the palate first. It’s still an option later - just a little less convenient.
An argument in favor of waiting is that unlike with jaw surgery there is a lot of change and innovation happening with upper jaw expansion. I think the European expanders I talked about earlier and minimally invasive methods are game changing. If you can’t afford to travel to a doctor that does it maybe it’s worth the wait. I don’t find traditional MSE to be all that compelling a surgery.
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Kasey Li does this and I'm sure some other things too and calls the whole thing "EASE:" https://www.sleepapneasurgery.com/surgical-solutions-for-adults-ease/ Dr. Li by the way is an absolutely incredible surgeon and just all around good person.
An update for anyone who's interested:
I'm getting EASE surgery with Dr. Kasey Li in about a week. I looked very closely into all expansion options including MSE and it's clear to me now that Dr. Li in on the front lines of innovation in this field. His surgery techniques are on a totally different level than other surgeons. He leaves the other surgeons in the dust.
The most important thing I can say about the surgery (This is info you can't find well elaborated anywhere online) is that the VERTICAL expansion pattern is better than any other expander (Don't confuse this with the horizontal expansion pattern, i.e. what the lectures posted early in this thread address). The expansion mostly affects the midface, not the teeth. It's hard to explain, but here's a logical truth: the teeth can only be expanded to a certain point before the maxillary arch is too wide for the mandibular arch. If MSE and EASE are compared when expanded to this limit, EASE leaves a smaller tooth gap. That should tell you all you need to know about the veritcal expansion pattern (something rarely spoken about). The result with EASE is more expansion of the "real" maxilla (and importantly, the nasal passageway) than MSE offers. I believe this is due to Dr. Li's surgical technique of cutting certain parts of the bone and SCORING other parts (to weaken points of resistance). In short, MSE doesn't actually expand the bone the way it's supposed to (like when you see a demonstration video of a model skull being neatly split in half along the midpalletal suture). EASE does what MSE promises to do, but better.
Dr. Li also gave me anecdotal experience of 3 piece leftort 1s WORSENING the nasal passageway due to various factors (which I'm not smart enough to extensively elaborate on). He mentioned that the teeth will go where they want to go during recovery of jaw surgery, which sometimes means the cut up maxilla is rearranged during healing from the position it was placed in with plates. I cannot say this is universally true for all surgeons, but it's something to consider.
Anyways, nothing to report yet as far as personal experience goes- but things are looking good. I'll update with pictures once the expansion is done.
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An update for anyone who's interested:
I have about 10mm of expansion so far with EASE. This surgery has been great so far and is helping my nasal breathing ALOT. I can definitely recommend this surgery.
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Good to hear it helped. 10mm is impressive. How big a gap did you end up with?
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Good to hear it helped. 10mm is impressive. How big a gap did you end up with?
I ended up with no gap between my front teeth since my front teeth drifted back together during expansion. The 1cm worth of gaps was distributed through my other front teeth. The expansion ranged from 10mm anterior to 3-4mm posterior. My expansion wasn't parallel but the limit was the rear teeth, regardless, so I expanded as much as I could.
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Absolutely no reason you cannot do MSE after jaw surgery.
you can also use a regular expander which has been routinely used to expand maxillae