jawsurgeryforums.com
General Category => Aesthetics => Topic started by: dammit_daniel on July 02, 2018, 10:29:23 PM
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Hi all,
Can I please get advice on my surgeons plan for bimax surgery.
The purpose of the bimax surgery is to open up my airways due to sleep apnea. The surgeon has recomended bimax aswell as advancement and no genioplasty.
Can I get advice on the pictures attached in the link from a aesthetics point of view?
https://imgur.com/a/UZltISJ
Many thanks
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Not an expert, but aesthetically, it looks good to me. The proposed movements include counterclockwise rotation with a posterior downgraft, which is typically a good sign because it shows the surgeon is familiar with more complex procedures. The CCW along with your steeper occlusal plane also explains why you don't need a genioplasty, as you'll get a good amount of forward projection from the jaw swinging down. Mind sharing or PMing me the doctor's name?
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Thanks for sharing your opinion :) The surgeon is Dr Lance West in New Zealand.
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Would further advancement look better? Or would it be too far?
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Would further advancement look better? Or would it be too far?
No, I think your surgeon's plan looks good.
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The aesthetic and plan looks quite similar to what Gunson would do. For example the posterior down graft and the True Vertical Line (TVL) where he has it. Your doc must have studied (or payed attention) to what Gunson does. It's an optimized aesthetic as in good facial balance and where teeth should be as far as bite. You also got the BONUS of a morph WITH it.
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Is Gunson only doing CCW Rotation? Isn't it more optimal to do simultaneously with rotation a linear forwardmovement (translation) of the maxilla too?
When I see plans of surgeons who can do CCW rotation method they only do the rotation part. When I see surgeons who have no experience in CCW, they only do a linear forwardmovement without the rotation. Wouldn't it be better for the most cases if there is a good mix between these two extrem methods (only linear vs only rotation)?
With this question I only referring to cases, who needs a maximandibular advancement.
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Is Gunson only doing CCW Rotation? Isn't it more optimal to do simultaneously with rotation a linear forwardmovement (translation) of the maxilla too?
When I see plans of surgeons who can do CCW rotation method they only do the rotation part. When I see surgeons who have no experience in CCW, they only do a linear forwardmovement without the rotation. Wouldn't it be better for the most cases if there is a good mix between these two extrem methods (only linear vs only rotation)?
With this question I only referring to cases, who needs a maximandibular advancement.
Often surgeons who do CCW (through posterior downgrafting) will also advance ANS, so I think the premise of your question is slightly flawed.
Also, why is CW so underrepresented on this board?
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Also, why is CW so underrepresented on this board?
Because it's for Class 3 skeletons, and those cases are pretty straightforward (jaw puns!).
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Because it's for Class 3 skeletons, and those cases are pretty straightforward (jaw puns!).
Lol -- what about short faces though (which can be Class I or class II deep bite)?
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Lol -- what about short faces though (which can be Class I or class II deep bite)?
Yeah, it's appropriate for those, but that's fairly rare. I've seen some come through here. CelticCaveGirl comes to mind.
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Thanks for all the input guys. As someone who is new (and quite nervous) to all of this your input gives me reassurance that my doc knows what hes doing!
Also saw the doc this morning, he said he wouldn't want to advance any further as he thought the risk of relapse would be greater, although he said this was more likely with woman?
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Hi just reviving this post to seek opinions on the aesthetics view on further advancement by 3mm, onto of the original plan. So I think forward advancement would be 5.2mm instead of 3.2mm, but CCW rotation angle remains the same.
My surgeon is floating this idea of further advancement. He said that he wouldn't necessarily do this extra advancement and I'm not even sure if this is to improvement outcomes for treating sleep apnea or if hes just playing around with how I would look (Something I will clear up with him). He did say that this would increase the odds of relapse occuring. Are there any other issues that are more likely to occur the further you advance? (Nose,Nerve damage, lip problems, teeth appearance?)
Here are the photos with additional 3mm advancement https://imgur.com/a/lCiK9rz (https://imgur.com/a/lCiK9rz)
And the original plan(linked at the start of this thread) https://imgur.com/a/UZltISJ (https://imgur.com/a/UZltISJ)
I personally kind of like the additional 3mm, but does it look a bit off because I already have a vertically long face? Part of why I like it is my nose appears straighter.
I understand now the jaws/chin are further than the true vertical line. But does this automatically become less aesthetically pleasing for me and others in general or do some face types suit this look more than others?
How accurate are these dolphin simulated images? Does it usually simulate the nose changes adequately?
And would the extra 3mm really be worth the additional chance of relapse?(would both jaws relapse further than 3mm backwards, simultaneously or just random amounts?). Both advancements are ,I think, great improvements; so maybe it is trivial.
Any opinions would be kindly appreciated. Thanks.
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Not a fan of over-projected chins. That being said, you have quite a long nose, and your forehead is not short. I think in theory you should be able to get away with a lot of advancement without ending up with a too long lower third.
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Good to see you have a surgeon providing you with a good plan. Did you already have braces before (any extractions?) or need any lengthy treatment prior to surgery?
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Good to see you have a surgeon providing you with a good plan. Did you already have braces before (any extractions?) or need any lengthy treatment prior to surgery?
Hi Haven, yes he's pretty thorough although hard to get a hold of sometimes haha. Yeah I had braces in my teenage years and had a permanent retainer on my lower teeth so my bite is still pretty good according to my ortho and only minor adjustments are required and time in braces is expected to be 4-5 months. No extractions, just recently had all my wisdom teeth out. Apparently the holes left behind from the wisdom teeth are quite small so my max fac said I can probably have the operation sooner than the standard 6 month wait after wisdom teeth removal.
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Nice to hear. Avoiding extractions means you don't need to endure years of braces. I honestly don't see much difference in the second plan so the safe route would be to go with the first option as it doesn't come with risk of relapse?
Did you ever ask if getting invisalign could be used for your pre surgical ortho?
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Nice to hear. Avoiding extractions means you don't need to endure years of braces. I honestly don't see much difference in the second plan so the safe route would be to go with the first option as it doesn't come with risk of relapse?
Did you ever ask if getting invisalign could be used for your pre surgical ortho?
Yeah the ortho said I could possibly have extractions on lower teeth and would only need lower jaw surgery, but I said I didn't want to go down that route. Yeah I guess the less risk the better. No I didn't ask about invisalign. I don't know much about it, but it looks like a clear retainer you wear? I will be needing "thick" wires on the braces according to the ortho for the surgery, so I think for me I would just rather get the braces for the short time and be ready for surgery.
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I think this morph looks fantastic. Can you clarify how large the bi-bad movements will be ? You’re saying it was originally scheduled for 3mm advancement but I see 8 mm beside the maxilla and mandible osteotomy notes. Am I reading it wrong (probably)?
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So will the posterior downgraft be 8.9mm? I think I'm reading that right.
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I think this morph looks fantastic. Can you clarify how large the bi-bad movements will be ? You’re saying it was originally scheduled for 3mm advancement but I see 8 mm beside the maxilla and mandible osteotomy notes. Am I reading it wrong (probably)?
Hey, the doctor has noted the following for the original plan with 2.2mm of "foward advancement" and 10.5 degrees ccw ..
10.5 degree CCW of maxilla and mandibular.
Upper incisor edge advanced 8mmm, with no change vertically or transversely.
Posterior down graft of maxila with posterior nasal spine moving inferiorly 8.9mm and anteriorly 2.9mm
Lower incisor edge advanced 7.4mm and move inferiorly 0.3mm.
Pogonion would be moved forward 13.9mm and downwards 1.6mm.
Originally it was scheduled for 2.2mm of "foward advancement" of all jaws and the 2nd possible plan is 5.2mm of "forward movement" of all jaws.
I think you can tell the amount of translational movement by looking at the ANS point because this point is the centre of the ccw rotation (I think) and therefore not subject to movement from the CCW rotation. In the first plan it says 2.2mm and the second it says 5.2mm.
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I’m astonished there could be that much of a change in profile with 2 mm of advancement. Wow.
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Hope recovery is going well Daniel. Did you end up going with the larger advancement?
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Hey April, recovery is going well. Intense symptoms seem to be eleviating day to day. I would like to say a big thank you to the moderators, especially Kavan, and board members of this forum for their assistance with understanding the complex nature of jaw surgeries. The knowledge contained by some people here is amazing and I don't think is available anywhere else on the internet and would likely cost alot of money to to obtain through consultations. You really feel more at ease going to a consultation to discuss surgery when you know the terminology and things to look out for in a good surgeon.
Heres the final plan that we went with. The other variation links can be see earlier in this thread.
https://imgur.com/a/zhd17hR
It changed 2 days out from surgery. It was different to anything that was proposed earlier, and I was really happy about how it looked. Just waiting to see if the result is ok.
Some notes about the movement:
-The CCW rotation angle decreases compared to earlier suggestions. The surgeon said it was because orthodontics had shifted my teeth. I think the difference was about 2 degrees which resulting in additonal jaw advancement of both jaws being required to get it closer to where the incisors should be, with a measurement I am not familiar with(does anyone know what measurement is used for this?). I really liked this effect as the ANS point now projected my nose tip out more and my dropping nose looked for pronounced.
-The final chin placement I believe was a few mm behind the true vertical. A genio was a possibility however I turned it down because of the additional risk of nerve damage and cost. I actually thought the additional rotation suggested before in this post looked too "chiny" however I liked the nose projection. I think the new plan was the best of both worlds
-I did see additional advancement just out of interest. I thought it looked off and the surgeon said he was not comfortable with that amount of projection and there would be less bone healing contact with the maxilla and therefore a higher chance of relapse.
Questions If anyone would be kind enough to answer for me:
If anyone with knowledge about this movement could view my before and after on this video I would really appreciate it.
https://www.youtube.com/watch?v=4PK-kg7PQYA&feature=youtu.be - Before and After Ceph
If you pause it at the start and end and use your finger or something you can see my chin point has actually moved up vertically? According to the plan it should of actually decreased vertically by 1mm. What has happened or am I misunderstanding this? Also the asymmetry between each jawline has been fixed as you can see one jaw is lower than the other previously. How has this been fixed?
If anyone would like to know more about the operation I'm happy to answer questions. I will update with before and after photos once swelling goes down.
Discussion about the functional improvements can be found here: http://jawsurgeryforums.com/index.php?topic=7505.msg65936#new
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Hey April, recovery is going well. Intense symptoms seem to be eleviating day to day. I would like to say a big thank you to the moderators, especially Kavan, and board members of this forum for their assistance with understanding the complex nature of jaw surgeries. The knowledge contained by some people here is amazing and I don't think is available anywhere else on the internet and would likely cost alot of money to to obtain through consultations. You really feel more at ease going to a consultation to discuss surgery when you know the terminology and things to look out for in a good surgeon.
Heres the final plan that we went with. The other variation links can be see earlier in this thread.
https://imgur.com/a/zhd17hR
It changed 2 days out from surgery. It was different to anything that was proposed earlier, and I was really happy about how it looked. Just waiting to see if the result is ok.
Some notes about the movement:
-The CCW rotation angle decreases compared to earlier suggestions. The surgeon said it was because orthodontics had shifted my teeth. I think the difference was about 2 degrees which resulting in additonal jaw advancement of both jaws to get it closer to where the incisors should be, with a measurement I am not familiar with(does anyone know what measurement is used for this?). I really liked this effect as the ANS point now projected my nose tip out more and my dropping nose looked for pronounced.
-The final chin placement I believe was a few mm behind the true vertical. A genio was a possibility however I turned it down because of the additional risk of nerve damage and cost. I actually though the additional rotation suggested before in this post looked too "chiny" however I liked the nose projection. I think the new plan was the best of both worlds
-I did see additional advancement just out of interest. I thought it looked off and the surgeon said he was not comfortable with that amount of projection and there would be less bone healing contact with the maxilla and therefore a higher chance of relapse.
Questions If anyone would be kind enough to answer for me:
If anyone with knowledge about this movement could view my before and after on this video I would really appreciate it.
https://www.youtube.com/watch?v=4PK-kg7PQYA&feature=youtu.be - Before and After Ceph
If you pause it at the start and end and use your finger or something you can see my chin point has actually moved up vertically? According to the plan it should of actually decreased vertically by 1mm. What has happened or am I misunderstanding this? Also the asymmetry between each jawline has been fixed as you can see one jaw is lower than the other previously. How has this been fixed?
If anyone would like to know more about the operation I'm happy to answer questions. I will update with before and after photos once swelling goes down.
Discussion about the functional improvements can be found here: http://jawsurgeryforums.com/index.php?topic=7505.msg65936#new[/i]
Thanx. Well, it would be easier to look at if you just showed the before and after side by side and no video.
With CCW, it would rotate the pogonian (outer most point of chin) so what you saw on your x rays is consistent with what CCW would do to the chin point. Not sure but the - (negative) 1.2 displacement of Pog you see on your read out could refer to a decrease of it's position in the downward direction.
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Thanx. Well, it would be easier to look at if you just showed the before and after side by side and no video.
With CCW, it would rotate the pogonian (outer most point of chin) so what you saw on your x rays is consistent with what CCW would do to the chin point. Not sure but the - (negative) 1.2 displacement of Pog you see on your read out could refer to a decrease of it's position in the downward direction.
Speak of the devil! Thanks for continuing to follow my case :D
I think I what was happening was the angle I took the photo on look liked my chin had increased vertically in reality it hasn't.
https://imgur.com/a/dE4mUcx - Heres a photo where photos cephs are level.
The chin points looks slightly lower now to me, which is what the plan said all along!
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Speak of the devil! Thanks for continuing to follow my case :D
I think I what was happening was the angle I took the photo on look liked my chin had increased vertically in reality it hasn't.
https://imgur.com/a/dE4mUcx - Heres a photo where photos cephs are level.
The chin points looks slightly lower now to me, which is what the plan said all along!
It looks rotated in direction of CCW to me.
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Hey guys, I'm 9 weeks post op so I thought I'd put some photos and comparisons up for those interested
https://imgur.com/a/To6yGd8
I still have swelling on cheeks and upper lip.
It looks like the morph was way off in determining where my chin would end up. Not sure how it could be so off..I'm still happy with the new profile.
Breathing has improved but not as much as I would like, I am hoping there is further swelling to go down.
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I think you look great. Sure, you could've had a bit further chin projection, but you look handsome with noticeable improvements to your jawline, upper lip and nose.
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This is really weird to see, from where I'm sitting. You had a similarish starting point to me, maybe 4mm better just off the planned pogonion change (Gunson wants like 18-19mm for me where I see your plan called for 14mm). But then your actual pogonion advancement was like 2-4mm shy of plan, and now you look a lot like me with my 12mm chin implant, albeit with a better labiomental crease. So Gunson's plan is a 6mm advancement from where I'm at, but in reality... could end up quite close to the same chin advancement I already got with the implant.
https://imgur.com/iDCdf9v
Still looks like a great aesthetic improvement, for you, and hopefully without the unique lip drama I'm forever suffering from my first go-around with a chin implant (current is a revision). I'm probably staying put until I make a lot more $$, TMJ tech improves, and/or bimax improves.
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This is really weird to see, from where I'm sitting. You had a similarish starting point to me, maybe 4mm better just off the planned pogonion change (Gunson wants like 18-19mm for me where I see your plan called for 14mm). But then your actual pogonion advancement was like 2-4mm shy of plan, and now you look a lot like me with my 12mm chin implant, albeit with a better labiomental crease. So Gunson's plan is a 6mm advancement from where I'm at, but in reality... could end up quite close to the same chin advancement I already got with the implant.
https://imgur.com/iDCdf9v
Still looks like a great aesthetic improvement, for you, and hopefully without the unique lip drama I'm forever suffering from my first go-around with a chin implant (current is a revision). I'm probably staying put until I make a lot more $$, TMJ tech improves, and/or bimax improves.
I think that's a great result, didn't knew such big advancements as 12mm could be done with implant, and also look as natural. You're right, you could have more projection to optimize further if that's what you like. I don't think a good surgeon will be 4mm off, some people only have 4mm advancement for the entire surgery. It's however probably more complicated if it's gonna be done in one procedure, remove the implant and perform bimax. Can imagine it's hard to plan the outcome with an implant that's going out.
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I think that's a great result, didn't knew such big advancements as 12mm could be done with implant, and also look as natural. You're right, you could have more projection to optimize further if that's what you like. I don't think a good surgeon will be 4mm off, some people only have 4mm advancement for the entire surgery. It's however probably more complicated if it's gonna be done in one procedure, remove the implant and perform bimax. Can imagine it's hard to plan the outcome with an implant that's going out.
Agreed, just a lot of diminishing returns from here for more work in that area. I grew a tight beard (thicker than in that pic) and I probably improved another 1-2 points with that alone. If anything I want jaw angle implants but those are a crap shoot and can't be considered before bimax.
To be fair, a chin implant 6-7mm+, especially silastic, runs the risk of burring down the chin bone with micromovements. I should get a ceph x-ray done in a year or so to make sure nothing's changing there. I'm not too concerned though since mine appears positioned somewhat properly low, and a massive screw should be stabilizing it. Pretty sure a chunk of muscle got scraped off/disturbed by the screw head in the first implant, causing a unique incompetence in that dead center spot in my lower lip, vertical to the screw head. There's a consistent 'black' irregular line in my chin, in my ceph and ct scan, where the screw head used to stick out more :'(
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Thanks for the comments on the results guys. I'm happy with the result, the result looks more similar to the full face morph
https://imgur.com/a/tRDfrGr
I just didn't understand why I was given the other inaccurate MAIN morph. More importantly at week 10 I'm finally seeing a positive impact on my sleep and I'm not tired as hell recently.
Sorry to hear about your lip problems diiterbo but your result looks very good and and natural like Dogmatix said. Yes we do have quite similar profiles before and after!
So your plan is to remove your implants and possibly do bimax do the road? Yeah you might end up looking quite similar to how you already look? Idk it sounds more complicated than what I know.
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Thanks for the comments on the results guys. I'm happy with the result, the result looks more similar to the full face morph
https://imgur.com/a/tRDfrGr
I just didn't understand why I was given the other inaccurate MAIN morph. More importantly at week 10 I'm finally seeing a positive impact on my sleep and I'm not tired as hell recently.
Think this looks very good as well, I can see now that last picture I saw contained pretty much swelling which has gone down now. Also interesting how much your labiomental fold has improved.
Glad to hear your breathing is finally improving as well. Seems like a success to me. I'm following your case closely as it has similair movements as mine. If you really got 14mm, it calms me down as it doesn't seem like as big deal as I thought.
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Think this looks very good as well, I can see now that last picture I saw contained pretty much swelling which has gone down now. Also interesting how much your labiomental fold has improved.
Thanks Dogmatix, the last pic I linked is a morph as well.
I saw on your post that you mentioned you were looking into ADD. I was diagnosed with ADD a few years ago before I discovered my sleep issues. I am nearly 100% sure that my attention issues were due to my disturbed sleep because of my airways. This is because through trying CPAP and mandibular advancement devices I noticed my attention issues improved and finally my attention is getting much better of late due to the surgery. I found ADD medication never really helped me properly. I am not saying you have the same problem but thought I would share my experience.
I actually cut wheat/diary out of my diet as well and found that it helped my focus, I'd say that's probably quite specific to the individual though...
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Thanks Dogmatix, the last pic I linked is a morph as well.
I saw on your post that you mentioned you were looking into ADD. I was diagnosed with ADD a few years ago before I discovered my sleep issues. I am nearly 100% sure that my attention issues were due to my disturbed sleep because of my airways. This is because through trying CPAP and mandibular advancement devices I noticed my attention issues improved and finally my attention is getting much better of late due to the surgery. I found ADD medication never really helped me properly. I am not saying you have the same problem but thought I would share my experience.
I actually cut wheat/diary out of my diet as well and found that it helped my focus, I'd say that's probably quite specific to the individual though...
Wops, sorry, thought it was a real picture.
I read a paper where they found that 80% of the patients with OSA, also had AD(H)D. As the psychiatrist said, most people have some of these issues, the trick is finding out if it's enough to call it a disorder.
I don't have severe obstruction, but as we've discussed earlier, it's well outside the normal range. There was also another user on this forum who had surgery for sleep apnea, and got off her ADD medication post surgery. It's like finishing a puzzle, things connect in a way that makes sense and motivates me to continue with this. Chances are I'll have more than aesthetic improvements.
Had my visit with the orthodontist, seems like he wants to keep me for a while before surgery. He did an estimate maybe for late summer.
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I read a paper where they found that 80% of the patients with OSA, also had AD(H)D
Wow that's a huge number. You are lucky you have a therapist who understood there is sometimes a link, ones i have spoken to looked at me like i was crazy, i don't think its completely accepted by all health professionals. You're right it is like a puzzle. I've seen so many doctors, had heaps of blood tests and multiple surgeries to finally find some answers and get where i am. That's great you have an idea of the time frame now. All the best on your journey.
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Wow that's a huge number. You are lucky you have a therapist who understood there is sometimes a link, ones i have spoken to looked at me like i was crazy, i don't think its completely accepted by all health professionals. You're right it is like a puzzle. I've seen so many doctors, had heaps of blood tests and multiple surgeries to finally find some answers and get where i am. That's great you have an idea of the time frame now. All the best on your journey.
Nono, don't misread me, no one else than me is thinking about these links, they all think I'm crazy. Evaluating and treating the ADD is a separate investigation, the surgery etc is something I pay from my own pocket and have had to fight pretty hard for. I've had orthodontists lie straight to my face, refuse sending me to a surgeon and refuse appropriate x-rays. I had to fly abroad to arrange this.
The obsession about this is actually part of the ADD investigation :)
I don't find the paper I've read earlier, but found this. Here they say 20-30% have full blown ADHD, and attention deficiency in 95%.
https://www.ncbi.nlm.nih.gov/pubmed/21808754
Edit: Maybe I didn't read this correctly. Can it be the other way around that 20-30% of ADHD patients have OSA? Then it's a huge number.