jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: ditterbo on February 29, 2016, 09:28:48 PM
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See post on 11/26 (page 4) for latest updates and images.
Preamble and context: I had orthodontics completed by age 14 (ortho pic included)which appear to have given me a decent smile and bite, without extractions. 4 impacted wisdom teeth were pulled in 2010. A year ago (I’m 26, btw), I got a rhinoplasty with a large (7mm) terino anatomical chin implant. Not to get too into this surgery, but the left half of the implant is not in its designated pocket. The left wing is way up in my cheek, so the whole thing is contorting my lower lip movement pretty severely. As I'm also in pain from who knows what happening with the implant, I think my immediate need is to have the implant revised with the option for removal during jaw surgery.
Before and after plastic surgery I consulted with at least a dozen plastic surgeons and a few maxillofacial surgeons. Jaw surgery was never really brought up until one or two consultations I’ve had post plastic surgery, as I was looking to have the chin implant revised or removed. Two local max facs didn't recommend jaw surgery, but Dr. Posnick wants me to get double jaw surgery with 2 lower bicuspids probably extracted for maximum movement. Using “Andrews facial analysis”, he observed a class 2 malocclusion with significant maxillomandibular deficiency and clockwise rotation of the jaws. Two plastic surgeons recommended jaw surgery, solely from a cosmetic perspective. I live in DC with immediate family in NY, btw.
Per Dr. Posnick, I had a sleep study followed up with a CPAP titration study, as well as a visit with an orthodontist and ENT of his choosing. Below are the outcomes of those appointments:
I have very mild insomnia and some general anxiety, which I wonder how it might have affected my score, but I got a AHI of 9 and 14 on the two sleep studies, respectively (14 AHI with 4cm pressure. 12cm pressure got my score under 5). I only slept on my sides, which is pretty typical for me unless I'm extra tired.
The ENT noted nothing in my nose really causing sleep apnea, but the sleep study doctor (Dr. O'Donnell) noted in her medical records that my sleep apnea is caused by my set-back jaws. I do not know the size of my airway, but below is a ceph taken shortly after my plastic surgery. I'm a very thin guy (~140lbs, 5' 9.5") with a neck circumference of like 12”. The apnea score isn't very high but I do worry a bit how another 10-20 pounds might affect my AHI#, say if my metabolism slows or if I try to get into shape and pack on some muscle weight (in my dreams).
As for my teeth alignment, the orthodontist noted my lower jaw slides forward by 2-3mm (I've never noticed/voluntarily do so), and my bite is off on both sides. When I bite, I may hit certain teeth before others (notice this more after wearing my retainer). He recommended, ideally, double jaw surgery and bicuspid extractions, but that braces with bite correctors could work as a "limited treatment" option.
I don’t have any TMJ at all, but I do have fatigue on a daily basis that I'm going to see if a CPAP machine can correct (at least as an interim solution until jaw surgery, if I do it). I'm really struggling here on the medical necessity justification for jaw surgery, and wanted your guys' holistic opinion on it, versus just ‘camouflage’ treatment for vanity. I believe Dr. Posnick will do jaw surgery with little to no medical justification, but he didn’t have all the reports from the sleep doctor and ortho when I last saw him.
I just scheduled an appointment, in late July, with Dr's. Arnett & Gunson. Their direct assistant reviewed my pictures, ceph, etc. and told the scheduling assistant I should "definitely" see them for an appointment. I don't know if they do double jaw surgery for solely cosmetic reasons? I don’t intend to do this surgery if my insurance doesn’t cover it (predetermination, medical necessity, etc. etc.). I might try to get a phone consultation to see if they are thinking jaw surgery or just like a sliding genioplasty.
I look forward to reading what you guys suggest! Posting pictures from before plastic surgery in this post, and post op/very recent pics, and ceph in the following.
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A post plastic surgery pic taken the other day and ceph below.
[attachment deleted by admin]
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Not sure you can see my current profiles well with the ortho pics, so here's the rest of what I took the other day.
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Can someone explain (as if I was in the 5th grade) why do some surgical plans entail extractions on the bottom????? Wouldn't the advancement in the lower jaw open up a gap in the teeth so what's the purpose of removing teeth??
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^ It is because you need your bite to be perfectly stable after surgery to heal. But i'll get back to that.
So, in order to lengthen the lower jaw in more in relation to the upper jaw... you need an overjet (bottom front teeth further back than upper front teeth). Jut your lower jaw forward. How do your bottom front teeth line up in relation to your upper front teeth? Jutting your jaw recreates the forward movement of the lower jaw in relation to the upper jaw. So, it "replicates" a BSSO. If you jut your jaw 10mm, the bottom teeth will be in a similar spot if you had your jaw extended via BSSO by 10mm (while leaving your upper jaw alone).
So, do your lower teeth meet the upper teeth? Well, then your bite after surgery will be stable and you don't need to remove any teeth.
However, what if jutting your jaw gives you an underbite? That indicates that the BSSO will result in the same unless an overjet is create between the front bottom and front top teeth. You need to have that space that is then corrected via lengthening the jaw.
Unfortunately, that overjet is often now there for many with small mandibles? Why? Well, often because either tongue thrust or intentional orthodontics has tilted the lower teeth forward to meet the upper teeth. This helps functionally give you more space and help to bite things. However, it's not the ideal solution. The ideal solution is not to lessen the overjet by tilting the teeth forward but to extend the lower jaw itself.
So, how do we create the overjet? You need to pull those lower teeth backwards to get them upright. Well, unfortunately, a small jaw also often means the arch doesn't fit the teeth upright. This is because when you flare the teeth, you are also artificially creating more space for the teeth. The best way to depict this would be... I guess take your hand and put all your fingertips together (including thumb) like your making a shadow puppet. Let the fingers touch one another. Point the tips to the ceiling. This would be your teeth all next to other in a small arch lower. It's crowded. Now open your fingers... you'll see that you are essentially "flaring" them and now there is ample space between your finger tips. If you were to trace the "arch" created it would be wider.
When someone has crowded teeth and they can't actually expand underlying bone, they tilt the teeth to create space. If your teeth are dramatically tilted to create space to get them to simply not be crowded... then how can you expect to remove the tilt without severely crowding the teeth? There is no space! Sure, sometimes maybe they will shave down all your teeth a bit so they can make room. But usually there isn't a solution.
You say... doesn't the BSSO create room.
Of course it does. However, bringing it back to jutting your jaw, if you were to create the space while your teeth didn't have the necessary overjet, your bottom front teeth after creating the space via jaw surgery would go past the front teeth. Now you have an underbite and your jaws have just been broken. You won't heal properly and it would never be stable. Sure, things like distraction (where they slowly lengthen the jaw) can work to lengthen jaw and bring the lower teeth back simultaneously, but that isn't done because it isn't as exact, it works while your growing, and if you need your upper jaw adjusted then you still need jaw surgery... so what's the point?
Hopefully that helps explain it.
There are still people on here who say extractions never ever and I have yet to hear a response as to how the specific issue I mention can be solved without extractions. I'd love to know because it'd be more choice! However, it doesn't seem very possible. I'm not an expert though... so who knows.
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To the OP...
You have a similar level of a recession to me and I'd say, yes, you do need jaw surgery without a doubt. Is it worth it? Well, you need to decide if improving aesthetically is worth the expense, recovery, and potential (honestly, likely but generally it seems minor to most) nerve damage. The chin implant looks somewhat unnatural and I feel bad that no plastic surgeon at least mentioned that a genioplasty would be a far better option for someone with a recessed mandible. Still, genioplasty really comes with same risks as jaw surgery since it seems like it's the cutting of the chin that really is where the nerve damage occurs more than anything.
It will without a doubt improve your airway. Whether or not you truly have or will ever get sleep apnea... who knows. It's not guaranteed just because you have recessed jaws. Same with jaw pain and stuff like that. I guess if you really gained a good amount of weight (muscle wouldn't contribute to this) then you'd likely get sleep apnea. CPAP machines seem hellish to me. Not that jaw surgery is a walk in the park either.
Anyway, good luck with whatever you decide. I know, for me (I'm in NY), it's been a tough decision. My insurance currently doesn't cover anything related to "tooth structures" so don't think my out of network (or in network for that matter) covers anything and I certainly cannot afford jaw surgery without insurance reimbursement. It sucks.
For me... sometimes I am happy enough about my looks despite my recessed chin. I can grow a decent beard and that helps. I despise that I can't really hold my tongue properly on the roof of my mouth and have some lip incompetence (you don't seem to have that) that has gotten worse since my bite opened up a bit over past 10+ years since braces removal (I'm 28).
Feel free to message me if you'd like to discuss!
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We do have very similar profiles, JayJaw! It would definitely be interesting to see if you get a similar score as me in a sleep study (high side of mild sleep apnea to low moderate). We have similar daytime sleepiness symptoms as you described it in your thread.
What I'm still really struggling to resolve here is proceeding with tooth extractions and jaw surgery to correct what sounds like very mild and low-impacting medical issues. Am I misunderstanding?
If this is really just a cosmetic issue, then why not go to like Dr. Yarumchuk in Boston and load your face with implants? You'll have a 'close enough' outcome with half the cost and risk of double jaw surgery. If insurance thinks your doing jaw surgery for cosmetic reasons, they won't cover follow on surgery from any of the myriad complications you may incur.
Also, has anyone seen the articles linking memory loss to missing teeth? Basically, your teeth send signals to your hippocampus. When they aren't present, your hippocampus gets less stimuli and atrophies. My memory is already plenty bad due to anxiety.
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I'd get jaw surgery with Posnick, I've read his book and he is awesome, it will improve your appearance a lot more than any implant.
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I'd get jaw surgery with Posnick, I've read his book and he is awesome, it will improve your appearance a lot more than any implant.
I've had two consultations with him and he's a little scary in-person... like he's very gruff and all business, almost unsettlingly so. I get that he's one of the best so I may return to him if I decide to go forward. My CPAP machine comes in this weekend so I'll see how that goes (again only a 14 apnea score).
What I like about Dr. Gunson is they do a visual morph of how I'll look post op. Not sure how I'd benefit or want to deal with HA, but they seem to uniquely offer that as well (if I need it?).
Does my ceph x-ray or anything really indicate a need for jaw surgery though??
I feel like I may just be a case of plain old ugly, and massive amounts of surgery may not help me look much more attractive, just 'normal'.
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There are still people on here who say extractions never ever and I have yet to hear a response as to how the specific issue I mention can be solved without extractions. I'd love to know because it'd be more choice! However, it doesn't seem very possible. I'm not an expert though... so who knows.
You can expand your jaw horizontally with SARME, it is like SARPE but for the mandible. It is much more invasive though.
You can also advance the maxilla(most people benefit from a maxilla advancement anyway, ape face is a myth) together with the lower jaw so you can advance the mandible more, of course the end result must be stable so if your lower teeth are extremely crowded or proclined you may need extractions.
I've had two consultations with him and he's a little scary in-person... like he's very gruff and all business, almost unsettlingly so. I get that he's one of the best so I may return to him if I decide to go forward. My CPAP machine comes in this weekend so I'll see how that goes (again only a 14 apnea score).
What I like about Dr. Gunson is they do a visual morph of how I'll look post op. Not sure how I'd benefit or want to deal with HA, but they seem to uniquely offer that as well (if I need it?).
Does my ceph x-ray or anything really indicate a need for jaw surgery though??
I feel like I may just be a case of plain old ugly, and massive amounts of surgery may not help me look much more attractive, just 'normal'.
Alright, I only know him from the book so I can't tell how he is in person.
About the x-ray you can ask your surgeon or orthodontist to point out your deformities.
It is hard to do here, you need an instrument to measure angles and stuff, also the
From my ceph the lab that made it sent some information, like my measurements and how they compare with the norm. My gonial angle was alright, my upper airway was 10mm vs the ideal 14mm(IIRC), and my upper incisors are proclined(naturally, but I'd have an underbite otherwise), my ortho and surgeon then used that to plan it, right now I got braces to decompensate my upper teeth so I will develop an underbite lol, then I will get the bimax surgery and advance both, but the maxilla slightly more to correct the underbite.
About HA, it is temporary, I'm not really interested but it gives some good aesthetic results.
About being ugly, having bad bones is the main reason men are ugly, jaw surgery can fix a great deal of that and it is not like you have treacher collins or sth which there is no hope.
Of course you will not become brad and marry angelina.
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You can expand your jaw horizontally with SARME, it is like SARPE but for the mandible. It is much more invasive though.
You can also advance the maxilla(most people benefit from a maxilla advancement anyway, ape face is a myth)
Do you have any reading material on SARME?
Also, how is ape face a myth? I've seen a butt load of people look like chimps post maxillary advancement. Pulled cheeks and upper lip protruding in front of bottom.
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Do you have any reading material on SARME?
Also, how is ape face a myth? I've seen a butt load of people look like chimps post maxillary advancement. Pulled cheeks and upper lip protruding in front of bottom.
Here, about SARME.
http://e-kjo.org/search.php?where=aview&id=10.4041/kjod.2009.39.4.257&code=0123KJOD&vmode=PUBREADER
That is the idea, the upper lip should be in front of bottom. I don't think I've ever saw somebody look worse after surgery, except in cases of a doctor mistake(treating an underbite causing an overbite etc) or some severe complication like a non-union.
For example, that's an extreme advancement:
(http://i.imgur.com/z9WmNGt.jpg)
I still don't think it looks bad lol, but my point is that it seems to become prevalent that if you advance your maxilla 5mm or something you will look like a chimp, Sailer creates those freaks because he advances people over 10mm and give some women chins too big, but for a men I wouldn't worry that much. People get so scared of advancing the maxilla that they prefer to have lower jaw only needing more extractions and ending up with disappointing results.
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Here, about SARME.
http://e-kjo.org/search.php?where=aview&id=10.4041/kjod.2009.39.4.257&code=0123KJOD&vmode=PUBREADER
That is the idea, the upper lip should be in front of bottom. I don't think I've ever saw somebody look worse after surgery, except in cases of a doctor mistake(treating an underbite causing an overbite etc) or some severe complication like a non-union.
For example, that's an extreme advancement:
I still don't think it looks bad lol, but my point is that it seems to become prevalent that if you advance your maxilla 5mm or something you will look like a chimp, Sailer creates those freaks because he advances people over 10mm and give some women chins too big, but for a men I wouldn't worry that much. People get so scared of advancing the maxilla that they prefer to have lower jaw only needing more extractions and ending up with disappointing results.
Okay, I see what you mean. Thanks for clarifying and the link too.
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I see that woman exampled a lot and I have to say it is one of the best results I have seen. I wouldn't call it extreme, just a large advancement. It was necessary and she went from ugly to good looking.
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I think it is a fantastic change too. The maxilla could've been slightly less for my taste though, imo that would have made her look even better. Her chin and mandible is what looks very good also the angle of her jaw. Lot of change there. If you cover that up it is not only the forward maxilla that looks good. Yeah it looks a lot better and she needed more forward maxilla but it is a bit too much I find and she looks slighty apelike. If you morph that slightly less she looks even better. The mandible is what gave her enormous change. Not just the maxilla.
What did he do to her jaw angle? Looks good. Some people have said some after pictures of Sailer are not completely real and have been touched up: is this true or just something people write?
Just look at the pics, she had bad hair, acne, crap lighting and so on on the before pic. I'd also give her less advancement but my point is that it still doesn't look that bad, it looks better at least.
She had some ccw rotation maybe which flared up her gonial angle,
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Just look at the pics, she had bad hair, acne, crap lighting and so on on the before pic. I'd also give her less advancement but my point is that it still doesn't look that bad, it looks better at least.
She had some ccw rotation maybe which flared up her gonial angle,
Jaw angle implants.
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I was told my nerve damage is like 1 out of 50 or 100. Anyway, you need surgery. Don't take it the wrong way, but you will hardly look any worse after it. You probably need CCW. Ask how much posterior maxillary downdraft you need and how stable it is. What will happen if it relapses. Ask all the hard questions.
Are you just agreeing with me that jaw surgery isn't, by itself, going to help me look much 'better' in my case?
I'm really pretty green regarding these technical maneuvers.. a big part of me just wants serious confirmation that this is worth it from a medical standpoint. I've had wisdom teeth pulled, an ill fitting, malpositioned chin implant that I need revised, a rhinoplasty that left me with a septal bone spur & consequential deviated septum, permanent light bleeding, worse breathing... I don't have a lot left in me for more majorly invasive surgery to my face and more surprise complications, but I'm also somewhat unhappy with my looks (a bit less so since the rhinoplasty and chin implant, even with its complications).
I agree, having also spoken a little about my case with Posnick, that I need CCW rotation. I wish I got a more specific evaluation from him for my $175 consultation fee. No ceph analysis, diagnostics, movement plan, etc., just a lot of describing how one's jaw position affects their appearance. My jaws seem small in all directions, but so too appears the rest of my facial features.
I'm also really not keen on losing my two lower bicuspids, but I see Lazlo posting that at least some max facs have found ways (unknown to me) to avoid extractions. Kind of hoping to see him weigh in on my case. ;)
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If done properly, you will definitely look better. Just be realistic. You won't be a model after this. The only people coming out of these looking like models are those who looked like models with a dentofacial deformity before surgery.
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Are you just agreeing with me that jaw surgery isn't, by itself, going to help me look much 'better' in my case?
I'm really pretty green regarding these technical maneuvers.. a big part of me just wants serious confirmation that this is worth it from a medical standpoint. I've had wisdom teeth pulled, an ill fitting, malpositioned chin implant that I need revised, a rhinoplasty that left me with a septal bone spur & consequential deviated septum, permanent light bleeding, worse breathing... I don't have a lot left in me for more majorly invasive surgery to my face and more surprise complications, but I'm also somewhat unhappy with my looks (a bit less so since the rhinoplasty and chin implant, even with its complications).
I agree, having also spoken a little about my case with Posnick, that I need CCW rotation. I wish I got a more specific evaluation from him for my $175 consultation fee. No ceph analysis, diagnostics, movement plan, etc., just a lot of describing how one's jaw position affects their appearance. My jaws seem small in all directions, but so appears the rest of my facial features.
I'm also really not keen on losing my two lower bicuspids, but I see Lazlo posting that at least some max facs have found ways (unknown to me) to avoid extractions. Kind of hoping to see him weigh in on my case. ;)
From what I've read Posnick is against extractions in most cases, so if he recommends it for you, you must really need it. Extractions will make it possible to advance your lower jaw a lot more and let's agree it is pretty small.
I don't see how jaw surgery cannot be beneficial in your situation, you will make your small mandible bigger, more ccw rotated, you will get a septoplasty too, it will improve your looks and breathing.
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Hey, looks like the rhino was an improvement. It's a complicated surgery, can I ask who your surgeon was? However, I think the jaw was the real issue, and that made your nose look worse. I think men can carry off lower tips and higher bridges, anyway jaw surgery will be a definite aesthetic improvement.
I'd definitely speak with Dr Gunson, they'll do a VERY thorough analysis and identify any imperfections you have (some of which you may not have even noticed). You can even do a paper consultation, if you can send them x-rays, intra-oral photos and models of your teeth, then they can do a preliminary analysis before you fly out to them. That's what I did, then I flew out and they'll do everything again in person before surgery. I'm actually scheduled for surgery tomorrow, but everyone at the office is very professional, they even made a 3D model to identify where my nerves are, they've spent a lot of time planning and I feel confident in them. I'd definitely speak to them and get their opinion.
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Thanks for sharing your thoughts on this, SJ. PMing you my op doc but honestly I don't think he does good tip work. I want to get my now retracted alar rims and hanging columella fixed in the future.
Gunson has everything except the teeth models, I think, to do a preliminary analysis. Was the prelim analysis any help though before seeing him in person? Do you know if they provide a morph of the surgery outcome at the consult? I really wish I could visualize how I would look coming out of this surgery.
What's really making it hard for me is how my side profile, pre plastic surgery, looks like a textbook jaw surgery case. Yet I am somewhat(?) lacking an OSA, teeth, or TMJ reason to go down this route. I really need insurance to at least pay the hospital fees.
I'm in the US (DC), and so I just can't fathom spending 30-50k for surgery + orthodontics, as well as potential future surgeries out of pocket. Insurance doesn't pay for complications stemming from what they deem as cosmetic procedures.
I think you all have pushed me to at least try for a positive predetermination from my insurance company. If they don't accept it, then I am probably relegated to camouflage treatment. I'm actually about a week away from possibly scheduling revision chin implant surgery with Dr. Harrison Lee. Just debating now if I should get a custom implant, anatomic vs wings, etc.. Should I save the SG option for the future, when I'm absolutely sure whether or not I'm getting jaw surgery?
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What if I just did a chin wing, slid forward? The hardest part would be finding a doctor to do the chin wing. I had a very mild class 2 post orthodontics (though they did have the retainer do some work post braces that I don't have pictures of), and relapsed maybe 1-2mm into a slightly more moderate class 2 now since I neglected to wear my retainer for a stretch.
Chin wing is probably not performed anywhere on the US east coast, right?
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Yeah, the alar rims can scar inwards and upwards, leaving retracted nostrils and asymmetry... this was an issue after my primary. Be careful who you go to, some docs can fix this and some very reputable surgeons cannot.
The paper consultation was very useful, they'll do a full analysis of your face and give you a report telling you which areas you are deficient in, jaws, teeh, cheek bones, the lot. Then you can skype with them to talk it over. My treatment plan didn't change, the analysis from the paper consult was virtually the same as the in person. Dr Gunson will provide morphs, if you ask.
If I was you, I wouldn't bother with more implants. I don't think they're the long term answer and I suspect you still won't be happy after having them. I know it's frustrating and you just want to 'fix things now', but I'd save the money and put it towards a permanent fix... whatever that may be.
Chin wings are done in Europe, Germany and Switzerland, perhaps some other countries.
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Ur problem is similar to mine. Good bite with no functional issues http://imgim.com/sefoelet.jpg . Speak with 3 ortho and all said u dont need surgery. Speak online onemaxfac surgeon and he said i need mandibular advancement if i push my mandibula forward long face and underbite coming. Its weird i want surgery but orthos say no u dont need. Ill speak with 2-3 ortho and 2-3 surgeons more next year. and I start feel depressed because i cant fix my problem. Hope u can find somethind because i cant find.
The only i find good molar relationship before surgery like me http://ovortho.com/jaw-surgery/ with extraction 4 biscupid and and without extraction http://imgur.com/gallery/gru8D arnett gunson
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You definitely double jaw with CCW, plus maybe after a chin-wing. I going to make some observations and if you want further advice from me please answer to each comment specifically.
1) you had an open rhino, the scar is evident. Who was the surgeon: name please. While you had a run-of-the-mill job, it was done by my standards and those of what I'm going to call the "new school" of thought in rhinoplasty surgery --incompetently. Your bridge was lowered way too down in an effort to balance your still retruded jaws. I can see your scar which was not hidden well and ALSO you have severe "alar retraction" you can see far too into your nose in the profile view. It's not terrible, but it's not a really well done rhino according to the Cochrane, Toriumi etc. school of thought which is to build up the nose more.
2) what did you have done to your teeth? Did you have your fillings taken out? Bridges? Or implants? Where did all your fillings go and what materials were used to replace them?
3) The terino implant should be taken out. Posnick's plan sounds good. If you go with Gunson you'll probably want to ask them to do a more aggressive genioplasty of the chin than they usually do, I find Gunson/Arnett's genios to be too conservative but that may be a matter of taste. For all health, sleep etc. purposes a CCW will be beneficial. Aesthetically it will help, certainly better than the terino implant (motherf**king cosmetic surgeons don't know s**t and implants are f**king horrible --the whole field is run by retards).
Okay, that will give you a game plan. If you had the money I'd have that rhino re-done by Cochrane or Toriumi or someone really trained in revisions and will apply caudal struts, a septum strut etc.
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btw, does anyone know what happened to that girls ear... the sailer patient. It looks like a chunk is missing.
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to the op Our profiles are very similar i said it. I speak with 3 ortho only one said and he say'' ask a surgeon but i think he didnt accept surgery'' My chin to neck so close and im not fat maybe vertical jaw growth with small ramus.and im 5'10 and 155 lbs. Im gettin depressed more everyday. When no consultation i was thinking one day i can fix this then when i speak with doctors and searchin internet my case i have good bite and cant get surgery probably. This got me more depressed. I just want to ask have u have this mental problems too or im so weak? I cant stop thinking that. I just want to sleep everyday and dreaming be normal.
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Jaw angle implants.
That's correct: http://www.sailerclinic.com/en/specialist-fields/aesthetic-surgery/jaw-line-enhancement-double-chin-reduction/
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You definitely double jaw with CCW, plus maybe after a chin-wing. I going to make some observations and if you want further advice from me please answer to each comment specifically.
1) you had an open rhino, the scar is evident. Who was the surgeon: name please. While you had a run-of-the-mill job, it was done by my standards and those of what I'm going to call the "new school" of thought in rhinoplasty surgery --incompetently. Your bridge was lowered way too down in an effort to balance your still retruded jaws. I can see your scar which was not hidden well and ALSO you have severe "alar retraction" you can see far too into your nose in the profile view. It's not terrible, but it's not a really well done rhino according to the Cochrane, Toriumi etc. school of thought which is to build up the nose more.
2) what did you have done to your teeth? Did you have your fillings taken out? Bridges? Or implants? Where did all your fillings go and what materials were used to replace them?
3) The terino implant should be taken out. Posnick's plan sounds good. If you go with Gunson you'll probably want to ask them to do a more aggressive genioplasty of the chin than they usually do, I find Gunson/Arnett's genios to be too conservative but that may be a matter of taste. For all health, sleep etc. purposes a CCW will be beneficial. Aesthetically it will help, certainly better than the terino implant (motherf**king cosmetic surgeons don't know s**t and implants are f**king horrible --the whole field is run by retards).
Okay, that will give you a game plan. If you had the money I'd have that rhino re-done by Cochrane or Toriumi or someone really trained in revisions and will apply caudal struts, a septum strut etc.
To your points:
1) Messaging you the op doc. Correct, it was an open rhino. If I'm looking at jaw surgery though, should I even be thinking about correcting anything now with my nose? BTW this guy installed a columellar strut graft, bilateral spreader graft, dorsal septum struts, and bilateral lateral crural struts. Per operating notes, I was left with a "generous 6 to 7mm dorsal and caudal strut for support". So seems like he tore my nose down, did some reconstruction and reinforced the foundation, so to speak? But YES, I really dislike how the tip came out.
2) The silver amalgam fillings were all replaced with composite resin.
3) Cosmetically, I can't imagine the change but it sounds like bimax+sg, and a chin wing is the correction for retrognathia and microgenia. I'm replacing the terino implant on April 13th to hopefully get some relief from the smile and cheek distortions, and pain. Otherwise I risk an ~8mm void from a 1.5 y/o implant. Also, how do you suggest I get around the $30-50k cost barrier to picking a trustworthy doctor? That's like almost my life savings. With a mild amount of OSA, treatable by CPAP, I don't think I have an insurance case. My airway looks almost normal, I think. I've been told I'll need 15mm+ in jaw advancement, and apparently not many surgeons do that. Ideally, I wouldn't do any more cosmetic surgery after bimax.
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To your points:
1) Messaging you the op doc. Correct, it was an open rhino. If I'm looking at jaw surgery though, should I even be thinking about correcting anything now with my nose? BTW this guy installed a columellar strut graft, bilateral spreader graft, dorsal septum struts, and bilateral lateral crural struts. Per operating notes, I was left with a "generous 6 to 7mm dorsal and caudal strut for support".
2) The silver amalgam fillings were all replaced with composite resin.
3) Cosmetically, I can't imagine the change but it sounds like bimax+sg, and a chin wing is the correction for retrognathia and microgenia. I'm replacing the terino implant on April 13th to hopefully get some relief from the smile and cheek distortions, and pain. Otherwise I risk an ~8mm void from a 1.5 y/o implant. Also, how do you suggest I get around the $30-50k cost barrier to picking a trustworthy doctor? That's like almost my life savings. With a mild amount of OSA, treatable by CPAP, I don't think I have an insurance case. My airway looks almost normal, I think. I've been told I'll need 15mm+ in jaw advancement, and apparently not many surgeons do that. Ideally, I wouldn't do any more cosmetic surgery after bimax.
Why did you change your nose so much? I just had a closed rhino where he shaved down the bone to make it straight. I don't think your nose had any problems except the dorsal hump
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Yeah it's tough, a lot of us are spending our life's savings on this surgery, so that's just the way it goes. Some people get 3-4 jobs working simultaneously to pay for these things. That's the norm on this board, unless you're like megawealthy.
And yup, bi-max with chin-wing, genio is the fix, but that's what it'll take with a primo surgeon.
About the change of resin fillings to amalgam --did teeth sensitivity change? And how much did it cost? That's a selfish question on my part since I'd maybe like to have that done down the road. Made your mouth look so much better.
I dunno, I wouldn't even bother with the rhino till you're all done with everything else.
Man your rhino doc seems to have followed all protocol, but you still got some pretty serious rotation of the tip and alar shrinkage. Did you ask for a small upturned nose? Did he show you any sort of visualization or imaging of what your nose would look like? Like did you guys come up with a desired outcome, visually, together? I'm curious what the process was like for you because if so, this would just be an unfortunate case of post-rhinoplasty problems.
The real truth no one tells you. Almost 50 percent maybe higher, of rhinoplasties require revision, and part of that is cause it's just a really, really unpredictable procedure --except in really simple cases where someone has thin skin and just wants their hump removed or something like that.
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I don't think your rhino was a complete disaster, my primary was a lot worse, and in some ways it's an improvement! It does also depend on one's aesthetic taste, but I'm kind of with Lazlo here... I prefer a stronger bridge and a lower, slightly pointy tip for a man. I think Johnny Depp has the perfect male nose, strong but not too strong.
Here's my two cents... I think the dorsal hump needed to be conservatively shaved down. This was made more apparent by the low radix, which could have been elevated slightly. Your tip was slightly too low, and did need to be conservatively lifted, hence the columellar strut graft. Your surgery did not leave you with an inverted v deformity and your mid vault hasn't caved in, which is a common issue with such a reduction in the bridge, and this is all thanks to the spreader grafts. If you were going to revise the nose, I would elevate the bridge slightly with an onlay graft, have the alar rims pulled down, and have the columellar tucked in. I wouldn't formally derotate the tip as it will naturally look lower and less projected once the bridge is elevated and the columellar tucked. The onlay and the columellar tuck should be simple procedures, but I'm guessing all your septal cartilage was taken for grafting in the primary. You would therefore need to use costal cartilage from the chest wall, which should not be taken lightly as it will leave a scar of significant length, and in the worse case lead to a punctured lung. Alternatively, you could use a gortex implant but these are prone to infection, or donor cartilage but these are had to work with and often warp. Ultimately, your nose is not a disaster, it could be improved but it would be costly with potential complications.
I appreciate that you may not agree with my comments, and I hope you take them in a constructive way. If you do go for a revision, be very careful who you pick as you don't want to make matters worse.
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If anythign you're being super helpful SJ by sharing your experiences, taste and expertise.
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I went with my op doc because he seemed to understand nasal anatomy extremely well, seemed like a perfectionist, and conservative. He specializes in revision rhinoplasties and has I think 15-20 years experience. However, he's just a PS and has his limitations that you find out on your own if you're not careful enough. I didn't look at pictures of his other patients, and we only discussed the problem areas and how he'd change them in surgery - bulbous tip, nasal valve collapse, high bridge (iirc). He actually stressed he'd have to be careful how much he reduced because he saw my nose could quickly become too feminine. I'm not sure why but I don't see my nose, in-person, quite as upturned as it looks in those post op profile shots. The bridge also seems bigger in person, but I think everything's being distorted, in my eyes, by the retracted rims and hanging columella. In most ways (except the bridge), my nose actually seems bigger to me than before.
That said, I hated my old nose for a variety of reasons, so this one is an OK improvement to me. IF I decide against jaw surgery and just to fix my nose, and IF I have any septal cartiledge left to spare, I'd probably forego the onlay graft and just fix the columellar and retracted alar rims. Would a CT scan show how much septum is left? Does tucking in the columellar afford me with spare cartilage as well? Thanks for all that specific feedback SJ! That has probably saved me weeks of research for that future date when I reassess my nose situation.
Honestly the big problem is I have a bone spur in my left septum that is super annoying. I haven't had such breathing problems through my left nostril before. An ENT thinks the bone spur may be causing a deviated septum, pushing it into the left airway.
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Yeah it's tough, a lot of us are spending our life's savings on this surgery, so that's just the way it goes. Some people get 3-4 jobs working simultaneously to pay for these things. That's the norm on this board, unless you're like megawealthy.
And yup, bi-max with chin-wing, genio is the fix, but that's what it'll take with a primo surgeon.
About the change of resin fillings to amalgam --did teeth sensitivity change? And how much did it cost? That's a selfish question on my part since I'd maybe like to have that done down the road. Made your mouth look so much better.
I dunno, I wouldn't even bother with the rhino till you're all done with everything else.
Every max facs I've seen, except Posnick & A&G, have advised against anything more than an SG. Dr. Harrison Lee, who used to do jaw surgery, insisted I'd get "very little" cosmetic improvement from bimax. I wonder if most max facs just don't know how to do 15mm+ BSSO's, CCW's, etc..
Also seeing an old forum post raised back up here, and it's just made me realize my gonial angle is horrendous. That's one area I'd probably want addressed at the same time as bimax, however possible.
The change over to composite resin fillings was several years ago, but I don't recall much change in teeth sensitivity. One of the molar fillings hurts my tooth sometimes if I chew into something hard. Maybe has to do with how the filling is in a pressure point on the tooth.
I confirmed with my insurance that jaw surgery is reimbursable if deemed medically necessary, so maybe between Gunson's and Posnick's analysis, I'll have a case. Also maybe Dr. Sinn is worth a look? Again though I'm in Washington DC...
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Your surgeon should know exactly how much septal cartilage you have left for grafting. They can't take it all as some is obviously needed. I don't think tucking the columellar will free up any useable cartilage. If you're happy with the bridge, then there's enough cartilage in the ear to take a small graft for the nostrils. In fact, my surgeon was able to fix my nostrils without rim grafts, he simply repositioned the existing lower lateral cartilages, so it depends on what's causing the problem. If you're happy with your nose, then it's probably best to leave well alone.
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Regarding the bi-max, I suspect that's a significant factor. If you go to a surgeon with a limited toolkit, sadly most don't have the decency to point you in the direction of someone more able, but instead try to sell you something they can do. They need the business, and they don't want you going to the competition. It's a simple problem of incentives, and theirs are certainly not the same as yours. You've got to look out for yourself, and therefore go to a highly skilled surgeon with a very large toolkit. This way, they have all options available to them and can select the one which is actually best for you, and not constricted to their limited ability.
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Regarding the bi-max, I suspect that's a significant factor. If you go to a surgeon with a limited toolkit, sadly most don't have the decency to point you in the direction of someone more able, but instead try to sell you something they can do. They need the business, and they don't want you going to the competition. It's a simple problem of incentives, and theirs are certainly not the same as yours. You've got to look out for yourself, and therefore go to a highly skilled surgeon with a very large toolkit. This way, they have all options available to them and can select the one which is actually best for you, and not constricted to their limited ability.
This. Needs to be front and center in your thinking !
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Every max facs I've seen, except Posnick & A&G, have advised against anything more than an SG. Dr. Harrison Lee, who used to do jaw surgery, insisted I'd get "very little" cosmetic improvement from bimax. I wonder if most max facs just don't know how to do 15mm+ BSSO's, CCW's, etc..
Also seeing an old forum post raised back up here, and it's just made me realize my gonial angle is horrendous. That's one area I'd probably want addressed at the same time as bimax, however possible.
The change over to composite resin fillings was several years ago, but I don't recall much change in teeth sensitivity. One of the molar fillings hurts my tooth sometimes if I chew into something hard. Maybe has to do with how the filling is in a pressure point on the tooth.
I confirmed with my insurance that jaw surgery is reimbursable if deemed medically necessary, so maybe between Gunson's and Posnick's analysis, I'll have a case. I presume you recommend consulting Dr. Sinn?
Plastic surgeons usually love implants and dislike jaw surgery. In the US apparently there is some overlap between the two as some PS also do jaw surgery but if you go to a guy who is a maxfac first and foremost like Posnick you should have better results.
In Brazil maxfacs don't go to med school but follow a different path becoming a dentist first as an "undergrad"(5 year university course after high school instead of 4 year college) and learning surgery later as a grad and they have completely different approach from the MD plastic surgeons.
When I got my rhino my PS was pretty good at it but I told him about my jaw problems and he said I didn't need anything and how jaw surgery was bad, I should consider an implant, he was also wearing a fancy suit and looked like a douchebag.
I went to a maxfac later and he was extremely professional like you expect from a doctor and explained me in details how orthognatic surgery could help me and he said he is against implants except when there is a complete lack of bone due to a gunshot or similar.
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Regarding the bi-max, I suspect that's a significant factor. If you go to a surgeon with a limited toolkit, sadly most don't have the decency to point you in the direction of someone more able, but instead try to sell you something they can do. They need the business, and they don't want you going to the competition. It's a simple problem of incentives, and theirs are certainly not the same as yours. You've got to look out for yourself, and therefore go to a highly skilled surgeon with a very large toolkit. This way, they have all options available to them and can select the one which is actually best for you, and not constricted to their limited ability.
These super surgeons don't exist.
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Every max facs I've seen, except Posnick & A&G, have advised against anything more than an SG. Dr. Harrison Lee, who used to do jaw surgery, insisted I'd get "very little" cosmetic improvement from bimax. I wonder if most max facs just don't know how to do 15mm+ BSSO's, CCW's, etc..
I've seen a picture of a bi-max on a guy with something like 12mm BSSO and 7 mm LF1 advancement. He looked hardly different. I think it depends on the case. In general, the cases where CCW was required but was not performed are the ones that look like "what was the point?".
The common refrain regarding CCW is that it's "unstable". I am not sure what it means - perhaps the down graft of the posterior maxilla? But then many surgeons do CW with down grafts for short face syndromes. The man who invented CCW says the reason it's not done more often is that the people who need it the most often have joint problems, and if they are not addressed, CCW will make the problem worse.
Personally, I think it's because CCW is just plain hard to do. You have multiple movements in 2 dimensions (3 if a 3-piece LF1 is done) and everything is just floating there. To get it all right is hard. And then you have to factor in minor relapse post surgery - e.g. posterior maxilla downdraft relapses by 1 mm - what effect does this have on the bite? etc.. It's much easier to just move things forward and back.
IMO, you should leave the nose alone until you're done with jaw surgery. Ideally, you should have not done anything with it until after jaw surgery. The nose changes a lot due to surgery. The tip often goes up - may be controlled with anterior nasal spine reduction, but in some cases it may be a good thing, and it would be balanced by a more forward chin in your case anyway.
The nostrils flare a bit - this may be controlled by an alar cinch. But one thing that cannot be controlled is the fact that your cheeks come forward due to the LF1 and the nose just looks smaller in profile even if the tip goes up and it becomes more projected. This completely changes the way your nose looks in profile. You may have not needed any bridge reduction at all had your cheeks been more forward.
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^ I don't agree about the cheeks coming forward, but I agree the advanced maxilla can actual makes some peoples' noses look better, and I certainly agree that if getting jaw surgery, one should hold off on rhino or any other work until afterward.
For me personally, regarding implants... I just don't like them. The possible infections, possible shifting, and thinking about having an implant under my skin kind of gives me the creeps for some reason (though fixation screws and plates seem okay to me so IDK why that is). Aside from rhino if somebody needs it, I think any facial issues are ideally addressed with surgical bone movement. It sure would be nice if there was an easy way to get wider gonial angles via max facs though.
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I've seen a picture of a bi-max on a guy with something like 12mm BSSO and 7 mm LF1 advancement. He looked hardly different. I think it depends on the case. In general, the cases where CCW was required but was not performed are the ones that look like "what was the point?".
Do you have pics? On the very least he doesn't have an underbite anymore.
About the nose looking smaller, I hope it does, even after rhino which removed the hump my nose is still extremely big. However I'm glad the surgeon didn't give me a little upturned nose as it would look bad after the Lefort.
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Do you have pics? On the very least he doesn't have an underbite anymore.
He was class ii before. I think he just had a very retrognathic face in general. He looked virtually the same afterwards.
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I bet my chin will look worse after I get this revision in a week. The implant will probably follow my steep jaw angle, unlike my current one. I haven't read into exactly how CCW works, but I think my op doc intentionally angled my current implant 'forward', as if to give my chin CCW rotation. Problem with that is, I suspect that's a big reason why my lower lip is tethered up.
I agree with everyone on dropping the implant route, but I can't wrap my mind around spending 50k+ on bimax surgery. I just don't want this badly enough to go through the whole ordeal AND empty out my life savings. Until I can find a more reasonably priced doctor without sacrificing quality, or I get some insurance coverage, bimax seems like a distant dream.
A part of me hopes a morph from like Dr. Gunson will show me how I would look *so* much better with bimax, and convince me it's worth the investment. But I'm also aware of how my whole face is recessive and would probably need more bone work to really start looking any good.
The way I see things, I've gotten a decent paying job and scraps of a social life despite these cosmetic issues and other factors. I'm afraid jaw surgery will completely throw me overboard and lose everything I've built up so far. They say (out here on the east coast anyways) that once you take off from work a month or more, you never really return.
EDIT: Is my rationale reasonable here, or have I already gone off the deep end? ;D
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Again don't take it the wrong way, but you would benefit hugely from ccw. You're lucky to live in us where ccw is relatively common. OK, according to one patriarch I saw - only about a dozen surgeons. But that's probably 10 times more than what you'd find in Europe.
(The "1 month off is the end of the world" must be an American thing however. )
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He was class ii before. I think he just had a very retrognathic face in general. He looked virtually the same afterwards.
Yeah, I was supposed to write overbite. Sometimes people look very similar from the front but better from profile view, which is important in real life as people see you from angles usually.
Some people are still ugly after jaw surgery but it is almost always an improvement in my opinion.
I see sometimes people posting before after of old, bald men and saying oh look jaw surgery is worthless. But what did they expect?
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Ummm..........excuse me........lol!
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I shaved off the stubble beard, as seen in my first posts and sooo many issues struck me at once... The abnormal cheek dimpling from the malpositioned implant is more obvious (to me), as well as the 'fake' looking projection of my chin. My lower lip looks weird how it protrudes out over this chin.. maybe that's caused by the labiomental groove this implant created? And my jawline looks just like it has pre op, but a sort of obvious wing extension on my right side that just looks stupid.
Dr. Lee I'm afraid might give me an anatomic chin, where it looks unnaturally projected off my face. I don't really know what would look good. The chin implant is hardly helping me while the rest of the jaw looks so terribly small and recessed... the stubble beard gave me a break from seeing it and created a fake jaw line. To clarify again about this implant, I'm really just getting a revision to hopefully catch a break from all the complications I had with the first one. The projection is welcome, however little it's helped. Happy to remove it with a SG or whatever in the future if combined with some treatment correcting my whole jaw.
I'll have to do more research on how extracting teeth affects everything else.. even if there isn't a bulletproof link to memory loss yet, I've gathered that the arch your pulling the teeth from will shrink. Would the jaw shrink as well? There's gotta be a trade off between being able to advance your jaw more but losing two bicuspids in the process, right?
PS please keep the doc recommendations coming. :)
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Your surgeon should know exactly how much septal cartilage you have left for grafting. They can't take it all as some is obviously needed. I don't think tucking the columellar will free up any useable cartilage. If you're happy with the bridge, then there's enough cartilage in the ear to take a small graft for the nostrils. In fact, my surgeon was able to fix my nostrils without rim grafts, he simply repositioned the existing lower lateral cartilages, so it depends on what's causing the problem. If you're happy with your nose, then it's probably best to leave well alone.
What's the next best option to asking my surgeon how much cartilage is left? I've lost my good graces with him after he asked for money over his quoted amount (due to insurance kicking in late) and I finally got pissed at him, over email, asking him for that difference after all the damages he's caused. I'm 90% sure the enormous screw he used to secure my first implant caused permanent damage to the mentalis muscle and motor nerve, because it literally jutted out several millimeters out in front of the implant. My lower lip is still tethered up when I smile due to the lack of pull down action right at the center of the lip, above where that screw poked out.
PS the new implant's left wing is AGAIN crooked and painful (and this is an anatomic chin, ffs). When I see him next, I'll ask about replacing it with a custom implant, no surgical fee. Also going to look into nerve specialists just to confirm I'm basically f****** at this point since the mentalis muscle nerves are probably microscopic and impossible to revive.
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You have about a one inch square section of spare septal cartilage.
See here for pics/more info - http://www.davisrhinoplasty.com/rhinoplasty-glossary-terms.html
Your surgeon should know how much he took, and how much is left.
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Well I found out from Gunson that my chin implant is fairly straight, yay! Both the previous and current 12mm implant has over-tightened and/or pushed up the mentalis muscles, causing the deformity in the center lower lip
I'm not sure if the taughtness of the mentalis muscle is time sensitive or not if I relieved the muscle at a TBD date... that's giving me a lot of anxiety.
Here's what I look like now with the 12mm implant: user requested photos removed.
He would NOT do extractions, and basically called Posnick old fashioned. It would mess up my bite and give me a more unaesthetic result, according to him.
The problem is... who the heck regularly manages 9mm+ posterior maxillary downgrafts safely besides Gunson? Obviously his bill was astronomical (won't post it here) and I'd prefer not to lose everything on bimax.
I think the only other way to skin this cat is to do a weaker posterior downgraft, add in anterior maxillary impaction but with like 5-10mm maxilla advancement as opposed to Gunson's 3mm to compensate for my already ideal gum show. Just a hunch, but I think THAT is what Posnick and most other surgeons would do, and requires lower bicuspid extractions for the amount of forward movement my jaw needs to compensate for the relative lack of CCW. I don't think a baby jaw surgery movement is worthwhile since I already have mild OSA, and is pretty much the only functional improvement I stand to gain from bimax besides less back teeth wear. My lower jaw slides forward about 2-3mm to make my bite, which supposedly causes the wear and tear on the back teeth.
I'm opposed to bicuspid extractions, but I wonder if the additional 3-7mm maxilla forward movement would help my facial aesthetics more than the 3mm maxilla projection in Gunson's plan? Obviously Gunson would lather my cheeks up in HA as part of his plan, but maybe Z can do a Z(S)O simultaneously. Thoughts on all this?
To answer Bobbit & everyone else wondering why I got a chin implant: Before I knew any better, my first op doc (who did the rhino + 1st chin) wanted me to do an SG that moved my chin down and forward. He referred me to a max fac that would only move it forward (about 6mm). So, all things considered in risk vs reward, I went with a chin implant, and ended up with a size large (7mm) terino extended anatomical. That one was royally cucked up, so I eventually revised it with what was SUPPOSED to be a smaller implant in every way to also help my smile. Instead, Harrison Lee put in this enormous 12mm anatomic implant. So here we are... At least it's an improvement over the first one, but my smile is still just as wack as before.
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Why did you do an implant rather than a sliding genioplasty ?
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Most doctors call me a borderline case though for bimax. The one side profile pic I posted might be deceiving, all I have to do is aim my head slightly off angle or slightly down and the actual recession looks 10x worse.
Here's a ceph from a CAT scan pre-everything: http://i.imgur.com/HahmpOx.png
That should show my old profile exactly...
Or maybe this one: http://i.imgur.com/NpcIRyx.jpg?1
But at any rate, really trying to understand if Gunson's approach makes more sense or the theoretical one I described with bigger maxilla forward movement. This really harks back to my need for MORPHS...
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Your midface is quite long. Maintaining the steep occlusal plane and doing a mostly linear advancement will make your lip fuller and thus the midface will look longer than it is (closer to the observer, the actual lip will not lengthen). There nose will look smaller in profile, but the tip will surely rise and the nostrils widen. Lf1 advancement can work wonders where it's really needed, but it can make you uglier when it's not. I think you need CCW.
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I think a morph of Gunson's surgery plans would really help!
I wonder if the larger CCW/smaller advancement VS smaller CCW/larger advancement is a matter of taste.
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Surely Gunson didn't say that? And those doctors you asked are they unknown random s**tty ones, or ones with a bit of reputation?
https://gyazo.com/b95fb11aaf91bb5e7bdc4d5a1b21c155
Your nose could have looked like this if you didn't get a nose job got a bimax. Your current nose looks a bit downtilted and bimax might still make your new nose look better, but it might look a bit scooped now. I just brought the tip upwards in this morph. You would really benefit from some brow augmentation as well. Chin wing would be great for you as well since your jaw looks a bit narrow from the front, but that would probably just be overkill for your desires. Do you have a gummy smile?
I say get it done mate! I think you would benefit greatly compared to most on this forum.
Let me know if you want me to delete the picture :)
That is an incredible morph! Really good job, though unfortunately A&G do not do brow augmentation...but seeing this morph I really wish they did because I see what an amazing difference it makes. I had surgery with Arnett almost 4 years ago and I had even more bimax retrusion than the OP. While I'm sure the OP will have a fantastic result with Gunson, I'm not sure that he would get a result as transformative as your morph, having seen many, many before and afters. But seriously, that is a wonderful morph!
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Can you elaborate on how lf1 makes the mid face appear longer? Would not fuller lips create the illusion of a smaller philtrum and mid face?
I think a lf1 could have done wonders for OP's nose. And I don't think nostril flare is always a negative aesthetically speaking.
I have no idea where people got this ridiculous notion that a lefort is some kind of beauty operation.
By fullness I meant the upper part of the lip ie. Nasal base. When the occlusal plane is steep, you move the maxillaa forward and you end up with a straight vertical lip at best or a convex lip at worst since the teeth are to vertical and not propping up the vermilion. It looks ugly in profile. In the frontal view while the lip is not physically any longer it is now closer to the observer and seemingly takes up more of the face. Maybe OK in some cases, but if the midface is long to begin with it looks ugly.
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That is an incredible morph! Really good job, though unfortunately A&G do not do brow augmentation...but seeing this morph I really wish they did because I see what an amazing difference it makes. I had surgery with Arnett almost 4 years ago and I had even more bimax retrusion than the OP. While I'm sure the OP will have a fantastic result with Gunson, I'm not sure that he would get a result as transformative as your morph, having seen many, many before and afters. But seriously, that is a wonderful morph!
Seriously, I'm in love with that morph lol. I think the chin is 3-6mm further out than Gunson would like, unfortunately.
Treevernal, since you've seen so many before/after's, where do you think I fall in the spectrum of cases A/G have treated? I've really got no functional issues aside from mild OSA and premature back molar wear. Maybe a slowly receding gumline & teeth roots from teenage camouflage orthodontics. Bite isn't terrible, think it's a mild class 2. 3-4mm overbite, 2mm overjet. Chin implant messed up my smile, which is making me itch for this or some other surgery. I have all my teeth save for all 4 wisdoms. I'm 27, btw. Pre-surgeries shots were from when I was 24. Having a hard time justifying bimax to myself and even more so to immediate family, who are super unsupportive of aesthetic surgery.
Out of the 30 or so doctors (mostly local PS or max fac) I've seen, I'd say about 5 have clearly came out for bimax. Even Deschamps Braly doesn't recommend it, but he's the only bigly who advised against it (other big shots being Posnick and Gunson). My smile WAS great before the chin implant. Partially why I'm concerned about the CCW I think Posnick and most other max facs have in mind.
So to PloskoPlus and others, I agree I need CCW. But what Gunson appears to be doing in his plan is 0 maxilla anterior impaction, and nearly 10mm posterior downgrafting. Doesn't more 'traditional' CCW includes anterior impaction, a 3mm or smaller posterior downgraft, and bicuspid extractions if the lower jaw needs more than, idk say 10mm advancement? If my gum show is basically perfect as it is now (I think?), then the maxilla has to move forward say 5-10mm to negate the anterior impaction affect on my upper tooth show. I had also thought that forward maxilla movement helped reduce the appearance of deficient cheeks and maybe even reduced some scleral show. I "have a long face" - as in my cheek bones are really weak, right? So I''ll look worse if I get more than like 2mm upper advancement if the cheek bones aren't treated at the same time or after the fact? Idk if this helps but this is maybe my cheek angle (even worse now, this is 3 years ago): http://i.imgur.com/79v7Beb.jpg?1
I'm just trying to understand if there's really only Gunson's way to do my CCW or if I can get very similar or even better results with the weaker posterior downgraft + maxilla impaction & 5-10mm maxilla forward plan that most max facs pedal. Both are CCW but very different approaches, I think?
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Ok wow I was way off on how the more 'down to earth' max fac would do a typical class 2 bimax. Watched a CCW video, and the anterior maxilla is tipped up as it moves forward followed by a downgraft in the posterior space opened up. No anterior impaction, the maxilla just slides forward past the nasal spine bone allowing it to move up but not fold over bone above it. Soo I don't know what the more basic bimax plan would look like that most other surgeons would use on class 2 vs Gunson's plan.
Trying to visualize it, less posterior downgrafting means less forward jaw movement is possible, all else remaining equal. By removing lower bicuspids, Posnick can still make a large lower jaw advancement before my upper and lower incisors meet up. Is that all there is to 'plan b' really? So with my class 2 kind of case, you either do a huge CCW via a large posterior maxilla downgraft, or you do a smaller CCW but extract teeth?
A segmental lefort 1 is also a typical Gunson move, but I think he does that so he can make those huge posterior downgrafts without creating the affect of the incisors moving up in your mouth, similar to how they would with anterior impaction. So is a smaller posterior downgraft, bicuspid extractions and one-piece lefort 1 the more routine surgical plan? How can doctors have less aesthetic plans than like Gunsons, so long as they (presumably) aim for the same vertical line in Gunson's model block surgery? Maybe most docs only aim for proper teeth occlusion? Sleep apnea patients can be fixed with bicuspid extractions and some range of maxilla movement skewed on the super low end so as to avoid grafting?
Sorry if this is hard to follow. Trying to talk through the different movements a doc would conceivably do on a class 2, and what makes the big league max facs surgical plans any more special than a run of the mill type.
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just trust me, go with gunson's plan.
he's so f**king smart as far as his advice on no extractions etc. Posnick is a f**king moron. I wish I had known what I know now back then how much better all of this could have gone. No teeth being extracted etc. etc. You have great teeth and a great bite. Just follow Gunson's plan end of story.
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just trust me, go with gunson's plan.
he's so f**king smart as far as his advice on no extractions etc. Posnick is a f**king moron. I wish I had known what I know now back then how much better all of this could have gone. No teeth being extracted etc. etc. You have great teeth and a great bite. Just follow Gunson's plan end of story.
I agree. I'm kicking myself for not seeing him before my crummy surgery. I think he has a very good aesthetic eye as well.
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I'm going to see a periodontist to see if there is any merit in extracting teeth, from a long term gum health perspective. I have some slight recession but nothing really noticeable, and I'm not sure if the cause is teeth flaring/orthodontic camouflage related.
I've had this 'in between things' idea to replace the chin implant with a 4-6mm SG. Primary reason being to hopefully fix my tethered up and crooked lower lip. But that SG would take me from 12mm to 4-6mm augmentation tops, and I'm afraid an SG will weaken the chin muscular attachments at a time when the chin pad is already at risk of drooping from implant removal. Also I think SG's have the potential to add vertical length to a chin, but Gunson's plan is to actually push my chin forward 3mm and up 1.5mm in bimax (see block model surgery plan).
Dr. Zide is the only doc I think would know how to avoid mentalis drooping / witches chin deformities with this procedure, but he doesn't listen to his patients desires on augmentation amount and tends to go too big. Some weird neck muscle work he does concurrently as well without advance notice that makes people super pissed about him, among other things. I won't be happy with implant removal w/o replacement, and I don't want another 2 standalone surgeries on my chin. Waste of time and money.