jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: x on April 29, 2013, 01:07:32 PM
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I've been increasingly interested in this form of underdevelopment and how best to treat it lately, so decided to start a topic
Options seem pretty limited in bringing the whole midface forward, as it can't be done efficiently without compromising a lot of safety/invasiveness. In an ideal world we could all get Lefort III's ;D , but that seems unlikely in the near future given it's high risk
(http://radiographics.rsna.org/content/26/3/783/F21.large.jpg)
From the location the cuts are made it seems that the Lefort I (and II) leaves a lot to be desired. Usually when a maxilla is flat it's cause the entire midface (zygoma + nasal base too) is recessed and failed to grow horizontally and laterally. When it's ONLY the maxilla that's recessed, you get results like this:
Kristian: Upper Jaw Surgery before and after (thanks Ben) (http://www.youtube.com/watch?v=2pb2QLQWQ-k#)
People here keep talking about midface distraction, would be interested to see some examples of that.
Also if anyone knows anything about this case or has her profile pic, I'd really like to know her movements. Somehow maxillary advancement caused her cheekbones to pop, no idea why (unless implants/grafting)
(http://i.imgur.com/vpPnVK4.jpg)
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some Lefort 1's for good measure:
(http://www.scielo.br/img/revistas/jaos/v16n4/14f1.jpg)
(http://www.scielo.br/img/revistas/jaos/v16n4/14f4.jpg)
(http://img.springerimages.com/Images/Springer/JOU=12631/VOL=2011.4/ISU=3/ART=125/MediaObjects/WATER_12631_2011_125_Fig5_HTML.jpg)
(http://img.springerimages.com/Images/Springer/JOU=12631/VOL=2011.4/ISU=3/ART=125/MediaObjects/WATER_12631_2011_125_Fig4_HTML.jpg)
(http://mcgannfacialdesign.com/wp-content/uploads/2012/10/BA_Richard.jpg)
(http://orthocj.com/journal/uploads/2000/06/imaging-before-after.jpg)
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the problem with discussing underdevelopment is the bones are already hard so there is no real frame of reference. you can make educated guesses but the only sure way to see where your features should be is to take your DNA and make a copy of yourself LOL.
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the problem with discussing underdevelopment is the bones are already hard so there is no real frame of reference. you can make educated guesses but the only sure way to see where your features should be is to take your DNA and make a copy of yourself LOL.
True, but would you not agree that optimal healthy puberty tends to result in balanced faces with proper positioning and contour? Obviously there will be deviations here and there, but there's also clear cut cases of normal and abnormal growth
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True, but would you not agree that optimal healthy puberty tends to result in balanced faces with proper positioning and contour? Obviously there will be deviations here and there, but there's also clear cut cases of normal and abnormal growth
generally yes, but some people simply have less ideal genes than others. but when you see a pattern of people that are showing very similar proportions combined with diagnosed jaw/facial growth deformity something is definitely up. we cant kid ourselves genes are not set in stone.
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generally yes, but some people simply have less ideal genes than others. but when you see a pattern of people that are showing very similar proportions combined with diagnosed jaw/facial growth deformity something is definitely up. we cant kid ourselves genes are not set in stone.
Not disputing that, but in my case as well as the befores/afters posted itt and the posters on this forum, the root cause seems likely environmental issues not bad genetics
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Not disputing that, but in my case as well as the befores/afters posted itt and the posters on this forum, the root cause seems likely environmental issues not bad genetics
unfortunately that ship has sailed and you'll probably end up even more frustrated if you decide to explore this problem further. i rather be ignorant than aware of this knowledge.
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hey he even got a mandibular wing osteotomy
What do you mean by that? Like they put HA on the mandibular gonial angle to make less steep or some inverted L procedure or what do you mean? I have a steep gonial angle but I dont think they can do CCW because my oclusion line is a little to the flat side and Id probably need CW because of my recessed maxilla and flared teeth
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What do you mean by that? Like they put HA on the mandibular gonial angle to make less steep or some inverted L procedure or what do you mean? I have a steep gonial angle but I dont think they can do CCW because my oclusion line is a little to the flat side and Id probably need CW because of my recessed maxilla and flared teeth
http://translate.google.com/translate?hl=en&sl=de&u=http://de.wikipedia.org/wiki/Chin_Wing&prev=/search%3Fq%3Dmandibula%2Bwing%2Bosteotomy%26safe%3Doff%26biw%3D768%26bih%3D912 (http://translate.google.com/translate?hl=en&sl=de&u=http://de.wikipedia.org/wiki/Chin_Wing&prev=/search%3Fq%3Dmandibula%2Bwing%2Bosteotomy%26safe%3Doff%26biw%3D768%26bih%3D912)
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http://translate.google.com/translate?hl=en&sl=de&u=http://de.wikipedia.org/wiki/Chin_Wing&prev=/search%3Fq%3Dmandibula%2Bwing%2Bosteotomy%26safe%3Doff%26biw%3D768%26bih%3D912 (http://translate.google.com/translate?hl=en&sl=de&u=http://de.wikipedia.org/wiki/Chin_Wing&prev=/search%3Fq%3Dmandibula%2Bwing%2Bosteotomy%26safe%3Doff%26biw%3D768%26bih%3D912)
Oh, I see, its only a bit of the outer part, thanks :)
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I was the one that originally linked that picture
(http://i.imgur.com/s5eahoQ.jpg)
surgeon was Dr Santana (supposed to be an A&G prodigy)
while I'm not sure on her exact movements I know that she had a maxillary impaction + upper/lower jaw advancement + genio and buccal fat removal
+1 to what CK said. abnormal/improper and lack of proper growth must be spotted, addressed (braces and/or distraction osteogenesis) + corrected (surgery: appropriate alignment and rotation of jaws) ASAP.
Dr Schendel has an interesting presentation on this ^
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I don't think Le Fort I affect the cheek-bones all that much tbh
(http://i.imgur.com/BcV2TlO.jpg)
(http://i.imgur.com/zPYiSSG.jpg)
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I don't think it would affect them at all. A high lefort might provide a minor improvement but not much. That girl's cheekbones obviously popped from the buccal fat removal
Palatal expansion can add a bit of fullness to the midface
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+1 to what CK said. abnormal/improper and lack of proper growth must be spotted, addressed (braces and/or distraction osteogenesis) + corrected (surgery: appropriate alignment and rotation of jaws) ASAP.
i cant believe how casual and disinterested so many dentists/orthos and at times surgeons are in discovering abnormal growth. doctors seem fearful of operating on children but it's the only time growth can be altered. after that it's just correction according to a surgical standard...
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alright found a bunch of before/afters that showcase mid-face deficiencies (everyone had a Le Fort 1 + some form of grafting)
(http://i.imgur.com/aFbmnJX.jpg)
(http://i.imgur.com/40Q7DO7.jpg)
(http://i.imgur.com/Eb0vjBu.jpg)
(http://i.imgur.com/qWE7aCC.jpg)
(http://i.imgur.com/E4hw11t.jpg)
(http://i.imgur.com/evlLso6.jpg)
(http://i.imgur.com/Yh03Fio.jpg)
(http://i.imgur.com/xJfjKlf.jpg)
(http://i.imgur.com/Vsu7K6O.jpg)
This girl had a Le Fort 1 + Le Fort III and a BSSO
(http://i.imgur.com/6toB1QD.jpg)
(http://i.imgur.com/yPWL2sU.jpg)
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what are your thoughts on the second guy?
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what are your thoughts on the second guy?
don't like it
nose widened, philtrum went from flat-ish to convex, tear through depression is now much more prominent and he gained minimal paranasal projection
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did a quick (correction) morph and honestly in the grand scheme of things the difference is minimal
(http://i.imgur.com/5cAqtIW.jpg)
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dont think it's luck.
edit: third guy? you mean second?
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alright found a bunch of before/afters that showcase mid-face deficiencies (everyone had a Le Fort 1 + some form of grafting)
(http://i.imgur.com/qWE7aCC.jpg)
(http://i.imgur.com/E4hw11t.jpg)
I really don't like this guy's results. I think his upper jaw was advanced too far, which looks unnatural and washes out all the definition in his face.
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That's an easy fix with fillers
fillers have a short shelf life and can easily become an expensive habit
Looks like he had lower jaw implants too.
No implants at all -> "With the mandibular setback comes an improvement in the contour of the gonial angle."
Here is the URL for the entire sciencedirect page: http://www.sciencedirect.com/science/article/pii/S0094129807000697 (http://www.sciencedirect.com/science/article/pii/S0094129807000697)
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i think he looks great. not sure how it could have been better.
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i think he looks great. not sure how it could have been better.
I think he looked a lot better before surgery.
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I really don't like this guy's results. I think his upper jaw was advanced too far, which looks unnatural and washes out all the definition in his face.
seriously, what happened here. goes to show jaw surgery doesn't always lead to an aesthetic improvement as one doctor warned me. he looks incredibly worse off after, so sad.
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I think he looked a lot better before surgery.
i almost have a feeling in his case the advancement was done too low and gave him this weird full mouth bulgy cheek look and that clashes with the really shallow cheekbones. His upper face/cheekbones needed to be advanced or the advancement should have been done much higher. this is a really scary and cautionary example i feel.
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His upper face/cheekbones needed to be advanced or the advancement should have been done much higher. this is a really scary and cautionary example i feel.
Unfortunately higher cuts only increase invasiveness exponentially
Once again a case in point in how spacing of features can be critical to final results
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i think he looks great. not sure how it could have been better.
Agreed, he looks much improved to me.
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it has to do with the profile line from his forhead to his nose and chin which was actually quite balanced before. the upper advancement really made that line more obtuse. And from the front he now has this really oblong/rectangular bottom heavy look to his face.
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objectively he looks much better imo.
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he does. i agree. first he looks like an ugly version of BASTIAN SCHWENSTEIGER or VLADO PETKOVIC
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http://topnews.in/files/bastian-schweinsteiger.jpg (http://topnews.in/files/bastian-schweinsteiger.jpg) bastian
http://www.fifa.com/mm/photo/worldfootball/clubfootball/01/68/61/91/1686191_full-lnd.jpg (http://www.fifa.com/mm/photo/worldfootball/clubfootball/01/68/61/91/1686191_full-lnd.jpg) vlado
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guys i'd say this: let's see how things turn out.
if we really look funny we'll get additionall surgery.
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alright found a bunch of before/afters that showcase mid-face deficiencies (everyone had a Le Fort 1 + some form of grafting)
(http://i.imgur.com/40Q7DO7.jpg)
(http://i.imgur.com/Eb0vjBu.jpg)
(http://i.imgur.com/qWE7aCC.jpg)
(http://i.imgur.com/E4hw11t.jpg)
These two scare me, how come the maxilla and mid face appear to have moved forward but the mandible/chin seems to have stayed behind in both cases? Were they advanced the same?
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Did some morphing, would something like this have been possible to achieve for this guy?
(http://img18.imageshack.us/img18/2165/feef.jpg)
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Did that guy have a slight underbite before surgery?
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These two scare me, how come the maxilla and mid face appear to have moved forward but the mandible/chin seems to have stayed behind in both cases? Were they advanced the same?
I think his maxilla was advanced too much. He started with a strong bone structure, but the maxillary advancement seemed to wash it out. The change in his 3/4 view is what bothered me the most -- he had originally had some concavity under his cheekbones, which is desirable in men, but advancing the maxilla caused it to become convex. This is what he should have looked like imo.
(http://i.imgur.com/ZLks5tO.jpg)
It's actually quite similar to his starting point, which is why I don't think he needed surgery at all.
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your changes look much better. What did you do?
Just did a very fast morphing while watching soccer. :)
But I gave him a softer lower third by shaving off the square jaw and chin. CCW to bring the lower jaw and chin forward while improving the nasolabial angle. No restrictions with photoshop!
Is this possible to achieve? No idea!
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I think his maxilla was advanced too much. He started with a strong bone structure, but the maxillary advancement seemed to wash it out. The change in his 3/4 view is what bothered me the most -- he had originally had some concavity under his cheekbones, which is desirable in men, but advancing the maxilla caused it to become convex. This is what he should have looked like imo.
How is concavity under cheekbones (which aren't really prominent) different from mid-face hypoplasia? I guess midface hypoplasia is more characterized by lack of cheek bones etc.? It almost looks like the grafting (I'm assuming there was grafting) was done too low.
I agree it looks like his maxilla was advanced too much. I guess it is possible he still had swelling in that picture.
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How is concavity under cheekbones (which aren't really prominent) different from mid-face hypoplasia? I guess midface hypoplasia is more characterized by lack of cheek bones etc.? It almost looks like the grafting (I'm assuming there was grafting) was done too low.
I agree it looks like his maxilla was advanced too much. I guess it is possible he still had swelling in that picture.
personally im skeptical about what "could" have been done. we dont have access to his ceph, we dont know anything about his actual bone structure. his pre-op status might have had several mitigating factors that prevented what *we* think should have happened.
every face is different, and the upper jaws development varies from person to person. photoshop showing soft tissue changes are often reasonable, but full-scale bone warps aren't realistic.
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personally im skeptical about what "could" have been done. we dont have access to his ceph, we dont know anything about his actual bone structure. his pre-op status might have had several mitigating factors that prevented what *we* think should have happened.
every face is different, and the upper jaws development varies from person to person. photoshop showing soft tissue changes are often reasonable, but full-scale bone warps aren't realistic.
or his surgeon could have been a s**thead
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;D
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(http://i.imgur.com/qWE7aCC.jpg)
(http://i.imgur.com/E4hw11t.jpg)
I have the paper. This guy had a 13 mm (!!) maxillary advancement at the LeForte 1 level!
Overall:
Case 2: retromaxillism, narrow maxilla,
mandibular retroalveolism
Clinical characteristics
Frontal view showing narrow facies with poor
gonial angle contour (Fig. 2A)
Concave profile
Flat midface: maxilla and malar
??Edentulous?? facial expression
The chin prominent but in normal position
Lack of dental support to the upper and lower lip
Prominence of nasolabial folds and crease
Narrow alar base
Class I molar and canine relation
Crowding in the maxillary and mandibular
dental arches
Incongruent curves of Spee
Protrusive maxillary incisors
Treatment plan
The treatment plan is a combined surgical and
orthodontic approach. The two-stage surgical
approach (Figs. 2B?D) is
1. Anterior mandibular alveolar segment distrac-
tion osteogenesis [4,5] and surgically assisted
rapid palatal expansion (see Fig. 2B).
2. Orthodontic alignment of two dental arches,
including full decompensation of the existing
skeletal anomalies. Now it becomes clear that
this case is a class III case (retro-/micromaxil-
lism). The occlusion before the second surgical
procedure shows class III molar relation and
a negative overjet. The opened space behind
the canines will be managed by dental implants
at the end of the treatment.
3. Bimaxillary surgery: 13 mm of maxillary
advancement at the LeFort I level, mild mandib-
ular set back through BSSO [6], and clockwise
rotation of both jaws. In addition, vertical chin
augmentation and, again, mandibular segmen-
tal osteotomy for widening of the mandible
(see Fig. 2D).
Outcome
The outcome shows improved facial aesthetics with
good lip support, balanced skeletal relation, and
widened maxilla and mandible (Fig. 2E). From
the frontal view, the face has harmonized, with
normal mandibular width and gonial angles. The
occlusion shows a normal overbite and overjet.
The creation of a gap behind the canines allows
class II molar relation. The bone and gingiva gener-
ated there through distraction is excellent and ready
for dental implants.
What I put in bold may be of interest to those with narrow faces.
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That guy looks weird post-op (not better just different)
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That guy looks weird post-op (not better just different)
His face is still a bit long but otherwise I think it's a huge improvement. It looks like his upper jaw was advanced slightly too much though. I don't see any mention of HA grafts so I don't understand how they managed to advance his entire midface so much though since most surgeons told me that couldn't be done in my case.
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His face is still a bit long but otherwise I think it's a huge improvement. It looks like his upper jaw was advanced slightly too much though. I don't see any mention of HA grafts so I don't understand how they managed to advance his entire midface so much though since most surgeons told me that couldn't be done in my case.
They widened his mandible. I thought it was impossible.
Sigh... And the Le Fort III girl looks outstanding. Like a completely different person.
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some Lefort 1's for good measure:
(http://www.scielo.br/img/revistas/jaos/v16n4/14f1.jpg)
(http://www.scielo.br/img/revistas/jaos/v16n4/14f4.jpg)
(http://img.springerimages.com/Images/Springer/JOU=12631/VOL=2011.4/ISU=3/ART=125/MediaObjects/WATER_12631_2011_125_Fig5_HTML.jpg)
(http://img.springerimages.com/Images/Springer/JOU=12631/VOL=2011.4/ISU=3/ART=125/MediaObjects/WATER_12631_2011_125_Fig4_HTML.jpg)
(http://mcgannfacialdesign.com/wp-content/uploads/2012/10/BA_Richard.jpg)
(http://orthocj.com/journal/uploads/2000/06/imaging-before-after.jpg)
I have wide cheekbones, eyebrows that are basically right above my eyes, positive canthal tilt, no scleral show, yet I know that my maxilla is retruded. Is this indicative that my midface has developed correctly apart from my maxilla?
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VERY INTERESTING ARTICLE FOR ALL OF YOU , INCLUDING HYPOPLASIA ISSUE
http://www.aicef-chirurgiaplasticafacciale.it/contiene_i_PDF_e_allegati/Beauty%20Arch%20Concorso%20AICEF%20Marianetti.pdf
+ THIS http://www.readcube.com/articles/10.1097%2FSCS.0b013e3181f4ab9f you can see preview
if anyone has free access for such articles, let me know. I started to buy some (others) but it's a lot of many interesting articles. I will bankrupt buying all of them :)
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Would a LF1 cut at an angle, sliding the upper jaw out and up help with a flat maxilla and "long face" syndrome? I think my issue is that my maxilla hangs too low and leaves my mouth long and no tooth show when I smile or rather I have a shallow smile. I'm really wanting to get the LF2 but, it's a matter or experience and I haven't found anyone in the States that can provide. I also found this article in regards to the mass fear of going blind during a LF2:
http://www.ncbi.nlm.nih.gov/pubmed/23351774 (ftp://www.ncbi.nlm.nih.gov/pubmed/23351774)
Seems legit? But again, who's getting it done and where are the actual results?
Eugene Keller at the Mayo clinic does Le Fort IIs. FWIW, it seems that as rare as LFIIIs are, they are more common than LFIIs. Probably because LFII is a "neither here nor there" operation. Does not have the flexibility of a correcting bite issues that LFI has, does not address severe upper mid face recession the way LFIII can.
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what a horrible results (except for the girl who undergone LF3). No wonder a doc straightly said that I need LF3 for midface deficiency, because doing anything else is just waste of everything.
The first woman looks good too
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I remember seeing results of a woman that got a lefort II and it looked pretty good. I wonder though, if getting a lefort II would give you a fish face, if that makes sense. Since The zygos don't get advanced. If you have a big/ long nose wouldn't that make it bigger?
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27F so you rule out ZSSO without knowing what it exactly is ?
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I wrote about this 3 times....
http://www.readcube.com/articles/10.1097%2FSCS.0b013e3181f4ab9f
you can read one page there....unfortunately the rest you have to buy, but it's cheap
About 4 people here are interested in this article, we can do little kinda fund-raiser
It costs 40E :) :P Generally I could buy it, but since I bought already 2 medical articles, I do not want spend too much money for such "fun"
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Great thread. I just wanted to add my own personal experience of midface hypoplasia.
I had Leukaemia when I was age 5, and was treated with cranial radiation. I started to notice a change in my face during puberty but only 20 years later I was able to get a rough diagnosis of midface hypoplasia from a plastic surgeon. After finding out about my condition I then went to go see a Maxilofacial surgeon and was given the diagnosis, plus he believed it was a direct result of the radiotherapy.
I am based in the UK so have been trying with great effort to get my condition treated on the NHS. Here it seems like the facial surgeons are living in the stone age. I have spent two years going to appointments with general plastic surgeons, as well as a jaw surgeon and orthodontist. They started out giving the belief that they would fix it, only to change their minds last minute.
Currently I have seen another surgeon that wants to fix my midface hypoplasia with a Lefort I, so having braces applied first to pull back the angle of my front teeth as well as make room. From all my research I know that only addresses half of the issue so I mentioned about the option of cheek implants and the surgeons reaction is "That's something we could think about".
My experience of maxilofacial surgeons has now become quite poor. So now having to see a third surgeon, whom I've already seen privately. He is the first maxilofacial surgeon I have seen that just sat me down, looked at the structure of my face and saw the issues and told me he would be happy to see me on the NHS and treat me.
So fingers crossed I will now be able to get my condition fixed. Will update the post later.
_Ck
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Great thread. I just wanted to add my own personal experience of midface hypoplasia.
I had Leukaemia when I was age 5, and was treated with cranial radiation. I started to notice a change in my face during puberty but only 20 years later I was able to get a rough diagnosis of midface hypoplasia from a plastic surgeon. After finding out about my condition I then went to go see a Maxilofacial surgeon and was given the diagnosis, plus he believed it was a direct result of the radiotherapy.
I am based in the UK so have been trying with great effort to get my condition treated on the NHS. Here it seems like the facial surgeons are living in the stone age. I have spent two years going to appointments with general plastic surgeons, as well as a jaw surgeon and orthodontist. They started out giving the belief that they would fix it, only to change their minds last minute.
Currently I have seen another surgeon that wants to fix my midface hypoplasia with a Lefort I, so having braces applied first to pull back the angle of my front teeth as well as make room. From all my research I know that only addresses half of the issue so I mentioned about the option of cheek implants and the surgeons reaction is "That's something we could think about".
My experience of maxilofacial surgeons has now become quite poor. So now having to see a third surgeon, whom I've already seen privately. He is the first maxilofacial surgeon I have seen that just sat me down, looked at the structure of my face and saw the issues and told me he would be happy to see me on the NHS and treat me.
So fingers crossed I will now be able to get my condition fixed. Will update the post later.
_Ck
Which surgeon was it? Tell us
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I have the paper. This guy had a 13 mm (!!) maxillary advancement at the LeForte 1 level!
Overall:
Case 2: retromaxillism, narrow maxilla,
mandibular retroalveolism
Clinical characteristics
Frontal view showing narrow facies with poor
gonial angle contour (Fig. 2A)
Concave profile
Flat midface: maxilla and malar
??Edentulous?? facial expression
The chin prominent but in normal position
Lack of dental support to the upper and lower lip
Prominence of nasolabial folds and crease
Narrow alar base
Class I molar and canine relation
Crowding in the maxillary and mandibular
dental arches
Incongruent curves of Spee
Protrusive maxillary incisors
Treatment plan
The treatment plan is a combined surgical and
orthodontic approach. The two-stage surgical
approach (Figs. 2B?D) is
1. Anterior mandibular alveolar segment distrac-
tion osteogenesis [4,5] and surgically assisted
rapid palatal expansion (see Fig. 2B).
2. Orthodontic alignment of two dental arches,
including full decompensation of the existing
skeletal anomalies. Now it becomes clear that
this case is a class III case (retro-/micromaxil-
lism). The occlusion before the second surgical
procedure shows class III molar relation and
a negative overjet. The opened space behind
the canines will be managed by dental implants
at the end of the treatment.
3. Bimaxillary surgery: 13 mm of maxillary
advancement at the LeFort I level, mild mandib-
ular set back through BSSO [6], and clockwise
rotation of both jaws. In addition, vertical chin
augmentation and, again, mandibular segmen-
tal osteotomy for widening of the mandible
(see Fig. 2D).
Outcome
The outcome shows improved facial aesthetics with
good lip support, balanced skeletal relation, and
widened maxilla and mandible (Fig. 2E). From
the frontal view, the face has harmonized, with
normal mandibular width and gonial angles. The
occlusion shows a normal overbite and overjet.
The creation of a gap behind the canines allows
class II molar relation. The bone and gingiva gener-
ated there through distraction is excellent and ready
for dental implants.
What I put in bold may be of interest to those with narrow faces.
if you have this paper can you tell me the name of the doctors? I have a very similar case except with a steep mandibular plan and high occlusal plane. My case is very complex and I haven't received good advice from anyone on the forum, despite researching all day. It seems the best option for me would unironically be a lefort 3 with BSSO, but maybe this doctor, who in my opinion, treated case 2 very successfully, can help. Can you tell me that doctor's name??