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General Category => Functional Surgery Questions => Topic started by: Dogmatix on June 11, 2018, 07:05:06 AM
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I've been looking at some videos of Lf1 surgery and I've been reading some discussions regarding how different procedures alter the nose.
I've also been looking at a lot of before and after pictures, and I honestly almost never see any big difference to the nose, unless there has been an obvious rhinoplasty.
From looking at the videos, I now understand that the lf1 cut goes pretty high and that the entire palate is cut loose. I also see that the cut goes just below the nasial airways. So it certainly makes sense if the nose would be altered.
Could anyone elaborate a bit on this and maybe show some before and after pictures and point out what is expected in this context? I'm especially interested in what a ccw rotation would do.
It's a bit inconclusive to me as the surgeon I'm consulting says that the nose itself will be unchanged, but everywhere I read people talk about it. Is it big changes that occur, or what is it that actually happens.
A picture would say more than a thousand words :)
Below is a video of my understanding of where the cut goes. Even the animation doesn't show any nose change, except for the lip below.
https://www.youtube.com/watch?v=h8Nceh_m1cg
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This is exactly the same question I had going into my bi-max procedure.
It is true, that whenever a LF1 patient has impaction into the nasal cavity, that the base of the nose does widen. It's also called monkey nose. The base of the nose would have to be stitched up (alar stitch) to prevent it from spreading, or the bones would have to be surgically moved together. Of course you have patients where the nose will tip up (or down), depending again on how much impaction and if there was advancement of the maxilla.
I've noticed from a local surgeons office of a girl who appears to have this thickening around the base of the nose, and this is clearly botched and can be repaired.
http://www.daytonfacialsurgery.com/procedures/jaw-surgery/
Basically you run into problems when the procedure impacts further into the nasal cavity.
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This is exactly the same question I had going into my bi-max procedure.
It is true, that whenever a LF1 patient has impaction into the nasal cavity, that the base of the nose does widen. It's also called monkey nose. The base of the nose would have to be stitched up (alar stitch) to prevent it from spreading, or the bones would have to be surgically moved together. Of course you have patients where the nose will tip up (or down), depending again on how much impaction and if there was advancement of the maxilla.
I've noticed from a local surgeons office of a girl who appears to have this thickening around the base of the nose, and this is clearly botched and can be repaired.
http://www.daytonfacialsurgery.com/procedures/jaw-surgery/
Basically you run into problems when the procedure impacts further into the nasal cavity.
Aha, so it's more a widening of the nose that is common. You see it when you know where to look.
How did it turn out for you, did you get a big change?
I've been looking at some real surgery movies, and I'm twisting my self every time *why do you need to go that high to move my teeth* :)
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Don't depend on Dolphin videos to show you everything you are wanting to see shown to you.
They are TARGETED to isolate the illustrations to the specific topic of the video.
Here's a way to think about it:
The hard palate of the maxilla, otherwise know as the 'roof of your mouth' is also the 'floor' of the nose. Kind of like the ceiling in one's apartment is the floor of the person who lives above.
On a ceph diagram that marks out the points, this part of the maxilla is marked as ANS-PNS; anterior nasal spine to posteror nasal spine.
The ANS is the SUPPORT for the BASE of the nose.
A cut to displace this part of the maxilla cuts through (slightly above) the anterior nasal spine and takes the ANS for 'a ride' with it.
That 'ride' can be a number of displacements. The easiest one to start visualizing is 'linear advancement' meaning along the (same) 'line' or 'slope' ANS-PNS is oriented. In terms of an X, Y axis , diagonal lines either have a positive or negative slope.
The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.
If it's a sleep apnea case (with linear advancement) where they might have to advance out the ANS-PNS a LOT to accommodate a significant BSSO to open the airway, you want to look also at the CONTOUR of the ANS because the more the contour of it is pushed forward, the more CONVEX the labial ledge will become ('monkey lip). Here is a link where the doc seems to be doing linear advancement for sleep apnea cases. https://www.sylvainchamberland.com/en/treated-cases/sleep-apnea_orthosurgery-treatment/ Here, you can see the positive ANS-PNS slopes in these cases and how a CONVEXITY to the nose/upper lip area can be kicked up when a LOT of advancement is needed for those extreme sleep apnea cases.
On the DOLPHIN video, well they did the illustration so that ANS-PNS was on a HORIZONT (not on a positive slope as in the real life extreme apnea cases above). Technically, moving the ANS forward in that illustration (IF they actually WANTED to show the lip changes to the labial ledge area between red border of upper lip and base of nose) would become less conCAVE as in a little straighter. But PRAGMATICALLY the lesson in illustration is to show airway and face balance changes in a cartoon of lucky person who is IDEAL candidate for maxing out aesthetics with linear advancement.
Combinations of rotations with impactions and advancements are more challenging to visualize and also to explain. Some people (eg. MIT types) can just to that in their heads (right side of brain) but hard (or just tedious) to verbalize it (left side of brain) or it just becomes a time intensive tutorial process to train someone elses brain to do that.
That said, my advice for 'brain training' to assist with understanding some of this stuff is to revisit Euclid as that type of rigorous observation training is needed as ground work so that a lot of these relationships (which relate to geometrical concepts) eventually become 'intuitive'.
By the way, the video does NOT show 'impaction'.
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Don't depend on Dolphin videos to show you everything you are wanting to see shown to you.
They are TARGETED to isolate the illustrations to the specific topic of the video.
Here's a way to think about it:
The hard palate of the maxilla, otherwise know as the 'roof of your mouth' is also the 'floor' of the nose. Kind of like the ceiling in one's apartment is the floor of the person who lives above.
On a ceph diagram that marks out the points, this part of the maxilla is marked as ANS-PNS; anterior nasal spine to posteror nasal spine.
The ANS is the SUPPORT for the BASE of the nose.
A cut to displace this part of the maxilla cuts through (slightly above) the anterior nasal spine and takes the ANS for 'a ride' with it.
That 'ride' can be a number of displacements. The easiest one to start visualizing is 'linear advancement' meaning along the (same) 'line' or 'slope' ANS-PNS is oriented. In terms of an X, Y axis , diagonal lines either have a positive or negative slope.
The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.
If it's a sleep apnea case (with linear advancement) where they might have to advance out the ANS-PNS a LOT to accommodate a significant BSSO to open the airway, you want to look also at the CONTOUR of the ANS because the more the contour of it is pushed forward, the more CONVEX the labial ledge will become ('monkey lip). Here is a link where the doc seems to be doing linear advancement for sleep apnea cases. https://www.sylvainchamberland.com/en/treated-cases/sleep-apnea_orthosurgery-treatment/ Here, you can see the positive ANS-PNS slopes in these cases and how a CONVEXITY to the nose/upper lip area can be kicked up when a LOT of advancement is needed for those extreme sleep apnea cases.
On the DOLPHIN video, well they did the illustration so that ANS-PNS was on a HORIZONT (not on a positive slope as in the real life extreme apnea cases above). Technically, moving the ANS forward in that illustration (IF they actually WANTED to show the lip changes to the labial ledge area between red border of upper lip and base of nose) would become less conCAVE as in a little straighter. But PRAGMATICALLY the lesson in illustration is to show airway and face balance changes in a cartoon of lucky person who is IDEAL candidate for maxing out aesthetics with linear advancement.
Combinations of rotations with impactions and advancements are more challenging to visualize and also to explain. Some people (eg. MIT types) can just to that in their heads (right side of brain) but hard (or just tedious) to verbalize it (left side of brain) or it just becomes a time intensive tutorial process to train someone elses brain to do that.
That said, my advice for 'brain training' to assist with understanding some of this stuff is to revisit Euclid as that type of rigorous observation training is needed as ground work so that a lot of these relationships (which relate to geometrical concepts) eventually become 'intuitive'.
By the way, the video does NOT show 'impaction'.
my head hurts
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Welcome to the land of bone cutting, beyondconfused.
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Don't depend on Dolphin videos to show you everything you are wanting to see shown to you.
They are TARGETED to isolate the illustrations to the specific topic of the video.
Here's a way to think about it:
The hard palate of the maxilla, otherwise know as the 'roof of your mouth' is also the 'floor' of the nose. Kind of like the ceiling in one's apartment is the floor of the person who lives above.
On a ceph diagram that marks out the points, this part of the maxilla is marked as ANS-PNS; anterior nasal spine to posteror nasal spine.
The ANS is the SUPPORT for the BASE of the nose.
A cut to displace this part of the maxilla cuts through (slightly above) the anterior nasal spine and takes the ANS for 'a ride' with it.
That 'ride' can be a number of displacements. The easiest one to start visualizing is 'linear advancement' meaning along the (same) 'line' or 'slope' ANS-PNS is oriented. In terms of an X, Y axis , diagonal lines either have a positive or negative slope.
The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.
If it's a sleep apnea case (with linear advancement) where they might have to advance out the ANS-PNS a LOT to accommodate a significant BSSO to open the airway, you want to look also at the CONTOUR of the ANS because the more the contour of it is pushed forward, the more CONVEX the labial ledge will become ('monkey lip). Here is a link where the doc seems to be doing linear advancement for sleep apnea cases. https://www.sylvainchamberland.com/en/treated-cases/sleep-apnea_orthosurgery-treatment/ Here, you can see the positive ANS-PNS slopes in these cases and how a CONVEXITY to the nose/upper lip area can be kicked up when a LOT of advancement is needed for those extreme sleep apnea cases.
On the DOLPHIN video, well they did the illustration so that ANS-PNS was on a HORIZONT (not on a positive slope as in the real life extreme apnea cases above). Technically, moving the ANS forward in that illustration (IF they actually WANTED to show the lip changes to the labial ledge area between red border of upper lip and base of nose) would become less conCAVE as in a little straighter. But PRAGMATICALLY the lesson in illustration is to show airway and face balance changes in a cartoon of lucky person who is IDEAL candidate for maxing out aesthetics with linear advancement.
Combinations of rotations with impactions and advancements are more challenging to visualize and also to explain. Some people (eg. MIT types) can just to that in their heads (right side of brain) but hard (or just tedious) to verbalize it (left side of brain) or it just becomes a time intensive tutorial process to train someone elses brain to do that.
That said, my advice for 'brain training' to assist with understanding some of this stuff is to revisit Euclid as that type of rigorous observation training is needed as ground work so that a lot of these relationships (which relate to geometrical concepts) eventually become 'intuitive'.
By the way, the video does NOT show 'impaction'.
Very interesting, I'll read through this a couple of more times later and maybe come back with some questions. Earlier I've thought about it as an intraoral osteomety and been wondering about step-offs inside the mouth etc. After reading up on this and watching some real surgical movies, I realize how invasive this procedure actually is. It's not just moving the teeth, they break loose the whole shabang.
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It's hard for me to understand exactly why the nose would get wider. Would it be correct if I think about it this way that the nose itself doesn't actually get wider. I mean, if I would measure the lowest point of the nose and closest to the face, it's still connected to the same spots. But I can understand that pushing the maxilla forward or rotating it will move the base and make the soft nostrils more round and "wider" in case of advancement or ccw. Don't know if this explanation makes any sense, but if I hold 2 pieces of paper flat together and start moving the ends, they'll form something like this <>, which will get wider the more I push, or in this case, advance or rotate the maxilla? It's like the maxilla moves forward, but the nose bone is connected higher up, so the soft tissue need to escape somewhere, which will be to the sides.
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From a relative layman's perspective, a lot of the photos with significant advancement of the maxilla it looks as if the soft tissue is 'filled out' and therefore more stretched which spreads out the soft tissue of the nose at the level of the nostrils. For a lot of people I think this looks quite good depending on their starting point. Unfortunately in my case I have a nose that is short and fat but also a bit pinched (as bizarre s that sounds). A doctor that I consulted about jaw surgery casually ignored my bite complaints and proceeded to tell me everything that was wrong with my nose and how rare it was and why rhino was the way forward if I wanted to look good, despite the fact I hadn't even mentioned any issue with it!
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It's hard for me to understand exactly why the nose would get wider. Would it be correct if I think about it this way that the nose itself doesn't actually get wider. I mean, if I would measure the lowest point of the nose and closest to the face, it's still connected to the same spots. But I can understand that pushing the maxilla forward or rotating it will move the base and make the soft nostrils more round and "wider" in case of advancement or ccw. Don't know if this explanation makes any sense, but if I hold 2 pieces of paper flat together and start moving the ends, they'll form something like this <>, which will get wider the more I push, or in this case, advance or rotate the maxilla? It's like the maxilla moves forward, but the nose bone is connected higher up, so the soft tissue need to escape somewhere, which will be to the sides.
Explanations that make sense to me are my OWN or those from others explaining something I, MYSELF, don't understand.
Well, what I can tell you is what I already told you which is the floor/base of the nose is the roof of the hard palate (part of maxilla bone which they term ANS-PNS on a ceph) and displacement of ANS-PNS will cause some displacement of BASE of the nose because ANS; anterior nasal spine is part of nose base at FRONT. Sometimes it will be noticeable. Sometimes not.
This does NOT refer to the 'nose BONES' which are high up on the bridge of the nose. It refers to BASE of nose.
The more OBVIOUS base of nose changes as far as nostril width is concerned is when they split the maxilla (hard palate part) in 2 pieces to separate them (widen the palate) and also bring it forward. That combo is very obvious and I hope 'intuitively' so. Another obvious change to base of nose is in an extreme linear advancement sleep apnea case where moving the ANS very much forward moves the 'A' point too far out (for aesthetics), in which case the 'base' of the nose, in part, is the area of the labial ledge right below it where the person gets the conVEX labial ledge which they can call 'chimp lip'.
In some cases, the CALIPER distance from the alar rims at nose base remains the same before and after advancement. Like no 'stretch' widens that area. However, when that area is brought forward, it's closer to the eye of the observer (the owner of the face sporting the nose looking in the mirror) and can LOOK wider to them.
If a doctor tells you your nose won't change at all, it just means he doesn't intend to do the type of displacements that will be that noticible as far as the nose is concerned.
Bottom line is that any displacement to ANS-PNS will also be a displacement to ANS and therefore a displacement to the base of the nose whether it's noticeable or not. Good surgeons anticipate the possible UNFAVORABLE very noticeable nose changes and can do a variety of techniques to mitigate those types.
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Happy to share my experience if it's helpful...I'm 5 weeks out from a Lefort1 + BSSO + Genioglossus Advancement. While the goal of the surgery was to resolve a medical issue, I still had concerns about aesthetics; primarily changes to the philtrum, lips, and nose (Actually, Kavan was very helpful in explaining the general shape/changes that I could expect, though it is, of course, hard to predict soft tissue changes and results will vary by individual).
After I left the ICU and was finally able to look at my face, I was pretty surprised at just how much my nose changed. Luckily, it was a very positive change (and I was totally fine with my nose before), one which seems much more harmonious with my "new" face.
The biggest changes: The base of my nose is wider, there's a bit of a slope to the bridge, and the tip is slightly upturned. These changes were more exaggerated in the days immediately following surgery, but have seemed to mellow out as my swelling subsides. My nose was very narrow before surgery, so the extra width looks more balanced, but my surgeon did use an alar stitch suture to prevent the base from widening too much.
Of course, YMMV, but you said pictures would be helpful. Here's a comparison of my profile at (from L to R):
2 days pre-op -> 6 days post-op -> 2 weeks post-op -> 4 weeks post-op:
[attachment deleted by admin]
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In Bex's pictures, you see the base of the nose is going forward and the tip of the nose, supported by the base is also projecting more forward. The surgery itself does not move the 'nose bones' (nasal bones) that make up the UPPER bridge of then nose. They STAY put. Due to the forward projection of the nose TIP area, the nose bones look relatively more behind which is what gives somewhat of 'scoop' look (or slope) to the LOWER bridge and tip . So the base of the nose and parts of nose supported by base (like the TIP) are being displaced in the same direction as ANS-PNS; ROOF of the palate of the maxilla and FLOOR of the nose.
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Happy to share my experience if it's helpful...I'm 5 weeks out from a Lefort1 + BSSO + Genioglossus Advancement. While the goal of the surgery was to resolve a medical issue, I still had concerns about aesthetics; primarily changes to the philtrum, lips, and nose (Actually, Kavan was very helpful in explaining the general shape/changes that I could expect, though it is, of course, hard to predict soft tissue changes and results will vary by individual).
After I left the ICU and was finally able to look at my face, I was pretty surprised at just how much my nose changed. Luckily, it was a very positive change (and I was totally fine with my nose before), one which seems much more harmonious with my "new" face.
The biggest changes: The base of my nose is wider, there's a bit of a slope to the bridge, and the tip is slightly upturned. These changes were more exaggerated in the days immediately following surgery, but have seemed to mellow out as my swelling subsides. My nose was very narrow before surgery, so the extra width looks more balanced, but my surgeon did use an alar stitch suture to prevent the base from widening too much.
Of course, YMMV, but you said pictures would be helpful. Here's a comparison of my profile at (from L to R):
2 days pre-op -> 6 days post-op -> 2 weeks post-op -> 4 weeks post-op:
Thanks for sharing. I think I see some of it, a bit hard at different angles though. How much were you advanced?
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Attached the list of movements from my VSP - I think there ended up being slightly less pogonian advancement, but I doubt that impacts the nose anyhow.
[attachment deleted by admin]
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Attached the list of movements from my VSP - I think there ended up being slightly less pogonian advancement, but I doubt that impacts the nose anyhow.
Very interesting. Do you have the meassurements of the final result? Just interested since I see that these displacement meassurements are made in mm with 2 decimal accuracy, and I have to wonder if such accuracy is even close to possible to reproduce at the actual result, or what kind of accuracy the surgeons work with. I would to some extent suppose that these are more like guidelines?
I see e.g that your ANS is advanced less than your A point etc, is this the mechanics of the ccw rotation working?
Is this considered a large advancement of the maxilla, or in what region are we? Looking at your pictures it's a noticeable change (you look great). Just asking because my surgeon haven't provided me with a real plan, just said "slight" maxillary advancement, and in my case, I think your 6mm would be too much for me.
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Very interesting. Do you have the measurements of the final result? Just interested since I see that these displacement measurements are made in mm with 2 decimal accuracy, and I have to wonder if such accuracy is even close to possible to reproduce at the actual result, or what kind of accuracy the surgeons work with. I would to some extent suppose that these are more like guidelines?
If you look at ISU1 (midline of upper incisor) planned movement you'll see relatively "neat" numbers -- 10.00mm advancement, 0.50mm left, 3.50mm up. This suggests that the surgeon "manually" planned/specified the movement of the upper incisor midline, and the other landmarks' numbers are generated (mostly) computationally.
Obviously 1/100th of a mm accuracy is not achievable. https://www.ncbi.nlm.nih.gov/pubmed/28950997 is one example of a study measuring accuracy in VSP cases.
I see e.g that your ANS is advanced less than your A point etc, is this the mechanics of the ccw rotation working?
Yes.
Is this considered a large advancement of the maxilla, or in what region are we? Looking at your pictures it's a noticeable change (you look great). Just asking because my surgeon haven't provided me with a real plan, just said "slight" maxillary advancement, and in my case, I think your 6mm would be too much for me.
I'd say ~7.5mm of anterior movement at A point is a relatively large advancement (not a "slight" one). However, I would say it's good practice to ask for your surgical plan before your actual surgery.
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If you look at ISU1 (midline of upper incisor) planned movement you'll see relatively "neat" numbers -- 10.00mm advancement, 0.50mm left, 3.50mm up. This suggests that the surgeon "manually" planned/specified the movement of the upper incisor midline, and the other landmarks' numbers are generated (mostly) computationally.
Obviously 1/100th of a mm accuracy is not achievable. https://www.ncbi.nlm.nih.gov/pubmed/28950997 is one example of a study measuring accuracy in VSP cases.
Yes.
I'd say ~7.5mm of anterior movement at A point is a relatively large advancement (not a "slight" one). However, I would say it's good practice to ask for your surgical plan before your actual surgery.
Interesting report. Basically in a context where people discuss jaw movements with mm or even more accurate, the reality is that the result is 1mm+-1 (roughly), so it can be 2mm difference within one standard deviation.
You say 7.5mm is a rather large advancement, but is it really sensible to discuss surgery if the deviations are smaller, given the accuracy you can operate at? I mean, giving a surgery where the planned advancement is 2mm, and at worst case you end up at 4mm, so you're basically at same situation as before, just at the other end.
I've been looking at a lot if surgery movies, and there doesn't seem to be much magic going around in the surgery room. They use same tools as I have in my toolbox, saw, hammer etc and it doesn't exactly seem to be laser precision.
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You say 7.5mm is a rather large advancement, but is it really sensible to discuss surgery if the deviations are smaller, given the accuracy you can operate at?
I'd say it's important to consider the context of the deviations. I believe that the study only looked at the "absolute deviation" (made up term) -- the deviation of say point A from the planned position. I'd bet that the "occlusal deviation" (made up term) -- the deviation of the actual occlusal relationship from the planned occlusal relationship -- is less than the absolute deviation, due to the accuracy of the surgical splints.
Since the goal of orthognathic surgery is often to improve occlusion, those 1-2mm absolute deviations really don't matter so much.
Also, 1mm deviations don't have a significant effect on appearance. You give an example of a 2mm advancement, but no one would get a 2mm advancement for solely the sake of 2mm advancement.
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At the end of the day the surgeon follows the occlusal splint. The best surgeons have 1mm accuracy.
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Very interesting. Do you have the meassurements of the final result? Just interested since I see that these displacement meassurements are made in mm with 2 decimal accuracy, and I have to wonder if such accuracy is even close to possible to reproduce at the actual result, or what kind of accuracy the surgeons work with. I would to some extent suppose that these are more like guidelines?
I see e.g that your ANS is advanced less than your A point etc, is this the mechanics of the ccw rotation working?
Is this considered a large advancement of the maxilla, or in what region are we? Looking at your pictures it's a noticeable change (you look great). Just asking because my surgeon haven't provided me with a real plan, just said "slight" maxillary advancement, and in my case, I think your 6mm would be too much for me.
I'm admittedly a hell of a lot less knowledgeable than others in this thread about the more technical aspects of the surgery, but I'll try to answer what I can (all, please feel free to correct any info that I've misunderstood/is inaccurate)
- (1) I don't have the final measurements, but when my surgeon debriefed me post-op, he reminded me that the VSP is not 100% exact, but they try to adhere to the plan as much as possible. Because the plates you see in the VSP (see below) are custom to my face, it more or less requires that the movements here adhere to the plan. I can't imagine that the movements differed too much from the plan that I shared, aside from the pogonion advancement.
- (2) Yes, that sounds right. I also included the VSP visuals below, if that helps to visuals the movements.
- (3) As I mentioned, this surgery was a medical necessity. My bite was perfect, but my airway was collapsing when I slept and exercised, and the lack of oxygen was causing some serious health issues. It's my understanding that in order to have this surgery covered by insurance (as mine was), your surgery must require pretty significant advancement. So - that being said, I think you're correct in your assumption that 6mm is much greater than your surgeon's idea of a "slight" advancement.
[attachment deleted by admin]
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At the end of the day the surgeon follows the occlusal splint. The best surgeons have 1mm accuracy.
Yes, but correct me if I'm wrong. The occlusal splints say noting about the relationship to the skull, just the relationship between the jaws themself. In case if a bimax you fracture both jaws so they basically move freely. The occlusal splints give the surgeon the exact teeth match, but the other part is how you attach the maxillomandibular complex back to the skull which gives the aesthetics, and seems far less accurate and more of a free hand work.
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Yes, but correct me if I'm wrong. The occlusal splints say noting about the relationship to the skull, just the relationship between the jaws themself. In case if a bimax you fracture both jaws so they basically move freely. The occlusal splints give the surgeon the exact teeth match, but the other part is how you attach the maxillomandibular complex back to the skull which gives the aesthetics, and seems far less accurate and more of a free hand work.
Bex's surgeon actually used custom made plates (though her surgeon is in the minority) to get more precise movement. These plates guide the maxilla directly in relationship to the skull. Check out the picture "VSP - KLS Plates.jpg" she posted.
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Bottom line is that any displacement to ANS-PNS will also be a displacement to ANS and therefore a displacement to the base of the nose whether it's noticeable or not. Good surgeons anticipate the possible UNFAVORABLE very noticeable nose changes and can do a variety of techniques to mitigate those types.
Would ANS reduction/shaving be one of those techniques?
Do you know in which situation that would be most indicated? An already open nasolabial angle pre-surgery?
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Would ANS reduction/shaving be one of those techniques?
Do you know in which situation that would be most indicated? An already open nasolabial angle pre-surgery?
Sometimes.
When there is too much tension to the upper lip nose angle giving an OPEN angle. So it would be done to make the angle LESS.
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The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.
Could you explain what type of ANS-PNS movement would be considered "moving forward" resulting in bringing forward the base and tip of the nose?
More specifically I'm wondering if my planned maxillary movement would fall into your description.
Thanks!
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Could you explain what type of ANS-PNS movement would be considered "moving forward" resulting in bringing forward the base and tip of the nose?
More specifically I'm wondering if my planned maxillary movement would fall into your description.
Thanks!
Looks like setback.
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Could you explain what type of ANS-PNS movement would be considered "moving forward" resulting in bringing forward the base and tip of the nose?
More specifically I'm wondering if my planned maxillary movement would fall into your description.
Thanks!
You have a negative sign on your A-P movement of ANS, meaning to move the ANS back. So this is the opposite of advancing the base of the nose.
Am I right that you have a rather large overjet and some gummy smile?
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Could you explain what type of ANS-PNS movement would be considered "moving forward" resulting in bringing forward the base and tip of the nose?
More specifically I'm wondering if my planned maxillary movement would fall into your description.
Thanks!
With reference to the maxilla, displacement in the Anterior-Posterior (A-P) direction that is denoted by a + sign, before the number denoting the millimeter displacement, refers to ADVANCING an area 'forward'.
Look at the SIGN (+ or -) before the number denoting the millimeter displacement on your chart and it should be self explanatory whether or not you planned maxillary movement would fall into my prior description.
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Add-on question to this thread- does anyone know if a setback of the maxilla would actually narrow the nose (opposite of the widening effect when advancing)?. Intuitively it seems this would be unlikely; just as when certain materials are 'stretched out' they do not revert to their original form on release of tension.
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I don't think so, because what causes the widening is cutting the muscles. This is why the stitch is useful keeping the muscles in place.
Maybe it's possible to go in and try to reattach those muscles. That I don't know.
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You have a negative sign on your A-P movement of ANS, meaning to move the ANS back. So this is the opposite of advancing the base of the nose.
Am I right that you have a rather large overjet and some gummy smile?
Yes! How could you tell it's a rather large overjet?
It makes sense that in my case the base of my nose would be set back a little. Discussions on this forum seem to tend to associate maxillary impaction with likelihood of unfavorable nose change. Does that mean maxillary impaction and ccw don't always entail maxillary advancement and it's the actual a-p values that determines nose change?
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Anything done to the maxilla can have an effect on the nose. The soft tissue has to go somewhere.
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I don't think so, because what causes the widening is cutting the muscles. This is why the stitch is useful keeping the muscles in place.
Maybe it's possible to go in and try to reattach those muscles. That I don't know.
I don't really know, but just thinking about it I would believe settingt he nose back can make it more narrow. I mean if you press the base of the nose forward, the soft tissue will escape to the sides and making the nose wider. Setting the base back seems to do the opposite and take some of the soft tissue that sticks out on the side and stretch when moving back.
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Yes! How could you tell it's a rather large overjet?
It makes sense that in my case the base of my nose would be set back a little. Discussions on this forum seem to tend to associate maxillary impaction with likelihood of unfavorable nose change. Does that mean maxillary impaction and ccw don't always entail maxillary advancement and it's the actual a-p values that determines nose change?
It's basically in plain text in your numbers. The lower incisor move forward significantly more than your upper. Either you have an overjet, or you will get an underbite after surgery. Also your ANS have significant impaction, which resolves to getting less teeth show after surgery.
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I don't think so, because what causes the widening is cutting the muscles. This is why the stitch is useful keeping the muscles in place.
Maybe it's possible to go in and try to reattach those muscles. That I don't know.
I just read a few articles on upper jaw surgery's impact on the nasal base. From what I've gathered it's the separation of muscles from the skeleton that contributes to nasal base's widening - I have yet to figure out why pushing maxilla back (which also requires separation of the muscles from the bone) doesn't seem to affect nasal base in the same way.
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I've noticed from a local surgeons office of a girl who appears to have this thickening around the base of the nose, and this is clearly botched and can be repaired.
http://www.daytonfacialsurgery.com/procedures/jaw-surgery/
Basically you run into problems when the procedure impacts further into the nasal cavity.
Oh my dear God. I just saw this post and opened the link. I look almost exactly like that girl in the photos (except she is 20 years younger). My teeth, my chin, my jaw, even my upper face is really similar. She looks so so so f@cked up in the after - not just the nose, everything. She looks awful. I am having very, very serious second thoughts about the whole surgery thing. Doing nothing except some orthodontics to 'hide' the teeth as much as possible seems like an appealing option to me right now...
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Oh my dear God. I just saw this post and opened the link. I look almost exactly like that girl in the photos (except she is 20 years younger). My teeth, my chin, my jaw, even my upper face is really similar. She looks so so so f@cked up in the after - not just the nose, everything. She looks awful. I am having very, very serious second thoughts about the whole surgery thing. Doing nothing except some orthodontics to 'hide' the teeth as much as possible seems like an appealing option to me right now...
Which girl is it?
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I think she means the first. She had a great midface but only gummysmile. Now she has her nose too much upturned and a long and at the same time pointy chin. Her philtrum seems longer as well. She went down. Nostrils should be maximum 2 millimeter visible from the front. Her philtrum is like 1-1.5 millimeter too long. Incredible that just 1 millimeter makes the difference.
I'm not that big of a fan of genios with women. Imo having a weak chin as a woman is better. Sometimes it turns out good, but I see too many women complaining after genio for having a too masculine chin/face or something like that. Imo some female genios need to be mixed with some chinshaving if that's possible.
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She had a lot maxilla vertical excessiveness so the impaction must be significant, hence the much widened nose.
I agree - chin shaving is worth considering in genioplasty for women.
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I think she means the first. She had a great midface but only gummysmile. Now she has her nose too much upturned and a long and at the same time pointy chin. Her philtrum seems longer as well. She went down. Nostrils should be maximum 2 millimeter visible from the front. Her philtrum is like 1-1.5 millimeter too long. Incredible that just 1 millimeter makes the difference.
I'm not that big of a fan of genios with women. Imo having a weak chin as a woman is better. Sometimes it turns out good, but I see too many women complaining after genio for having a too masculine chin/face or something like that. Imo some female genios need to be mixed with some chinshaving if that's possible.
Her philtrum lengthened even more than mine- thank god im a guy and can keep some facial hair to help disguise it.
I can’t believe surgeons downplay the effects on the philtrum/nose so much. That’s a huge aesthetic downside.
Honestly if she gets a good rhino I think she would still come out ahead. The gummy smile was a more significant aesthetic defect IMO
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Which girl is it?
I was too horrified to scroll down and realize there were more :). I meant the first one.
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Her philtrum lengthened even more than mine - thank god im a guy and can keep some facial hair to help disguise it.
I can’t believe surgeons downplay the effects on the philtrum/nose so much. That’s a huge aesthetic downside.
Honestly if she gets a good rhino I think she would still come out ahead. The gummy smile was a more significant aesthetic defect IMO
Seriously, with the obvious asymmetry, horrifying witch chin, strange looking crooked mouth and nose, you think she looks better than she did before the operation? Wow. She was so pretty before except for the teeth which was distracting, she could have just had braces with extractions plus lip filler etc. to fix the gummy smile. She is very young too, her philtrum will be much longer in later life. They ruined her face for life, as far as I am concerned. She only looks slightly better from profile but who's going to keep staring at someone from profile? It's the front view that counts.
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I'm not that big of a fan of genios with women. Imo having a weak chin as a woman is better. Sometimes it turns out good, but I see too many women complaining after genio for having a too masculine chin/face or something like that.
That's right, I hardly saw any good examples on women, and many awful ones.
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Her philtrum lengthened even more than mine- thank god im a guy and can keep some facial hair to help disguise it.
I can’t believe surgeons downplay the effects on the philtrum/nose so much. That’s a huge aesthetic downside.
Honestly if she gets a good rhino I think she would still come out ahead. The gummy smile was a more significant aesthetic defect IMO
That’s because they are the biggest liars I’ve ever met. They’ll say anything to get you into surgery. They work on the principle that it’s easier to ask for forgiveness than permission, especially if they refuse to see you afterwards, something they do all the time.
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Gummysmile is an overrated flaw imo. You don't have to smile. Doing heavy bonecutting with unknown consequences only to get rid of some gummy smile... I don't know. Good old fashioned orthodontic work might be better than heavy bonecutting. But maybe it has more to do with the surgeon's skills. The other results of this surgeon on that page were quite good, but they weren't the same roocedure.
Just make sure as a woman that you keep a weak chin. Weak chin = good.
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Gummysmile is an overrated flaw imo. You don't have to smile. Doing heavy bonecutting with unknown consequences only to get rid of some gummy smile... I don't know. Good old fashioned orthodontic work might be better than heavy bonecutting. But maybe it has more to do with the surgeon's skills.
Good points, also gummy smile / tooth show becomes 'better' with age, which is why Le Fort 1 can make people look older (which is what most of us don't want, especially women).
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The nose and philtrum length are a trade-off of whatever she had done, but the chin is just unforgivable. They didn't have to do a genio.
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She was so pretty before except for the teeth which was distracting, she could have just had braces with extractions plus lip filler etc. to fix the gummy smile.
Extractions might've also lengthened her philtrum. That's my experience anyway, when teeth get retracted back the philtrum & upper lip are less supported and drape differently.
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The nose and philtrum length are a trade-off of whatever she had done, but the chin is just unforgivable. They didn't have to do a genio.
Her profile improved, she had a weak chin. The thing I don't understand is western surgeons not doing additional boneshaving. It seems to be a typical asian procedure, but some caucasian women would improve with this procedure I guess.
Sometimes, as a man, I find women with retruded chins more sexy.
I personally don't like the Jennifer Lopez bonestructure.
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Extractions might've also lengthened her philtrum.
Definitely, but she wouldn't have had the additional problems (weird nose, lower jaw / chin messed up, asymmetry etc.). I think the first picture was taken before she had any orthodontic treatment (I used to look almost exactly the same, with the same teeth, before braces - the resemblance is almost scary). So would have looked a lot better with the right kind of orthodontics, even without surgery. It looks like she had some kind of an improvement after surgery because her teeth look so bad in the 'before' photos, but there are other solutions for that then surgery.
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That’s because they are the biggest liars I’ve ever met. They’ll say anything to get you into surgery.
I have to agree, especially when it comes to the so called 'functional' improvements. When I first consulted a surgeon about my bite over twenty years ago, he said my teeth will fall out, I will have digestive problems (because of not being able to chew properly...), speech problems, TMJ pain and so on if I do nothing. I did nothing except orthodontics and never had any problems with anything. On the other hand, practically everyone that has surgery will have problems with numbness, pain, sometimes speech and eating and so on. I'm pretty sure the surgery causes more functional problems than it solves. The main reason I can see for getting it, for most people, is to improve their looks - and in that case we need to understand the potential aesthetic drawbacks like nose changes etc.
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Her profile improved, she had a weak chin. The thing I don't understand is western surgeons not doing additional boneshaving. It seems to be a typical asian procedure, but some caucasian women would improve with this procedure I guess.
Sometimes, as a man, I find women with retruded chins more sexy.
I personally don't like the Jennifer Lopez bonestructure.
Her profile looks nice. The projection is ok. But from the front the chin is too long and the shape is odd.
Yeah, I'm with you. I'm a straight female but I also think most women look better & softer with a short and slight-moderate retrusive chin.
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Her profile looks nice. The projection is ok. But from the front the chin is too long and the shape is odd.
Yeah, I'm with you. I'm a straight female but I also think most women look better & softer with a short and slight-moderate retrusive chin.
If you can have a better profile without making the front of the chin look too long or too masculine, then the procedure is a succesfull one. Appearantly, in many cases, surgeons achieve a better profile but worse front with genio. So maybe they should reconsider the technique or improve it, until they get it right.
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I have to agree, especially when it comes to the so called 'functional' improvements. When I first consulted a surgeon about my bite over twenty years ago, he said my teeth will fall out, I will have digestive problems (because of not being able to chew properly...), speech problems, TMJ pain and so on if I do nothing. I did nothing except orthodontics and never had any problems with anything. On the other hand, practically everyone that has surgery will have problems with numbness, pain, sometimes speech and eating and so on. I'm pretty sure the surgery causes more functional problems than it solves. The main reason I can see for getting it, for most people, is to improve their looks - and in that case we need to understand the potential aesthetic drawbacks like nose changes etc.
I started consulting when I was 36. No one was really pulling that functional s**t on me too much. Because obviously if I had no issues at my age it, it was highly unlikely I’d have them henceforth. (others in my family with a similar bite were well on their way to losing their teeth at the same age) The surgeon I eventually went with did bark at me “well at least you’ll have a good bite!” after he got tired of my questioning regarding all the aesthetic pitfalls (all of which came true). This is how they justify their crimes. Nerve damage, chimp lip. Don’t matter, because good bite! They know full well that most people are doing this surgery for aesthetic reasons first and foremost, yet many will sell it on aesthetic grounds, and when aesthetics turn out poor, will gaslight you and tell you how you knew “it’s just a bite-fixing operation”.
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Seriously, with the obvious asymmetry, horrifying witch chin, strange looking crooked mouth and nose, you think she looks better than she did before the operation? Wow. She was so pretty before except for the teeth which was distracting, she could have just had braces with extractions plus lip filler etc. to fix the gummy smile. She is very young too, her philtrum will be much longer in later life. They ruined her face for life, as far as I am concerned. She only looks slightly better from profile but who's going to keep staring at someone from profile? It's the front view that counts.
No, I think with a proper rhino she could look better. As it stands she looks worse.
Gummy smile is a flaw that stands out to me personally. As you said, she might have been better off overall addressing it by other means and avoided the tradeoffs she got.
With less nostril show and flare I think she would look quite good in the smiling pic. Maybe something can still be done about the chin too.
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Maybe something can still be done about the chin too.
Yeah, I'm sure she could potentially look better with even more surgery, my point is, she has just had major surgery to make her look better and overall, she ended up looking worse.
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The surgeon I eventually went with did bark at me “well at least you’ll have a good bite!” after he got tired of my questioning regarding all the aesthetic pitfalls (all of which came true). They know full well that most people are doing this surgery for aesthetic reasons first and foremost, yet many will sell it on aesthetic grounds, and when aesthetics turn out poor, will gaslight you and tell you how you knew “it’s just a bite-fixing operation”.
Exactly, that obsession with the 'good bite' and the 'fixing the bite card' to justify it if things go wrong, or to justify the whole operation in the first place. Who wants a 'good bite'? Apparently I have had a 'bad bite' for all these years and it never bothered me a bit. What bothers me is aesthetics and, recently, some breathing issues but so far I have no evidence that it's jaw related (still trying to work that one out).
I am new here and don't know your story, sounds like you had some bad experiences with surgery? Did you write more about that somewhere on the forum?
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The nose and philtrum length are a trade-off of whatever she had done, but the chin is just unforgivable. They didn't have to do a genio.
BINGO! She didn't get a BSSO and got chin instead. She got single jaw surgery with genio. It's just that we don't know circumstances of not doing the BSSO. Doctor's design or patient desire to avoid it? Like what if the patient was afraid a BSSO would have made her look 'more masculine' and attributed a more 'heart shaped' face with being more feminine.
I mention that because the outcome looks like it could have resolved to SOMEONE making those types of associations and I've seen those types of auto-associations made on this board.
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Yeah, I'm sure she could potentially look better with even more surgery, my point is, she has just had major surgery to make her look better and overall, she ended up looking worse.
I think her outcome looks exactly what an association driven design would look like. That's what BSSO avoidance on a female with her face could look like when associations like: 'BSSO on female = masculine' and 'Heart shaped face = feminine' DRIVE the DECISION.
Surely, you've read those types of associations being made on this board. It's not a thing where the associations are 'wrong' to make. It's more of a matter of when to use them to drive a decision.
We just don't know who's the 'driver', the doctor or the patient.
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Definitely, but she wouldn't have had the additional problems (weird nose, lower jaw / chin messed up, asymmetry etc.). I think the first picture was taken before she had any orthodontic treatment (I used to look almost exactly the same, with the same teeth, before braces - the resemblance is almost scary). So would have looked a lot better with the right kind of orthodontics, even without surgery. It looks like she had some kind of an improvement after surgery because her teeth look so bad in the 'before' photos, but there are other solutions for that then surgery.
I think your reactions, on this thread, to her outcome such as the following, just to quote a few, should be shared with the next doctor(s) you consult with (along with her photos). I mean, descriptions such as; 'horrifying', 'ruined her face for life'...etc; the reactions you had to her changes would help the doctor steer you in the right direction as in assist with a choice; surgery for you or no surgery for you.
I was too horrified ......
.....with the obvious asymmetry, horrifying witch chin, strange looking crooked mouth and nose...They ruined her face for life......
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BINGO! She didn't get a BSSO and got chin instead. She got single jaw surgery with genio. It's just that we don't know circumstances of not doing the BSSO. Doctor's design or patient desire to avoid it? Like what if the patient was afraid a BSSO would have made her look 'more masculine' and attributed a more 'heart shaped' face with being more feminine.
I mention that because the outcome looks like it could have resolved to SOMEONE making those types of associations and I've seen those types of auto-associations made on this board.
Point taken Kavan
Although I'm going to go with doc design here because 1) 95% of regular patients just go along with whatever the first surgeon they see says, and don't think critically about it 2). Her surgeon put her result up on his website, and first result, no less - he must think she looks pretty good and 3) assuming their aim was also to get her bite right, you can't just do a genio in lieu of a BSSO when one is needed for that. So presumably her bite fits w/o a bsso?
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Point taken Kavan
Although I'm going to go with doc design here because 1) 95% of regular patients just go along with whatever the first surgeon they see says, and don't think critically about it 2). Her surgeon put her result up on his website, and first result, no less - he must think she looks pretty good and 3) assuming their aim was also to get her bite right, you can't just do a genio in lieu of a BSSO when one is needed for that. So presumably her bite fits w/o a bsso?
Well, on the other hand, her photo would not be up there either if she, the patient wasn't happy with it. So, yes, the situation would have been one where the upper jaw surgery alone affected the bite to be right. But I'm not so sure it was one where there was no option to alter the displacements to the upper jaw such that a BSSO could have been done. Do you think that Gunson would have found a way to displace upper jaw differently so a BSSO could have been done (with right bite there too) as to avoid the chin exaggeration she has from the front?
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Well, on the other hand, her photo would not be up there either if she, the patient wasn't happy with it. So, yes, the situation would have been one where the upper jaw surgery alone affected the bite to be right. But I'm not so sure it was one where there was no option to alter the displacements to the upper jaw such that a BSSO could have been done. Do you think that Gunson would have found a way to displace upper jaw differently so a BSSO could have been done (with right bite there too) as to avoid the chin exaggeration she has from the front?
You're right, she must be happy too. That's a good thing at least.
Yeah Gunson would've displaced both jaws. Maybe he would've done a larger rotation and then used multisegement to reposition the front teeth after that. Idk, I can't really guess what he would do, except that it would be DJS. He has a lot of tools at his disposal, this guy might not. Although in me saying that, that's not an excuse at all for this guy to disregard her front view when planning such a genio.
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You're right, she must be happy too. That's a good thing at least.
Yeah Gunson would've displaced both jaws. Maybe he would've done a larger rotation and then used multisegement to reposition the front teeth after that. Idk, I can't really guess what he would do, except that it would be DJS. He has a lot of tools at his disposal, this guy might not. Although in me saying that, that's not an excuse at all for this guy to disregard her front view when planning such a genio.
Well, your main guess that G would do double jaw seems right to me. Some of his displacement proposals do a LOT as to make the chin augmentation as minor as possible.
Does this one look less weird?
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Not more than 2mm of nostrils should be visible from the front. That's the 'geometrical' rule, like facial thirds (1/3rd). Her lower third was too long as well. I reduced the chin length.
Still not a very good morph. Was difficult to morph the nose.
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She looks much better with a shorter chin. More like herself.
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Back on topic, I found out something interesting while reading an article by Raffaini. He often does a modified le fort called a 'subspinal' osteotomy. It's a lower le fort (I think the cut dips below ANS) and the nose isn't supposed to be affected as much. The incisions are also less invasive (they tunnel through avoiding some of the muscles).
But he also does cosmetic rhinos so it's hard to know if his noses truly get affected or not.
A surgeon I saw last year was trying to explain the same thing to me about tunneling through and not needing to worry about the nose but I had no clue what she was talking about, so I kinda checked out. One of her patients did have a much wider nose afterwards so maybe it's not fool proof.
Looking at the two Alfaro 3d plans posted on this forum, he also cuts just below ANS.
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Exactly, that obsession with the 'good bite' and the 'fixing the bite card' to justify it if things go wrong, or to justify the whole operation in the first place. Who wants a 'good bite'? Apparently I have had a 'bad bite' for all these years and it never bothered me a bit. What bothers me is aesthetics and, recently, some breathing issues but so far I have no evidence that it's jaw related (still trying to work that one out).
I am new here and don't know your story, sounds like you had some bad experiences with surgery? Did you write more about that somewhere on the forum?
Well, my bite did not bother me either.. But now that I have a "good bite", I wouldn't want to go back to my old bite. So a "good bite" surgery with a mediocre aesthetic result can ironically be one of the worst places to be - you don’t like the way it looks, but can't stomach the risk of ending up with a worse bite. And when you talk with surgeons about a revision you get a completely different perspective on how likely a good bite is. Before surgery they make it sound that a good bite is a sure thing. After surgery - "but you'll be risking your bite!"... "A good bite doesn't always happen", etc.. this really makes one think that you can go though all this hell FOR NOTHING - look no better, possibly worse, no improvement in occlusion, possibly worse... and nerve damage, which my fat surgeon claimed was a 10-12% thing, but which in reality is all but guaranteed after a certain age.
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Well, my bite did not bother me either.. But now that I have a "good bite", I wouldn't want to go back to my old bite. So a "good bite" surgery with a mediocre aesthetic result can ironically be one of the worst places to be - you don’t like the way it looks, but can't stomach the risk of ending up with a worse bite. And when you talk with surgeons about a revision you get a completely different perspective on how likely a good bite is. Before surgery they make it sound that a good bite is a sure thing. After surgery - "but you'll be risking your bite!"... "A good bite doesn't always happen", etc.. this really makes one think that you can go though all this hell FOR NOTHING - look no better, possibly worse, no improvement in occlusion, possibly worse... and nerve damage, which my fat surgeon claimed was a 10-12% thing, but which in reality is all but guaranteed after a certain age.
If you're trying to fix something that's broken, the worst case is that it will be broken in another way and there's really no alternative than trying to fix it. Yes, things can of course always get worse, but you understand it's another risk/reward trying to fix something that doesn't really need to be fixed. I would also prefer to do surgeries where there is a problem to solve, than trying to not f**k up what is already good. I think this is can be a reason for the differens responses.