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General Category => Functional Surgery Questions => Topic started by: jawsandsleep on October 31, 2019, 04:08:33 AM
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Hi everyone
I would like to ask for advice about my current situation:
I had Lefort I, BSSO and sliding genio done. Advancement at chin 26mm and upper incisor 16mm.
Today at 7 weeks post operative, the maxilla has relapsed quite a bit (about 5mm) and the mandible is crooked to the right. I am now unsure about how to proceed.
It appears that doing a revision as soon as possible makes sense as the bone is not fully formed. Surgeon wants to do surgery next week.
- Either I bring the maxilla forward according to the original plan
- Or I bring back the mandible to the current relapsed maxilla.
I posted pictures here: https://imgur.com/gallery/vb3SiJR
I am mostly interested on what makes most sense aesthetically speaking. Thanks.
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Sorry to hear that. That's terrible.
Out of those two options I'd bring the mandible back. This could allow some correction of the cant to the right, too, so it seems to be more bang for the buck. Did the surgeon say what's causing the cant to the right? You/we need to know the cause of the relapse, too. Did he say if it's due to the large movement or is it something anatomical?
I'd like to see more photos, cephs, and hear any insight your doc gave about "why" before confirming my opinion.
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I'm also interested to hear more details as to how the relapse happened. It's both a significant relapse and you also say both mandible and maxilla moved.
What happened between day 10 and week 7?
Was it because starting to put load on it with chewing too early? Inadequate stabilization with elastics? Or was the situation as unstable that it couldn't heal in right position?
What kind of advancement did you have, was it ccw rotation? What does your surgeon say?
As to aethetics I think you had a good result straight after and 10 days after surgery, but also having the mandible straightened is a priority. I assume the reason your surgeon don't want to do a full bimax revision is because of the risk it can happen again and rather focus on one jaw.
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Thank you for the quick reply. I feel a bit lost right now, especially since the doctor is wanting to do surgery as soon as next week.
The surgeon is covering the expense for the revision. I actually havent brought up with him the "maxilla advancement" option. I guess it wouldnt just be a maxilla solution as the mandible needs to be adressed either way. So it would essentially be a double jaw surgery vs. a mandibular set back.
The surgeon didnt explain to me what caused the cant to the right. I will have to ask him, but it was apparent directly after surgery and increased in appearance as the swelling went down.
He told me the relapse was caused by my strong muscles and the flexible fixation of the maxilla.
I believe the surgeon prefers to perform a mandibular setback as its the easier fix for the problem. But right now I am trying to figure out whether maxillary advancement is an option (as it was the original plan).
The entire surgery was very ambitious. I had a significant posterior downgraft CCW and an anterior downgraft performed. I believe 1,5cm posterior downmovement and 5mm anterior. So yeah, naturally not the most stable movement.
I have pre and post OP CBCTs. I attached a pre OP ceph and generated a post OP ceph from the CBCT (7 weeks PO). Right now my SNA is 82, SNB is 83,5 vs pre OP SNA 74 and SNB 74. I mention this to highlight the skeletal deficiency pre OP. Right now in the post OP situation my SNA is normal. But eventually, soft tissue is what matters most in assessing an outcome.
Are the pictures in the previous album not sufficient? I have some more in case.
CEPHS https://imgur.com/gallery/RnGbwh6
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The entire surgery was very ambitious. I had a significant posterior downgraft CCW and an anterior downgraft performed. I believe 1,5cm posterior downmovement and 5mm anterior. So yeah, naturally not the most stable movement.
Do you mind sharing who the surgeon was?
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Thank you Dogmatix for the reply. I was in slight Class III immediately after surgery and it simply increased gradually. I was put on soft chew after a week, but maintained a mostly liquid diet for a month. I was wearing strong elastics for most of the time.
I also liked the (admittedly swollen) result directly after surgery. I wasnt even aware of the maxilla relapsing until last week. I just thought the swelling subsided and was horryfied with the look.
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I will not share the surgeons name. I dont suspect any misconduct by the surgeon and we are currently working towards a solution.
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But right now I am trying to figure out whether maxillary advancement is an option (as it was the original plan).
The thing is, if the mandible have a cant and you want to match the maxilla with that, you have to give the maxilla a cant as well. I'm not a surgeon or don't have full insight, but I would guess that regardless of what you do to the maxilla, the cant of the mandible probably is mandatory to fix.
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The thing is, if the mandible have a cant and you want to match the maxilla with that, you have to give the maxilla a cant as well. I'm not a surgeon or don't have full insight, but I would guess that regardless of what you do to the maxilla, the cant of the mandible probably is mandatory to fix.
Agreed. Thats why a maxilla only solution is technically not possible and double jaw surgery would be needed.
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Something else I need to mention.
I originally went into surgery with the intention of getting rid of my mild sleep apnea, but I was also hoping to improve my recessed face. Looking back, I feel like such an idiot for going down this road as I was much happier with my looks than I am now. I dont believe that a mandibular set back is going to impact my airway in any way as the intial advancement was such a large one (26mm chin).
So yeah, there is a part of me that wants to go back to how I used to look. A maxillary advancement would push me further away from my original looks.
I feel like making this decision is really hard for me.
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Something else I need to mention.
I originally went into surgery with the intention of getting rid of my mild sleep apnea, but I was also hoping to improve my recessed face. Looking back, I feel like such an idiot for going down this road as I was much happier with my looks than I am now. I dont believe that a mandibular set back is going to impact my airway in any way as the intial advancement was such a large one (26mm chin).
So yeah, there is a part of me that wants to go back to how I used to look. A maxillary advancement would push me further away from my original looks.
I feel like making this decision is really hard for me.
Do you wish for your original looks because of the problems you have, or because you don't prefer the result as it was intended right after or 10 days after surgery? It's natural to feel discouraged at this point, but even to go back is a new surgery and the fractures need to heal in that position. Now when the dice is rolled you need to look past those doubts and work from the situation. As to revision bimax, it's important that your surgeon have a plan that will prevent same kind of relapse again if doing that. As I wrote maybe that's part of the reason to only suggest fixing the mandible, as the maxilla should be stable after 7 weeks and getting into trying to keep both jaws stable in a new position a second time require some kind of plan as both relapsed last time. Removing the maxilla from the equation is less gamble.
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Do you wish for your original looks because of the problems you have, or because you don't prefer the result as it was intended right after or 10 days after surgery? It's natural to feel discouraged at this point, but even to go back is a new surgery and the fractures need to heal in that position. Now when the dice is rolled you need to look past those doubts and work from the situation. As to revision bimax, it's important that your surgeon have a plan that will prevent same kind of relapse again if doing that. As I wrote maybe that's part of the reason to only suggest fixing the mandible, as the maxilla should be stable after 7 weeks and getting into trying to keep both jaws stable in a new position a second time require some kind of plan as both relapsed last time. Removing the maxilla from the equation is less gamble.
I believe I just miss my old face. The problem is that I dont know how I would look like with the maxilla advanced. I only have the picture from the operating table and when the relapse took place, I was mostly swollen. Realistically, it doesnt make sense to go back to how it was. But I was thinking that bringing the mandible back wouldnt change my face as much as bringing the maxilla forward (thus preserving some of the old "esthetics").
Its just such a hard situation psychologically speaking. I am devastated when I see my current looks, so naturally, my instinct is to revert things some what. I guess its just fear and there is a good chance that its just the Class III causing this dysbalance and a maxillary advancement could in fact help.
I understand your point. He actually replied me with a short sentence and told me that bringing the maxilla forward is theoretically possible and he will do whatever I want. I havent asked about the details. But this kind of leaves me in the dark because how am I supposed to tell as a lay person how a movement is going to impact my face?
Brb going to get a hair cut.
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I believe I just miss my old face. The problem is that I dont know how I would look like with the maxilla advanced. I only have the picture from the operating table and when the relapse took place, I was mostly swollen. Realistically, it doesnt make sense to go back to how it was. But I was thinking that bringing the mandible back wouldnt change my face as much as bringing the maxilla forward (thus preserving some of the old "esthetics").
Its just such a hard situation psychologically speaking. I am devastated when I see my current looks, so naturally, my instinct is to revert things some what. I guess its just fear and there is a good chance that its just the Class III causing this dysbalance and a maxillary advancement could in fact help.
I understand your point. He actually replied me with a short sentence and told me that bringing the maxilla forward is theoretically possible and he will do whatever I want. I havent asked about the details. But this kind of leaves me in the dark because how am I supposed to tell as a lay person how a movement is going to impact my face?
Brb going to get a hair cut.
Yes. So it's a valid opinion that the result you have now is worse than when you started. I see it, you see it and your surgeon see it. I just want to tell you that this doesn't necessarily mean that going back yield the best result. It's hard for you to imagine a balanced result in the situation you're in and you think it's the advancement that is the problem. The problem is the underbite and it would be regardless of where it's positioned. The advancement as it looked after surgery was balanced and more than you have now with the relapse. I think what ever you chose or agree with your surgeon it will be a good result, the key is the balance and not have the under bite. You need to have a dialog with your surgeon, it's not enough information with "I will do what ever you want". You need to ask what he suggest for best result, how you prevent same situation from happening again etc.
I'd greatly appriciate if you could look through your private messages.
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Aesthetically speaking, I'd put the maxilla back where it was since:
a: THAT is the KEY problem and you looked better WHERE it WAS put before relapse
b: you probably need lower jaw advanced where it is for open airway and lower jaw looks OK advanced where it is now.
c: that was ORIGINAL plan
I would hesitate to bring the mandible back to 'match' the maxilla that has gone astray because it's possible that's what is ALSO kicking up the unevenness to the mandible. I can't tell you exact cause of mandible being crooked. But I can tell you that when someone has a 'can't' (crookedness), it CAN come from the maxilla being uneven and I think it is MORE possible that the mandible got a little crooked as a function of the maxilla moving out of place.
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I don't really have anything of value to add except to say that I'm really, really sorry. I always hear about maxillary downgrafts being unstable (from my local surgeons, not the top surgeons), but I've never seen it actually happen to somebody before.
What at a tough situation to be in.
The way you're feeling, missing your face and feeling regrets, I'm sure is completely normal given the situation. For what it's worth, I think you looked really good in the immediate post-op photo.
15mm posterior, 5mm anterior is indeed massive. Did your surgeon use some sort of bone graft or HA blocks in between the gaps?
What is your bite like at the back - posterior open bite?
I agree with Dogmatix. If they intend to do maxilla surgery again, you need to find out how they will prevent this from happening again.
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Thanks for all the new replies. I have been sad long enough and I have to make this decision soon. As I am supposedly still in the bone healing phase and a revision should be less eventful, I am getting surgery ASAP, but I am not ruling out revision down the road. There are other things I dont like like the increase in vertical face length and the fact that I cant close my lips (might need a reduction genioplasty), but at this point I need to adress the primary issue as I cant be walking around like this.
HA was used for grafting. I am not entirely sure how to bite is at the back.
@ Dogmatix: Its a good point you make about balance.
I am still going back and forth about whether to do maxillary advance or mandibular setback.
@ kavan:
a.) I agree. Although I only have these two pictures which makes it hard for me to predict the outcome. How would my midface react (cheekbones)? How would my nose react?
b.) Also agreed, although the setback could most likely still be accommodated. cephalometric wise I am at the verge of prognathia.
c.) The original plan was unfortunately not made with regard to how my individual soft tissue would react and rather aimed to put my jaws at a reference point.
The last point you make, is something that had me worrying as well. The current position of the maxilla is just a random one and a mandibular setback could only be a compromise at this point.
I actually consulted with two surgeons in the last couple days. One very renowned one said he would rather advance the maxilla. But I think he was mostly considering the sleep apnea. I didnt talk with him about aesthetics much unfortunately. Another one said he would bring the mandible back because he things my maxilla looks good
What confuses me is, that I consulted with a handful of surgeons before surgery and most surgeons were a lot more conservative with their plans. Like maxilla 8-10mm and mandible accordingly with a slight CCW at best.
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I am still not sure how to procede, but I have been thinking about the advantages of a mandibular setback:
1.) the maxilla is in a position that was originally proposed by other surgeons in regards to soft tissue and nasal changes. I can only estimate, but I believe I am still about 8, 9 mm advanced compared to the pre OP position when looking at the maxillary incisor. As Dogmatix pointed out, flatness of the face is perceived in relation to the madible as balance is most imporant. If looking at the maxilla isolated right now, I have slight improvements in regards to lips and midface.
2.) skeletally speaking, my maxilla is in the norm (SNA 81). I know that this is an unreliable number, but I started out with a 74 which is a couple of standard deviations below.
3.) I used to believe that a forward grown face was the best thing for all men, but I am starting to think you cant bring all jaws to the same point and expect them to harmonize with your face. I am afraid that such a large movement would have a negative impact on my nose and let my cheeks look hollow.
Maybe its because I am asian, but I feel like the current jaw looks oversized on me and a more delicate one would suit me better.
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Thanks for all the new replies. I have been sad long enough and I have to make this decision soon. As I am supposedly still in the bone healing phase and a revision should be less eventful, I am getting surgery ASAP, but I am not ruling out revision down the road. There are other things I dont like like the increase in vertical face length and the fact that I cant close my lips (might need a reduction genioplasty), but at this point I need to adress the primary issue as I cant be walking around like this.
HA was used for grafting. I am not entirely sure how to bite is at the back.
@ Dogmatix: Its a good point you make about balance.
I am still going back and forth about whether to do maxillary advance or mandibular setback.
@ kavan:
a.) I agree. Although I only have these two pictures which makes it hard for me to predict the outcome. How would my midface react (cheekbones)? How would my nose react?
b.) Also agreed, although the setback could most likely still be accommodated. cephalometric wise I am at the verge of prognathia.
c.) The original plan was unfortunately not made with regard to how my individual soft tissue would react and rather aimed to put my jaws at a reference point.
The last point you make, is something that had me worrying as well. The current position of the maxilla is just a random one and a mandibular setback could only be a compromise at this point.
I actually consulted with two surgeons in the last couple days. One very renowned one said he would rather advance the maxilla. But I think he was mostly considering the sleep apnea. I didnt talk with him about aesthetics much unfortunately. Another one said he would bring the mandible back because he things my maxilla looks good
What confuses me is, that I consulted with a handful of surgeons before surgery and most surgeons were a lot more conservative with their plans. Like maxilla 8-10mm and mandible accordingly with a slight CCW at best.
You asked a clear straight forward question in your first post. I addressed and with clarity. I also gave my aesthetic take and reasoning behind my advice. My advice as it stood, is not confusing. I can't predict your outcome or resolve all the uncertainty you have. In terms of PROBABILITY, the maxilla deviance is the MORE likely culprit to the lower jaw deviation.
You now bring in uncertainty and confusion based on information others have given you.
When I give my advice on here or my 'take' based on an initial question, it's not my task to resolve all confusion or uncertainties OTHERS have posed in the event the poster brings those in AFTER their initial post.
So, in this situation, I see no need to adapt or change the advice already given to the confusion OTHERS have introduced and/or your present ruminations as your aesthetic preferences.
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You asked a clear straight forward question in your first post. I addressed and with clarity. I also gave my aesthetic take and reasoning behind my advice. My advice as it stood, is not confusing. I can't predict your outcome or resolve all the uncertainty you have. In terms of PROBABILITY, the maxilla deviance is the MORE likely culprit to the lower jaw deviation.
You now bring in uncertainty and confusion based on information others have given you.
When I give my advice on here or my 'take' based on an initial question, it's not my task to resolve all confusion or uncertainties OTHERS have posed in the event the poster brings those in AFTER their initial post.
So, in this situation, I see no need to adapt or change the advice already given to the confusion OTHERS have introduced.
Dear Kavan,
I apologize for my confusion. I believe its just the panic and I am simply reacting instead of thinking clearly.
Considering the mandible: The deviance appears to be on the horizontal plane and it seems to put together wrongly.
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I believe I just miss my old face. The problem is that I dont know how I would look like with the maxilla advanced. I only have the picture from the operating table and when the relapse took place, I was mostly swollen. Realistically, it doesnt make sense to go back to how it was. But I was thinking that bringing the mandible back wouldnt change my face as much as bringing the maxilla forward (thus preserving some of the old "esthetics").
Its just such a hard situation psychologically speaking. I am devastated when I see my current looks, so naturally, my instinct is to revert things some what. I guess its just fear and there is a good chance that its just the Class III causing this dysbalance and a maxillary advancement could in fact help.
I understand your point. He actually replied me with a short sentence and told me that bringing the maxilla forward is theoretically possible and he will do whatever I want. I havent asked about the details. But this kind of leaves me in the dark because how am I supposed to tell as a lay person how a movement is going to impact my face?
Brb going to get a hair cut.
I think you looked great just post-op before the swelling set in, so that's what I'd aim for. I think bringing the mandible back would be a big mistake.
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Dear Kavan,
I apologize for my confusion. I believe its just the panic and I am simply reacting instead of thinking clearly.
Considering the mandible: The deviance appears to be on the horizontal plane and it seems to put together wrongly.
You don't need to apologize. I'm just saying that when I give clarity and/or my reasoning behind my advice, I don't adapt it to confusion when I feel there's no need for me to do so. Deviance FROM the maxilla can result in deviance to mandible (horizontal plane). If one side of downgraft of maxilla deviates more than the other, for example, you can see that in the mandible. I'm not diagnosing but just saying MOST LIKELY reason.
If you have your own advice for yourself, I have no issue with your taking who's ever advice you want.
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I think you looked great just post-op before the swelling set in, so that's what I'd aim for. I think bringing the mandible back would be a big mistake.
Yes. RIGHT AFTER surgery, looks much better in terms of aesthetics. Also right after is before swelling sets in and shows how it would/should look IF all stays put.
He asked about AESTHETICS and the aesthetics right after surgery are infinitely better than his prior aesthetic IMO also. Now, he introduces a possible preference for his PRIOR (poor) aesthetic. So, no 'coaching' from me as to how to get back most of prior aesthetic because my aesthetic advice was based on seeing that is RIGHT AFTER surgery aesthetic was an excellent improvement over his prior one.
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OP, moving the maxilla forward a second time puts a lot of risk to your nose widening more. The photos are no longer up, so I can't see how much it widened the first time. This is one reason I don't like it. In the second photo you posted, from memory, your lower jaw looked too far out for your upper face. So moving the mandible back would make more sense. Cutting the mandible a second time increases the risk of nerve damage, as you might know. So there's that to factor in. I agree with others who said you looked good in the first photo right out of surgery (again, from memory), but you were swollen and in general photos are some of the worst records for assessing anything. You mentioned soft tissue in a post, and again from memory you were Asian and appeared to have thin soft tissue that is somewhat typical in Asians. This will make any movement more apparent since the tissue doesn't hide anything, and it's another reason I think mandible, especially if you miss your old face. Mandible would get you closer to the old face, though you have to accept the actual old face is gone forever. My big issue with the maxilla is moving it a second time puts so much risk to the nose area. It's worth considering because it did look good in that one photo, but I wouldn't consider it without more info from the surgeon. Maybe request an emergency consultation to go over everything. Good luck, buddy. Tough situation.
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Thanks for the input and taking your time. I will reupload the photos in a bit.
@ GJ: Thanks for providing your insight. I believe what you say is true, especially the asian part.
I am not saying that my old face is my goal, I was obviously unhappy with many things. I was skeletally very deficient and I believe the thin soft tissue did a good job at hiding my flaws to an extend.
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Thanks for the input and taking your time. I will reupload the photos in a bit.
@ GJ: Thanks for providing your insight. I believe what you say is true, especially the asian part.
I am not saying that my old face is my goal, I was obviously unhappy with many things. I was skeletally very deficient and I believe the thin soft tissue did a good job at hiding my flaws to an extend.
Okay, I think you need to decide what you want. Eyeballing it (from memory), your maxilla is now recessed outside of the normal range relative to your skull (brow, etc). You looked GREAT immediately post-op, and if there's a way to get back to that spot I personally think that's the route you should take.
GJ is correct that maxilla advancement can kick up changes to the nose, especially widening at the base and upturning the tip. I think this element of risk is worth it though because there are rhinoplasty techniques for correcting this issue if it arises. IMO you should focus on getting your jaws in best position because a rhinoplasty is way less expensive and invasive than another bimax revision.
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OP, moving the maxilla forward a second time puts a lot of risk to your nose widening more.
Is it bigger risk for the nose to widen the second time? Why is that?
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I am currently thinking about doing the mandibular set back and getting a vertical reduction genioplasty at some point. This is how I envision it: https://imgur.com/gallery/4QnSOa5
pre OP vs plan https://imgur.com/gallery/NdBw6tm
I thought about it a lot. While the post OP picture looks good, it probably doesnt accurately reflect the truth. I believe its best to aim for a natural looking result and one that fits my asian face.
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What confuses me is, that I consulted with a handful of surgeons before surgery and most surgeons were a lot more conservative with their plans. Like maxilla 8-10mm and mandible accordingly with a slight CCW at best.
But who were these surgeons? Because one of the reason to chose a high profile surgeon is because they can handle other movements that the local surgeon can't. Posterior downgrafting is not offered every where, and definitely not 15mm posterior AND 5mm anterior. So that this was not offered may not mean that they don't agree with the aesthetic benefits from it, but it's out of the range of what they do. I understand that this response backfires a bit because obviously there is some risk to it even for a surgeon who offers it.
I can some how try to imagine that it's a volatile situation when the maxilla is displaced so much both anterior and posterior. There is no point of contact more than the grafting material. I'm just a bit curious. 10 days after surgery, you were probably still on a liquid diet and having elastics keeping it stable. Is there any chance that the problem occured when you started chewing and this is when it started drifting away, and that such significant move require longer healing?
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Is it bigger risk for the nose to widen the second time? Why is that?
I think he's just saying maxillary advancement impacts the nose, and this risk is part of the revision if he goes that route. Not that revision advancement after relapse is necessarily riskier to the nose than initial advancement.
While the post OP picture looks good, it probably doesnt accurately reflect the truth. I believe its best to aim for a natural looking result and one that fits my asian face.
I'm not sure what you mean here. The immediate post-op picture 'reflects' the truth much more 'accurately' than your 10 day pic. At 10 days you still have a ton of swelling. It can literally take 6 months to a year for all swelling to dissipate. Your choice though.
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It was gradually and most likely caused by the muscles.
I believe the challenging part of jaw surgery is making predictions about how soft tissue will react. There are different philosophies and every surgeon will have a different outcome. Some surgeons are more aggressive and aim for a certain look and some are more conservative. If it was only technical skill limiting a surgeon, then jaw surgery would be trivial.
I think my surgeon has created great outcomes for others, but I dont think my face accomodates it well.
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Is it bigger risk for the nose to widen the second time? Why is that?
I'd have to see the photos again, but it's likely it widened the first time.
It's likely it would widen again because the muscles that were stitched have to be cut once more. Maybe it doesn't, but it's something to ask the surgeon about (they might downplay the risk, though). I'd ask an objective surgeon who wasn't performing the surgery, personally. He's on a bit of a time crunch so it's tougher to be diligent.
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I think he's just saying maxillary advancement impacts the nose, and this risk is part of the revision if he goes that route. Not that revision advancement after relapse is necessarily riskier to the nose than initial advancement.
I'm not sure what you mean here. The immediate post-op picture 'reflects' the truth much more 'accurately' than your 10 day pic. At 10 days you still have a ton of swelling. It can literally take 6 months to a year for all swelling to dissipate. Your choice though.
I think neither pictures reflect the reality. I dont have a front picture and the angle distorts it a little.
I understand what you are all thinking. I was ecstatic when I first saw the picture, but in the current situation I am not willing to take to risk to get to that position. Its essentially moving me from a very recessed hyperdivergent growth face into a very forward grown one. I just feel like there is a good chance the result wont be as good as it seems. There is a good reason why people discuss Lefort 3 and zygomatic osteotomies etc on this board.
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Regarding the nose changes: https://imgur.com/gallery/bfnppEG
Barely any, but the surgeon employs some special suture technique.
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I am currently thinking about doing the mandibular set back and getting a vertical reduction genioplasty at some point. This is how I envision it: https://imgur.com/gallery/4QnSOa5
pre OP vs plan https://imgur.com/gallery/NdBw6tm
I thought about it a lot. While the post OP picture looks good, it probably doesnt accurately reflect the truth. I believe its best to aim for a natural looking result and one that fits my asian face.
It's funny with these morphs, because what you show here looks perfectly reasonable, and it revert to previous discussion. Your post op picture also looked very good so it's the balance and I'm sure what ever you chose will give you a good result. I don't think moving the maxilla forward will give you a strange look, and I don't think moving the mandible back will either. What is best? Well you ask a forum full of people like me who want the strong jaw line and soft tissue support, moving something back is not what we do :). But, I guess the net movement from where you started will still be very significant even if you move the mandible back.
Could you put up the post op pictures again as reference?
I think you should discuss this with your surgeon. Ask him what he thinks give you the best result and discuss the risks etc. Chance is that he still have same opinion as on first plan though, why would it change.
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I think neither pictures reflect the reality. I dont have a front picture and the angle distorts it a little.
I understand what you are all thinking. I was ecstatic when I first saw the picture, but in the current situation I am not willing to take to risk to get to that position. Its essentially moving me from a very recessed hyperdivergent growth face into a very forward grown one. I just feel like there is a good chance the result wont be as good as it seems. There is a good reason why people discuss Lefort 3 and zygomatic osteotomies etc on this board.
But you are a bit inconsistent. You start the thread asking what yields the best aesthetic result, you seem inclined to full bimax revision and that you liked the post op result. Now not so much.
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I believe I am inconsistent. I find it incredible hard to get a grasp for whats right. The post OP picture always looked good, but the morph also looks good and would be a significant improvement from the current situation. I was trying to find out which way I should go and I feel like the set back is the more realistic and natural solution.
You make a good point about the preference for strong jaws. I believe its this notion that got me into all this hassle in the first place. Im not gonna lie, I was always self conscious about it and Western esthetics do place a strong preference on this trait. But my genetic make up is Asian, so maybe its not meant to be :-\
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I believe I am inconsistent. I find it incredible hard to get a grasp for whats right. The post OP picture always looked good, but the morph also looks good and would be a significant improvement from the current situation. I was trying to find out which way I should go and I feel like the set back is the more realistic and natural solution.
You make a good point about the preference for strong jaws. I believe its this notion that got me into all this hassle in the first place. Im not gonna lie, I was always self conscious about it and Western esthetics do place a strong preference on this trait. But my genetic make up is Asian, so maybe its not meant to be :-\
Eastern genetics absolutely do not preclude a strong jaw. At this point I'm not sure anyone can help you until you make up your mind about what sort of aesthetic you want and which risks you are willing to take. And at that point, I think you'll have answered your own question.
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Yeah, I wasnt thinking when I wrote this. My face was recessed, no matter what culture I was living in. Interestingly, Asian esthetics dont put such an emphasis on strong jaws.
And I guess you are right. I believe, I was mostly using this thread to articulate my own thoughts. I hope you guys dont mind and I thank you all for the civil discussion.
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I believe I am inconsistent.
To me this is totally normal and unless someone went through a bad surgery they might not get it.
Back to your nose...it looks like about 1mm of widening, maybe 1.5mm. I wouldn't call that insignificant, but I'd say it's within norms and not excessive. If you get another 1mm via a revision you'll have trouble. You're likely referring to the Alar stitch. It helps, but it's not a miracle. He'll have to re-cut the muscles that he cut the first time and stitched up. How they react is hard to predict. I'd mentally plan for .5 to 1mm more of widening. Then if you don't get it, great.
I'd try to get him in a consult asap and run concerns by him. If you're happy with is answers do the revision. Don't let the board confuse you further. Listen to your gut, clear your head as to what you want, and then see if his answers are satisfactory. That's about the best you're going to do in an unfortunate situation.
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To me this is totally normal and unless someone went through a bad surgery they might not get it.
Back to your nose...it looks like about 1mm of widening, maybe 1.5mm. I wouldn't call that insignificant, but I'd say it's within norms and not excessive. If you get another 1mm via a revision you'll have trouble. You're likely referring to the Alar stitch. It helps, but it's not a miracle. He'll have to re-cut the muscles that he cut the first time and stitched up. How they react is hard to predict. I'd mentally plan for .5 to 1mm more of widening. Then if you don't get it, great.
I'd try to get him in a consult asap and run concerns by him. If you're happy with is answers do the revision. Don't let the board confuse you further. Listen to your gut, clear your head as to what you want, and then see if his answers are satisfactory. That's about the best you're going to do in an unfortunate situation.
Thank you GJ, I appreciate your help. I just feel lost sometimes because its all happening so fast.
Basically, I am trying to see if a mandible only approach is feasible. I will have to evaluate whether the current position of the maxilla makes sense.
I wish I had more time to double check everything, but the revision is now planned for next week. I was told that I shouldnt let too much time pass as the bone continues to heal.
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I was told that I shouldnt let too much time pass as the bone continues to heal.
From everything I've read and heard that's true, and it's ideal to do it while the bone is soft (easier cuts, etc), but you can do it later. People have revisions 20 years later. Just more risk of a bad split, etc.
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I don't blame you at all for having inconsistent thoughts about this. You're in the thick of it, with a pretty significant complication (that I think no one here has gone through, nor hopes to go through) and it's always harder to think about your own case clearly and let alone after a complication. Your thoughts will be back and forth as you try work this out. Your decision is also time sensitive, which makes it so much harder.
If considering maxilla, definitely ask your surgeon about preventing future relapse. I mean, how can they be sure it won't happen all over again?
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OP, moving the maxilla forward a second time puts a lot of risk to your nose widening more. The photos are no longer up, so I can't see how much it widened the first time. This is one reason I don't like it. In the second photo you posted, from memory, your lower jaw looked too far out for your upper face. So moving the mandible back would make more sense. Cutting the mandible a second time increases the risk of nerve damage, as you might know. So there's that to factor in. I agree with others who said you looked good in the first photo right out of surgery (again, from memory), but you were swollen and in general photos are some of the worst records for assessing anything. You mentioned soft tissue in a post, and again from memory you were Asian and appeared to have thin soft tissue that is somewhat typical in Asians. This will make any movement more apparent since the tissue doesn't hide anything, and it's another reason I think mandible, especially if you miss your old face. Mandible would get you closer to the old face, though you have to accept the actual old face is gone forever. My big issue with the maxilla is moving it a second time puts so much risk to the nose area. It's worth considering because it did look good in that one photo, but I wouldn't consider it without more info from the surgeon. Maybe request an emergency consultation to go over everything. Good luck, buddy. Tough situation.
They use a lot of things to suppress the swelling during the surgery. So a photo taken right afterwards pretty much shows how it will look (if no complications, relapse etc.) when it heals. Swelling sets in hours after surgery and peaks at day 2 or 3.
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I think he's just saying maxillary advancement impacts the nose, and this risk is part of the revision if he goes that route. Not that revision advancement after relapse is necessarily riskier to the nose than initial advancement.
I'm not sure what you mean here. The immediate post-op picture 'reflects' the truth much more 'accurately' than your 10 day pic. At 10 days you still have a ton of swelling. It can literally take 6 months to a year for all swelling to dissipate. Your choice though.
Correct. Immediate post op reflects the outcome with NO swelling. That's why they take them.
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I'd have to see the photos again, but it's likely it widened the first time.
It's likely it would widen again because the muscles that were stitched have to be cut once more. Maybe it doesn't, but it's something to ask the surgeon about (they might downplay the risk, though). I'd ask an objective surgeon who wasn't performing the surgery, personally. He's on a bit of a time crunch so it's tougher to be diligent.
I saw them. Although nostrils can widen with advancement. His nose in profile looked great with the max advancement and less prominent to his face.
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Regarding the nose changes: https://imgur.com/gallery/bfnppEG
Barely any, but the surgeon employs some special suture technique.
Perhaps alar cinch which they use to prevent excess widening.
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I think you managed to remain remarkably calm and rational in the circumstances. I can't give any advice but wish you well and hope the revision will be successful and you will be happy with the final outcome.
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If it were me, i would step back and wait a couple of weeks before making this decision. I have no medical background but its my understanding that the temporalis muscle and other muscles of the jaw atrophy after a BSSO so I wonder how your strong jaw muscles caused this problem. And if so how are the dealing with the muscle pull as you go into another surgery? I would want to know the reason for the cant as well. You dont want to have to get a third surgery if this is not exactly the right correction for you.
According to Arnett, “early relapse is mostly caused by movements at the osteotomy site (osteotomy slippage) or temporomandibular joint sag and is usually called surgical displacement. Two different types of force vectors interact with healing bone fragments. On one side, the stretched paramandibular connective tissue (skin, sub cutis, muscles and periosteum) tends to deviate the tooth-bearing fragment into its original position; on the other side, osteosynthesis hardware, in some cases skeletal suspension and the condyle if seated into the fossa tends to stabilize the fragments. Disharmony of these forces occurs in case of inappropriate fixation and/or wrong peroperative condylar position>” The more your tissues and muscles were stretched, the greater the risk of an early relapse.
If there is no harm to you in giving yourself a little bit of time to fully understand the recommendations, the risks and the benefits and to understand how this strong muscle pull will affect an area that will now have been operated twice in a short period of time, then i would step back and not make a rush decision. There are only a handful of surgeons in the USA that would perform such a large advancement.
I know you have your reasons to be skeptical and are caught in a bad situation. But I wouldn't advice to wait and would very much appreciate if the surgeon want to deal with things as soon as possible if it was me. It's not a rush decision, the dice is cast and this is more a situation to get back on the path that is already decided. It's mentally draining to be in a situation of uncertainty. Yes, there are questions that needs to be asked in order to make the right decision, but I think asking the questions and deal with the situation now will be better than staying in this bubble of uncertainty and anxiety. Your situation is different where you have complications and as I understand don't have a good offer on the table. In this situation the surgeon, patient and this board of experts (JSF approved stamp) agree on the problem and that it can be fixed.
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IMO you look significantly better. Did your tooth show change significantly? I have a big fleshy nose. The advancement did widen it a little bit, but I’m not bothered by it. In general those with fine thin noses, nostrils get the worst deal. Furthermore, anterior downgrafts spare the nose a little compared with other movements (impaction and advancement being the worst).
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IMO you look significantly better. Did your tooth show change significantly? I have a big fleshy nose. The advancement did widen it a little bit, but I’m not bothered by it. In general those with fine thin noses, nostrils get the worst deal. Furthermore, anterior downgrafts spare the nose a little compared with other movements (impaction and advancement being the worst).
I most definitely dont look much better. My tooth show increased to about 1mm at rest. I feel like my nose was mostly spared.
However, an anterior downgraft + a CCW rotation is going to increase vertical face length. If youre starting with a long face type like I do, this should be taken into consideration. I am seeking a chin reduction at some point.
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I am seeking a chin reduction at some point.
How much of your movement was chin?
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I think you managed to remain remarkably calm and rational in the circumstances. I can't give any advice but wish you well and hope the revision will be successful and you will be happy with the final outcome.
Thank you, I appreciate the kind words. I guess its human nature to just move on with life. I was devastated, but I do think I have some hope left.
If it were me, i would step back and wait a couple of weeks before making this decision.
I have been postponing the revision for two weeks already to clear my head a little. At this point I am considering getting the mandible back thus restoring function and improving aesthetics. I am definitely not fully informed, but if the mandibular set back is indeed a smallish procedure as the bones arent fully formed, then it would be preferable to walking around in my currernt state.
I will have to trust my surgeon on this one.
Why I have decided to get the mandibular setback: https://imgur.com/gallery/NdBw6tm
I believe there is only so much a Lefort I can do without disrupting the harmony of ones face. I have gained fullness in my midface and my lips and its a significant improvement. Notice how the are below the eyes remain in their hollow position. At this point, I have to ask myself: What do I have to gain from advancing the maxilla even more? I am a long face type patient which means there are many related deficiencies leading to this phenotype. When you see a person with notable forward growth, it usually is accompanied by other features which cannot be easily achieved by surgery (cheekbones, infraorbitals, etc.)
A CCW lefort is already an optimized approach as it provides more favorable changes to the lips and takes care of my sleep apnea.
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How much of your movement was chin?
anterior downgraft of about 5mm + rotating the mandible forward have increased facial length. The genioplasty has done almost nothing and only moved the chin a few mm in the horizontal plane.
Basically, what I am trying to say: anterior downgraft moves down the chin, ccw rotation of a cw rotated chin brings it into a more vertical position, thus adding to the vertical length. Both these things have significantly lengthened the lower third and I am not able to passively close my lips.
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IMO you look significantly better. Did your tooth show change significantly? I have a big fleshy nose. The advancement did widen it a little bit, but I’m not bothered by it. In general those with fine thin noses, nostrils get the worst deal. Furthermore, anterior downgrafts spare the nose a little compared with other movements (impaction and advancement being the worst).
Are you referring to the morph? Original pics were deleted I think.
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anterior downgraft of about 5mm + rotating the mandible forward have increased facial length. The genioplasty has done almost nothing and only moved the chin a few mm in the horizontal plane.
Basically, what I am trying to say: anterior downgraft moves down the chin, ccw rotation of a cw rotated chin brings it into a more vertical position, thus adding to the vertical length. Both these things have significantly lengthened the lower third and I am not able to passively close my lips.
Na...CCW rotation to the extent you implied you had that via a posterior downgraft brings the chin FORWARD up and out with the CCW posterior downgraft rotation and can do so with little or no genio. You better check your records as to WHAT displacements you had lest you make a decision not knowing what means what. Also, when still in the process of requesting advice or 'explaining' the actual results, those photos should REMAIN up there during duration of active discussion. Morphs are no substitute for removing the photos you entered to query for feedback.
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Thank you, I appreciate the kind words. I guess its human nature to just move on with life. I was devastated, but I do think I have some hope left.
I have been postponing the revision for two weeks already to clear my head a little. At this point I am considering getting the mandible back thus restoring function and improving aesthetics. I am definitely not fully informed, but if the mandibular set back is indeed a smallish procedure as the bones arent fully formed, then it would be preferable to walking around in my currernt state.
I will have to trust my surgeon on this one.
Why I have decided to get the mandibular setback: https://imgur.com/gallery/NdBw6tm
I believe there is only so much a Lefort I can do without disrupting the harmony of ones face. I have gained fullness in my midface and my lips and its a significant improvement. Notice how the are below the eyes remain in their hollow position. At this point, I have to ask myself: What do I have to gain from advancing the maxilla even more? I am a long face type patient which means there are many related deficiencies leading to this phenotype. When you see a person with notable forward growth, it usually is accompanied by other features which cannot be easily achieved by surgery (cheekbones, infraorbitals, etc.)
A CCW lefort is already an optimized approach as it provides more favorable changes to the lips and takes care of my sleep apnea.
I'm very conversant in morphing and know what the 'no nos' are. What you did was take your after which showed your mouth area being very open. You morphed that. I see the SEAM to the morph where part of shortening your chin involved also shortening the MOUTH OPENING to your after. Act of 'grabbing' THROUGH the open mouth area to shorten the chin. That's a NO NO in morphing. So, good luck if you think that a morph that CUTS through your mouth area to shorten both your chin and the mouth opening illustrates what's possible to do during surgery. Better have your surgeon take a close look at that morph and the SEAM in there showing where you cut through to shorten both mouth opening with the chin which ISN'T even a morph of your before surgery photo yet morphs an after surgery photo WITHOUT the actual after surgery photo beside it. Yup. Good luck on acting on information based on that and let us know how that works out for ya.
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You have to converse with your surgeon then follow your gut. There are issues such as your ethnicity and how you relate to your face at play here, and so nobody can tell you how to objectively quantify something so subjective. People gave their opinions. I'd take them as just that and then follow your gut after speaking with your surgeon.
I don't know if this helps at all, but I feel your anxiety and pain. It's a bad situation and wish you the best.
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Are you referring to the morph? Original pics were deleted I think.
I guess it was the morphs.
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I most definitely dont look much better. My tooth show increased to about 1mm at rest. I feel like my nose was mostly spared.
However, an anterior downgraft + a CCW rotation is going to increase vertical face length. If youre starting with a long face type like I do, this should be taken into consideration. I am seeking a chin reduction at some point.
What was your pre-op tooth show at rest? 1 mm at rest is good for a man.
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How are you jawsandsleep, any updates?