jawsurgeryforums.com
General Category => Aesthetics => Topic started by: lsubuilder on April 09, 2020, 11:31:53 AM
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Need some advise. Had braces as a kid. My bite was fixed (and im told my upper teeth tilted in to compensate) but it left me looking like this. also have been developing sleep apnea. Ive been talking to a new orthodontist who referred me to a local surgeon for bimax. Well the surgeon disagrees and thinks I only a bsso. His plan is to pull lower teeth and create an overjet to bring my jaw forward. Im not sure this is going to improve my profile much. Recently found out he only like to preform surgery on one jaw. Does this guy sound like he knows what hes talking about?
So looks like I will have to travel out of state for this. Im in Louisiana and was looking in either Houston or Dallas. I know Gunson is great in California. Im confused how that would work for follow up appointments as air travel would add up.
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ceph
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Looks like your occlusal plane is pretty steep. I think you need a bimax with counter clockwise rotation. Gunson would be good for getting comprehensive analysis, and a good surgeon if you can afford him. Some big names that do what I think you need.
Wolford (kinda old though)
Movahed
Relle
Alfaro (Spain)
Gunson
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You need a pretty drastic rotation, so I agree with PB's list. Though, there are a lot of no-name surgeons that do good work, too, so maybe you can find one in your area. If you get local leads try to also talk to their patients. Richard Joseph in Flordia has nice results, but last I heard he was only taking FL residents. You might be close enough he'd work on you. There was a guy in the Northeast (Henry? I think that was the last name) who I heard did good work, too.
Any extractions as a kid? Some people do get recommended lower extraction only so they can move the jaw linearly. Not sure that would do enough for you. It's generally better for flat occlusions and where not a lot of advancement is needed. You have a steep occlusion and need quite a bit of advancement. Hence a big CCW movement might be best, though it can be unstable.
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Well, your upperjaw would best NOT be brought forward. Lower only (if that can be done) would bring some improvement. But tradeoff is lower jaw tooth extractions to do it. However, the upper jaw could be cut, tilted down in the back and posterior part of it filled with a big downgraft. That would allow minimum upper jaw forward displacement and tend to maximize the advancement to the lower jaw and more so than the single BSSO offered to you.
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No never had any extractions. I had a feeling the guy i went to didnt know what he was talking about. I he acted like i was crazy asking about rotation. Ill have to look into those doctors thanks. Ive looked into Alfaro but im not sure how this all works when traveling overseas. My orthodontist already seemed shocked when i said i was looking in other states
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Of those mentioned, Relle is the most conservative, but few complain about him. Alfaro and Gunson are known to have left so many bad bites, that I wouldn’t trust either. Wolford invented CCW. Movahed is supposedly his best student. Taylor in Houston is also supposed to be very good and affordable. Realistically you only have one shot at this, so make it count. You need significant CCW rotation.
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No never had any extractions. I had a feeling the guy i went to didnt know what he was talking about. I he acted like i was crazy asking about rotation. Ill have to look into those doctors thanks. Ive looked into Alfaro but im not sure how this all works when traveling overseas. My orthodontist already seemed shocked when i said i was looking in other states
The cost of going to a different state or even international is nothing compared to a lifetime of unhappiness due to A poor functional and/or aesthetic outcome. This is a complex and risky procedure. Not the time for deal-hunting
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Of those mentioned, Relle is the most conservative, but few complain about him. Alfaro and Gunson are known to have left so many bad bites, that I wouldn’t trust either. Wolford invented CCW. Movahed is supposedly his best student. Taylor in Houston is also supposed to be very good and affordable. Realistically you only have one shot at this, so make it count. You need significant CCW rotation.
Movahed does seem to get almost universally positive reviews. I’m not sure if this is a function of the type of cases he takes on, the fact that his operation volume is still relatively low since he’s young, or if he’s actually just that good.
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Movahed does seem to get almost universally positive reviews. I’m not sure if this is a function of the type of cases he takes on, the fact that his operation volume is still relatively low since he’s young, or if he’s actually just that good.
I distinctly remember mentioning here that some of his patients have posterior open bites in the photos on his site. Those photos are no longer there.
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I distinctly remember mentioning here that some of his patients have posterior open bites in the photos on his site. Those photos are no longer there.
The one negative review I found complained of posterior open bite. Not sure if it’s the same case.
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Go on a consultation spree, a lot of the high volume top guys will give you a full surgical plan in your very first appointment.
Since you have an old school ceph, it looks like your surgeon didn't take a CBCT scan aka 3D xray. I'd avoid surgeons who don't do 3D planning.
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Go on a consultation spree, a lot of the high volume top guys will give you a full surgical plan in your very first appointment.
Since you have an old school ceph, it looks like your surgeon didn't take a CBCT scan aka 3D xray. I'd avoid surgeons who don't do 3D planning.
Most won’t do the CBCT until the planning appointment immediately prior to surgery. This is Gunson’s method too.
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Most won’t do the CBCT until the planning appointment immediately prior to surgery. This is Gunson’s method too.
Ohh Gunson wanted a CBCT's for me but maybe it's because I was a revision case.
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Ohh Gunson wanted a CBCT's for me but maybe it's because I was a revision case.
I'm also a revision case but he didn't take a CBCT during the consult. Maybe it's case-by-case. Should definitely go with a surgeon that uses one for the week-of-surgery planning.
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From looking at your contour in the FLESH, it looks like you have an Anterior Nasal Spine that sticks out too much. Because the upper lip looks to be 'tethered' to an area at base of nose that is too far out which is a type of contour associated with the ANS* being too far out.
FRom looking at your ceph it looks like the green dot I marked as ANS COULD BE where your ANS is. I'm not entirely sure of 'exact' location which is why I put a question mark (?) to it. But what I've pretty sure of is that you have a prominent ANS, which gives appearance that your maxilla is overly forward. But it isn't. That is to say, you don't have an overly high SNA angle but the LOOK of the area looking too far forward relative to the lower jaw is most likely attributed to a very protrusive ANS.
The ANS can be CUT DOWN during a bimax surgery along with other rhinoplasty type adjustments. So, that very possibility will SHIFT you towards bimax and to a maxfax that has more tools in his tool box than the one you consulted with already.
As to exact location of ANS on your ceph, you would need to get a tracing of your ceph where dots were placed over the exact points.
*NOTE: ANS is abbreviation for Anterior Nasal Spine but NOT the angle formed by the landmark points; 'S', 'N' and 'A'. ANS is also a landmark point.
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Thanks for the advice everybody. I’m going to get consults with the surgeons mentioned. I’ve had a consult scheduled with randy Sanovich in Dallas but it got pushed back because of the virus. I don’t know much about him he was recommended by a friend. I unfortunately have to drive out there. Working on a consult with Gunson but his office wants a doctors referral which I don’t have.
I will definitely mention the ans. Always hated that and was told I’d need a rhinoplasty before I knew my jaws were the issue. Would be great if I could get that tethered look fixed. Maybe the surgeon I went to figured I didn’t need the upper jaw moved forward because of that?
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Thanks for the advice everybody. I’m going to get consults with the surgeons mentioned. I’ve had a consult scheduled with randy Sanovich in Dallas but it got pushed back because of the virus. I don’t know much about him he was recommended by a friend. I unfortunately have to drive out there. Working on a consult with Gunson but his office wants a doctors referral which I don’t have.
I will definitely mention the ans. Always hated that and was told I’d need a rhinoplasty before I knew my jaws were the issue. Would be great if I could get that tethered look fixed. Maybe the surgeon I went to figured I didn’t need the upper jaw moved forward because of that?
That could have been a factor if he wasn't braced to do the rhino techniques that might have to be done when the ANS is cut down.
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Thanks for the advice everybody. I’m going to get consults with the surgeons mentioned. I’ve had a consult scheduled with randy Sanovich in Dallas but it got pushed back because of the virus. I don’t know much about him he was recommended by a friend. I unfortunately have to drive out there. Working on a consult with Gunson but his office wants a doctors referral which I don’t have.
I will definitely mention the ans. Always hated that and was told I’d need a rhinoplasty before I knew my jaws were the issue. Would be great if I could get that tethered look fixed. Maybe the surgeon I went to figured I didn’t need the upper jaw moved forward because of that?
Another surgeon worth considering.
https://profilesofs.com/steven-sullivan
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I also will add that what you have going on with the (suspected) EXCESS of the ANS is most certainly in rhinoplasty land. It would tend to explain why a rhinoplasty doctor told you the problem was with your nose. It's because it plays a significant role in making your upper jaw LOOK too far forward and thereby, RELATIVELY making the lower jaw look too far backward. So, it's not a thing where the problem is to your jaw/s INSTEAD of your nose. It's more of a thing where who ever does the jaw surgery will also need to be very competent in rhinoplasty.
As to the doctor you consulted with who wanted to do single jaw BSSO, it just seems unlikely that his overall preference (for a patient population) is single lower jaw surgery. That is to say, it doesn't make much sense to me that a maxfax would have much of a practice if he didn't perform BIMAX surgery. It's more likely he recognized his limitation in RHINOPLASTY but also recognized single jaw surgery would help improve the convex profile. Similarly, the rhino doctor, before that, saw that a rhino would improve your profile.
Advice from consults is usually limited to what's in the doctor's toolbox where they just look for the stuff they CAN do. For the most part, they don't evaluate in terms of what's in other doctor's tool boxes.
Your nose would need to be DEPROJECTED and cutting down the ANS is just part of that. Hence, a rhinoplasty and a good one is an important part for aesthetic improvement which is more likely to be in a rhino guy's 'tool box' than the maxfax guys. So, I wouldn't rule out consulting with rhino doctors also. Here's a link to a tutorial on ANS rhinoplasty. It has photos on how big the ANS can be.
http://www.facialsurgery.com/ClkoffTPgt3_2011_09_01bh.html
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I actually had a consult with dr denenburg for a rhinoplasty. He was great to talk to an recommended de projection. Would it be better to look into a rhinoplasty before or after jaw surgery? Or should I look for a surgeon that would do both at the same time?
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I actually had a consult with dr denenburg for a rhinoplasty. He was great to talk to an recommended de projection. Would it be better to look into a rhinoplasty before or after jaw surgery? Or should I look for a surgeon that would do both at the same time?
Personally I feel as though these procedures should be done separately, although they are often performed jointly. Performing them simultaneously adds an extra layer of risk because the soft tissue changes are less predictable. More moving parts at once means more room for error. Rhino should come second.
I’m currently pursuing a revision and feel as though I need a rhino to address some of the side effects of my original surgery. But in addition to financial reasons, I’m delaying the rhino until a year minimum after my revision in order to have a more predictable result. Realistically it will be several years though because this stuff is so expensive.
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I actually had a consult with dr denenburg for a rhinoplasty. He was great to talk to an recommended de projection. Would it be better to look into a rhinoplasty before or after jaw surgery? Or should I look for a surgeon that would do both at the same time?
I would isolate nose to rhino guy. Most likely first and separate given that area needs a lot of time/attention to it. Max fax nose work is often just some minor adjustments. The de projection will give better balance and you would be in a better place to isolate the lower jaw BSSO only if you wanted. It shouldn't preclude bimax either, later down the line if you wanted that instead. All those 'big names' given to you do surgeries where prior surgeries have already been done.
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This is the morph dr dendenburg sent me. It does help my profile. Ill bring it up in the consults I get. Sounds like I do need that first then I’d hate to get a bimax and it looks even worse lol. Just more money lol
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This is the morph dr dendenburg sent me. It does help my profile. Ill bring it up in the consults I get. Sounds like I do need that first then I’d hate to get a bimax and it looks even worse lol. Just more money lol
That's consistent with my thoughts on the matter where that alone does make LESS the how much the lower jaw looks to be recessed. That is to say, WITHOUT the nose being addressed, it makes maxilla protrusion LOOK like MORE than it is and mandible retrusion also look MORE than it really is via RELATIVE comparison. Basically, the nose is giving too much of an OPTICAL ILLUSION as to the extent of the jaw imbalance. With the nose out of the way first, the conservative choice would be the single BSSO offered to you.
ETA: A nose a good rhino guy can do (and Dennenberg can be considered such) might not be something you can expect the maxfax to do.
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OP, I personally don't think you need a nose job. But if you decide to go that path, I'm going to PM you some info on a lead in your area who is excellent.
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One last question. If I end up having bimax with ccw as some have suggested i need, would that make the nasolabial angle worse or better if i leave out any rhinoplasty work?
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That's consistent with my thoughts on the matter where that alone does make LESS the how much the lower jaw looks to be recessed. That is to say, WITHOUT the nose being addressed, it makes maxilla protrusion LOOK like MORE than it is and mandible retrusion also look MORE than it really is via RELATIVE comparison. Basically, the nose is giving too much of an OPTICAL ILLUSION as to the extent of the jaw imbalance. With the nose out of the way first, the conservative choice would be the single BSSO offered to you.
ETA: A nose a good rhino guy can do (and Dennenberg can be considered such) might not be something you can expect the maxfax to do.
In my opinion, his occlusal plane is (looks) steep enough that only a bimax will be able to achieve the optimal result. If he will ultimately get a bimax, I think he should do that first since CCW rotation will impact the nose independent of any ANS shaving. My fear is that he gets a good rhino and then has to revise it because the bimax changed his nose.
Also, I feel as though jaw surgery will set the 'canvas' for his face to which the rhino can be tailored. I.e, I think he should get the jaw in the right place first and then detail the nose to fit his new face. The nose will play little role in BSSO planning whereas the jaw might impact aesthetic planning for the nose.
Edit: UNLESS the OP is happy with the morph from the rhino doc, which is a perfectly acceptable face.
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One last question. If I end up having bimax with ccw as some have suggested i need, would that make the nasolabial angle worse or better if i leave out any rhinoplasty work?
CCW will improve your nasolabial angle, but it will not fix the 'tethered' look without intervention at the ANS.
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Thing is, you stand to get more facial balance 'relief' from having the ANS cut down than you would with jaw surgery alone without that. The jaw to jaw balance brought about by maxfax whether you get the single BSSO or the BIMAX with CCW stands to NOT look like good facial balance (soft tissue contour) if the ANS is not cut down.
The ANS cut down is a 'deprojection rhino' and they just can't lop it off without doing other rhino adjustments along with it which are best done by a nose guy who demonstrates they are familiar with managing protrusive ANS and doing so to also improve overall aesthetics of nose.
For those of you on here who are familiar with Gunson's TVL line for the CCW, you would know that the Gunson TVL passes through WHERE the BASE of nose MEETS the UPPER LIP. I've drawn one in GREEN on his ceph. (His S-N line/plane is actually parallel with plane of photo. So looks like he's close to the type of head rotation they want.) NOTE how the line suggests ALOT of maxilla advancement and of course mandible advancement with that for the lips to 'kiss' a bit past the line and the chin point to line up with it. Now, WITH THAT, try to VISUALIZE how his nose to lip angle would look with the maxilla brought forward so the lips are close to that line. If you can't visualize what that could look like, I can tell you it would look BAD. THAT'S WHY I called the GREEN TVL a FALSE one. It's because his protrusive ANS gives a FALSE reading of where the TVL should be placed as guideline to displace both maxilla and mandible.
The BLUE TVL is adusted to (approximately) WHERE that line should pass through the BASE of the nose where it meets the upper lip. So, the BLUE adjusted TVL is a better aesthetic guideline with reference to a Gunson type CCW posterior downgraft rotation BIMAX. However, for the TVL to pass through where the base of then nose meets the lip, the ANS would need to be cut down.
So, it's not a thing where he needs a rhino just for nose aesthetics. But rather he needs one because the ANS would need to be cut down for good JAW SURGERY aesthetics where the situation is one where cutting ANS down will require other alterations of nose best done by a rhino guy.
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In my opinion, his occlusal plane is (looks) steep enough that only a bimax will be able to achieve the optimal result. If he will ultimately get a bimax, I think he should do that first since CCW rotation will impact the nose independent of any ANS shaving. My fear is that he gets a good rhino and then has to revise it because the bimax changed his nose.
Also, I feel as though jaw surgery will set the 'canvas' for his face to which the rhino can be tailored. I.e, I think he should get the jaw in the right place first and then detail the nose to fit his new face. The nose will play little role in BSSO planning whereas the jaw might impact aesthetic planning for the nose.
Edit: UNLESS the OP is happy with the morph from the rhino doc, which is a perfectly acceptable face.
A protrusive ANS if NOT cut down during the surgery would tend to limit maxilla advancement even if only a few mms were needed in the process of CCW rotation and BSSO advancement. That is to say, it could pose a limit of 0 maxillary advancement which in turn would limit mandible advancement.
Thing is if it's cut down during the surgery, OTHER rhino techniques would have to be used with it, lest resultant nose aesthetics would not look good.
See my post on here about the TVL used in planning a bimax CCW surgery.
The top CCW docs are not known for rhinoplasties. Just for some adjustments to compensate for maxillary advancements. There was a case a few years back where Alfaro did a rather significant CCW posterior downgraft BIMAX advancement which looked great EXCEPT for the NOSE. He had to remove part of the ANS to get the jaw balance. But the nose tip drooped down with that and the nose suffered. It was a situation where Alfaro was not really versed in doing the rest of the rhinoplasty that would have had to go with the ANS cut down.
Moral of story: An ANS cut down had to be done for the BIMAX advancement (and that was WITH CCW downgraft). But he, a top maxfax, didn't do the rest of the rhino needed with the ANS cut down.
IMO, a 'good' maxfax probably would cut down his ANS during the bimax CCW surgery. But I'm not too sure that they would be good at doing all the rhino techniques with that to make the nose good. I tend to think that a maxfax would have an easier time balancing the jaws if they didn't have to worry about thier limitations to do a good rhino along with balancing the jaws.
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A protrusive ANS if NOT cut down during the surgery would tend to limit maxilla advancement even if only a few mms were needed in the process of CCW rotation and BSSO advancement. That is to say, it could pose a limit of 0 maxillary advancement which in turn would limit mandible advancement.
Thing is if it's cut down during the surgery, OTHER rhino techniques would have to be used with it, lest resultant nose aesthetics would not look good.
See my post on here about the TVL used in planning a bimax CCW surgery.
The top CCW docs are not known for rhinoplasties. Just for some adjustments to compensate for maxillary advancements. There was a case a few years back where Alfaro did a rather significant CCW posterior downgraft BIMAX advancement which looked great EXCEPT for the NOSE. He had to remove part of the ANS to get the jaw balance. But the nose tip drooped down with that and the nose suffered. It was a situation where Alfaro was not really versed in doing the rest of the rhinoplasty that would have had to go with the ANS cut down.
Moral of story: An ANS cut down had to be done for the BIMAX advancement (and that was WITH CCW downgraft). But he, a top maxfax, didn't do the rest of the rhino needed with the ANS cut down.
IMO, a 'good' maxfax probably would cut down his ANS during the bimax CCW surgery. But I'm not too sure that they would be good at doing all the rhino techniques with that to make the nose good. I tend to think that a maxfax would have an easier time balancing the jaws if they didn't have to worry about thier limitations to do a good rhino along with balancing the jaws.
Ok, I see what you're saying. I didn't think about the relationship between the ANS and TVL with regard to planning. In the cases with prominent ANS then, it might be preferable to perform the rhino first and then bimax based on the new ANS position.
Alternatively, I suppose it's possible to ask the maxfac to plan the procedure around where the ANS 'should' be after the rhino (blue line on your diagram). Presumably this could make the final nose result more predictable by having the detail work done after the bimax movement. This assumes OP actually wants a bimax and would also require close coordination between the maxfac and rhino surgeon.
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Ok, I see what you're saying. I didn't think about the relationship between the ANS and TVL with regard to planning. In the cases with prominent ANS then, it might be preferable to perform the rhino first and then bimax based on the new ANS position.
Yes. That's what I'm saying.
Alternatively, I suppose it's possible to ask the maxfac to plan the procedure around where the ANS 'should' be after the rhino (blue line on your diagram). Presumably this could make the final nose result more predictable by having the detail work done after the bimax movement. This assumes OP actually wants a bimax and would also require close coordination between the maxfac and rhino surgeon.
That could leave the maxfax result looking terrible if they had to advance the maxilla. So could cutting the ANS during the surgery and telling him to get a rhino later. He could be stuck with about a year's worth of very WONKY face. He could get the rhino first and tell the doctor to give him a neutral to slightly downwardly rotated tip position. In that way, if the bimax includes a few mms forward advance to maxilla, the tip won't take on an overly upward rotation of the tip. A neutral tip position and also a slight downward rotation of tip is within normative nose. But the rhino should not have upward tip rotation because then any advancement of maxilla will have that veer toward a less than optimal aesthetic for the nose.
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That could leave the maxfax result looking terrible if they had to advance the maxilla. So could cutting the ANS during the surgery and telling him to get a rhino later. He could be stuck with about a year's worth of very WONKY face. He could get the rhino first and tell the doctor to give him a neutral to slightly downwardly rotated tip position. In that way, if the bimax includes a few mms forward advance to maxilla, the tip won't take on an overly upward rotation of the tip. A neutral tip position and also a slight downward rotation of tip is within normative nose. But the rhino should not have upward tip rotation because then any advancement of maxilla will have that veer toward a less than optimal aesthetic for the nose.
That's true. i was just considering what might be optimal for the final result. I'm sensitive to the impact of the LF1 on nose appearance given the changes I had, even though my LF1 advancement was far beyond anything OP should consider. It's one of the risks maxfacs should inform their patients of, but often don't.
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That's true. i was just considering what might be optimal for the final result. I'm sensitive to the impact of the LF1 on nose appearance given the changes I had, even though my LF1 advancement was far beyond anything OP should consider. It's one of the risks maxfacs should inform their patients of, but often don't.
I totally agree. They should tell them about the nose changes.
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Just had a consult with Alfaro. He was great answered all of my questions. He wants to do a bimax with ccw rotation. I asked about the prominent nasal spine. He said not to do anything and that he would cut below it so it would not be an issue. Also said he would do surgery first and theres a chance i dont need braces after at all since my bite is fine. 1.5 hour surgery time is crazy fast compared to here. Just waiting to see what the prize is on that. I have a consult with Gunson next week as well.
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Just had a consult with Alfaro. He was great answered all of my questions. He wants to do a bimax with ccw rotation. I asked about the prominent nasal spine. He said not to do anything and that he would cut below it so it would not be an issue. Also said he would do surgery first and theres a chance i dont need braces after at all since my bite is fine. 1.5 hour surgery time is crazy fast compared to here. Just waiting to see what the prize is on that. I have a consult with Gunson next week as well.
Refer to reply #30 on this thread. You need to be very careful about letting the maxfac entirely handle nose modifications.
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Yes i am concerned about that. He said my nasal spine looks prominent because my jaws are so recessed compared to it. He would cut around it and move everything else. Does that make sense to you? Ive never heard that before
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Yes i am concerned about that. He said my nasal spine looks prominent because my jaws are so recessed compared to it. He would cut around it and move everything else. Does that make sense to you? Ive never heard that before
Sorry- I misread your earlier reply. I thought you were saying he said not to worry and that he would cut it down. That's what happens when you skim.
Typically the lefort 1 cut is above the ANS. I'm not sure how he's going to do that.
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Its possible i misunderstood what he said. I will have to ask him again if i go forward
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Its possible i misunderstood what he said. I will have to ask him again if i go forward
Here's a diagram of the standard lefort1 fracture: https://medicine.uiowa.edu/iowaprotocols/facial-fracture-management-handbook-lefort-fractures
As you can see, the fracture is above the ANS. I'm not familiar with a lefort fracture that would leave the ANS in place.
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Thats what i thought. I told him i was worried about that moving forward and making my nose worse. Which is when he said he could cut around it. Ill have to get him to clarify.
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Just had a consult with Alfaro. He was great answered all of my questions. He wants to do a bimax with ccw rotation. I asked about the prominent nasal spine. He said not to do anything and that he would cut below it so it would not be an issue. Also said he would do surgery first and theres a chance i dont need braces after at all since my bite is fine. 1.5 hour surgery time is crazy fast compared to here. Just waiting to see what the prize is on that. I have a consult with Gunson next week as well.
That's an admission that Alfaro can't do the rhino which would need to go with an ANS cut if he removed it during the surgery which is what I was saying in response #30.
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Yes i am concerned about that. He said my nasal spine looks prominent because my jaws are so recessed compared to it. He would cut around it and move everything else. Does that make sense to you? Ive never heard that before
Your nasal spine 'looks' prominent because it IS prominent and your jaws would look LESS recessed by comparison if you had a deprojection rhino.
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Thats what i thought. I told him i was worried about that moving forward and making my nose worse. Which is when he said he could cut around it. Ill have to get him to clarify.
Such a 'clarification' would show up in a surgical displacement diagram and READ OUT where the read-out section for the maxilla, under the category of 'ANS' displacements in the horizontal direction read ZERO, 0, nulla, ninch.
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So there is no way to move the maxilla forward without the ans? Thats what i thought but he made it sound like it is what he wanted to do.
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One thing to remember is that top maxfac surgeons are also businessmen. They make a ton of money off of surgical fees and have an interest in getting you to agree to their plan. So Alfaro may downplay the necessity of a rhinoplasty because his own skillset cannot fully address that issue.
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My guess is he said he'd cut down the ANS. Somewhat common to reduce it, if prominent, during surgery.
Clarify that with him.
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Which is when he said he could cut around it. Ill have to get him to clarify.
this is correct. he does a modified le fort where the ANS is not moved nor touched. he cuts around it.
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On all the x-rays of Alfaro’s patients that I’ve seen he does bugger all fixation. I mean he does huge movements, yet uses few screws and plates. This is probably how he does his surgeries so fast.
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Thought id give an update. Had consults with gunson, relle and alfaro. These are the two plans i got. Alfaro unfortunately wouldnt give me any plan until i go there for scans and molds. His consult was great but that makes me hesitant. All three want to do bixmax with rotation. Gunson seems to rotate more. im not 100% sure im reading these correctly or which one would be better.
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Thought id give an update. Had consults with gunson, relle and alfaro. These are the two plans i got. Alfaro unfortunately wouldnt give me any plan until i go there for scans and molds. His consult was great but that makes me hesitant. All three want to do bixmax with rotation. Gunson seems to rotate more. im not 100% sure im reading these correctly or which one would be better.
Hell of a downgraft from Gunson. My god. Yes he is rotating you quite a bit more whereas Relle is opting for more linear advancement. Your ANS is coming forward by twice as much under Relle's plan.
Gunson's plan is the 'high risk, high reward' option here. Relle's more conservative approach comes at the cost of more ANS advancement. Personally under both plans I would like to see a stronger genioplasty, which you could probably request. That's a personal preference though.
One option is to get the rhino with ANS adjustment and then come back to Relle for a more conservative rotation but add a genioplasty if you want a stronger chin. I'm guessing the price of rhino + genio + bimax with Relle might be equal to the price of Gunson bimax alone; though I could be wrong. I don't know much about Relle's prices.
There are still some questions in orthognathic literature about the stability of posterior downgrafts. That risk is correlated with the size of the movement. The above option may give you a good result that's more stable and for a more reasonable price. IMO you're going to need the rhino regardless of the surgeon. You've got quite an ANS. For reference, here's my tracing from Gunson: https://imgur.com/xmsbhf1
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I havent gotten a price from Relle yet but Gunsons quote was pretty heafty. Almost 20k more than alfaro(although he did not give me any measurements) for his fee alone. Gunson also threw in cheek augmentation.
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I havent gotten a price from Relle yet but Gunsons quote was pretty heafty. Almost 20k more than alfaro(although he did not give me any measurements) for his fee alone. Gunson also threw in cheek augmentation.
If Relle's prices are similar to Gunson's then my above statement regarding prices is true.
Alfaro is likely to give a plan more similar to Gunson. I think he may be a good option for you since your bite is not a significant issue. The reason he won't give you a tracing right now is because he typically takes the 'surgery first' approach. Other surgeons pretty much have to give you a plan because they can't just say "ok spend $7k on braces and i'll tell you my plan in 6 months". He did give me one, but I think that's because he considered pre-op braces a possibility in my case.
All 3 surgeons are competent. The way I see it is this:
Gunson: More attention to detail, large rotations. Probably best for cases with complex bite issues. Exorbitantly expensive.
Alfaro: Also large rotations. Tends to propose a slightly better chin for men than Gunson. More reasonable prices (both surgical fees and hospital). Best for cases requiring large rotation where the bite is already pretty good.
Relle: More conservative rotations. Prices are reasonable (I think, need to verify). Best for people who are risk averse and/or needs less rotation.
My reading of this is that Alfaro could be the best option for you depending on his plan and your risk tolerance. I think it's hard to justify Gunson's prices in your case since your bite isn't a major problem. My concern with Relle's plan is how far forward he is bringing your ANS. That's the opposite of what you need. However if you got a rhino first, all that is potentially subject to change.
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Awesome thanks for the advice. I am leaning towards Alfaro but getting so much info from these two and little from Alfaro threw me off. Pretty much every detailed question i had he said it will be determined when i get there. Which i understand but still scary. Both Gunson and Relle want to do a 3 piece lefort to widen my jaw. Apparently thats still doable with surgery first but again Alfaro would only say he will determine if thats needed when i come. The price differences are pretty crazy.
I was surprised how much Relle advanced my ans as well. In our consult he said 9mm upper advancement and 14mm lower. He seemed confident that my ans would be fine but i dont see how lol.
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Awesome thanks for the advice. I am leaning towards Alfaro but getting so much info from these two and little from Alfaro threw me off. Pretty much every detailed question i had he said it will be determined when i get there. Which i understand but still scary. Both Gunson and Relle want to do a 3 piece lefort to widen my jaw. Apparently thats still doable with surgery first but again Alfaro would only say he will determine if thats needed when i come. The price differences are pretty crazy.
I was surprised how much Relle advanced my ans as well. In our consult he said 9mm upper advancement and 14mm lower. He seemed confident that my ans would be fine but i dont see how lol.
If Alfaro is making you pay the surgical fees before giving you a preliminary CEPH tracing then that is not acceptable. I would not go along with that if I were you. If he's trying to do that then I think you need to push to see what you're getting into before coughing up that kind of cash.
It's difficult to compare CEPHs between surgeons because each surgeon rotates the CEPH to a different degree before performing the analysis. Changing the orientation of the CEPH can shift the magnitude of the vertical and horizontal vector components for any given 'absolute' diagonal displacement. For example, if Gunson's and Relle's A-P displacement readouts were the same but Gunson rotated the CEPH more clockwise for planning than Relle, then Gunson's A-P displacements are actually larger than Relle's when normalizing the CEPHs to the same orientation.
The upshot is that CEPH readouts between surgeons are not always apples-to-apples comparisons. However, the differences here are so large that it gives you enough info to draw meaningful distinctions between surgical approaches.
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They havent given me anything other than the quote. He explained his plan during the consult but no tracings or anything. I will email them again to see what the deal is
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They havent given me anything other than the quote. He explained his plan during the consult but no tracings or anything. I will email them again to see what the deal is
Did you see them in-person or remotely?
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It was remotely. I sent in xrays and pictures from my orthodontist. All 3 consults were done remotely
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Relle's plan looks nice. Walline is a great guy. Met him on the elevator while consulting with Relle...super nice, and I think he assists.
G's plan looks aggressive, but you are quite recessed so it makes sense to go that dramatic. You'd have to wonder if that large a rotation would remain stable. That would be my only concern there.
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16 mm must be some kind of record.
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You really ought to ask him what’s the biggest downgrafti he’s done and what material did he use. What material does he plan on using on you?
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You really ought to ask him what’s the biggest downgrafti he’s done and what material did he use. What material does he plan on using on you?
Almost certainly HA blocks. That’s what Gunson told me when I asked him. Alfaro too.
What I don’t understand is how relapse is possible with HA blocks since they don’t disintegrate. I guess the bone can still resorb.
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I actually forgot to ask him that. You’re right Alfaro told me Ha blocks. I did not realize this much rotation is not common. I’ll have to ask what he’s done before
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Jesus Christ. Shocking what they want to do to work around your ANS. eg. Gunson's OVER ROTATION to shift the point of the ANS upwards where some of the over rotation goes toward minimizing the ANS horizontal advancement. Gunson's ceph tracing of the before is better than Relle's though because it shows the 'tethering' aspect of the upper lip to the nose base. Are the tracings from the same ceph? I ask because Relle's ceph tracing which gives AP advancement of approx 6 does not show the same extent of the tethering of the upper lip. IF Relle's tracing was from same ceph, they it looks like he FUDGED the before tracing. Then you have Alfaro wanting to cut around the ANS. So, extra cuts in addition to a 3 piece L1.
What I see is that the surgery proposals are MORE than they would be if you went in there with a deprojection rhinoplasty where the ANS was addressed.
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I actually forgot to ask him that. You’re right Alfaro told me Ha blocks. I did not realize this much rotation is not common. I’ll have to ask what he’s done before
No. It's not that common. It's like what I said, where they are doing too much due to work arounds re. the ANS. None of them are humble enough to suggest you first get a rhino to address the ANS so they don't have to OVER ROTATE you to work around the ANS given that none of them are in capacity to do the type of rhino you would need.
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Relle's plan looks nice. Walline is a great guy. Met him on the elevator while consulting with Relle...super nice, and I think he assists.
G's plan looks aggressive, but you are quite recessed so it makes sense to go that dramatic. You'd have to wonder if that large a rotation would remain stable. That would be my only concern there.
Sure it looks nice. It's because he FUDGED the lip contour in his before tracing. I am assuming the SAME ceph was used in the OP's 'remote' or 'cyber' consults.
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Alfaro responded. He doesnt do any 2D tracings. Either wait until i go for surgery or go in for an in person consult
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No. It's not that common. It's like what I said, where they are doing too much due to work arounds re. the ANS. None of them are humble enough to suggest you first get a rhino to address the ANS so they don't have to OVER ROTATE you to work around the ANS given that none of them are in capacity to do the type of rhino you would need.
I thought that you should never do a rhino before, because the nose will change anyway after a jawsurgery.
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Alfaro responded. He doesnt do any 2D tracings. Either wait until i go for surgery or go in for an in person consult
Whoever from his office told you this is misinformed or being dishonest. This is the 2D CEPH tracing I received when I requested it after my consult in December: https://imgur.com/a/s4vXfP1
Maybe his policies have changed, not sure.
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I thought that you should never do a rhino before, because the nose will change anyway after a jawsurgery.
Read the rest of the thread for context and justification
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I asked if they would provide any ceph tracing so i can get a rough idea and this is what i got back "We do not provide cephalogram, because all of our surgeries are planned in 3D software. You can discuss your 3D planning with Prof Hernandez Alfaro but it should be done right before the surgery (3days before), unless you would like to come to Barcelona and have an in-situ visit with the doctor and all the tests could be performed and then come back only for surgery"
Looks like ill have to go in person
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Alfaro has access to software to do the 2-d ceph tracings.
During the time of CORONA VIRUS, where Spain is very hard hit and when many doctors are doing CYBER CONSULTS, Alfaro wants you to go in person. OK :o
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Kind of ridiculous. I’ve asked twice and that’s all they say
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You say your consult with Alfaro was 'great'. But how great could a consult be in the absence of the type of information you wanted to get from it.
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Alfaro sent me this
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Well, I could tell you a very OBVIOUS difference compared to the presentation of the other 2 diagrams that I noticed on the 'this is what Alfaro sent me' document. But I'm curious to see if you noticed it.