jawsurgeryforums.com
General Category => Aesthetics => Topic started by: Gadwins on May 21, 2020, 06:09:53 AM
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So I think the subject says everything. I want to anticipiate my aesthetic resultat and I really want to have concave philtrum. I am not sad, if I get a chimp lip, solong there are possiblities to correct it.
I know that an over advancement could produce a chimp lip. But how much is too much? Does the angle of my upper teeth play a role?
Thank you for your answers.
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So I think the subject says everything. I want to anticipiate my aesthetic resultat and I really want to have concave philtrum. I am not sad, if I get a chimp lip, solong there are possiblities to correct it.
I know that an over advancement could produce a chimp lip. But how much is too much? Does the angle of my upper teeth play a role?
Thank you for your answers.
Even the 'correct' amount of maxilla advancement can cause chimp-lip because the LF1 is not a perfect osteotomy. In my opinion, all we can really talk about is tendencies rather than absolute measures:
Factors that will tend toward chimp-lip:
- Larger advancement
- Retroclined incisors
- Flat pre-op philtrum
- Steep occlusal plane
Factors that will tend toward philtral concavity:
- Smaller advancement
- Proclined incisors
- Concave pre-op philtrum
- Flat occlusal plane
I don't think there's a sure-fire way to predict the outcome other than making an educated guess based on the above criteria. Everybody's bone and soft-tissue structure is different, and soft-tissue response to bone movement is different. You need the right amount of bone support at the right angle with the right tissue thickness and elasticity for an ideal philtrum. That's too many factors to identify and predict with any certainty.
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The most common culprit for chimp lip is linear advancement of the maxilla in cases where the maxillary plane (Maxillary Plane (MxPl) The plane demonstrated by a line through the anterior and posterior nasal spines) or the Occlusal plane is inclined 'too far away' from a horizontal plane. Basically, a situation where to get the horizontal displacement vector for the maxilla, an UNWANTED vertical vector comes with it because one is advancing over somewhat of a steep diagonal line.
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So that means, if my maxillary plane is already in ccw direction and it will be advanced along this line, then I shouldn't get a chimp lip?
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So that means, if my maxillary plane is already in ccw direction and it will be advanced along this line, then I shouldn't get a chimp lip?
That is the tendency but no guarantee. One user on this forum who shared their result with me got a convex philtrum despite having a pretty flat occlusal plane. Their advancement was in the mid-range.
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Post-Bimax's list is pretty complete.
I'm interested how much the teeth effect it. Proclined incisors cause gum recession. Yet, in theory, it seems they should help with this. I just don't know if they do to any meaningful degree.
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So that means, if my maxillary plane is already in ccw direction and it will be advanced along this line, then I shouldn't get a chimp lip?
if you get 'a lot' of linear advancement when ANS-PNS is in a 'steep' CCW direction, you can get an overly rotated nose tip; 'pig snout'.
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ok, but as far I understood, that correcting a nose seems to be no problem. But to correct a bad philtrum seems to be not easy, right? There seems to be something like a spina nasalis osteotomy, but how well could it make a convex philtrum to a concave one?
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ok, but as far I understood, that correcting a nose seems to be no problem. But to correct a bad philtrum seems to be not easy, right? There seems to be something like a spina nasalis osteotomy, but how well could it make a convex philtrum to a concave one?
Changes to the philtral area are a function of many factors, including but not limited to your start point orientation, displacement vectors associated with the maxillary advancement. The function has a CURVE and that curve can be seen on a ceph displacement proposal as the contour diagram. My suggestion would be to find a surgeon who gives you a ceph displacement diagram where you can see the estimated contour of the changes to the profile because the changes to the the philtral area are somewhat predictable by the person KNOWING the factors of the multi-factorial function.
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ANS reduction is often done to minimize the effect on the lip. Sometimes the ANS is removed entirely. It can be overdone.
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ok, but as far I understood, that correcting a nose seems to be no problem. But to correct a bad philtrum seems to be not easy, right? There seems to be something like a spina nasalis osteotomy, but how well could it make a convex philtrum to a concave one?
I wouldn't go this far. There are potential solutions, but rhinoplasties have one of the highest revision rates of all plastic surgeries. A rhino + revision could easily sink you another $20k.
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ok, I assume you are talking about the US. But from another topic I understood so far, that your prices are behind the moon.
Just one thing what I didn't get: If I have already a straight philtrum and it is over average long, am I also in risk to get a chimp lip independently from all the other factors, which you told me?
edit: @kavan: thank you for your answer, I will keep it in my mind.
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ok, I assume you are talking about the US. But from another topic I understood so far, that your prices are behind the moon.
Just one thing what I didn't get: If I have already a straight philtrum and it is over average long, am I also in risk to get a chimp lip independently from all the other factors, which you told me?
edit: @kavan: thank you for your answer, I will keep it in my mind.
Any time you get LF1 advancement you are 'at risk' to get chimp lip. The above are potential mitigating or exacerbating factors
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ANS reduction is often done to minimize the effect on the lip. Sometimes the ANS is removed entirely. It can be overdone.
That patient actually did NOT need any ANS removal because she started with an overly acute base of nose to philtrum angle + maxillary recession. Advancement of the maxilla to take it out of it's recessive position would have actually normalized her overly acute nose to lip angle and SUPPORTED her downwardly rotated tip. That is to say, her nose AND lip would have IMPROVED with the maxillary advancement (in her case). I'm AGHAST as 'what was he thinking' when he removed her ANS because that's something to do, for example, when a person starts with an overly OBTUSE nose to lip angle where there is 'tethering' of the lip to the base of the nose. He just ended up making her overly ACUTE base of nose to philtrum angle MORE overly acute and caused her to SACRIFICE the the colum support and counter rotation of the downward rotated tip that she could have had with the maxillary advancement. What a dumb dumb doctor.
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Any time you get LF1 advancement you are 'at risk' to get chimp lip. The above are potential mitigating or exacerbating factors
Operative concept is OVER advancement of the maxilla; advancement in excess of what could actually be avoided if the surgeon had all the right 'tools' in his box. Although sometimes, some unwanted advancement can't be avoided and can be considered a 'trade-off' of getting a LOT of OTHER aesthetic problems improved. So, here I'm defining 'over advancement' as type that could be avoided rather than that of a trade-off that could come from a surgeon needing to correct a 'boat load' of aesthetic problems where a 'trade-off' of convex lip can't be avoided.
The risk is lower if one starts with a short philtrum, overly acute nose to lip angle and maxillary recession. Have a look at the photo Plosko entered and my response to follow my drift.
One exception I can think of to that is if someone, in addition to having a recessed maxilla (class 3 type), the ALSO have EXCESS lower jaw advancement. Like class 3 with recessive maxilla AND pro-gnathic mandible and they get ONLY maxilla advanced to match the pro-gnathic mandible and not a BSSO to set the mandible back. In which case, one would get an OVERLY advanced maxilla where the over advancement would be proportional to the the BSSO set back that was NOT also done.
Risks are higher, and IMO, the highest when the doctor wants to do LINEAR ADVANCEMENT of both jaws by an equal amount when both jaws DON'T 'need' to be advanced equally along their 'native plane'. Classic example of OVER advancement of the maxilla is in a sleep apnea case where one wants to expand the airway where instead of the doctor doing a CCW rotation of the maxilla to minimize unwanted maxillary advancement and maximize wanted mandibular advancement, maximization of the mandibular advancement comes with the aesthetic 'cost' of maximizing UNWANTED maxillary advancement AND along a NATIVE PLANE (diagonal) that's unfavorable to aesthetic optimization.
So, those are 2 examples of OVER advancement of the maxilla. There are some maxillary advancements that can be quite favorable to the nose to lip angle and contour.
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ok, I assume you are talking about the US. But from another topic I understood so far, that your prices are behind the moon.
Just one thing what I didn't get: If I have already a straight philtrum and it is over average long, am I also in risk to get a chimp lip independently from all the other factors, which you told me?
edit: @kavan: thank you for your answer, I will keep it in my mind.
I don't think you are going to predict your own outcome (or have anyone else here predict it for you) by the responses here in the absence of a surgical plan and in the absence of ANY visual (like a ceph or profile shot) of what you're starting out with.
If you wanted to get into predicting potential outcomes, you would need to look at many many maxfax cases where you're shown the start point and end point of the patient and also the displacements the patient had and could relate that back to a solid grounding in geometrical relationships.
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Operative concept is OVER advancement of the maxilla; advancement in excess of what could actually be avoided if the surgeon had all the right 'tools' in his box. Although sometimes, some unwanted advancement can't be avoided and can be considered a 'trade-off' of getting a LOT of OTHER aesthetic problems improved. So, here I'm defining 'over advancement' as type that could be avoided rather than that of a trade-off that could come from a surgeon needing to correct a 'boat load' of aesthetic problems where a 'trade-off' of convex lip can't be avoided.
The risk is lower if one starts with a short philtrum, overly acute nose to lip angle and maxillary recession. Have a look at the photo Plosko entered and my response to follow my drift.
One exception I can think of to that is if someone, in addition to having a recessed maxilla (class 3 type), the ALSO have EXCESS lower jaw advancement. Like class 3 with recessive maxilla AND pro-gnathic mandible and they get ONLY maxilla advanced to match the pro-gnathic mandible and not a BSSO to set the mandible back. In which case, one would get an OVERLY advanced maxilla where the over advancement would be proportional to the the BSSO set back that was NOT also done.
Risks are higher, and IMO, the highest when the doctor wants to do LINEAR ADVANCEMENT of both jaws by an equal amount when both jaws DON'T 'need' to be advanced equally along their 'native plane'. Classic example of OVER advancement of the maxilla is in a sleep apnea case where one wants to expand the airway where instead of the doctor doing a CCW rotation of the maxilla to minimize unwanted maxillary advancement and maximize wanted mandibular advancement, maximization of the mandibular advancement comes with the aesthetic 'cost' of maximizing UNWANTED maxillary advancement AND along a NATIVE PLANE (diagonal) that's unfavorable to aesthetic optimization.
So, those are 2 examples of OVER advancement of the maxilla. There are some maxillary advancements that can be quite favorable to the nose to lip angle and contour.
I agree LF1 can improve lip contour depending on the starting position. I remember that case Plosko shared from another thread (it may have been one of mine actually). Catastrophic decision.
When I said even the 'correct' LF1 advancement can result in chimp lip, I meant 'correct' advancement with regard to other orthognathic relationships. As you noted, sometimes the tradeoff of chimp-lip is still worth it if bigger issues are solved. My point was that the surgeon could do everything right and still have the patient end up with a convex philtrum, which is the detail Gadwins was curious about.
I think the two examples of over-advancement you provided describe Plosko's case and my case, respectively (Plosko can correct if I'm wrong). It's good that CCW-r is becoming more widely practiced. Older surgeons who continue to apply linear MMA in every case out of pride are stubbornness are a threat to prospective patients.
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Surgeons who refuse to do CCW-r claim it's unstable.
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I agree LF1 can improve lip contour depending on the starting position. I remember that case Plosko shared from another thread (it may have been one of mine actually). Catastrophic decision.
When I said even the 'correct' LF1 advancement can result in chimp lip, I meant 'correct' advancement with regard to other orthognathic relationships. As you noted, sometimes the tradeoff of chimp-lip is still worth it if bigger issues are solved. My point was that the surgeon could do everything right and still have the patient end up with a convex philtrum, which is the detail Gadwins was curious about.
I think the two examples of over-advancement you provided describe Plosko's case and my case, respectively (Plosko can correct if I'm wrong). It's good that CCW-r is becoming more widely practiced. Older surgeons who continue to apply linear MMA in every case out of pride are stubbornness are a threat to prospective patients.
OK, I was just responding to what I quoted:
Any time you get LF1 advancement you are 'at risk' to get chimp lip. The above are potential mitigating or exacerbating factors
But, ya even a correct advancement could kick it up. We are both making same/similar point.
I get my examples by looking at a lot of cases and/or reading what revision doctors tell the patient with 'this or that' thing they want fixed. But I 'de-identify' the info (just in case).
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Chimp lip is certainly caused by overadvancement, but nobody should take comfort if their advancement is moderate or even mild since the positioning or tilt of the maxilla has equal impact. I had a flat nasiolabial angle preop and was advanced only 6 mm and have a bit of a chimp lip. CCW-r would have mitigated this by providing support to the vermillion as opposed to the mid-philtrhum getting all the “push.”
I can’t really imagine one getting chimp lip if the tilt of the maxilla is such that the teeth lend an upward curl to the vermillion - even in cases of moderate to large advancement. Models have prognathic maxillas but good support at the ‘correct’ place.
Connor mcgregor for example has a chimp lip in profile because in addition to a prognathic maxilla he has a vertically long downward rotated maxilla, bulging out the mid philtrhum like this (, where the bottom of the line is the vermillion, getting less support or “push out.”
Others, e.g. models, can also have prognathic maxillas but with different lip support which looks more like this ), which offsets this appearance.
So what causes this: Steep occlusal plane/ vertically long maxilla getting a linear advancement, or a flat occlusal plane getting CW rotational advancement (Which happened to me). That said, my occlusal plane was flat to ‘tipped up’ pre-op and my vermillion still didn’t have any support... that’s where soft tissue can play a role and exacerbate things even more, so having thin unsupported lips pre-op is also a risk factor.