To protrude or not to protrude, augment or setback?

[madeira]

Hello everyone, this is my first post here, pleasure to meet you all and thanks for the great information you have all posted so far.

I have a deviated mandible and nose along with a protruding mouth area (orbicularis oris). My plan would be possible jaw surgery to fix the asymmetry/deviations and either to pull back the teeth (after extractions) or augment the area around the mouth. I also have a depression in the infra-orbital cheek area.

My last consultation I was advised to pull back the teeth which I must say I do not like that idea for several reasons; 1.I don't think it looks good (judging by my simulations), 2. I do not like the idea of extractions and the aging/ soft tissue problems associated, and 3. I do not like the idea of being in braces again to get the teeth into place.

In my opinion, if the symmetry issue could be sorted, then augmenting the chin along with slight nasal tip deprojection and septal shaving. It would need some sort of augmentation to the labiomental fold, low on the alveolar bone maybe. Also implants for the infra-orbital and rim area. However I was advised against this at the consultation, that it would be excessive chin projection.

Here are simulations to show what I mean, also snapshots of my CT scans. I would like to hear some opinions if you have the time. Thanks in advance.

symmetry lines frontal:


left comparison of setback (left), now (middle) and augmentation (right):


right comparison of setback (left), now (middle) and augmentation (right):


CT scan lateral with teeth protrusion:


CT scan oblique showing infra-orbital depression:

[sean89]

Nose surgery possibly.

But jaw is fine (asymmetry not worth noting and I don't think any surgeon would take you on), chin is good (and will be even better if you get septo-rhino) and not worth taking out the existing implant. There are a lot better things you can spend your money on.

Don't know if braces will do much for your protrusion - pretty invasive again - but I can see why you might consider it.

I don't know enough about implants to advise.

[PloskoPlus]

Madeira,

Perfectly symmetrical faces do not exist.  However, like me, you seem to have significant scleral show on your left side (left side is higher than the right side).  This has far more impact on your appearance than any mandible or chin asymmetry.  IMO, it's the most critical thing to fix.  Space created by extractions will take a looong time to close with braces.  BTW, is that a silastic chin implant in the CT scan?  Impacted wisdom teeth?

[madeira]

Thanks Sean89 and PloskoPlus for your replies.

I feel I should firstly add I have had previous rhino, chin implant, otoplasty and braces. Also functionally I am good. It is mostly aesthetic surgery I am considering.

@Sean89: I do think that it is the deviation of my nose which is deharmonizing the face with uneven width in the cheeks. If you also look at the jaw gonial points in the frontal you will see they are contrasted with the eye positions: low left eye yet right gonion is lower than left, a similar effect from the outline of the chin sloping CW while the eye line is sloping CCW. I take your point that the chin is good in terms of width albeit off-center, but also in terms of horizontal projection. If I take a profile pic and my attempt to make the frankfurt plane and a perpendicular line down from the radix, the chin does seem to match ideal. However when I simulate extra horizontal projection I do find it more aesthetically pleasing. This is more of an ante-face and requires less "work" to the nose and teeth. But maybe my ideal is skewed towards ante-faces now.

@PloskoPlus: good point that you mention the eyes, I do consider myself that they play a crucial role in overall aesthetic value of the face. Apparently the area within the triangle surrounding the eyebrows and tapering down including the mouth is the epicentre of beauty on the face. This would suggest the mandible bone is secondary. I haven't considered the sclera show before, what I was thinking is that my brow ridges around the nasion area (or top corners of eye close to nose) are weak. I think this is due to my previous rhino where the nasal bone was scooped and now maybe not enough support underneath. I see what you are saying about achieving perfect symmetry. I do think though interestingly that my bilateral asymmetry is distorted due to the deviation of the nose and lower third. Frontally, as the nose could be seen to represent the divider between left and right, since it is deviating to one side it is creating the illusion that both sides of the face are unequal. When I look at the frontal picture I posted and cover below the line at the submalar and cover the nose too, everything lines up. I should add my asymmetry/deviation is caused by a cranial tilt. My skull is tilted on its axis. This caused the maxillofacial growth distortion (deviation). So you plan for a cantoplasty for the eyelids in your case?
The more I think about a long process with braces, the more I sway to the side of chin/infra orbital augmentation.
I have a medpor chin implant, my wisdom teeth are not impacted, the tops ones are fully erupted and the bottom ones almost fully.

[PloskoPlus]

@PloskoPlus: good point that you mention the eyes, I do consider myself that they play a crucial role in overall aesthetic value of the face. Apparently the area within the triangle surrounding the eyebrows and tapering down including the mouth is the epicentre of beauty on the face. This would suggest the mandible bone is secondary. I haven't considered the sclera show before, what I was thinking is that my brow ridges around the nasion area (or top corners of eye close to nose) are weak. I think this is due to my previous rhino where the nasal bone was scooped and now maybe not enough support underneath. I see what you are saying about achieving perfect symmetry. I do think though interestingly that my bilateral asymmetry is distorted due to the deviation of the nose and lower third. Frontally, as the nose could be seen to represent the divider between left and right, since it is deviating to one side it is creating the illusion that both sides of the face are unequal. When I look at the frontal picture I posted and cover below the line at the submalar and cover the nose too, everything lines up. I should add my asymmetry/deviation is caused by a cranial tilt. My skull is tilted on its axis. This caused the maxillofacial growth distortion (deviation). So you plan for a cantoplasty for the eyelids in your case?
The more I think about a long process with braces, the more I sway to the side of chin/infra orbital augmentation.
I have a medpor chin implant, my wisdom teeth are not impacted, the tops ones are fully erupted and the bottom ones almost fully.

I'm a class III.  My midface is recessed.  Solving this may solve the scleral show.  I only became aware of it a year ago when I consulted my max fac.  He said that a "a highish Le Fort 1 will give better support for the eyes".  I had no idea what he was talking about.  My distortion filters are strong, I don't see it in the mirror, unless I wilfully disassociate myself from the reflection.  The photos reveal the cold hard truth however, and I've been strongly aware of it for about 6 months.  I'll be seeing my maxfac in a week, and will drill him about it.  He does do higher Le Forts (II and III).  Maybe I'm a candidate (doubt it).

P.S.
To be honest, I think much of PS is a scam.  Your bones are your face.  Eyelid surgery seems like a great way to get ugly scars and dry eyes for life.  Orbital implants are not trivial either.  So, if a max fac can't solve it, no-one can.

[madeira]

@PloskoPlus: So I am guessing a lack of underlying skeletal support means your skin is sagging and therefore the sclera show. Do you think even a high LefortI would solve the issue? I'm guessing that it would bring out more of the infra-orbital rim, but the surest way in theory would be Lefort III and bring out the entire area of recession no? Although I am sure a lot of maxfacs won't do this unless absolutely necessary. What about lefort I for the bite and malar/ infra-orbital implants?
I agree with you that the underlying facial structure is the main determinant of the beauty of a face. I am hesitant about any form of soft tissue work myself. I think maxfac is definitely the only way to go on that issue.

In relation to my case I am very cynical that an orthognathic surgery could pull this all off without problems, I am trying to imagine what sort of surgery plan would be needed and it seems to be complex with no guarantee of success, I find the idea of custom implants appealing but they are expensive and will not solve the symmetry/deviation issues. For now I will have to think it over...

[madeira]

I do think genio is a far better choice in terms of what it can do for positioning. It can move in all 4 directions and rotate. An implant will only fix to a surface and augment. However the reason I bring up the possibility of having implants instead is since my case would not be straightforward and require perhaps multi segmental osteotomies there is a lot of room for human error if done by hand, Rather custom implants could be made up to offset the differences instead of changing positions of bones and they are by nature made-to-measure.

I have heard cases of silicone implants causing bone erosion but since medpor promotes tissue ingrowth I think it has less chance of eroding the bone.

I wonder if I were to advance the chin only would it affect my current lip positioning. My way around the protruding mouth area would be genio the chin out (funny as a verb!), implant the lower alveolar bone to fix resulting deep labiomental fold, and also augment the infra-orbital area. However this increase in volume in these areas could mean more needed in the cheeks to keep balance. If i could find an easy way to fix the deviation problem the other procedures seem straightforward.

I don't think there is any need for my jaws to be horizontally advanced, that is the difficulty with my case, it is trying to align the jaws and features without bringing them outward or inward. I would be too afraid of lip and nasal tip upturning from jaw advancement which is already a problem for me now. So recessing in order to later advance as you say is not worth it.

I am taking on board the point of reward versus risk as mentioned.

[PloskoPlus]

It's rarely done, but another option is maxillary setback.  You'd need mandibular setback as well to keep your occlusion.  This will decrease your airway size, however.

[madeira]

I did consider that at one stage, actually i was thinking lefort I and just under the bottom teeth on the alveolar bone and bring them back. But I am not so sure about setback and the resulting extra soft tissue after. Less airway can't be good either. I see it is commonly done in Asia where bimax protrusion is more common. Having said that i do feel the more ante-face profile in my case is better looking. I am open to opinions on that though.

[dantheman]

I wouldn't do anything if I were you man.

[PloskoPlus]

@PloskoPlus: So I am guessing a lack of underlying skeletal support means your skin is sagging and therefore the sclera show. Do you think even a high LefortI would solve the issue? I'm guessing that it would bring out more of the infra-orbital rim, but the surest way in theory would be Lefort III and bring out the entire area of recession no? Although I am sure a lot of maxfacs won't do this unless absolutely necessary. What about lefort I for the bite and malar/ infra-orbital implants?

I'll post my pics in the private forum at some point.  Have a look at the modified Le Fort III thread.  Implants are no safer.  This doctor was hyping implants for years on realself.com:
http://www.lidlift.com/
However, lately he's cooled on implants and now promotes fillers as a fix.  At least he smites the idea of  lid surgery (canthoplexy and the like) as a fix for scleral show.  In fact, he says it will probably make it worse.  Probably the only such surgeon on realself.

(Realself is a bit of a sick place... or PS surgeons are sick.  Virtually every second answer is some bulls**t filler recommendation.)

[LoveofScotch]

I would actually recommend spending time on RealSelf (I'm in NO way saying you should do anything!), but if you have already made up your mind to do something, I think the site could be hugely helpful. Something tells me you are already well aware of the site; I just think reading about the experience of others can be of value.