Surgical plans for bimax advancement with CW-r

[Chris]

I have learned a lot from reading this forum, and would be grateful for any thoughts, advice, or comments on my case. I apologize in advance for the length of this post!

I am 45 years old and have horizontal and vertical bimaxillary deficiency, and mandibular asymmetry (Class II subdivision right). Also, my nose is significantly overprojected. (Photos and radiographs are linked to below.)

I consulted with an orthodontist last year (Dr. L. in NYC), who took a CBCT, told me that bimax advancement with maxillary downgrafting was indicated in my case, and wrote up a report for orthodontic treatment for before and after surgery.

Also last year, I met with 4 orthognathic surgeons. In order of visits: Dr. N. at NYCOMS in NYC, Dr. T. at Mount Sinai in NYC, Dr. S. at Yale, and Dr. R. in Los Angeles. As far as I can tell, each is well respected (as is Dr. L, the orthodontist I saw).

Dr. N., Dr. S., and Dr. R. all recommended having bimax advancement with maxillary downgrafting. Dr. R. added that he would also rotate the mandible to the left. The orthodontist indicated that the maxillary surgery would/should be a 3-piece LeFort (I assume that this is because of the narrowness of my arch forms, which he mentioned in his report).

I think, though am not totally sure, that all 3 of these surgeons, along with the orthodontist, concur on these surgical plans (of course, I need to find out about that—for example, whether any or all of the 3 surgeons would do the LeFort as a 3-piece (I noticed that the CPT code that Dr. R. put in his report—CPT code 21145—is for a 1-piece LeFort, not a 3-piece)).

Dr. T., however, recommended doing nothing surgically—saying that he worried that he might make me look worse—and said my case was fine for orthodontics-alone. (The orthodontist, however, pointed out in his report that “the underlying problem is clearly skeletal in nature and is related to the difference in the size and position of the jaw structures,” and discouraged orthodontics-alone.)
 
Note: I had a primary rhinoplasty, chin implant (silicone, medium-size), and submental liposuction 2 years ago (summer of 2019). The rhinoplasty reduced a dorsal hump, but did not de-project the nose (and did not address the asymmetry at the top of the nose, which was caused by a nasal fracture I had in a bike accident many years ago, and did not address the deviation of the dorsum and the tip). And the chin implant (it is an “anatomical” one, i.e., with wings) was placed too high on the chin (as can be seen in the CBCT images and the photos below), which placement exaggerates the depth of the mentolabial fold (and also changes the face shape from oval to square). (The chin implant will most likely need to be removed before jaw surgery—and relevant to this anticipated removal, the “true” degree of my chin’s soft-tissue projection (relevant to any future JS) is shown in the pre-chin-implant X-ray (from 2018) in Image #1 in the imgur album linked to below (rather than in the later radiographs—because the chin’s soft-tissue projection in the later radiographs is exaggerated by the implant).)

Also, I have mild scoliosis, which causes my head to be a bit tilted and off-to-the-side relative to the rest of my body (this is shown in Image #34 in the imgur album linked-to below). (I didn’t think to mention this to any of the surgeons, or to the orthodontist—though I have read a study suggesting a correlation between scoliosis and malocclusion, and perhaps this would be relevant to potential jaw surgery.)   

My personal concerns regarding the jaws and teeth are mostly aesthetic, though there are some functional annoyances:

         (1) when I bite down, my lower jaw collapses behind (and upward into) the upper jaw;
         (2) my lower jaw often slides around, seeking where to meet the upper jaw; and
         (3) I routinely posture my mandible forward, without realizing at first that I am doing so.

Below is a link to an imgur album containing the following images, in order:

    •   Radiographs (X-rays and CBCT images) and ceph analyses with measurements (from Dolphin imaging) (Images #1–#20 of the album—all radiographs are current, except for Image #1)

    •   Photos (Images #21–#37) All are current photos, except for those labeled otherwise. The 3/4 view when smiling (Image #33 in the album) seems to be the most unaesthetic of the current photos,       and perhaps reveals most clearly that I could benefit from orthognathic (and orthodontic) correction.

    •   Treatment simulations, including Dr. R.’s and Dr. N.’s morphs (Images #38–#46)

    •   Additional photos (Images #47–#61) These were taken with my phone, so the proportions are a bit distorted—but they show some different angles:

https://imgur.com/a/XTxGfbD

            Note: adding “/layout/grid” after the url listed above will display the images in a grid view (though in grid view the image-numbers and image captions that I put in below each image are not                               shown).

Attached is a PDF comprising:

Dr. R.’s report (pp. 1–4) and the orthodontist’s report (pp. 5–7)

(I do not have written treatment plans from Dr. N. or Dr. S, the other two orthognathic surgeons who recommended having bimax advancement.)

Also attached are a jpeg of Dr. R.’s proposed surgical movements and a jpeg of Dr. R.’s simulation (these jpegs also appear as Images #38 and 39 in the imgur album, but I wanted to highlight them by also attaching them).

The following is a SUMMARY OF Dr. R.’s FINDINGS (as on pp. 3–4 of the attached PDF of his report):
   
• Mild brachyfacial pattern with short lower face height
• Horizontal and vertical maxillary deficiency ICD-10 CM M26.02
• Horizontal mandibular hypoplasia (camouflaged with chin implant) ICD-10 CM M26.04
• Nasal asymmetry (tip and dorsum to right)
• Mandibular asymmetry (more fullness on right side, midline slightly right) ICD-10 CM M26.12
• Excessive horizontal overlap ICD-10 CM M26.23
• Anomalies of interarch distance (impinging deep bite/constricted envelope) ICD-10 CM M26.25
• Class II subdivision right dental relationship ICD-10 CM M26.212
• Narrow arch forms
• Masticatory dysfunction ICD-10 CM R13.10
• Crowding of fully erupted teeth ICD-10 CM M26.31
• Spacing of fully erupted teeth ICD-10 CM M26.32
• Upper anterior tooth wear
• Retained unerupted upper third molars
   
Additional aesthetic (and some functional) concerns of my own:

•   Obtuse chin-throat angle. Looking at the X-ray in Image #1 in the imgur album, it may be that it is the low position of the hyoid bone (together
        with the short neck-to-chin distance), rather than much remaining neck fat (including subplatysmal fat), that makes the chin-throat angle obtuse
        and makes the submental tissue hang and bulge.
•   Deep mentolabial fold. As mentioned above, the chin implant is placed too high on the chin and exaggerates the mentolabial fold, and, if anything,
        makes the lower face look even shorter than it looked before the implant was inserted.
•   Substantial gap between the upper central incisors (the orthodontist’s report indicates that he can close that gap).
•   “Over-closed” feeling (and appearance) created by the deep bite
•   Lower lip is canted (downward on the right side) when smiling (as in Image #24). (This may be a muscle issue, and is perhaps uncorrectable.)
•   Upper lip is flat and doesn’t shown much of the vermilion.
•   Dark buccal corridors—narrow smile (Dr. R. noted this in his report [which, again, is in the PDF attached to this post])—this is most apparent in the
        left photo in Image #24 in the imgur album.
•   When I smile, the upper teeth are only partially visible (low smile line) (as in Image #24)
•   Nose is too far projected, and the tip droops slightly when smiling (as in Image #26)
•   Lateral discrepancy between the nasal tip and the maxillary midline (as in Image #24)—this seems primarily due to the nose, rather than the
        maxilla itself, being deviated relative to the facial midline.
•   That without bimax advancement, my face may age more quickly, because the jaws are recessed and unable to provide skeletal support for the soft
        tissues when those tissues begin to sag and descend.
•   A note on self-perception: I had always thought that my maxilla was protruded relative to my mandible (based on my own perception of my facial structure). The orthodontist’s report contradicts that self-perception, however—he writes: “Deficient development of the upper jaw structure … Excessive forward growth of the lower jaw relative to the upper jaw …The cephalometric radiograph demonstrates: The tendency towards excessive forward growth of the lower jaw relative to the upper … This specific skeletal pattern is most prone to problems with the joint of the lower jaw.” The surgeons (Drs. R., N., and S.) didn’t describe my jaw situation in quite the same way as the orthodontist did, but they did emphasize that both jaws are retruded.

Dr. R.’s surgical plan is the following (as on p. 4 of the attached PDF of his report):

   • Midface reconstruction, Le Fort I maxillary osteotomy with graft- advance and downgraft CPT code 21145

   • Mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid fixation- advance, clockwise rotation, and rotate to left CPT code 21196
   
   • 3-D virtual surgical planning and interocclusal surgical guides CPT code 21085
   
It seems like I have 2 options:

(1) Have bimax advancement (with maxillary downgrafting, CW rotation of the mandible, and rotation of the mandible to the left), with or without an accompanying genioplasty (out-and-down direction)—followed a year later by rhinoplasty (to de-project the nose)

Or

(2) No jaw surgery; instead, have rhinoplasty (to de-project the nose), re-placement of the chin implant (with better positioning, lower on the chin), and possibly a procedure to lift or tighten the soft tissues below the mandible.

The ENT surgeon whom I met with in 2018—and liked (but who, unfortunately, I didn’t choose for the rhinoplasty and chin implant that I had in 2019)—showed me a simulation of what he would do (without any jaw surgery). (This simulation is Image #41 in the imgur album). This simulation closely represents what I would hope for IF choosing option #2. (This result might be more difficult to achieve now than it was 3 years ago, however, because since then I have already had primary procedures (in 2019) to the nose and chin (and submental lipo), and a surgery now would be a revision of these procedures, and consequently would have to contend with the scar tissue that formed as a consequence of those primary procedures.)

I am inclined to go with option #1, however, because

•   I would like for my jaws to be balanced, both in relation to each other and in relation to the rest of   
      my face and head;
•   I would like for my bite to be aligned and to feel more comfortable with my appearance when smiling
     (and the orthodontist told me that orthodontics alone, without surgery, wouldn’t work well);
•   I would like to avoid future jaw-joint problems and tooth wear that may be more likely to occur if I
      don’t have corrective jaw surgery to balance the jaws; and
•   I would like for there to be more skeletal support for the soft tissues of my face, especially as I age;

Also, I notice that if I drop a vertical line down from the base of the nose in Image #1 (the pre-chin-implant lateral X-ray)—as Kavan has done for illustration in JSF posts—the most anterior point of my upper lip, lower lip, and chin lies quite far behind that line (a mitigating factor in this observation could be, however, that in that X-ray my head seems slightly downward-pointing). I think this suggests that bimax advancement is in fact appropriate and indicated in my case.

QUESTIONS:

(1) I suppose that, at this early stage, the main question I should be asking is not precisely how many millimeters the surgical movements should be, but rather whether or not I should have jaw surgery at all—because I have to decide whether or not to begin (decompensatory) pre-surgical orthodontics, and in order to make THAT decision I need to have decided whether or not to have jaw surgery (because it would not make sense to begin decompensatory orthodontics if I’m not sure whether it is a good idea to have the surgery).

To get at the aesthetic advantages and disadvantages of a potential DJS, in Image #42 in the imgur album I have juxtaposed a photo of the ENT surgeon’s simulation next to a photo of Dr. R.’s jaw-surgery simulation COMBINED with my simulation (made in facetouchup.com) of an added genioplasty and post-jaw-surgery rhinoplasty (i.e., I took Dr. R.’s simulation and added a hypothetical genioplasty and rhinoplasty to it).

I’m comparing the ENT surgeon’s simulation with Dr. R’s jaw-surgery simulation PLUS a rhinoplasty simulation, rather than with Dr. R’s jaw-surgery simulation ALONE (which is shown in the attached file, and in Image #39), because I plan on having rhinoplasty whether I have jaw surgery or not (because it seems to me that de-projecting the nose, if done well, will be aesthetically beneficial either way—though the extent of de-projection performed will depend on whether I will have had bimax surgery). Regarding genioplasty, Dr. R. mentioned it but didn’t include it in his simulation, because of the option of leaving the chin implant in place—in (p. 4 of) his report, he wrote: “There would be no reason to remove [the implant] if Christopher is satisfied with the current shape of his chin. It could be alternatively removed and then there would be consideration of genioplasty.” Since I DO in fact dislike the current shape of my chin created by the implant—though unfortunately I forgot to mention that to Dr. R. during the consultation—I WOULD want it removed (or at least re-positioned), so that it why I altered the chin shape in my addition to his morph (of course, the addition I made to his morph might not be something that is actually possible, surgically).

It is not clear to me which of these 2 simulations in Image #42 works best, aesthetically.

I’m concerned that the simulations by Dr. R. and Dr. N. (in images #39 and #40)—especially the simulation by Dr. N. (perhaps because he may not have incorporated CW rotation in his morph, and because his advancements are larger than Dr. R.’s)—make me look “cro-magnon”-like, whereas the ENT surgeon’s simulation looks more “natural.” It may be, however, that I am just unused to seeing myself with more forward jaws, and that, objectively, the increased jaw projection that Dr. R. and Dr. N. are proposing does indeed produce a more balanced profile. (Incidentally, I saw in a video of a lecture by Alfaro that he, Alfaro, sees aesthetic judgement of frontal and occlusal relations as “objective,” but that of sagittal relations (“A-P and vertical”) as “subjective”: at 7:55 in this video: https://www.youtube.com/watch?v=TJUK6WZ07fM)

Also, I realize that this comparison of the two simulations is probably NOT a fair comparison, because jaw-surgery morphs don’t accurately depict/predict the soft tissue changes that are likely to occur as a result of the orthognathic-surgical movements. (Dr. N. said that the actual surgical result “always looks better than the computer simulation”—though I can’t imagine that is truly always the case.) I think I can assume that the reason that the ENT surgeon’s morph looks more natural than Dr. R.’s and Dr. N.’s is BECAUSE of this inability of jaw-surgery morphs to accurately depict the soft tissue changes that are likely to result from the orthognathic-surgical movements. (Dr. N. mentioned that the lips, in particular, are difficult for a jaw-surgery morph to depict).

Something I am also considering is that although the ENT surgeon’s morph may look better than the “bimax advancement + rhinoplasty” morph NOW, in 10 years from now (at age 55) I might regret not having had the bimax advancement, as my face might have aged quickly/prematurely, without the skeletal support for the aging soft tissues that the bimax surgery could have provided. (Of course, I might additionally regret not having had my occlusion fixed!)

MY WORRIES ABOUT UNWANTED EFFECTS OF THE SURGERY:

     •   Concern about potential permanent numbness of the lower lip, especially given that this is a greater risk in older patients. Related to this, I play the trumpet (though it is not my career), and Dr. R. warned me that I might not be able to play the trumpet (ever) again after surgery, because of potential permanent numbness of the lower lip. (He wasn’t discouraging me from having the surgery, but he did mention this as a risk.)
     •   Genioplasty (if a genioplasty was added to the bimax surgery): If I remember correctly, Dr. R. suggested that a genioplasty could be more difficult in my case, because of the scar tissue that has (inevitably) formed in that area, as a result of the insertion of the chin implant two years ago.

(2) I read the jawsurgeryforums posts (and read the article and watched the video that Kavan linked to) on Piezo ultrasonic surgery. Given my concerns (described above) about potential permanent numbness of the lower lip, the possibility of Piezo is very appealing (for its greater potential for avoiding permanent damage to the inferior alveolar nerve during SSO than with traditional surgical instruments).

In my case, might it be better to go with a surgeon who, like Dr. R., does not (yet) use ultrasonic techniques but does have a lot of experience and seems to have a good aesthetic sense? (Also, I really liked and felt good about Dr. R. when I met with him.) Or, given my priority of avoiding permanent numbness to the lower lip, would it make best sense for me to prioritize finding and using a surgeon who does Piezo surgery? (Unfortunately, I don’t know which surgeons in the US use Piezo.)

(3) Given that my philtrum is currently straight, rather than concave, I am concerned about “chimp lip” (i.e., a convex philtrum) resulting from the maxillary advancement and downgrafting. (I have read, and am grateful for, the JSF threads on chimp lip, and for Kavan’s diagrams on rotation.)

The following is a link to an album I put together of 3 photos that seem to me to be examples of chimp lip (though, as far as I know, none are JS patients; and I’m not sure whether my interpretation of these as “chimp lip” examples is accurate):

https://imgur.com/a/l7ZXtJt

The Holdaway soft-tissue analysis of my ceph (in Image #18) indicates that my maxillary/superior sulcus is very shallow/forward (norm is 3 mm deep; mine is 0.4 mm deep) and the maxillary-sulcus angle (ULA–A’–Sn, from the Bergman analysis in Image #19) is abnormally obtuse (norm is 151^o; mine is 175.2^o). (And this is obvious from the photos, even without the measurements from the analysis.) I imagine that this would put me at risk of chimp lip.

If I understand them correctly, however, I think that Dr. R.’s plans (described below) may lessen this risk. In his preliminary plan of movements (attached, and in Image #38), both the ANS and the PNS are downgrafted and advanced by the same amount (looks like +4.8 mm forward and +1.3 mm down for both ANS and PNS in the plan), which I think means that the maxilla would NOT be rotated clockwise. (Dr. R. did indicate, however, that the MANDIBLE would be rotated, clockwise.) I notice that in Dr. R.’s plan for surgical movements (in the attached jpeg), “Rotate Md @ Hinge axis” is set to -1.6, but “Rotate Mx+Md @ Hinge axis” is set to 0.0.

Maybe the reason that Dr. R indicates CW rotation for the mandible, but not for the maxilla, is because he is taking into consideration the deep-bite—maybe rotating the mandible clockwise but keeping the maxilla on its original plane is a way of opening the bite (?). (This is just my naive guess—I hadn’t previously heard or read about the possibility of rotating the mandible without also rotating the maxilla, and I didn’t think to ask Dr. R. about this aspect of his plan.)

Also, I see that in Dr. R.’s morph (and in his displacement diagram) my philtrum is actually more CONCAVE after surgery than before—which would be great! I just can't figure out how an increase in concavity could result from downgrafting and advancing the ANS and PNS by the same amount, because I thought that would simply push the philtrum as a whole forward, along the maxillary plane. I did notice, however, that in his morph (and in his displacement diagram), the upper incisors are more proclined post-surgery than they are at present (pre-orthodontics), and perhaps it is that increased proclination (which maybe the pre-surgical orthodontics could provide me) that creates the concavity of the philtrum in the morph?

I would be grateful for any thoughts you would be willing to share!

[kavan]

I see that you mentioned my name here. But for now, I can't go through all your material point by point. Instead, I'm going to look at Dr. R's assessments and give my ' take' on it and you can apply my take to some of your questions. Keep in mind my 'take' to DIFFERENT PERSON (eg. Pzeizo electric tools) is in reference to THEIR post and might not apply to another.

Your main aesthetic issue is what is sometimes called 'short chin' with deep bite; class 2 div. 2 which effectively is anteriorly short lower '1/3rd' ( the vertical distance from base of  nose to base of chin) and very common to have some recession along with that.

Dr. R's plan is straight forward (no pun intended) which is to vertically 'drop down' the maxilla (equally) by modest amount (+1.3) and to advance by +4.8. I am impressed by his displacement proposal and how it kicks up optimal 'aesthetic geometry'. I am not impressed by the other doctor's presentations, so I won't focus on them. But of course, others may in my stead.

The 'drop down' to the maxilla is what is called the DOWN GRAFT. It is a UNIFORM one with no (extra) rotation to the maxilla. On close inspection, the maxilla has a very slight native/natural clockwise rotation; a very slight downward diagonal orientation relative to a pure horizontal. Hence the vector displacements components along this ever so slight downward diagonal orientation of the maxilla are 4.8 horizontal displacement ('forward') and modest (1.3) vertical displacement (downward). IMO, geometrically speaking, I think this plan is a smart one because it's not an isolated anterior downgraft to affect CW rotation where that type can rotate the mandible backwards. So, the uniform downgraft with no (added) rotation other than your slight native CW orientation of your maxilla (ANS-PNS) allows for a (very slight) 'down and out' displacement of the maxilla which is very close to almost a 'pure' horizontal displacement. It also has the potential of rotating the base of your nose a little bit downward along with the 'forward' advancement and that, in turn, will DECREASE the angle formed by the base of your nose and upper lip.

As to 'CHIMP LIP', or let's call it a very UN-AESTHETIC nose to lip angle, that is (usually) associated with an OVERLY OBTUSE nose to lip angle (or overly conVEX upper lip contour) that is brought about when the maxillary plane (ANS-PNS) is inclined ('too much') away from a pure horizont and ALSO when the maxillary advancement is 'too much' which is often the case when they use linear advancement (advancement of both jaws equally) in a sleep apnea case. This happens when the lower jaw needs to be advanced 'a lot' to clear the airway. So the act of ALSO advancing the maxilla EQUALLY can be 'too much' for the maxilla and especially so the more the maxillary plane is inclined away from a pure horizontal orientation. So, for the 'wanted' advancement to the lower jaw (to open the airway), comes the 'unwanted' maxillary advancement which is MORE than what is needed for good aesthetics to the nose to lip angle or contour. So, that sort of thing is more associated with a 'garden variety' INSURANCE case maxfax who would use LINEAR ADVANCEMENT even though it kicked up an unwanted poor aesthetic to the nose to lip angle. So, you are not getting THAT kind of surgery.   Also, you are not getting an (isolated) anterior downgraft to give more CW to the maxilla than you already have (again, downgraft is UNIFORM).

Your advancement to the maxilla is pretty close to a 'pure horizont' which is what is strived for in CCW rotation (even though you are not getting CCW-r). That's because the orientation of your ANS-PNS is almost a pure horizont, yet a little downward incline (which is a GOOD thing in YOUR case). If you measure the angle formed (before vs. after) from the base of the nose to the upper lip in your contour diagram, the contour diagram shows that the proposed displacement to the maxilla makes the nose to lip angle LESS obtuse. That's due to your ANS-PNS having a very slight CW orientation.

So, here, you seem to be worried about getting MORE of an overly obtuse nose to lip angle than you already have where the displacement diagram CLEARLY shows the plan is to make the nose to lip angle LESS obtuse. As to why the nose to lip angle does not get more obtuse when the ANS is brought out close to a horizontal vector displacement, the very slight downward displacement that the ANS has relative to a 'pure horizont' will have the base of the nose rotating a little bit downward with the advancement which will help CLOSE some of the overly obtuse nose to lip angle you have now. Geometrically speaking, that's why his proposal does NOT create a more obtuse nost to lip angle (or overly conVEX upper lip contour). Also, a good maxfax has the capacity to trim down the ANS during the surgery IF it looks like the advancement is kicking up an unaesthetic nose to lip angle. In short, it doesn't look like an unaesthetic nose to lip angle is something to worry about with R's proposal.

Now for the mandible, we look at where the POG point goes; its displacement vectors. So, the lower jaw (via the BSSO) where the chin point (POG) is taken 'for the ride' has a horizontally outward displacement of 5.5 and a vertically DOWNWARD displacement of 3.5. Again, it's the vertically downward vector displacement (to the lower jaw) that is needed address 'short chin' as to ELONGATE (anteriorly) the lower '1/3rd' of the face and of course, it is the horizontal displacement vector that addresses RESIDUAL RECESSION to the mandible because recession to the mandible will be there even with a chin implant you have in there. Dr. R's displacement proposal addresses the recession at the MANDIBLE and also the SHORT lower 1/3rd to the anterior face in addition to the DEEP BITE.

The reason you are getting relatively more of a downward displacement of the chin point (at mandible) than that of the maxilla is rooted in simple geometrical concepts. The orientation of the mandible (almost every one's) is always going to have more of a downward incline relative to that the maxilla has. Hence, moving 'forward' along a 'plane' that has a downward inclined orientation will have relatively more of a downward displacement vector than moving 'forward' along a maxillary plane that (in your case) is almost horizontal. Even what they call 'low angle' (reference to mandibular plane angle) patients--the ones with deep bite and 'short chin'-- have a steeper mandibular plane angle than the maxillary plane angle. So, here, it looks like he is moving pretty much along your native MPA to give you the WANTED extra anterior facial height (elongation of the lower '1/3rd' of the face) and also the WANTED advancement to the lower jaw. I can confirm this by drawing what they call a TVL (true vertical line) that passes through the vertex of the new nose to lip angle. Both lips are slightly anterior to it and the chin 'kisses' the TVL and that is considered an EXCELLENT aesthetic BALANCE relationship to the jaws. Your DEEP BITE is also FIXED in this process. So, you will not and possibly COULD NOT even come CLOSE to to the type of aesthetic BALANCE (and deep bite correction) correction shown on Dr. R's plan with ANY attempt (or second MISTAKE) to have rhinoplasty, chin implant correction instead.

OTHER:

3 piece Lefort 1. Not uncommon for a good maxfax to use a 3 piece to address transverse discrepancies for example a 'buccal corridor' (black triangles to posterior upper 'smile') or if part of maxilla is responsible for making part of mandible look uneven. If one part of mandible is uneven but not due to the maxilla, it's not uncommon for a good maxfax to give a little 'twist' (rotation) to that part with the BSSO to even things out.

Your morphs of plastic surgery. Disregarded. REASON: Evaluation here (by me) is on the maxfax surgery alone and proposal thereof. However, I will point out that PS whether rhino or neck work is most often evaluated AFTER the jaws (and bite) are corrected. That is because the maxfax surgery has potential of making the nose (and chin/under chin area) look in better balance or could result in needing a(nother) rhino. The LOGISTICS are usually to get the maxfax first and then the PS.

Your facial relationship now post rhino and chin implant: That just DEMONSTRATES that a chin implant and a rhino does not 'fix' recession and deep bite and short anterior height to lower '1/3rd' of face. You would be a fool to think that another try with a different rhino and/or different chin implant would have a chance of 'correcting' what this Dr. R's plan looks like it can TRULY correct. Furthermore, he showed you a DISPLACEMENT PROPOSAL plan. Some of those other presentations from the other doctors which are what I call; 'MUTE MORPHS' don't cut the ice with me.

Chin implant: R's proposal doesn't show anything done to the chin itself (genioplasty). So, you might be able to keep it.

Your INITIAL MISTAKE (as a low angle-MPA- patient with jaw recession) called 'short chin' (short anterior facial height of lower '1/3rd') was an attempt to COMPENSATE for BOTH jaw recession and SHORT anterior facial height to the lower '1/3rd' with a stick on, stuck on CHIN IMPLANT that did little more than bring the shortness of your lower '1/3rd' more forward. That did LITTLE TO NOTHING for your problem (short anterior facial height of lower 1/3) and DEEP BITE. Your chin implant displaced your chin HORIZONTALLY which is NOT the thing to do when the problem is a LOW MPA. That is to say, your chin implant just advanced your SHORT anterior facial height more forward which is why you STILL present with SHORT anterior facial hieght post chin implant.  So, even though you have a low MPA (mandibular plane angle) it still is a downward diagonal orientation (as is most people's even low angle patients). Hence, the act of ADVANCING the MANDIBLE 'forward' (the part way posterior to the chin) via the BSSO resolves to the act of advancing 'forward' along a downward diagonal incline where the chin point will be advanced DOWN (and out) with the bsso to elongate the short lower 1/3rd and that is what you would need for CORRECTION (even while keeping your chin implant in there if that's an option).

In closing, Dr. R's presentation is the most complete and IMO a very good surgical plan to bring balance to the JAWS and BITE and the one worth my time to opine on over all the others. Also, you would need to understand that your INITIAL MISTAKE was to have plastic surgery for a problem that was CLEARLY in the venue of maxfax surgery in the first place. So, if your OTHER option is to try to use more PS instead of the bimax proposed by Dr. R, you would just be REPEATING a MISTAKE.

[GJ]

I haven't read Kavan's response or the surgical recommendations because I like to remain unbiased. I read the first few paragraphs to get a general idea of the situation, and then your questions. I didn't read all the surgeon's opinions.

My opinion is both jaws are slightly recessed, and if your pursue surgery, a liner movement would be best in your case. Maybe a little CCW to try to gain support for the philtrum, but your face is already short, so I don't think you can do much. You can try to get better support there by proclining the teeth, if the angulation is off (I can't tell). Your head position changes in the records, btw.

The chin should probably be redone using bone rather than an implant. Your lower central incisor roots look a little short, and it makes me wonder if the implant is eroding bone and/or causing root issues. It could be the scan angle or artifacts making the roots look short, though. Hard to say.

No strong opinion on the 3-piece, and that needs to be worked up using models and articulators to really see if you need that. Surgeons should all be able to agree one way or the other on that because you either have stable width or you don't. Your bite looks pretty good traverse so I'd lean toward no but it's not a strong opinion, and it depends how stable that position is and how your tongue behaves (thrust, etc). The people analyzing you in-person should be able to come to a conclusion on this better than us.

Regarding Piezo - I had this done and had no numbness. I can only speak to that experience. Everything I've heard from surgeons and read say it does help. They say odds of numbness are around 10%, but it seems higher to me based on talking with patients. I'd say most patients I talk to have some type of sensation change.

Aging is a strange thing. I've seen people with poor support and retro faces who age great. I think skin quality and things like that might be a huge factor. I'm not sure how much "bone support" comes into play. In theory, it makes sense and you'd think it would work like that, but I'm just not positive that it does.

To me you're a borderline case. I'm not sure if I'd do surgery or not.

[Chris]

Kavan, thank you so much for your analysis and your comments! I am very grateful.

From your explanations, I think that I now have a better understanding of how downgrafting the maxilla uniformly (ANS and PNS by equal amount), coupled with advancement of the maxilla along its current (slightly downward oriented, as you pointed out) plane, would actually make the nasolabial angle LESS obtuse, rather than more obtuse and more chimp-like, as I was worried about.

I understand, from your description, that the plastic surgery that I had, and that I have contemplated having revised (as a possible alternative to jaw surgery), does not address the deep bite and the shortness of the lower third of the face—the fundamental and underlying skeletal issues with my facial structure—and that, as you mentioned, pursuing revision plastic surgery instead of (Dr. R.’s plan for) orthognathic surgery would be to repeat the mistake I made two years ago.

I had thought that the problem with the plastic surgery I had two years ago was that the plastic surgeon had poor aesthetic judgment and poor surgical execution/precision (in, for example, his decision not to de-project the nose, and in placing the chin implant too high on the chin), but I think that I see now that, though that surgery could certainly have been done better than it was (to yield better balance and proportions), the underlying issues of the jaws and bite would have still remained unaddressed.

And thank you for pointing out the lesser usefulness/adequacy of what you referred to as “mute morphs,” compared to a displacement proposal plan. I think I can see that more clearly now—especially, for example, when I try to make sense of Dr. N.’s morph, which I’ve had difficulty doing, given its unusual appearance and the absence of information about the specific skeletal movements.

[kavan]

You're very welcome.

Plastic surgery looks best on people with basic jaw to jaw balance. It's the jaw balance that becomes the 'canvas' for plastic surgery to correct the features or other contours of the face. For example if someone got a rhino and a chin implant and looked GREAT afterwards, 10 to 1, those 2 things were the ONLY problems with the face and those 2 things were DETRACTING from their inherant jaw balance. When the main problem is lack of jaw to jaw balance and someone gets rhino and chin implant (for example), it's quite common for them to say to themselves; 'Why doesn't my face look that much better?' or 'Why didn't this make me very good looking?' IMO, it's because the MIND'S EYE wants to 'see' the the result of the PS framed by jaw balance. Some PS patients can chase their tails for a long time getting correction after correction with PS before they even realize it's the jaw imbalance that is the key issue. So, the people who are good candidates for the PS are those who start off with the basic jaw balance. From there more structure can be built in or sculpted with the PS.

In maxfax, the morph should be based on the proposed DISPLACEMENTS that are charted out. There are some ultra high tech programs out there that allow the surgeons to 'plug in' and alter the displacements they want to the bone structure and the program churns out a displacement profile contour diagram. From there, they can overlay a lined up photo of the patient with the skeletal structure and the program can churn out a morph from an appropriate photo. The morph usually will have a bunch of numbers on it (because it's based on the displacement proposal). If it's just a 'mute' morph and you don't get a displacement proposal with it along with the proposed displacements, you can't be too sure that the surgeon just didn't 'wing it' with a simple morph program in absence of charting out any quantifiable displacements.

In PS they can make a morph and usually, it's what I call a 'mute' morph. But a good one will use it to design his vision of correction and then take it back to his desk to measure out distance relationships and/or what the changes made resolve to in terms of surgical adjustments. Some of the really good PS's who are artistically talented can show the patient what their vision is by DRAWING it for them.

Kavan, thank you so much for your analysis and your comments! I am very grateful.

From your explanations, I think that I now have a better understanding of how downgrafting the maxilla uniformly (ANS and PNS by equal amount), coupled with advancement of the maxilla along its current (slightly downward oriented, as you pointed out) plane, would actually make the nasolabial angle LESS obtuse, rather than more obtuse and more chimp-like, as I was worried about.

I understand, from your description, that the plastic surgery that I had, and that I have contemplated having revised (as a possible alternative to jaw surgery), does not address the deep bite and the shortness of the lower third of the face—the fundamental and underlying skeletal issues with my facial structure—and that, as you mentioned, pursuing revision plastic surgery instead of (Dr. R.’s plan for) orthognathic surgery would be to repeat the mistake I made two years ago.

I had thought that the problem with the plastic surgery I had two years ago was that the plastic surgeon had poor aesthetic judgment and poor surgical execution/precision (in, for example, his decision not to de-project the nose, and in placing the chin implant too high on the chin), but I think that I see now that, though that surgery could certainly have been done better than it was (to yield better balance and proportions), the underlying issues of the jaws and bite would have still remained unaddressed.

And thank you for pointing out the lesser usefulness/adequacy of what you referred to as “mute morphs,” compared to a displacement proposal plan. I think I can see that more clearly now—especially, for example, when I try to make sense of Dr. N.’s morph, which I’ve had difficulty doing, given its unusual appearance and the absence of information about the specific skeletal movements.

[Breakingbad]

You're very welcome.

Plastic surgery looks best on people with basic jaw to jaw balance. It's the jaw balance that becomes the 'canvas' for plastic surgery to correct the features or other contours of the face. For example if someone got a rhino and a chin implant and looked GREAT afterwards, 10 to 1, those 2 things were the ONLY problems with the face and those 2 things were DETRACTING from their inherant jaw balance. When the main problem is lack of jaw to jaw balance and someone gets rhino and chin implant (for example), it's quite common for them to say to themselves; 'Why doesn't my face look that much better?' or 'Why didn't this make me very good looking?' IMO, it's because the MIND'S EYE wants to 'see' the the result of the PS framed by jaw balance. Some PS patients can chase their tails for a long time getting correction after correction with PS before they even realize it's the jaw imbalance that is the key issue. So, the people who are good candidates for the PS are those who start off with the basic jaw balance. From there more structure can be built in or sculpted with the PS.

In maxfax, the morph should be based on the proposed DISPLACEMENTS that are charted out. There are some ultra high tech programs out there that allow the surgeons to 'plug in' and alter the displacements they want to the bone structure and the program churns out a displacement profile contour diagram. From there, they can overlay a lined up photo of the patient with the skeletal structure and the program can churn out a morph from an appropriate photo. The morph usually will have a bunch of numbers on it (because it's based on the displacement proposal). If it's just a 'mute' morph and you don't get a displacement proposal with it along with the proposed displacements, you can't be too sure that the surgeon just didn't 'wing it' with a simple morph program in absence of charting out any quantifiable displacements.

In PS they can make a morph and usually, it's what I call a 'mute' morph. But a good one will use it to design his vision of correction and then take it back to his desk to measure out distance relationships and/or what the changes made resolve to in terms of surgical adjustments. Some of the really good PS's who are artistically talented can show the patient what their vision is by DRAWING it for them.

This information is incredibly useful. Thank you for posting it. I am wondering if you can suggest how one might go about verifying that their maxfac surgeon is using these "ultra high tech programs" and going through this more tedious procedure that you described?

Surely, this methodology would tend to produce better results, so your suggestions on how a patient might try to identify a doctor who uses it would be highly appreciated.

[kavan]

This information is incredibly useful. Thank you for posting it. I am wondering if you can suggest how one might go about verifying that their maxfac surgeon is using these "ultra high tech programs" and going through this more tedious procedure that you described?

Surely, this methodology would tend to produce better results, so your suggestions on how a patient might try to identify a doctor who uses it would be highly appreciated.

You find out when you ask for (and they give you, even if they charge extra) a preliminary displacement proposal plan. It should come with a read out of all the displacements proposed/planned (even if you don't understand what it means) and also with a profile diagram of what the 'numbers' look like on a contour diagram where first contour diagram is that of your present profile and the displacement proposal one is that of the 'vision' the maxfax has for you.