Rami asymmetry

[Sequelae]

I am pursuing jaw surgery to correct asymmetry and mandibular recession. However, I have concerns that a typical BSSO will not be able to fix my asymmetry, as a lot of it is in the rami. My right ramus is longer; additionally, the widest part of the ramus, where it flares out, goes much further forward on this side. I appreciate that it may be difficult to understand, but I can't think of a better way to describe it. If you look at the images, you can see two distinct flair-outs on the longer side, which is what I am referring to. I don't think BSSO would be able to improve any of this.


I have been looking at alternative osteotomies, such as the High oblique sagittal split osteotomy, but it's hard to find much information on surgeons who perform this, particularly those who would take international patients. I would really appreciate any advice on this.


https://imgur.com/a/Qz3tiUt

[Tomasjohn]

A chin wing can be used to address asymmetry by cutting manipulating the lower mandibular border. I've seen cases on the web where for example only one side of the mandibular border was lowered or flared especially to address asymmetry. Many examples online. However if combined with BSSO, a higher cut for the BSSO is necessary in order to combine both treatments at the same time.

As far as i know, the pool of surgeons that perform a BSSO and a full, long chin wing simultaneously is relatively small.

I know for sure, that a certain Dr. in Berlin does it, as other members in this forum had exactly this procedure.

Also, I personally don't think the asymmetry at the gonial angle is that bad in flesh.
I think it's more the different shapes (left/right) of the bone from mid mandible to the chin.
But I think most of the asymmetry is actually visible in the lip?

[Sequelae]

I really appreciate the reply. Would you be able to give me some of the names of these surgeons?

[kavan]

I am pursuing jaw surgery to correct asymmetry and mandibular recession. However, I have concerns that a typical BSSO will not be able to fix my asymmetry, as a lot of it is in the rami. My right ramus is longer; additionally, the widest part of the ramus, where it flares out, goes much further forward on this side. I appreciate that it may be difficult to understand, but I can't think of a better way to describe it. If you look at the images, you can see two distinct flair-outs on the longer side, which is what I am referring to. I don't think BSSO would be able to improve any of this.


I have been looking at alternative osteotomies, such as the High oblique sagittal split osteotomy, but it's hard to find much information on surgeons who perform this, particularly those who would take international patients. I would really appreciate any advice on this.


https://imgur.com/a/Qz3tiUt

I think your description of what you see on the FRONT scan is a good one but with reference to looking at a 3-object on a 2-D plane. A front photo of the face and/or a front scan of the scull is how something in 3-D PROJECTS ONTO the 2-plane.

For example, if your mandible was rotated to the left, the left (mandibular) angle of the jaw would receed more in the background so you didn't see a double flair and would project HIGHER on a 2D plane. The right (mandibular) angle would come more forward in the foreground bringing the double flair into view and project LOWER on the 2D plane which is pretty much what you are describing as to what you 'see'.

Thing is, with reference to a VERTICAL axis drawn through the scan that passes through the middle of the periform aperture and between the middle of the upper central incisors, the mid-line axis doesn't pass through the middle of the front lower lateral incisors. So, what you see on the FLAT plane of the 2-D projection of the scull scan looks like it could be a rotation of the mandible around a vertical axis.

This could be something where both jaw angles are similar in length and flair (or not too much dissimilar) but they project on the 2-D plane that way due to a ROTATION around a VERTICAL midline axis.

I think this could be in the venue of what they call a 'YAW'; when one side rotates backwards (receeds into the background) and the other rotates forward into the foreground. So, you would want to consult about possibly having a yaw and if and how that could be corrected.

I have no comment on mandible recession (and BSSO need) because I think that is best seen via a soft tissue profile photo.

Also, as to the asymmetry, you haven't told us WHICH side you like better. IF you liked the nice 'squaring' to the right side jaw angle area, something like soft tissue filler to the left could be used to square out the left one.

Included is an illustration.

[kavan]

A chin wing can be used to address asymmetry by cutting manipulating the lower mandibular border. I've seen cases on the web where for example only one side of the mandibular border was lowered or flared especially to address asymmetry. Many examples online. However if combined with BSSO, a higher cut for the BSSO is necessary in order to combine both treatments at the same time.

As far as i know, the pool of surgeons that perform a BSSO and a full, long chin wing simultaneously is relatively small.

I know for sure, that a certain Dr. in Berlin does it, as other members in this forum had exactly this procedure.

Also, I personally don't think the asymmetry at the gonial angle is that bad in flesh.
I think it's more the different shapes (left/right) of the bone from mid mandible to the chin.
But I think most of the asymmetry is actually visible in the lip?

As to the lip asymmetry, the corner on his right side is lower than the corner on the left and the 'pulp' of the right lower lip comes more forward than on the left side. So the asymmetry there follows the asymmetry to the mandible area  of the face. It's consistent with a type of rotation around the midline axis of the face called a 'yaw'. I've explained what I mean in an earlier post.

[Sequelae]

I think your description of what you see on the FRONT scan is a good one but with reference to looking at a 3-object on a 2-D plane. A front photo of the face and/or a front scan of the scull is how something in 3-D PROJECTS ONTO the 2-plane.

For example, if your mandible was rotated to the left, the left (mandibular) angle of the jaw would receed more in the background so you didn't see a double flair and would project HIGHER on a 2D plane. The right (mandibular) angle would come more forward in the foreground bringing the double flair into view and project LOWER on the 2D plane which is pretty much what you are describing as to what you 'see'.

Thing is, with reference to a VERTICAL axis drawn through the scan that passes through the middle of the periform aperture and between the middle of the upper central incisors, the mid-line axis doesn't pass through the middle of the front lower lateral incisors. So, what you see on the FLAT plane of the 2-D projection of the scull scan looks like it could be a rotation of the mandible around a vertical axis.

This could be something where both jaw angles are similar in length and flair (or not too much dissimilar) but they project on the 2-D plane that way due to a ROTATION around a VERTICAL midline axis.

I think this could be in the venue of what they call a 'YAW'; when one side rotates backwards (receeds into the background) and the other rotates forward into the foreground. So, you would want to consult about possibly having a yaw and if and how that could be corrected.

I have no comment on mandible recession (and BSSO need) because I think that is best seen via a soft tissue profile photo.

Also, as to the asymmetry, you haven't told us WHICH side you like better. IF you liked the nice 'squaring' to the right side jaw angle area, something like soft tissue filler to the left could be used to square out the left one.

Included is an illustration.

Thanks so much for your detailed reply, it is illuminating.

How can I confirm if yaw is contributing to my asymmetry? If it is the issue, can a regular BSSO fix this? I have consulted with some surgeons, but they haven't provided much detail on how they would address the asymmetry. Do you have any surgeons in Europe you would recommend?

I didn't include a soft tissue profile photo because I feel that may be easier to correct than the asymmetry, so I didn't think it was necessary to get any advice on it. However, I can include one if you think it would be helpful.

I definitely prefer the more square side, but I have heard some negative things about fillers, so I'm hesitant to pursue that option. What about an implant? Can that be done at the same time as jaw surgery?

[kavan]

Thanks so much for your detailed reply, it is illuminating.

How can I confirm if yaw is contributing to my asymmetry? If it is the issue, can a regular BSSO fix this? I have consulted with some surgeons, but they haven't provided much detail on how they would address the asymmetry. Do you have any surgeons in Europe you would recommend?

I didn't include a soft tissue profile photo because I feel that may be easier to correct than the asymmetry, so I didn't think it was necessary to get any advice on it. However, I can include one if you think it would be helpful.

I definitely prefer the more square side, but I have heard some negative things about fillers, so I'm hesitant to pursue that option. What about an implant? Can that be done at the same time as jaw surgery?

As to 'confirming' the yaw, what you have to confirm first is if you can 'identify' with my explanation solely in terms of taking an object with mirror symmetry, holding it in front of you straight on and then rotating it around a vertical as to observe how one side of the object would come more forward and the opposite would receed more backwards. Perhaps more intuitively obvious with somewhat of an art or drawing background. But with a little practice and observation, the concept of that relates to the yaw.

A surgeon would tend to confirm a yaw by using a 3-d program. But with some clue that you might have a yaw (I can't confirm things 'medically'), you would first want to determine IF that's something the surgeon corrects. I don't have specific surgeons to suggest. Here, I just give some idea of what someone might have which they can look into further. To the best of my understanding, it takes a lot of decompensation that can differ on either side and this can involve adjusting the maxilla cut in addition to the BSSO cut.

As to implant at same time of surgery, it's possible. But in general putting an implant over a fresh BSSO cut can increase risk of infection. For fillers, you would need to find a good dermatologist.