Surgery Advice: What can I do to fix my downward growth

[downwardgrowth]

Hello: I am a 21 year old african american male. I  grew up mouth breathing with a class 3 bite and crossbite. I had compensation ortho at 19, that tipped my wide lower jaw behind my narrow and recessed upper palate, and I feel it made my face longer. I have pics of my face and my side profile throughout the years if anyone wants to see to further help me with advice, but for now I am just going to show my skull. I am currently in the process of prepping for jaw surgery, and doing consults. SO far I have had two consults with two different Jaw surgeons.

The first, Reza Movahed, told me I had an very tiny airway and my midline is off (I do have noticeable facial asymmetry). He said I need 8 mm of advancement, but due to my protruding teeth, he couldn't advance me that much, so he would widen my jaw with surgery, advance it only a few, maybe 3-5 mm, and give me genio. He said I would not get a huge aesthetic improvement, and most of the improvement would be in the genio.


Surgeon two said my case wasn't extreme enough.

I understand I will need more than just jaw surgery for this, but the goals I'm going for are:

Reduce my incredibly steep gonial angle, its probably like 150 degrees.
Fix my nasolabial folds, that have shown up due to jaw recession, particularly in the maxilla
Improve my chubby cheeks - despite being skinny, when I smile I get this chubby cheek look I hate.
Add more volume to my midface - it looks extremely flat.
Get rid of my baby face look.
Improve the width of my face, and shorten it, so it's not so long and narrow.
Fix my eye area, which constantly looks tired.
Fix my asymmetry

Can someone give me advice on how to proceed with these goals in mind? I would like surgeon and procedure recommendations, preferably in the southern or north eastern US.

I will send pics personally in DM if anyone asks, but here are my skull scans, unfortunately these are the only pics I have that dont show my face, but if anyone needs more information, I can send you in the DM.

An example of something I would hope to acheive off jaw surgery alone is this case: https://www.institutomaxilofacial.com/en/caso-clinico/edgar/

[kavan]

It's best not to use other people's photos as a goal point for yourself when asking questions on here. However if you like a patient's result from any particular doctor, consider they put them up there as 'carrots' towards consulting with them.

Your maxilla looks somewhat long. But no way to tell from skull photos alone whether or not you have excess gum show. ONLY IF you had excess gum show as in 'gummy smile' (which you alone would know) would shortening the maxilla be on the table to suggest. Your jaw angles are HIGH relative to your chin bone. So, assuming Reza was going to do a genio that advanced outward and vertically shortened the chin (diagonally upward sliding genio), that's consistent with mitigating some of the perceived excess length.

Some of your verbalized goals having to do with soft tissue are internally inconsistent and of course, no way for COLLECTIVE relies in absence of seeing the soft tissue (your face). For example a complaint about 'chubby cheeks' and 'get rid of my baby face' is inconsistent--self negating-- with wanting more VOLUME to the midface which comprises the CHEEK area.

Other than that, it is true that excess protrusion of the teeth (and lips that follow) can put an aesthetic limit on advancing the jaw/s.

[downwardgrowth]

my midface lacks volume, so I feel as though when I smile all this skin bunches up. I dont have masculine Zygos or cheekbones and they are relatively flat, so I feel as though it makes me look younger. An example of someone else with this ailment is someone who I have put in the attachements. Lacking midface volume giving him a weird baby face look.

Additionally, I do not have a gummy smile, unfortunately.

Would doing an MSE before jaw surgery allow me to do ortho to undo the proclining in my teeth? If not, how would I get around this. Also, I can send you my face so you can see what I mean in DMs if that's ok with you

[kavan]

my midface lacks volume, so I feel as though when I smile all this skin bunches up. I dont have masculine Zygos or cheekbones and they are relatively flat, so I feel as though it makes me look younger. An example of someone else with this ailment is someone who I have put in the attachements. Lacking midface volume giving him a weird baby face look.

Additionally, I do not have a gummy smile, unfortunately.

Would doing an MSE before jaw surgery allow me to do ortho to undo the proclining in my teeth? If not, how would I get around this. Also, I can send you my face so you can see what I mean in DMs if that's ok with you

The person in the photo has PLENTY of midface VOLUME. 'Volume' refers to the FLESH of the face; soft tissue, thickness thereof. He just doesn't have chiseled cheek bones or maybe he does but his soft tissue volume obliterates them. Chiseled cheek bones are a function of both the THINNESS of the soft tissue and prominence to the cheek bones. Adding more prominence to the bones themselves doesn't really create chisel because it does NOT REDUCE the soft tissue VOLUME needed to show chisel. It can just make the face look BULKIER than it does already. Besides, jaw surgery doesn't alter the cheek bones or thin out thick soft tissue.


'I don't know' and 'no' in response to your last questions.

DISCLOSURE: Addressing an initial post is not an 'invitation' to address questions that have nothing to do with the content of my initial post. Questions need to be limited to what you don't understand about what I said and not about other topic matter.

[downwardgrowth]

UPDATE:

Had an appointment yesterday afternoon.

What I learned:

I do have slight excess gum show as @kavan said
I only needed slight advancement

What I knew:
My chin is retruded compared to my jaws
I do have asymmetry.
Narrow upper palate


What I was told: 3-4 mm forward in upper maxilla, I would get a few millimeters of impaction, and then CW

Question: Is maxillary impaction bad for you??

[GJ]

Question: Is maxillary impaction bad for you??

Only if they impact excessively.

[kavan]

From your bone photos, your main problem is mouth protrusion and from what dr reza told you is that he's hard pressed to advance much at all. It's the MOUTH PROTRUSION that's going to LIMIT advancing the jaws because it will just kick up more mouth protrusion.

So, what you have is called BIMAX PROTRUSION.
The type of surgery to correct it isn't commonly done in US. It's something they do a lot in Korea because it's a common enough problem there. Problem is also one that Afro-americans have. What they do is cut out a section of tooth bearing bone that houses the first pre-molars and push the front tooth bearing bone segments backwards to fill in the gap made by removing the tooth bearing bone (and gum) connected to the first pre-molars. The link I provided at the bottom of this post has a diagram of what I'm referring to.

With that type of mouth protrusion, the chin usually looks recessive by RELATIVE COMPARISON. That's probably why your chin looks retruded in comparison to your jaws. But once the mouth protrusion is addressed (the way they do it in Korea), the chin can look in BALANCE once the mouth protrusion (that makes the chin look recessive) is removed.

The name of 'Mouth protrusion' surgery is Anterior Segmental Osteotomy (ASO). Although it's sometime referred to as Sub apical osteotomy.

Here's a link to a place in Korea where it looks like they give on line consults about that type of surgery. https://eng.idhospital.com/orthognathic-surgery/mouth-protrusion-surgery/

[downwardgrowth]

From your bone photos, your main problem is mouth protrusion and from what dr reza told you is that he's hard pressed to advance much at all. It's the MOUTH PROTRUSION that's going to LIMIT advancing the jaws because it will just kick up more mouth protrusion.

So, what you have is called BIMAX PROTRUSION.
The type of surgery to correct it isn't commonly done in US. It's something they do a lot in Korea because it's a common enough problem there. Problem is also one that Afro-americans have. What they do is cut out a section of tooth bearing bone that houses the first pre-molars and push the front tooth bearing bone segments backwards to fill in the gap made by removing the tooth bearing bone (and gum) connected to the first pre-molars. The link I provided at the bottom of this post has a diagram of what I'm referring to.

With that type of mouth protrusion, the chin usually looks recessive by RELATIVE COMPARISON. That's probably why your chin looks retruded in comparison to your jaws. But once the mouth protrusion is addressed (the way they do it in Korea), the chin can look in BALANCE once the mouth protrusion (that makes the chin look recessive) is removed.

The name of 'Mouth protrusion' surgery is Anterior Segmental Osteotomy (ASO). Although it's sometime referred to as Sub apical osteotomy.

Here's a link to a place in Korea where it looks like they give on line consults about that type of surgery. https://eng.idhospital.com/orthognathic-surgery/mouth-protrusion-surgery/

Yea, Movahed talked to me about that. He said "I should give you 8 mm of advancement for optimal airway, but because of your protrusion I can only give you 4 without making you look like a primate" or something along those lines.

To me, I don't like anything involving extractions, and Movahed said that ASO is not a healthy surgery. He said something about it causing airway issues down the line.

Maybe I am not educated about ASO, but I have already kind of in my head made a decision to not do it due to health concerns. I am pretty averse to anything involving extractions. Is this a valid reason?

Rather, I would simply advance and rotate as much as I can without looking uncanny, fix asymmetry, and get genio to make my chin not look so retruded. Is this a valid plan that will yield a good aesthetic result? Or should I just suck it up and do ASO?

Attached is a genio-only result I thought was good, for reference

[downwardgrowth]

Additionally, is it possible to get similar results to ASO without extractions?

This lady claims she had 0 extractions and expanded first, and got her surgery done in Korea.

https://www.reddit.com/r/jawsurgery/comments/dayy8u/my_before_after_double_two_surgery_and/

[kavan]

Yea, Movahed talked to me about that. He said "I should give you 8 mm of advancement for optimal airway, but because of your protrusion I can only give you 4 without making you look like a primate" or something along those lines.

He was right about that.

To me, I don't like anything involving extractions, and Movahed said that ASO is not a healthy surgery. He said something about it causing airway issues down the line.......Maybe I am not educated about ASO, but I have already kind of in my head made a decision to not do it due to health concerns. I am pretty averse to anything involving extractions. Is this a valid reason? .

I don't think so because it's not moving the whole maxilla or mandible backwards, just a bone bearing segment of front teeth from lateral to central incisors. But with the ASO, not only are the teeth removed but also a track of bone with gum on it. So, it's more specialized surgery which would need to be pursued or consulted about outside of doctors who don't do it and within the venue of doctors who do do it and many to most are in Korea.
 

Rather, I would simply advance and rotate as much as I can without looking uncanny, fix asymmetry, and get genio to make my chin not look so retruded. Is this a valid plan that will yield a good aesthetic result? Or should I just suck it up and do ASO?

Well, I can't tell you to suck it up and do ASO. But I can suggest you take the time to do more research on it and seek out opinions from doctors who do it. Start with sending your photos to that Korean place. TONS more Korean places that do it.
 

Attached is a genio-only result I thought was good, for reference

He doesn't start with protrusive mouth. Only recessive chin

Also to your subsequent question on this string, I don't know if expansion can substitute for ASO.  But since the woman in the link you gave had her surgery in Korea, a consult with a doctor there would probably lead you to the possibilities and options as to addressing the mouth protrusion. Again, can't apply other people's results to a different person. Don't get in the habit of doing that because if you consult with a doctor using other people's results he'll tell you he's not operating on them.

[downwardgrowth]

Thank you for your help thus far. I will likely schedule a Korean consultation soon, in that case. Additionally, I got a letter from the doctor today detailing treatment plan:

21yo with a history of [redacted] and a facial asymmetry resulting from likely excess
late maxillary growth or R late joint growth. His features are consistent with vertical
maxillary excess and he is class III highly compensated bite from prior ortho. He is
transverse discrepant on the left side with about 4mm width deficiency. He has both
maxillary and mandibular yaw, posterior maxillary excess on both sides (4mm
posterior gingival show, 2mm anterior). There is a very steep mandibular plane and I
can't see it d/t facial hair, but there is some chin retrusion with his pogonion 3-4mm
behind the lower incisor tip. There is significant malar hollowing, and the vertical facial
height leaves him with a very high open bite tendency in the future.
My recommendation is for upper jaw and lower jaw surgery, and by advancing upper
jaw probably 4mm net at ANS, rotating the incisor back, setting the mandible into it,
that would correct his excess proclination. The vertical impaction would help his cheek
fullness but additional malar augmentation would be indicated as well. We discussed
angle augmentation that would help with the steep mandibular plane, but impaction
with genioplasty would do so more effectively. He would be a segmental LeFort (2-
piece) to correct the transverse as well, we would reduce the turbinates and perform
inferior septoplasty.
Tx in summary:
1-segmental LeFort I osteotomy (2-piece) with advancement (4mm), impaction
posterior 4-5mm, impaction anterior 2-3mm and global clockwise rotation
2-mandibular advancement with clockwise rotation that would be compensated by
genioplasty and the maxillary impaction to flatten the mandibular plane
3-septoplasty and turbinectomy given the turbinate hypertrophy, septal spurring, and
mucosal irritation.
4-Stage II malar augmentation with maxillary hardware remova

The thing that disappointed me today was when he sent before and after pics of patients which looked virtually the same. Realistically, how different would I look after these changes?

[kavan]

Thank you for your help thus far. I will likely schedule a Korean consultation soon, in that case. Additionally, I got a letter from the doctor today detailing treatment plan:

The thing that disappointed me today was when he sent before and after pics of patients which looked virtually the same. Realistically, how different would I look after these changes?

Get real!  It's not a realistic question to ask here in the absence of photos. Even if you showed photos, you can't assume JSF is a ceph analysis evaluation service to predict how you are going to look. I'm going to need to close further 'back and forth' about this because your questions revolve around needing predictions about how you are going to look either based on OTHER people's photos and/or the absence of your own.