What do I need? (Pics, Ceph+)

[PloskoPlus]

Again don't take it the wrong way, but you would benefit hugely from ccw. You're lucky to live in us where ccw is relatively common. OK, according to one patriarch I saw - only about a dozen surgeons. But that's probably 10 times more than what you'd find in Europe.

(The "1 month off is the end of the world" must be an American thing however. )

[Tezcatli]

He was class ii before. I think he just had a very retrognathic face in general. He looked virtually the same afterwards.

Yeah, I was supposed to write overbite. Sometimes people look very similar from the front but better from profile view, which is important in real life as people see you from angles usually.

Some people are still ugly after jaw surgery but it is almost always an improvement in my opinion.
I see sometimes people posting before after of old, bald men and saying oh look jaw surgery is worthless. But what did they expect?

[buzzhead]

Ummm..........excuse me........lol!

[ditterbo]

I shaved off the stubble beard, as seen in my first posts and sooo many issues struck me at once... The abnormal cheek dimpling from the malpositioned implant is more obvious (to me), as well as the 'fake' looking projection of my chin.  My lower lip looks weird how it protrudes out over this chin.. maybe that's caused by the labiomental groove this implant created?  And my jawline looks just like it has pre op, but a sort of obvious wing extension on my right side that just looks stupid.

Dr. Lee I'm afraid might give me an anatomic chin, where it looks unnaturally projected off my face.  I don't really know what would look good. The chin implant is hardly helping me while the rest of the jaw looks so terribly small and recessed... the stubble beard gave me a break from seeing it and created a fake jaw line.  To clarify again about this implant, I'm really just getting a revision to hopefully catch a break from all the complications I had with the first one.  The projection is welcome, however little it's helped.  Happy to remove it with a SG or whatever in the future if combined with some treatment correcting my whole jaw.

I'll have to do more research on how extracting teeth affects everything else.. even if there isn't a bulletproof link to memory loss yet, I've gathered that the arch your pulling the teeth from will shrink.  Would the jaw shrink as well?  There's gotta be a trade off between being able to advance your jaw more but losing two bicuspids in the process, right?

PS please keep the doc recommendations coming.

[ditterbo]

Your surgeon should know exactly how much septal cartilage you have left for grafting. They can't take it all as some is obviously needed. I don't think tucking the columellar will free up any useable cartilage. If you're happy with the bridge, then there's enough cartilage in the ear to take a small graft for the nostrils. In fact, my surgeon was able to fix my nostrils without rim grafts, he simply repositioned the existing lower lateral cartilages, so it depends on what's causing the problem. If you're happy with your nose, then it's probably best to leave well alone.

What's the next best option to asking my surgeon how much cartilage is left?  I've lost my good graces with him after he asked for money over his quoted amount (due to insurance kicking in late) and I finally got pissed at him, over email, asking him for that difference after all the damages he's caused.  I'm 90% sure the enormous screw he used to secure my first implant caused permanent damage to the mentalis muscle and motor nerve, because it literally jutted out several millimeters out in front of the implant. My lower lip is still tethered up when I smile due to the lack of pull down action right at the center of the lip, above where that screw poked out. 

PS the new implant's left wing is AGAIN crooked and painful (and this is an anatomic chin, ffs).  When I see him next, I'll ask about replacing it with a custom implant, no surgical fee.  Also going to look into nerve specialists just to confirm I'm basically f****** at this point since the mentalis muscle nerves are probably microscopic and impossible to revive.
   

[SJay]

You have about a one inch square section of spare septal cartilage.

See here for pics/more info - http://www.davisrhinoplasty.com/rhinoplasty-glossary-terms.html

Your surgeon should know how much he took, and how much is left.

[ditterbo]

Well I found out from Gunson that my chin implant is fairly straight, yay! Both the previous and current 12mm implant has over-tightened and/or pushed up the mentalis muscles, causing the deformity in the center lower lip
I'm not sure if the taughtness of the mentalis muscle is time sensitive or not if I relieved the muscle at a TBD date... that's giving me a lot of anxiety.

Here's what I look like now with the 12mm implant: user requested photos removed.

He would NOT do extractions, and basically called Posnick old fashioned.  It would mess up my bite and give me a more unaesthetic result, according to him.

The problem is... who the heck regularly manages 9mm+ posterior maxillary downgrafts safely besides Gunson? Obviously his bill was astronomical (won't post it here) and I'd prefer not to lose everything on bimax. 

I think the only other way to skin this cat is to do a weaker posterior downgraft, add in anterior maxillary impaction but with like 5-10mm maxilla advancement as opposed to Gunson's 3mm to compensate for my already ideal gum show.  Just a hunch, but I think THAT is what Posnick and most other surgeons would do, and requires lower bicuspid extractions for the amount of forward movement my jaw needs to compensate for the relative lack of CCW.  I don't think a baby jaw surgery movement is worthwhile since I already have mild OSA, and is pretty much the only functional improvement I stand to gain from bimax besides less back teeth wear.  My lower jaw slides forward about 2-3mm to make my bite, which supposedly causes the wear and tear on the back teeth.

I'm opposed to bicuspid extractions, but I wonder if the additional 3-7mm maxilla forward movement would help my facial aesthetics more than the 3mm maxilla projection in Gunson's plan?  Obviously Gunson would lather my cheeks up in HA as part of his plan, but maybe Z can do a Z(S)O simultaneously.  Thoughts on all this?

To answer Bobbit & everyone else wondering why I got a chin implant: Before I knew any better, my first op doc (who did the rhino + 1st chin) wanted me to do an SG that moved my chin down and forward.  He referred me to a max fac that would only move it forward (about 6mm).  So, all things considered in risk vs reward, I went with a chin implant, and ended up with a size large (7mm) terino extended anatomical.  That one was royally cucked up, so I eventually revised it with what was SUPPOSED to be a smaller implant in every way to also help my smile.  Instead, Harrison Lee put in this enormous 12mm anatomic implant.  So here we are... At least it's an improvement over the first one, but my smile is still just as wack as before. 

[Bobbit]

  Why did you do an implant rather than a sliding genioplasty ?

[ditterbo]

Most doctors call me a borderline case though for bimax.  The one side profile pic I posted might be deceiving, all I have to do is aim my head slightly off angle or slightly down and the actual recession looks 10x worse.

Here's a ceph from a CAT scan pre-everything: http://i.imgur.com/HahmpOx.png
That should show my old profile exactly...
Or maybe this one: http://i.imgur.com/NpcIRyx.jpg?1

But at any rate, really trying to understand if Gunson's approach makes more sense or the theoretical one I described with bigger maxilla forward movement.  This really harks back to my need for MORPHS...

[PloskoPlus]

Your midface is quite long. Maintaining the steep occlusal plane and doing a mostly linear advancement will make your lip fuller and thus the midface will look longer than it is (closer to the observer, the actual lip will not lengthen). There nose will look smaller in profile, but the tip will surely rise and the nostrils widen. Lf1 advancement can work wonders where it's really needed, but it can make you uglier when it's not. I think you need CCW.

[Wheatsnax]

I think a morph of Gunson's surgery plans would really help!

I wonder if the larger CCW/smaller advancement VS smaller CCW/larger advancement is a matter of taste.

[treevernal]

Surely Gunson didn't say that? And those doctors you asked are they unknown random s**tty ones, or ones with a bit of reputation?

https://gyazo.com/b95fb11aaf91bb5e7bdc4d5a1b21c155

Your nose could have looked like this if you didn't get a nose job got a bimax. Your current nose looks a bit downtilted and bimax might still make your new nose look better, but it might look a bit scooped now. I just brought the tip upwards in this morph. You would really benefit from some brow augmentation as well. Chin wing would be great for you as well since your jaw looks a bit narrow from the front, but that would probably just be overkill for your desires. Do you have a gummy smile?

I say get it done mate! I think you would benefit greatly compared to most on this forum.

Let me know if you want me to delete the picture

That is an incredible morph!  Really good job, though unfortunately A&G do not do brow augmentation...but seeing this morph I really wish they did because I see what an amazing difference it makes.  I had surgery with Arnett almost 4 years ago and I had even more bimax retrusion than the OP.  While I'm sure the OP will have a fantastic result with Gunson, I'm not sure that he would get a result as transformative as your morph, having seen many, many before and afters.  But seriously, that is a wonderful morph!

[PloskoPlus]

Can you elaborate on how lf1 makes the mid face appear longer? Would not fuller lips create the illusion of a smaller philtrum and mid face?

I think a lf1 could have done wonders for OP's nose. And I don't think nostril flare is always a negative aesthetically speaking.

I have no idea where people got this ridiculous notion that a lefort is some kind of beauty operation.
By fullness I meant the upper part of the lip ie. Nasal base.  When the occlusal plane is steep, you move the maxillaa forward and you end up with a straight vertical lip at best or a convex lip at worst since the teeth are to vertical and not propping up the vermilion. It looks ugly in profile. In the frontal view while the lip is not physically any longer it is now closer to the observer and seemingly takes up more of the face.  Maybe OK in some cases, but if the midface is long to begin with it looks ugly.

[ditterbo]

That is an incredible morph!  Really good job, though unfortunately A&G do not do brow augmentation...but seeing this morph I really wish they did because I see what an amazing difference it makes.  I had surgery with Arnett almost 4 years ago and I had even more bimax retrusion than the OP.  While I'm sure the OP will have a fantastic result with Gunson, I'm not sure that he would get a result as transformative as your morph, having seen many, many before and afters.  But seriously, that is a wonderful morph!

Seriously, I'm in love with that morph lol.  I think the chin is 3-6mm further out than Gunson would like, unfortunately.

Treevernal, since you've seen so many before/after's, where do you think I fall in the spectrum of cases A/G have treated?  I've really got no functional issues aside from mild OSA and premature back molar wear. Maybe a slowly receding gumline & teeth roots from teenage camouflage orthodontics.  Bite isn't terrible, think it's a mild class 2. 3-4mm overbite, 2mm overjet. Chin implant messed up my smile, which is making me itch for this or some other surgery.  I have all my teeth save for all 4 wisdoms. I'm 27, btw.  Pre-surgeries shots were from when I was 24. Having a hard time justifying bimax to myself and even more so to immediate family, who are super unsupportive of aesthetic surgery.

Out of the 30 or so doctors (mostly local PS or max fac) I've seen, I'd say about 5 have clearly came out for bimax.  Even Deschamps Braly doesn't recommend it, but he's the only bigly who advised against it (other big shots being Posnick and Gunson). My smile WAS great before the chin implant. Partially why I'm concerned about the CCW I think Posnick and most other max facs have in mind. 
 
So to PloskoPlus and others, I agree I need CCW.  But what Gunson appears to be doing in his plan is 0 maxilla anterior impaction, and nearly 10mm  posterior downgrafting.  Doesn't more 'traditional' CCW includes anterior impaction, a 3mm or smaller posterior downgraft, and bicuspid extractions if the lower jaw needs more than, idk say 10mm advancement? If my gum show is basically perfect as it is now (I think?), then the maxilla has to move forward say 5-10mm to negate the anterior impaction affect on my upper tooth show.  I had also thought that forward maxilla movement helped reduce the appearance of deficient cheeks and maybe even reduced some scleral show.  I "have a long face" -  as in my cheek bones are really weak, right?  So I''ll look worse if I get more than like 2mm upper advancement if the cheek bones aren't treated at the same time or after the fact?  Idk if this helps but this is maybe my cheek angle (even worse now, this is 3 years ago): http://i.imgur.com/79v7Beb.jpg?1

I'm just trying to understand if there's really only Gunson's way to do my CCW or if I can get very similar or even better results with the weaker posterior downgraft + maxilla impaction & 5-10mm maxilla forward plan that most max facs pedal.  Both are CCW but very different approaches, I think?

[ditterbo]

Ok wow I was way off on how the more 'down to earth' max fac would do a typical class 2 bimax.  Watched a CCW video, and the anterior maxilla is tipped up as it moves forward followed by a downgraft in the posterior space opened up. No anterior impaction, the maxilla just slides forward past the nasal spine bone allowing it to move up but not fold over bone above it.  Soo I don't know what the more basic bimax plan would look like that most other surgeons would use on class 2 vs Gunson's plan.

Trying to visualize it, less posterior downgrafting means less forward jaw movement is possible, all else remaining equal.  By removing lower bicuspids, Posnick can still make a large lower jaw advancement before my upper and lower incisors meet up.  Is that all there is to 'plan b' really? So with my class 2 kind of case, you either do a huge CCW via a large posterior maxilla downgraft, or you do a smaller CCW but extract teeth?

 A segmental lefort 1 is also a typical Gunson move, but I think he does that so he can make those huge posterior downgrafts without creating the affect of the incisors moving up in your mouth, similar to how they would with anterior impaction.  So is a smaller posterior downgraft, bicuspid extractions and one-piece lefort 1 the more routine surgical plan? How can doctors have less aesthetic plans than like Gunsons, so long as they (presumably) aim for the same vertical line in Gunson's model block surgery? Maybe most docs only aim for proper teeth occlusion?  Sleep apnea patients can be fixed with bicuspid extractions and some range of maxilla movement skewed on the super low end so as to avoid grafting?

Sorry if this is hard to follow.  Trying to talk through the different movements a doc would conceivably do on a class 2, and what makes the big league max facs surgical plans any more special than a run of the mill type.