What surgeries do I need?

[lowlhfsh]

So genetics,  mouth breathing, child injuries, molar extractions, bad orthodontics, put me in this situation.

I'm pretty sure I'm needing corrective jaw surgery to fix face and bite. So I will be thankful reading your suggestions about my case. 

What do you think would be the best movements to improve my facial funcion and aesthetics?
Take in consideration that I'm a skeletal and molar III class, with edge to edge anterior occlusion, steep occlusal plane, extremely elongated anterior face height, long philtrum, and mildly gummy smile. Slightly open bite in the right side because of extractions. I think my maxilla is not retruded if you trace a line from the upper line to the brow.   Nowadays my muscular tone is nule because of lack of posterior teeth and the ones that I have were drilled, so I can barely chew and apply forces. This causes my face to look even puffier and longer.

I was thinking the following:  subtle mandibular setback, and very subtle upper and forward maxilla movement. Not sure about the forward movement because of chimp look and philtrum worsening, even not sure about the impaction because I'm affraid of ending without posterior vertical dimension which would lead to the skull falling downwards.  What's your oppinion? I want  a shorter face with a anteriorly projected jaw, as well as a good profile relationship between both jaws and forehead/brow in the sagital direction.   I'm doing this for the functional aspect though, because my speaking, chewing, talking and sleeping are absolutely terrible.

Would be thankful reading any suggestions.-

[stupidjaws]

double jaw with advancement and ccw rotation, chin wing and  malar osteotomy.

[Tezcatli]

double jaw with advancement and ccw rotation, chin wing and  malar osteotomy.

What kind of malar osteotomy?


OP, stop with that philtrum non sense and chimp look, you need Lefort I with advancement and impaction, BSSO with advancement and CCW rotation, possibly a genio. I cannot comment on chin wing because I think it is only performed in a few countries/surgeons.
Obviously you will need braces before that and x-rays and ct scan to see how much you need of each. No way to tell if your Lefort will need to be segmented or how much impaction you need just from cellphone pics

[strongjawman]

No way to tell if your Lefort will need to be segmented or how much impaction you need just from cellphone pics

What are signs that a lefort will need to segmented?

[stupidjaws]

His orbital rims are recessed, no malar Sandwich osteotomy that stupidjaws seems to be referring to is going to fix that. It can accentuate the recessed orbits though. And I've seen enough pics in which that happened.

in my case the malar osteotomy improved that area-it stretched everything out and smoothened stuff out. malar fat pads are now much leaner and this aided the tear trough/cheek junction

Orbital rims may be done by addressed by an extended malar osteotomy. i think i heard triaca does tuff like that. my surgeon does not; a pity.

[Vic]

You need to upload a Ceph X-ray before a proper analysis can be done. People on here are just calling out different surgeries with proper view of what your situation is

[Picollo30]

His orbital rims are recessed, no malar Sandwich osteotomy that stupidjaws seems to be referring to is going to fix that. It can accentuate the recessed orbits though. And I've seen enough pics in which that happened.

what about malar fat grafts / implants?

[Picollo30]

what about malar fat grafts / implants?

i had malar fat grafts and improved the area a lot too bad most of the fat is lost/absorbed and the fat that stays only lasts for 6/7 months. orbital rim implants/ malar implants are what i recommend and want for myself, i have the same problem as OP.

[Bobbit]

i had malar fat grafts and improved the area a lot too bad most of the fat is lost/absorbed and the fat that stays only lasts for 6/7 months. orbital rim implants/ malar implants are what i recommend and want for myself, i have the same problem as OP.

Done properly - - fat grafting is reasonably predictable for a skilled plastic surgeon.  Yes,  you will have a percentage of the injected fat be reabsorbed.  But if the donor fat tissue is properly processed and prepared before injection,  then you will keep a reasonably predictable amount. 

But it has to done by a surgeon that knows how to process the donor fat and then how to inject and judge how much to over inject to allow for the predictable loss.  There are likely some "trade secrets" for the individual surgeon involved in that.   Often it is done in two sessions or even three - - over a period of time so as not to "over do it."

[stupidjaws]

I really liked that procedure; will post pictures soon

[Tezcatli]

What are signs that a lefort will need to segmented?

Curve of spee, some kinds of gummy smile, the need for a small expansion of the palate. A segmented lefort can expand your palate to a much smaller degree than SARPE.

[lowlhfsh]

I'm updating with the cephalometric x rays for a better analysis if you want to add something.

What do you think?

Thanks for all the replies.


[attachment deleted by admin]

[Tezcatli]

You will probably need maxillary advancement with ccw rotation of the mandible and a genio. I don't think your mandible should be setback, but it doesn't need advancement either, mostly ccw rotation, but maybe it will advance 1-2mm due to the rotation.

[lowlhfsh]

You will probably need maxillary advancement with ccw rotation of the mandible and a genio. I don't think your mandible should be setback, but it doesn't need advancement either, mostly ccw rotation, but maybe it will advance 1-2mm due to the rotation.

CCW rotation of the mandible, how do you achieve that? Maxilla impaction? Or does exist a lower jaw proccedure to do that?          I agree that I don't need mandible set back, actually I'm a III class only that the jaw is so CW rotated that It doesn't look like it.   

I'm a bit worried about upper jaw proccedures because of the widening of the alar base. I think I'm in the limit of what you would consider as a "normal" alar base.  A little change in this could ruin my aesthetics.

Also, how much maxilla advancement do you think I need?

[Tezcatli]

CCW rotation of the mandible, how do you achieve that? Maxilla impaction? Or does exist a lower jaw proccedure to do that?          I agree that I don't need mandible set back, actually I'm a III class only that the jaw is so CW rotated that It doesn't look like it.   

I'm a bit worried about upper jaw proccedures because of the widening of the alar base. I think I'm in the limit of what you would consider as a "normal" alar base.  A little change in this could ruin my aesthetics.

Also, how much maxilla advancement do you think I need?

Impaction but also you have to cut the mandible, it is double jaw surgery.
You can get an alar cinch to reduce alar widening but it may cause your nose to upturn more, or you can go for a rhino later. I'd use the alar cinch suture.

I don't know how much you need.