Lefort1 cut, ccw and nose altering

[Dogmatix]

I've been looking at some videos of Lf1 surgery and I've been reading some discussions regarding how different procedures alter the nose.
I've also been looking at a lot of before and after pictures, and I honestly almost never see any big difference to the nose, unless there has been an obvious rhinoplasty.

From looking at the videos, I now understand that the lf1 cut goes pretty high and that the entire palate is cut loose. I also see that the cut goes just below the nasial airways. So it certainly makes sense if the nose would be altered.

Could anyone elaborate a bit on this and maybe show some before and after pictures and point out what is expected in this context? I'm especially interested in what a ccw rotation would do.

It's a bit inconclusive to me as the surgeon I'm consulting says that the nose itself will be unchanged, but everywhere I read people talk about it. Is it big changes that occur, or what is it that actually happens.
A picture would say more than a thousand words


Below is a video of my understanding of where the cut goes. Even the animation doesn't show any nose change, except for the lip below.
https://www.youtube.com/watch?v=h8Nceh_m1cg

[XXRyanXXL]

This is exactly the same question I had going into my bi-max procedure.
It is true, that whenever a LF1 patient has impaction into the nasal cavity, that the base of the nose does widen. It's also called monkey nose. The base of the nose would have to be stitched up (alar stitch) to prevent it from spreading, or the bones would have to be surgically moved together. Of course you have patients where the nose will tip up (or down), depending again on how much impaction and if there was advancement of the maxilla.
I've noticed from a local surgeons office of a girl who appears to have this thickening around the base of the nose, and this is clearly botched and can be repaired.
http://www.daytonfacialsurgery.com/procedures/jaw-surgery/
Basically you run into problems when the procedure impacts further into the nasal cavity.

[Dogmatix]

This is exactly the same question I had going into my bi-max procedure.
It is true, that whenever a LF1 patient has impaction into the nasal cavity, that the base of the nose does widen. It's also called monkey nose. The base of the nose would have to be stitched up (alar stitch) to prevent it from spreading, or the bones would have to be surgically moved together. Of course you have patients where the nose will tip up (or down), depending again on how much impaction and if there was advancement of the maxilla.
I've noticed from a local surgeons office of a girl who appears to have this thickening around the base of the nose, and this is clearly botched and can be repaired.
http://www.daytonfacialsurgery.com/procedures/jaw-surgery/
Basically you run into problems when the procedure impacts further into the nasal cavity.

Aha, so it's more a widening of the nose that is common. You see it when you know where to look.

How did it turn out for you, did you get a big change?

I've been looking at some real surgery movies, and I'm twisting my self every time *why do you need to go that high to move my teeth*

[kavan]

Don't depend on Dolphin videos to show you everything you are wanting to see shown to you.
They are TARGETED to isolate the illustrations to the specific topic of the video.

Here's a  way to think about it:



The hard palate of the maxilla, otherwise know as the 'roof of your mouth' is also the 'floor' of the nose. Kind of like the ceiling in one's apartment is the floor of the person who lives above.

On a ceph diagram that marks out the points, this part of the maxilla is marked as ANS-PNS; anterior nasal spine to posteror nasal spine.

The ANS is the SUPPORT for the BASE of the nose.

A cut to displace this part of the maxilla cuts through (slightly above) the anterior nasal spine and takes the ANS for 'a ride' with it.

That 'ride' can be a number of displacements. The easiest one to start visualizing is 'linear advancement' meaning along the (same) 'line' or 'slope' ANS-PNS is oriented. In terms of an X, Y axis , diagonal lines either have a positive or negative slope.

The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.

If it's a sleep apnea case (with linear advancement) where they might have to advance out the ANS-PNS a LOT to accommodate a significant BSSO to open the airway, you want to look also at the CONTOUR of the ANS because the more the contour of it is pushed forward, the more CONVEX the labial ledge will become ('monkey lip).  Here is a link where the doc seems to be doing linear advancement for sleep apnea cases. https://www.sylvainchamberland.com/en/treated-cases/sleep-apnea_orthosurgery-treatment/  Here, you can see the positive ANS-PNS slopes in these cases and how a CONVEXITY to the nose/upper lip area can be kicked up when a LOT of advancement is needed for those extreme sleep apnea cases.

On the DOLPHIN video, well they did the illustration so that ANS-PNS was on a HORIZONT (not on a positive slope as in the real life extreme apnea cases above). Technically, moving the ANS forward in that illustration (IF they actually WANTED to show the lip changes to the labial ledge area between red border of upper lip and base of nose) would become less conCAVE as in a little straighter. But PRAGMATICALLY the lesson in illustration is to show airway and face balance changes in a cartoon of lucky person who is IDEAL candidate for maxing out aesthetics with linear advancement.

Combinations of rotations with impactions and advancements are more challenging to visualize and also to explain. Some people (eg. MIT types) can just to that in their heads (right side of brain) but hard (or just tedious)  to verbalize it (left side of brain) or it just becomes a time intensive tutorial process to train someone elses brain to do that.

That said, my advice for 'brain training' to assist with understanding some of this stuff is to revisit Euclid as that type of rigorous observation training is needed as ground work so that a lot of these relationships (which relate to geometrical concepts) eventually become 'intuitive'.

By the way, the video does NOT show 'impaction'.

[beyondconfusedtbh]

Don't depend on Dolphin videos to show you everything you are wanting to see shown to you.
They are TARGETED to isolate the illustrations to the specific topic of the video.

Here's a  way to think about it:



The hard palate of the maxilla, otherwise know as the 'roof of your mouth' is also the 'floor' of the nose. Kind of like the ceiling in one's apartment is the floor of the person who lives above.

On a ceph diagram that marks out the points, this part of the maxilla is marked as ANS-PNS; anterior nasal spine to posteror nasal spine.

The ANS is the SUPPORT for the BASE of the nose.

A cut to displace this part of the maxilla cuts through (slightly above) the anterior nasal spine and takes the ANS for 'a ride' with it.

That 'ride' can be a number of displacements. The easiest one to start visualizing is 'linear advancement' meaning along the (same) 'line' or 'slope' ANS-PNS is oriented. In terms of an X, Y axis , diagonal lines either have a positive or negative slope.

The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.

If it's a sleep apnea case (with linear advancement) where they might have to advance out the ANS-PNS a LOT to accommodate a significant BSSO to open the airway, you want to look also at the CONTOUR of the ANS because the more the contour of it is pushed forward, the more CONVEX the labial ledge will become ('monkey lip).  Here is a link where the doc seems to be doing linear advancement for sleep apnea cases. https://www.sylvainchamberland.com/en/treated-cases/sleep-apnea_orthosurgery-treatment/  Here, you can see the positive ANS-PNS slopes in these cases and how a CONVEXITY to the nose/upper lip area can be kicked up when a LOT of advancement is needed for those extreme sleep apnea cases.

On the DOLPHIN video, well they did the illustration so that ANS-PNS was on a HORIZONT (not on a positive slope as in the real life extreme apnea cases above). Technically, moving the ANS forward in that illustration (IF they actually WANTED to show the lip changes to the labial ledge area between red border of upper lip and base of nose) would become less conCAVE as in a little straighter. But PRAGMATICALLY the lesson in illustration is to show airway and face balance changes in a cartoon of lucky person who is IDEAL candidate for maxing out aesthetics with linear advancement.

Combinations of rotations with impactions and advancements are more challenging to visualize and also to explain. Some people (eg. MIT types) can just to that in their heads (right side of brain) but hard (or just tedious)  to verbalize it (left side of brain) or it just becomes a time intensive tutorial process to train someone elses brain to do that.

That said, my advice for 'brain training' to assist with understanding some of this stuff is to revisit Euclid as that type of rigorous observation training is needed as ground work so that a lot of these relationships (which relate to geometrical concepts) eventually become 'intuitive'.

By the way, the video does NOT show 'impaction'.

my head hurts

[ditterbo]

Welcome to the land of bone cutting, beyondconfused.

[Dogmatix]

Don't depend on Dolphin videos to show you everything you are wanting to see shown to you.
They are TARGETED to isolate the illustrations to the specific topic of the video.

Here's a  way to think about it:



The hard palate of the maxilla, otherwise know as the 'roof of your mouth' is also the 'floor' of the nose. Kind of like the ceiling in one's apartment is the floor of the person who lives above.

On a ceph diagram that marks out the points, this part of the maxilla is marked as ANS-PNS; anterior nasal spine to posteror nasal spine.

The ANS is the SUPPORT for the BASE of the nose.

A cut to displace this part of the maxilla cuts through (slightly above) the anterior nasal spine and takes the ANS for 'a ride' with it.

That 'ride' can be a number of displacements. The easiest one to start visualizing is 'linear advancement' meaning along the (same) 'line' or 'slope' ANS-PNS is oriented. In terms of an X, Y axis , diagonal lines either have a positive or negative slope.

The displacement of the ANS is what would be seen as a change to the base of the nose and sometimes right under the base of the nose at where the upper lip area (or labial ledge) is close to the base of the nose. So, when ANS-PNS is along a positive slope line, moving 'forward' with linear advancement will bring forward the base of the nose and the tip area is advanced and can rotate up slightly. For someone with a narrow nose base and a dorsal hump, it would improve the nose contour. But if they had a wide nose base and already upward tilted nose, it would just exaggerate that particular aesthetic problem.

If it's a sleep apnea case (with linear advancement) where they might have to advance out the ANS-PNS a LOT to accommodate a significant BSSO to open the airway, you want to look also at the CONTOUR of the ANS because the more the contour of it is pushed forward, the more CONVEX the labial ledge will become ('monkey lip).  Here is a link where the doc seems to be doing linear advancement for sleep apnea cases. https://www.sylvainchamberland.com/en/treated-cases/sleep-apnea_orthosurgery-treatment/  Here, you can see the positive ANS-PNS slopes in these cases and how a CONVEXITY to the nose/upper lip area can be kicked up when a LOT of advancement is needed for those extreme sleep apnea cases.

On the DOLPHIN video, well they did the illustration so that ANS-PNS was on a HORIZONT (not on a positive slope as in the real life extreme apnea cases above). Technically, moving the ANS forward in that illustration (IF they actually WANTED to show the lip changes to the labial ledge area between red border of upper lip and base of nose) would become less conCAVE as in a little straighter. But PRAGMATICALLY the lesson in illustration is to show airway and face balance changes in a cartoon of lucky person who is IDEAL candidate for maxing out aesthetics with linear advancement.

Combinations of rotations with impactions and advancements are more challenging to visualize and also to explain. Some people (eg. MIT types) can just to that in their heads (right side of brain) but hard (or just tedious)  to verbalize it (left side of brain) or it just becomes a time intensive tutorial process to train someone elses brain to do that.

That said, my advice for 'brain training' to assist with understanding some of this stuff is to revisit Euclid as that type of rigorous observation training is needed as ground work so that a lot of these relationships (which relate to geometrical concepts) eventually become 'intuitive'.

By the way, the video does NOT show 'impaction'.

Very interesting, I'll read through this a couple of more times later and maybe come back with some questions. Earlier I've thought about it as an intraoral osteomety and been wondering about step-offs inside the mouth etc. After reading up on this and watching some real surgical movies, I realize how invasive this procedure actually is. It's not just moving the teeth, they break loose the whole shabang.

[Dogmatix]

It's hard for me to understand exactly why the nose would get wider. Would it be correct if I think about it this way that the nose itself doesn't actually get wider. I mean, if I would measure the lowest point of the nose and closest to the face, it's still connected to the same spots. But I can understand that pushing the maxilla forward or rotating it will move the base and make the soft nostrils more round and "wider" in case of advancement or ccw.  Don't know if this explanation makes any sense, but if I hold 2 pieces of paper flat together and start moving the ends, they'll form something like this <>, which will get wider the more I push, or in this case, advance or rotate the maxilla? It's like the maxilla moves forward, but the nose bone is connected higher up, so the soft tissue need to escape somewhere, which will be to the sides.

[Meefly]

From a relative layman's perspective, a lot of the photos with significant advancement of the maxilla it looks as if the soft tissue is 'filled out' and therefore more stretched which spreads out the soft tissue of the nose at the level of the nostrils. For a lot of people I think this looks quite good depending on their starting point. Unfortunately in my case I have a nose that is short and fat but also a bit pinched (as bizarre s that sounds). A doctor that I consulted about jaw surgery casually ignored my bite complaints and proceeded to tell me everything that was wrong with my nose  and how rare it was and why rhino was the way forward if I wanted to look good, despite the fact I hadn't even mentioned any issue with it!

[kavan]

It's hard for me to understand exactly why the nose would get wider. Would it be correct if I think about it this way that the nose itself doesn't actually get wider. I mean, if I would measure the lowest point of the nose and closest to the face, it's still connected to the same spots. But I can understand that pushing the maxilla forward or rotating it will move the base and make the soft nostrils more round and "wider" in case of advancement or ccw.  Don't know if this explanation makes any sense, but if I hold 2 pieces of paper flat together and start moving the ends, they'll form something like this <>, which will get wider the more I push, or in this case, advance or rotate the maxilla? It's like the maxilla moves forward, but the nose bone is connected higher up, so the soft tissue need to escape somewhere, which will be to the sides.

Explanations that make sense to me are my OWN or those from others explaining something I, MYSELF, don't understand.

Well, what I can tell you is what I already told you which is the floor/base of the nose is the roof of the hard palate (part of maxilla bone which they term ANS-PNS on a ceph) and displacement of ANS-PNS will cause some displacement of BASE of the nose because ANS; anterior nasal spine is part of nose base at FRONT. Sometimes it will be noticeable. Sometimes not.

This does NOT refer to the 'nose BONES' which are high up on the bridge of the nose. It refers to BASE of nose.

The more OBVIOUS base of nose changes as far as nostril width is concerned is when they split the maxilla (hard palate part) in 2 pieces to separate them (widen the palate) and also bring it forward. That combo is very obvious and I hope 'intuitively' so. Another obvious change to base of nose is in an extreme linear advancement sleep apnea case where moving the ANS very much forward moves the 'A' point too far out (for aesthetics), in which case the 'base' of the nose, in part, is the area of the labial ledge right below it where the person gets the conVEX labial ledge which they can call 'chimp lip'.

In some cases, the CALIPER distance from the alar rims at nose base remains the same before and after advancement. Like no 'stretch' widens that area.  However, when that area is brought forward, it's closer to the eye of the observer (the owner of the face sporting the nose looking in the mirror) and can LOOK wider to them.

If a doctor tells you your nose won't change at all, it just means he doesn't intend to do the type of displacements that will be that noticible as far as the nose is concerned.

Bottom line is that any displacement to ANS-PNS will also be a displacement to ANS and therefore a displacement to the base of the nose whether it's noticeable or not. Good surgeons anticipate the possible UNFAVORABLE very noticeable nose changes and can do a variety of techniques to mitigate those types.

[bex]

Happy to share my experience if it's helpful...I'm 5 weeks out from a Lefort1 + BSSO + Genioglossus Advancement. While the goal of the surgery was to resolve a medical issue, I still had concerns about aesthetics; primarily changes to the philtrum, lips, and nose (Actually, Kavan was very helpful in explaining the general shape/changes that I could expect, though it is, of course, hard to predict soft tissue changes and results will vary by individual). 


After I left the ICU and was finally able to look at my face, I was pretty surprised at just how much my nose changed. Luckily, it was a very positive change (and I was totally fine with my nose before), one which seems much more harmonious with my "new" face.

The biggest changes: The base of my nose is wider, there's a bit of a slope to the bridge, and the tip is slightly upturned. These changes were more exaggerated in the days immediately following surgery, but have seemed to mellow out as my swelling subsides. My nose was very narrow before surgery, so the extra width looks more balanced, but my surgeon did use an alar stitch suture to prevent the base from widening too much.

Of course, YMMV, but you said pictures would be helpful. Here's a comparison of my profile at (from L to R):
2 days pre-op -> 6 days post-op -> 2 weeks post-op -> 4 weeks post-op:





[attachment deleted by admin]

[kavan]

In Bex's pictures, you see the base of the nose is going forward and the tip of the nose, supported by the base is also projecting more forward. The surgery itself does not move the 'nose bones' (nasal bones) that make up the UPPER bridge of then nose. They  STAY put. Due to the forward projection of the nose TIP area, the nose bones look relatively more behind which is what gives somewhat of 'scoop' look (or slope) to the LOWER bridge and tip . So the base of the nose and parts of nose supported by base (like the TIP) are being displaced in the same direction as ANS-PNS; ROOF of the palate of the maxilla and FLOOR of the nose.

[Dogmatix]

Happy to share my experience if it's helpful...I'm 5 weeks out from a Lefort1 + BSSO + Genioglossus Advancement. While the goal of the surgery was to resolve a medical issue, I still had concerns about aesthetics; primarily changes to the philtrum, lips, and nose (Actually, Kavan was very helpful in explaining the general shape/changes that I could expect, though it is, of course, hard to predict soft tissue changes and results will vary by individual). 


After I left the ICU and was finally able to look at my face, I was pretty surprised at just how much my nose changed. Luckily, it was a very positive change (and I was totally fine with my nose before), one which seems much more harmonious with my "new" face.

The biggest changes: The base of my nose is wider, there's a bit of a slope to the bridge, and the tip is slightly upturned. These changes were more exaggerated in the days immediately following surgery, but have seemed to mellow out as my swelling subsides. My nose was very narrow before surgery, so the extra width looks more balanced, but my surgeon did use an alar stitch suture to prevent the base from widening too much.

Of course, YMMV, but you said pictures would be helpful. Here's a comparison of my profile at (from L to R):
2 days pre-op -> 6 days post-op -> 2 weeks post-op -> 4 weeks post-op:

Thanks for sharing. I think I see some of it, a bit hard at different angles though. How much were you advanced?

[bex]

Attached the list of movements from my VSP - I think there ended up being slightly less pogonian advancement, but I doubt that impacts the nose anyhow. 

[attachment deleted by admin]

[Dogmatix]

Attached the list of movements from my VSP - I think there ended up being slightly less pogonian advancement, but I doubt that impacts the nose anyhow.

Very interesting. Do you have the meassurements of the final result? Just interested since I see that these displacement meassurements are made in mm with 2 decimal accuracy, and I have to wonder if such accuracy is even close to possible to reproduce at the actual result, or what kind of accuracy the surgeons work with. I would to some extent suppose that these are more like guidelines?

I see e.g that your ANS is advanced less than your A point etc, is this the mechanics of the ccw rotation working?

Is this considered a large advancement of the maxilla, or in what region are we? Looking at your pictures it's a noticeable change (you look great). Just asking because my surgeon haven't provided me with a real plan, just said "slight" maxillary advancement, and in my case, I think your 6mm would be too much for me.