MMA relapse, now 7 weeks PO. How to proceed?

[jawsandsleep]

Hi everyone

I would like to ask for advice about my current situation:
I had Lefort I, BSSO and sliding genio done. Advancement at chin 26mm and upper incisor 16mm.
Today at 7 weeks post operative, the maxilla has relapsed quite a bit (about 5mm) and the mandible is crooked to the right. I am now unsure about how to proceed.
It appears that doing a revision as soon as possible makes sense as the bone is not fully formed. Surgeon wants to do surgery next week.

- Either I bring the maxilla forward according to the original plan
- Or I bring back the mandible to the current relapsed maxilla.

I posted pictures here: https://imgur.com/gallery/vb3SiJR

I am mostly interested on what makes most sense aesthetically speaking. Thanks.

[GJ]

Sorry to hear that. That's terrible.

Out of those two options I'd bring the mandible back. This could allow some correction of the cant to the right, too, so it seems to be more bang for the buck. Did the surgeon say what's causing the cant to the right? You/we need to know the cause of the relapse, too. Did he say if it's due to the large movement or is it something anatomical?

I'd like to see more photos, cephs, and hear any insight your doc gave about "why" before confirming my opinion.

[Dogmatix]

I'm also interested to hear more details as to how the relapse happened. It's both a significant relapse and you also say both mandible and maxilla moved.
What happened between day 10 and week 7?
Was it because starting to put load on it with chewing too early? Inadequate stabilization with elastics? Or was the situation as unstable that it couldn't heal in right position?
What kind of advancement did you have, was it ccw rotation? What does your surgeon say?

As to aethetics I think you had a good result straight after and 10 days after surgery, but also having the mandible straightened is a priority. I assume the reason your surgeon don't want to do a full bimax revision is because of the risk it can happen again and rather focus on one jaw.

[jawsandsleep]

Thank you for the quick reply. I feel a bit lost right now, especially since the doctor is wanting to do surgery as soon as next week.

The surgeon is covering the expense for the revision. I actually havent brought up with him the "maxilla advancement" option. I guess it wouldnt just be a maxilla solution as the mandible needs to be adressed either way. So it would essentially be a double jaw surgery vs. a mandibular set back.
The surgeon didnt explain to me what caused the cant to the right. I will have to ask him, but it was apparent directly after surgery and increased in appearance as the swelling went down.
He told me the relapse was caused by my strong muscles and the flexible fixation of the maxilla.
I believe the surgeon prefers to perform a mandibular setback as its the easier fix for the problem. But right now I am trying to figure out whether maxillary advancement is an option (as it was the original plan).

The entire surgery was very ambitious. I had a significant posterior downgraft CCW and an anterior downgraft performed. I believe 1,5cm posterior downmovement and 5mm anterior. So yeah, naturally not the most stable movement.

I have pre and post OP CBCTs. I attached a pre OP ceph and generated a post OP ceph from the CBCT (7 weeks PO). Right now my SNA is 82, SNB is 83,5 vs pre OP SNA 74 and SNB 74. I mention this to highlight the skeletal deficiency pre OP. Right now in the post OP situation my SNA is normal. But eventually, soft tissue is what matters most in assessing an outcome.

Are the pictures in the previous album not sufficient? I have some more in case.

CEPHS https://imgur.com/gallery/RnGbwh6

[Dogmatix]

The entire surgery was very ambitious. I had a significant posterior downgraft CCW and an anterior downgraft performed. I believe 1,5cm posterior downmovement and 5mm anterior. So yeah, naturally not the most stable movement.

Do you mind sharing who the surgeon was?

[jawsandsleep]

Thank you Dogmatix for the reply. I was in slight Class III immediately after surgery and it simply increased gradually. I was put on soft chew after a week, but maintained a mostly liquid diet for a month. I was wearing strong elastics for most of the time.
I also liked the (admittedly swollen) result directly after surgery.  I wasnt even aware of the maxilla relapsing until last week. I just thought the swelling subsided and was horryfied with the look.

[jawsandsleep]

I will not share the surgeons name. I dont suspect any misconduct by the surgeon and we are currently working towards a solution.

[Dogmatix]

But right now I am trying to figure out whether maxillary advancement is an option (as it was the original plan).

The thing is, if the mandible have a cant and you want to match the maxilla with that, you have to give the maxilla a cant as well. I'm not a surgeon or don't have full insight, but I would guess that regardless of what you do to the maxilla, the cant of the mandible probably is mandatory to fix.

[jawsandsleep]

The thing is, if the mandible have a cant and you want to match the maxilla with that, you have to give the maxilla a cant as well. I'm not a surgeon or don't have full insight, but I would guess that regardless of what you do to the maxilla, the cant of the mandible probably is mandatory to fix.

Agreed. Thats why a maxilla only solution is technically not possible and double jaw surgery would be needed.

[jawsandsleep]

Something else I need to mention.
I originally went into surgery with the intention of getting rid of my mild sleep apnea, but I was also hoping to improve my recessed face. Looking back, I feel like such an idiot for going down this road as I was much happier with my looks than I am now. I dont believe that a mandibular set back is going to impact my airway in any way as the intial advancement was such a large one (26mm chin).
So yeah, there is a part of me that wants to go back to how I used to look. A maxillary advancement would push me further away from my original looks.
I feel like making this decision is really hard for me.

[Dogmatix]

Something else I need to mention.
I originally went into surgery with the intention of getting rid of my mild sleep apnea, but I was also hoping to improve my recessed face. Looking back, I feel like such an idiot for going down this road as I was much happier with my looks than I am now. I dont believe that a mandibular set back is going to impact my airway in any way as the intial advancement was such a large one (26mm chin).
So yeah, there is a part of me that wants to go back to how I used to look. A maxillary advancement would push me further away from my original looks.
I feel like making this decision is really hard for me.

Do you wish for your original looks because of the problems you have, or because you don't prefer the result as it was intended right after or 10 days after surgery? It's natural to feel discouraged at this point, but even to go back is a new surgery and the fractures need to heal in that position. Now when the dice is rolled you need to look past those doubts and work from the situation. As to revision bimax, it's important that your surgeon have a plan that will prevent same kind of relapse again if doing that. As I wrote maybe that's part of the reason to only suggest fixing the mandible, as the maxilla should be stable after 7 weeks and getting into trying to keep both jaws stable in a new position a second time require some kind of plan as both relapsed last time. Removing the maxilla from the equation is less gamble.

[jawsandsleep]

Do you wish for your original looks because of the problems you have, or because you don't prefer the result as it was intended right after or 10 days after surgery? It's natural to feel discouraged at this point, but even to go back is a new surgery and the fractures need to heal in that position. Now when the dice is rolled you need to look past those doubts and work from the situation. As to revision bimax, it's important that your surgeon have a plan that will prevent same kind of relapse again if doing that. As I wrote maybe that's part of the reason to only suggest fixing the mandible, as the maxilla should be stable after 7 weeks and getting into trying to keep both jaws stable in a new position a second time require some kind of plan as both relapsed last time. Removing the maxilla from the equation is less gamble.

I believe I just miss my old face. The problem is that I dont know how I would look like with the maxilla advanced. I only have the picture from the operating table and when the relapse took place, I was mostly swollen. Realistically, it doesnt make sense to go back to how it was. But I was thinking that bringing the mandible back wouldnt change my face as much as bringing the maxilla forward (thus preserving some of the old "esthetics").
Its just such a hard situation psychologically speaking. I am devastated when I see my current looks, so naturally, my instinct is to revert things some what. I guess its just fear and there is a good chance that its just the Class III causing this dysbalance and a maxillary advancement could in fact help.

I understand your point. He actually replied me with a short sentence and told me that bringing the maxilla forward is theoretically possible and he will do whatever I want. I havent asked about the details. But this kind of leaves me in the dark because how am I supposed to tell as a lay person how a movement is going to impact my face?
Brb going to get a hair cut.

[Dogmatix]

I believe I just miss my old face. The problem is that I dont know how I would look like with the maxilla advanced. I only have the picture from the operating table and when the relapse took place, I was mostly swollen. Realistically, it doesnt make sense to go back to how it was. But I was thinking that bringing the mandible back wouldnt change my face as much as bringing the maxilla forward (thus preserving some of the old "esthetics").
Its just such a hard situation psychologically speaking. I am devastated when I see my current looks, so naturally, my instinct is to revert things some what. I guess its just fear and there is a good chance that its just the Class III causing this dysbalance and a maxillary advancement could in fact help.

I understand your point. He actually replied me with a short sentence and told me that bringing the maxilla forward is theoretically possible and he will do whatever I want. I havent asked about the details. But this kind of leaves me in the dark because how am I supposed to tell as a lay person how a movement is going to impact my face?
Brb going to get a hair cut.

Yes. So it's a valid opinion that the result you have now is worse than when you started. I see it, you see it and your surgeon see it. I just want to tell you that this doesn't necessarily mean that going back yield the best result. It's hard for you to imagine a balanced result in the situation you're in and you think it's the advancement that is the problem. The problem is the underbite and it would be regardless of where it's positioned. The advancement as it looked after surgery was balanced and more than you have now with the relapse. I think what ever you chose or agree with your surgeon it will be a good result, the key is the balance and not have the under bite. You need to have a dialog with your surgeon, it's not enough information with "I will do what ever you want". You need to ask what he suggest for best result, how you prevent same situation from happening again etc.

I'd greatly appriciate if you could look through your private messages.

[kavan]

Aesthetically speaking, I'd put the maxilla back where it was since:

a: THAT is the KEY problem  and you looked better WHERE it WAS put before relapse

b: you probably need lower jaw advanced where it is for open airway and lower jaw looks OK advanced where it is now.

c: that was ORIGINAL plan

I would hesitate to bring the mandible back to 'match' the maxilla that has gone astray because it's possible that's what is ALSO kicking up the unevenness to the mandible. I can't tell you exact cause of mandible being crooked. But I can tell you that when someone has a 'can't' (crookedness), it CAN come from the maxilla being uneven and I think it is MORE possible that the mandible got a little crooked as a function of the maxilla moving out of place.

[april]

I don't really have anything of value to add except to say that I'm really, really sorry. I always hear about maxillary downgrafts being unstable (from my local surgeons, not the top surgeons), but I've never seen it actually happen to somebody before.

What at a tough situation to be in.

The way you're feeling, missing your face and feeling regrets, I'm sure is completely normal given the situation. For what it's worth, I think you looked really good in the immediate post-op photo.

15mm posterior, 5mm anterior is indeed massive. Did your surgeon use some sort of bone graft or HA blocks in between the gaps?

What is your bite like at the back - posterior open bite?

I agree with Dogmatix. If they intend to do maxilla surgery again, you need to find out how they will prevent this from happening again.