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

[jawsandsleep]

Thanks for all the new replies. I have been sad long enough and I have to make this decision soon. As I am supposedly still in the bone healing phase and a revision should be less eventful, I am getting surgery ASAP, but I am not ruling out revision down the road. There are other things I dont like like the increase in vertical face length and the fact that I cant close my lips (might need a reduction genioplasty), but at this point I need to adress the primary issue as I cant be walking around like this.

HA was used for grafting. I am not entirely sure how to bite is at the back.

@ Dogmatix: Its a good point you make about balance.
I am still going back and forth about whether to do maxillary advance or mandibular setback.

@ kavan:
a.) I agree. Although I only have these two pictures which makes it hard for me to predict the outcome. How would my midface react (cheekbones)? How would my nose react?

b.) Also agreed, although the setback could most likely still be accommodated. cephalometric wise I am at the verge of prognathia.

c.) The original plan was unfortunately not made with regard to how my individual soft tissue would react and rather aimed to put my jaws at a reference point.

The last point you make, is something that had me worrying as well. The current position of the maxilla is just a random one and a mandibular setback could only be a compromise at this point.

I actually consulted with two surgeons in the last couple days. One very renowned one said he would rather advance the maxilla. But I think he was mostly considering the sleep apnea. I didnt talk with him about aesthetics much unfortunately. Another one said he would bring the mandible back because he things my maxilla looks good

What confuses me is, that I consulted with a handful of surgeons before surgery and most surgeons were a lot more conservative with their plans. Like maxilla 8-10mm and mandible accordingly with a slight CCW at best.

[jawsandsleep]

I am still not sure how to procede, but I have been thinking about the advantages of a mandibular setback:

1.) the maxilla is in a position that was originally proposed by other surgeons in regards to soft tissue and nasal changes. I can only estimate, but I believe I am still about 8, 9 mm advanced compared to the pre OP position when looking at the maxillary incisor. As Dogmatix pointed out, flatness of the face is perceived in relation to the madible as balance is most imporant. If looking at the maxilla isolated right now, I have slight improvements in regards to lips and midface.

2.) skeletally speaking, my maxilla is in the norm (SNA 81). I know that this is an unreliable number, but I started out with a 74 which is a couple of standard deviations below.

3.) I used to believe that a forward grown face was the best thing for all men, but I am starting to think you cant bring all jaws to the same point and expect them to harmonize with your face. I am afraid that such a large movement would have a negative impact on my nose and let my cheeks look hollow.
Maybe its because I am asian, but I feel like the current jaw looks oversized on me and a more delicate one would suit me better.

[kavan]

Thanks for all the new replies. I have been sad long enough and I have to make this decision soon. As I am supposedly still in the bone healing phase and a revision should be less eventful, I am getting surgery ASAP, but I am not ruling out revision down the road. There are other things I dont like like the increase in vertical face length and the fact that I cant close my lips (might need a reduction genioplasty), but at this point I need to adress the primary issue as I cant be walking around like this.

HA was used for grafting. I am not entirely sure how to bite is at the back.

@ Dogmatix: Its a good point you make about balance.
I am still going back and forth about whether to do maxillary advance or mandibular setback.

@ kavan:
a.) I agree. Although I only have these two pictures which makes it hard for me to predict the outcome. How would my midface react (cheekbones)? How would my nose react?

b.) Also agreed, although the setback could most likely still be accommodated. cephalometric wise I am at the verge of prognathia.

c.) The original plan was unfortunately not made with regard to how my individual soft tissue would react and rather aimed to put my jaws at a reference point.

The last point you make, is something that had me worrying as well. The current position of the maxilla is just a random one and a mandibular setback could only be a compromise at this point.

I actually consulted with two surgeons in the last couple days. One very renowned one said he would rather advance the maxilla. But I think he was mostly considering the sleep apnea. I didnt talk with him about aesthetics much unfortunately. Another one said he would bring the mandible back because he things my maxilla looks good

What confuses me is, that I consulted with a handful of surgeons before surgery and most surgeons were a lot more conservative with their plans. Like maxilla 8-10mm and mandible accordingly with a slight CCW at best.

You asked a clear straight forward question in your first post. I addressed and with clarity. I also gave my aesthetic take and reasoning behind my advice. My advice as it stood, is not confusing. I can't predict your outcome or resolve all the uncertainty you have. In terms of PROBABILITY, the maxilla deviance is the MORE likely culprit to the lower jaw deviation.

You now bring in uncertainty and confusion based on information others have given you.

When I give my advice on here or my 'take' based on an initial question, it's not my task to resolve all confusion or uncertainties OTHERS have posed in the event the poster brings those in AFTER their initial post.

So, in this situation, I see no need to adapt or change the advice already given to the confusion OTHERS have introduced  and/or your present ruminations as your aesthetic preferences.

[jawsandsleep]

You asked a clear straight forward question in your first post. I addressed and with clarity. I also gave my aesthetic take and reasoning behind my advice. My advice as it stood, is not confusing. I can't predict your outcome or resolve all the uncertainty you have. In terms of PROBABILITY, the maxilla deviance is the MORE likely culprit to the lower jaw deviation.

You now bring in uncertainty and confusion based on information others have given you.

When I give my advice on here or my 'take' based on an initial question, it's not my task to resolve all confusion or uncertainties OTHERS have posed in the event the poster brings those in AFTER their initial post.

So, in this situation, I see no need to adapt or change the advice already given to the confusion OTHERS have introduced.

Dear Kavan,
I apologize for my confusion. I believe its just the panic and I am simply reacting instead of thinking clearly.
Considering the mandible: The deviance appears to be on the horizontal plane and it seems to put together wrongly.

[Post bimax]

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.

I think you looked great just post-op before the swelling set in, so that's what I'd aim for.  I think bringing the mandible back would be a  big mistake.

[kavan]

Dear Kavan,
I apologize for my confusion. I believe its just the panic and I am simply reacting instead of thinking clearly.
Considering the mandible: The deviance appears to be on the horizontal plane and it seems to put together wrongly.

You don't need to apologize. I'm just saying that when I give clarity and/or my reasoning behind my advice, I don't adapt it to confusion when I feel there's no need for me to do so. Deviance FROM the maxilla can result in deviance to mandible (horizontal plane). If one side of downgraft of maxilla deviates more than the other, for example, you can see that in the mandible. I'm not diagnosing but just saying MOST LIKELY reason.

If you have your own advice for yourself, I have no issue with your taking who's ever advice you want.

[kavan]

I think you looked great just post-op before the swelling set in, so that's what I'd aim for.  I think bringing the mandible back would be a  big mistake.

Yes. RIGHT AFTER surgery, looks much better in terms of aesthetics. Also right after is before swelling sets in and shows how it would/should look IF all stays put.
He asked about AESTHETICS and the aesthetics right after surgery are infinitely better than his prior aesthetic IMO also.  Now, he introduces a possible preference for his PRIOR (poor) aesthetic. So, no 'coaching' from me as to how to get back most of prior aesthetic because my aesthetic advice was based on seeing that is RIGHT AFTER surgery aesthetic was an excellent improvement over his prior one.

[GJ]

OP, moving the maxilla forward a second time puts a lot of risk to your nose widening more. The photos are no longer up, so I can't see how much it widened the first time. This is one reason I don't like it. In the second photo you posted, from memory, your lower jaw looked too far out for your upper face. So moving the mandible back would make more sense. Cutting the mandible a second time increases the risk of nerve damage, as you might know. So there's that to factor in. I agree with others who said you looked good in the first photo right out of surgery (again, from memory), but you were swollen and in general photos are some of the worst records for assessing anything. You mentioned soft tissue in a post, and again from memory you were Asian and appeared to have thin soft tissue that is somewhat typical in Asians. This will make any movement more apparent since the tissue doesn't hide anything, and it's another reason I think mandible, especially if you miss your old face. Mandible would get you closer to the old face, though you have to accept the actual old face is gone forever. My big issue with the maxilla is moving it a second time puts so much risk to the nose area. It's worth considering because it did look good in that one photo, but I wouldn't consider it without more info from the surgeon. Maybe request an emergency consultation to go over everything. Good luck, buddy. Tough situation.

[jawsandsleep]

Thanks for the input and taking your time. I will reupload the photos in a bit.
@ GJ: Thanks for providing your insight. I believe what you say is true, especially the asian part.
I am not saying that my old face is my goal, I was obviously unhappy with many things. I was skeletally very deficient and I believe the thin soft tissue did a good job at hiding my flaws to an extend.

[Post bimax]

Thanks for the input and taking your time. I will reupload the photos in a bit.
@ GJ: Thanks for providing your insight. I believe what you say is true, especially the asian part.
I am not saying that my old face is my goal, I was obviously unhappy with many things. I was skeletally very deficient and I believe the thin soft tissue did a good job at hiding my flaws to an extend.

Okay, I think you need to decide what you want. Eyeballing it (from memory), your maxilla is now recessed outside of the normal range relative to your skull (brow, etc).  You looked GREAT immediately post-op, and if there's a way to get back to that spot I personally think that's the route you should take.

GJ is correct that maxilla advancement can kick up changes to the nose, especially widening at the base and upturning the tip.  I think this element of risk is worth it though because there are rhinoplasty techniques for correcting this issue if it arises.  IMO you should focus on getting your jaws in best position because a rhinoplasty is way less expensive and invasive than another bimax revision.

[Dogmatix]

OP, moving the maxilla forward a second time puts a lot of risk to your nose widening more.

Is it bigger risk for the nose to widen the second time? Why is that?

[jawsandsleep]

I am currently thinking about doing the mandibular set back and getting a vertical reduction genioplasty at some point. This is how I envision it: https://imgur.com/gallery/4QnSOa5
 pre OP vs plan https://imgur.com/gallery/NdBw6tm

I thought about it a lot. While the post OP picture looks good, it probably doesnt accurately reflect the truth. I believe its best to aim for a natural looking result and one that fits my asian face.

[Dogmatix]

What confuses me is, that I consulted with a handful of surgeons before surgery and most surgeons were a lot more conservative with their plans. Like maxilla 8-10mm and mandible accordingly with a slight CCW at best.

But who were these surgeons? Because one of the reason to chose a high profile surgeon is because they can handle other movements that the local surgeon can't. Posterior downgrafting is not offered every where, and definitely not 15mm posterior AND 5mm anterior. So that this was not offered may not mean that they don't agree with the aesthetic benefits from it, but it's out of the range of what they do. I understand that this response backfires a bit because obviously there is some risk to it even for a surgeon who offers it.

I can some how try to imagine that it's a volatile situation when the maxilla is displaced so much both anterior and posterior. There is no point of contact more than the grafting material. I'm just a bit curious. 10 days after surgery, you were probably still on a liquid diet and having elastics keeping it stable. Is there any chance that the problem occured when you started chewing and this is when it started drifting away, and that such significant move require longer healing?

[Post bimax]

Is it bigger risk for the nose to widen the second time? Why is that?

I think he's just saying maxillary advancement impacts the nose, and this risk is part of the revision if he goes that route.  Not that revision advancement after relapse is necessarily riskier to the nose than initial advancement.

While the post OP picture looks good, it probably doesnt accurately reflect the truth. I believe its best to aim for a natural looking result and one that fits my asian face.

I'm not sure what you mean here.  The immediate post-op picture 'reflects' the truth much more 'accurately' than your 10 day pic.  At 10 days you still have a ton of swelling.  It can literally take 6 months to a year for all swelling to dissipate. Your choice though.

[jawsandsleep]

It was gradually and most likely caused by the muscles.

I believe the challenging part of jaw surgery is making predictions about how soft tissue will react. There are different philosophies and every surgeon will have a different outcome. Some surgeons are more aggressive and aim for a certain look and some are more conservative. If it was only technical skill limiting a surgeon, then jaw surgery would be trivial.
I think my surgeon has created great outcomes for others, but I dont think my face accomodates it well.