Recommendation for achieving better face harmony

[Mrtn]

I'm looking for advice based on normal pictures to achieve a more harmonic, more masculine look.
The reason I'm looking for advice is because I'm a bit hesitant to spend 1000 usd on CT and X-ray scans because I'm not even sure if I could benefit from any surgeries. I know it's not easy to give any advice without those, but I hope I could get some useful information based on normal pictures.

I have asked already a few surgeons online and I talked with one maxillofacial surgeon and orthodontist face to face.

The online evaluations resulted in the following suggestions (from different surgeons):

- double jaw surgery and genioplasty
- only double jaw surgery
- only geinoplasty (cheapest option)
- V-line surgery with fat grafting under eyes (I find the V-line a bit odd)
- double jaw surgery + ASO (three jaw surgery basically) + genioplasty (most expensive option)

I'm not an expert in this area, so please forgive me if I make mistakes with terminology or anything related to this topic.

The face to face consultation with an orthodontist and maxillofacial surgeon:

The surgeon told me, my jaw and bite are not that bad at all and he does not recommend double jaw surgery. He told me that my side profile is somewhat recessed but it is still within an okay range and probably a double jaw surgery would not give me a much better look. He even told me that probably my profile would more flat after surgery and it's not necessarily more harmonic than my profile now.
 
However, he told me maybe genioplasty with implant would be a solution to achieve a more harmonic look (a little bit of contradiction here I think).
He also mentioned that I might need a revision surgery many years later and it's possible that it will look fake. Note that I went to a big hospital in East Asia as a Caucasian male (29). It was a general hospital so not specalized place for jaw surgeries.


My concerns about my look and questions related to it:

- My upper lip is protruded, and in some lighting I have noticeable nasolabial folds (and I always had, not age related problem). I'm wondering if braces or/and jaw surgery could help with that.
- I dislike my smile but I'm also wondering if it is possible to change it with braces or surgery. Like, I show only 8 or 6 teeth when I'm smiling and it would be nice to have a fuller smile with less "empty" space showing
- Overall, my cheeks look flat (for me), and I'm wondering if my maxilla recessed and 2 jaw surgery would help on that. I was also thinking if fillers only could improve that area and my look in general.
- I believe I have mild plagiocephaly, I just share this because it could be relevant.
- Something I dislike is that my chin and jaw from the front view are a bit small, not too masculine. Do you think the above mentioned surgeries could help to get more masculine look in my lower third?

I have tried to edit my pictures but it looked really odd for me somehow. I'd appreciate it if someone could edit my pictures that could be achieved by surgeries, but maybe it's impossible to predict anyways.

What I'd like to know and find out on this forum are the followings:

- what kind of surgery could I benefit the most based on my photos?
- do you think jaw surgery would significantly improve my face harmony?
- if not jaw surgery, than is there any other recommended surgery for me?
- do you think those recommendations are legit from the doctors or they just try to get a new customer and profit?
- if I decide to get surgery, would you recommend me getting in East Asia (since I live there) or in Europe?
- I'm thinking to get braces, regardless having a surgery later or not. Treatment with braces would have any difference whether I get surgery or not?
I'm asking this because I could get the braces sooner, and I could still think about surgery later.
- Is that possible that getting those recommended surgeries would result in a worse, less harmonic (uglier?) face? I'm really afraid of putting lot of money and effort in this whole procedure and getting some devastating results in exchange.

I appreciate any help.

Pictures: https://imgur.com/a/Dpms09V

[kavan]

Although I won't be directly addressing all of the contents/concerns of your post, I'll relay what I observe in your photos which I hope makes it a little bit easier for you evaluate your concerns within the perspective of my observations.

1: Your maxilla area, in particular, the part which would correspond to a Lefort 1 advancement (of upper jaw) looks to be protrusive relative to your lower jaw area; the part corresponding to a BSSO advancement. Conversely, your lower jaw looks retrusive compared to your upper jaw.

2: Your nose to lip angle is a little on the high side as in more than 90 deg and the upper lip area ('philtum') is slightly conVEX. That type of angle and upper lip contour puts you at RISK for getting a 'chimp lip' with maxillary advancement because advancement of that area will EXAGGERATE what presently is only a slight aesthetic problem with that area.

3: Your nose to lip angle and philtral conVEX contour coupled with what looks to be retrusion of the lower jaw (which would definitely benefit from advancement) would tend to SHIFT you in direction of 2 surgical OPTIONS:

Option A: The more 'expensive' option of finding a surgeon who does CCW rotation via a posterior downgraft where this option would MINIMIZE advancement of upper jaw yet MAXIMIZE advancement of lower jaw. This type of option often includes a 3 piece Lefort where they can kind of 'fill out' the side areas of the smile.

Option B: The less expensive option would be one of BSSO only. But with that is extraction of pre-molar teeth in order to push lower teeth backwards in preparation of a surgery that advances the lower jaw.

Some chin advancement could be included with both because the chin could also be brought forward.

CAVEATS:

Chin ONLY is a BAD option. Here is why:

Although the chin could be brought forward, this is best done DURING either a BIMAX surgery (option A) or a BSSO only (option B). Otherwise, there is the aesthetic risk of a doctor trying to COMPENSATE for the lower jaw retrusion by advancing the chin 'too much' which does NOT look good and EVEN IF they bring the chin to where it 'should be' (slightly behind a vertical line dropped from the lower lip), the jaw retrusion will still be visible.

BRACES:

Don't get braces before getting a surgical plan. That's because braces in preparation for a surgery, in particular, the way they MOVE the teeth (decompensation), are going to be in a DIFFERENT direction than braces aimed at getting the 'bite right' when no surgery is to take place.

NOTES:

This observation done relative to SOFT TISSUE profile in absence of a CEPH. A ceph would be needed to take a closer look at the angles formed by distinct landmarks of the scull.

[Mrtn]

Although I won't be directly addressing all of the contents/concerns of your post, I'll relay what I observe in your photos which I hope makes it a little bit easier for you evaluate your concerns within the perspective of my observations.

1: Your maxilla area, in particular, the part which would correspond to a Lefort 1 advancement (of upper jaw) looks to be protrusive relative to your lower jaw area; the part corresponding to a BSSO advancement. Conversely, your lower jaw looks retrusive compared to your upper jaw.

2: Your nose to lip angle is a little on the high side as in more than 90 deg and the upper lip area ('philtum') is slightly conVEX. That type of angle and upper lip contour puts you at RISK for getting a 'chimp lip' with maxillary advancement because advancement of that area will EXAGGERATE what presently is only a slight aesthetic problem with that area.

3: Your nose to lip angle and philtral conVEX contour coupled with what looks to be retrusion of the lower jaw (which would definitely benefit from advancement) would tend to SHIFT you in direction of 2 surgical OPTIONS:

Option A: The more 'expensive' option of finding a surgeon who does CCW rotation via a posterior downgraft where this option would MINIMIZE advancement of upper jaw yet MAXIMIZE advancement of lower jaw. This type of option often includes a 3 piece Lefort where they can kind of 'fill out' the side areas of the smile.

Option B: The less expensive option would be one of BSSO only. But with that is extraction of pre-molar teeth in order to push lower teeth backwards in preparation of a surgery that advances the lower jaw.

Some chin advancement could be included with both because the chin could also be brought forward.

CAVEATS:

Chin ONLY is a BAD option. Here is why:

Although the chin could be brought forward, this is best done DURING either a BIMAX surgery (option A) or a BSSO only (option B). Otherwise, there is the aesthetic risk of a doctor trying to COMPENSATE for the lower jaw retrusion by advancing the chin 'too much' which does NOT look good and EVEN IF they bring the chin to where it 'should be' (slightly behind a vertical line dropped from the lower lip), the jaw retrusion will still be visible.

BRACES:

Don't get braces before getting a surgical plan. That's because braces in preparation for a surgery, in particular, the way they MOVE the teeth (decompensation), are going to be in a DIFFERENT direction than braces aimed at getting the 'bite right' when no surgery is to take place.

NOTES:

This observation done relative to SOFT TISSUE profile in absence of a CEPH. A ceph would be needed to take a closer look at the angles formed by distinct landmarks of the scull.

Thank you for your useful insights!

Questions regarding your reply:

 Since you addressed my nose to lip angle and the convexity of that area. Is it possible to correct the angle and flatten the convexity or make it a little bit concave?
I'm really not familiar with surgical methods but ASO combined with BSSO wouldn't eliminate that problem?

Is it possible to have a surgery without the risk of getting chimp lips? What I can understand from your reply is that, both option A and option B have the chance of getting it, but option A has less. I believe there is no "miracle" method that would give me a desired look without the risk of getting chimp lips?

[kavan]

I don't know what 'ASO' stands for. You say it's '3 jaw' surgery but there are only 2 jaws.

There are a few folks on here who got more of an exaggerated conVEXity from the maxillary but linear advancement technique (not CCW-r technique) who consulted around, yet found there is no straight forward option to flatten it and make it more concave. One is getting REVISION surgery (involving BOTH jaws) just to address the thing. So, I don't know of any isolated correction for it. Just conveying, you've got the contour that is high risk for getting it with maxillary advancement. It's relatively lower risk for people who have recessed maxilla, and a short and very up flipped or conCAVE upper lip/philtral area.

Option B is SINGLE JAW to the MANDIBLE which doesn't move the upper jaw.

Option A is DOUBLE JAW but one where the upper jaw movement is MINIMAL or sometimes nothing. It is a counter clockwise ROTATION via posterior downgrafting which allows them to advance the LOWER JAW. It's your best bet for having 2 jaw surgery to advance your lower jaw and chances are good they can do it WITHOUT advancing your upper jaw.

[Mrtn]

ASO: Anterior Segmental Osteotomy (ASO) is required to move the bones of the gum area backwards. If the protruded mouth has complex problems, then the two jaw surgery should be applied. (See the pic.)

Question regarding this: is this something I should consider, since it seems to address the issue of upper lip area?

Until now I didn't understand how it's possible to push my mandible forward, but I think I get it now:
Two of my teeth would be removed from my lower teeth and with braces to fill the "gap" would go backwards, so there would be a bigger distance between my lower and upper teeth, thus they can push my whole mandible forward.

I'm still confused however because a surgeon told me, he could do the whole surgery without braces treatment before.

[kavan]

OK. 'ASO' is common in ASIA for something called 'bimax protrusion' which is more common for Asians than Occidentals. I'm not suggesting you get that. I'm suggesting you look into CCW-r (counter clockwise rotation) via POSTERIOR DOWNGRAFTING.

Surgery without braces BEFORE the surgery is called 'surgery first' which they do in Asia and also in Europe. The braces come AFTER.

[Post bimax]

Three-jaw surgery 

[Mrtn]

OK. 'ASO' is common in ASIA for something called 'bimax protrusion' which is more common for Asians than Occidentals. I'm not suggesting you get that. I'm suggesting you look into CCW-r (counter clockwise rotation) via POSTERIOR DOWNGRAFTING.

Surgery without braces BEFORE the surgery is called 'surgery first' which they do in Asia and also in Europe. The braces come AFTER.

Thanks!
Something bothers is if actually I could really "improve" my look with this surgery. I read a few cases when the person regretted getting bimax and I'm really afraid of being that person. I didn't even think about the compromises of getting this surgery before reading your suggestions.
Edit: I'm trying to figure out what "posterior downgraft" actually means, could you explain it to me?

[kavan]

It's a graft that effects a counter clockwise rotation of the maxilla.

ETA: The board has a SEARCH function.  Plug in 'CCW' (short for counter clockwise rotation) and you can find many topics on that matter.

[Mrtn]

It's a graft that effects a counter clockwise rotation of the maxilla.

ETA: The board has a SEARCH function.  Plug in 'CCW' (short for counter clockwise rotation) or 'posterior downgraft' and you can find many topics on that matter.

Is it possible that my midface will have any length change after bimax? The least I want is having a longer midface.

Edit: If let's say, I get the worst outcome and get 'chimp lips', will be there any solution for that?
I also read that the nose can change after jaw surgery, but not sure if it would change with Option A.

I just want to prepare myself for the worst so I won't get surprised.

[kavan]

I didn't say CCW would increase your nose to lip angle. I said this technique had possibility of no maxillary advancement, only a rotation that would allow for a BSSO advancement.

CCW, via posterior downgrafting isn't a surgery aimed at lengthening the midface.

I can't opine on what ever photos you're looking at that fall under the general catagory of 'bimax' where there ar TONS of multible combinations of various displacements.

My suggestion is to consult with doctors who do the CCW technique.

[kavan]

Is it possible that my midface will have any length change after bimax? The least I want is having a longer midface.

Edit: If let's say, I get the worst outcome and get 'chimp lips', will be there any solution for that?
I also read that the nose can change after jaw surgery, but not sure if it would change with Option A.

I just want to prepare myself for the worst so I won't get surprised.

Reply #3 on this string. Re-read it. Nose changes with maxillary advancement which I'm NOT suggesting you get. I'm suggesting you avoid it by looking into CCW via posterior downgrafting OR look into single lower jaw surgery.

[Mrtn]

Reply #3 on this string. Re-read it. Nose changes with maxillary advancement which I'm NOT suggesting you get. I'm suggesting you avoid it by looking into CCW via posterior downgrafting OR look into single lower jaw surgery.

https://www.schlafapnoe.com/en/op-video/?cn=354

So basically I supposed to get something like that (option A), I assume? Excuse my stupidity, I just want to make sure I understand the concept and won't get the wrong surgery.

[kavan]

https://www.schlafapnoe.com/en/op-video/?cn=354

So basically I supposed to get something like that (option A), I assume? Excuse my stupidity, I just want to make sure I understand the concept and won't get the wrong surgery.

....and I just want to make sure my my time is not wasted when someone doesn't have good reading comprehension. I've already told you that it's possible to do CCW technique with NO maxillary advancement. Get back to us after you've gone on some consults about that possibility.  Giving someone a suggestion of what to look into further, is not meant to be an invitation for me to unconfuse them about confusion they have garnered in the past or to fill in every possible gap they have as it relates to 'digesting' information. Otherwise, best of luck on what ever you decide to do. I am now extricating myself from your decision process.

[Mrtn]

....and I just want to make sure my my time is not wasted when someone doesn't have good reading comprehension. I've already told you that it's possible to do CCW technique with NO maxillary advancement. Get back to us after you've gone on some consults about that possibility.  Giving someone a suggestion of what to look into further, is not meant to be an invitation for me to unconfuse them about confusion they have garnered in the past or to fill in every possible gap they have as it relates to 'digesting' information. Otherwise, best of luck on what ever you decide to do. I am now extricating myself from your decision process.

No worries, dyslexia is my worst enemy, especially if I read in English (not my native language).