Opinions on my Ceph. Do I need CCW rotation? Or will simple MMA do?

[canuker]

Hi there,

Based on this Ceph does it look like I would need CCW rotation in my case? Purpose of the surgery is to fix my sleep apnea, but also increase aesthetics.

https://imgur.com/a/p9zG67z

The reason I ask is I don't think any surgeons in my area (Vancouver, Canada) perform CCW rotation. I have sleep apnea so with provincial insurance I know a MMA + Genio will only cost me around $7000 here. So if all I need is advancement then I would opt to stay close to home.

If I need CCW am looking abroad for surgeons which will end up being more expensive and more logistically challenging for obvious reasons.

Sorry the ceph isn't zoomed out more. This is what my ortho sent me. I can post other photos if needed but none will be of high quality.

Surgeons I'm considering here are:

Dr. Fain
Dr. Wittenburg

Neither seem to be great options when compared to other prominent names that get thrown around on this forum.

*Edit* added CT for an additional view. Not sure if this helps.

https://imgur.com/a/likdJKO

[GJ]

Your jaw angle is steep, but your bite plane looks level. You also have a large overjet. Given all of that, I think linear would work out well here, and if you do need some CCW to address the steep mandible then they could do that via the chin.

You also have an anti-gonial notch, which maybe could be filled in to help a bit with aesthetics.

These are just my opinions of course. You're best off consulting with several surgeons.

[canuker]

Your jaw angle is steep, but your bite plane looks level. You also have a large overjet. Given all of that, I think linear would work out well here, and if you do need some CCW to address the steep mandible then they could do that via the chin.

You also have an anti-gonial notch, which maybe could be filled in to help a bit with aesthetics.

These are just my opinions of course. You're best off consulting with several surgeons.

Thanks GJ. I have a couple of consults coming up with an Alfaro trained surgeon, and an Arnett trained surgeon. Both in Brasil. They perform CCW regularly so I will be curious to get their opinions. Here are their IG handles for anyone interested:

@octaviocintra
@drorionhaas

Next, I have a consultation with my local guy, Dr. Fain. I will clarify if this is something he preforms or not, and if he thinks its necessary.

Also, did I post this in the right forum or should this have gone in aesthetic?

[kavan]

It kind of looks like you could have single jaw BSSO to close over jet and then a sliding upward and outward genio to give more of a 'look' of CCW and maybe a bit of reduction to the excess of the chin (where it's too pointy) also with that. Because, It looks like it's the CHIN is kicking up the 'look' or effect of a steep mandibular plane.

[canuker]

So far the surgeons I've consulted have all recommended double (plus genio for chin reduction, so triple I guess).

It's funny, it never occurred to me until right this second that if it weren't for my large pointy chin (which in person looks completely normal) my profile would be much worse.

Interesting to hear that Kavan and GJ both have similar opinions on this though. Reading this forum it's very easy to get stuck in the mindset of "needing" CCW for the best aesthetic outcome but I guess it's not really indicated in every case. Hence the need for a surgeon with a good eye.

I have a couple of consults coming up with the Brazilian guys who do preform CCW more regularly. One of them is on Monday. I will post their plan here for anyone interested.

[canuker]

I feel like this case is very similar to mine. The main difference is I don't suffer from any lip deviation.

https://www.youtube.com/watch?v=Non7iKMNumQ

[canuker]

Update:

I had a consult with a surgeon today and he showed me some tentative planning he did based on the files that I sent him. He actually recommends CW rotation and not CCW. I guess this goes to show that guesses as a lay person can often miss the mark.

Proposed 1.5mm maxilla advancement, 12ish mm mandibular advancement.

[kavan]

Very ingenious plan because most of the rotation is acheived by direct rotation of the mandible itself. That its to say the CW rotation to the mandible looks to be independant of the rotation coming from rotating the maxilla. With respect to the second diagram, it looks like independantly rotating the mandible spares your chin from being cut either for genio or for a little 'lop off' the tip along with a genio. It is because the rotation sets it somewhat downward and backward whereas it could stick out too much with either CCW or or advancement of mandible along its present orientation.

Care to openly tell us who the doctor is?

[canuker]

Yeah it was very interesting. Here I was thinking they would have to cut a significant amount of bone off my chin due to its abnormal length but he says the long chin can be advantageous.

His name is Dr. Nilo Gama from Sao Paulo, Brasil. @dr.niloagama

There are other more experienced doctors on the top of my list, but I found his IG profile a while ago and we've been messaging back and forth for months now. So, I figured it was time to do an official consult with him. Him being young and less experienced certainly gives me pause, but it I'll keep him in mind. Him and a group of other young maxillofacial surgeons in Sao Paolo seem to be very collaborative with one another and host a podcast together on maxillofacial surgery. I like to see that sort of passion and shared knowledge. But, it's hard to replace decades of legitimate experience.

Curious to see how other plans differ from this one. I have a few more consults in the coming weeks.

[kavan]

Yeah it was very interesting. Here I was thinking they would have to cut a significant amount of bone off my chin due to its abnormal length but he says the long chin can be advantageous.

His name is Dr. Nilo Gama from Sao Paulo, Brasil. @dr.niloagama

There are other more experienced doctors on the top of my list, but I found his IG profile a while ago and we've been messaging back and forth for months now. So, I figured it was time to do an official consult with him. Him being young and less experienced certainly gives me pause, but it I'll keep him in mind. Him and a group of other young maxillofacial surgeons in Sao Paolo seem to be very collaborative with one another and host a podcast together on maxillofacial surgery. I like to see that sort of passion and shared knowledge. But, it's hard to replace decades of legitimate experience.

Curious to see how other plans differ from this one. I have a few more consults in the coming weeks.

Brazil has very good aesthetic surgeons, always has. Of course that doesn't speak for all of them. I personally think the Latin doctors have more flare.  Maybe you found an up and coming one who will be a 'big name' in the future. The up and coming ones are good to grab before they become well known and uber pricely, that is IF you can spot them.

[canuker]

Brazil has very good aesthetic surgeons, always has. Of course that doesn't speak for all of them. I personally think the Latin doctors have more flare.  Maybe you found an up and coming one who will be a 'big name' in the future. The up and coming ones are good to grab before they become well known and uber pricely, that is IF you can spot them.

I agree. I have a whole host of Brazilian surgeons I found on instagram that have great aesthetic results. Some of them are already well known and pricey (Augusto Pary, Jonathas Claus) and others fly under the radar and cost significantly less. I have consultations with a few of them coming up in the next week or so.

The Brazilian surgeons (and many latin american surgeons for that matter) are also strong proponents of Alfaro's minimally invasive approach. I've been told I'm a good candidate for this technique because I have great TMJ so I'm very interested in it.

[GJ]

I guess this goes to show that guesses as a lay person can often miss the mark.

Do you mean yourself or the people who chimed in here?

I said get the CCW from the chin...linear makes sense, and when you move the jaw linearly when the mandible and bite plan have grown downward, that's on net a CW movement. Expect your face to elongate a bit.

[kavan]

I agree. I have a whole host of Brazilian surgeons I found on instagram that have great aesthetic results. Some of them are already well known and pricey (Augusto Pary, Jonathas Claus) and others fly under the radar and cost significantly less. I have consultations with a few of them coming up in the next week or so.

The Brazilian surgeons (and many latin american surgeons for that matter) are also strong proponents of Alfaro's minimally invasive approach. I've been told I'm a good candidate for this technique because I have great TMJ so I'm very interested in it.

Gotta say again, that guy's plan was very ingenious. Alfaro's minimally invasive approach is to use PIEZO ELECTRIC cutting tools (through smaller incisions) PZE tools are cutting edge (limits some collateral damage from the cutting). So, good sign if this Latin doctor also uses them. Alfaro is pretty FAST at completing a surgery. So, experience does kick up doing it in less time. 'Skill' can be seen as ability to complete a (good) result in in less TIME than another kicking up same/similar result in MORE time. So a good guy with LESS experience using similar tools/techniques might take more time to complete as to be thorough than someone more experienced. But, personally, I don't think that makes a difference in a situation where both could kick up a good result but one can kick up faster than the other. Personally, I think the probability is higher for better docs in Brazil than than finding in Canada.

[canuker]

Do you mean yourself or the people who chimed in here?

I said get the CCW from the chin...linear makes sense, and when you move the jaw linearly when the mandible and bite plan have grown downward, that's on net a CW movement. Expect your face to elongate a bit.

I meant myself!

[canuker]

Personally, I think the probability is higher for better docs in Brazil than than finding in Canada.

I would have to agree.

I will keep this thread updated with my upcoming consultations. Curious to see how similar or different other surgery plans are to the one I posted above.