General Category > Aesthetics

Aesthetic outcome of my jaw surgery

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VincentGT:
I’m a 32-year-old male considering jaw surgery.  Well, I have decided already actually.

Here you find the CBCT scans of my face and skull. 

Here you find pictures of my face, in different lightings and positions. Taken by different surgeons.

And finally, here you can find a few morphs I made myself with the desired results. Not all of these are exactly the same or as good, but I believe they might give an idea what I’m looking for. 

I have seen a few surgeons and I finally decided who my surgeon would be. He was advised by many; I can’t find any negative review online and my orthodontist vouches for him too. 

Functional issues
I am a mouth breather; breathing through my nose is very hard and I can’t seem to make a habit of it. 
I am also diagnosed with mild sleep apnea and I experience vocal fatigue if I’m talking for extended periods, probably due to not breathing correctly.
I have had orthodontics 15+ years ago, which created a class I bite, but skeletal I’m still a class II.

Aesthetic issues
I have a weak jawline and recessed chin, a permanent double chin (because of the short mandible) and my nose appears larger than it actually is. I considered getting chin filler or a chin implant, but that would make my teeth relatively even ‘deeper’ in my face instead of bringing the jaws forward. With the chance of ending up with a witch chin, I didn’t follow through.

Most of the surgeons all said the same thing: I would benefit from bimax surgery. During camouflage orthodontics (15+ years ago) my maxilla was pulled back to compensate for my small mandible, so both jaws are recessed now. 

The suggestion of my orthodontist and surgeon is the following: 
- Step 1) Pull 4 teeth: upper 2 wisdom teeth and lower 2 pre-molars. This is scheduled tomorrow afternoon; 
- Step 2) Bring back the bottom teeth that are now inclined too much forward and thus ‘recreate’ the overbite through orthodontics (braces will be placed in 6 weeks);
- Step 3) Have the bimax surgery and bring forward the mandible more than the maxilla (hence surgically correcting the recreated overbite).
- PS: CCW rotation is not yet decided upon.
- PPS: Neither is genioplasty, but the 3D virtual treatment planning would make this more clear.
- PPPS: In any case, I was planning to get rhinoplasty surgery after jaw surgery, to get rid of the hump and straighten my deviated septum. I have seen another surgeon for this, who advised me to get the jaw surgery first and advised not to let the jaw surgeon touch the nose too much, because often this means in less cartilage which he needs for the rhinoplasty.

I have listed for myself the things I ideally would want from this surgery aesthetically speaking and the things I definitely want to avoid. I suppose this will make communication with my surgeon easier during the work-up. 

WANTS (Look at my own morphs) 
1. I want to have a jawline and + a more forward chin (so the double chin is gone and my nose is more in proportion)
2. I want my facial thirds to still be in proportion (I feel like they are today)
3. I don’t really have a severe gummy smile, but when I smile very wide you do see the gums. So I might benefit from a little less gum/teeth show (maxilla impactation) 
4. Ideally, I’d like a bit more upper lip. I feel like it’s ‘curled’ inside now, because of the lack of teeth support

DO NOT WANTS
1. I don’t want a sharper gonial angle. If I look at my CBCT scan, I think it’s good as is. A sharper angle will make my face look too boxy (like this)...
2. I don’t want a chin that is too short or too long. In frontal view, I kind of like the current length of my chin as it seems in proportion
3. I want to avoid thinner (upper or lower) lips. Too often I see this post jaw surgery
4. I don’t want my philtrum to look longer post-op. This too I see too often
5. I don’t want my nose to get wider. If, despite counter measurements, my nose still got any wider I might ask my rhinoplasty surgeon to include alarplasty (alar base reduction)

What do you think of this approach? Is it a good idea? 
What do you think of my morphs and wishes? Is this achievable? 
How do you feel about the following (given my aesthetic hopes): 
- CCW rotation? 
- Alar cinch? 

Thanks so much for all the support and information on this forum!

GJ:

--- Quote ---- CCW rotation?
- Alar cinch?
--- End quote ---

Yes, this is probably going to be your best option. The thing is, I'm not sure you'll get all your desires. You have 4 things you want and 5 things you don't want. My educated guess would be you'll get some things you want corrected, but other things you won't like. This is generally what happens.

Pulling teeth is almost always a bad idea.

VincentGT:
All the surgeons and orthodontists I saw told me I need the pre-molar extractions to make room for the teeth that are now flaring out.

I asked my surgeon this as well and he told me he would never pull teeth if not necessary, but pulling them in order to make room for the advancement in jaw surgery is often necessary. If I want to keep all teeth they can do bimax, but I'd still be a skeletal class II.

kavan:
OK, your scans, cephs and morphs certainly confirm you are candidate for maxfax (double jaw) surgery.

The suggestions of your ortho and surgeon are certainly in line with pre-surgery preparation in braces to 'decompensate' your bite (the bite you were given 15 years ago).

It's also true in most cases (and here in yours) that rhino should be done AFTER maxfax. One 'lucky' example of that is when there is hump on nose and/or the nose just looks too big on the face. Bringing forward the maxilla (Lefort aspect of surgery) advances the nasal base and gives a straighter nose bridge because when base of the nose is advance with the maxilla, the hump or conVEXity of upper nose bridge VISUALLY 'goes away' simple because its appearance is RELATIVE to the base of nose being too far behind.  Also, in the event, the nostril areas could be predicted (by the maxfax surgeon) to widen too much from the maxillary advancement, they can do something called an 'alar cinch' to mitigate the widening.In such a 'lucky' case, no rhino is needed after the maxfax surgery and it can resolve to a 'free rhino'. Why? Because the nose hump going away due to the maxilla advancement, in addition to the nostril widening being mitigated by the alar cinch has very good chance of fixing/improving aesthetic issues with nose so you don't need a rhino afterwards even though the maxfax technically is NOT performing a rhino. Your situation with the nose looks to veer in the direction of what I call a 'lucky' one. Also, maxillary advancement would tend to unfurl your upper lip which is also 'lucky' since you want that.

A word about morphs. Morphs don't predict the outcomes of a surgery. Although they visually communicate a desired result which can be in the venue of good aesthetics (which yours is), keep in mind you are using a morph program where you can make automatic changes in accordance to your aesthetic preference but you don't know what actual measure displacements you are doing (with the morph) as they relate to maxillary displacements (advancements and/or rotations), mandibular displacements and balancing that all with the BITE. So, a morph used to show a desired aesthetic outcome can't be used as PREDICTIVE software for the desired outcome. Hence, it can't be used as a DIRECTIVE to the surgeon to kick up the desired outcome you want to see in the mirror that your morph shows. You need to understand that.

The type of predictive software a maxfax surgeon can use is kind of complex. But it is something that allows them to displace the jaws in a variety of ways in addition to balancing the bite which is done first on the SKULL MODEL scan. Basically, the program conveys which combination of complex movements are allowable relative to a combined objective of balancing the aesthetics with the bite. That is to say, it can convey to the surgeon 'this or that' displacement can come with 'this or that' TRADE-OFF and let them keep on trying other combinations to optimize all. Software can also make somewhat of a prediction of soft tissue changes (the part you see to the FACE FLESH over the changed bone structure). However the program can't predict exactly the soft tissue changes. So, the surgeon can use the software to OPTIMIZE bite with AESTHETICS and take your morph into consideration when using the program to optimize all. But there can still be some deviations from the norm or desired aesthetic 'perfection'.

Anyway, a surgeon using a sophisticated program that is very close to PREDICTIVE SOFTWARE should be able to show you a visual CONTOUR CHANGE of the profile relative to your start point and that should give you some idea of how it compares to your morph.

The point I am making here (or at least trying to make) is that your chances of having a GREAT IMPROVEMENT are very HIGH. But it is not a thing where you can rule out; 'I don't want this and I don't want that' in any trade-off despite your morph showing exactly what you want to be achieved from the surgery. It doesn't work that way. Your trade-offs will probably be MINOR relative to the MAJOR IMPROVEMENT you stand to get from the surgery.

Feel free to cross reference everything I said here with your surgeon.

VincentGT:
Hi kavan,

I was hoping you would answer.

Yes, you’re certainly right regarding desires and expectations. My surgeon told me the same thing. Still, I believe a morph of my own making and a list of concerns and ‘wishes’ might help with directing the final result without having unrealistic expectations.

Do you understand the choice for extracting the premolars and upper wisdom teeth? My surgeon is supposed to be one of the best of my country and was advised by the office of Dr Raffaini (as surgery in Italy wasn’t an option). The other surgeons I saw all advised the same extractions.

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