How to properly plan jaw surgery (DJS, trimax, orthogonatic)

[Usurper]

So I have started orthodontics about 6 months ago. Initially I had no surgery in mind, didn't know much in general and ortho said I shouldn't. I have Class I and dentally biggest issue is lower jaw crowding and a bunch on compensation in the maxila.

But about 2 months after starting ortho, I consulted with a surgeon initially with the idea of considering a genioplasty only, but after discussing a bit, seeing my CTs, etc. I realized that I was very recessed. For reference my SNA is 75 degrees. So we talked about doing a trimax, which I was clearly a candidate for, although surgeon said that I should consider if it was worth it to me since this would be a purely cosmetic case. After I agreed he talked with ortho to ensure that the new plan moved to a pre-op de-compensation ortho.

Fast forward to now and I am continuing with ortho but have no idea about any specifics of the plan.

So I messaged the surgeon to see if it would make sense to discuss now, with special consideration to if ortho is moving in a direction which would limit possible options in the future. I hope not, otherwise I would very very much not happy with him not taking initiative.

But anyway. I know proper execution of a trimax involves:
- Adequate forward movement, no under-advance, no over-advance.
- Adequate ccw rotation.
- Factors like perioral area (chimp lips), upper third convexity, E line, ghonial angle can limit max forward movement and influence ccw rotation. Biggest risk of these is perioral.
- Technique influences areas of risk: custom has relapse issues due to improper condyle positioning and increased perioral risk. Non-custom has precission issue.
- Possible future enhacements with rhinoplasty and midface implants may influence some movement decisions.
- Can L cut in BSSO be performed to gain a little flare or not?

So my question is, what is the proper due-diligence on my end to reduce these risks as much as possible? Should I get multiple opinions?

 

[Gittes]

Yes, definitely get a few extra opinions to make sure you're making the right decision or, at the very least, help clarify/inform your decision-making with alternative surgical plans.

All of the points you've raised about what constitutes a good bimax should be raised with prospective surgeons. Literally ask them to walk you through each point. That's your best way to mitigate risk. Comparing plans and bouncing points off of different surgeons is the best course of action.

 

[Usurper]

Scan with some of my basic understanding on top. I will need rhino afterwards that's pretty obvious. And I don't think my manual draft of soft tissue is realistic, I think it will be more but.

 

[czechpsl]

Can L cut in BSSO be performed to gain a little flare or not?

Is your jaw narrow? Don’t forget that condylar torque adds width to the entire ramus, so it can make you look bloated.

 

[Usurper]

Is your jaw narrow? Don’t forget that condylar torque adds width to the entire ramus, so it can make you look bloated.

Not really, no, and I have pretty ideal bizygomatic width to bighonial. Maybe not a good idea then. I would prefer having taller ramus and a bit of flare, but without any of this personally I am happy.

I put those lines into a photo of me and simulated the movements. And as long surgeon can get the lip and ANS right, which means little movements there to prevent chimp lip. I would be very happy.