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.

 

[czechpsl]

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.

If you want a taller ramus, consider a post-gonial cut BSSO

 

[Prøphet]

Brutal how we need to achieve a doctoral understandin of the maxillofacial complex just to try and avoid getting botched

 

[gravlek]

Brutal how we need to achieve a doctoral understandin of the maxillofacial complex just to try and avoid getting botched

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

 

[gravlek]

If you want a taller ramus, consider a post-gonial cut BSSO

Do any of the reputable surgeons offer this to non-syndromic patients? Feel like they will deem it too unnecessary risk (higher instability) and would rather throw in implants

 

[Animepilled]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

Women are blackpilled as hell. They just dont go that deep into things. Their brain doesnt work that way

 

[gravlek]

Women are blackpilled as hell. They just dont go that deep into things. Their brain doesnt work that way

You know what I mean tho bro, I’m talking about their approach to surgery. They think simply getting a procedure will ascend them, whereas men recognise the need to actually dissect the whole thing and make sure the outcome/result is optimised through an optimal surgical plan

 

[Prøphet]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

“My philosophy is that”

 

[Animepilled]

You know what I mean tho bro, I’m talking about their approach to surgery. They think simply getting a procedure will ascend them, whereas men recognise the need to actually dissect the whole thing and make sure the outcome/result is optimised through an optimal surgical plan

Yeah it doesnt make them bluepilled tho.

 

[gravlek]

Yeah it doesnt make them bluepilled tho.

Bluepilled in surgery to be blackpilled on tinder

 

[Prøphet]

You know what I mean tho bro, I’m talking about their approach to surgery. They think simply getting a procedure will ascend them, whereas men recognise the need to actually dissect the whole thing and make sure the outcome/result is optimised through an optimal surgical plan

Bitches be getting a rhino just to still have the facial convexity of a waning crescent

 

[gravlek]

Bitches be getting a rhino just to still have the facial convexity of a waning crescent

This is what I see too often, girls who need a djs for their huge overbite but think a rhino will save them jfl. And even after the surgery still not able to tell what’s wrong with their side profile

 

[Prøphet]

This is what I see too often, girls who need a djs for their huge overbite but think a rhino will save them jfl. And even after the surgery still not able to tell what’s wrong with their side profile

“I need a rhino revision it’s off by 2.4 nanometers that’s why I still look like a Simpsons character”

 

[gravlek]

“I need a rhino revision it’s off by 2.4 nanometers that’s why I still look like a Simpsons character”

rhino is the most abused surgery in the book, I honestly think most normies would be better off getting a genioplasty. The rhino surgeons created millions of piggy nose revision normies

‘My dorsal hump is finally gone’

 

[Usurper]

Bitches be getting a rhino just to still have the facial convexity of a waning crescent

Very real bro, I remember being at the consultation waiting room for rhino, and I kid you not 2 out of 3 foids I saw needed DJS or at least genio.

 

[Usurper]

So based on my measurements I'll probably be looking at 6 to 7mm for incisor position, little or no vertical component, ANS and A advanced around 2mm, 7 degree or so counterclockwise. The CT drawing I did the incisor position in red isn't correct and is too forward, and will result in a lot more soft tissue changes. It seems that ortho is decompensating and removing reducing a bit incisor rotation which is good for maxillary rotation. But will confirm.

Another question I have is wether any possible ANS refinement (I saw some surgeon saying he did it sometimes) should be left to rhino surgeon or should be consider and wether I am a candidate or not. I know these parts are hard to predict so maybe it's better to just leave it to a subsequent op.

 

[czechpsl]

Do any of the reputable surgeons offer this to non-syndromic patients? Feel like they will deem it too unnecessary risk (higher instability) and would rather throw in implants

I know Ramieri does that, as well as Raffaini and Alfaro. But I haven't done much research on that, so probably way more surgeons offer it

 

[Usurper]

I know Ramieri does that, as well as Raffaini and Alfaro. But I haven't done much research on that, so probably way more surgeons offer it

Aside from stability, is there issues with masseter dehiscence? And that is the biggest problem with ghonial angle implants.

 

[czechpsl]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

I ain't leaving the operating room without an ideal gonial angle and forward growth. TF is Ramieri thinking?

 

[Gittes]

So based on my measurements I'll probably be looking at 6 to 7mm for incisor position, little or no vertical component, ANS and A advanced around 2mm, 7 degree or so counterclockwise. The CT drawing I did the incisor position in red isn't correct and is too forward, and will result in a lot more soft tissue changes.

What benchmark are you using to ensure optimal bite correction/jaw movements (SNA angle, A to Nasion etc...)?

It seems that ortho is decompensating and removing reducing a bit incisor rotation which is good for maxillary rotation. But will confirm.

I'm pretty sure the whole purpose of decompensation is to give the surgeon as much latitude as possible for jaw movements, including rotation as well as any linear advancements.

Another question I have is wether any possible ANS refinement (I saw some surgeon saying he did it sometimes) should be left to rhino surgeon or should be consider and wether I am a candidate or not. I know these parts are hard to predict so maybe it's better to just leave it to a subsequent op.

Due to the unpredictability of soft tissue changes, I'd wait until after the surgery personally.

 

[czechpsl]

Aside from stability, is there issues with masseter dehiscence? And that is the biggest problem with ghonial angle implants.

There might be a problem—that's the thing I want to ask the surgeons about soon, but I'm sure it'll be way less than with implants, maybe not at all. Below is an example of the result, doesn't seem like dehiscence at first glance

 

[Gittes]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

No, I just think Ramieri's male patients, especially foreign ones, are self-selecting since they're far more likely to have heard of him from looksmaxxing forums. Your average bimax patient - male or female - will defer almost completely to the surgeon.

 

[Usurper]

There might be a problem—that's the thing I want to ask the surgeons about soon, but I'm sure it'll be way less than with implants, maybe not at all. Below is an example of the result, doesn't seem like dehiscence at first glance

Ok, I'll do some research on this as well.

 

[czechpsl]

Your average bimax patient will defer almost completely to the surgeon.

Yeah, and then they wonder why they look worse than before (got chin lip, inferior border notching, and a terrible ramus-to-mandible ratio).

 

[Gittes]

Yeah, and then they wonder why they look worse than before (got chin lip, inferior border notching, and a terrible ramus-to-mandible ratio).

No, many won't notice and will just be pleased with some degree of improvement while overlooking any shortcomings.

Funny that you mention Alfaro before because thanks to his infamous "Barcelona line", he's been guilty of a lot of over-advancement as well,