Input on upper midfacial implant design

[MazeFly]

Is there anyone here who thinks they would be capable of giving meaningful input on the design upper midfacial implants?

My history briefly: Bimax done twice, including zygomatic sandwich osteotomy during my second bimax. First bimax movements were almost 0 (it was totally botched), second bimax I got 5mm A-point, 8mm pogonion. Total movement on pogonion I got across both surgeries is about 10mm. I had moderate sleep apnea, now it's fully cured (AHI 0.9 with virtually no RERAs). I have continued dissatisfaction over facial appearance, I have a gummy smile, a slightly elongated philtrum (normal range, but it was very short prior to these surgeries and my facial harmony was better that way, now it's on the longer end of the normal range), lack of ogee curve due to excess lower maxillary projection relative to zygomatic projection (due to second bimax, ZSO didn't compensate enough). Mild lower eyelid retraction with tight orbicularis oculi musculature at rest to compensate (my eyes get dry quickly when I relax the muscle, this has been the case my whole life, it's not a consequence of my prior surgery). I have a negative orbital vector and excessively rounded inferior orbital rims.

I'm current considering this path:
Bimax hardware removal combined with placement of saddled titanium mesh infras with extensions into the zygomatic body and arch, followed by TAD-assisted orthodontic intrusion of the maxillary incisors with the aim of reducing tooth/gum show by about 2-3mm and shortening philtrum by about 0.5-0.7mm (my superimpositions of images from publications on TAD-intrusion suggest this is possible due to decreased area the philtrum skin has to stretch over and mandibular autorotation that accompanies such intrusion), followed by a convervative botox lip flip and maybe slight lower lip filler, aiming to achieve a final philtrum shortening around 1-1.25mm, followed by maybe a small amount of filler into the mandible to balance out the slight zygo arch widening.

Please only bother replying to my thread if you're decently knowledgeable, thanks for not wasting my time.

 

[imontheloose]

You're right with this IMO. The skeleton is the right place to work first.

Them infra-malars will be great. Will correct the negative vector, restore ogee, support lower lid-cheek junction, and balance the lower maxilla > zygoma look from the second bimax. I'd concentrate most the projection anterolaterally, a few mm at the rim apex and a touch more at the malar body (this of course depends on your CT which I cannot see), then feather medially and superiorly to avoid nasal sidewall fullness and those overly rounded "marble" rims. Keep the arch extension thin and sweeping, around 2mm-ish, to lengthen the skull laterally without looking like a brick.

Your surgeon will know this already, but it's worth stating you don't want an overly rounded rim: I've saw this happen with surgeons inexperienced on male aesthetics and it makes the client look oddly feminine/uncanny. Include a notch/relief around the foramen, don't get a sharp saddle over the nerve. Standard practise, but worth checking.

If you have baseline mild retraction/dryness, I will really recommend looking into a transconj approach with maybe even canthopexy, or at least canthal support; you can look into SOOF suspension as an and/or. The point of this is that you greatly lower the risk of postoperative lid descent; a preventative measure, not an optional one. I am biased to PEEK (tends to contour smoothly in thin midface tissue), so I will recommend it over titanium, but titanium does work obviously. It can just be a bit palpable or edgy in the midface. If you insist on titanium, just make sure to demand broad, feathered rims and generous soft-tissue coverage. Bizyg/bigon correction will some minor filler has the green light from me too.

TAD incisor intrusion will reduce gingival show and de-strain the upper lip on smile for sure, but it isn't going to truly shorten the philtrum. You may notice a small apparent reduction because the lip isn't being stretched over tooth edges and the vermilion sits more favourably, but treat that as a bonus, not a guarantee by any means. Now, the nuance that does actually matter is that anterior intrusion helps a gummy smile without meaningful mandibular autorotation. Posterior intrusion / maxillary impaction is what rotates the mandible CCW. If you're happy with your lower third after the second bimax, keep intrusion anterior-focused so you don't reopen the occlusal plane conversation. Just document your upper incisor show at rest and gingiva on full smile pre- and post- aiming for about 3mm-ish at rest and negligible gingiva on full smile respectively.

Important to note, use botox on the elevators (LLSAN, LLS, and zygomaticus minor) to limit the excessive elevation on smile, not a lip flip. Consider depressor septi too if columella pulls down. The lip flip everts the vermilion; it can increase tooth show if you over-relax it. If your principle is less gum, do tiny units or even skip it until you see what intrusion achieved. Micro-fillering your lower-lip will probably help soften a labiomental fold, so go ahead if it feels harsh after intrusion/autorotation. Just make sure to use judiciously.

If you remain bothered after correction, the only true reducer is a lip lift. That being said, you were right to solve display first; a lift is only safe if you're comfortably at 0-2mm gum on smile afterwards.

 

[chadisbeingmade]

You're right with this IMO. The skeleton is the right place to work first.

Them infra-malars will be great. Will correct the negative vector, restore ogee, support lower lid-cheek junction, and balance the lower maxilla > zygoma look from the second bimax. I'd concentrate most the projection anterolaterally, a few mm at the rim apex and a touch more at the malar body (this of course depends on your CT which I cannot see), then feather medially and superiorly to avoid nasal sidewall fullness and those overly rounded "marble" rims. Keep the arch extension thin and sweeping, around 2mm-ish, to lengthen the skull laterally without looking like a brick.

View attachment 4181955

Your surgeon will know this already, but it's worth stating you don't want an overly rounded rim: I've saw this happen with surgeons inexperienced on male aesthetics and it makes the client look oddly feminine/uncanny. Include a notch/relief around the foramen, don't get a sharp saddle over the nerve. Standard practise, but worth checking.

View attachment 4181958

If you have baseline mild retraction/dryness, I will really recommend looking into a transconj approach with maybe even canthopexy, or at least canthal support; you can look into SOOF suspension as an and/or. The point of this is that you greatly lower the risk of postoperative lid descent; a preventative measure, not an optional one. I am biased to PEEK (tends to contour smoothly in thin midface tissue), so I will recommend it over titanium, but titanium does work obviously. It can just be a bit palpable or edgy in the midface. If you insist on titanium, just make sure to demand broad, feathered rims and generous soft-tissue coverage. Bizyg/bigon correction will some minor filler has the green light from me too.

TAD incisor intrusion will reduce gingival show and de-strain the upper lip on smile for sure, but it isn't going to truly shorten the philtrum. You may notice a small apparent reduction because the lip isn't being stretched over tooth edges and the vermilion sits more favourably, but treat that as a bonus, not a guarantee by any means. Now, the nuance that does actually matter is that anterior intrusion helps a gummy smile without meaningful mandibular autorotation. Posterior intrusion / maxillary impaction is what rotates the mandible CCW. If you're happy with your lower third after the second bimax, keep intrusion anterior-focused so you don't reopen the occlusal plane conversation. Just document your upper incisor show at rest and gingiva on full smile pre- and post- aiming for about 3mm-ish at rest and negligible gingiva on full smile respectively.

Important to note, use botox on the elevators (LLSAN, LLS, and zygomaticus minor) to limit the excessive elevation on smile, not a lip flip. Consider depressor septi too if columella pulls down. The lip flip everts the vermilion; it can increase tooth show if you over-relax it. If your principle is less gum, do tiny units or even skip it until you see what intrusion achieved. Micro-fillering your lower-lip will probably help soften a labiomental fold, so go ahead if it feels harsh after intrusion/autorotation. Just make sure to use judiciously.

View attachment 4181862View attachment 4181869

If you remain bothered after correction, the only true reducer is a lip lift. That being said, you were right to solve display first; a lift is only safe if you're comfortably at 0-2mm gum on smile afterwards.

Please only bother replying to my thread if you're decently knowledgeable, thanks for not wasting my time.

Blud did NOT waste his time. Mirin. I’ll shut up now and honour OPs request since my reply is more than useless.

 

[SlayerJonas]

Blud did NOT waste his time. Mirin. I’ll shut up
now and honour OPs request since my reply is more than useless.

You're right with this IMO. The skeleton is the right place to work first.

Them infra-malars will be great. Will correct the negative vector, restore ogee, support lower lid-cheek junction, and balance the lower maxilla > zygoma look from the second bimax. I'd concentrate most the projection anterolaterally, a few mm at the rim apex and a touch more at the malar body (this of course depends on your CT which I cannot see), then feather medially and superiorly to avoid nasal sidewall fullness and those overly rounded "marble" rims. Keep the arch extension thin and sweeping, around 2mm-ish, to lengthen the skull laterally without looking like a brick.

View attachment 4181955

Your surgeon will know this already, but it's worth stating you don't want an overly rounded rim: I've saw this happen with surgeons inexperienced on male aesthetics and it makes the client look oddly feminine/uncanny. Include a notch/relief around the foramen, don't get a sharp saddle over the nerve. Standard practise, but worth checking.

View attachment 4181958

If you have baseline mild retraction/dryness, I will really recommend looking into a transconj approach with maybe even canthopexy, or at least canthal support; you can look into SOOF suspension as an and/or. The point of this is that you greatly lower the risk of postoperative lid descent; a preventative measure, not an optional one. I am biased to PEEK (tends to contour smoothly in thin midface tissue), so I will recommend it over titanium, but titanium does work obviously. It can just be a bit palpable or edgy in the midface. If you insist on titanium, just make sure to demand broad, feathered rims and generous soft-tissue coverage. Bizyg/bigon correction will some minor filler has the green light from me too.

TAD incisor intrusion will reduce gingival show and de-strain the upper lip on smile for sure, but it isn't going to truly shorten the philtrum. You may notice a small apparent reduction because the lip isn't being stretched over tooth edges and the vermilion sits more favourably, but treat that as a bonus, not a guarantee by any means. Now, the nuance that does actually matter is that anterior intrusion helps a gummy smile without meaningful mandibular autorotation. Posterior intrusion / maxillary impaction is what rotates the mandible CCW. If you're happy with your lower third after the second bimax, keep intrusion anterior-focused so you don't reopen the occlusal plane conversation. Just document your upper incisor show at rest and gingiva on full smile pre- and post- aiming for about 3mm-ish at rest and negligible gingiva on full smile respectively.

Important to note, use botox on the elevators (LLSAN, LLS, and zygomaticus minor) to limit the excessive elevation on smile, not a lip flip. Consider depressor septi too if columella pulls down. The lip flip everts the vermilion; it can increase tooth show if you over-relax it. If your principle is less gum, do tiny units or even skip it until you see what intrusion achieved. Micro-fillering your lower-lip will probably help soften a labiomental fold, so go ahead if it feels harsh after intrusion/autorotation. Just make sure to use judiciously.

View attachment 4181862View attachment 4181869

If you remain bothered after correction, the only true reducer is a lip lift. That being said, you were right to solve display first; a lift is only safe if you're comfortably at 0-2mm gum on smile afterwards.

All that for OP to resume playing Pubg mobile on his Xiaomi.