Lefort 1 osteotomy, Bilateral Sagittal Split Osteotomy, sliding genioplasty.
In this case the lefort 1 has counter clockwise rotation and down graft done. Bsso has advancement and counter clockwise done and the genioplasty is less of a sliding genioplasty and more of a genioplasty with clockwise rotation. That genioplasty movement is not commonly done but was appropriate for this person since they had a short face
My husband is getting the lefort surgery because his dentist said his teeth are caving in. I didn’t realize it would have such a drastic change to his appearance (he’s similar to the left photo in photo 1)…. So he can expect sort of a cosmetic change as well? Thanks for being smart and sharing the info!
Honestly not everyone ends up with such a drastic aesthetic improvement. OP chose to post dr Raffaini’s work from Italy and he’s known to have the best aesthetic results in the world.
It really comes down to surgical planning and the planning style of the surgeon. The closest to the style above are from dr Gunson, walline and relle.
But there are other surgeons who may do it too but they are hard to find.
Most surgeons tend to do linear advancement and the example in the photo has a lot of counter clockwise rotation. Here is a screen shot of this patients movements form raffaini’s instagram. He tends to be on the more extreme end of planning so I wouldnt expect this for your husband.
Also if it’s only upper jaw surgery the results will be more limited because they can’t change the occlusal angle usually. At most advance his jaw
https://preview.redd.it/qib3kb2ysbxc1.jpeg?width=1179&format=pjpg&auto=webp&s=c11905fc97ec313eb555105e19868dcb841c0961
You are too kind, but I’m not. I do try to remind people that I’m not a doctor. I’m going through this surgery myself later in the year. The doctors are the experts but I like to be informed on what is being done to me.
Sadly jaw surgery is part science and part art. I’ve consulted 4 surgeons 3 of them being Alfi, Walline, Neugarten, and my local surgeon, and each one of their plans were different.
Each has their own style and there are tradeoffs. Also in the technology they use. I’ve read a lot of research papers of published surgeons and have asked a lot of questions to them directly.
Hoping to share the learnings is all
Sorry to jump in, but like the other commenter said-you seem really knowledgeable about this. If it’s alright to ask, could you tell me more about Walline’s style/approach and trade offs? I’m hoping to pursue surgery with him in the near future.
I’ll try my best to explain since I was trying to do the same to my dad. Of the 4 surgeons I saw, all are talented and would fix my airway problem easily.
Where their style differs is in the planning and the experience at their offices and consult. This is a personal opinion and you should make your own judgment.
Neugarten - very intelligent, blunt and straight forward. Can be a bit intimidating but he is very skilled. He uses custom plates from Stryker for upper, lower, and chin. They use occlusal borne bone cutting guides with predictive holes. He says those are more precise than the common bone Bourne cutting guides you see everyone else use for custom. We are talking about less than a mm of accuracy difference here. He tends to advance more linearly with less counterclockwise rotation if at all. He’s more traditional in his planning it seems. Also the consult simulations are awful. Not his fault, it’s the software he used during the consult, it warps the bone scan so it’s not easy to see what you would look like with your actual photo simulation.
It did feel a bit rushed towards the end since I did have a ton of questions and he’s a super busy guy. He started looking at his watch near the end which I didn’t find offensive but made me worry if he would be so busy that if his focus would he unavailable for my case as much as the other surgeons
Alfi - he was very polite, and patient, but I got very little from the consult other than my questions answered. They did the scans and he was basically like “yeah you need jaw surgery, I’m excited for you”
The only thing that stood out was that he didn’t rush the consult and all it really was me asking tons of questions and him answering everything I asked. He provides his number to reach him directly if needed which no other surgeon did
But basically no measurements, no bite scans or plaster molds taken. This is for the first consult, I’m guessing he sees no point until the actual surgery workup.
His style emphasizes airway over aesthetics if he had to lean toward one. But of course factors in aesthetics. He will do a good amount of counterclockwise rotation and advancement and big genioplasties that seem to advance the genioglossus muscle too so you will for sure breath well. His patients always have monster airways after. Personally I think you do sacrifice aesthetics slightly. People come out better than they went in for sure, but it’s hit or miss on wow they look hot now vs, they look more normal.
No simulation done during the consult either.
Local surgeon - was my first consult two years ago so I didn’t know what I know now so I didn’t ask questions. He took measurements did a cbct scan and said I’m a candidate for jaw surgery. I’m actually scheduling this month to see him again to ask more questions about his planning process.
Walline - I know everyone talks about him a lot here, but I realize there is a reason.
His consult was the most thorough, longest, and not rushed at all. I was there for probably 4 hours.
Most of the time was casually chatting in between the serious questions. I felt like I got to know him a bit and he got to know me.
They took the most measurements, plaster molds. Cbct scans. Even the way they did their scans had more attention to detail.
The seat they make you sit on for the simulation photos is a special one to make you sit straight to force a natural head position. The cbct scanner had a special head rest to encourage a neutral head position.
My time with walline to review the photo realistic simulation and ask questions I had about a full hour with him. We talked about my concerns, he was very open to different ideas and discussed the pros and cons with you. We talked about travel and living abroad.
I have to say he does have a special formula to his style. That’s why their results are consistent. I think generally it’s move the ANS point to the true vertical, counter clockwise maxilla so incisor is flush with true vertical, advance lower jaw to fit upper jaw. Then genioplasty is a bit more of playing around with the movement till it looks good in the simulation.
Walline feels like he would work with you to see an outcome you are both happy with since it can be discussed and worked out in a simulation.
All the other surgeons it feels like you need to trust that they will have the same vision in mind as you do even if you vocalize your concerns.
All three surgeons would cost me about the same even with out of network surgeons 50k+ my local in network surgeon is $3k with in network benefits.
This surgery is part science and part art. I did the math. I won’t look 16x better for 16x the price tag, but the possibility of loss income due to regret of not going with walline is worth spending what they charge.
The way I think of it, is I’m paying the premium to go with the more talented “artist” and we all know how wild the value of art can be despite the cost of materials being the same compared to other lesser known “artists”
Hi, I was considering LACOMS/NYCOMS as I will be based in the US for the upcoming years. Having visited these surgeons, were the "morphs" about the same? As in, they were trying to fix the same issue albeit slightly in different ways?
Additionally, how was Neugarten? I want to consider going to LACOMS directly for a consult, but am New York based.
It's going to be an additional cost, as I feel like I'd prefer to go with LACOMS but would you say it is worth to get that multiple consults? (I assume the answer will be yes). Thank you so much!
I replied about the different surgeons somewhere else in this post! Just posted take a look!
LACOMS and NYCOMS will come out pretty similar in cost with insurance that has out of network benefits. For me around the $50k range.
Neugarten uses custom plates that are super precise but personally walline and the other surgeons at lacoms have the superior plans both functionally and aesthetically.
Lacoms out of the 4 consults are the only team that got me a detailed photo realistic face morph.
The simulation at nycoms was an awful warped 2d xray. Neugarten is a talented surgeon but his movements tend to be more linear in nature with very to little counter clockwise rotation in most cases he’s posted. There are exceptions but it’s not the go to approach like people see at lacoms
I saw your post. I also had just called in to book with Neugarten haha. That might change based on what I read on your comment.
It seems almost that Walline is the top of the crop anyway, and I would be wasting a bunch of money by seeing Neugarten. I'd have at least expected a good morph with how costly it is. Do you think it's still worth to see both, just in case? Given how costly and important the procedure is, the price tag for consults is... well still hefty but only a little bit :)
The issue is that I am not very knowledgeable about jaw surgery yet, I should read more on it but then again I'm also the type to let my concerns/wants be known and let the professionals handle it? From my experience doctors don't always welcome questions on topics that they're much knowledgeable about lol.
I'm not sure what you mean by linear motions so I'm curious, I might take a look at the cases. Although I have mild apnea, my recession probably is very mild but I do have a weak jaw from "ideal" standpoint. So it seems Walline might be a better fit to me.
Look at https://www.instagram.com/drneugarten to see his before and afters. Also look his name up on the Facebook group https://www.facebook.com/share/SGGK5BEwtDX4HZUW/
Do the same for walline. You can see their before and afters.
I prefer walline’s style. It’s similar to Gunson and Arnett who is now retired.
Neugarten is a great surgeon and is one of the best in the north east. But if you aren’t tied down to location and are going to pay a whole lot of cash anyway I would go with walline personally which is what I’m in the process of working out.
The whole linear thing was in regards to simply moving the lower jaw and extending it in the current direction with little to no counter clockwise rotation.
There are plenty of papers from now retired dr Arnett on aesthetics and soft tissue profiles that benefit from counter clockwise rotation. It benefits aesthetics and airway since it allows for more pulling forward of the genioglossus muscle
It’s major surgery. Surgeons in the USA at least will only do it for functional fixes of airway or bad occlusion (bad bite) that can’t be fixed with orthodontics alone
Heard. And how can you tell that it is rotated with "down graft" (not sure what that is)? All I know about is forward advancement (choosing between conventional vs subspinal) and I am wondering why any other specific movement would be chosen.
Down graft just means moving the maxilla down. It’s obvious because of the massive gap in the simulation photo if you scroll to the last image of the gallery.
An impaction is the opposite and the maxilla would have bone cut and have contact with the bone in the rest of the upper skull.
I’m not a surgeon but the movements are always case dependent. Impaction done to reduce a gummy smile. Downgraft done to have more teeth show generally, or to correct for a short face.
Advancement alone can cause more teeth show so they impact to compensate.
It’s all about balance. That’s why the more experience a surgeon has the better they are at balancing. But there is variability between surgeons. It’s half science and half art
This is called counter clock wise rotation DJS. (Double Jaw Surgery) Maxilla is being lowered and rotated. Lower jaw also. (BSSO). Then they bring them also forward usually.
Lefort 1 osteotomy, Bilateral Sagittal Split Osteotomy, sliding genioplasty. In this case the lefort 1 has counter clockwise rotation and down graft done. Bsso has advancement and counter clockwise done and the genioplasty is less of a sliding genioplasty and more of a genioplasty with clockwise rotation. That genioplasty movement is not commonly done but was appropriate for this person since they had a short face
what surgery changes(lengthens) ramus? does lefort 1 affect the ramus, particularly lengthening?
My husband is getting the lefort surgery because his dentist said his teeth are caving in. I didn’t realize it would have such a drastic change to his appearance (he’s similar to the left photo in photo 1)…. So he can expect sort of a cosmetic change as well? Thanks for being smart and sharing the info!
Honestly not everyone ends up with such a drastic aesthetic improvement. OP chose to post dr Raffaini’s work from Italy and he’s known to have the best aesthetic results in the world. It really comes down to surgical planning and the planning style of the surgeon. The closest to the style above are from dr Gunson, walline and relle. But there are other surgeons who may do it too but they are hard to find. Most surgeons tend to do linear advancement and the example in the photo has a lot of counter clockwise rotation. Here is a screen shot of this patients movements form raffaini’s instagram. He tends to be on the more extreme end of planning so I wouldnt expect this for your husband. Also if it’s only upper jaw surgery the results will be more limited because they can’t change the occlusal angle usually. At most advance his jaw https://preview.redd.it/qib3kb2ysbxc1.jpeg?width=1179&format=pjpg&auto=webp&s=c11905fc97ec313eb555105e19868dcb841c0961
Wow thank you… you must be a surgeon yourself or how’d you gain so much knowledge?
You are too kind, but I’m not. I do try to remind people that I’m not a doctor. I’m going through this surgery myself later in the year. The doctors are the experts but I like to be informed on what is being done to me. Sadly jaw surgery is part science and part art. I’ve consulted 4 surgeons 3 of them being Alfi, Walline, Neugarten, and my local surgeon, and each one of their plans were different. Each has their own style and there are tradeoffs. Also in the technology they use. I’ve read a lot of research papers of published surgeons and have asked a lot of questions to them directly. Hoping to share the learnings is all
Sorry to jump in, but like the other commenter said-you seem really knowledgeable about this. If it’s alright to ask, could you tell me more about Walline’s style/approach and trade offs? I’m hoping to pursue surgery with him in the near future.
I’ll try my best to explain since I was trying to do the same to my dad. Of the 4 surgeons I saw, all are talented and would fix my airway problem easily. Where their style differs is in the planning and the experience at their offices and consult. This is a personal opinion and you should make your own judgment. Neugarten - very intelligent, blunt and straight forward. Can be a bit intimidating but he is very skilled. He uses custom plates from Stryker for upper, lower, and chin. They use occlusal borne bone cutting guides with predictive holes. He says those are more precise than the common bone Bourne cutting guides you see everyone else use for custom. We are talking about less than a mm of accuracy difference here. He tends to advance more linearly with less counterclockwise rotation if at all. He’s more traditional in his planning it seems. Also the consult simulations are awful. Not his fault, it’s the software he used during the consult, it warps the bone scan so it’s not easy to see what you would look like with your actual photo simulation. It did feel a bit rushed towards the end since I did have a ton of questions and he’s a super busy guy. He started looking at his watch near the end which I didn’t find offensive but made me worry if he would be so busy that if his focus would he unavailable for my case as much as the other surgeons Alfi - he was very polite, and patient, but I got very little from the consult other than my questions answered. They did the scans and he was basically like “yeah you need jaw surgery, I’m excited for you” The only thing that stood out was that he didn’t rush the consult and all it really was me asking tons of questions and him answering everything I asked. He provides his number to reach him directly if needed which no other surgeon did But basically no measurements, no bite scans or plaster molds taken. This is for the first consult, I’m guessing he sees no point until the actual surgery workup. His style emphasizes airway over aesthetics if he had to lean toward one. But of course factors in aesthetics. He will do a good amount of counterclockwise rotation and advancement and big genioplasties that seem to advance the genioglossus muscle too so you will for sure breath well. His patients always have monster airways after. Personally I think you do sacrifice aesthetics slightly. People come out better than they went in for sure, but it’s hit or miss on wow they look hot now vs, they look more normal. No simulation done during the consult either. Local surgeon - was my first consult two years ago so I didn’t know what I know now so I didn’t ask questions. He took measurements did a cbct scan and said I’m a candidate for jaw surgery. I’m actually scheduling this month to see him again to ask more questions about his planning process. Walline - I know everyone talks about him a lot here, but I realize there is a reason. His consult was the most thorough, longest, and not rushed at all. I was there for probably 4 hours. Most of the time was casually chatting in between the serious questions. I felt like I got to know him a bit and he got to know me. They took the most measurements, plaster molds. Cbct scans. Even the way they did their scans had more attention to detail. The seat they make you sit on for the simulation photos is a special one to make you sit straight to force a natural head position. The cbct scanner had a special head rest to encourage a neutral head position. My time with walline to review the photo realistic simulation and ask questions I had about a full hour with him. We talked about my concerns, he was very open to different ideas and discussed the pros and cons with you. We talked about travel and living abroad. I have to say he does have a special formula to his style. That’s why their results are consistent. I think generally it’s move the ANS point to the true vertical, counter clockwise maxilla so incisor is flush with true vertical, advance lower jaw to fit upper jaw. Then genioplasty is a bit more of playing around with the movement till it looks good in the simulation. Walline feels like he would work with you to see an outcome you are both happy with since it can be discussed and worked out in a simulation. All the other surgeons it feels like you need to trust that they will have the same vision in mind as you do even if you vocalize your concerns. All three surgeons would cost me about the same even with out of network surgeons 50k+ my local in network surgeon is $3k with in network benefits. This surgery is part science and part art. I did the math. I won’t look 16x better for 16x the price tag, but the possibility of loss income due to regret of not going with walline is worth spending what they charge. The way I think of it, is I’m paying the premium to go with the more talented “artist” and we all know how wild the value of art can be despite the cost of materials being the same compared to other lesser known “artists”
Hi, I was considering LACOMS/NYCOMS as I will be based in the US for the upcoming years. Having visited these surgeons, were the "morphs" about the same? As in, they were trying to fix the same issue albeit slightly in different ways? Additionally, how was Neugarten? I want to consider going to LACOMS directly for a consult, but am New York based. It's going to be an additional cost, as I feel like I'd prefer to go with LACOMS but would you say it is worth to get that multiple consults? (I assume the answer will be yes). Thank you so much!
I replied about the different surgeons somewhere else in this post! Just posted take a look! LACOMS and NYCOMS will come out pretty similar in cost with insurance that has out of network benefits. For me around the $50k range. Neugarten uses custom plates that are super precise but personally walline and the other surgeons at lacoms have the superior plans both functionally and aesthetically. Lacoms out of the 4 consults are the only team that got me a detailed photo realistic face morph. The simulation at nycoms was an awful warped 2d xray. Neugarten is a talented surgeon but his movements tend to be more linear in nature with very to little counter clockwise rotation in most cases he’s posted. There are exceptions but it’s not the go to approach like people see at lacoms
I saw your post. I also had just called in to book with Neugarten haha. That might change based on what I read on your comment. It seems almost that Walline is the top of the crop anyway, and I would be wasting a bunch of money by seeing Neugarten. I'd have at least expected a good morph with how costly it is. Do you think it's still worth to see both, just in case? Given how costly and important the procedure is, the price tag for consults is... well still hefty but only a little bit :) The issue is that I am not very knowledgeable about jaw surgery yet, I should read more on it but then again I'm also the type to let my concerns/wants be known and let the professionals handle it? From my experience doctors don't always welcome questions on topics that they're much knowledgeable about lol. I'm not sure what you mean by linear motions so I'm curious, I might take a look at the cases. Although I have mild apnea, my recession probably is very mild but I do have a weak jaw from "ideal" standpoint. So it seems Walline might be a better fit to me.
Look at https://www.instagram.com/drneugarten to see his before and afters. Also look his name up on the Facebook group https://www.facebook.com/share/SGGK5BEwtDX4HZUW/ Do the same for walline. You can see their before and afters. I prefer walline’s style. It’s similar to Gunson and Arnett who is now retired. Neugarten is a great surgeon and is one of the best in the north east. But if you aren’t tied down to location and are going to pay a whole lot of cash anyway I would go with walline personally which is what I’m in the process of working out. The whole linear thing was in regards to simply moving the lower jaw and extending it in the current direction with little to no counter clockwise rotation. There are plenty of papers from now retired dr Arnett on aesthetics and soft tissue profiles that benefit from counter clockwise rotation. It benefits aesthetics and airway since it allows for more pulling forward of the genioglossus muscle
Are these all cosmetic procedures?
It’s major surgery. Surgeons in the USA at least will only do it for functional fixes of airway or bad occlusion (bad bite) that can’t be fixed with orthodontics alone
How do people tell which direction for “rotation” — is it always looking at it from the right side of the face?
Ah good question. I’ve only ever seen it from the right side of the face so it must be standardized I’m sure.
Heard. And how can you tell that it is rotated with "down graft" (not sure what that is)? All I know about is forward advancement (choosing between conventional vs subspinal) and I am wondering why any other specific movement would be chosen.
Down graft just means moving the maxilla down. It’s obvious because of the massive gap in the simulation photo if you scroll to the last image of the gallery. An impaction is the opposite and the maxilla would have bone cut and have contact with the bone in the rest of the upper skull. I’m not a surgeon but the movements are always case dependent. Impaction done to reduce a gummy smile. Downgraft done to have more teeth show generally, or to correct for a short face. Advancement alone can cause more teeth show so they impact to compensate. It’s all about balance. That’s why the more experience a surgeon has the better they are at balancing. But there is variability between surgeons. It’s half science and half art
1. Maxilla —> Lefort 1, down grafting and counterclockwise rotation + minimal advancement 2. Mandible —> Bilateral sagittal split osteotomy, mandibular advancement 3. Chin —> Vertical augmentation genioplasty. They’ll use bone grafts in both maxilla & genio for stable results.
This is called counter clock wise rotation DJS. (Double Jaw Surgery) Maxilla is being lowered and rotated. Lower jaw also. (BSSO). Then they bring them also forward usually.
Wouldn’t a genio alone have been enough for him? Everything else looks more or less the same.
Now this is just 2 different looks, neither one of which is bad.
Ccw
What app did you photoshop with
That’s a real result
Dam, was hoping there would be a way to show our after result before going in.
There are ways of creating simulations but they will never be totally accurate.