Very often, I have new patients who ask me what surgery I think they need before even telling me what aspect of their face is bothering them. Some of these patients have been told by their friends many times over that their jaw is too long, too short, too crooked, etc, and they assume that it is pretty obvious that they need surgery. Hence, they skip everything else and get on with the question of what surgery, rather than if surgery is needed. There are others who are not happy with the way they look but can't quite put on figure on where the problem lies and are pretty sure that some kind of surgery can help them solve their problem.
At that point, I have to stop them from putting the cart before the horse and get back to the fundamental question of what they are not happy about
Some patients have obvious dentofacial deformities. For example, the most commonly sought after orthognathic surgery is shortening of a long lower jaw, commonly referred to as an underbite. However, there are different degrees of underbite, some may be very mild, perhaps not noticeable until careful observation, while others may have a lower jaw that is so long that they have difficulty chewing. These are primarily discrepancies in the horizontal dimensions of the jaw. Our facial bones are 3 dimensional structures and discrepancies can occur in all three directions and to different degrees.
What the patient perceives
The primary concern of the patient is the most important. If the patient cannot state clearly what is bothering him, a diagnosis cannot be made and no treatment plan can be formulated. Sometimes, patients are unable to articulate their own needs and desires and some discussion and questioning is needed to coax them to open up. This is critical as you cannot solve a problem that you have not identified.
What the surgeon finds
After understanding what the patient wants changed, I will do an aesthetic facial assessment. At this stage, I will assess the things like facial symmetry and proportion. I will also assess the lower one third of the face when the patient is smiling as well as when not smiling. Intraoral examination is also needed to determine the bite and alignment of the teeth. Radiographic assessment is also done at this stage. From this assessment, a diagnosis of the facial aesthetic will be made. This is then correlated with the patient's own perceived aesthetic flaws.
Once a diagnosis is made, a few treatment options are discussed with the patient. The use of computer-simulation of postoperative facial appearance helps tremendously as a communication tool. However, do bear in mind that computer simulated appearance is not always accurate, especially if the degree of change needed is minor. Nonetheless, because the various treatment options can be simulated live with the patient's input, I get to understand the patient's own aesthetic sense. Those cases whereby there is a huge functional discrepancies are the easiest to plan as the need and desire is obvious. However, increasingly, I am getting patients who desire relatively minor changes in facial aesthetics that though minor, cannot be achieved through non-surgical means. These are the cases whereby repeat consultations and discussions are often need to ensure that the patient is absolutely sure of what he wants. Patients with borderline dentofacial deformities often change their perception of what they want and proceeding with surgery for this group would lead to dissatisfactory results. For this group, I will only proceed with surgery if the patient is consistent in articulating what he wants over three or four different visits.
Beauty lies in the eye of the beholder
I almost never answer a patient's question of what surgery I think he or she needs. I don't suggest to patients what I think is not aesthetically optimal to patients without them articulating their own perception first. Very often, my own aesthetic sense may be significantly different from the patient and I take great pains to avoid planning the surgery to fit my personal taste. This is the most important part of the diagnostic workup for this is the goal setting phase. If a wrong goal is set, even if the surgery is done perfectly, the results will still be wrong.