jawsurgeryforums.com
General Category => Aesthetics => Topic started by: eranthe on February 13, 2018, 02:44:59 AM
-
Hi, first time poster.
I began with an acute Class II with VME. August 2014 I had a SARPE and October 2015 I had a Le Fort and BSSO which left me with good tooth-show and lip competency but a mid-line markedly off to the left, a deviated septum and crooked nose. In 2016 I had a revision Le Fort to try and centre the mid-line and straighten the nose. The surgery improved the mid-line position somewhat, however, for some reason my surgeon removed of a LOT of VME. This left me with noticeable mid-face deficiency so my mid-face appear short and flat, my nose is now too long and wide for my face (my surgeon does not use alar cinch), and I have zero tooth-show at rest and perhaps 2mm in a full smile (which will no doubt revert back to -2mm when the braces that are holding my top lip up are removed).
I realize aesthetic changes are to be expected (I had the surgery for sleep apnoea which has somewhat improved but not as much as I hoped as I don't feel my mandible was brought forward far enough to improve either breathing or profile), the combination of asymmetry, wider longer nose and lack of any tooth-show have made me look old, tired, toothless and angry and it has been extremely distressing. I feel sad every time I look in the mirror and have become depressed and anti-social. I realize attractiveness is subjective, but honest friends have confirmed the disappointing changes.
For the last year my surgeon has been trying to discourage me from a down-graft, pushing me towards plastic surgery. He has been focusing on the risks of down-grafting the maxilla (possible non-union; lack of blood supply to the face) and the negative affects (accompanying backward rotation of the mandible; relapse). Whilst I understand it is an inherently risky and notoriously unstable procedure, and whilst I am angry that I must now risk further backwards rotation of the mandible when it was not brought forward far enough originally, I just don't think a plastics approach will work. I feel as though a rhinoplasty and lip lift will concentrate my features in the centre of my face, further shorten my face, accentuate the asymmetry and leave me with lip incompetency and mentalis strain.
Finally in the last few days my surgeon has agreed to a revision down-graft in March. Whilst this is a relief, I'm now left feeling anxious about the potential risks of this surgery. So I'm hoping to connect with others who have undergone a down-graft (and also the harvesting procedure from the iliac crest which frightens me) who may be able to offer some honest insight into the procedure, recovery, risks, stability and (hopefully) achievements post-op. It would be great to hear/see some positive results from this procedure as my team have really been focusing on the neg aspects.
Thanks :)
-
You're screwed if you go back to your old doctor.
-
Hi, first time poster.
I began with an acute Class II with VME. August 2014 I had a SARPE and October 2015 I had a Le Fort and BSSO which left me with good tooth-show and lip competency but a mid-line markedly off to the left, a deviated septum and crooked nose. In 2016 I had a revision Le Fort to try and centre the mid-line and straighten the nose. The surgery improved the mid-line position somewhat, however, for some reason my surgeon removed of a LOT of VME. This left me with noticeable mid-face deficiency so my mid-face appear short and flat, my nose is now too long and wide for my face (my surgeon does not use alar cinch), and I have zero tooth-show at rest and perhaps 2mm in a full smile (which will no doubt revert back to -2mm when the braces that are holding my top lip up are removed).
I realize aesthetic changes are to be expected (I had the surgery for sleep apnoea which has somewhat improved but not as much as I hoped as I don't feel my mandible was brought forward far enough to improve either breathing or profile), the combination of asymmetry, wider longer nose and lack of any tooth-show have made me look old, tired, toothless and angry and it has been extremely distressing. I feel sad every time I look in the mirror and have become depressed and anti-social. I realize attractiveness is subjective, but honest friends have confirmed the disappointing changes.
For the last year my surgeon has been trying to discourage me from a down-graft, pushing me towards plastic surgery. He has been focusing on the risks of down-grafting the maxilla (possible non-union; lack of blood supply to the face) and the negative affects (accompanying backward rotation of the mandible; relapse). Whilst I understand it is an inherently risky and notoriously unstable procedure, and whilst I am angry that I must now risk further backwards rotation of the mandible when it was not brought forward far enough originally, I just don't think a plastics approach will work. I feel as though a rhinoplasty and lip lift will concentrate my features in the centre of my face, further shorten my face, accentuate the asymmetry and leave me with lip incompetency and mentalis strain.
Finally in the last few days my surgeon has agreed to a revision down-graft in March. Whilst this is a relief, I'm now left feeling anxious about the potential risks of this surgery. So I'm hoping to connect with others who have undergone a down-graft (and also the harvesting procedure from the iliac crest which frightens me) who may be able to offer some honest insight into the procedure, recovery, risks, stability and (hopefully) achievements post-op. It would be great to hear/see some positive results from this procedure as my team have really been focusing on the neg aspects.
Thanks :)
If the salient problem is lack of upper tooth show, it does seem TOO MUCH (pain, suffering and risk) to get yet another maxfax surgery where as a LL will give you more tooth show. A lip lift is not going to leave you with lip incompetency and mentalis strain.
-
Hi eranthe.
Ditterbo is absolutely right.
I've seen different surgeons, an several times a downgraft was offered to me. Nobody told me about the risk of instability.
Maybe you're a difficult case, regarding your past jaw surgeries.
Or, your surgeon has not enough skills to do this, which is possible because he has already botched you.
How much mm downgraft to you need ?
My advice is to have at least 2 others surgeons'opinion.
-
Is a downgrafting inherently more risky than other bone cutting surgeries??
Dr defranq seems to have a number of examples on his website, you may want to talk with him.
-
Thanks for the replies.
Ditterbo I'm screwed either way. I'm a public patient who had this surgery for functional reasons (breathing and sleep apnea). My treating hospital is based on my residential postcode, and my surgeon is the head of maxfac at that hospital. I simply don't have the money to pay for revision surgery privately with a new surgeon.
Kavan whilst the salient problem is tooth-show, my occlusion also feels awkward and constricted since the revision lefort when I was further impacted. I suspect he also did some degree of CCW rotation as my upper teeth are now very upright and seem to rest in mid air when my mouth is closed (as in my teeth don't meet). When I bite it feels as though I have to raise my lower teeth quite a bit to make contact, and when I do my top teeth sit on top of my bottom teeth, rather than sliding over them comfortably. I have to almost retract my mandible slightly to allow my upper teeth to slide over the lower teeth.
In relation to the rhinoplasty/lip lift option (which I would love to be able to opt for), when I lift my top lip up even a couple of mm's to mimic the subtlest lip lift, I have to force my lower lip up to meet my top lip, it forces my lips into a downward grimace and causes my chin to dimple. As it is, after all these surgeries, I sleep with my mouth hanging open. Also, these surgeries have left me with asymmetry and I have lost a LOT of mid-face length ... a shorter face accentuates those asymmetries.
Framboise, yes I know Ditterbo is right ... but I have no other options but to stay like this or trust that my surgeon gets it right this time. If I had money I would be taking Italias advice and flying to Dr Defranq (I'm in Australia) :) During a frank conversation, my surgeon admitted it was a suboptimal aesthetic outcome and noted that he was more of a functional surgeon and would like to involve the hospitals plastics team this time around to help with aesthetic elements etc so maybe that will help. I do sense he feels a little out of his depth with my case.
Italia, is down-grafting inherently more risky? I really don't know, that is what I am here to research. This is what my surgeon and team are telling me, but I also suspect they are trying to steer me in the direction of plastic surgery as this is all a bit of a headache for them now. As you say, there are examples of down-grafting on many websites, so people must be having them successfully - and I'd love to find those people. I just want to make a sensible and informed decision based on what is right for me, not what is convenient for my surgeon. Things might be crap now, but they will be a whole lot crapper if I end up with a bad plastic surgery outcome on top of all this ...
-
Sorry to hear about your dissatisfaction with your jaw surgeries :( I can empathize with having high expectations pre-surgery that were not met.
Has anyone here had surgery with Dr Defranq? Is it more affordable to have surgery done in Europe?
-
Thanks, although I don't think I had unrealistically high expectations. There are fairly standardized facial esthetic parameters ... what I have been left could have been avoided.
-
Thanks for the replies.
Ditterbo I'm screwed either way. I'm a public patient who had this surgery for functional reasons (breathing and sleep apnea). My treating hospital is based on my residential postcode, and my surgeon is the head of maxfac at that hospital. I simply don't have the money to pay for revision surgery privately with a new surgeon.
Kavan whilst the salient problem is tooth-show, my occlusion also feels awkward and constricted since the revision lefort when I was further impacted. I suspect he also did some degree of CCW rotation as my upper teeth are now very upright and seem to rest in mid air when my mouth is closed (as in my teeth don't meet). When I bite it feels as though I have to raise my lower teeth quite a bit to make contact, and when I do my top teeth sit on top of my bottom teeth, rather than sliding over them comfortably. I have to almost retract my mandible slightly to allow my upper teeth to slide over the lower teeth.
In relation to the rhinoplasty/lip lift option (which I would love to be able to opt for), when I lift my top lip up even a couple of mm's to mimic the subtlest lip lift, I have to force my lower lip up to meet my top lip, it forces my lips into a downward grimace and causes my chin to dimple. As it is, after all these surgeries, I sleep with my mouth hanging open. Also, these surgeries have left me with asymmetry and I have lost a LOT of mid-face length ... a shorter face accentuates those asymmetries.
Framboise, yes I know Ditterbo is right ... but I have no other options but to stay like this or trust that my surgeon gets it right this time. If I had money I would be taking Italias advice and flying to Dr Defranq (I'm in Australia) :) During a frank conversation, my surgeon admitted it was a suboptimal aesthetic outcome and noted that he was more of a functional surgeon and would like to involve the hospitals plastics team this time around to help with aesthetic elements etc so maybe that will help. I do sense he feels a little out of his depth with my case.
Italia, is down-grafting inherently more risky? I really don't know, that is what I am here to research. This is what my surgeon and team are telling me, but I also suspect they are trying to steer me in the direction of plastic surgery as this is all a bit of a headache for them now. As you say, there are examples of down-grafting on many websites, so people must be having them successfully - and I'd love to find those people. I just want to make a sensible and informed decision based on what is right for me, not what is convenient for my surgeon. Things might be crap now, but they will be a whole lot crapper if I end up with a bad plastic surgery outcome on top of all this ...
Well, having a lip lift would not result in (lower) lip incompetence which is what you are describing. But it does sound that if you have to force your lower lip to meet your upper lip, you ALREADY have lip incompetence. That's a function of how the chin lines up with the lower lip. Shortest path is close to a straight vertical line such that a vertical line dropped from lower lip has the chin close to it and NOT too diaganally oriented behind or forward to that imaginary line.
Since one of your problems is you feel your lower jaw was not brought forward enough, it would follow your chin might be too far back, especially coupled with the complaint of lip incompetence and NO MENTION of genioplasty with either of your surgeries.
BASED on your descriptions, it sounds like an advancement genioplasty would help and also allow for the lip lift. Perhaps explore that option. Also ask if having veneers to lengthen the teeth is an option to compensate for the 2ncd revision surgery which left you with little tooths show.
It kind of sounds like your maxfax hesitates to do a 3rd cut through the maxilla but is SHIFTING all the risk to the act of getting a down graft. In terms of people who do get downgrafts, WHEN DONE by docs who are good at doing them, they can be stable.
I don't think the real issue here is 'stability of a downgraft'. I think it's more of a matter of a 3RD CUT to the maxilla whether or not it's for a downgraft.
-
Kavan,
I'm not sure a new BBSO would solve the problem since
I have to almost retract my mandible slightly to allow my upper teeth to slide over the lower teeth.
Isn't rather the upper jaw which is not long enough ?
The problem with the lips seems contradictory though....
I believe that lip incompetency is due to the maxillary which has lost his vertical dimension.
Facelift dentistery costs an arm ( french expression sorry) and it's not certain that it would change something to lip position. But maybe I'm wrong... If good results are possible, you have to beable to pay 10 000 dollars at least. (I had a proposal for that)
Eranthe, I don't know if your bones can endure a third surgery and Kavan's advices are relevant regarding to this aspect.
I'm in a difficult situation too, and I need a down graft but I'm taking my time because a bad surgery can worsen things.
PS : I saw Defrancg and he is the best so far (th most human and he listens !!!) I've chatted with a guy who have had a revision surgery with him and he is satisfied
-
Kavan,
I'm not sure a new BBSO would solve the problem since ...
Well, I didn't say it would.
Isn't rather the upper jaw which is not long enough ?
OP is saying too much removed in revision surgery which resulted in lack of tooth show.
The problem with the lips seems contradictory though....
I believe that lip incompetency is due to the maxillary which has lost his vertical dimension.
Lip incompetency is basically from straining the chin muscle when lifting up the lower lip. It does not arise from a short maxilla. It arises from the orientation of the chin bone relative to the lower lip. I explained that in my post.
Facelift dentistery costs an arm ( french expression sorry) and it's not certain that it would change something to lip position. But maybe I'm wrong... If good results are possible, you have to beable to pay 10 000 dollars at least. (I had a proposal for that)
Not sure where 'face lift dentistry' comes in here. Having the upper teeth elongated for more tooth show is not defacto 'face lift dentistry'.
Eranthe, I don't know if your bones can endure a third surgery and Kavan's advices are relevant regarding to this aspect.
Perhaps there are language difficulties in recognizing the relevance of the rest of it? None the less, the OP would be better served by looking for feedback from people who have had their maxilla cut into 3X to see how that worked out for them.
I'm in a difficult situation too, and I need a down graft but I'm taking my time because a bad surgery can worsen things.
PS : I saw Defrancg and he is the best so far (th most human and he listens !!!) I've chatted with a guy who have had a revision surgery with him and he is satisfied
Yes. Good idea to take one's time.
-
Kavan : :D Yeah sometimes I misunderstood stuffs !
Well, I talked about facelift dentistery because it functions with veneers helping to restaure the vertical dimension. It's not just mere veneers aiming at lenghtening teeth, it also reestablishes a good occlusion. As eranthe was descibing issues with his occlusion, I thought you were talking about that.
Since one of your problems is you feel your lower jaw was not brought forward enough
...
indeed you talk about a genio just after and not a bsso.
I didn't know that genio had a function, I thought it was just something do for aesthetical reasons.
(In my case, one surgeon told me that my chin should me moved backward while another said it should be moved forward after surgery.... So I'm a little confused about that, still don't know what's the point. But that's another subject.)
Anyway, I'm sorry for you eranthe and I hope you will find a solution
-
Kavan : :D Yeah sometimes I misunderstood stuffs !
Well, I talked about facelift dentistery because it functions with veneers helping to restaure the vertical dimension. It's not just mere veneers aiming at lenghtening teeth, it also reestablishes a good occlusion. As eranthe was descibing issues with his occlusion, I thought you were talking about that.
...
indeed you talk about a genio just after and not a bsso.
I didn't know that genio had a function, I thought it was just something do for aesthetical reasons.
(In my case, one surgeon told me that my chin should me moved backward while another said it should be moved forward after surgery.... So I'm a little confused about that, still don't know what's the point. But that's another subject.)
Anyway, I'm sorry for you eranthe and I hope you will find a solution
No problem. Hope I explained some stuff.
-
If your doctor screwed up the first time to the extent you described, and you have no other doctor choices, you're probably better off doing nothing at all from a max facs perspective.
-
If your bite fits (and maybe even if it doesn't), you may have trouble finding another surgeon in Australia to revise your surgery. "Go back to your surgeon" is the standard answer. Directing you to plastic surgeons after your surgery is also the norm. IOTW, standard procedure in Australia is:
* Withhold information (detailed surgical plans, even cephs) - a good patient is an ignorant one. Say something in passing about potential permanent numbness (it'll certainly be in the consent form), but certainly say nothing about potential aesthetic downsides. "Anything I'll do is an improvement" is implied.
* Make the bite fit with the simplest laziest surgery possible - no down grafting ("it's unstable!", although some will do down grafting for short face syndromes), certainly no CCW rotation with posterior down grafting. I have not seen your pre-op ceph, but I suspect you probably should have had less anterior impaction and some posterior down grafting to affect the same amount of CCW... But when all you have is a hammer impaction in your toolbox, you tend to overuse it. Steep occlusal planes are hard to make look good (even more so when there is no gummy smile, so there is nothing to impact). AFAIK, no surgeon in Australia will do CCW with posterior down grafting.
* Deny that any aesthetic issues may have been caused by their surgery - "wait till the swelling comes down", etc., etc..
* Tell you to see a plastic surgeon. "The things you're complaining about were pre-existing and unaffected by my surgery" is implied.
If you show your lower teeth when talking, you will probably end up with lip incompetence after a lip lift.
-
Kavan : :D Yeah sometimes I misunderstood stuffs !
Well, I talked about facelift dentistery because it functions with veneers helping to restaure the vertical dimension. It's not just mere veneers aiming at lenghtening teeth, it also reestablishes a good occlusion. As eranthe was descibing issues with his occlusion, I thought you were talking about that.
...
indeed you talk about a genio just after and not a bsso.
I didn't know that genio had a function, I thought it was just something do for aesthetical reasons.
(In my case, one surgeon told me that my chin should me moved backward while another said it should be moved forward after surgery.... So I'm a little confused about that, still don't know what's the point. But that's another subject.)
Anyway, I'm sorry for you eranthe and I hope you will find a solution
I made the mistake of putting 10 veneers on my upper. To compensate for long upper lip and mild short maxilla/cant etc, I got Gary Busey like choppers, ended up hating them. I'm going to eventually replace them and go through with lefort 3 piece downgraft.. Makes me nervous though, I also keep reading about stability issues. Veneers can be tricky (hella expensive to get wrong). I paid nearly 18 g when said and done.
-
If your bite fits (and maybe even if it doesn't), you may have trouble finding another surgeon in Australia to revise your surgery. "Go back to your surgeon" is the standard answer. Directing you to plastic surgeons after your surgery is also the norm. IOTW, standard procedure in Australia is:
* Withhold information (detailed surgical plans, even cephs) - a good patient is an ignorant one. Say something in passing about potential permanent numbness (it'll certainly be in the consent form), but certainly say nothing about potential aesthetic downsides. "Anything I'll do is an improvement" is implied.
* Make the bite fit with the simplest laziest surgery possible - no down grafting ("it's unstable!", although some will do down grafting for short face syndromes), certainly no CCW rotation with posterior down grafting. I have not seen your pre-op ceph, but I suspect you probably should have had less anterior impaction and some posterior down grafting to affect the same amount of CCW... But when all you have is a hammer impaction in your toolbox, you tend to overuse it. Steep occlusal planes are hard to make look good (even more so when there is no gummy smile, so there is nothing to impact). AFAIK, no surgeon in Australia will do CCW with posterior down grafting.
* Deny that any aesthetic issues may have been caused by their surgery - "wait till the swelling comes down", etc., etc..
* Tell you to see a plastic surgeon. "The things you're complaining about were pre-existing and unaffected by my surgery" is implied.
If you show your lower teeth when talking, you will probably end up with lip incompetence after a lip lift.
Yep that pretty much covers it Plosko! Incredible ... your points describe my experience to a T! I take it you're in Aus then? :)
-
Yep that pretty much covers it Plosko! Incredible ... your points describe my experience to a T! I take it you're in Aus then? :)
Yes. There is a member here who tried to talk me out of having surgery in Australia (I could afford any surgeon back then). I didn't listen. Having surgery by "one of the best surgeons in Australia" was a terrible mistake.
-
Well, having a lip lift would not result in (lower) lip incompetence which is what you are describing. But it does sound that if you have to force your lower lip to meet your upper lip, you ALREADY have lip incompetence. That's a function of how the chin lines up with the lower lip. Shortest path is close to a straight vertical line such that a vertical line dropped from lower lip has the chin close to it and NOT too diaganally oriented behind or forward to that imaginary line.
Since one of your problems is you feel your lower jaw was not brought forward enough, it would follow your chin might be too far back, especially coupled with the complaint of lip incompetence and NO MENTION of genioplasty with either of your surgeries.
BASED on your descriptions, it sounds like an advancement genioplasty would help and also allow for the lip lift. Perhaps explore that option. Also ask if having veneers to lengthen the teeth is an option to compensate for the 2ncd revision surgery which left you with little tooths show.
It kind of sounds like your maxfax hesitates to do a 3rd cut through the maxilla but is SHIFTING all the risk to the act of getting a down graft. In terms of people who do get downgrafts, WHEN DONE by docs who are good at doing them, they can be stable.
I don't think the real issue here is 'stability of a downgraft'. I think it's more of a matter of a 3RD CUT to the maxilla whether or not it's for a downgraft.
Kavan, please forgive my delayed reply.
It's really interesting that you suggested I may already have lip incompetence. TBH I didn't think that I did, however, a few weeks ago my surgeon asked me to stop wearing elastics (as we had done the pre-operative radiology and he didn't want any further dental movements to happen between now and the revision surgery). Since I've stopped sleeping with elastics (which were holding my mandible forward) I have found it impossible to keep my mouth closed when I lie down to sleep. I have also started snoring again and waking up with a sore throat, dry mouth and dried-out sinuses. I'm also having nightmares where I wake up choking again and I'm tired all the time. This is absolutely devastating for me as the sleep apnea was the reason I had this surgery in the first place. I seemed to be sleeping and breathing quite well after the original bi-max surgery, but since the revision Lefort where my maxilla was further impacted, all the old symptoms seem to have returned. I always thought the position of the mandible was responsible for my sleep apnea as I could clearly feel it collapse on my airway when I lay down on my back (and you could see the narrowing of my airways on xray), but now I'm wondering just how much the position of the maxilla also affects breathing and whether that revision maxillary impaction has made my breathing worse again.
As I feel my mandible was not brought forward far enough in the bi-max (and no, I've not had a genio), I'm now wondering if I should be considering a maxillary advancement (without the down-graft), and an advancement genio - that way I would be doing all I could to protect my airway? The only problem with that is that I've lost so much mid-face length that my face is now quite short and square and flat looking - that makes me a bit scared to lengthen my chin. I wish there was some way of knowing the aesthetic outcome of those movements prior to surgery ...
-
Kavan, please forgive my delayed reply.
It's really interesting that you suggested I may already have lip incompetence. TBH I didn't think that I did, however, a few weeks ago my surgeon asked me to stop wearing elastics (as we had done the pre-operative radiology and he didn't want any further dental movements to happen between now and the revision surgery). Since I've stopped sleeping with elastics (which were holding my mandible forward) I have found it impossible to keep my mouth closed when I lie down to sleep. I have also started snoring again and waking up with a sore throat, dry mouth and dried-out sinuses. I'm also having nightmares where I wake up choking again and I'm tired all the time. This is absolutely devastating for me as the sleep apnea was the reason I had this surgery in the first place. I seemed to be sleeping and breathing quite well after the original bi-max surgery, but since the revision Lefort where my maxilla was further impacted, all the old symptoms seem to have returned. I always thought the position of the mandible was responsible for my sleep apnea as I could clearly feel it collapse on my airway when I lay down on my back (and you could see the narrowing of my airways on xray), but now I'm wondering just how much the position of the maxilla also affects breathing and whether that revision maxillary impaction has made my breathing worse again.
As I feel my mandible was not brought forward far enough in the bi-max (and no, I've not had a genio), I'm now wondering if I should be considering a maxillary advancement (without the down-graft), and an advancement genio - that way I would be doing all I could to protect my airway? The only problem with that is that I've lost so much mid-face length that my face is now quite short and square and flat looking - that makes me a bit scared to lengthen my chin. I wish there was some way of knowing the aesthetic outcome of those movements prior to surgery ...
Lip incompetence is associated with chin position.
-
Risk and stability of down graft is like risk and stability of SKIING.
First you want to know IF the person is actually a skier.
Then you want to know how good of skier they are as to master steep and slippery slopes.
Moral of story is that the risks and stability will depend on who's doing it and whether or not they are good at doing it. In your case revision surgery.
-
Risk and stability of down graft is like risk and stability of SKIING.
First you want to know IF the person is actually a skier.
Then you want to know how good of skier they are as to master steep and slippery slopes.
Moral of story is that the risks and stability will depend on who's doing it and whether or not they are good at doing it. In your case revision surgery.
Good analogy.. So, kavan, who's the best skier you know of?
-
Good analogy.. So, kavan, who's the best skier you know of?
I guess those who make the Olympic team.
-
Probably Wolford because he does so many.
-
Bit of an update!
A colleague recently invited me for dinner to meet a friend of his - a semi-retired Professor of Maxfac who taught at one of our top Universities for many years. He has been living and practicing in Asia for years but is still maintains connections here. I showed him my radiology, before and after photographs and took him through the last five years of my treatment. He agreed that, whilst it was 'good surgery generally', it was a poor aesthetic result. He said something along the lines of "originally I'd planned to advise you today against further surgery, but after meeting you and hearing you speak, and after seeing your before and after photographs, it's pretty clear that you will never be happy trying to live with this result - therefore I think the potential benefit is worth the risk in your case. He then said that another reason he changed his original position was that he had worked out who had done my surgery whilst we were talking (as I had mentioned the hospital where I'd had my surgery). He told me that my surgeon is extremely highly regarded and reassured me that, if I were to proceed with such delicate surgery, then my surgeon really was the ONLY person he would recommend to do it (no they are not friends, although they have met on occasion, he is just aware of him professionally)! However, he also agreed that surgeons who do a lot of trauma work can sometimes develop a blunted aesthetic over time and noted that my surgery - whilst good in functional terms, was not a good aesthetic outcome. He advised me to go back to my surgeon with very specific instructions "just go back and tell him what you want him to do - be specific. If anyone can do it, he can!"
A couple of days later, I met with my surgeon and he appeared to have a renewed sense of enthusiasm about my case. It seems as though he has accepted the situation and stopped trying to talk me out of surgery and is now directing that energy towards looking for new approaches and workarounds. He seemed enthusiastic! He mentioned that this time he would be using Patient Specific Implants, saying that he felt this new technology would be extremely helpful with my case and arranged my workup with the registrar. A few days after that, I met my new registrar for this year - a lovely woman!!! (the first female registrar I've ever seen in the maxfac clinic in over five years) who wants to specialize in cosmetic max-fac surgery. She was kind, whip smart, extremely thorough and spent THREE AND A HALF HOURS with me looking at radiology and old photos and asking me what I disliked about my face and function! Whilst my surgeon will be performing the actual surgery, she will help me in terms of examining the realms of possibility in terms of what I hope to achieve. I really look forward to working with her!
I'm booked in for plate removal surgery next Monday 6th (as we will need 3 months healing time after that), and jaw surgery in June. I am hoping that now - with my new registrars interest in aesthetics, my surgeons confirmed expertise (which has renewed my confidence in him) and this new technology - along with the knowledge and support I receive from you guys here - I may actually have a fighting chance at a good outcome this year!
All appendages crossed etc :)
-
It kind of sounds like your maxfax hesitates to do a 3rd cut through the maxilla but is SHIFTING all the risk to the act of getting a down graft. In terms of people who do get downgrafts, WHEN DONE by docs who are good at doing them, they can be stable.
I don't think the real issue here is 'stability of a downgraft'. I think it's more of a matter of a 3RD CUT to the maxilla whether or not it's for a downgraft.
Kavan, could you possibly explain the specific danger in re-cutting the maxilla for a 3rd time please? In my mind, during each revision surgery I imagine they re-cut through the previous cut-line, debride the area and then re-plate (I know they also made a platelet rich plasma paste with my blood to apply to the area during my last revision also). Obviously I know nothing at all about surgical techniques, but is there a specific reason why a 3RD CUT through the maxilla is inherently more dangerous than a 1st or 2nd cut (also, including the SARME surgery this will be my 4th cut). Instinctively I understand that the more surgeries one has in any area of the body, the weaker that area becomes and thus the more potential for issues, but is there something specific to the maxilla that I need to understand about this? Until your comment, I was focusing my concern on the stability of the graft post-surgery, not so much the cut. Many thanks to you as always.
-
Kavan, could you possibly explain the specific danger in re-cutting the maxilla for a 3rd time please? In my mind, during each revision surgery I imagine they re-cut through the previous cut-line, debride the area and then re-plate (I know they also made a platelet rich plasma paste with my blood to apply to the area during my last revision also). Obviously I know nothing at all about surgical techniques, but is there a specific reason why a 3RD CUT through the maxilla is inherently more dangerous than a 1st or 2nd cut (also, including the SARME surgery this will be my 4th cut). Instinctively I understand that the more surgeries one has in any area of the body, the weaker that area becomes and thus the more potential for issues, but is there something specific to the maxilla that I need to understand about this? Until your comment, I was focusing my concern on the stability of the graft post-surgery, not so much the cut. Many thanks to you as always.
No. Because I'm not your doctor and also because my statement was that I thought it 'sounded like' (seemed like to me) that your doctor was shifting (the mention of risk) to just the act of a down graft when the salient circumstance also included a 3RD time cut.
If I've said anything that you feel needs surgical descriptions of the techniques used to lower your risks of a 3rd surgery, it would be in the spirit of you're inquiring further to the surgeon who would be in a better capacity to explain/tutor if that's what you need to make your decision.
-
Thanks Kavan, so just to clarify, are you saying that there are two separate areas of potential risk: the re-cutting and subsequent healing of bones and soft-tissue AND the possibility of a failed down-grafting procedure, and that my surgeon is possibly confounding the two but shifting the main focus onto the latter?
-
The risk of a down graft is a function of the capacity of the doctor doing it. Risks are lower with doctors who have experience enough to be more successful with them. There are also risks involved with multiple surgeries to similar areas. In your case, you're getting a surgery to a similar area you've had prior and getting that for a down graft. I can't tell you what your specific risk factors are or how they relate to the capacity of your surgeon. I'm just saying is these are things you should explore further with the doctors advising you.
You have more information about your situation than I do. You also have access to the professor you mentioned in another post who has viewd your medical file in addition to the attending surgeon. I'm suggesting you explore what ever your risk is WITH those doctors. You relay one of them who viewed your case told you the risk was worth it. What did he tell you the risk was?
-
Thanks for the clarification Kavan. Before I go on, I just want to thank your for all the time and effort you dedicate to responding to these questions! It's extraordinarily generous work that you do here and I am very greatful for it!
After speaking with the professor, I felt reassured in terms of the 'capacity of the doctor doing it'. It is the risk with multiple surgeries that I am now trying to unpack and examine.
You relay one of them who viewed your case told you the risk was worth it. What did he tell you the risk was?
Thanks for this question as it prompted me to go back over my shorthand notes. Initially on the phone the Prof said "based on what you've told me I don't like the idea, you've already had a downward fracture of the maxilla and that cut off all the blood supply to the face (except for the greater palatine artery?), then they've gone in again to do the bimax, so they've cut the blood supply off again, that's twice! Then they've gone in a third time! Every time they do it, you're getting more and more fibrous tissue and less and less chance of healing".
However after we met in person the following day and talked for a couple of hours, and he had a chance to look at my pre and post surgery photographs, he changed his tune and said "oh yeah ... that is an extremely disappointing result. After meeting you and watching you speak, I think there is good reason to do it and your surgeon really is the best person to do it. He's given you a good functional result, but it's not at all what you would want ... anyway the new 3D technology will give you a much more predictable result. I'd say go for it ... you'll never be happy if you don't give it a try, I can tell that just by talking to you!" (verbatim)
So I guess this is why I'm still searching for additional opinions/advice ... my surgeon was strongly opposed to the idea of this revision for a long time, focusing on the risks ... however, he is now 'on-board'. Likewise the Prof. began with a conservative view in theory but changed it when he met me. Because both doctors initially expressed reservations, it's left me with some residual uncertainty I guess.
-
Thanks for the clarification Kavan. Before I go on, I just want to thank your for all the time and effort you dedicate to responding to these questions! It's extraordinarily generous work that you do here and I am very greatful for it!
After speaking with the professor, I felt reassured in terms of the 'capacity of the doctor doing it'. It is the risk with multiple surgeries that I am now trying to unpack and examine.
Thanks for this question as it prompted me to go back over my shorthand notes. Initially on the phone the Prof said "based on what you've told me I don't like the idea, you've already had a downward fracture of the maxilla and that cut off all the blood supply to the face (except for the greater palatine artery?), then they've gone in again to do the bimax, so they've cut the blood supply off again, that's twice! Then they've gone in a third time! Every time they do it, you're getting more and more fibrous tissue and less and less chance of healing".
However after we met in person the following day and talked for a couple of hours, and he had a chance to look at my pre and post surgery photographs, he changed his tune and said "oh yeah ... that is an extremely disappointing result. After meeting you and watching you speak, I think there is good reason to do it and your surgeon really is the best person to do it. He's given you a good functional result, but it's not at all what you would want ... anyway the new 3D technology will give you a much more predictable result. I'd say go for it ... you'll never be happy if you don't give it a try, I can tell that just by talking to you!" (verbatim)
So I guess this is why I'm still searching for additional opinions/advice ... my surgeon was strongly opposed to the idea of this revision for a long time, focusing on the risks ... however, he is now 'on-board'. Likewise the Prof. began with a conservative view in theory but changed it when he met me. Because both doctors initially expressed reservations, it's left me with some residual uncertainty I guess.
Well, he gave you a good explanation as to the risk. Sounds like they both know you want it and it might be worth taking the risk and also the doctor is going to try to negotiate the risks to find a way to work around them. (like on a steep ski slope)
-
He's had 2 goes at it. I think that's enough. Especially considering that he has no experience with virtual surgery planning or downgrafts. It almost sounds like you'll be his first patient on whom he will try these. Before I had my surgery I got cold feet and consulted with another surgeon, who did nothing but praise my originally chosen surgeon. So I stuck with the "best guy in the state", who then proceeded with the laziest, sloppiest surgery possible. BTW, he too does not believe in downgrafts and doesn't use 'computers'. That old semi-retired guy simply had nothing to lose by recommending you to go back to your original surgeon (BTW, was the old guy's name David David?) It's not like he has to live with the consequences. Professionals like to praise their alumni. Unfortunately max fac surgery in Australia is bush league. So it's just one bush league champion praising another.
I think the real reason why he "wants to have another go" is that your bite may be off. When I consulted with my butcher he got more and more weary and irritated by my constant questioning, especially regarding the aesthetic consequences of the surgery and blurted out "at least you'll have a good bite". That pretty much distils the "philosophy" of Australian surgeons - "it's a bite fixing operation". To them we're just meat bags with dental arches to be matched. The bite is the only obligation they think they have towards us, nothing else - not tooth show, not symmetry, not facial balance, nothing else.
-
He's had 2 goes at it. I think that's enough. Especially considering that he has no experience with virtual surgery planning or downgrafts. It almost sounds like you'll be his first patient on whom he will try these. Before I had my surgery I got cold feet and consulted with another surgeon, who did nothing but praise my originally chosen surgeon. So I stuck with the "best guy in the state", who then proceeded with the laziest, sloppiest surgery possible. BTW, he too does not believe in downgrafts and doesn't use 'computers'. That old semi-retired guy simply had nothing to lose by recommending you to go back to your original surgeon (BTW, was the old guy's name David David?) It's not like he has to live with the consequences. Professionals like to praise their alumni. Unfortunately max fac surgery in Australia is bush league. So it's just one bush league champion praising another.
I think the real reason why he "wants to have another go" is that your bite may be off. When I consulted with my butcher he got more and more weary and irritated by my constant questioning, especially regarding the aesthetic consequences of the surgery and blurted out "at least you'll have a good bite". That pretty much distils the "philosophy" of Australian surgeons - "it's a bite fixing operation". To them we're just meat bags with dental arches to be matched. The bite is the only obligation they think they have towards us, nothing else - not tooth show, not symmetry, not facial balance, nothing else.
Hey Plosko, sorry for the delayed reply. I had my plates and screws removed on Monday and the GA really knocked me around this week (took me 3 hours to wake up in recovery and I've been weak and exhausted all week - but surgery went well). Yeah I've had all the same thoughts you have mentioned (and no the guy I spoke to wasn't David David). Well I guess I have three months up my sleeve now whilst I wait for the old plate holes to heal up ... lot's of time for thinking ...