Author Topic: So....how did my surgeon do?  (Read 2838 times)

Dharma

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So....how did my surgeon do?
« on: April 22, 2016, 09:46:54 PM »
So I'm ~4 week out from MMA for sleep apnea.  I'm an healthy athletic male in my mid 30s who was in an accident when I was young resulting in a broken jaw which didn't grow correctly. 

In an attempt to avoid MMA, my surgeon performed a 10mm genioglossal advancement 2 years ago which, actually, did the trick but my tissues grew slack and my apnea returned. It was time for MMA.   

~4 weeks ago he moved both jaws about 10mm forward with CCW (incisors up about 3mm from molars). 

At this point, I look pretty terrible.  I was a decent looking guy before the surgery but I've got a pretty solid monkey-pig thing going now--devastating....

My surgeon has acknowledged my concerns and actually offered to go back in (in a few days) and "shave my maxilla" down about 4-5mm posterior.  He is hoping that this will attenuate my strong mesognathic projection as well as lower my nose tip.  He is also going to narrow/reduce my alar base.

To add insult to injury, it appears that the stretch of the advancement has resulted in some degree of chin ptosis--my mentalis and chin fat pad sort of sit just at the tip of my chin bone and any facial movement causes it to shift below.  He is willing to go in an address this is about a month pending my recovery from the maxilla shave in a few days.   

I really feel like I needed more CCW/midface impaction.  I have somewhat scalloped midface/cheekbones already and the advancement of the lower third of my face exacerbated the situation.  When we had modeling done, it did not appear to affect things that much--soft tissue is, apparently, very unpredictable.  Though this surgery was functionally successful (my airway went from 2-3mm to ~11 or close), I think I would have rather wrestled with CPAP for 1000 years than look like I do. 

I think I may need either a revision or some serious plastic surgery to look normal again.  Being a young bachelor and professional, I kind of needed my face...

It appears that many of you on this forum know a great deal about things--I've learned a lot. 

With that said, here are some images--I would really really appreciate any thoughts/advice/rude comments or anything else you'd like to send my way.  Particularly, I'd be interested in your thoughts on whether the MMA could have been done is such a way as to improve the esthetic outcome.  Additionally, any thoughts on the maxilla shaving and chin ptosis?  Lastly, I'm thinking I may need cheek implants or something to further attenuate the look I have going on.  My right mandible is significantly hypoplastic d/t the accident--might need a mandibular implant. Thoughts?

Note that the chin ptosis is not evident in the image below because I had not been put in tight elastics yet (that happend around week two which pulled my mandible forward and thats when things went south--pun intended).  Also, you have to put your chin in this little plastic cup thing for the CT so that pushed it up as well. 

Note--due to my professional life I don't think I can put actual pictures of my face online.  Sorry.  I hope that something can be said with just the anatomical images.       

http://imgur.com/gbIUYww

http://imgur.com/ICIwdUf




SJay

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Re: So....how did my surgeon do?
« Reply #1 on: April 23, 2016, 02:00:44 AM »
FYI, alar base reduction will leave scars. They tale a small wedge out of the alar, where the nostrils meet the cheeks and stitch it back up. It'll leave a scar on each, and often the scarring can progress upwards and inwards due the to forces on the nose as it heals, which can lead to retraction and asymmetry of the nostrils. So, it's a risk, you'll be trading in a wider base for a scarred one. It should hopefully fade with time, but there's obviously no guarantees.

Dharma

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Re: So....how did my surgeon do?
« Reply #2 on: April 23, 2016, 02:28:06 PM »
SJay--thanks for the reply.

I should have clarified as the way I put it was very misleading.  He is, indeed, going to reduce my alar base, though not in the traditional way someone would, say, if you went to a plastic surgeon for this procedure on its own.  As he explained it, when he goes in to shave the maxilla he's going to remove the wire and tissue holding things together and re-suture things in tighter narrowing my alar base from the inside (the same way he did it during the MMA to prevent it from being even wider).  So there shouldn't be any external scars.   

Dharma

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Re: So....how did my surgeon do?
« Reply #3 on: April 23, 2016, 02:44:28 PM »
Anyone have cheek implants or other procedures after MMA or orthognathic surgery to attenuate the new contrast from upper/mid to lower face? 

JimmyTheGent

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Re: So....how did my surgeon do?
« Reply #4 on: April 24, 2016, 12:26:28 PM »
lol I cant post pics because of my job..  Another undercover CIA operative with botched jaw surgery.  Id figure secret service agents in deep cover would have access to surgeons that don't make mistakes. Guess I was wrong.  :o
The more I learn about the gamble that is jaw surgery the more afraid I become!!!   :-(

Dharma

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Re: So....how did my surgeon do?
« Reply #5 on: April 24, 2016, 09:08:29 PM »
Damn, cover blown.....

Actually, I'm a physician and researcher.   

So I'm sitting in my hotel room anxiously awaiting my procedure tomorrow.  I really hope I'm doing the right thing....

If anyone reads this in the next 12 hours or so and has some spare luck you're willing to send my way, it would be appreciated.

Here goes nothin.....

PloskoPlus

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Re: So....how did my surgeon do?
« Reply #6 on: April 25, 2016, 02:08:12 AM »
Damn, cover blown.....

Actually, I'm a physician and researcher.   

So I'm sitting in my hotel room anxiously awaiting my procedure tomorrow.  I really hope I'm doing the right thing....

If anyone reads this in the next 12 hours or so and has some spare luck you're willing to send my way, it would be appreciated.

Here goes nothin.....
Good luck.  I can't believe you're doing this so quickly.

JimmyTheGent

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Re: So....how did my surgeon do?
« Reply #7 on: April 25, 2016, 09:33:08 AM »
Damn, cover blown.....

Actually, I'm a physician and researcher.   

So I'm sitting in my hotel room anxiously awaiting my procedure tomorrow.  I really hope I'm doing the right thing....

If anyone reads this in the next 12 hours or so and has some spare luck you're willing to send my way, it would be appreciated.

Here goes nothin.....

If a physician and researcher doesn't know exactly what to do when it comes to jaw surgery how on Earth does the laymen like myself have the slightest clue?? Good luck on your surgery!
The more I learn about the gamble that is jaw surgery the more afraid I become!!!   :-(

PloskoPlus

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Re: So....how did my surgeon do?
« Reply #8 on: April 25, 2016, 09:45:13 AM »
If a physician and researcher doesn't know exactly what to do when it comes to jaw surgery how on Earth does the laymen like myself have the slightest clue?? Good luck on your surgery!
The surgeon's themselves are making educated guesses half the time. Imo, a lot comes down to experience, intuition.

Dharma

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Re: So....how did my surgeon do?
« Reply #9 on: April 25, 2016, 08:16:45 PM »
Preemptive caveat to all I say/type here:  I'm super swollen, sore, and on opiates.  Things might get sloppy but I want to share. 

So...Updates:

First, for everyone who sent good vibes my way, THANK YOU.


Second, though I'm a doc and researcher, my expertise is certainly (obviously..) not jaw surgery (though I know one or five surgeons, they aren't max fac).  I  DO have access to all the research articles I want, know what I'm doing when interpreting it, understand the anatomy, and have studied the techniques, have access to fellow physician friends opinions, and feel competent choosing my own providers wisely.   I did my best, and I believe my surgeon did his best, and unfortunately, those things don' always beat the odds.  Given my professional life, I was very aware of this going in and I took the risk.  Most of anything in medicine is a risk/probable-benefit equation. 

That said, despite the last month long saga of unfortunate fate, I have some relatively promising news to report. 

So I did decide to go through with the partial revision this morning (bum bum bum....).

My surgeon (the same one) shaved my maxilla down about 4-5mm, starting at the most anterior maxillary prominence (right behind the bottom of my nose) and removing bone posteriorly. The amount of bone removed was taperep laterally, limited by the amount of overlap of the boney shelf created by the MMA as well as my incisor roots (which d/t what orthodontists thought was great to do in the 90s, were almost straight up and down!--damn it).

He also revised my alar cinch--tightening that sucker up quite a bit.  Although I was still pretty sedated and out of it when he explained things, he added a few extra "cinches" to help lower the tip and further decrease the width of my alar base.  I'll need to discuss this with him more in depth at my next visit because I'm not sure I understand how he went about this. 

Oh, and I almost forgot, he removed both my lefort plates in order to gain access to the area needed to shave.  He was originally going to just cut the bottom part off for fear of further messing with V2, but he said the tissues were easily lifted up and access was not overly difficult, so he did it.  He was able to do it without directly interacting with the nerve--this is huge as I still have significant numbness/parasthesia. 


Alright--the OUTCOME:

I seriously underestimated the effect that walking around as a monkey-pig-man-beast after my MMA would have on me.  I was also very surprised by how such subtle anatomical changes (mm's!) result in quite drastic results in the whole esthetic gestalt of a human face and people's interpretation of it. Obviously, from my posts above, I was very tentative about doing this today and my expectations were neutral at best, and if I'm honest, possibly leaning on the pessimistic side. 

Damn, sorry for the suspenseful delay.

My nose looks so much better!  As the swelling increases throughout the day, its starting to get a little lost and seems to be reaching for my left ear (its subtle though).  I think the crookedness is likely due to asymmetrical swelling.  Either way, the pig anatomy has completely been eliminated.  I went from showing everything in my barn sized nostrils to anyone in front of me to a close semblance of my old thin, sleek nose.  Via his reported measurements, he decreased the width of my nose by 7-8mm! 

Those of you more familiar with plastic surgery probably already understand how much the nose effects the whole face.  This change alone, has given me hope that I may not scare children away in the near future. 

The nose change was complex and was the result of both the maxillary shaving and the actual work on the nose.  Though the pig may be gone, the monkey is ever stronger!  D/t the swelling, my upper lip is pretty awesome right now--the terrible kind of awesome.  Of course, its all swelling but the truth is we don' really know how projected and mesognathic I'll remain after this.   

Another huge benefit that my surgeon saw coming but I did not came in the form of my bite improving rapidly!  So I'm only 4 weeks out from MMA, my bones are not even through the acute stages of healing.  Removing the plates at this time, like we did, is risky and requires me to be very careful and return to stupid tight elastics damn near 24/7.  BUT, given that the bone is still quite malleable, my bite on the right side has improved.  My surgeon is confident that my bite will be 100% in a few weeks, if we're careful, after the revision and this current plan.  I was pretty nervous about the plate thing--again, its always a calculated risk/benefit deal.  Despite my further luck, I think I might have won a bit today!   

With the change in my nose, however, and the revision of my mentalis in about a month (which will bring my chin forward--where its supposed to be!) I think I'm actually going to end of with an acceptable ante-face look rather than the look of someone who ate lead and BPA plastic sandwiches as a child and now enjoys Fukashima water shakes.   

I think the esthetic goal for those seeking MMA for sleep apnea, or any orthognathic movement above 8mm+, should be along the lines of "different but not terrible."  Any improvements, no matter how likely, should be considered icing on the cake.  I think a lot of suffering, including my own, would have been attenuated to some degree if I could retroactively follow my own advice.     

Today, for the first time in a month, I see  some esthetic hope--I'll never quite look like myself old self again, but I will gladly accept anything close to normalcy at this point.  With any luck, I may return to some degree of attractiveness--which is something I more or less gave up on post op week 2-3 (though early days, I could tell things were not going to pan out well even then). 

I will continue to update things as they progress.  I hope that my tale of an unexpected esthetic rally, albeit modest, may given hope to some of you out there. 

 A last point:  As overly miserable as I was about things initially, I may be overly optimistic about things now (could also be the oxy talking afterall!).  I'm just happy to have some hope at this point.  We'll see how I look/feel over the next few days. 

 




PloskoPlus

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Re: So....how did my surgeon do?
« Reply #10 on: April 25, 2016, 10:10:33 PM »
Thanks for the update.  Sounds like a trial.  Hope everything will turn out well.  Removing LF1 plates so soon is concerning.

Dharma

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Re: So....how did my surgeon do?
« Reply #11 on: April 27, 2016, 12:42:37 PM »
Def a trial...  Thanks for the well wishes.  LF plate removal at this point def may have been risky--time will tell if we made the right move.   

Post Op day 2: 

I'm am completely unrecognizable d/t swelling.  My nose blends into my cheeks which are encroaching on my vision they're so big.  I could shelter a small family from the sun with my upper lip.  I'm certainly as swollen (possible more?) as I was post MMA but with the emphasis around my midface rather than my lower face and neck.   

The pain from this surgery was significantly worse than MMA--I think that's because my nerve function has continued to return.  I've used more narcotics after this procedure than with any surgery I've ever had (and I hate narcotics).   

Wearing these tight elastics is not fun.  My bite is not as corrected as I thought it was right after the surgery--I still have a consistent half a mm gap between my right upper/lower molars.  If I close my mouth naturally my left front canine and teeth on either side touch before anything else--with elastics in, these teeth are mashed together painfully.  This suggests that the bone may be more solidly repaired than I initially thought.  Really hope this gets corrected but this late in the game it seems unlikely.  I see orthodontics and teeth shaving/contouring in my future....

It is national super heroes day.  Here's a pic of me wearing a legit t-shirt in support:

 


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