Dr Hernandez Alfaro

[girl]

But it's obvious that UKMaxfac didn't want a revision rhino which entailed doing that weird and experimental manoeuvre all over again.

Upper jaw surgery causes massive swelling in the mid face. How can he get anyone's nose to reliably "match" their new facial proportions if their face (and nose) are clouded by massive swelling from upper jaw surgery? How can a surgeon plan a revision rhinoplasty in advance of all this when the nose will change in an unpredictable way when the upper jaw is moved only 1-2 hours before? 

Unlike a normal rev rhino, he'll be operating on a swollen nose and face and "guessing" whether the end result will look good on the new face.  Plus the recovery will be very traumatic. This is probably what UKmaxfac was questioning, and I'd do the same.

I think it's better to separate these surgeries but Alfaro capitalises on how quick he is, and with that comes the desire to cram everything in at once, I suppose. 

Seriously. If someone got the 'floor' of their nose lowered via direct access through the maxilla and then later wants bi max where the maxilla needs to be cut through again and a rev rhino is contingent on having similar acess to the maxilla as was the case with the septo rhino wanting to be revised, what kind of patient would think it was more 'sensible' to go through the maxilla again, a 3rd time to revise at a later time after bi-max.

He probably doesn't want a patient who thinks that's more sensible. It isn't.

[kavan]

But it's obvious that UKMaxfac didn't want a revision rhino which entailed doing that weird and experimental manoeuvre all over again.

Upper jaw surgery causes massive swelling in the mid face. How can he get anyone's nose to reliably "match" their new facial proportions if their face (and nose) are clouded by massive swelling from upper jaw surgery? How can a surgeon plan a revision rhinoplasty in advance of all this when the nose will change in an unpredictable way when the upper jaw is moved only 1-2 hours before? 

Unlike a normal rev rhino, he'll be operating on a swollen nose and face and "guessing" whether the end result will look good on the new face.  Plus the recovery will be very traumatic. This is probably what UKmaxfac was questioning, and I'd do the same.

I think it's better to separate these surgeries but Alfaro capitalises on how quick he is, and with that comes the desire to cram everything in at once, I suppose.

Didn't seem too obvious to me that he even knew what he got in the first place. Best time to rev the rhino is when they are working with the bony nose base at the maxilla via the bi max. Sorry you don't get it. By the way, the swelling is kept down during the surgery with a cocktail of meds. The massive swelling comes in later.

[girl]

If it wasn't obvious to him, then how could he object to his questioning of whether it was a "good idea" to do it or not?

Even if they do keep the swelling down with meds, the nose will still look different after the jaw surgery has been completed. Therefore, a surgeon can't reliably plan a revision rhinoplasty with the patient's input when the status of the nose after the jaw will change, and the patient won't ever get to see that change or appreciate how it changes their starting point.

Whether it's technically better to do it during jaw surgery is another question. I heard that this dual assault can compromise blood supply to the area.

Personally, I think revision rhino needs its own "space" unless a minor adjustment is proposed.

Didn't seem too obvious to me that he even knew what he got in the first place. Best time to rev the rhino is when they are working with the bony nose base at the maxilla via the bi max. Sorry you don't get it. By the way, the swelling is kept down during the surgery with a cocktail of meds. The massive swelling comes in later.

[kavan]

If it wasn't obvious to him, then how could he object to his questioning of whether it was a "good idea" to do it or not?

Even if they do keep the swelling down with meds, the nose will still look different after the jaw surgery has been completed. Therefore, a surgeon can't reliably plan a revision rhinoplasty with the patient's input when the status of the nose after the jaw will change, and the patient won't ever get to see that change or appreciate how it changes their starting point.

Whether it's technically better to do it during jaw surgery is another question. I heard that this dual assault can compromise blood supply to the area.

Personally, I think revision rhino needs its own "space" unless a minor adjustment is proposed.

When I said it was not obvious to 'him', I was referring to the patient. Not the doctor. His prior 'rhino' was actually surgery to and through the maxilla. So the rev of it would best be done during surgery to and through the maxilla which allows the doctor to address the 'floor' of the nose and also the spine of the nose at the same time when both are moved anyway during the max surgery. It's one of those things that's just so obvious to me, it becomes tedious to explain further than I have. Also a given that it's obvious to the doctor. If he doesn't want the rev rhino with the max surgery, he most surely will need one after it and it. However with no access through the maxilla to address the altered 'floor' of the nose, there will be more limits to revising than there would be if he got it revised during the max surgery.

There is no 'dual assault' to address the parts of the nose that are going to be displaced ANYWAY during a max surgery. The dual assault comes in when you have to get another surgery to do what you could have done in the first place.

[girl]

The more you do to that area at once, then surely more risk will be incurred in terms of blood supply, or lack thereof.

So you're assuming that a revision rhino would involve another internal approach to the nasal floor?

Another doctor's approach to a revision rhino would likely not involve the same nasal floor access, simply because it's not the norm and can probably be revised externally. So there would be no argument for doing it at the same time on that account IF the same approach was not going to be utilised anyway.

You say that after jaw surgery he'd need a revision rhino anyway - which, from my perspective, is best assessed when the look of the face is stable and you can see what you'd like to do to your nose to "match" your (new) face??

Maybe it's easier for the DOCTOR to do it "at the same time" but is it best for the patient's safety and their goals, well, that is the question I was asking.

[PloskoPlus]

Well the swelling does not set immediately and Alfaro does operate very fast.

[kavan]

The more you do to that area at once, then surely more risk will be incurred in terms of blood supply, or lack thereof.

So you're assuming that a revision rhino would involve another internal approach to the nasal floor?

Another doctor's approach to a revision rhino would likely not involve the same nasal floor access, simply because it's not the norm and can probably be revised externally. So there would be no argument for doing it at the same time on that account IF the same approach was not going to be utilised anyway.

You say that after jaw surgery he'd need a revision rhino anyway - which, from my perspective, is best assessed when the look of the face is stable and you can see what you'd like to do to your nose to "match" your (new) face??

Maybe it's easier for the DOCTOR to do it "at the same time" but is it best for the patient's safety and their goals, well, that is the question I was asking.

I'm assuming that the roof of the maxilla which is basically the access path to the 'floor' of the nose is going to be cut into during the max surgery. Actually, it's OBVIOUS the maxilla along with the spine of the nose will be involved in the max surgery. Due to that the doc will be braced to make alterations to the nose while doing the max surgery. So, yes, I'm assuming that since his problem to the nose arises from lowering the floor of it, he's better off having it revised during max surgery when they have access to the floor of it if that needs to be changed/reversed.

Of COURSE, another doctors way of revising the nose after bimax will not be including direct access through the roof of maxilla to do it or UNDO what was prior done to it through there, which is exactly what I meant by LIMITATION if access via the maxilla is needed to fix it.

If rhinos were 'too risky' to do DURING a max fax surgery due to 'blood supply' then it would not be common practice to perform them DURING a maxfax surgery now would it. But I guess your personal opinion that they are 'unsafe' to do during max surgery trumps the standard practice of doing them during a max surgery.

Rhinos can be and are done after a max surgery but not the kind to UNDO a poor result from lowering the floor of nose if that needs to be undone.

Water under the bridge at this point because he's not going to have the doctor who could revise his nose during the max surgery.

 

[girl]

True, the doctor will not be operating on him. Which IMO is for the best if he is always in such a rush to get things finished as if he wants to make a world record attempt. TBH that speed factor "brag" serves a dual purpose. Firstly, it's transparent marketing directed towards his ideal customer base: people who aren't surgery vets and more likely to be "scared" of anesthesia/death vs. living with their natural face, which is what scares surgery vets more. And secondly, it's basically him trying to squeeze as much as possible into one day, i.e. he's money orientated or rates his skills very highly and thinks that speed is a measure of this.

This provides some insight into this doctor's disdain for those who dare to "ask questions" because he is targeting the uninformed and the complaint, which is what he usually gets I'd bet, given the Spanish aren't remotely as pedantic about aesthetics as the Americans/Northern Europeans are.

But about common practices and risks... those two are not mutually exclusive in the world of surgery, whereas time and money are intrinsically related.

[kavan]

True, the doctor will not be operating on him. Which IMO is for the best if he is always in such a rush to get things finished as if he wants to make a world record attempt. TBH that speed factor "brag" serves a dual purpose. Firstly, it's transparent marketing directed towards his ideal customer base: people who aren't surgery vets and more likely to be "scared" of anesthesia/death vs. living with their natural face, which is what scares surgery vets more. And secondly, it's basically him trying to squeeze as much as possible into one day, i.e. he's money orientated or rates his skills very highly and thinks that speed is a measure of this.

This provides some insight into this doctor's disdain for those who dare to "ask questions" because he is targeting the uninformed and the complaint, which is what he usually gets I'd bet, given the Spanish aren't remotely as pedantic about aesthetics as the Americans/Northern Europeans are.

But about common practices and risks... those two are not mutually exclusive in the world of surgery, whereas time and money are intrinsically related.

The doctor probably doesn't want or need 'know it all know nothing' patients who question things in the absence of knowing the basics. Not saying the OP is that but if he adapts your way of thinking, he probably will be on his way of being rejected by other doctors or maybe will find one who won't alter his nose during the max surgery and will wind up with however it would look via displacements of just the max surgery and no displacements aimed at countering some unfavorable displacements of the nose that CAN occur during a max surgery. But be my guest if you wish to support his decision not to get it reved during his max surgery.

Hell, be my guest in also contending that that SWELLING is so bad DURING a surgery, that the doctor could not possibly perform a rhino during it. Add your 'personal opinion' that it's 'unsafe' to perform a rhino during a max surgery 'because' it compromises blood supply.

Your insights don't reflect much about the doctor at all. Let's see, the ability to perform something FAST and perform it well, reflects SKILL. But you don't differentiate skill from 'rushing'. These surgery 'vets' you speak of, would those be people who do it wrong the first time and have a pattern of doing wrong multiple times who want to use the same thinking process they used to do it wrong to be a back seat driver to tell the doctor what to do? Doctors who know how to do things right don't like patients like that and why should they.Good doctors deserve good patients and have every right to pick and choose which ones are the most appropriate candidates for what they do. Your insights reflect more of a SOUR GRAPES stance more than much about the doctor.

[girl]

You're right, they don't "reflect much about the doctor" because I am not approaching this from a doctor's perspective; rather, from a patient's. Is that so radical on a forum like this?

You are basically saying the OP, who is not a doctor, has asked a question about a topic he doesn't know the ins and outs of because he is not a doctor, and that got him blacklisted. You seem to think that is a reasonable way of dealing with non-medical laypeople when you are a doctor who operates on and derives all of his income from... non-medical laypeople. 

From my perspective, the doctor lacked the emotional intelligence to make sense of the sentiments behind his question (conflicting information heard from other doctors and on forums) without taking it as a personal affront. By extension, other conclusions could be drawn about his character, supplemented by a recent Google review from an actual patient that describes him ignoring a patient when things went wrong.

As for "sour grapes". Let me say that I got myself into bad situations purely because I didn't refuse the things that pushy doctors forcefully made it a requirement for me to get along with other surgeries, using similarly "logical" arguments that you espouse here with about as much vigour. I felt like I had no choice, due to that line of thinking that I no longer adopt. And so my subsequent criticism of a pickly doctor is "sour grapes", in your opinion.

Also, a few weeks ago, I posted 2 results that I personally find to be poor from Alfaro. I attributed these to a lack of finesse and skill (assembly line approach to surgery), so my criticism is a lot more material than you state. Moreover, it was in fact based on the statements and pictorial evidence HE put out there on his own site.

For everything you've said, you neglect the human (you might say "irrational") feelings that accompany making such decisions, along with the trepidation people have when they've had a bad experience. These aspects trump diagrams and logic when someone decides to make that final bank transfer. People are not perfect and they do not mind read accurately, and that is also the case with you as much as it is with me.

The doctor probably doesn't want or need 'know it all know nothing' patients who question things in the absence of knowing the basics. Not saying the OP is that but if he adapts your way of thinking, he probably will be on his way of being rejected by other doctors or maybe will find one who won't alter his nose during the max surgery and will wind up with however it would look via displacements of just the max surgery and no displacements aimed at countering some unfavorable displacements of the nose that CAN occur during a max surgery. But be my guest if you wish to support his decision not to get it reved during his max surgery.

Hell, be my guest in also contending that that SWELLING is so bad DURING a surgery, that the doctor could not possibly perform a rhino during it. Add your 'personal opinion' that it's 'unsafe' to perform a rhino during a max surgery 'because' it compromises blood supply.

Your insights don't reflect much about the doctor at all. Let's see, the ability to perform something FAST and perform it well, reflects SKILL. But you don't differentiate skill from 'rushing'. These surgery 'vets' you speak of, would those be people who do it wrong the first time and have a pattern of doing wrong multiple times who want to use the same thinking process they used to do it wrong to be a back seat driver to tell the doctor what to do? Doctors who know how to do things right don't like patients like that and why should they.Good doctors deserve good patients and have every right to pick and choose which ones are the most appropriate candidates for what they do. Your insights reflect more of a SOUR GRAPES stance more than much about the doctor.

[kavan]

You're right, they don't "reflect much about the doctor" because I am not approaching this from a doctor's perspective; rather, from a patient's. Is that so radical on a forum like this?

You are basically saying the OP, who is not a doctor, has asked a question about a topic he doesn't know the ins and outs of because he is not a doctor, and that got him blacklisted. You seem to think that is a reasonable way of dealing with non-medical laypeople when you are a doctor who operates on and derives all of his income from... non-medical laypeople. 

From my perspective, the doctor lacked the emotional intelligence to make sense of the sentiments behind his question (conflicting information heard from other doctors and on forums) without taking it as a personal affront. By extension, other conclusions could be drawn about his character, supplemented by a recent Google review from an actual patient that describes him ignoring a patient when things went wrong.

As for "sour grapes". Let me say that I got myself into bad situations purely because I didn't refuse the things that pushy doctors forcefully made it a requirement for me to get along with other surgeries, using similarly "logical" arguments that you espouse here with about as much vigour. I felt like I had no choice, due to that line of thinking that I no longer adopt. And so my subsequent criticism of a pickly doctor is "sour grapes", in your opinion.

Also, a few weeks ago, I posted 2 results that I personally find to be poor from Alfaro. I attributed these to a lack of finesse and skill (assembly line approach to surgery), so my criticism is a lot more material than you state. Moreover, it was in fact based on the statements and pictorial evidence HE put out there on his own site.

For everything you've said, you neglect the human (you might say "irrational") feelings that accompany making such decisions, along with the trepidation people have when they've had a bad experience. These aspects trump diagrams and logic when someone decides to make that final bank transfer. People are not perfect and they do not mind read accurately, and that is also the case with you as much as it is with me.

On this string (back pages) the OP showed an e mail where he asked about the rhino and got a response/answer to his question. So, who knows if he kept on expressing circumspection later down the line to the doc. He also expressed that he thought some of the doctors work looked 'done'. His ground point was that he wasn't too sure about Alfaro anyway and may have needed the doctors time to resolve all the uncertainties he had about the doctor.

For a busy and skillful doc who needs to use his time to DO,  his approach was to resolve circumspection and uncertainty by declining treatment.

As far as emotional intelligence goes the doc is not going to spend his time coddling or persuading the patient to have surgery as the time to DO surgery on those who are sure they want it trumps the time needing to be spent resolving the uncertainties of a circumspect patient.

In that way, the OP has all the time in the world to find a doc to do his bi max who will accommodate his request not to have rev rhino during it if his 'emotions' are telling him not to get that done during same time.

[girl]

OK, I agree with that, in that if this was part of a series of questions that expressed trepidation about the surgery, then that could make one come off as a "time waster" rather than a possible patient.
 
I've always thought that the tone of emails, esp if the recipient's first language isn't English, can be misread somewhat. Paying for another consult or a Skype consult could be an alternate strategy.

[kavan]

OK, I agree with that, in that if this was part of a series of questions that expressed trepidation about the surgery, then that could make one come off as a "time waster" rather than a possible patient.
 
I've always thought that the tone of emails, esp if the recipient's first language isn't English, can be misread somewhat. Paying for another consult or a Skype consult could be an alternate strategy.

Yes. I think for the most part, this doctor wants to use his time doing the surgeries and uses the consult time to to TELL a patient what he can do and not SELL a patient on it.

The back threads show the e mail where the OP's question about rhino in same surgery was answered to the effect of; 'We do it and always do it with the bimax'. It didn't say; 'You asked the wrong question and now your out.' So, if he asked similar again as to call into question the safety of that, the doc elected to resolve his circumspection to not getting the surgery.

Like in the e mail he showed, there was nothing wrong with his question and he got an answer. So, if he later he came off as; 'Well, I'm not convinced of the safety of what you're proposing, the doc is probably thinking that in the same time he'd need to convince or pursuade the OP, the doc could be doing a surgery. So, he's prioritizing time to those who are sure they want his surgery.

Personally, I'm not a big fan of docs who spend a lot of time essentially selling a patient on a surgery. Ironically, those are the types who know how to indulge the circumspect patient as to make them more 'sure' he/she is the right doctor for them where that might not be the case at all.

[uj]

It seems like quite a few people have consulted with him. I'm curious what your experience was like, and what you thought of him.

I did see in this thread

- Spanish surgeon (Alfaro). Had online consult and he agreed to send through his recommendations in writing based on what he'd seen, along with morphs etc. Never came through. Never responded to my e-mails. Again, my money was taken and nothing was gained.

Those who have consulted with him:

• In person or by videoconference?
• What did you receive as far as information, analysis, and planning, and how did this compare to other surgeons' consultations? Did you receive a treatment plan?
• If interested were you given the option to pay for and receive a surgical workup prior to/without committing to surgery?
• Did he ask you for/seem receptive to your opinions? Did you discuss aesthetics?
• If applicable to your case, were you recommended downgrafting (including counterclockwise rotation with posterior downgrafting)?

Also does anyone have links to Spanish forums or other reviews (besides the testimonials on their site and social media)?

alright so I have been snooping this Spanish orthognathic forum and this is what I learned (regarding Instituto Maxilofacial)

a) for the Spaniard lurkers. I.M. does not accept insurance
b) surgery costs around 12K (euros) per jaw
c) you will be treated like cattle, apparently there are dozens of dental students (soon to be surgeons) that do all the consulting (x-ray, ct scan, dental impression, pictures, etc..) Alfaro eventually pops in, talks to the patient for 10 minutes and bolts. you won't see him again til surgery day
d) his rhinoplasty sucks

at these (some of their social media/linked reviews are like this too):

Hernandez Alfaro is a great professional, but very busy though. I had an appointment with him (at his office in Barcelona) and he had an outstanding comprehension of my problems and really attentive.
However this is just my first impression with him, I hope it doesn't change quite when I have done my surgery in mid 2015.
I recommend you to come over and see him at his office, by the way you can visit Barcelona.

they have no prices on the website, but you can ask here: http://institutomaxilofacial.com/en/appointment
I've heard Dr.Alfaro is top 1 in Spain and they have pretty good medical services and an international services department too....the place looks great btw...

[ITALIA]

I saw him in person last month. Travelled from London and returned ln the same day.

The hospital itelf is big and very impressive. Its in a very exclusive part of Barcelona.

The office of Dr Alfaro seems on the compact side,. I could be wrong  because I only saw tbe reception and a couple of offices. Everything looks nice and very modern.

Dr Alfaro speaks very good English and  is charming and honest.  Based on my interaction he doesn't do a sales pitch or anythkng like that.

My consultation pretty much lasted 2 minutes - He said there was nothing to be done and when I told him my concerns  he did give me a look of surprise so I didn't push him on it.