Treatment options

[ArtVandelay]

Hi, I'm debating going down the orthognathic road a second time. I'd appreciate if anyone in this community can share any insights or comments. Attached is my latest ceph x-ray. Thanks in advance for your help.

Brief story: I had a Lefort I and BSSO done in 2013 to treat a 5mm open bite. They actually had to perform the same operation twice, spaced a week apart, since according to my surgeon I clenched too hard immediately after being woken from anesthesia and moved the bite so I needed an immediate revision. Apparently this happens in ~4% of the cases or so, when your jaw muscles don't cooperate, so it's not entirely rare.

(Side story: yes I had a BSSO done even though there are no metal plates on my lower jaw in the ceph, after the revision they were not reinserted because "there was no space to drill fresh holes". None of the OMFS doctors I have visited since then think that makes any sense but that's what I was told)

Surgeon: Dr. David Behrman from New York Presbyterian hospital

Problem: I still have lip incompetence, about 6mm plus or minus 1mm depending on who measures. This strain is present throughout the whole day as it affects your resting posture and I'm finally mentally ready to address this. Also my airway feels narrower than before surgery if you can believe that.

Question: Could I get by with just a Sliding Genioplasty (I was told I could advance as much as 8mm forward but I'm worried my current angle would leave a noticeable stair step) or would I also need to have an Lefort I performed (still have almost the same gummy smile as pre-op, my maxilla wasn't impacted upwards enough as initially planned) or even worse is a full revision needed.

Thanks for your help.

Update after a year: The problem isn't lip incompetence as much as my lips have to travel a diagonal distance to close as opposed to straight line vertical. That's whats causing the strain.

[ditterbo]

Wow, I'm sorry to read you went through TWO bimax surgeries (albeit b/c of that complication) for THAT result.

[ArtVandelay]

Wow, I'm sorry to read you went through TWO bimax surgeries (albeit b/c of that complication) for THAT result.

In the back of my mind I keep wondering if the surgeon changed the plan for the second surgery as a consequence of the first failing. Dr. Behrman wouldn't even speak to me during my last visit, instead he sent out a 1st year resident who was unfamiliar with my case, so I was unable to ask any of these questions.

Do you have any recommendations for how to go from here?

[ditterbo]

My guess is another bimax with a serious CCW of the posterior down-graft variety, and a small genio advancement + upward movement.

[kavan]

Lip incompetence; difficulty getting the lower lip to meet the upper lip and STRAIN in the attempt, is usually a function of the chin ORIENTATION for example chin bone being too long in vertical direction and too backwards in horizontal direction.  It's basically mechanical inefficiency due to the orientation of the lifting mechanism. The lifting mechanism is the mentalis/ CHIN MUSCLE and it gets more efficient at lifting the lower lip when the orientation is closer to a VERTICAL than when it's oriented DIAGONALLY BACKWARDS. So, basically,lifting your lower lip straight up to meet your upper lip would be EASIER if the LIFTING MECHANISM; the mentalis muscle were not oriented so much diagonally backwards.

Your chin is oriented DIAGONALLY BACKWARDS which is consistent with a complaint of lip incompetence (mentalis strain when trying to lift lower lip to meet upper lip). For that reason
the displacment to it which would tend to COUNTER its present orientation would be a movement that is:

a: horizontally forward

b: vertically UPWARD as in to shorten.

That would be done via a diagonal cut where when the chin is SLID 'forward' along the diagonal cut, the 2 'vector' displacements with that are; 'a' and 'b' as stated above.

In essence, the explanation above is consistent with what a sliding genio usually does; a diagonal cut is made, along which the chin is slid forward along the cut and the individual displacements broken down into 'horizontal' and 'vertical' are horizontally forward to advance out chin and vertically upward to be shorter.


OK, it's possible you could get by with just a sliding genio. But also possible to have revision surgery with CCW to maxilla which would allow the lower jaw to be advanced out more so that the extent of genio would be LESS than if done alone. However, even so, revision surgery with CCW would not really compensate for the excessively high orientation of the mandibular plane. But once you entertain option of revision surgery, you need a really GOOD guy and the suggestion here for that is usually to seek out a consult with Gunson in the event you want to entertain the option of REVISION SURGERY. (But don't bother with him if it's only the chin genio you want.)

As to your PRIOR doctor, Behrman, you must write him a DEMAND letter requesting your surgical records. He could be hiding something (disclosure of whether or not it is true what he told you was true) given he refused to speak to you. You need to obtain your surgical records with him so the revision surgeon has them.

See a prior LAW SUIT against the guy:

https://cases.justia.com/new-york/other-courts/2015-2015-ny-slip-op-32205-u.pdf?ts=1448057576

Also, it appears that his negative reviews are consistent with his MISHAP with your case followed by refusal to discuss the problems it resulted in with you.

https://www.ratemds.com/doctor-ratings/48578/Dr-David-Behrman-NEW+YORK-NY.html

Don't bother with him any more other than to demand your surgical records from him.

[kavan]

ETA to my prior post to you:

What you have relayed about this doctor is enough to arouse suspicion. Not to mention a prior lawsuit against him where the plaintiff contended he failed to inform properly. There is enough to QUESTION whether or not you actually got a BSSO with your first surgery. Like maybe your wisdom teeth did not 'get in the way' of a BSSO because you didn't actually have a BSSO.

So to determine whether or not you actually had a BSSO in the first surgery, you need to obtain your surgical RECORDS with him eg. cephs and all documentation as to what was done.

There are red flags here where he could be hiding something from you. So, you absolutely need to demand your surgical records from him, ALL OF THEM, to establish what was done vs. what may not have been done, especially so when seeking out REVISION where the maxilla would need to be cut into again.

From your present ceph, it's CERTAIN that no genio was done. Hence, that's 'virgin' area where possible to get isolated genio to fix lip incompetence. It's also certain, the maxilla was displaced, cut into. But there is NO certainty in that ceph (at least to my eye) whether or not you had a BSSO. The uncertainty of such is against a BACKDROP of the doctor being UNRELIABLE with reference to forthright disclosure.

One of my regrets during my double jaw surgery (which didn't go well) is that I left my impacted wisdom teeth in place prior to the operation. My surgeon said he would remove them if they got in the way. But do you really want your surgeon making a judgment call on wisdom teeth during the operation rather than focusing on the planned movements?

(Side story: yes I had a BSSO done even though there are no metal plates on my lower jaw in the ceph, after the revision they were not reinserted because "there was no space to drill fresh holes". None of the OMFS doctors I have visited since then think that makes any sense but that's what I was told)

Surgeon: Dr. David Behrman from New York Presbyterian hospital

[ArtVandelay]

Thank you for the detailed reply Kavan.

Wow you seem even more skeptical about the whole experience than me. I do have similar concerns but I'm not going to voice them here. I'm trying to keep this thread lawsuit-proof as I do not intend to honor a removal request even if I receive papers with a lawyer's letterhead. In my case the results speak for themselves.

I've reached out and began the process of obtaining my records. Between the 2 surgeries there were pano's done so that should clear up the BSSO question. For what it's worth, I think the BSSO was performed; my lower slip still has some minimal numbness to this day and insurance was charged for it. It just wasn't performed as planned (pure speculation: maybe because of my impacted wisdom teeth?)

Regarding future treatments, one surgeon did tell me I can get by with just a SG and do not risk any revision if your bite is fine. Another did recommend a Lefort1 + a SG but did mention the L1 has a smaller marginal benefit than SG alone (2/3rd benefit comes from SG alone). This time around I won't even consider a BSSO unless my wisdom teeth are removed beforehand and are allowed ample time to heal. Thank you for the Gunson suggestion, after accepting a full revision might be needed I did schedule a consultation, it's just many months away.

However, even so, revision surgery with CCW would not really compensate for the excessively high orientation of the mandibular plane.

Is there any way to address this steepness. I've started looking into chin wings. Though admittedly it's too early in my research to have an idea if it's appropriate, and the lack of US surgeons doing this operation doesn't help in researching this. I'll get back once/if I find similar cases.

[kavan]

I think the hardware is more visible on Profile ceph as to whether or not you had the BSSO. Also, profile ceph shows the airway. So a prior one of prior surgery would give some hint of an airway increase with a BSSO if you had one.

The 2 consults you went on pretty much are saying what I was conveying which is most of the benefit would come from the SG and you COULD get revision with a L1 BUT more CCW with the L1 won't significantly reduce your steep mandibular plane. Instead what it would tend to do is allow for a BSSO which would advance chin with it and make LESS the extent of the SG vs SG done alone.

As to options to further reduce the inclination of the mandibular plane, I find as far as I'm concerned there's somewhat of a FUTILITY involved in time spent to give suggestions. Like I'm disinclined to give suggestions that may include materials other than your own bone and then find out the person is AVERSE to anything but their own bone and/or others chime in with said aversion. So, screw that.

Then we have a precedent being (prior) set here as to a scam artist being key mouth piece for chin wings along with others who just read about them (haven't had them themselves and/or won't post photos) suggesting them. Add that there are only a few doctors doing them (3 known ones) and this board can become a free defacto advertising venue for them. Screw that too.

So, I think it's sufficient info to tell you what I already did.

[kavan]

ETA: [The lower lip and chin receive sensory innervation from branches of the mandibular nerve.]

So, he could have ATTEMPTED (could be possible that he attempted) to do the BSSO, ran into problems with the nerve (perhaps subsequent to the CUT he made) and then stopped. With that type of possibility, an ATTEMPT to do one is not the actual act of doing one that did not go as planned because the forward movement could have been ABORTED as a result of the wrong cut.

I don't mean to speculate here as to 'exactly' what happened. But rather to give a POSSIBILITY of an ATTEMPTED BSSO that did not result in any actual advancement that comes with a BSSO but rather just nerve damage.

[ArtVandelay]

Also, profile ceph shows the airway. So a prior one of prior surgery would give some hint of an airway increase with a BSSO if you had one.

Thanks again for your detailed feedback. Attached my ceph prior to any surgery. I kept copies of all my pre-surgery x-rays / photos.

Ok I didn't realize there was some bad history on this forum wrt chin wings.

[kavan]

Thanks again for your detailed feedback. Attached my ceph prior to any surgery. I kept copies of all my pre-surgery x-rays / photos.

Ok I didn't realize there was some bad history on this forum wrt chin wings.

OK. So you started with anterior open bite and he closed the bite and made less chin strain (lower lip incompetence that would have gone along with that type of bite). What kind of lefort did you get, one with posterior impaction or anterior downgraft?

So, you are left with RESIDUAL lip incompetence, not from something he did but something he didn't do and the most CERTAIN thing not done was the SG. It's likely the SG would help the residual lip incompetence/chin strain.

[ArtVandelay]

What kind of lefort did you get, one with posterior impaction or anterior downgraft?

I'll confirm with the records once I receive them but it was a posterior impaction as I had vertical maxillary excess. And the BSSO was a minor setback, so as not to move my maxilla too much forward.

I have an consolation coming up with an OMFS surgeon, who seems to have a more aesthetic eye, and has good results for SG's online. Lately I'm leaning towards just getting the SG done to see if that solves issues before considering anything more invasive.

[kavan]

I'll confirm with the records once I receive them but it was a posterior impaction as I had vertical maxillary excess. And the BSSO was a minor setback, so as not to move my maxilla too much forward.

I have an consolation coming up with an OMFS surgeon, who seems to have a more aesthetic eye, and has good results for SG's online. Lately I'm leaning towards just getting the SG done to see if that solves issues before considering anything more invasive.

OK. I was thinking in terms of the BSSO being advancement. If it was a set back then it's looking closer that you may have had THAT.

[ArtVandelay]

Ok I got a copy of the Operative Notes, still waiting on full records. Transcribing some details:

"The impacted 3rd molar was noted to be entirely within the distal segment; it was decided not to remove the tooth as that would entail additional manipulation of the mandibular nerve". Ok, the setback was supposed to be minor so it's very possible that my wisdom teeth did not get in the way.

Also I did have "6-hole titanium orthognathic plate and 4 monocoritcal screws" placed on my lower jaw after the first operation. No mention why they weren't re-inserted and only IMF fixation was used instead.

As for the problems making a 2nd operation necessary, hardly anything is mentioned: "Examination of the osteotomy suggested the possibility that there was some displacement to the patient's right"

Now for the actual operation on the maxilla it's stated the some of screws were loosened and it was "repositioned with gentle digital pressure" and afterwards "the osteotomy still demonstrated appropriate positioning".

Combing this with what the 1st year resident told me when I was trying to get a sense if the planned movements were performed (my take is they weren't), they ignored that question and claimed that post surgery it doesn't even need to be checked (I never had a ceph done post-surgery, just panos) because quoting the resident: the bite guides the surgery.

Putting everything together, here's what I think happened during that eventful week: the second surgery focused on the bite. It feels partly like being a salvage operation with priority being to close the bite at all costs; even if the planned movements had to be sacrificed

[kavan]

Well, initially, I was operating on the principle of; 'WTF a BSSO?' but was thinking in terms of an ADVANCEMENT but now I find out it was a BACKWARDS direction one. The X rays reveal that the surgery went towards fixing your bite and that was his goal. Your residual lip incompetence along with an improved aesthetic can be improved by the SG which will allow you to keep the corrected bite.