Surgical options and opinions

[kavan]

It's hard to make it out, but I think the posterior down graft is 10 mm which is a hell of a lot.  Did he say what material he'd use for the gap?

Yup. Extent of the downgraft is found on read out for Maxilla. PNS Vertical component is listed as approx 10mm.  The fact that it's a lot further confirms the case is well beyond being 'fixed' with chin only advancement.

[GJ]

AFAIK, he uses porous hydroxyapatite granules for onlay augmentation which need to be mixed with blood (or something in the blood). It's more amenable to molding than other types of 'bone paste' used to fill in dents and dingies.

Porous hydroxyapatite also comes in blocks (that can be carved) and he could use that or MEDPORE for down grafts.

He uses HA for the cheek grafts, but I think very large down grafts like this one uses BMP.
I could be wrong, but I think so.

[kavan]

I think he uses BMP (bone morphogenic protein).
I haven't researched that material in a long time, but 5+ years ago it had a correlation to cancer.
Maybe look it up again and also double check with Gunson. He might have moved on to some other material.

Well, ya...the HA cheek 'grafts' are the ONLAYS made from the porous hydroxyapatite granules which are granules they mix in with blood or blood components. So HA granules for the onlays. Onlays referring to a substance they place anterior to the bone surface, like 'on top' or over the cheek area to augment it. The subtance is kind of 'squishy' which allows it to be molded on top of a bone surface.

Now the DOWNGRAFT is a bone BUTTRESS; something sandwiched in between a bone CUT. It's not an onlay and not same 'squishy' mixture made with the granulated HA used for say a cheek onlay to augment the cheek.  Although the material itself can be porous HA  (or Medpore), a BLOCK of it is needed because the wedge shape of the  downgraft needs to be CARVED out of the block and the shape needs to be FIRM (and not squishy) as to BUTTRESS between the bone cut as to maintain the distance of the vertical posterior drop.

BMP; bone morphogenic protein is a growth factor that facilitates bone repair, can help induce bone formation and used in bone surgeries. So, ya, that certainly can be used/incorporated into the surgery he's doing but it's not the actual downgraft itself (because it's not a firm material one can carve into a WEDGE SHAPE bone buttress of the downgraft).

So, the downgraft actually has to be CARVED from something carvable (like a porous HA block or Medpore block). But to facilitate the actual GRAFTING process, like so the graft will take, your bone will grow into the pores of the material used, BMP would facilitate that.

[ghiggson90]

I recommend you do not get the extensive amount of surgery Dr. Gunson has proposed for you. In fact, I recommend you do nothing.

The potential for problems from a BSSO, introducing HA and titanium and god knows what else into your face, a multi-piece LeFort and genioplasty at your age is significant. Not to mention root resorption from the orthodontics and the surgery itself. Hard pass if I'm you.

[GJ]

In fact, I recommend you do nothing.

Really? He is super recessed and setup for apnea later in life.
I guess you can argue do the surgery then, but he will be older, which of course carries more risk.

[Tempus]

Thanks everyone for the further feedback it's greatly appreciated. It's given me a lot of additional information to deliberate on.

[ghiggson90]

Really? He is super recessed and setup for apnea later in life.
I guess you can argue do the surgery then, but he will be older, which of course carries more risk.

I don't believe we have enough information here to conclude he's "setup for apnea." On the contrary, he says he has no issues of this sort and Gunson told him his airway isn't narrow, only that "he has some characteristics that could put [him] at risk of sleep [apnea]." Not sure what this means, but if at his age he doesn't even snore, I can't imagine things will get much worse.

I just think the expected benefit here is well below the expected cost. Curious to hear what OP ultimately decides.

[kavan]

I don't believe we have enough information here to conclude he's "setup for apnea." On the contrary, he says he has no issues of this sort and Gunson told him his airway isn't narrow, only that "he has some characteristics that could put [him] at risk of sleep [apnea]." Not sure what this means, but if at his age he doesn't even snore, I can't imagine things will get much worse.

I just think the expected benefit here is well below the expected cost. Curious to hear what OP ultimately decides.

Recession like he has it is an indicator of potential apnea later in life. It's not an absolute predictor of it. But apnea is common with that type of recession. Hence; 'If not now, maybe later.' Also, a more open airway would mitigate the chances.

To lower the costs, he'd have to try to track down a doctor who uses the Arnett way of assessing these things and doing them. It's called 'FAB'. Face (aesthetics) Airway and Bite. That is to say there would be other doctors who would suggest and do similar but don't have a 'big name'.

[ghiggson90]

Recession like he has it is an indicator of potential apnea later in life. It's not an absolute predictor of it. But apnea is common with that type of recession. Hence; 'If not now, maybe later.' Also, a more open airway would mitigate the chances.

To lower the costs, he'd have to try to track down a doctor who uses the Arnett way of assessing these things and doing them. It's called 'FAB'. Face (aesthetics) Airway and Bite. That is to say there would be other doctors who would suggest and do similar but don't have a 'big name'.

I don’t mean financial costs (though those are certainly worth considering) but rather the extremely high chances of some degree of nerve damage, plus all of the other well-known complications that are all the more likely given his age and the extensive amount of surgery proposed, compared to the benefit of mitigating some risk of a sleep apnea. Yes, the profile is retruded, but he has an average sized airway of about 11 mm, so there’s no way the risk of apnea can be that significant here.

[kavan]

I don’t mean financial costs (though those are certainly worth considering) but rather the extremely high chances of some degree of nerve damage, plus all of the other well-known complications that are all the more likely given his age and the extensive amount of surgery proposed, compared to the benefit of mitigating some risk of a sleep apnea. Yes, the profile is retruded, but he has an average sized airway of about 11 mm, so there’s no way the risk of apnea can be that significant here.

You are predicting his chances for complications? Do you have a number as far as his odds?
I must of missed his age. How old is he?
He's on the AESTHETICS section of board. So, most of the benefit would be toward improvement.
About 11 mm is about average which is neither spacious nor breathing problems 'now' but the surgery for aesthetic balance comes with the benefit of mitigating sleep apnea later down the line.

[ghiggson90]

You are predicting his chances for complications? Do you have a number as far as his odds?
I must of missed his age. How old is he?
He's on the AESTHETICS section of board. So, most of the benefit would be toward improvement.
About 11 mm is about average which is neither spacious nor breathing problems 'now' but the surgery for aesthetic balance comes with the benefit of mitigating sleep apnea later down the line.

Yes, I am assessing his chances of complications, and I don’t have ‘a number’ because ‘a number’ does not exist, only the probabilistic ranges that we have from the medical literature. I do know he is clearly over 30, possibly over 40. The odds of nerve damage vary per study, but are high, as high as 100%, most likely much higher than his odds of developing sleep apnea (what’s the number there?) Most complications have a higher probability of occurring the older the patient. The rate of dissatisfaction for this procedure is higher among patients seeking solely aesthetic benefits. I am directionally correct here. He’ll have to do his homework if he wants greater precision, if he feels that matters. I feel satisfied having shed light on what for him might be unknown knowns and unknowns.

The aesthetic effect also suffers from some degree of unpredictability. The soft tissue changes around the nasolabial area largely unpredictable, with nasal widening of some degree very likely if not guaranteed. This isn’t to say Gunson’s plan isn’t a good one, just want OP to understand this surgery isn’t flicking a light switch, as the vast archive of dissatisfaction on this forum and elsewhere evidences.

[Tempus]

Hi, I’ve just caught up with the discussion. To add a bit more context I’m 39, which I realise is quite a lot older than most people who follow up on jaw surgery. I should’ve pursued this a lot earlier, but got tied up with work, travel etc.

Cost is not an issue, but weighing up the risks and benefits associated with any plan of action is very important. So, I really appreciate the push by ghiggson90 and the responses so far from Kavan and GJ.

I don’t know if there is a compromise between achieving aesthetic/functional benefits and minimising potential risks e.g. reducing some of the more risky movements. This may be just a naïve idea as all surgery retains risks and you may as well look to maximise benefits should you decide to proceed. In any case, I'll look to get another surgical opinion for comparison and give you an update. 

[kavan]

Hi, I’ve just caught up with the discussion. To add a bit more context I’m 39, which I realise is quite a lot older than most people who follow up on jaw surgery. I should’ve pursued this a lot earlier, but got tied up with work, travel etc.

Cost is not an issue, but weighing up the risks and benefits associated with any plan of action is very important. So, I really appreciate the push by ghiggson90 and the responses so far from Kavan and GJ.

I don’t know if there is a compromise between achieving aesthetic/functional benefits and minimising potential risks e.g. reducing some of the more risky movements. This may be just a naïve idea as all surgery retains risks and you may as well look to maximise benefits should you decide to proceed. In any case, I'll look to get another surgical opinion for comparison and give you an update.

Keep in mind that medical risks are probabilities of things that could occur based on incidences in patient populations in which they did occur. The probabilities are low and in general chances are in one's favor of 'winning'. So, can be looked at as 'negative lottery' where despite high chances of 'not losing', you lose.

Medical risks with the surgery should be ascertained and/or entertained directly with the doctor. The risks with the OVERALL field or orthognactic surgery would be higher than risks of say a highly skilled doctor. Kind of like overall risks of skiing are higher with less experienced skiers than olympic competitors who are better at negotiating slippery slopes.


I posted an article about many of the risks/complications of maxfax surgery. Here is link:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5342970/

Discussion of it is on this board is here:

http://jawsurgeryforums.com/index.php/topic,7749.0.html

Each doctor will have a risk list document patients must sign. It is legal disclosure that lists risks and/or % chances of occurring. So just ask: 'May I have a copy of risk disclosure document that I would need to sign.' If there is anything on there of particular concern to you, discuss with doctor. Also, good idea to have your health checked and cleared by your primary care doctor before any surgery.

Keep in mind that the reason people seek out doctors they have good reason to believe are 'good' and skilled is to MITIGATE the risks associated with the field in general. For example risks associated with the field in general are garnered from a LARGE POOL of doctors whereas seeking out a doctor whom you have good reason to believe is highly skilled IS an effort on the patient's part of LOWERING chances of risks.

Also keep in mind that good doctors are RISK AVERSE too. They don't want those things happening to their patients. So if there is anything in PARTICULAR eg. possible med issue YOU have that you think might make your risks higher, discuss those with your primary care doc and also the surgeon.

On a side note, there is actually a field of science of 'Risk Analysis, decision making under Uncertainty'. Beyond the scope of discussion here. But if you are interested in the general topic of decision making under uncertainty (which is used in actuarial science--insurance risks--, medicine and business), this might be a topic worth exploring.

[kavan]

Yes, I am assessing his chances of complications, and I don’t have ‘a number’ because ‘a number’ does not exist, only the probabilistic ranges that we have from the medical literature. I do know he is clearly over 30, possibly over 40. The odds of nerve damage vary per study, but are high, as high as 100%, most likely much higher than his odds of developing sleep apnea (what’s the number there?) Most complications have a higher probability of occurring the older the patient. The rate of dissatisfaction for this procedure is higher among patients seeking solely aesthetic benefits. I am directionally correct here. He’ll have to do his homework if he wants greater precision, if he feels that matters. I feel satisfied having shed light on what for him might be unknown knowns and unknowns.

The aesthetic effect also suffers from some degree of unpredictability. The soft tissue changes around the nasolabial area largely unpredictable, with nasal widening of some degree very likely if not guaranteed. This isn’t to say Gunson’s plan isn’t a good one, just want OP to understand this surgery isn’t flicking a light switch, as the vast archive of dissatisfaction on this forum and elsewhere evidences.

I'm sorry BUT some of what you're saying here rings patently incorrect to me, in particular the statement that 'odds of nerve damage are as high as 100%'. I liken that particular statement to saying the 'odds' of winning the lottery are as high 100% . Sure, a person who won it might think that but an isolated outcome to one or a few does not reflect the 'odds' or probability assessments of the occurrence.

ETA: As to odds of damage to mandibular branch of nerve, I agree that those are higher than some of the really extreme risks. Although I don't have the statistical probabilities at hand, that particular risk is certainly something to inquire about with the doctor as to some feedback of what it is in his hands vs. one's particular circumstances.

With regard to a patient experiencing a particular risk associated with a particular surgery, EMOTIONALLY, the 'risk' is 100% to that patient after the outcome occurs. But that is not a statistical predictor of any one other particular patient or patient population as whole.

For example, the lottery exploits IRRATIONAL thinking where they get you to think in terms of winning. But in terms of a typical example where one uses the actual probability of winning multiplied by the financial pay off and compares that to the cost of a ticket to take the chance, the EMV (estimated monetary value) of taking the chance (1M) is about 1/13th of a cent which would be the break-even point to pay for a lottery ticket (as opposed to the $1 cost). Point being is there are more irrational thinkers than rational and that's how the Lottery itself is always the winner. Can go the other way around with Alarmists and Fear mongering where the focus is on losing (bad outcome). Promoting that sort of thinking has nothing to do rationally going about taking a risk under uncertainty.

As to his doing his 'homework', I've already given him some advice, in particular having to do with the science of Risk Analysis and decision making under uncertainty, I've already suggested he look into that. I would suggest you do the same. It is an extremely rational field which deals with such things as 'risk aversion' when justified and when irrational, using probabilities in taking a calculated risk. In short, there is a highly RATIONAL way of thinking involved with decision making analysis.

The only 'absolute' here, if one is in pursuit of absolute 'certainty' (100% certainty) is that no surgery at all will bring the risks associated with surgery to 0% which appears to be your assessment here.