How to vet surgeons?

[Ithomiidae]

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[Dogmatix]

It's a gamble and always will be. There is only so much you can do. Not even Arnett-Gunson have all success stories and not even money can guarantee the best result.
I think the best thing you can do when chosing a surgeon is to speak to a previous patient, then you get a real opinion from someone who has actually been through it and you speak to someone who objectively doesn't care if you chose this surgeon. In-network surgeons have the benefit that they're held responsible to the network and are being watched in another way than private surgerons. Private surgeons have the benefit that they sometimes can do more advanced procedure and walk the extra mile to optimize aesthetics and result, if you pay for it of course.

I would say it's a pretty good review to have another max-fac surgeon who've jeopardize his own face to this surgeon, and still recommends him. You can also see if you think he have a good result. You won't get a better recommendation from him, the question you always want to ask when someone forwards you to a surgeon is where would you go yourself. It says more than any bulls**t you can get from anyone.

It's one thing how people in this field always seem to protect eachother and it's impossible to know who you can trust. It's like when you get investment tips from your bank, I don't care about their advices unless they show me that they do same with their private money. Have your local surgeon told you that he doesn't feel comfortable doing the surgery himself and have forwarded you to this one, or how come you have contact with both of them? If that's the case he sounds like a very good guy that rather forward you than try himself.

One thing you can do is to check his papers and research and see where his interest is and what he seems capable of. It's also good to know what kind of surgeries he can do. I don't know what movements you'll have or need. But you want a surgeon who have all tools and can chose the appropriate ones. Some surgeon can't or won't do posterior down grafting, but if you're in for a MMA, then CCW rotation with posterior downgrafting is common, and you at least want an opinion from a surgeon who is capable of doing it. Someone who is not capable may do the surgery any way with a linear advancement that solves the problem, but not in the best way.

[Ithomiidae]

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[Post bimax]

Can someone explain how a “significant counterclockwise movement of the mandible” can be achieved without a change to the occlusal plane? Maybe I’m missing something.  I don’t understand exactly what he’s suggesting there.

[ArtVandelay]

Do not rush this.

It sounds like you're in orthodontics already without having finalized your surgeon. Don't rush this decision, I can't stress that enough.

Approach it as a two step process. First get multiple opinions with the exact precise surgical movements. You have to be confident the final plan is correct and having multiple confirmations is one way to do it. If a surgeon won't give you an exact plan run away from their office immediately.

I think the best thing you can do when chosing a surgeon is to speak to a previous patient, then you get a real opinion from someone who has actually been through it and you speak to someone who objectively doesn't care if you chose this surgeon.

Agree with this. Obviously if a surgeon supplies a list of patients it should only be used as away to ELIMINATE the surgeon and not confirm him. That list is biased to patients he thought he did a great job, so it should show glowing reviews. If those reviews are ambivalent then again you should run.

[Dogmatix]

Can someone explain how a “significant counterclockwise movement of the mandible” can be achieved without a change to the occlusal plane? Maybe I’m missing something.  I don’t understand exactly what he’s suggesting there.

It seems like a very general description, I wouldn't mark the words.

Have you got an actual plan?

[Ithomiidae]

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[ArtVandelay]

At the very least get a plan and post it here to get feedback.

[Post bimax]

It seems like a very general description, I wouldn't mark the words.

Have you got an actual plan?

The “up and forward” of the maxilla sounds like anterior impaction with advancement which would allow CCW of the mandible. But I’d be surprised to hear that’s  indicted in the majority of his cases since poor incisor show (indicating the opposite movement) is pretty common.

Obviously we need to see a plan to make a true judgement. Just trying to make sure the surgeon isn’t selling him on some buzzwords.

[Ithomiidae]

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[kavan]

I'm a 19 year old man who is four months away from completing orthodontic decompensation before an aggressive maxillomandibular advancement to correct an underbite (maxillary hypoplasia) and cure sleep apnea.

I seem to have settled on an in-network surgeon. He's a "clinical associate professor" at a major university hospital's department of oral and maxillofacial surgery. This university's college of dentistry is a volume operation, accepting most insurance plans and servicing an entire region of the US. They really turn and burn jaw cases.

He comes recommended by my local maxfac, who's own MMA surgery was performed by the same surgeon. He's a surgeon's surgeon. He has performed "thousands" of MMA procedures; 200 a year, 60 of which to treat sleep apnea. He and his university are a clear cut above my other in-network options.

Yet I have doubts. Is this as good as it gets in the crapshoot of orthognathic surgery? He's not "Arnett-Gunson" level prestigious, but the university is supposed to be my region's jaw surgery mecca. Is the oral and maxillofacial department's status as a teaching hospital promising? Are there more telling criteria that I am missing?

I'm tearing myself apart with stress. I've been delirious with sleep deprivation for three years and live in chronic pain. It's ruined my mind and probably badly disrupted my development. I'm a formerly bright student who's had to postpone college indefinitely.

Anyway, what else could I ask for in a maxillofacial surgeon? He seems good on paper, but am I missing anything? This is my face after all.

Firstly, I could tell right off from your presentation you are very BRIGHT. So, not a thing of your being 'PRIOR' so. You still are but I understand and can empathize with how pain can disrupt the quick connections one could make in the absence of it.

Selection of something, here a surgeon, will be a function of  constraints.

Constraints can be the selection 'pool'. For example, the pool to select from is smaller when the selection pool has constraints of 'close to HOME' location and insurance paying for surgery as opposed to a larger pool with 'bigger fish' that is far away and very costly to catch. So, it's not a thing where you're drowning in a sea of choices here because it sounds like the constraints are; 'Who's the big fish in the small pond who's free to catch'.

Other constraints are those you are fortunate NOT to have, such as limited intellectual capacity. Like you're not asking about having esoteric surgeries to look like 'male model' where you need to be 'spoon fed' about what they actually are and are not. Nor are you presenting with an aimless goal in search of 'best surgeon in world' to achieve it. Basically if you know what's causing your brain not to work at full capacity, that's a whole lot better than some who don't even know they're not thinking correctly or don't start with capacity to do so.

OK, so the constraints here are that you are limited to surgeons in your vicinity and for insurance to pay for it. That constraint does not preclude the surgeon's capacity to perform MMA to give releif from apnea as to displace both your jaws and to do it where the positioning also stands to give improved facial balance. Also, the sub constraint of having a good doc narrowed down for you is a good sign.

Your case and face position from it sound pretty bad. So, this is a surgery that will bring great relief which is NOT going to make you look any worse. It's like your case sounds so extreme that even if you got the most straight forward type of MMA which is 'linear advancement', you'd still be better off. Linear advancement can be done when the PALATAL plane (defined by ANS-PNS, anterior nasal spine to posterior nasal spine) has a position where it's rotated CCW away from a horizontal; with respect to a Cartesian coordinate graph, a positive diagonal, a diagonal for which a CW rotation would align it to the x axis. So, 'forward' advancement along that diagonal brings the maxilla up and out. In fact the term; 'MMA' usually implies linear advancement for sleep apnea. It's when they travel along your 'own' palatal plane and they get the BSSO to follow. So, EVEN IF that's the plan set out for you whereas CCW posterior downgrafts are associated with aesthetic maximization, I would NOT fret about it because it sounds like you will still come out ahead given how behind your jaws are. Not to mention that this is FUNCTIONAL surgery that stands to improve your function. So, I would not fret about the surgeon 'not being Arnett-Gunson'.

[Post bimax]

Linear advancement can be done when the PALATAL plane (defined by ANS-PNS, anterior nasal spine to posterior nasal spine) has a position where it's rotated CCW away from a horizontal; with respect to a Cartesian coordinate graph, a positive diagonal, a diagonal for which a CW rotation would align it to the x axis.

Ah, right. Now this needs to be determined with a ceph with NEUTRAL head orientation, as head orientation could alter the perceived angle between the ANS-PNS and horizontal, no?

[GJ]

Anyway, what else could I ask for in a maxillofacial surgeon? He seems good on paper, but am I missing anything? This is my face after all.

It sounds like it's more your life than your face. It's put your entire life on hold and eroded your mind (sleep deprivation does this). What exactly is the sleep problem? If you've already described it below, sorry; I haven't read the thread. Post your records so we can see what's going on.

There's no way to approve any surgeon. Just need to see if the plan is appropriate for your issues. The other thing you can do is seek out and ask former patients. There are surgeons on national healthcare systems who have produced results that beat any US surgeon. It's kind of hit and miss and depends on the plan, communication (ortho and surgeon), and execution.

[kavan]

Can someone explain how a “significant counterclockwise movement of the mandible” can be achieved without a change to the occlusal plane? Maybe I’m missing something.  I don’t understand exactly what he’s suggesting there.

The occlusal plane is changed by rotating the palatal plane (ANS-PNS) eg. a posterior downgraft. Rotation of the occlusal plane requires rotation of the palatal plane above it. No rotation of PP=no rotation of OP.

The PP on a ceph can be looked at as a line from ANS to PNS. Diagonal lines are either oriented in CCW or CW direction. With reference to a clock with diameter from 3 to 9, a diagonal made by big hand at 2 would be considered in CCW orientation because you'd have to rotate it CW to get it to 3. A diagonal made by big hand being at 5 would be considered in CW orientation because you'd have to rotate it CCW to get it at 3. So, orientation with reference to a horizont on a clock. THe OP is a DIFFERENT plane and if it diverges too much in CW direction from PP, the only way to change rotation of OP is to rotate the PP.

So if someone already has a PP oriented in a CCW direction (relative to a horizont) and an OP that is not 'too steep' or 'too much' in a CW orientation, they don't have to rotate the PP to change the OP. Moving the maxilla 'forward' along the (diagonal) line of the PP is the act of moving up and outwards. If the palatal plane is oriented in a CCW direction, advancing 'forward' on it is in the same direction in which the plane is aready oriented and the OP does not change because the PP wasn't rotated.

The BSSO will follow the direction the upper jaw is moving in.

[kavan]

Ah, right. Now this needs to be determined with a ceph with NEUTRAL head orientation, as head orientation could alter the perceived angle between the ANS-PNS and horizontal, no?

I would assume his surgeon could look at one and adjust for head orientation.