Intermaxillary fixation without rigid plates with Dr. David Behrman

[ArtVandelay]

TLDR; 8mm over-rotation due to lack of fixation

Thanks. I'm also adding a pre-surgery versus after revision comparison here. You can see that after my surgery my impacted wisdom tooth is close to the border of my jaw. This has caused difficulties in finding a surgeon to remove it. Good news is I found one, bad news is I have to wait until lockdown ends to travel there...

Also in the image you can see the extent of the forward rotation of the proximal fragment (segment with the condyle and ramus). This was over-rotated due to muscle pull and lack of fixation. The plan is to rotate the proximal fragment down to match the inferior borders of the mandible. As far as I can tell pano's preserve vertical distances, measured a bunch of different landmark points and they're all preserved. By my measurement it's off by around 8mm. I can feel this step off physically and 8mm feels right. Fixing this is a top priority and kind of a kicker for me not to go the segmental route (If I can fix this + better airway then I'll be the happiest person on earth, Curve of Spee and Curve of Wilson be damned).

Now a note on lack of fixation. As far as I can tell this was something that was phased out decades ago, this statement is from my own research. One surgeon (will not name) even refused to believe I had a BSSO, thinking I must be a confused patient; he claimed no one would actually forgo lower fixation. Dr. Behrman told me this happens to around 4 of his patients a year (fixation failure). This technique is out of date and a disservice to patients to use it.

Note: these are panorex x-rays and not cephs. I can un-crop it if anyone prefers.

[XXRyanXXL]

I was reading the reviews online for D. Behrman, and a majority of the reviews sound like a horror story. I cannot fathom that people would just post negative outcomes to destroy someone's career out of sheer frustration or not living up to there expectations. Does anyone know if these reviews have merit?

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

[ArtVandelay]

There's several things at play here. First, IMO Dr. Behrman plays a high stakes game with the customer service side of his practice. He lets residents do mostly everything before and after surgery (claims not during surgery and I still believe him on that point). Especially afterwards, you're lucky to get a glimpse of him. I barely saw him after surgery and I had serious complications (mouth wired shut almost 3 months). Not giving patients face-time is in itself not a problem IF you're delivering good results. I recall hearing a lot of medical malpractice suits happen because of the poor relationship between the doctor and patient. All surgeons will have some percentage of bad cases, it is inevitable in a game of millimeters, it's probably how truthful and forthcoming the surgeon is that determines the scale of unhappiness.

Here's my customer service experience at New York Presbyterian. A couple days after my first surgery, I had to decide whether or not I wanted a full revision (what I eventually choose) or having him manually push my maxilla into place under local anesthesia. So here I was after a failed surgery with a big time-sensitive decision to make and he gave short answers to everything, didn't volunteer any information unless explicitly asked, and even bullied and blamed me for "biting to hard after waking up from anesthesia" which other surgeons have said is almost impossible. And he never once mentioned he wouldn't use lower plates on my mandible (creating the drawbacks you see in this thread) nor that I would have my jaw wired shut, losing nearly 50 pounds. Imagine waking up from surgery and finding out you have your jaw shut (to be fair it's probably likely he decided during or shortly before surgery). And I only found out about the lack of lower plates weeks after when I glanced at an x-ray during one of my appointments. And in follow-up appointments he would refuse to speak with me, a resident would enter my room and say Dr. Behrman says your concerns aren't valid, etc, etc, etc etc.. The customer service policy feels like: uniformed patients make the best patients.

Now I consider myself pretty thick skinned, his yelling and bullying, while unpleasant didn't bother me at all. But I can imagine his attitude hits a nerve with a subset of the population. So the customer service angle of his practice is not doing him any favors. He's playing a high stakes game and not hedging any of his downside, and those hedges are cheap. But the thing is, he doesn't even need them, he has a full patient pipeline with long delays to make an appointment, lots of NYC orthodontists send patients to him, so this approach works for him. A lot of people, like myself at the time, assume orthodontists know what they're talking about when it comes to jaw surgery (I went to several orthodontist in the NYC since they were free appointments and called many others and he was a popular choice among them.)

I mentioned there are several things at the top, but this a long post already so I'll break it out.

[PloskoPlus]

I have to say, given all the crimes perpetuated by surgeons, I am surprised I've never heard of patients "taking matter into their own hands".  A bad aesthetic outcome is one thing, but time and time again I hear about patients physically suffering post-op - people's live are ruined.  Europeans, Australians, Canadians being soft-cocks is one thing, but what about militant Americans?  Forget physical retribution (BTW, I'm not advocating anything), people (some of them obviously wealthy enough to do so) don't even bother to sue their surgeon (this I heartily endorse).  A common excuse is "damages are limited to X, what's the point?". Money is not the point, and neither is justice.  It is all about retribution.  The scumbag surgeon should get to feel at least a fraction of the pain and discomfort that he has caused.  But people are even afraid to name their torturer surgeon.

[ArtVandelay]

people (some of them obviously wealthy enough to do so) don't even bother to sue their surgeon (this I heartily endorse).

Lawyers generally don't like taking orthognathic cases unless the surgery brought about some serious disabilities. The cases are considered expensive from their side due to the need for expert witnesses. I really wasn't interested in suing, regret it a little now. Your only retribution option in most cases of surgeon misconduct is to name and shame them like you say.

I also don't get why a lot of unhappy patients refuse to name their surgeon. My surgeon claims to have done a good job so if anything he should be delighted I've put my x-rays online.

[Gadwins]

[...]. But people are even afraid to name their torturer surgeon.

That isn't really my experience in germany. Several days ago I found a german bimax group on facebook. I even contacted some "unhappy" patients. What was really strange, that some talk a lot bad things, but didn't want to provide further information like pictures or even x-ray. Some did provide pictures, but the outcome wasn't bad at all.

I think, that bad cases are real (like here in this topic). But many patients just seems to have some mental problems, or didn't analyze their face before. One Patient complained about a crooked chin after a genioplasty, but her mandible was already asymmetrical before.



ok, but in the US a surgeon could sue the s**t out of you. Your fines are lunatic. Maybe that is the reason, why in the us the patients wants to sue their surgeons rather to give them some physical beating. In Europe the last one is a better option.

[PloskoPlus]

Lawyers generally don't like taking orthognathic cases unless the surgery brought about some serious disabilities.

You seem to be worse off than before surgery and suffering.  That's all that matters.

[PloskoPlus]

That isn't really my experience in germany. Several days ago I found a german bimax group on facebook. I even contacted some "unhappy" patients. What was really strange, that some talk a lot bad things, but didn't want to provide further information like pictures or even x-ray. Some did provide pictures, but the outcome wasn't bad at all.

I think, that bad cases are real (like here in this topic). But many patients just seems to have some mental problems, or didn't analyze their face before. One Patient complained about a crooked chin after a genioplasty, but her mandible was already asymmetrical before.

I don't mean bad to mediocre aesthetic outcomes (and there are plenty of those).  I mean surgery which results in physical suffering — whatever functional issues the patient may have had before, he is much worse off post-op and suffering.  And yet the patient is afraid to even mention the surgeon's name, let alone seek legal recourse.  It's Stockholm syndrome.

[ArtVandelay]

The second thing at play is his technique. He's a real old school surgeon who doesn't use 3D virtual planning. This has functional implications, you can't get an accurate airway measurement without a 3D xray. Evidently Dr. Behrman is unaware airway management is a component of a successful jaw surgery plan. He never once performed any airway measurements on me during the whole process. Currently, my airway is a small 58 mm^2, to my knowledge he never measured this before surgery. I have no idea what the change was from my operation, even if it shrunk or increased. I mentioned sleep problems during my consultations, but was unsure if this was because of my open bite/lip strain or other reasons. This can't possible be state of the art care. I had pre-molars removed as a child, so my maxilla was and still is obviously recessed. My tonsils crowd my throat since they have no place to go, giving the appearance I'm sick when examined, dentists and doctors have sometimes asked me if I currently have a cold during appointments. Yet his plan was to advance my ANS point by a whooping 2mm.

I should have sued him on grounds the plan was inappropriate. The plan was convenient for him since he claim he improved the bite so surgery was a "success" in his eyes but any surgeon could have improved my open-bite with the starting position I was in. Improvement is a low bar, if you need a revision after two attempts then the surgery was a colossal failure. And even with this simple inappropriate plan the surgery was botched, poor plan poorly executed.

Other surgeons have a face-airway-bite philosophy, IMO Dr. Berhman's philosophy is bit, I'm leaving of the last 'e' since even for the bite the standards were low (I've been told from my pre-op pics that my orthodontics for surgery were shoddy and I needed more time, this might have contributed to the poor result). I needed 15 months of orthodontics post-surgery to stabilize things, which included filing down a corner of a molar which was hitting early (without that drilling my bite would not be closed). He's just too old school to provide appropriate treatment plans. His goal is to improve your bite in any minimal sense, that way he can argue the surgery was a "success" and any complications were a known risk. A very different objective from what patients are looking for.

Another more technical note. I may mix up details here as I don't want to pull up references. It's impossible to perfectly place two jaws in a bimax such that they bite will be perfect as is. Instead you need to allow some wiggle room on the order of ~1mm to let it settle into place. One way to accomplish this wiggle is with hard elastics right after surgery before the bones heals. Now most modern surgeons prefer to leave the maxilla a little loose. Not Dr. Behrman, as seen in this thread, in my case he was of the opinion the best way to achieve this settling in is by skipping the titanium fixation part in your mandible. What you get is the complication in this thread.

Edit: airway is 58 mm^2 and I'm over 6 feet, can't find a link for statistics on minimum airway size of OSA patients will reply when I find it

[ArtVandelay]

3D planning is pretty sophisticated and amazing now. Look at this video. The human error is still on the order of 1mm and too high to get perfection but a good plan makes the surgeons jobs easier, less surprises in the operating room.

https://www.youtube.com/watch?v=kqRfYdvuaEk

In my opinion Dr. David Behrman is still doing jaw surgery the way his uncle, Dr. Stanley Behrman, taught him back in the 80's.

[ArtVandelay]

Regarding the airway, when I actually confronted them after my surgery if they even followed my pathetically inadequate plan. They completely dismissed my question and called the plan irrelevant. They said the plan is only a rough guide, in the operating room "the bite guides the surgery" . There's no guarantee you'll get anything close to your movements since if the bite improves they are done and out of there. The face - airway - bit ('e' intentionally dropped) philosophy. From my perspective he's not talented enough to manage your airway during the surgery. It wasn't even considered according to their own words. The best you can hope for is some marginal bite improvement.

[ArtVandelay]

Found an interesting article on stability and relapse:

https://head-face-med.biomedcentral.com/articles/10.1186/1746-160X-3-21

Not the main point of the article but one point is relevant here: "For Class II patients, rigid fixation is needed for stability when both jaws are operated: the single jaw procedures are stable without rigid fixation but not when the procedures are combined. With rigid fixation, significant change (>2 mm) beyond what is created by mandibular rotation when the splint is removed occurs in only about 20% of the patients treated by a two jaw procedure (Figure 5). Clinically, an excellent result is obtained in 90% of the patients with rigid fixation, but in only 60% without it"

[GJ]

Man, great username.

So what's the status?
Did you find someone to do revision, and do they think it will be reasonably successful? Any plan? etc

[ArtVandelay]

Man, great username.

So what's the status?
Did you find someone to do revision, and do they think it will be reasonably successful? Any plan? etc

Due to the complications listed in this thread it has been impossible to find a local oral surgeon to take out my impacted lower molars. Good news I found one, bad news is international travel is banned at the moment. Funnily enough one well respected surgeon was fine removing my impacted wisdom teeth during the operation. But when I showed him my post surgery x-rays where you can see the cuts like above then he immediately flipped his rec'd to getting them out beforehand, too much danger of a fracture or bad cut with them in place. The general reaction I receive when showing surgeons, both oral and max-fac, these x-rays is one of horror; they're shocked someone would go medieval like that on a mandible.

My complications are twofold. First my treatment plan was, let's just say, inadequate; with a meager 2mm maxilla advancement. My surgeon was unable to juggle two problems at once, he focused on the open bite and ignored airway and bimax retrusion completely. Fixing this part is a straightforward case of advancement of around 5mm with a small amount of CCW. No need for any crazy downgrafts. (Decided against a segmental L1, leaving my maxilla slightly narrow as it's not my most salient problem) This part isn't complex to fix.

What makes it more complicated is that I was the victim of a "sloppy surgeon" who was fine letting my mandible float and rotate in all 3 axes by forgoing titanium plates. Complications include, 1.) destroying my ramus 2.) canting my mandible/maxilla slightly, 3.) causing a huge step-off on one side because the condolye rotated excessive forward and 4.) introducing general asymmetries. This part is tougher. It is possible to improve, the goal is to realign these pieces, a reunion years in the making. We're talking rotations in all 3 axes here.

This complication is encountered occasionally by the top revision docs. You need three factors for this to happen 1.) a surgeon who practices like it's 1979 2.) a fixation failure due to poor planning. 3.) terrible plan which needs a revision. Unfortunately for society, but fortunately for me, these aren't that rare, and these 3 factors are far from independent. The top guys might see this complication to some extent a couple times a year in a revision operation. I'll be satisfied with an 80% improvement here. Oddly enough, because my pieces are so far off and disjoint, it actually makes it easier to place the BSSO cut.