Concerns about planned surgery with dr. Gunson

[kavan]

May I ask more about this specifically? AKA what you asked of Dr. G/ the aspects he most closely focused on during the surgery (emphasis on advancement vs emphasis on balance)?

Personally, I think that (upper) midface augmentation whether it be modified L3 or orbital rim implants or any other modality should be addressed AFTER THE bimax surgery in a SEPARATE SURGERY when the bimax surgery will let you SEE the relative deficiency to the mid face and WHERE it is. Although you can be pretty confident that Gunson would do a good job on the CCW bimax and opening the airways and all, I would NOT extrapolate that his midface augmentation would balance a significant bi max advancement. That's because the HA 'paste' (actually granules) goes up to 3mm and/or could be isolated to 'easy' areas like malar prominence (zygoma) or paranasal but not to orbital rim whereas implants and mod L3s can get up to 5mm.

So, Gunson, although quite GOOD at the bimax could be operating on the principle that the patient does not want to 'wait and see' what needs to be done in a SEPARATE surgery after the bimax or that patient wants ALL at SAME TIME. 

That said, I shall tell you that IF you MIGHT need a SIGNIFICANT midface augment after a SIGNIFICANT bimax advancement, you should consider a SEPARATE surgery later down the line, especially if it's something like 5mm to orbital rim. That is to say, Gunson can't augment with the HA to parts of midface to the extent he can do the bi-max advancement. Nothing to do with skill. Rather the MATERIAL does not lend itself to more than 3mm. Material is good if you can 'frost' a large surface area of upper midface with it. So you really need to determine if he's going to BROAD BASE the stuff (good) or isolate to small area like malar eminence of cheek bone.

Personally, I think it's quite OK to have a RELATIVELY recessive midface after a bimax advancement. Just like it's OK to have a nose that might need adjustment after bimax. Then you go to ANOTHER doctor who is well versed in correcting what needs be corrected after the bimax.

[tyler93245]

So, Gunson, although quite GOOD at the bimax could be operating on the principle that the patient does not want to 'wait and see' what needs to be done in a SEPARATE surgery after the bimax or that patient wants ALL at SAME TIME. 

Personally, I think it's quite OK to have a RELATIVELY recessive midface after a bimax advancement. Just like it's OK to have a nose that might need adjustment after bimax. Then you go to ANOTHER doctor who is well versed in correcting what needs be corrected after the bimax.

Sounds like the 'smart'/ aesthetically minded thing to do would indeed be to hold out for a seperate surgery. However the principle you outlined exactly encapsulates my desires, since I really don't think I could be bothered to have a separate surgery for the sole purpose of aesthetics. I'll make a final decision when I speak to him again, however I do think my decision is set, for the most part. I can't "have it all" with convenience AND aesthetic results and I'm alright with that. Since a ml3 is not possible in conjunction with a lower jaw surgery, and the issue with HA paste augmentation is with the material (and not the coverage application, as you've informed me) it seems like there are no options for convenient, significant midface advancement at this current time that exist in the medical field. I'll leave an update if there's anything significant I learn on the topic of convenient/ simultaneous midface advancement.

[kavan]

Sounds like the 'smart'/ aesthetically minded thing to do would indeed be to hold out for a seperate surgery. However the principle you outlined exactly encapsulates my desires, since I really don't think I could be bothered to have a separate surgery for the sole purpose of aesthetics. I'll make a final decision when I speak to him again, however I do think my decision is set, for the most part. I can't "have it all" with convenience AND aesthetic results and I'm alright with that. Since a ml3 is not possible in conjunction with a lower jaw surgery, and the issue with HA paste augmentation is with the material (and not the coverage application, as you've informed me) it seems like there are no options for convenient, significant midface advancement at this current time that exist in the medical field. I'll leave an update if there's anything significant I learn on the topic of convenient/ simultaneous midface advancement.

Well, you could still ask him if he can broad base the stuff over a larger midface surface area as opposed to isolating it to just the malar area. This question is best asked with a request of 'show me with diagram on my photo where it will go'. Even if the extent of augmentation isn't as much as some others, it's still better than nothing. Besides, your Anterior-Posterior (AP) read out for maxilla area says it's 1.8mm. So, the thickness limits of the material would still be within the relative midface recession to compensate for with the stuff.

[ArtVandelay]

I still don't get the mechanism for sleep apnea. I'm a guy over 200 pounds with a 58 mm^2 min airway size versus yours of 136 mm^2 and I don't have OSA. My airway issues manifest during the day instead.

Are you sure your OSA isn't caused by your nasal region e.g. do you have a deviated septum? People have gotten apnea improvements from just expanding their maxilla's e.g by an MSE. There's also a less invasive than jaw surgery procedure for that whose name eludes me performed by otolaryngology-ists, have you spoken to one?

[tyler93245]

I still don't get the mechanism for sleep apnea. I'm a guy over 200 pounds with a 58 mm^2 min airway size versus yours of 136 mm^2 and I don't have OSA. My airway issues manifest during the day instead.

Are you sure your OSA isn't caused by your nasal region e.g. do you have a deviated septum? People have gotten apnea improvements from just expanding their maxilla's e.g by an MSE. There's also a less invasive than jaw surgery procedure for that whose name eludes me performed by otolaryngology-ists, have you spoken to one?

Yes, I've had a septoplasty and a tonsillectomy this past year. The surgeries did not solve my apnea issue.

Do you sleep on your side/ back? It is possible that doing so would free up some airway space through redistribution of how fat sits on your neck, camouflaging the apnea. That, however, makes assumptions about your BMI and jaw growth.

I, myself, am set on the surgery in hopes of curing teeth grinding, sleep apnea, and some daytime airway issues.

[ArtVandelay]

Yes, I've had a septoplasty and a tonsillectomy this past year. The surgeries did not solve my apnea issue.

Do you sleep on your side/ back? It is possible that doing so would free up some airway space through redistribution of how fat sits on your neck, camouflaging the apnea. That, however, makes assumptions about your BMI and jaw growth.

I, myself, am set on the surgery in hopes of curing teeth grinding, sleep apnea, and some daytime airway issues.

Ok looks like you covered all the bases. Was there any improvement in your apnea?

I definitely sleep on my side, with limbs sprawled so tossing and turning requires a lot of angular momentum. Occasionally I sleep on my back until inevitably I wake up in the middle of night after a gasp of air.

[tyler93245]

Ok looks like you covered all the bases. Was there any improvement in your apnea?

I definitely sleep on my side, with limbs sprawled so tossing and turning requires a lot of angular momentum. Occasionally I sleep on my back until inevitably I wake up in the middle of night after a gasp of air.

There wasn't an improvement in my apnea, but the surgeries were most certainly necessary. The tonsils block the airway right behind the tongue- which is not affected by the size of the jaw. From what I can tell, the degree to which my tonsils blocked my airway is less than the degree to which my jaw does. I will only see results from the tonsillectomy after I have my jaw operated on (it being the most limiting factor in my airway).

That seems to check out then. I get good sleep on my side but I will inevitably accidentally sleep in the wrong position every few nights or so, like you, and end up waking up without rest.