My first consultation with Alfaro

[eglantine]

Hello everyone !
My name is Eglantine and I have been considering jaw surgery for years. But due to lack of time, I got my first appointment with a surgeon, dr Alfaro, only yesterday.

I saw that several participants here have acquired a lot of knowledge concerning jaw surgery and I would highly appreciate it if you could give me any advice or insight on my case.
I am also eager to get any information about Dr Alfaro and to be suggested other surgeons that I could consult (I am ready to travel all around the world).

- Alfaro told me that with his minimally invasive technique, there is zero risks for nerve damage. Have you any thought about that?
- When I asked him for his range of prices, he replied that he didn't know and that his secretary would get back to me to tell me. I was a bit surprised by this answer. Does anyone know what kind of prices he practices?

Considering my case, I thought I had prognathism but he told me that I have Maxillo-mandibular retrusion with a bad inclination of my front teeth that are too much horizontal. He advised me to first have their inclination fix (to get them more vertical) through orthodontic treatment, and then to have my upper and lower jaws move forward with surgery.
He said that this would make the tip of my nose higher, fix the sagging of my neck and give it a better definition, and more generally (if I understood correctly)  lift the soft tissues of my face (that, without operation, would go down with aging).

Thank you very much to anyone who could help me !! It's a very hard choice to make and it is most valuable to have your insights

[GJ]

The first thing I noticed is how proclined your teeth are, so he's correct on that. Do you have a tongue thrust? Usually that's a cause of this, and it would be worth fixing trust before any surgery.

Regarding your jaws, the record is taken at an angle where you head is pointed downward. This makes little sense, and I wonder why it was taken this - rarely good reasons. Your mandible tilts downward right around the midpoint of the body. There's a mild notch. Many times this is due to trauma (falling as a kid). Sometimes it's genetics. Some argue tongue thrust causes this, which brings me back to my first question, given your incisor flair.

All said, from what I can see, you look pretty good. I don't see any under neck sag, and everyone ages. Surgery won't prevent any of that. In theory, with more bony support in the lower jaw, you could "stretch" the skin and pick up slack. But slack and sag is mostly due to collagen production and skin quality.

I'd personally do nothing based on the records you provided. I'd have to see more and a justification for the surgery. Why do you want to do this? If you did get surgery, it looks to me like you have a straightforward CCW type case, but again, a record with your head in a more neutral position would help here.

PS. We don't discuss price on the forum since surgeons read this forum.

[kavan]

It looks and sounds like he told you right. Although the ceph is a crappy one, sometimes they use the head tilt down posture (rotation of head in clockwise direction) when they are indeed entertaining CCW (counter clockwise rotation) for bimax advancement (of both jaws). Your front teeth are indeed bucked out a lot and you DON'T have prognathism. Quite the OPPOSITE of that like he told you. The bimax advancement, particularly the lower jaw would tend to give more soft tissue support as he said. It's just that the head tilt down posture (and I don't know if that was done by him) is often done when they are entertaining a significant/dramatic advancement. You should try to get a VISUAL proposal from him that estimates or gives you some idea what he has in mind. They can do that by using a photo taken in the office and using a computer program where the proposed movements of the bones/teeth are plugged in to give a basic visual of how the changes could look on you.

[PloskoPlus]

Any surgeon claiming zero risk of nerve damage is a liar (unless he has a special definition of nerve damage like "permanent numbness is not nerve damage"). I know multiple people who have had surgery with him and ended up with permanent numbness.

[GJ]

Any surgeon claiming zero risk of nerve damage is a liar (unless he has a special definition of nerve damage like "permanent numbness is not nerve damage"). I know multiple people who have had surgery with him and ended up with permanent numbness.

Yeah, to make any prediction is foolish. They should just say they'll do their best to avoid damage. I was told surgeons sometimes knowingly "sacrifice the nerves" to make a cut...did they tell the patient that? Likely not.

In general, piezosurgery does help a bit, so if he used that I'd say it gives better odds.

[kavan]

piezosurgery is what he uses.

[kavan]

Advantages of piezoelectric surgery.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672167/#:~:text=Piezoelectric%20bone%20surgery%20is%20a%20technology%20based%20on%20the%20high,until%20the%20early%2021st%20century.

• Selective cutting of mineralized tissue
• Significant reduction of trauma to soft tissue
• Reduced hemorrhage (cavitation effect)
• Excellent visibility within the surgical field, due in part to minimal bleeding, to high luminosity LED lights and effective irrigation
• Precise cutting (limited vibration amplitude and specific design of osteotome tips)
• Curvilinear cutting
• No thermal damage
• Sterile irrigation – steam sterilization
--------------------------------
Excuse reference to veterinary maxfax surgery. Same concept as for humans. This article easier to read. Preserves neurological and vascular structures.

[eglantine]

The first thing I noticed is how proclined your teeth are, so he's correct on that. Do you have a tongue thrust? Usually that's a cause of this, and it would be worth fixing trust before any surgery.

Regarding your jaws, the record is taken at an angle where you head is pointed downward. This makes little sense, and I wonder why it was taken this - rarely good reasons. Your mandible tilts downward right around the midpoint of the body. There's a mild notch. Many times this is due to trauma (falling as a kid). Sometimes it's genetics. Some argue tongue thrust causes this, which brings me back to my first question, given your incisor flair.

All said, from what I can see, you look pretty good. I don't see any under neck sag, and everyone ages. Surgery won't prevent any of that. In theory, with more bony support in the lower jaw, you could "stretch" the skin and pick up slack. But slack and sag is mostly due to collagen production and skin quality.

I'd personally do nothing based on the records you provided. I'd have to see more and a justification for the surgery. Why do you want to do this? If you did get surgery, it looks to me like you have a straightforward CCW type case, but again, a record with your head in a more neutral position would help here.

PS. We don't discuss price on the forum since surgeons read this forum.

Thanks a lot for your reply !!
Noone had ever mentioned my tongue before you, but I am indeed worried that I have a very big tongue that might push forward my teeth (and that would possibly spoil the result of a surgery if I have one). Do you have any idea how to fix a tongue thrust ?

What you say about the notch is very interesting and I hadn't noticed it.

Why do you think CCW would be a good fit for me ?

"Why do you want to do this? "

I had been advised since I was a kid to do something for my jaws (or teeth) that are too much forward and when I was a teenager an orthodontist advised I should have jaw surgery (which was not possible at that time because my parents don't have the money). I've never stopped thinking about it since then because I do think that my face would be much more harmonious without this flaw...

Can I ask you what you think of Alfaro and if you know of any other surgeons that would be worth consulting ?

Thanks again very much for your reply ! It is very helpful

[eglantine]

@Kavan Thank you very much for your reply !and the information on the technique used by Alfaro. He claimed he had invented it (the minimal invasive technique): is that true ?

[eglantine]

Any surgeon claiming zero risk of nerve damage is a liar (unless he has a special definition of nerve damage like "permanent numbness is not nerve damage"). I know multiple people who have had surgery with him and ended up with permanent numbness.

You know of people who had bad experience with Alfaro? Thanks a lot for sharing it, that's a very precious information for me ! How many people do you know who ended up with permanent dumbness after an operation with him?

Actually, he not only said that there were zero risk of nerve damage when having an operation with him, but when I asked him about the risks in general, he enumerated a list of risks which he said were only "theoretical" but had never happened to his patients (he mentioned some felt a numbers but said that it weren't permanent).

May I ask you what you think of him as a surgeon ? And if maybe you know of some other surgeons that you could advise to visit ?

[eglantine]

One of my concern is that I have quite big teeth: I'm afraid they would look much too long if they were in a more vertical position...

I also would like to shorten my face... Alfaro said this would be possible but I have no idea how...

[GJ]

Thanks a lot for your reply !!
Noone had ever mentioned my tongue before you, but I am indeed worried that I have a very big tongue that might push forward my teeth (and that would possibly spoil the result of a surgery if I have one). Do you have any idea how to fix a tongue thrust ?

What you say about the notch is very interesting and I hadn't noticed it.

Why do you think CCW would be a good fit for me ?

Can I ask you what you think of Alfaro and if you know of any other surgeons that would be worth consulting ?

I'm not sure how to fix a tongue thrust. You'd probably need to see someone who specializes in that, though I think YouTube has lessons on how to have better tongue posture. Look into that maybe.

I have no idea about Alfaro. No opinion either way.

The latest photos made me change my mind on CCW. It almost looks like you have an underbite in one, so I looked at the scan again, and it seems your incisors are almost edge to edge, and your lips are a bit protrusive in profile (have you had extractions, or did anyone recommend them ever?). I'd have to see more scans before solidifying an opinion here. Things look a bit different in every record.

[kavan]

@Kavan Thank you very much for your reply !and the information on the technique used by Alfaro. He claimed he had invented it (the minimal invasive technique): is that true ?

Actually, I gave you information on the science and technology behind piezoelectric surgery. It is this type of technology that allows for selective cutting of bone without damage to soft tissue/nerves etc. It's something that certainly allows for a minimal invasive technique and would allow him to claim virtually no nerve damage.  Piezoelectric science has been known for quite some time for many applications. Modern surgery is example of putting it to use for yet another application. I don't know if he 'invented' it. He may have designed a tool for it and he's very likely to be one of the first 'movers and shakers' to incorporate the technology into his practice. He's using a technology that by vibrational frequency can SELECTIVELY cut one type of tissue but not harm another type and thereby significantly reduces the risk of 'collateral damage' of other tissues.

Undoubtedly, he's braggadocious though.

[GJ]

Literally every surgeon I've talked to claims they pioneered piezosurgery...

[Gadwins]

[...]

Actually, he not only said that there were zero risk of nerve damage when having an operation with him, but when I asked him about the risks in general, he enumerated a list of risks which he said were only "theoretical" but had never happened to his patients (he mentioned some felt a numbers but said that it weren't permanent).

[...]

Surgeons like to say things in a way, what is strictly true, but not really true for somebody, who does not share the same definition of some words. For example nerve damage could mean anything. There is for sure a definition in medical books, what is a nerve damage and it could have a total other meaning, than what you understand as a nerve damage.

I can only advice for your further consultation to name specific your concerns. I mean, what is your real concern behind a nerve damage? To not move your muscles? To not have the same feeling afterward? .... and so on.

About the second part, that he is watering down some risks: I would inform yourself about the law in spain, so you can understand the attitude of the surgeons. For example in germany, there is a diferent between surgeries for medical reasons and for purely aesthetical reasons.

In germany surgeons are somehow allowed to water down some risks, if the surgery is for medical reasons. If it is a purely aesthetical surgery, than they aren't allow to do this and can really break their neck, if they don't follow this rule. BUT: Even if many patients undergo a jawsurgery for aesthetical reasons, it is NOT an aesthetical surgery in germany. So the surgeons are allowed to water down the risks like Alfaro did.Also there could be some nuance for example, who has to prove in a lawsuit certain things. In germany the surgeon has to prove, what he told in a consultation.

[...]

I also would like to shorten my face... Alfaro said this would be possible but I have no idea how...

You should ask him this more specific. It should be no problem to have a second consultation with him.