Seeking advice - jaw surgery complications and repair

[bayman]

Hi Forumers,

I'm on a frustrating journey of dealing with sleep apnea and jaw surgery complications. I'm hoping to get some advice from this forum regarding:
- Doctor recommendations
- Comments on Dr. Gunson and Dr. Li
- Comments proposed surgical plan

Below is my timeline. This all started because I was sleeping very poorly and had nasal/sinus issues. When I finished graduate school in 2016, I did not have enough energy to hold down a full-time job. I still don't.

May 2017 - palate expansion
Dec 2017 - palate graft
May 2018 - MMA - less-than-expected advancement due to thin bone in mandible (that was not discovered until during the surgery)
Mar 2019 - diagnosed with palate defect and maxillary non-union
Sep 2019 - root canal to clear palate defect infection
Sep 2020 - 1 year post root canal, infection clear
Present - need surgery to repair palate defect, maxillary non-union, and improve airway (I still sleep very poorly). If I have an MMA revision, it will be very difficult because of the thin bone.

My palate expansion and MMA surgeries were performed by Dr. Stanley Liu at Stanford. He failed to diagnose the palate defect and maxillary non-union so I will no longer work with him. I'm currently deciding between Dr. Michael Gunson (Santa Barbara) and Dr. Kasey Li (Palo Alto). Would one of them be better than the other for my situation? Are there other doctors I should strongly consider? I'm from Salt Lake City and living in the Bay Area, so mostly looking for California and Utah doctors. I'm open to other areas if there's good reason for it.

Dr. Gunson told me, "there are complicated cases, and then there is you." I think he's right. Here is a description of Gunson's surgical plan (written by him). If anyone has the expertise to comment on it, I would appreciate your thoughts:

1. "Inspect the anterior left maxilla where the bone is missing, debride the area (clean it out) and graft the area as needed
2. Remove hardware in the maxilla
3. Inspect the maxilla for non union or missing bone
4. If there is non union, I will remove any scar tissue, re-apply plates and screws and bone graft as needed. If there is any missing bone areas I will graft those areas as needed
5. Inspect sagittal osteotomy sites, both sides, and remove hardware on right side
6. With the above information after the surgery, I will decide if revision jaw surgery is possible or even recommended
7. If revision orthognathic surgery is recommended, work with Dr. Yoon [orthodontist] to prepare for that surgery which can occur after the grafts are mature in 9-12 months."

[GJ]

What don't you understand about Gunson's notes? They seem self-explanatory except maybe #1, which just means he's going to remove whatever grew inbetween your maxilla and the rest of your skull so he can create a union.

[bayman]

Thanks for responding. I do understand them. I'm more wondering if the experts in this forum think it's a good plan. And also if they think Gunson, Li, or someone else is the right guy for the job. Does that make sense?

[GJ]

It sounds very reasonable to me. Seems conservative, which is probably what you need if you're a difficult case.

Basically he's just going to fix the non-union? I actually didn't know that was possible in isolation (i.e. not part of a total revision surgery). I'd personally use Gunson for this over Li - heard he can be cranky and difficult to work with, so not worth it if you have a solid approach already. Relle would be the only other CA surgeon I'd consult with.

[kavan]

Revision surgery is contingent on the maxilla having good and strong UNION.
So, of course it's a good plan to first attempt to FIX the NON-union.

There is no chance of any revision surgery with pre-existing non-union.
There is a chance of revision surgery IF the non-union is sufficiently corrected.
Sufficient correction is in turn, contingent on quality of bone and whether or not the graft takes which can't be predicted in advance which is WHY there is a 'wait and see' period after Gunson's plan to address the non-union to see whether or not revision surgery can be recommended.

[bayman]

It sounds very reasonable to me. Seems conservative, which is probably what you need if you're a difficult case.

Basically he's just going to fix the non-union? I actually didn't know that was possible in isolation (i.e. not part of a total revision surgery). I'd personally use Gunson for this over Li - heard he can be cranky and difficult to work with, so not worth it if you have a solid approach already. Relle would be the only other CA surgeon I'd consult with.

May I ask why it seems conservative? I agree - conservative would be a good thing for me.

I'll look into Relle. Why do you recommend him? Thanks again for your reply.

[bayman]

@kavan Thank you for the explanation. That makes a lot of sense to me. Gunson explained his plan to me in much the same way. It’s reassuring to hear you both use the same reasoning.

[Post bimax]

@kavan Thank you for the explanation. That makes a lot of sense to me. Gunson explained his plan to me in much the same way. It’s reassuring to hear you both use the same reasoning.

FWIW, I just had DJS revision surgery with Gunson and so far the result is very good imo. No complications and my bite is precise. If my healing goes well it will have been a huge success.

My problem was different than yours, but Gunson is very experienced in revision cases. The main drawback is his price tag.

[bayman]

FWIW, I just had DJS revision surgery with Gunson and so far the result is very good imo. No complications and my bite is precise. If my healing goes well it will have been a huge success.

My problem was different than yours, but Gunson is very experienced in revision cases. The main drawback is his price tag.

Glad to hear you've had a positive experience so far. Thanks for your comments.

You're the second person I've heard say he's good at revision cases. The other was my cousin-in-law who's a jaw surgeon. Is that something you've learned from this forum or more the word on the street between doctors?

[Post bimax]

Glad to hear you've had a positive experience so far. Thanks for your comments.

You're the second person I've heard say he's good at revision cases. The other was my cousin-in-law who's a jaw surgeon. Is that something you've learned from this forum or more the word on the street between doctors?

I've heard it on this forum and others, as well as speaking with Gunson himself.  He does a relatively high volume of revision surgeries compared to other surgeons.  Many people (not all) consider him to be the best, so he's a natural choice for revisions because a lot of times there's no 'third try' in jaw surgery.

[GJ]

there's no 'third try' in jaw surgery.

I actually know someone who's had four...

[Post bimax]

I actually know someone who's had four...

That is insane. I can’t imagine

[bayman]

I actually know someone who's had four...

Would love to avoid that 😬