New Poster wanting input on initial workup. My primary goal is to eliminate OSA.

[gohoos1998]

https://docs.google.com/document/d/1xgmRXdp6Hb4wS27Pslg2KdtWG2XvUjKHfaUb3HcSnHI/edit?usp=sharing

Above is a link to my initial work-up. Please let me know if you cannot see it for whatever reason.

My 2nd in-lab PSG showed a 4.5 AHI 4% with an RDI of 31 with an oral appliance advanced 5 mm - a big step up from my initial 4% figure of 22. This was the initial data that pushed me towards jaw surgery. Nasal breathing is very bad - I wear intake breathing which helps my external nasal collapse, but I do still have OSA.

I underwent a DISE and it showed primary epiglottic collapse. I got it stitched to my tongue base and it did not do anything. Now that I have this CBCT, it seems like it was collapsing just because the airway is so narrow - it explains why it did nothing to my symptoms. It most likely is still collapsing (just because the area is so smalll).

Anyway, my whole case is attached. I am fine with my name/face out here as I know there are many identifying factors in the PDF.

I did notice they did the airway analysis at the top of the airway all the way down to just above my epiglottis. My airway is fine up until then - it seems that they one part of the airway they didn't do any analysis on was where my actual bottleneck is. You can see how small it gets at that point.

OVERALL:

Looks like I am recessed in both jaws and have the classic short face. They recommended a regular Lefort 1 and BSSO, but aren't giving much more info until I come in again.

I'd love to hear any and all comments on this. Do you think that this is the right recommendation? Do you think a 3 piece would be advantageous? My IMW is 35.79 mm (from another CBCT), which I believe is a bit low for a bigger male. Would a lot of posterior downgraft with a little anterior downgraft with CCWR rotation to lengthen the face, steepen the OP and open up the airway be a good idea here? Also, would do you get an improved capacity to nasal breathe from just a regular lefort 1?

Again, primary objective is to cure (or improve OSA as much as I can) but would not be upset with some aesthetic improvement if those two aren't at odds with each other.

I've done a decent amount of reading on the subject, but obviously nowhere near as knowledgeable as most here. Looking forward to what everyone has to say.

[GJ]

To me it looks like double jaw surgery with a linear (forward) movement would be the best solution. This would get your midface outward more, and it would create a little length. Both would be positives, I think.

[kavan]

The doctors at Mount Sinai made very astute observations/analysis of your case, documented the salient measurements, synopsized your 'problem set' (to be fixed) and gave a general surgical treatment plan; a Lefort1 advancement and a BSSO advancement.

Based on their letter to another doctor (which I assume is your surgeon) they are doing their due diligence by requesting him to cross reference and give feedback their proposal. So, with the other doctor's (yours) feedback, the doctors at Mt. Sinai will be able to make some fine tuning to a computer generated (virtual) surgical plan if needed.

It looks very promising in terms of pre-surgical observations that stand to accommodate your objectives; both in venue of correcting sleep apnea and also recession of  the  the maxillomandibular complex yielding some aesthetic improvement.

As to any 3 piece lefort, the letter seems to indicate pre-surgical ortho adjustments will allow for a one piece lefort as does the term (advancement of) 'the maxillomandibular complex'. The letter also indicates that feedback from the doctor the letter is addressed to could accommodate that as an adjustment IF your doctor thought so. So, not for me to 'jump' what conclusions they come to subsequent your second consult or second guess that sort of thing.

As to your question about a LOT of posterior downgraft with a mixture of a little anterior downgraft (net CCW-R), I can tell you that CCW-r usually in NOT indicated for a SHORT face. Basically, your question TRANSLATES to asking: 'I have a short face. Should I get CCW-r to rotate it UPWARD so it looks even shorter?'

As to your question of will 'JUST' a 'regular' Lefort 1 improve capacity to nasal breathing, the answer is YES. However, we don't refer it (call it) 'just a regular' lefort AS if it's somehow not as good as a multi-segment lefort. It's called a one piece lefort. It's moving (forward) the ROOF of your palate which is actually the FLOOR of the nasal cavity.

In short, you look like a candidate for linear advancement which is often called; advancement of 'the maxillomandibular complex' which is when they advance the maxilla and mandible basically as one unit. Basically along your native angle of maxillary inclination. Like with little to no rotations to the maxilla. You are what they call a 'low angle' patient in terms of the angle of inclination the mandible has with a horizontal line. So, that is not an indicator for CCW-r. On the contrary, it's a counter indication for it. Although you have a low mandibular plane angle (MPA), it's still oriented in somewhat of downward diagonal line with reference to the horizont. So, when that's moves 'forward', that 'forward' direction is OUTWARD + DOWNWARD. Hence, the downward displacement vector will yield more 'length' to the face.