jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Optimistic on June 03, 2014, 07:56:40 PM
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Not sure why I bother doing this when I'm arbitrarily banned from accessing the most important part of the forum. Still I'll share what I learn for now. /rant
So I had a consult with Dr Triaca last night. I'll have another soon once I send more photos and scans - he's very professional might I add. I'll consider doing a write-up once I've had my second consult. All I'll say is 1) he performs a huge number of chin wings and various other osteotomies 2) He has developed and offers a large range of highly specialised osteotomies and DO procedures that nobody else in the world offers. The short end of it is that he has found numerous ways to make the labiomental fold a moot issue with undergoing jaw surgery. I knew this already after looking up a few of his studies, however he took the time to explain a few more.
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So onto the most important part that I wanted to bring up here. I was talking to him about hydroxyapatite and various other things. In his own words he said that he doesn't use any "onlays" as the evidence is that they end up absorbing the bone they're attached to. He said that he sees it a lot, and just recently treated a young girl who came in and literally had a hole in her mandible!
Has anyone heard of this before? It's a scary thought.
Moreover it begs the question then of what he uses instead. What are other alternatives to modestly augmenting various parts of the face and smoothing over contour irregularities from jaw surgery?
I know for a fact that his malar osteotomy is NOT a 'sandwich' osteotomy for this very reason. He doesn't employ the use of foreign objects except for titanium which he said was very good.
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Dafuq? Do you mind asking him if he has any case studies by himself or his colleagues that demonstrate this ?
- can you ask him how many months post op that he sees this?
- does it depend on where it was used or the amount used ?
- is it reversible ?
I've heard the complete OPPOSITE about HA that it stabilizes bone . s**t.
....Will not lie reading this gave me a sinking feeling in my gut. :-\
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Oh, s**t...really?
I would be super interested, if you come across any more information.
Thanks!
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Dafuq? Do you mind asking him if he has any case studies by himself or his colleagues that demonstrate this ?
- can you ask him how many months post op that he sees this?
- does it depend on where it was used or the amount used ?
- is it reversible ?
I've heard the complete OPPOSITE about HA that it stabilizes bone . s**t.
....Will not lie reading this gave me a sinking feeling in my gut. :-\
I'll absolutely do that. If people have questions about this put them here and I'll ask as I honestly found his response quite shocking. After all most studies have mentioned reabsorption and stability issues but never actual native bone loss.
The other thing that I'm not sure I emphasised enough in my original post was he kept referring to "onlays" when discussing this. Perhaps there is a nuance I'm missing here? However I never mentioned implants only ever hydroxyapatite so I can't imagine that there was much confusion. I'll be sure to confirm just what he means by 'onlay' and whether he is talking about HA paste or some other kind of similar grafting / filler substance. He also said many surgeons seem to prefer to use "onlays" as it can be done far quicker and simpler than recitfying the problem with an osteotomy or distraction (in reference to me talking about MM and jaw angles). It was also following this thread of conversation that he brought up titanium as an excellent choice. So MAYBE he was referring to implants all along? Although titanium is also used for the screws and brackets in maxfac work. Who knows?
It definitely warrants some digging into. Dr Triaca didn't come across like the kind of guy who would lie about this, nor do I see a reason why he would lie about it.
If you think about it, lying about results of a malar osteotomy in the case of Dr Alfaro makes sense. He claimed that his malar osteotomies were unstable and kept reverting to baseline when every other surgeon's experience is the exact opposite. So there is something in it for him to trash a ZSO / ZO. However in the case of HA paste any surgeon can use it, it clearly has a great deal of utility. Avoiding using it would only be to the surgeons detriment.
Hope you can follow that line of thought. I find it bizarre that HA paste could truly cause such things.
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How much does he want for a surgery?
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Is HA the exact same regardless of the surgeon using it, or do different clinics utilize different compositions? Besides being curious about the specific composition, I also wonder if all surgeons prepare it the same way? What about how it's cured/set?
I wonder if there's some sort of pattern between the answers to the questions above, and the issues we are potentially seeing with HA. Or...maybe, it comes down to all this being a coin toss.
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Thanks for sharing this with us, Disillusioned...bet your name feels even more appropriate now!
Regarding HA, could he be dissing it with the intent of selling people the much more costly titanium implants? These guys are businessmen at the end of the day.
I believe A&G mix it with something before slapping it on, could it be your own blood or am I seriously off track here...it's something more organic than just the raw stuff iirc.
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No one uses the "raw" stuff. Mommaerts mixes it with fibrin and other stuff I can't remember. Arnett and Gunson does do something differently though since they're able to mold the HA for a long time after the surgery.
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I've also read that. Hydroxiappatite tends to erode to the bone and some surgeon was quoted saying it's useless and the surgeon trying to make more money. He said only calvarial bone grafts don't reabsorb. I have read it somewhere on the jawsurgeryforums I suppose.
The amount of money that Arnett and Gunson charge for HA grafts is shocking.
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The amount of money that Arnett and Gunson charge for HA grafts is shocking.
Indeed, especially when the results are said to be modest at best...was it CK that was less than impressed?
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Indeed, especially when the results are said to be modest at best...was it CK that was less than impressed?
So how much of antbee's "improvement" was just post operative swelling.
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So how much of antbee's "improvement" was just post operative swelling.
I wish she'd come back and tell us.
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Indeed, especially when the results are said to be modest at best...was it CK that was less than impressed?
My HA augmentation is definitely very noticable although I don't like it much due to how it was placed.
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GS,
This is probably a silly question, but you can't feel it, right? Like when you're sleeping on your side with your face pressed into your pillow, it feels normal, correct?
Thanks!
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It does feel strange when I touch that area with my fingers. It's a bit harder and much more numb than the rest of my face.
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Interesting post Disillusioned. Shame if this is true, HA does seem like it could be a perfect solution for a permanent sculpted augmentation short of custom implants. This info is confusing as I thought the claim for HA was it encourages new bone growth. Some things I have come across mentioned it more as a "scaffolding" structure to encourage new bone growth when used in a hollow, "filling it in". Can it be used extending beyond the surface bone structure (i.e. like an implant, and at what depth)?
Also I had a consultation with Dr. van der Dussen who uses HA direct to permanently mould cheeks and he mentioned he mixes it with something to allow him time to shape it before it sets. I can't remember for certain but maybe it was with Bioalcamid (of which I have read very bad reviews from HIV wasting patients online, another quote found there was: ?Most [permanent] soft tissue fillers have not stood the test of time and thus should still be considered experimental.?
A later consultation with Dr. Daniel Sim?n (maxfac with Facial Team who worked with van der Dussen) said that they reviewed a few patients who had this HA mix and when they investigated the HA area it was still wet (not sure how long after, whether due to complications or not). Just food for thought on the matter, sorry I can't be more certain but maybe someone could clarify some of this
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I have a consultation soon for revision rhino. The doc also does HA paste augmentation of cheekbones (he is a max fac as well as a PS). I will ask him about this and what he mixes it with
It's a shame custom titanium isn't more widely available....I'd love it for my gonial angles. I think in 5 years, its use will be much more common and not as crazy expensive. Sucks for us that 5 years is too late....
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I wish she'd come back and tell us.
Why did she leave?
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Why did she leave?
Not sure, I assumed she was happy with her surgery and just got on with her life. Hope so.
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Might be of interest
The Fate of Porous Hydroxyapatite Granules Used in Facial Skeletal Augmentation -
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906722/ (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906722/)
From the abstract
Thickness of original bone plus overlay of hydroxyapatite, thickness of the overlying soft tissue, and the overall projection (bone plus soft tissue) were recorded. It was found that 99.7% of the hydroxyapatite was maintained at 2 years, with no statistical difference (t test) from the baseline measurement. The overall projection (bony and soft tissue) was maintained as there was no evidence of native bone resorption or soft tissue atrophy. Radiographic results confirmed that the use of porous hydroxyapatite granules for enhancement of the facial skeleton is not only a predictable procedure, but maintains full bony projection at 2 years.
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I will most likely be seeing Mendelson about under eye augmentation.
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Thanks for taking the time to dig up that study. I wish it was 10 years, not 2 years, but it's a good start.
Thanks!
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Thanks for taking the time to dig up that study. I wish it was 10 years, not 2 years, but it's a good start.
Thanks!
Mind you, mendelson is a ha paste booster.
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Mind you, mendelson is a ha paste booster.
You aren't concerned about his negative reviews?
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You aren't concerned about his negative reviews?
I've heard of them, but I've never seen them. Anyway, just want to hear what he has to say. I mean what's the alternative? Le Fort 3?
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Hey PP,
Sorry, this might be a double post; I don't know where it went.
There is the option of a Quadrangular LeFort I or II. I've only heard of Keller doing them, and it is my understanding that all incisions are through the mouth (like normal). I think there was a pretty long thread on them awhile back, maybe started by Lazlo? The thread may not have been started by him, but he certainly contributed a lot of information. I've consulted with Keller a handful of times (not for that), and he's a good guy.
Cheers!
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I've heard of them, but I've never seen them. Anyway, just want to hear what he has to say. I mean what's the alternative? Le Fort 3?
I have never seen anyone actually have that area augmented with HA. Mommaerts said that fat injections were better when I discussed it with him (although his opinion doesn't mean much at this point).
I'm planning on having a consultation with Triaca soon so I'll ask him what can be surgically done to enhance that area.
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i'm planning on having a consultation with Triaca soon so I'll ask him what can be surgically done to enhance that area.
Please do. I'm keen to hear what he has to say. You've seen my pics. Lefort i is not enough in my case.
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Please do. I'm keen to hear what he has to say. You've seen my pics. Lefort i is not enough in my case.
Honestly, you look much better than what I do in that regard. I don't think its's a big deal in your case. I'll send you a PM with some images so you can see for yourself.
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I have never seen anyone actually have that area augmented with HA. Mommaerts said that fat injections were better when I discussed it with him (although his opinion doesn't mean much at this point).
I'm planning on having a consultation with Triaca soon so I'll ask him what can be surgically done to enhance that area.
Didn't someone here have orbital rim HA grafts? Or obsess about the orbital rim?
I got filler. 1.5ml total. Made a big difference, so consider it. Go for a thicker filler and get it put in deep - non of this superficial bollocks (thats for individual lines)
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CK wrote that you can opt to have something done to the eye area when you have surgery with Arnett and Gunson but it's unclear if he went for that himself. I've never seen any results from them where the eye area was addressed so I dunno what exactly they do to it. Fillers might work great for many people but they are temporary and they just mask the real problem. The paranasal HA augmentation I got does not smoothly transition to the rest of the face so I need to have that addressed either way. I really hope it can be removed so I can get something similar done to what the girl from the Obwegeser thread had done.
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Didn't someone here have orbital rim HA grafts? Or obsess about the orbital rim?
I got filler. 1.5ml total. Made a big difference, so consider it. Go for a thicker filler and get it put in deep - non of this superficial bollocks (thats for individual lines)
Any idea who that was? I'm pretty interested in learning more about orbital rims myself.
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GS,
Will you let us know if it can be removed, whenever you find out?
Thanks in advance!
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I'll write an update if I can manage to get a consultation. I got a reply this morning but they wanted me to call them to arrange a consultation in person. I haven't received a reply to my request for a Skype or e-mail consulation. I'll call them on Monday and see what happens.
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Honestly, you look much better than what I do in that regard. I don't think its's a big deal in your case. I'll send you a PM with some images so you can see for yourself.
You look above average (and I judge harshly). But I can see your frustration. Q) What makes a handsome face? A) Robust bony framework + attractive features (lips, eyes, nose). You have a robust skull, nice features, but the midface is not projected forward enough from the eyeballs down. Almost there. (I used to think so of myself as well, "robust skull and all", but my bones are roundish, and my features are average at best (bad in the case of my nose)).
Regarding your LeFort 1, your maxilla looks like it should still be a bit further forward (but I'm no doctor).
Frankly, I don't know how the under-eye hollowness can be truly fixed, except with a Le Fort II or III. Because all class IIIs that were weak under the eye before Le Fort I remain so after Le Fort I. Class IIIs can look mean, solemn, "absorbed in thought", "lifeless" (I've been told 3 of the 4 at least). OTOH, this is a section from the maxillary orthognathic chapter in "Peterson's Principles of Oral and Maxillofacial Surgery 2nd ed 2004"
Modified Le Fort Osteotomies
Osteotomies that extend the traditional Le
Fort I have been called by many names
including modified Le Fort I, II, III; high Le
Fort I; and pyramidal, middle, intermediary,
quadrangular, and maxillary-malar-infraor-
bital osteotomies (Figure 57-45A?C). We
have used them all and have described them
previously. 105 This group osteotomies is
ofseverely limited regarding expansion, and
rotational and torquing movements. There-
fore, with the success of porous polyethyl-
ene implants to the malar, infraorbital, later-
al orbital, and paranasal regions, we rarely
see a need for these more invasive osteo-
tomies (Figure 57-46A?C).
That's it. A 1500 page textbook.
BTW, I don't know what your BF % is. But it might be worth trying to get down to 10-12%. I dropped down to 11% and learnt a lot about my face. I was like a potato before.
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Disillusioned did you ever ask Triaca or have him get back to you ??
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Disillusioned did you ever ask Triaca or have him get back to you ??
Not yet, still need to get some scans done before we can talk again. I will bring these things up when I speak to him next.
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Make sure to ask him if HA can be removed and what he can do about midface and infraorbital deficiencies. They haven't responded to any e-mails since the first one where they wanted me to call them to arrange a consultation and I don't feel like doing that until I know more about what he can do.
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Make sure to ask him if HA can be removed and what he can do about midface and infraorbital deficiencies. They haven't responded to any e-mails since the first one where they wanted me to call them to arrange a consultation and I don't feel like doing that until I know more about what he can do.
The only infraorbital case I could find on the web.
http://www.exploreplasticsurgery.com/2013/05/04/case-study-correction-of-eyeorbital-asymmetry-with-hydroxyapatite-cement/
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I'm not sure if infraorbital deficiency is what I have but that case doesn't look like my problem (he had eyes that were popping out).
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Make sure to ask him if HA can be removed and what he can do about midface and infraorbital deficiencies. They haven't responded to any e-mails since the first one where they wanted me to call them to arrange a consultation and I don't feel like doing that until I know more about what he can do.
That's weird. I got a totally different response. Perhaps it is a language thing?
Speaking their language goes a long way I think. Mommaerts was very friendly to me, which was in stark contrast to the experiences of other members. And now you mention this with Triaca.
I'll be asking these questions when I speak to him next, so if you wish to wait you can. Infraorbital augmentation is of interest to me.
Regarding midface what were your concerns specifically? Isn't that quite straightforward? A le fort is necessary?
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Are you consulting with him face to face or via Skype?