jawsurgeryforums.com
General Category => General Chat => Topic started by: ArtVandelay on January 28, 2020, 08:18:50 PM
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Recall I had double jaw surgery followed by a revision one week later. In the revision my surgeon opted not to use any rigid fixation in the mandible and opted for IMF (inter-maxillary fixation) instead. After speaking with other surgeons (will not name them) and reviewing my x-rays immediately after it's now clear to comment on the drawbacks of this approach.
Some comments:
1.) Using IMF instead of rigid fixation is an incredibly out of date practice. This was done in the last century but doctors were horrified someone was still practicing this approach today.
2.) My ramus/condoyle (the mandible piece left free floating) was pulled forward and rotated due to lacking rigid fixation. Muscles will always win here. This destroys jaw line definition since soft issue now sags.
3.) It is evident that point 2.) is true by examining my x-rays from immediately after my surgery when the cuts are still visible and my bones have not fused.
4.) It is possible to undo this movement in a revision (not sure if fully or partially.
5.) It's honestly just sad that a doctor is so out-of-date and doesn't feel a duty to give their patients the best practices available.
Not sure what others can learn from this, it's not like you're going to ask if in a revision will they abandon rigid fixation. But summarizing my findings here as it perplexed me for a while, I did not suspect the extent of my ramus excess rotation here. Can post xrays later if there is interest.
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Can you elaborate what IMF is and show show it looks on your x-ray? Is it like they skip the plates and just band it with the maxilla?
My surgeon explained that former approach was to fully fixate the maxilla, and not the mandible to be able to make small adjustments with elastics after surgery. But that they abandoned that approach and now instead do it the other way by fully fixate the mandible and have some semi-rigid fixation of the maxilla instead to guide the healing. I think you need to have some mobility either in the maxilla or mandible after surgery, as we're working with accuracy under a mm to have the teeth meet properly and you just can't do that by hand. Since your revision was only on the mandible, maybe he had to use some semi fixation as the maxilla was already fused, but it doesn't sound right if it was only 1 week after. Wonder if that's how they do it if they do only lower jaw surgery.
I'm just speculating, but maybe the other surgeons you've asked don't have full insight in your case and just think this fixation was done right away in first surgery, and also want to criticize to gain your trust that they can sell you something better. It's like when I had a painter to help me paint my living room. First thing he did was to criticize my paint job in another room that I by the way was very happy with. I thought wow, this guy must be good if he have that high standards. Turns out, my own job was way better and I had to go over and fix his work after he was done.
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maybe the other surgeons you've asked don't have full insight in your case and just think this fixation was done right away in first surgery, and also want to criticize to gain your trust that they can sell you something better.
+1
This is a common and effective sales tactic
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+1
This is a common and effective sales tactic
That makes me sad. Do you think they are despaired enough to make such a move?
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That makes me sad. Do you think they are despaired enough to make such a move?
The top surgeons (at least in the US) typically run their own practice and are businessmen as well as medical professionals. They have an interest in promoting their own style while being critical of alternative approaches.
Because it's such a frontier procedure with large aesthetic considerations, JS is much more of a 'product' than other medical procedures. Like, nobody is out there marketing hip replacements. But you see it with jaw surgery all the time.
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Sure I attached my xrays, one after my first surgery and another for a week later after my revision.
IMF- you are banded or wired fully shut. In my case four screws were attached to place strong rubber bands. I could not speak or open my jaws for 3 months and lost almost 50 pounds peak to trough in the process. IMF is independent of rigid fixation. You can and should also do the titanium plates if IMF is called for.
Lack of plates in my mandible rotated my ramus up and forward and it looks like it doesn't exist anymore. I looked much better before in that area. See the second xray and the blue arrows.
I'd be looking to undo as much as possible of this movement in my revision.
Since your revision was only on the mandible,
I had a full revision, he unscrewed the maxilla to reposition it too.
They have an interest in promoting their own style while being critical of alternative approaches.
We're not talking about differences in the movements. We're talking about a surgical technique for handling complications that was abandoned by almost every other surgeon because of the drawbacks.
I'm just speculating, but maybe the other surgeons you've asked don't have full insight in your case and just think this fixation was done right away in first surgery,
Over half the surgeons I spoke with were hesitant to criticize another surgeon, especially the ones from the same area. One actually recommended an upper jaw only plan (with massive impaction which would have been an aesthetic disaster for tooth show) just to avoid touching the lower jaw because he didn't understand what exactly went wrong.
But the others that were more interested in my history and willing to speak about it had no ambiguity about the details.
Lol about the painter.
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Sure I attached my xrays, one after my first surgery and another for a week later after my revision.
IMF- you are banded or wired fully shut. In my case four screws were attached to place strong rubber bands. I could not speak or open my jaws for 3 months and lost almost 50 pounds peak to trough in the process. IMF is independent of rigid fixation. You can and should also do the titanium plates if IMF is called for.
Lack of plates in my mandible rotated my ramus up and forward and it looks like it doesn't exist anymore. I looked much better before in that area. See the second xray and the blue arrows.
I'd be looking to undo as much as possible of this movement in my revision.
I had a full revision, he unscrewed the maxilla to reposition it too.
We're not talking about differences in the movements. We're talking about a surgical technique for handling complications that was abandoned by almost every other surgeon because of the drawbacks.
Over half the surgeons I spoke with were hesitant to criticize another surgeon, especially the ones from the same area. One actually recommended an upper jaw only plan (with massive impaction which would have been an aesthetic disaster for tooth show) just to avoid touching the lower jaw because he didn't understand what exactly went wrong.
But the others that were more interested in my history and willing to speak about it had no ambiguity about the details.
Lol about the painter.
I didn't mean to in any way miscredit what you were saying or diminish that there is a problem. I was genuinely interested in how the fixation was made, and also genuinely wanted to point out that these are very hard consultations to do and to know who to trust. It seems like you've made a good research and understand your situation.
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Sorry if I came off as hostile. I've been dealing with this issue again recently and it's been frustrating. I can't find a local oral surgeon willing to take out my wisdom teeth. I've just about resigned myself to getting them out during surgery since apparently they are easier to access during a BSSO. My surgeon couldn't care less about what he did, he only cares about performing surgeries, the second you're out of the OR is the second he disappears.
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An email from my surgeon:
"Non-rigid Intermaxillary Fixation with rubber bands was used instead of Rigid Fixation with hardware to better ensure that the correct surgical occlusion was established and maintained during healing.”
Translation:
I did such a poor job planning that your bite didn;'t have any chance in hell of fitting properly so I needed let your lower jaw float around and settle in an unnatural position to get any marginal occlusion. It rotated in all 3 axes and is as a result asymmetric but I don't care about any of that, also go f*** yourself.
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Sorry if I came off as hostile. I've been dealing with this issue again recently and it's been frustrating. I can't find a local oral surgeon willing to take out my wisdom teeth. I've just about resigned myself to getting them out during surgery since apparently they are easier to access during a BSSO. My surgeon couldn't care less about what he did, he only cares about performing surgeries, the second you're out of the OR is the second he disappears.
Why don't they want to remove your wisdome teeth? I thought that was what 95% of the surgeons spend their days doing. I had both lower removed during surgery and wouldn't say it was a problem, but most of my pain probably came from this and not the actual jaw surgery.
When was your surgery? Sounds like it was recent if you still have contact by mail? What you write kind of put the finger on what I wanted to highlight. Your surgeon probably made a good impression and told you how wrong everything was and how he was going to make it perfect before surgery. Just so you don't fall for that again, and understand what expectations that are reasonable.
I'm not educated enough to evaluate or comment on your outcome or what techniques are the proper ones. Did your surgeon see the need for a revision him self, or did you have to push for it? Just wonder because if he himself can spot that first outcome was not good and offered trying to fix it, it at least sounds like he doesn't want to give bad outcomes. But that of course doesn't help you if he use bad techniques or if his best is bad. Just wanted to balance the discussion that someone who offers a revision at least make an effort instead of flat out abandoning it.
I sure can understand the stress you're going through. When you do the first surgery you're full of hope and have never been more ready. When you do the second you're exhausted but figure mistakes happen. On the third you just don't know where to turn, who to trust or what to expect.
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When was your surgery? Sounds like it was recent if you still have contact by mail? What you write kind of put the finger on what I wanted to highlight. Your surgeon probably made a good impression and told you how wrong everything was and how he was going to make it perfect before surgery. Just so you don't fall for that again, and understand what expectations that are reasonable.
It was in 2013, that was an older email. I lost about 50 pounds and was too traumatized from the experience to even think about a revision until recently. My airway problems will only get worse with age.
Why don't they want to remove your wisdome teeth?
Two reasons, it's close to the nerve that runs near the bottom or your mandible and they're in a hard to access spot. I can feel them from the inside of my mouth but they have to drill from the top. But since my ramus is shifted up and forward there's a lot of bone to drill through to get them from the top. I'm debating blast emailing other local surgeons to find one willing to get them out from the inside of my mouth but I was told no one does it because there's a 'lingual nerve'? from that side. Haven't researched this yet.
Did your surgeon see the need for a revision him self, or did you have to push for it?
The need for a revision was mutual from the start, they didn't offer any resistance. I went in with an open-bite and after my surgery I still had almost the same open-bite. Also my maxilla midine was way off, visibly past the lip grove. It was apparent to me the very next day things didn't go as planned. I preferred my bite/appearance from before my 1st surgery to after. It was that bad.
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Two reasons, it's close to the nerve that runs near the bottom or your mandible and they're in a hard to access spot. I can feel them from the inside of my mouth but they have to drill from the top. But since my ramus is shifted up and forward there's a lot of bone to drill through to get them from the top. I'm debating blast emailing other local surgeons to find one willing to get them out from the inside of my mouth but I was told no one does it because there's a 'lingual nerve'? from that side. Haven't researched this yet.
Sounds like similar situation as mine. I went to the local surgeon to have my impacted wisdome tooth removed. I thought he was gonna remove it directly at my first visit, but he said he wanted to x-ray my nerves first. He then came back with the decision to not remove it, but rather split it and remove the crown and leave the root as it was tangled with the inferior alveolar nerve.
Then I had jaw surgery and woke up to "by the way, I removed both your wisdome teeth as well". Including the one my local surgeon had left in the bone 5+years earlier. Dont seem to suffer from any nerve damage at that side. I thought they always did this either before or during jaw surgery, was surprised to see you still having yours after a bsso. Even my orthodontist told me that they always remove them 6 months prior to surgery if I had done it in the public health care.
So what's your current plan and where are you in the process? Sounds like you've done some consulting and know what you want to do?
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I thought they always did this either before or during jaw surgery, was surprised to see you still having yours after a bsso.
I'm still not sure why they were not removed. My surgeon disappeared after my surgery and the residents were of no help. I had to mention getting a lawyer to acquire my records before he responded to me.
So what's your current plan and where are you in the process? Sounds like you've done some consulting and know what you want to do?
Still haven't fully committed to a plan.The first step was to figure out the wisdom teeth. The second step is the big one and I'm still debating, having 3 choices:
1.) Regular L1 & no braces pre-op
2.) Segmental L1 to widen maxilla, heavy braces to untorque lower tipped molars (should take 6 months of braces I was told). See curve of wilson in post #8 here: http://jawsurgeryforums.com/index.php/topic,7568.0.html
3.) Chin wing, drop at ramus, shorten at front
I've given myself three weeks to figure everything out.
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Could a mod please change Berhman to Behrman in the topic name? thanks
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done
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TLDR; 8mm over-rotation due to lack of fixation
Thanks. I'm also adding a pre-surgery versus after revision comparison here. You can see that after my surgery my impacted wisdom tooth is close to the border of my jaw. This has caused difficulties in finding a surgeon to remove it. Good news is I found one, bad news is I have to wait until lockdown ends to travel there...
Also in the image you can see the extent of the forward rotation of the proximal fragment (segment with the condyle and ramus). This was over-rotated due to muscle pull and lack of fixation. The plan is to rotate the proximal fragment down to match the inferior borders of the mandible. As far as I can tell pano's preserve vertical distances, measured a bunch of different landmark points and they're all preserved. By my measurement it's off by around 8mm. I can feel this step off physically and 8mm feels right. Fixing this is a top priority and kind of a kicker for me not to go the segmental route (If I can fix this + better airway then I'll be the happiest person on earth, Curve of Spee and Curve of Wilson be damned).
Now a note on lack of fixation. As far as I can tell this was something that was phased out decades ago, this statement is from my own research. One surgeon (will not name) even refused to believe I had a BSSO, thinking I must be a confused patient; he claimed no one would actually forgo lower fixation. Dr. Behrman told me this happens to around 4 of his patients a year (fixation failure). This technique is out of date and a disservice to patients to use it.
Note: these are panorex x-rays and not cephs. I can un-crop it if anyone prefers.
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I was reading the reviews online for D. Behrman, and a majority of the reviews sound like a horror story. I cannot fathom that people would just post negative outcomes to destroy someone's career out of sheer frustration or not living up to there expectations. Does anyone know if these reviews have merit?
https://www.ratemds.com/doctor-ratings/48578/Dr-David-Behrman-NEW+YORK-NY.html
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There's several things at play here. First, IMO Dr. Behrman plays a high stakes game with the customer service side of his practice. He lets residents do mostly everything before and after surgery (claims not during surgery and I still believe him on that point). Especially afterwards, you're lucky to get a glimpse of him. I barely saw him after surgery and I had serious complications (mouth wired shut almost 3 months). Not giving patients face-time is in itself not a problem IF you're delivering good results. I recall hearing a lot of medical malpractice suits happen because of the poor relationship between the doctor and patient. All surgeons will have some percentage of bad cases, it is inevitable in a game of millimeters, it's probably how truthful and forthcoming the surgeon is that determines the scale of unhappiness.
Here's my customer service experience at New York Presbyterian. A couple days after my first surgery, I had to decide whether or not I wanted a full revision (what I eventually choose) or having him manually push my maxilla into place under local anesthesia. So here I was after a failed surgery with a big time-sensitive decision to make and he gave short answers to everything, didn't volunteer any information unless explicitly asked, and even bullied and blamed me for "biting to hard after waking up from anesthesia" which other surgeons have said is almost impossible. And he never once mentioned he wouldn't use lower plates on my mandible (creating the drawbacks you see in this thread) nor that I would have my jaw wired shut, losing nearly 50 pounds. Imagine waking up from surgery and finding out you have your jaw shut (to be fair it's probably likely he decided during or shortly before surgery). And I only found out about the lack of lower plates weeks after when I glanced at an x-ray during one of my appointments. And in follow-up appointments he would refuse to speak with me, a resident would enter my room and say Dr. Behrman says your concerns aren't valid, etc, etc, etc etc.. The customer service policy feels like: uniformed patients make the best patients.
Now I consider myself pretty thick skinned, his yelling and bullying, while unpleasant didn't bother me at all. But I can imagine his attitude hits a nerve with a subset of the population. So the customer service angle of his practice is not doing him any favors. He's playing a high stakes game and not hedging any of his downside, and those hedges are cheap. But the thing is, he doesn't even need them, he has a full patient pipeline with long delays to make an appointment, lots of NYC orthodontists send patients to him, so this approach works for him. A lot of people, like myself at the time, assume orthodontists know what they're talking about when it comes to jaw surgery (I went to several orthodontist in the NYC since they were free appointments and called many others and he was a popular choice among them.)
I mentioned there are several things at the top, but this a long post already so I'll break it out.
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I have to say, given all the crimes perpetuated by surgeons, I am surprised I've never heard of patients "taking matter into their own hands". A bad aesthetic outcome is one thing, but time and time again I hear about patients physically suffering post-op - people's live are ruined. Europeans, Australians, Canadians being soft-cocks is one thing, but what about militant Americans? Forget physical retribution (BTW, I'm not advocating anything), people (some of them obviously wealthy enough to do so) don't even bother to sue their surgeon (this I heartily endorse). A common excuse is "damages are limited to X, what's the point?". Money is not the point, and neither is justice. It is all about retribution. The scumbag surgeon should get to feel at least a fraction of the pain and discomfort that he has caused. But people are even afraid to name their
torturer surgeon.
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people (some of them obviously wealthy enough to do so) don't even bother to sue their surgeon (this I heartily endorse).
Lawyers generally don't like taking orthognathic cases unless the surgery brought about some serious disabilities. The cases are considered expensive from their side due to the need for expert witnesses. I really wasn't interested in suing, regret it a little now. Your only retribution option in most cases of surgeon misconduct is to name and shame them like you say.
I also don't get why a lot of unhappy patients refuse to name their surgeon. My surgeon claims to have done a good job so if anything he should be delighted I've put my x-rays online.
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[...]. But people are even afraid to name their torturer surgeon.
That isn't really my experience in germany. Several days ago I found a german bimax group on facebook. I even contacted some "unhappy" patients. What was really strange, that some talk a lot bad things, but didn't want to provide further information like pictures or even x-ray. Some did provide pictures, but the outcome wasn't bad at all.
I think, that bad cases are real (like here in this topic). But many patients just seems to have some mental problems, or didn't analyze their face before. One Patient complained about a crooked chin after a genioplasty, but her mandible was already asymmetrical before.
ok, but in the US a surgeon could sue the s**t out of you. Your fines are lunatic. Maybe that is the reason, why in the us the patients wants to sue their surgeons rather to give them some physical beating. In Europe the last one is a better option.
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Lawyers generally don't like taking orthognathic cases unless the surgery brought about some serious disabilities.
You seem to be worse off than before surgery and suffering. That's all that matters.
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That isn't really my experience in germany. Several days ago I found a german bimax group on facebook. I even contacted some "unhappy" patients. What was really strange, that some talk a lot bad things, but didn't want to provide further information like pictures or even x-ray. Some did provide pictures, but the outcome wasn't bad at all.
I think, that bad cases are real (like here in this topic). But many patients just seems to have some mental problems, or didn't analyze their face before. One Patient complained about a crooked chin after a genioplasty, but her mandible was already asymmetrical before.
I don't mean bad to mediocre aesthetic outcomes (and there are plenty of those). I mean surgery which results in physical suffering — whatever functional issues the patient may have had before, he is much worse off post-op and suffering. And yet the patient is afraid to even mention the surgeon's name, let alone seek legal recourse. It's Stockholm syndrome.
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The second thing at play is his technique. He's a real old school surgeon who doesn't use 3D virtual planning. This has functional implications, you can't get an accurate airway measurement without a 3D xray. Evidently Dr. Behrman is unaware airway management is a component of a successful jaw surgery plan. He never once performed any airway measurements on me during the whole process. Currently, my airway is a small 58 mm^2, to my knowledge he never measured this before surgery. I have no idea what the change was from my operation, even if it shrunk or increased. I mentioned sleep problems during my consultations, but was unsure if this was because of my open bite/lip strain or other reasons. This can't possible be state of the art care. I had pre-molars removed as a child, so my maxilla was and still is obviously recessed. My tonsils crowd my throat since they have no place to go, giving the appearance I'm sick when examined, dentists and doctors have sometimes asked me if I currently have a cold during appointments. Yet his plan was to advance my ANS point by a whooping 2mm.
I should have sued him on grounds the plan was inappropriate. The plan was convenient for him since he claim he improved the bite so surgery was a "success" in his eyes but any surgeon could have improved my open-bite with the starting position I was in. Improvement is a low bar, if you need a revision after two attempts then the surgery was a colossal failure. And even with this simple inappropriate plan the surgery was botched, poor plan poorly executed.
Other surgeons have a face-airway-bite philosophy, IMO Dr. Berhman's philosophy is bit, I'm leaving of the last 'e' since even for the bite the standards were low (I've been told from my pre-op pics that my orthodontics for surgery were shoddy and I needed more time, this might have contributed to the poor result). I needed 15 months of orthodontics post-surgery to stabilize things, which included filing down a corner of a molar which was hitting early (without that drilling my bite would not be closed). He's just too old school to provide appropriate treatment plans. His goal is to improve your bite in any minimal sense, that way he can argue the surgery was a "success" and any complications were a known risk. A very different objective from what patients are looking for.
Another more technical note. I may mix up details here as I don't want to pull up references. It's impossible to perfectly place two jaws in a bimax such that they bite will be perfect as is. Instead you need to allow some wiggle room on the order of ~1mm to let it settle into place. One way to accomplish this wiggle is with hard elastics right after surgery before the bones heals. Now most modern surgeons prefer to leave the maxilla a little loose. Not Dr. Behrman, as seen in this thread, in my case he was of the opinion the best way to achieve this settling in is by skipping the titanium fixation part in your mandible. What you get is the complication in this thread.
Edit: airway is 58 mm^2 and I'm over 6 feet, can't find a link for statistics on minimum airway size of OSA patients will reply when I find it
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3D planning is pretty sophisticated and amazing now. Look at this video. The human error is still on the order of 1mm and too high to get perfection but a good plan makes the surgeons jobs easier, less surprises in the operating room.
https://www.youtube.com/watch?v=kqRfYdvuaEk
In my opinion Dr. David Behrman is still doing jaw surgery the way his uncle, Dr. Stanley Behrman, taught him back in the 80's.
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Regarding the airway, when I actually confronted them after my surgery if they even followed my pathetically inadequate plan. They completely dismissed my question and called the plan irrelevant. They said the plan is only a rough guide, in the operating room "the bite guides the surgery" . There's no guarantee you'll get anything close to your movements since if the bite improves they are done and out of there. The
face - airway - bit ('e' intentionally dropped) philosophy. From my perspective he's not talented enough to manage your airway during the surgery. It wasn't even considered according to their own words. The best you can hope for is some marginal bite improvement.
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Found an interesting article on stability and relapse:
https://head-face-med.biomedcentral.com/articles/10.1186/1746-160X-3-21
Not the main point of the article but one point is relevant here: "For Class II patients, rigid fixation is needed for stability when both jaws are operated: the single jaw procedures are stable without rigid fixation but not when the procedures are combined. With rigid fixation, significant change (>2 mm) beyond what is created by mandibular rotation when the splint is removed occurs in only about 20% of the patients treated by a two jaw procedure (Figure 5). Clinically, an excellent result is obtained in 90% of the patients with rigid fixation, but in only 60% without it"
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Man, great username.
So what's the status?
Did you find someone to do revision, and do they think it will be reasonably successful? Any plan? etc
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Man, great username.
So what's the status?
Did you find someone to do revision, and do they think it will be reasonably successful? Any plan? etc
Due to the complications listed in this thread it has been impossible to find a local oral surgeon to take out my impacted lower molars. Good news I found one, bad news is international travel is banned at the moment. Funnily enough one well respected surgeon was fine removing my impacted wisdom teeth during the operation. But when I showed him my post surgery x-rays where you can see the cuts like above then he immediately flipped his rec'd to getting them out beforehand, too much danger of a fracture or bad cut with them in place. The general reaction I receive when showing surgeons, both oral and max-fac, these x-rays is one of horror; they're shocked someone would go medieval like that on a mandible.
My complications are twofold. First my treatment plan was, let's just say, inadequate; with a meager 2mm maxilla advancement. My surgeon was unable to juggle two problems at once, he focused on the open bite and ignored airway and bimax retrusion completely. Fixing this part is a straightforward case of advancement of around 5mm with a small amount of CCW. No need for any crazy downgrafts. (Decided against a segmental L1, leaving my maxilla slightly narrow as it's not my most salient problem) This part isn't complex to fix.
What makes it more complicated is that I was the victim of a "sloppy surgeon" who was fine letting my mandible float and rotate in all 3 axes by forgoing titanium plates. Complications include, 1.) destroying my ramus 2.) canting my mandible/maxilla slightly, 3.) causing a huge step-off on one side because the condolye rotated excessive forward and 4.) introducing general asymmetries. This part is tougher. It is possible to improve, the goal is to realign these pieces, a reunion years in the making. We're talking rotations in all 3 axes here.
This complication is encountered occasionally by the top revision docs. You need three factors for this to happen 1.) a surgeon who practices like it's 1979 2.) a fixation failure due to poor planning. 3.) terrible plan which needs a revision. Unfortunately for society, but fortunately for me, these aren't that rare, and these 3 factors are far from independent. The top guys might see this complication to some extent a couple times a year in a revision operation. I'll be satisfied with an 80% improvement here. Oddly enough, because my pieces are so far off and disjoint, it actually makes it easier to place the BSSO cut.