jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Dharma on May 09, 2016, 08:26:07 PM
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Alright....
I've heard horror stories, I've heard miracles, I've seen photos that suggested some of the most aggressive approaches around.
I've been in contact with Dr. Deschamps-Daly, Gunson, Sabol, Walline, and others who were all open to performing my revision but were more or less conservative with both logistics, chronology, and approach.
I spoke with Wolford's staff today and they were like: come in yesterday and we will do ALL THE THINGS.....
It was both refreshing and...um...unsettling.
Not sure what to think. So what's the cutting edge consensus on this character?
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I don't have any experience with him, so this is just what I've read online, but apparently his approach is generally aggressive (at least in the case of joint issues, and some folks think he's overly aggressive in that regard). He is also supposedly one of the very best. Finally, he is expensive.
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Ya, I think I'm going to bob and weave when he tries to touch my TMJs. He actually already wants an MRI of my TMJ's and he hasn't seen me yet--so it was a thousand dollar imaging study prior to evaluation and without any talk of TMJ issues that has set an early precedent for our interactions.
If I can get a surgical chastity belt for my TMJ's and get him to focus all that surgical aggression on the osteotomy revisions maybe I'll be OK...
Expense: Him and A&G are like buying food at the airport. That said, the analogy dies when you consider their level of apparent expertise. "You get what you pay" for maybe an apropos aphorism here?
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Any brave soles willing to share their before/after's if they've seen him? Anyone else have access to ones not on his website?
Also, with the crazy amount of CCW and drastic occlusion plane changes he does, anyone know about any TMJ, stability, or esthetic issues (like your smile) after such movements? Maybe that's part of the reason he's so into TMJ repair? I'm so jaded.....
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Dr Wolford believes that joint surgery is safe and reliable and has concluded that few others do it because they don't offer it. He also believes that joint pathology is responsible for relapse and is willing to operate on them even when asymptomatic. He claims that 25% of OSA patients meet this criteria. I had my MRI done elsewhere but it was only a few hundred dollars as I recall, covered by insurance. No other surgeon has been able to reproduce these results and he claims that is because they don't do CCW rotations. If he determines that you do indeed have defective joints, then he will likely refuse to operate unless the joints are included.
My impression is that CCW rotations have been performed by most surgeons now for over a decade, especially younger ones, and joint pathology is very common, affecting up to 55% of the population at some point in life (only about 30% clinically). What I have observed is that Wolford is more aggressive in advancements than most surgeons because he believes that since you're already taking the risk the airway should be fixed while you're at it, a position I strongly agree with. I've seen way too many gummy smiles fixed by single jaw surgery. Still, I would think that were his conclusions correct there would be consensus as other oral surgeons should be seeing it often too. Other oral surgeons sharing his philosophy, while rare, appear to be piggybacking on his publications rather than independent research and experience. TMJ surgeries are rarely performed and there have been few publishes follow up studies on outcomes. It's not hard to find failures but successes or word of them appears to be completely lacking. I conclude that no one really knows what the true outcomes of joint surgery are. Most patients chose to suffer in silence or seek care elsewhere (or simply die off even in the worst cases without attribution).
Wolford tends to get referrals from more complicated cases so I wonder if there's selection bias in the patients he operates on. He's noted, for example, that nutrient deficiencies are common in his cohort and perhaps those are the ones more likely to be referred to him. Like your mom said, eat your spinach! My respect for Dr Wolford stems not only from his willingness to help anyone but also that he does believe he is delivering the best care long term to his patients, of which there are probably many thousands by this point mostly quiet on the internet. His publications are also excellent, even with biases I mentioned.
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Thanks M.
I'm also going to see Dr. Movahed, one of Dr. Wolford's proteges. Both of them have taken a look at some of my imaging already and feel that its likely I'll need bilat replacements--yikes.
I see Gunson next week, I'll be interested to hear he take on this. I'm also getting an MRI on the 1st to help check out the joints.
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I looked at Wolford's photos hoping to see extreme movements, but as always these look lackluster for me.
I want my jaws more foward, why is Sailer the ONLY surgeon I can find who does huge advancements? Most of his patients have a very stylized look, their jaws I mean. In real life
I wanted that but unfortunately my jaws aren't very foward, I don't know if muscle or something prevented him from going more.
So at some point I will want rotation again.
Can anyone show me ONE surgeon that has results like Sailer?
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Surgeons can advance the mandible up to 25mm but above 10mm there are many challenges. Finding sufficient bony overlap is hard, fixation is hard (and relapse increases), joint problems more common, notching all but guaranteed, potential functional problems to the upper airway, reduced chance of sensory recovery, greater transient ischemia and implied risk to teeth, greater chance of patient aesthetic rejection, limitation on multi-segment procedures, and unaesthetic fullness from the larger maxillary advancement needed. I've listed a lot of potential problems but I don't mean to imply that it can't be done. I know people who've had it done and the compromises have been fine for them. This is an elective procedure, one which most surgeons agree warrants only negligible risk. Most importantly, rarely are such large advancements needed to "make you normal". Growth occurs in the mandible body AND ramus but surgery traditionally affects only one site. It's approximately the same for small movements but for larger movements one should address both sites. The main justification I see is to increase odds of curing or preventing sleep apnea, however evidence is mixed as to whether advancements beyond 10mm result in better outcomes.
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Interesting information, thank you molestrip.
Is there anyone else like Sailer that move the jaws very far forward purely because that is how someone wants to look?
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Surgeons can advance the mandible up to 25mm but above 10mm there are many challenges. Finding sufficient bony overlap is hard, fixation is hard (and relapse increases), joint problems more common, notching all but guaranteed, potential functional problems to the upper airway, reduced chance of sensory recovery, greater transient ischemia and implied risk to teeth, greater chance of patient aesthetic rejection, limitation on multi-segment procedures, and unaesthetic fullness from the larger maxillary advancement needed. I've listed a lot of potential problems but I don't mean to imply that it can't be done. I know people who've had it done and the compromises have been fine for them. This is an elective procedure, one which most surgeons agree warrants only negligible risk. Most importantly, rarely are such large advancements needed to "make you normal". Growth occurs in the mandible body AND ramus but surgery traditionally affects only one site. It's approximately the same for small movements but for larger movements one should address both sites. The main justification I see is to increase odds of curing or preventing sleep apnea, however evidence is mixed as to whether advancements beyond 10mm result in better outcomes.
I feel like your knowledge of this procedure has now surpassed mine. I submit to you as master. Teach us.
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Lol thanks! It has, however, done me not one iota of good except to help relieve anxiety. And given me a general distrust of orthodontists and fear of health professionals in general.
I did want to add that large advancements can make sense in people with overbites, especially to avoid 2-jaw surgery, and, while all surgeons should be able to do them, not all will have done them and will be comfortable with it. For advancements beyond 12mm (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772572/), inverted-L osteotomy may make more sense than BSSO technically and aesthetically (or TJR but bleh).
Most surgeons stop at 7mm of maxillary protrusion because that's the limit of what's only mildly unaesthetic since the midface mostly isn't affected. The more you rotate the lower third the greater the change in facial posture. Downward rotation of the face causes the midface to recede relative to the upper third, hence the reason people with cheekbone grafts feel they're not changing anything on this board. They have compensated for your perceived loss of volume. It also increases scleral show since the eyes continue to look forward. The main mitigating factor for it is stretching of soft tissue from the advancement. Dr Posnick claims the scleral show decreases in a recent publication, I'm mildly curious about how he came to that conclusion if anyone wants to download the full article and share it with me.
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I can barely find anything on the open web about the L-osteotomy, with the big exception being your own thread here from 2015, molestrip. My occlusal plane is 10.8 and mandibular plane angle is 37.41 (Downs Analysis), so this ramus lengthening type osteotomy you revealed here caught my attention right quick. It's not practiced because it's not stable and doesn't help with OSA? Posnick guesstimated my lower jaw movement in like the 17mm range (after lower bicuspid extractions), so you've got me concerned in more ways than one if I just went with the BSSO + lefort 1 procedure... hah.
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That's because it's primarily only used for hemifacial microsomia cases. I know one person who had it done for that reason. Your occlusal plane is normal. Mandibular plane angle is high but that's really aesthetic. I saw a paper from Japan where a modified version was used to close about 80 open bites but otherwise it's not widely practiced. I couldn't get the source so I'm not sure what made it modified. I wouldn't worry about it. Until lab grown vascularized grafts appear or something replaces rigid internal fixation is replaced by something else, jaw surgery isn't likely to change much.
Bicuspid extractions won't change your jaw movements but 17mm is a large movement if that doesn't include genio, especially considering your starting occlusal plane. Mine was 19deg! Without wisdom teeth I think it drops to 14deg. I wouldn't worry if Posnick is your surgeon. I haven't met him and I hear he has a dry personality but from what I read in his textbook, his surgical philosophy is the best around IMO. I'm jealous that you get such a talented, non-controversial surgeon to operate on you. Spend your time basking in the worry free surgery you're going to get.
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Isabella is right. The problem with ALL implants except for Silicone (which is bad for other reasons, it can slide around and crap and high infection rate) is that the soft tissue also needs to be compensated and thats really really hard unless you're getting regular fillers or something from an expert. The people that have great cheekbones and stuff in real life that look good also have great soft tissue. Face it some people just hit the genetic lottery with a LOT Of things coming together: shape, proportion, symmetry, quality of skin, etc. etc. to give the overall GESTALT of looking pretty (man or woman). Sure there are differences but for some reason jaw surgery patients tend to look more natural (I don't mean those that have been augmented with a lot of lyocartillege or anythign foreign). Another thing all docs say that implants can look okay when you're younger, but as the facial volume atrophies they'll start to look more pronounced and artificial. Remember you can only hope for a slight improvement and it's best to be really cautious. Go extreme and you could have extreme problems. Unless you're fine with the "done" look.
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+ 1
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Well, Angelina Jolie and a few other examples show that a lot of Plastic Surgery doesn't need to look artificial as you get older. You just have to do it the right way - and have a the right doctor(s).
I have pretty good genes and started modeling at the age of 12. So there wasn't really anything wrong, but you can't blame a woman today of wanting to become better. Some women just naturally want to be the best and I did never understand why a few "luckier ones" who were dumb as >>>>> would get more things in life just because they looked a tiny bit better. Therefore Plastic S is a blessing to every ambitious woman who understood the GAME in this society and is ready to use it for her benefit-- and it also is the the Empowerment for women in a society that criticizes and judges every little imperfection in them.
Men are scared because it finally means they can't control us with phrases like" Well, wait until you lose your youth and looks" and so on. Their fear of beautiful women wants them to believe a woman has no control over her face and body and they simply need to wait until it fades. It makes them feel better about themselves when they can't approach the hot chick in the bar due to insecurities.
BUT TODAY WE HAVE CONTROL OVER OUR DESTINIES.
This is one reason why on one hand they promote PS but then bash you for having it.
We do not see intelligent women on Times magazine or on TV, we see attractive women everywhere and being attractive IS POWER in society.
You can't be blamed for enjoying and loving this power and combining it with your intelligence.
Some women get hyped (Miranda Kerr) for doing absolutely nothing-- but you seriously want women to GET OVER their appearance. You tell people to accept who they are, but what if their appearance doesn't match the self image and a woman simply believes she is WAY BETTER than just extremely pretty? Maybe she thinks she is the most beautiful and wants everybody to see it too.
But it is basically just like a transgender who doesn't agree with what nature gave to him. You will not be able to get it out of his system just by telling him to BE HIMSELF. If that even means anything From the philosophical point of you.
There are some incredibly talented and intelligent ladies out there, who will not get the right recognition they deserve just because they don't look appealing enough.
Actresses and models get hyped while there are too many of them who are obviously neither interesting, nor as intellectual as some women but men date them all the time and certainly not because they are great people.
After all the trouble I have experienced with Double Jaw Surgery, i would not advise anyone to get it done for cosmetic reasons.
I am still experiencing bouts of pain after over 18 months. I can really feel that my jaw was moved too far and it interferes with my speech.
It has improved to the point that the pain is only occasionally, and the stiffness sometimes disappears, but the pain was unbearable yesterday and I can clearly feel something just isn't right. From a certain angle I got the banana face look :-) lol, that's how those long faces look that Sailer does.
I still think that Plastic Surgery is great and I never experienced any functional issues before and I probably had up to 30 surgeries, fillers etc (ALL WORTH IT)!
And at least today, I look way more of what I saw in myself than ever before. SO NO PAIN, NO GAIN, right???
But I learned my lessons and stay away from mad scientists!
i dont know ur surgeon name but maybe the all faults is ur surgeon notthe jaw surgery? if i were in usa probably go arnett gunson in germany dr zarrinbal in italymirco raffaini or etc. Yeap its still not guarenteed but less risky.
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please forget sailer, just google his name and foundation scam
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she does consultations for free while he charges like 800 to be honest if he was an amazing doctor i wold not care about his character, frankly most people on this board would get their surgery done by osam.a if he could guarantee an amazing outcome, but i have no idea how he sustains his palatial practice.
lazlo , if you fixate silicon with titanium screws and if you fitted it well, even better if you had it made custom i dont see when it should flip around, and on the upside you have something that is reversible.