Sliding Genioplasty Journey with Dr. Gunson

[molestrip]

I'm 35/male. I took the MCAT but am not a doctor, though I did stay in a Holiday Inn Express once (bad joke, I know!).

OSA has caused me so much pain, it pretty much ruined my 20s. Gastroparesis, chronic conjunctivitis, CPPS, anxiety, jaw pain, BFS, tooth wear, and more. I need a cheat sheet to remember it all but basically anything that breaks when the nervous and immune systems start failing. I was so sleep deprived for so long that not only did I stop dreaming, I stopped getting sleepy. Not tired but can't sleep like an insomniac. Weird, huh?

[terry947]

@ molestrip - How did u stop osa? Cpap machine?

[molestrip]

Yup, been on CPAP for 5 years now. I tolerate it relatively well but they discontinued my mask and none of the others fit well. It's like they're designed for normal faces or something. However, my sleep study at Stanford showed that I still get a lot of RDIs despite high pressures. Sure it's much better than before but not perfect. I think loose tissue doesn't respond as well as fat tissue does. Despite being "C" for continuous, the machine actually does a lot of work to maintain a comfortable feeling pressure and I think it screws up a lot. And I'm a skinny young guy now, what's it gonna be like in 20-30 years? They still don't know what the long term effects are to the ears and I suspect they miss the stomach too. It doesn't matter anyway because my bite is so f**ked up that if I don't get surgery I won't have molars in a decade and I sure as hell ain't doing a single jaw surgery that will f**k my face up even more so fixing the sleep apnea is the only sensible option at this point.

[SGseeker]

@Molestrip - thank you SO much for taking that time to measure my CEPH vs. the arnett gunson study. There is room for error though correct? Based on what I saw there were some areas with >3SD of figures. Please confirm that these are for airway norms for people POST surgery not just the average person? I am so sorry that you have to live with this at such a young age. I read about laser therapy as one of the options in relieving sleep apnea. What are your thoughts on this? Again thank you so much! I will be pursuing the sleep study to find out more and to learn more about my sleep pattern/behaviour. I do plan to keep everyone updated.

On a separate note - I emailed my CEPH to Dr. Jamali and he doesn't think that I have sleep apnea based on it. Not sure what to think here? Since you said my airway is very similar to yours!! :S Is there something I am missing?

I know i am not really a candidate for upper and lower surgery as my bite is already good so it would mean bringing all of my teeth forward and making my face look off balanced (correct me if you think otherwise). So if I do have sleep apnea or get it in the future its CPAP or this laser therapy i believe ?

Thank you all again!!!

[molestrip]

There's room for error, maybe 1-2mm. I measured it by hand and it would have been better with a CBCT. I think these numbers are from all their patients and most probably weren't (knowingly) seeking surgery for sleep apnea so I'd expect it to be in line with the general non-OSA population. OSA is thought to be a normal finding in the general population at some age btw. The question is when we get it. It started for me in my teens I think, some in their 40s-50s, and most normal people in their 80s-90s I'd guess. I'd love to see a study here. Our airways shrink as we age, due to weight gain and muscle sagging. If you don't have it now, then I'd venture that you'd be in the middle crowd.

It is a big surgery so I don't know that I'd go down that route without a sleep study confirming you have it. Most good surgeons would agree I think. In that case, doing a SG now and watching for OSA would be prudent I think. Not all sleep labs are created equal, if you want to be sure you need to visit Stanford. A related disorder in women called UARS is often missed by other labs. I strongly advise against any soft tissue surgeries, especially in a person who'd be low risk for jaw surgery, and I think Stanford is moving this way too now. There are some relatively minor bone movements that can be done which might be ok. I don't think this problem will have any revolutions in treatment going forward. Jaw surgery technology will certainly improve and treatment options will improve but no cure in sight. The best hope is a pharmacological treatment, the idea being to modulate sleep so that your muscles don't relax at night. That's bound to have undesirable side effects.

I wouldn't trust Dr Jamali's opinion here. I've had an ENT, two oral surgeons, and two sleep doctors (one Mayo trained) look at my airway with puzzlement and tell me I should be fine. The sad reality is that they learn an immense amount in school and their knowledge is either dated, fuzzy, or a combination of the two. He's probably operated on less than 100 sleep apnea patients and it's just not worth his time to learn about the disorder in more detail. You are a good candidate for jaw surgery. You'd have other reasons if you also had a malocclusion (people like us tend to open bites). It's hard to describe in text but double jaw surgery is an alternative to SG. They cut and rotate the mandible forward. The maxilla is advanced forward to meet it and sometimes rotated. The aesthetic gain in the right surgeon is considerably better than a SG even as you could get a flat profile without messing up your labiomental fold. You probably couldn't get a flat profile with a SG alone anyway. Done by the wrong surgeon and it will probably look similar to a SG.

[SGseeker]

Thanks Molestrip. A few questions:

1)How much does the Stanford sleep study cost? In Canada a sleep study would be free for me so i want to understand the incremental cost. I am 100% going to get one just need to figure out the best one here or go to Stanford depending on price.

2) How exactly would I do a double jaw surgery if I have a good bite already (orthodontist lady wasn't too keen on the idea when I told her)? All my teeth are straight and aligned. I felt that made me more of a bad candidate, especially since they will move my whole mouth forward which i'm not sure will look good aesthetically.

3) Look at the attached results. Photo 1 is before (recessed chin), photo 2 is a badly positioned implant, photo 3 is implant removal and SG alone. I am looking for results like this (aesthetically) It was performed by Jamali btw. I feel this gives her a way better profile. Let me know what you think.

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[molestrip]

1) Insurance paid $8k I think. Often times you can get a better rate out of pocket. See if Canadian insurance would cover it and, if not, look into buying private insurance. Compared to costs down the line and money spent on these surgeries, it's peanuts, not to mention that it's your health. I'd start with a local study and only travel to Stanford if it comes back negative.

2) Get used to being your own advocate. You're going to encounter a lot of opinions along the way and they'll all be confident and different. The main implication and is that unless your arch is narrow, you may not need orthodontics. Lucky you Not all surgeons are comfortable with this approach so shop around. If you can make it to A/G, then they can give you a simulation of what to expect so you can see for yourself. Otherwise, you just need to trust us that it'll look very good. If you have sleep apnea, then you might need some aesthetic compromise but it'll still likely be a big win compared to your starting point.

3) Seeing your photos now, wow. Knowing what I know now, surgeons should be liable for malpractice for putting in implants and performing SG on patients who obviously are likely to have OSA. It's sooo common it's ridiculous that there's like only a dozen people on the planet who understand it. Studies report only 1-2% of the population has skeletal sleep apnea but I think that's based on diagnosed cases, which are known to only constitue 20% of all cases. That puts the number at closer to 5-10% of the general population, which is in line with what I see in public. Think about that for a second. 1/10 people in the world has a major health problem and many of those are getting surgery to fix the aesthetics. The wrong surgery. How does this happen today?? And half these guys will be retiring in the next 5 years.

[SGseeker]

Thanks for the info!!

Regarding point 3. He does mention in another one of his results ( posted below) that the patient didnt want to go ahead with Jaw surgery even though that's what he suggested and she only wanted the SG. I guess for some people they don't know the long term impact or they choose to ignore it.

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[SGseeker]

Little blurb!

Obstructive sleep apnea (OSA) is a common disease. A recent analysis concluded that 1 in 5 American adults has at least mild OSA. That translates to 40 million people. About one-third of that number has moderate or severe sleep apnea.

[molestrip]

It's worse than that. Why? We have a population bulge in baby boomers. Now you might say that the number should be better then, since prevalence increases with age right? The reason is that the incidence of allergies has increased substantially over the last century, while nutrition quality has decreased and Pottenger's Cat effects continue unabated. In other words, the number of 20-30 somethings who are destined to have/will develop moderate-severe sleep apnea is far greater now than it was for the boomer population. This is all in Sleep, Interrupted but analysis has shown that OSA is, in fact, on an epidemic trajectory if it's not addressed.

I personally believe we should be screening kids in public school along with Scoliosis, when it can still be address non-surgically. It should then be tested for again as prerequisite for entering college and every decade after like colonoscopy, breast cancer screening, etc. With the cost of home sleep studies so ridiculously low now, the payoff would be huge. Think of all the medical conditions affected by it? Heart disease, metabolic syndrome, type 2 diabetes, etc. All the major diseases are aggravated by sleep apnea. Savings would be huge, not to mention improvements in quality of life!

[SGseeker]

Hi Everyone!

Quick Update!!

I am seeing Dr. Jamali for an in person consult next week . Costs $250. I will let you know how that goes.

I have also been in touch with Arnett + Gunson. They are supposed to be THE guys in jaw surgery in North America/world. I sent them my patient info, photos, ceph etc. I asked if they thought top level if I would require Sliding Genioplasty or jaw surgery and they had Dr. Gunson's surgical team member review to give me an idea. Preliminary is that SG will be sufficient as she did not see any clear reasons to do the jaw surgery. I am now booked for an in person consult in May as I want to hear from Dr. Gunson if he thinks SG will be good enough and then how much it would cost (his jaw surgeries are like $50k :O ) . I'll let you know more about that later on - but for now i am crossing my fingers that SG will be all i need.

I also plan to book a sleep study in the next month to see what that tells me overall.

Thank you all so so much for your insight/support. It has been an eye opener for me and I am now trying to make sure I make the best/right decision.

Anyone know where I can see a before/after gallery of A+G work ?

Thanks!

[molestrip]

Your plan sounds perfect. There are some pictures on the A/G website but you'll plenty more in the office.

[SGseeker]

Your plan sounds perfect. There are some pictures on the A/G website but you'll plenty more in the office.

Thanks Molestrip- Have you consulted with Arnett or Gunson regarding you case ? How was it if you have ?

Thanks again for everything!

[SGseeker]

Hi Everyone!

Time for an update!!!! In the past month I have gone to NYC to consult with Dr. Jamali and to Santa Barbara to consult with Dr. Gunson from the 'famous' Arnett+Gunson duo.

Dr. Jamali was VERY nice and patient. I will upload his hand drawn treatment plan for me. He said that I have a recessive jaw and would require Upper Jaw surgery to do a rotational jaw movement + a genio on top OR I could just do the genio - they netted out looking pretty similar and the genio has less complications and I recently had a rhinoplasty so the idea of going through my nose (which is what he said we would need to do) was off the table. He recommended a straight 5mm advancement. You can PM me for pricing info if you like Jamali took xrays and ceph and used them  to draw out the results for me.

Dr. Gunson
WOW - what a team. These guys know what they are doing! Lena/Lina was my co-ordinator. Super sweet and helpful. I learnt SO much from this consult ($250 - the same as Jamali's but a lot more detail) but it was SO comprehensive!!! Loved it!!
1) They took molds of my teeth
2) They took 3D XRAYs of my skull
3) Dr. Gunson measured all aspects of my face, mouth, teeth etc
4) Gunson did a questionnaire with me and analyzed my face visually
5) They took photos and panoramic photos as well (that would later be layered onto my skull xray so cool)
6) Gunson then went to do his analysis for about 30 mins to come up with a treatment plan
7) Lena then walked me through their process and gave me other information

So Dr. Gunson did all of his analysis and it pointed towards double jaw surgery to give me 'ideal facial proportions'. He also did a genio plan and the difference was only 2mm so in the end his recommendation was to just do a genio as the double jaw surgery would only have a 2mm difference and I don't have any functional issues such as joint problems, sleep problems, bite problems. He also looked at the size and volume of my airway and it was all well above the average Sleep Apnea patient. I am still going to do a sleep study to 100% rule it out (didn't have time before the consult sadly) at least for now in my life. I really liked how comprehensive everything was at AG. Dr. Gunson is also going to be making a 3D visual of how i would look after the Genio advancement. Based on the model (black and white lines it looked great).

The other thing to note is that he does not want to do a straight genio rather a rotational genioplasty. He would shorten my chin by about 2mm, advance it 5mm (same number as Jamali) but with the rotation it would equal 6mm added projection. He doesn't want to do a straight one because my chin bone is flat so it would just move the flat portion of my chin forward. Making the rotation would give it a more natural look. He would then fill in the gaps with HA paste. We also discussed jaw contouring with HA as he wanted to do a higher genio but my nerve wont permit it as it goes very low on my jaw. In photos now if i tilt my face down slightly my lower third disappears and it is only my lips haha so this would solve the problem. I'd love to get your thoughts on all of this I am waiting for the hospital portion of the quote but Gunson's genio fee + HA contouring was very reasonable especially given his reputation etc. PM if you would like to know the details.

At this point - i need to see the hospital portion of Gunsons quote but I am leaning towards him as he has so many reviews on forums and blogs of real patients and I think he has a good overall aesthetic. Also the fact that he went into so much detail was really appreciated and showed me that he knows what he is doing and that he would get it right! Ill share the 3D once i receive it. Please let me know if you have any thoughts. Has anyone had a rotational genioplasty ? I'd love to know more about it.

[PloskoPlus]

Thanks do the update. Really interesting read. A&G really make an effort.