Bimax - Consensus on Dr. Zarrinbal?

[The Quest for Aesthetics]

So what's the general consensus with Dr. Zarrinbal for bimax? I mean we know that he does wonders with procedures like the chin wing - but how aesthetically minded is Dr. Z when it comes to bimax? And is he the sort of surgeon to listen to patient demand when it comes to things like maxillary repositioning (so if I describe the final maxillary shape that I would like - is he the type to ignore it and shrug it aside, or would he do his best to achieve what the patient wants?)

[ditterbo]

Does Dr. Z do 9mm+ posterior maxilla downgrafts?  Gunson has that in my surgical plan, and I'm guessing it's the only way I can avoid bicuspid extractions.

[PloskoPlus]

Does Dr. Z do 9mm+ posterior maxilla downgrafts?  Gunson has that in my surgical plan, and I'm guessing it's the only way I can avoid bicuspid extractions.

I'm gonna go out on a limb here and say that he probably doesn't. I think he'd rather use a chin wing (at the same time) as camouflage.  IMO, for those who need it, a well performed CCW rotation is probably the best thing possible.  The downside is questions over long term stability and it's not exactly easy to do - messing up the bite is what surgeons fear the most.

[mike888miller]

What Kind of bimax do you Need? do you need any Rotation? How much movement? From Consulting with different doctors, i have noticed that even if they realise that you need say 12mm max and 12mm man movement, they may try to talk you out of it because it falls outside their comforttzone (not directed at dr z, but at a different dc i saw). This is fair enough, athough ideally one wishes that they would refer us to the doctor that deals in such cases. Posnick Comes to mind in the US, in Europe I don't know who does the biggest advancement, I have heard from an Austrian doctor only.

[Bobbit]

What Kind of bimax do you Need? do you need any Rotation? How much movement? From Consulting with different doctors, i have noticed that even if they realise that you need say 12mm max and 12mm man movement, they may try to talk you out of it because it falls outside their comforttzone (not directed at dr z, but at a different dc i saw). This is fair enough, athough ideally one wishes that they would refer us to the doctor that deals in such cases. Posnick Comes to mind in the US, in Europe I don't know who does the biggest advancement, I have heard from an Austrian doctor only.

MIke,

Consider the alternative.   It is likely that the docs who do not refer you to others that are willing to get well outside the ~12mm range - -  are really just not willing to "go there"  because that type of procedure is associated with a well considered surgical consensus of an excessive risk to function for the patient.

Recommending that you go somewhere that routinely "practices" outside the "standard of care" would itself be a departure from the appropriate standard of care.

[mike888miller]

bobbit - i admire your idealism, as in theory that is what we would wish, doctors giong to the Limit of what is doable, maybe hard, but doable, before it gets risky.

my experience is that doctors will much prefer to give you a 50% solution, lets say giving you 7mm advancement, even though the 75% solution which would transform your life is not that much harder.

ist a question of incentives  -  he is not incentivesed to take slightly more risk, because most patients wont even care or know enough to care. we represent maybe 5% of Patients. most are just happy to get the Operation, and could not even tell you how much mm movement they got or will get.

and for that reason many doctors won't even engage into the discussions we are having, at least not the european ones.



where i live most People have no idea of

[Bobbit]

bobbit - i admire your idealism, as in theory that is what we would wish, doctors giong to the Limit of what is doable, maybe hard, but doable, before it gets risky.

my experience is that doctors will much prefer to give you a 50% solution, lets say giving you 7mm advancement, even though the 75% solution which would transform your life is not that much harder.

ist a question of incentives  -  he is not incentivesed to take slightly more risk, because most patients wont even care or know enough to care. we represent maybe 5% of Patients. most are just happy to get the Operation, and could not even tell you how much mm movement they got or will get.

and for that reason many doctors won't even engage into the discussions we are having, at least not the european ones.



where i live most People have no idea of

I do not think it is a thought process that grows out of idealism.   There are real risks.  For example,  keep in mind that in many or most of these cases, you are not just "stretching"  muscles and tendons and skin - -  which can accommodate, be repaired or grow back or repair themselves.   But you are also, in many or most cases,  stretching critical nerve bundles. 

An individual's anatomical tolerance to having their personal nerve bundles stretched - -  is likely to fall somewhere on a gaussian curve.  So it is likely that staying well inside 1 Std Dev as to what normal individuals' nerve bundles will tolerate is "good" practice.   

Otherwise,  you simply become a laboratory experiment.

[The Quest for Aesthetics]

What Kind of bimax do you Need? do you need any Rotation? How much movement? From Consulting with different doctors, i have noticed that even if they realise that you need say 12mm max and 12mm man movement, they may try to talk you out of it because it falls outside their comforttzone (not directed at dr z, but at a different dc i saw). This is fair enough, athough ideally one wishes that they would refer us to the doctor that deals in such cases. Posnick Comes to mind in the US, in Europe I don't know who does the biggest advancement, I have heard from an Austrian doctor only.

Thankfully, I don't need that much maxillary advancement for an ideal result. As patients we really have to do everything reasonable to push them to achieve the best aesthetic result possible. It's so discomforting to hear that surgeons are willing to skimp out on the best aesthetic result due to fears regarding their own reputation. If the doctor feels as if he isn't willing to give the patient the best result possible, he should make it known to the patient that it can be done (if indeed it can), but that he is not willing to do it - and proceed to direct the patient to somebody who may be willing and able. Anything less than that is pure deception on an unwitting patient.

[Bobbit]

Thankfully, I don't need that much maxillary advancement for an ideal result. As patients we really have to do everything reasonable to push them to achieve the best aesthetic result possible. It's so discomforting to hear that surgeons are willing to skimp out on the best aesthetic result due to fears regarding their own reputation. If the doctor feels as if he isn't willing to give the patient the best result possible, he should make it known to the patient that it can be done (if indeed it can), but that he is not willing to do it - and proceed to direct the patient to somebody who may be willing and able. Anything less than that is pure deception on an unwitting patient.

Let's take your thought and "see where it goes":   

Doctor A tells patient:  I can do the surgery you want done with the advancement you want done.   But in my judgment,  the risks outweigh the possible benefits.  Therefore, for ethical reasons I will not do that surgery in the way you want it done.

Patient:  Are there any surgeons who WILL do the surgery the way I want it done ?

Doctor A:  Yes.  Doctor  X,  or Doctor Y  will do the surgery the way you want it done .

Patient:  So why will you not do that ?  You are better trained.  You have more experience.   Why won't you do the surgery that you tell me Doctor X & Y will do ?

Doctor A:   Yes.  It is probably true that I am better trained and have more experience.   But that is not the reason.  The reason is because doing the surgery the way you want it done results in too many patient's from Doctor X & Doctor Y that come back to me and tell me that they wish they had listened to me in the first place.   

Patient:   But I will sign a release.    Doctor A:  Signing the release does not solve the problem.   The problem is an ethical problem.  The problem is one of exercising good medical judgment. 

[zygotic]

Does anyone know what kind of downgrafting Dr. Zarrinbal does for CCW rotation? Thanks.