Surgeon Review - Dr. Behrman from NYP in New York

[Pequod]

I'll keep this strictly factual, draw your own conclusions.

Brief story: I had a Lefort I and BSSO done to treat a 5mm open bite. They actually had to perform the same operation twice, spaced a week apart, since according to my surgeon I clenched too hard immediately after being woken from anesthesia and moved the bite so I needed an immediate revision. Apparently this happens in some small % of the cases, when your jaw muscles don't cooperate, so it's not entirely rare.

Surgeon: Dr. David Behrman from New York Presbyterian hospital

Result: There is minimal overlap between my anterior teeth, about 1mm. But the biggest issue is I still have lip incompetence, about 6mm plus or minus 1mm depending on who measures.

Afterwards: I wanted to speak with the surgeon about how to possibly address my functional problem (would a SG suffice?) but he simply refused to speak with me; instead he hid in his office while sending out a 1st year resident unfamiliar with my case.

Attached is my post surgery xray with the final result which Dr. Behrman claimed was a complete success. Currently I'm debating between an SG or pursuing orthognathic surgery a second (or third if you count the back to back operations as two separate attempts) time.

[Run10KToday]

It would be better if you can post more frontal X-rays or ct. Based on this ceph I personally don’t think the procedure is a complete success. I don’t think The surgeon has an idea of what esthetics is.

[Pequod]

I don't have a frontal x-ray, why would it help? I didn't have symmetry problems beforehand.

In addition to aesthetics, I'd argue, more problematically, this is a poor functional result as well. I have 6mm lip incompetence and 4mm upper incisor show (this is more than pre-surgery and was not the plan according to what was discussed pre-surgery.)

[kplatt2010]

I think what Run10today is looking for is the panoramic x-ray.

Are you in active braces treatment? If so; does the ortho think they can correct / mask this?

Every time you go into the OR; you are going to get more scar tissue as a result. This will make it challenging going forward for the next surgeon. I would give it a little time, get more feedback from the ortho (if you have one). If after six months; you are still not satisfied with the results, get a second opinion. Someone who has experience with complications. I would not recommend Dr. Jamali for second opinion; who is in your area.
Karla

[Pequod]

The surgery was many years ago, there was nothing for the orthodontist to do as I still have vertical maxillary excess.

I read the operative report and it sounds like in the second surgery they didn't cut any bone, just loosened screws and repositioned with no new cutting so I might just have 1 operation's worth of scar tissue.

Regarding the pano my bite is fine, even when I had a mild open bite it didn't bother me at all. The bigger problem was always the lip incompetence and chin strain which affects your resting posture 99% of the day.

I'm still consulting and debating between a SG or a revision.

[snapdresser]

Maybe you should get an opinion from another surgeon. I went to NYCOMS and got an opinion that covered aesthetics. Cost me $500 for the consult but the doc was an expert and I’m sure would answer all your questions. Or find another in-network surgeon with an eye for aesthetics to ask. My initial thought is more CCW rotitation and an SG would be ideal, and I don’t know if SG along would do the trick. That question may be better posed to a surgeon with a good aesthetic eye.

[Pequod]

Thanks yeah I'm just wrapping up my consultation spree of second opinions. I did actually consult with NYCOMS and liked them, thanks for the suggestion. Don't feel comfortable sharing their specific opinion here as I don't want to mention anyone publicly besides my original surgeon.

But so far the opinions I've received have spanned from just standalone SG to a full revision.

I still have one big name surgeon left to speak with before decision time.

[kplatt2010]

Hi There- what is an SG?
Karla

[assertives]

SG stands for sliding genioplasty.

[kplatt2010]

Been there done that one. Had a genioplasty when I was 21. Fast forward 29 years; back to the OR for the "works" (bsso + leforte 1)and the genioplasty was reversed . The rationale was because the oral surgeon said I would look like Jay Leno otherwise. I think in retrospect; it should have only been partially reversed. Part of my issues I think are related to the fact that the surgeon completed the surgery and then decided that he wanted to try and advance my jaw more. So he took all of his work down and tried without success. My opinion is that he did not plan very well prior to the procedure and really did not show me any after images; just told me what I would look like. I disregarded small red flags in hindsight.

One thing that I would consider is what this is going to do to your mid-face profile. I had very prominent naso-labial folds before 2nd surgery. That is not completely gone but much better. The lip incompetence is better but still there. I keep thinking it will get better once brace treatment is done and braces are off.

If you read through posts sometimes folks are really happy with genioplasty results and some not. It's almost like in order for you to have good results; the surgeon has to have a complimenting engineering / architect style mindset if that makes sense. If I had a do-over; I would get more than one opinion and hopefully someone who utilized computer images to demonstrate the "after" look or had models of my jaw at the very least. No free-hand drawing that you do the morning of the procedure.
Karla

[Pequod]

Thanks for your replies.

An update on my situation, I finished consulting and I'm convinced now to go through a full revision due to a variety of existing problems that can be fixed alongside my main issues (lip incompetence, bimax recession, gummy smile indicating some VME and a bad bite and the potential of airway improvements). A sliding genio would primarily be aesthetic and not hit the bulk of those problems.

I attached an image of the my bite from a current CBCT in case it's useful to anyone else in their research. If you have an anterior open bite, check to see if your maxilla is narrow and if so be sure to address it. My lower molars are tipped to fit into a narrow maxilla. This should have been addressed first time around; proper planning would have initially done a segmental L1.

[marycotter1982]

Pequod, can I contact you privately? I am in your area and need referrals for second opinion as well..

[Pequod]

Pequod, can I contact you privately? I am in your area and need referrals for second opinion as well..

Feel free to reach out.

[Pequod]

An update now that I've almost wrapped up consultations on a revision / read my records. This is written here in case it can help others.

1.) Why I needed an immediate revision?

I feel not unlike an aircraft crash investigator piecing things together. Recall I had a L1 + BSSO done which required a revision one week later. The reason given was "I woke up hard from anesthesia".

Now I have a better sense what went wrong. My molars (#1, #16) are over-erupted and say at a slanted 45 degree angle. They don't fit properly with the rest of my bite but are functional in chewing. After my revision I still had a mild open bite which required the orthodontist to drill down the over-erupted molar as only one corner was hitting early. Since this molar is also on the side which was displaced after my first surgery what I suspect it's the reason why things went wrong. The over-erupted tooth caused my bite to hit on exactly one point and after waking up all the force of my bite was applied there and it manged to overcome the plates and drastically shift my maxilla requiring an revision one week later.

This is personal speculation since Dr. Behrman would not speak with me and instead sent out a 1st year resident who couldn't answer any of this and I doubt was familiar with my case.

2.) Poor planning

This indicates poor planning. This time around surgeons are very mindful of my over-erupted molars while Dr. Behrman never discussed them with me besides saying their fine as is. One top surgeon wants them removed prior to surgery while another wants to salvage them but drill down further.

I don't think my bite had any hope of fitting after my first surgery.

3.) Why the bad result?
The simplest explanation is true in this case: I had a poor plan which was also poorly executed.

While no surgeon will admit it during your consultations, some do not want to be judged on functional/airway/aesthetic issues. They will just care about occlusion even if they make your face severely crooked or shrink your airway or introduce any other problems.

In my second surgery my surgeon most likely abandoned the plan, "the bite guides the surgery" I was told afterwards, without properly considering airway/retrusion. I made the mistake of thinking someone who had done this operation thousands of times and specialized in it was qualified to handle my case.