I wouldn't normally consider going outside the US for a big surgery like this but Europe has good doctors too. One name that comes up is Dr Federico Alfaro. I see his name pop up a few times here but I can't find any jaw surgery blogs specifically for him. What do you all know about him?
His website certainly sells well. 3d planning, piezo surgery, small incisions, etc. His selling point is minimally invasive. Website claims jaw surgery can be done outpatient with local anesthesia. Double jaw surgery in 50min and no orthodontia needed for sleep apnea cases. Liquid diet for 1 week and back to normal routine in 2-3 weeks. One video shows a Le Fort being stabilized with resorbable sutures only! This has got to be too good to be true, right?
His website lists a virtual consultation as an option. Should I bite? I was about to commit to a local surgeon but perhaps I should hold off a bit more?
Anyone use Dr Federico Alfaro
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Re: Anyone use Dr Federico Alfaro
I don't see why you would leave the US to get jaw surgery in Europe. Unless he's an oral surgeon at Hogwarts, he isn't doing any magic over there. And of course a remote surgeon makes follow-up care a bit of a bother if something comes up.
And I'm not buying a lot of those claims... double-jaw in under an hour; must have the quickest hands ever! And I'm not sure how "fixation" with sutures is even mechanically possible. Something's gotta hold those bits in place while the bone re-fuses. If it aint' plates/screws, it's gonna be old-school wires holding you shut.
And I'm not sure how you do a LeFort or BSSO in a "minimally invasive" fashion. Those surgeries require particular cuts in particular places; I don't see how anyone could magically make the needed bone cuts without making the standard incisions. This isn't like an appendectomy where you can make some tiny slits and jam some instruments down there... a "minimally invasive" orthognathic surgery makes about as much sense as a minimally invasive c-section.
And I'm not buying a lot of those claims... double-jaw in under an hour; must have the quickest hands ever! And I'm not sure how "fixation" with sutures is even mechanically possible. Something's gotta hold those bits in place while the bone re-fuses. If it aint' plates/screws, it's gonna be old-school wires holding you shut.
And I'm not sure how you do a LeFort or BSSO in a "minimally invasive" fashion. Those surgeries require particular cuts in particular places; I don't see how anyone could magically make the needed bone cuts without making the standard incisions. This isn't like an appendectomy where you can make some tiny slits and jam some instruments down there... a "minimally invasive" orthognathic surgery makes about as much sense as a minimally invasive c-section.
Re: Anyone use Dr Federico Alfaro
Agree with Sirwired (as always 
). Would also add that it takes 6 weeks for bone to heal, by the pure nature of physiology. I don't care how he's cutting and splicing it, but there ain't no way you can heal enough in 1 week to eat just anything you want without risking your face. The site sounds to me like trying to sell people to have something done by using all the right catchwords (minimally invasive, local anesthesia, outpatient).
I've heard of outpatient surgery being done, but I wouldn't personally feel comfortable with it after my experience. My airway nearly swelled shut in the hospital; I had to get IV steroids, and the doc was in to check on me about 4 times, so he must have been worried.
As for the local anesthesia, they have to put a "throat pack" in, where they pack your throat all full of gauze to keep you from choking on blood. How can that be done with local unless they anesthetize your whole neck? You'd be gagging all over the place.
). Would also add that it takes 6 weeks for bone to heal, by the pure nature of physiology. I don't care how he's cutting and splicing it, but there ain't no way you can heal enough in 1 week to eat just anything you want without risking your face. The site sounds to me like trying to sell people to have something done by using all the right catchwords (minimally invasive, local anesthesia, outpatient). I've heard of outpatient surgery being done, but I wouldn't personally feel comfortable with it after my experience. My airway nearly swelled shut in the hospital; I had to get IV steroids, and the doc was in to check on me about 4 times, so he must have been worried.
As for the local anesthesia, they have to put a "throat pack" in, where they pack your throat all full of gauze to keep you from choking on blood. How can that be done with local unless they anesthetize your whole neck? You'd be gagging all over the place.
Boodles8
Braced July, 2012
BSSO August, 2013
Debraced October 2, 2014
Braced July, 2012
BSSO August, 2013
Debraced October 2, 2014
Re: Anyone use Dr Federico Alfaro
Ok I dug in a little more. I don't think he does outpatient for double jaw surgery and the sutures were for a SARPE. I found this video on Youtube of his surgery. The lower jaw looks standard but the upper jaw looks far less invasive, no? I can see he uses titanium plates and screws now. There's a picture on his twitter feed of him with Dr Gunson.
I think I can get on board with his surgery. I saw another video of a le fort osteotomy and it just looks awful! How'd you all do it?
I think I can get on board with his surgery. I saw another video of a le fort osteotomy and it just looks awful! How'd you all do it?
Re: Anyone use Dr Federico Alfaro
I've heard of outpatient double-jaw before for patients paying out of pocket that can't swing the cost of the hospital overnight. It's possible, but it's a LOT of work for the caregiver, who is going to be pulling an all-nighter.
Was the local-anesthesia for the SARPE? Because that's the only orthognathic surgery I can imagine being done without general. There's too much blood with a LeFort and BSSO; I don't see any way around general anesthesia and nasal intubation so you don't choke on your own blood; suction can't get it all. (And I even had a naso-gastric down the other nostril to suck any swallowed blood out of my stomach... means I didn't need throat packing.)
I watched that video; looked like a standard double-jaw surgery to me. I didn't see anything unusual there, I don't remember my own LeFort I incision going back any farther. There ain't no way you would be able to go back to a normal diet after 2-3 weeks, no matter how small the incision is. I was on soft-chew (nothing stiffer than eggs) after just a couple days, but you can't do normal chew until the healing is totally complete, which isn't any faster than 6 weeks. (In my case, I had that accursed splint on for 9, which was horrible... thin bone.)
And yeah, once you see the part of a LeFort I where they get out the steel chisel and mallet for the final downfracture, you are VERY glad that you aren't awake for this. (They use the chisel precisely to avoid having to cut the gums any farther back; the surgeon takes advantage of the natural LeFort I fracture line instead of having to actually cut it loose all the way to the back. The cut with the handpiece is really just enough to get it started and give room to stick the chisel.) And you get even more glad when they are verifying your jaw is fully separated and pull your entire arch in and out of your mouth. You'd have to use enough drugs to get me higher than the space station to not freak out if I was awake for that!
How'd I do it? By being eternally grateful for the invention of General Anesthesia. You are in the OR one second, and are magically teleported into your hospital room the next. I don't even remember falling asleep or waking up. (According to my wife, I had an involved conversation with the nurse in recovery that I have absolutely no memory of; I don't remember recovery at all.)
You'd think recovery would be painful, but it's not. I never needed anything more than a minimum dose of Vicodin, and was off it in a few days... three, I think. It was Advil from there on out. I think because the surgery involves cutting through your gums and manipulating them, the nerves get quite bruised and you don't get the delight of feeling the healing process much. You are long-healed by the time the nerves grow back. (In my case, some wiring got shorted out; when I floss some of my upper-left teeth, it feels like I'm flossing my lip instead of my gums!)
I'm still not sure why you'd want to go all the way to Europe to get the work done, unless you don't have insurance and can get some kind of killer price over there. There are lots of qualified surgeons in the US, and most of them are cheaper than Arnett/Gunson.
Was the local-anesthesia for the SARPE? Because that's the only orthognathic surgery I can imagine being done without general. There's too much blood with a LeFort and BSSO; I don't see any way around general anesthesia and nasal intubation so you don't choke on your own blood; suction can't get it all. (And I even had a naso-gastric down the other nostril to suck any swallowed blood out of my stomach... means I didn't need throat packing.)
I watched that video; looked like a standard double-jaw surgery to me. I didn't see anything unusual there, I don't remember my own LeFort I incision going back any farther. There ain't no way you would be able to go back to a normal diet after 2-3 weeks, no matter how small the incision is. I was on soft-chew (nothing stiffer than eggs) after just a couple days, but you can't do normal chew until the healing is totally complete, which isn't any faster than 6 weeks. (In my case, I had that accursed splint on for 9, which was horrible... thin bone.)
And yeah, once you see the part of a LeFort I where they get out the steel chisel and mallet for the final downfracture, you are VERY glad that you aren't awake for this. (They use the chisel precisely to avoid having to cut the gums any farther back; the surgeon takes advantage of the natural LeFort I fracture line instead of having to actually cut it loose all the way to the back. The cut with the handpiece is really just enough to get it started and give room to stick the chisel.) And you get even more glad when they are verifying your jaw is fully separated and pull your entire arch in and out of your mouth. You'd have to use enough drugs to get me higher than the space station to not freak out if I was awake for that!
How'd I do it? By being eternally grateful for the invention of General Anesthesia. You are in the OR one second, and are magically teleported into your hospital room the next. I don't even remember falling asleep or waking up. (According to my wife, I had an involved conversation with the nurse in recovery that I have absolutely no memory of; I don't remember recovery at all.)
You'd think recovery would be painful, but it's not. I never needed anything more than a minimum dose of Vicodin, and was off it in a few days... three, I think. It was Advil from there on out. I think because the surgery involves cutting through your gums and manipulating them, the nerves get quite bruised and you don't get the delight of feeling the healing process much. You are long-healed by the time the nerves grow back. (In my case, some wiring got shorted out; when I floss some of my upper-left teeth, it feels like I'm flossing my lip instead of my gums!)
I'm still not sure why you'd want to go all the way to Europe to get the work done, unless you don't have insurance and can get some kind of killer price over there. There are lots of qualified surgeons in the US, and most of them are cheaper than Arnett/Gunson.
Re: Anyone use Dr Federico Alfaro
Oh they don't do a molar to molar cut anymore, like on this youtube video? That's a great relief!! Dr Alfaro's surgery didn't look all that bloody. That video I linked to looked really, really bloody. So this is where the term "bad split" comes from? How often does that happen? I guess that's why people often end up only with numbness in their front teeth.
Can you elaborate on that "wiring got shorted out" comment? I've worn a nighttime splint for 20 years and it never bothered me. I'm more concerned that they say I can't wear that anymore after the surgery, as there's no guarantee that my bruxism will stop.
He sells a minimally invasive procedure well, that's all. If I'm getting the same thing here then no point. Do you think a good local guy in a major city is just as good as Arnett/Gunson? I really liked Gunson but I imagine I'd get better follow up care locally. I don't have prominent cheekbones (runs in the family). Do you think I'd need (hydroxyaptite) cheek implants after a 10-12mm advancement? I'm very concerned about what that will do to me aesthetically but I also hate the idea of foreign bodies. Some threads claim those implants erode bones. I hear I'm handsome already lol and I'd rather not lose that.
Can you elaborate on that "wiring got shorted out" comment? I've worn a nighttime splint for 20 years and it never bothered me. I'm more concerned that they say I can't wear that anymore after the surgery, as there's no guarantee that my bruxism will stop.
He sells a minimally invasive procedure well, that's all. If I'm getting the same thing here then no point. Do you think a good local guy in a major city is just as good as Arnett/Gunson? I really liked Gunson but I imagine I'd get better follow up care locally. I don't have prominent cheekbones (runs in the family). Do you think I'd need (hydroxyaptite) cheek implants after a 10-12mm advancement? I'm very concerned about what that will do to me aesthetically but I also hate the idea of foreign bodies. Some threads claim those implants erode bones. I hear I'm handsome already lol and I'd rather not lose that.
Re: Anyone use Dr Federico Alfaro
I expect the length of the cut has a lot to do with your particular facial anatomy. In any case, even with a longer incision, it's no big deal. If this was, say, your abdomen, you'd worry about scarring. Since it's your gums, nobody will ever have see how big the incision is or isn't.
I've never heard the term "bad split", but I imagine it might refer to the LeFort I fracture line not cooperating with the chisel like it's supposed to and fracturing somewhere other than where the OMFS intends.
As far as my "wiring"... I mean that about a year out, my gums are still just a tiny bit numb, but somehow my nerves thinks some of my gum is also part of my lip. (The lip itself is fine.) So when I floss those particular teeth, I "feel" the floss on my lip even though it's not touching. It's just a little weird, not annoying or painful.
The splint was annoying because it is wired to your archwire, and therefore is impossible to clean. You can't use a waterpik because that runs the risk of hitting your incision. All the wires, nooks, and crannies trap all kinds of food bits that are difficult to dislodge. The lip on the inner side of the splint acts as a pocket that collects food, but no brush can get in there to get it out. I gagged from the stench when the assistant pulled that thing out and immediately brushed my teeth three or four times. I almost cried when the doctor said it would have to go in for another three weeks while my bone healed.
As far as "surgeon you should go to"? I'd take the list of surgeons that take your medical insurance to your ortho and ask him to pick the one he recommends. Mine was done by a professor at the state dental school who had worked frequently with my ortho.
I've never heard the term "bad split", but I imagine it might refer to the LeFort I fracture line not cooperating with the chisel like it's supposed to and fracturing somewhere other than where the OMFS intends.
As far as my "wiring"... I mean that about a year out, my gums are still just a tiny bit numb, but somehow my nerves thinks some of my gum is also part of my lip. (The lip itself is fine.) So when I floss those particular teeth, I "feel" the floss on my lip even though it's not touching. It's just a little weird, not annoying or painful.
The splint was annoying because it is wired to your archwire, and therefore is impossible to clean. You can't use a waterpik because that runs the risk of hitting your incision. All the wires, nooks, and crannies trap all kinds of food bits that are difficult to dislodge. The lip on the inner side of the splint acts as a pocket that collects food, but no brush can get in there to get it out. I gagged from the stench when the assistant pulled that thing out and immediately brushed my teeth three or four times. I almost cried when the doctor said it would have to go in for another three weeks while my bone healed.
As far as "surgeon you should go to"? I'd take the list of surgeons that take your medical insurance to your ortho and ask him to pick the one he recommends. Mine was done by a professor at the state dental school who had worked frequently with my ortho.
Re: Anyone use Dr Federico Alfaro
The length of the incision matters because greater incision means greater likelihood of nerve problems, not to mention risk of devitalization (there's a poor girl on realself right now dealing with that). Bruised nerves heal better than cut ones. Dr Alfaro's incision is 2.8mm vs molar to molar.
I can see why the splint would annoy you then. I keep a low carb paleo diet now. Think I can keep that up in recovery? That should keep the germs under control. Or at least I'll restrict the carbs to a small window each day.
My local surgeon is in network. I haven't gotten the price but I'd guess he'd be at least $50k cheaper than the celebrity surgeons I've seen. I'd gladly pay the money if it made a difference though.
I can see why the splint would annoy you then. I keep a low carb paleo diet now. Think I can keep that up in recovery? That should keep the germs under control. Or at least I'll restrict the carbs to a small window each day.
My local surgeon is in network. I haven't gotten the price but I'd guess he'd be at least $50k cheaper than the celebrity surgeons I've seen. I'd gladly pay the money if it made a difference though.
Re: Anyone use Dr Federico Alfaro
Sure you don't mean 2.8cm? In any case, I expect it depends on the depth of the arch, along with the thickness of the bone. Thick bone or deeper arches mean longer incisions because the cuts must be longer prior to the downfracture.
Can you maintain a paleo diet during recovery? Depends, I suppose. Can you turn a paleo diet into something consisting solely of liquids for a short while, followed by weeks of nearly not chewing? Staples of people recovering from surgery in the liquid phase usually include smoothies, milkshakes, meal replacement drinks, ice cream, yogurt, jello, etc. Soft-chew can include well-cooked veggies, eggs, etc. I think the single meal I ate more than anything else during soft-chew was canned corned beef and instant mashed potatoes mixed with generous amounts of shredded cheese, topped with ketchup and Sriracha sauce. I don't think a single thing on that list other than well-cooked veggies are on the paleo diet.
A non-dairy, low-carb, high-meat, liquid/soft really tasty diet? I'm drawing a blank here. You are quickly going to tire of pureed soup and almond milk. I will mention that if you can't imagine something tasting/feeling good pureed as a soup, you probably won't like it just tossed in the Food Processor or Blender either.
Can you maintain a paleo diet during recovery? Depends, I suppose. Can you turn a paleo diet into something consisting solely of liquids for a short while, followed by weeks of nearly not chewing? Staples of people recovering from surgery in the liquid phase usually include smoothies, milkshakes, meal replacement drinks, ice cream, yogurt, jello, etc. Soft-chew can include well-cooked veggies, eggs, etc. I think the single meal I ate more than anything else during soft-chew was canned corned beef and instant mashed potatoes mixed with generous amounts of shredded cheese, topped with ketchup and Sriracha sauce. I don't think a single thing on that list other than well-cooked veggies are on the paleo diet.
A non-dairy, low-carb, high-meat, liquid/soft really tasty diet? I'm drawing a blank here. You are quickly going to tire of pureed soup and almond milk. I will mention that if you can't imagine something tasting/feeling good pureed as a soup, you probably won't like it just tossed in the Food Processor or Blender either.
Re: Anyone use Dr Federico Alfaro
You are right, 2.8cm. He offers a virtual consultation so if it's not too expensive I'll start there and report back. Maybe I can get some names of Americans who've used him to speak to.
As for diet, yeah I wouldn't touch most of those foods these days. There's bone broth soup. I guess I'll need to experiment and see just how thin I can make a soup after going through a blender. I don't avoid dairy like most, just milk and low fat yogurt.
As for diet, yeah I wouldn't touch most of those foods these days. There's bone broth soup. I guess I'll need to experiment and see just how thin I can make a soup after going through a blender. I don't avoid dairy like most, just milk and low fat yogurt.