Tips, Tricks, and Comments – From a guy who’s done double jaw surgery TWICE!

[iamamused]

Hi All –
Figured I’d contribute to the site as it was helpful for me to read other users experiences on here and elsewhere. Most people don’t go through this twice so I wanted to share. This post is more a summary, and lessons learned, rather than a detailed day by day diary.

MY STORY / BACKGROUND:
34 year old male. Pretty healthy (physically & emotionally). Also very active. 6’1’’ 195lbs (normally). I note these things, because they changed after the first surgery. Started braces on 9/2014.

THE FIRST SURGERY
On 3/31/16 I had double jaw surgery performed (LEFORT 1 + BSSO) and a sliding genioplasty on my chin. This was to bring my lower jaw forward and in alignment with my upper jaw. The chin work was to increase my side profile / jaw line and to promote additional facial balance. Initially I was under the assumption that I only needed lower jaw surgery. But at the suggestion of my surgeon I allowed the upper to take place as well, as he wanted to increase the length of my face for further balance and symmetry.

The plan called for:
• Upper jaw movement to include a 1MM movement to the right on the midline, leveled cant, a 4mm disimpaction, a 2.5mm advancement, and a mandible rotation.
• Lower jaw movement to include 6mm advancement, 3mm elongation, slight yaw rotation, and a 2.5mm chin advancement.
• Fat grafting also occurred to fill out the chin and any facial gaps

I went with a highly regarded surgeon who is not just an oral surgery, but also a plastic surgeon (hence the fat grafting). He’s also known for using cutting edge computer aided modeling w/3D imaging. A 3D scan was done of my soft tissue and skeletal bones. This gets loaded into computer CAD modeling software where the surgeon works with a team of engineers to create the perfect set of splints and model movements.

I checked his references, spoke to prior patients, and looked up his medical license number. Everything checked out and I felt comfortable with him.

Unfortunately you know what they say about the best laid plans…

Early on (20 days in) I felt something was wrong. My mid-line was quite a bit off to my left (about 3/4s a tooth), and things felt slanted. My left jaw was much stronger than my right. With my right looking quite tapered. At the time, and for the next several months, my surgeon assured me it was swelling and that the mid-line would be corrected through orthodontics. Over the course of 6 months, my swelling did subside, but the angular nature to my face and the lack of asymmetry in my forward profile continued. I did have a perfect bite, but the jaws were in the wrong position in my face. Everything was off and stretched to the left.

6 months in my surgeon agreed, and a revision was scheduled for December 2017. He showed compassion and concerned for my plight. He and the hospital did right by me. They worked strongly with my insurance to get a 2nd surgery approved, and said they would cover any additional costs. I also owe a lot to my orthodontist; she really helped to push my surgeon to understand what was off and what could not be corrected by orthodontics.

I suppose I’ll never know what really went wrong. The usual order for double jaw surgery is to cut the upper jaw first. An intermediate split is placed between the jaws. This split lays over the existing positon of the lower jaw, and accounts for the new position of the upper jaw. Once the upper jaw is fixated, the lower jaw is cut, and a final split, aligning the lower jaw to the upper jaw is used. At which point the lower jaw is fixated. In my case, lastly the chin bone was cut. My guess is that my upper jaw was placed incorrectly slanted and to the left, at which point everything else followed. My lower jaw and chin were all in alignment with my upper jaw. The bite was great. But everything was off in relation to my face. My nose, philtrum, smile, lips, and jaw line were all off, pulled to the left. I felt like a Pablo Picasso painting come to life. Although my side profile was much improved, and my bite was great, my forward profile was worse off than before the surgery. It was quite disheartening.

THE EMOTIONAL ASPECT
I won’t delve too much into this, but I will say, even if everything goes to plan, you’ll need to get used to your new face. Your face will be under a level of scrutiny like it’s never been before. Family, friends, and co-workers will comment, and you will be your most ardent critic. Know your face very well before the surgery so you can better determine what’s changed. Take many pictures the day or two before. No one’s face is perfect and knowing your current imperfections, will help you better determine what’s been corrected or introduced after this surgery.

THE SECOND SURGERY
On 12/14/16 my second surgery was performed to revise the issues with the first.

The Plan Called for:
• Upper jaw movement midline 6.2mm to the right, 1.75mm advancement, 5mm posterior disimpaction, counterclockwise yaw rotation. This movement was done with 1 cut on the left upper jaw.
• Lower jaw would be cut in two places again, with a large 7.3mm gap on the left, and a smaller 2.5mm gap on the right. This would be to rotate the lower jaw into alignment with the new upper jaw center placement, and to balance out the jaw line.
• Possible chin repositioning and advancement (which did occur)
• Fat grafting to fill out any facial gaps

I am 5 weeks post the 2nd surgery. So things are still healing, but already I can tell my slanted-ness has been corrected and the mid-line is in a much better place. I do have some asymmetrical swelling on the left, since the larger movements were performed there. I also have additional ortho work that needs to be performed (closing the bite further & small midline corrections) – but overall I’m feeling much better about this 2nd surgery. At day 20+ I don’t feel the level of anxiety, uneasiness, and sadness that I felt with the 1st.

I will try to continue to follow-up on this thread with large progress milestones on the ultimate outcome. But please feel free to ask any questions and I’ll do my best to respond.

THE RECOVERY – TIPS, TRICKS and COMMENTS
My first surgery was rough, not just the un-intended outcome, but the recovery process as well. I had never felt so weak and for so long (weeks and weeks) in my life. I lost over 30 pounds, down to 163 at my lowest (from 195). I had poor breathing, lots of droll and large pockets of swelling that lasted for months. The worst was not being able to breathe well for 3 weeks. When my nose wasn’t bleeding, it was severely clogged with blood clots and swelling. This made it very difficult to “eat” (or use your syringe), as you are unable to breath while eating and it’s tough to sleep.

In general I was very weak – but I will say I was not in much pain, just a lot of discomfort. Outside the hospital I used nothing beyond ibuprofen for pain.
By contrast my second surgery was a breeze. A combination of knowing what I was getting into, having the right perspective, and preparing well is what really made the difference. This included a 2 week supplementation and eating plan prior to surgery as well as a post-surgery nutrition and recovery plan, which I’ll outline. Below is what worked for me and is intended to be a guide to help others. I don’t take any responsibility.

PRIOR TO SURGERY

EAT & EAT
When I knew the second surgery was coming, I had 3 months to prepare. I forced myself to gain as much weight as possible. I was still down 10lbs (~185lb) from my normal weight. For 3 months I ate and ate. This was probably the one enjoyable aspect of the entire ordeal. Certainly don’t make yourself unhealthy, but my goal was to be a little over my normal weight, to allow a cushion against the loss that was to occur. I was close to 200lbs by my 2nd surgery.

SUPPLEMENT & CLEAN LIVING
Two weeks prior to surgery I cut alcohol out of my diet entirely and began supplementing with bromelain, turmeric, and B1. The thought process being to get this built up in my system. 3 days prior to surgery, stop all supplementation. The surgeon instructed me to be off all supplementation 3 days prior to surgery, just to be safe with bleeding.

These dosages are a guide, and for a guy my size. You may want to adjust accordingly.
• Tumeric & bromelain are anti-inflammatory agents; I took 3,000mg per day of each. 3x500mg pills of each in the morning and the same 3x500 in the evening. The bromelain is most effective on an empty stomach, I believe the Tumeric can be taken with food. Although I took both on an empty stomach. I did not feel any discomfort.
• Vitamin B1 is for nerve regeneration. I took 400mg each day. 1x200mg in the morning and 1x200mg in the evening.

BREATHING TIPS, PRIOR TO SURGERY:
For any surgery under anesthesia with the jaw, the breathing tube is inserted into one of your nostrils. If you have upper jaw surgery, it’s very likely surgical tools will be inserted in the other nostril. The inside of the nose will be very very raw. You will have nose bleeds after this kind of surgery.

Tips for better breathing:
• Trim / Shave your nose hairs and really clean out your nose. Not only will this make the surgeons life easier it’ll make blood clotting for you better without hair in it.
• Pick up breathe right nose strips
• Pick up saline nasal gel (Ayr w/aloe is pretty good)
• Pick up saline nasal spray (this may be provided by your hospital)
• Have a humidifier

POST SURGERY:
I’ll be skipping a lot of the obvious larger items involved in this surgery and focusing on some of the more detailed, nuanced, items I learned doing it twice.

SWELLING PREVENTION - ICE & STERIODS
Ice. Ice. Ice like your life depended on it. For 72 hours as much as you can. I wish this was explained to me during the first surgery. The initial 3 day window is your best chance for keeping swelling down. The hospital provided me two cloth ice bags tied together and showed me how to wrap my face, completely covering the sides, jawline, and chin. The 1st surgery I found them uncomfortable and that I would get headaches from them. I wore them sporadically. Deal with this discomfort; it will help you much more later on. The 2nd surgery I lived in my jaw ice bags for 23 hours out of each day; only taking them off to eat and to refill. I also supplemented my lips with ice occasionally while awake (probably 8-10 hours a day). You will go through a ton of ice, buy ice bags from the store.

Large swelling of your cheeks and lips is inevitable. But ice will greatly reduce the size, severity, and duration. By 7 days my swelling was down to almost normal. I knew I still had (and have) some swelling, but it was no longer noticeable to anyone who wasn’t really detailing your face.
I was also prescribed a liquid steroid the 2nd time around, which also helps in swelling. Also, you should know, stay elevated, and sleep propped up.
Side note on swelling: for weeks, even months, you will have residual swelling. This is normal. It can flair up and increase throughout the day depending on how much excursion you perform.

BREATHING POST SURGERY
Below is how I cared for my nose. I was breathing adequately at day 3, comfortably at day 6, and no longer needing strips at day 10, compared to 3 weeks w/my 1st surgery.

Steps:
Do not blow your nose. This makes things worse and impedes the healing process. Your nose will have discharge; mucus, blood, or some combination of the two. You need to be gentle to your nose. No scraping, picking, or blowing. It’s raw and will need to heal.

To clean and treat:
1. Two sprays of saline nasal spray per nostril. Apply while to one nostril while holding the other closed and at an angle. You want the spray to coat the inner lining, not to spray up into your nasal sinus cavity. This will loosen things up.
2. Wait a couple minutes for the saline spray to work in. Then, twist into wads, and gently insert 1 square of bath tissue (toilet paper) into each nose, one at a time. Think like you’re trying to stop a nose bleed. And use the good, soft kind, like charmin ultra. Wait 30 seconds or so and gently remove. The tissue should have soaked up some of the fluid. You can do this several times in each nostril as you see fit.
3. Finish up by coating the inside with nasal gel to retain moisture. Take a q-tip and apply a drop of the gel. Use the q-tip to GENTLY coat your lower nostril. Do not go far up into the nose.
4. Apply a breathe right strip
5. Live right next to a humidifier. Have the humidifier mist almost directly on your face. I had two running on my night stand at night, and one next to me when watching TV in the recliner.

The above plan, in combination with a shaved nose, really eliminated the heavy blood clotting I experienced during my first surgery and allowed the nose to heal much quicker. If you do have blood clots you can (very carefully) pull them out with small tweezers (and a flashlight) after you’ve loosened things up. You do need to be careful, as removing the clot will re-open a cut. But sometimes the clots can be so large and uncomfortable, they require removal. My first surgery I was pulling stalactites the size of mini-Cheetos.

NUTRITION POST SURGERY:
The first surgery I lost 30+ pounds, the second it was only 10. Getting my breathing right went a long way towards better eating and sleep – but I also made a plan this second time around and started with supplementation (listed above) as soon as I got home. I shopped for blend-able items that packed the highest calories. I have a fast metabolism and eat between 3,000 – 3,500 calories per day to maintain my normal weight and active lifestyle. I felt with almost no activity, I could be comfortable around 2,500 calories per day. Drinking with a syringe is messy and a pain as well, so I wanted to reduce the amount of sitting required consuming these calories. I settled on 5 meals a day.

Now I won’t go so far to say this diet is terribly healthy – but it will keep your energy up. I felt a lot more like myself by week 2, where it was week 6+ when I could chew soft food with my first surgery. Ensures and fruit smoothies are not enough calorie content to sustain. Side note on ensures, I found they can upset my stomach, especially the “Plus” version. If you can stomach it, get the plus. I used the regular. Keep in mind you’ll want a high end blender. I use a vitamix. At $300 plus dollars it’s not cheap, but worth it as a blender. Almost any food can be pulverized.

Food that is cost effective, easy to blend:
- 18oz cans of Soup. The Campbell’s chunky soup line has high calorie soup without costing a ton. Look for flavors in the 170-220 calorie range, which will give you 400 or so per can. These include creamy chicken noodle, potato soup, etc.
- Cans of corn beef hash. Hormel has pre-cooked meat and 400 calories per serving, so 800 per can.
- Large cans of Dinty Moore Beef Stew. 38oz. One can of this is 1000 calories.
- Ice Cream, add peanut butter, milk, cookies, and chunks of chocolate
- Gatorade / PowerAde, about 130 calories per 20oz.

Here’s a typical day:
- 9am: 2x Regular Ensures, 18oz of regular PowerAde
o 220 Calories per ensure = 440 + 100 PowerAde = 540 Calories for breakfast

- *11am: 1xCan of Chunky Soup, PowerAde, 1x Ensure
o About 620 calories

- *2pm: 1xCan of Chunky Soup, PowerAde, 1x Ensure
o About 620 calories

- 5pm: 1xCan of Dinty Moore or Corn Beef Hash w/Water
o About 1,000 calories

- 9pm: 2x can of Ensure or Ice Cream
o 440 calories or 600 calories

*Two meals a day I would mix in my turmeric, bromelain, and B1 pills. This was until I was able to open wide enough to get a pill in. If you buy pills that have powder in them, you can separate the capsule and pour the powder into you soup while blending. The first few days you do need to work up to this diet. I ate a few less ensures, and skipped a meal, but I made it to 2500 calories pretty quickly and eventually got to the 3,000+ I’ve laid out above; which has been helpful since I will be 6 weeks on a blender diet.

EATING WITH A SYRINGE – CLEANING AND OILING
Ask for as many of the largest syringes possible you can get from the hospital. I would have no idea where you would get these otherwise. Maybe online? The largest I was provided was a 60ml plunger style syringe, with a catheter tube cut and attached to the end. I left with 5 of these.
I was unable to get more than 5 days out of each before they became gunked up with food and impossible to work. Then I learned some tricks on how to better maintain them.

1. After each use, dunk the syringe in a cup of water and suck up 2 or 3 syringes worth full of water, clearing out the food debris
2. Store the syringe half open (so the rubber seal doesn’t get stuck at the bottom)
3. Pour a little cooking oil or vegetable oil into a cap. Suck this into the syringe, and swirl it around to coat the lines of the chamber. Then pump several times (over the sink) to oil it up.

With the above I’m able to get close to 2 weeks out of a syringe.

OVERALL COMMENTS / REFLECTION:
I’m occasionally asked: “Was it worth it?” I find this a tough question to answer, “was it worth it” will certainly be very different from me to you. What I would urge you to do though is to be well aware of the complications and potential poor outcomes of this procedure. This may be old hat to your surgeon and orthodontist, but it’s not a surgery to be taken lightly. While a second surgery is not the norm, I’m one of the lucky (or unlucky ones depending on how you look at it) who had the opportunity / means for a revision. While researching my initial issues, I came across several stories of others who were unhappy with the outcome and could not afford a second surgery. Either their surgeon would not support them, or their insurance would not cover.

Keep in mind you should also have proper expectations for your outcome as well. No one’s face is perfect, slight asymmetry or a slightly off mid-line is well within the range of acceptance. I believe my final outcome will be much better, although not perfect, but in the end I will look and feel better than when I started this process almost 3 years ago.

Still, is it worth it? If I knew then, what I know now (and now is 5 weeks post the 2nd surgery) I would likely opt NOT to have gone through this process. I was comfortable with my face, I have a lovely wife and a wonderful family. My teeth were relatively straight. At most what slightly bothered me was my recessed chin and even if I really wanted (hint: it didn’t bother me enough) to correct that I could have just gotten a much less invasive chin job. No, I was sold on the fact that my poor bite would lead to bone deterioration and cause my light occasional snoring to become sleep apnea. My father has a very similar face structure and body type. He is in shape, but does have sleep apnea and has been through quite a bit of dental work. I also never knew what a perfect bite was like and thought I was missing out. I had been told these items for years from dental professionals since I was a teenager. The primary driver was to prevent these issues and finally know a “normal bite”. This coupled with the (slight) vanity of a nicer smile and an improved side profile had me start this trying process.

In the end, between the cost of braces ($7500, real cost ~$5,500 w/a FSA) and the surgery $8,000 ($3,000 for the Jaw not covered by insurance + $5,000 for the chin), I’ve spent $13k. Which honestly isn’t that bad considering. But add to it the recovery. 6 weeks out of work, and several weeks of reduced capacity. Add to it the toll it’s taken emotionally on me from the poor 1st outcome. Add to it the time I haven’t spent with my young kids and the slack my wife’s had to take on.

When those cons are weighted against the benefits I have a hard time thinking I’d make the same choices. Yes, my breathing is improved (both while awake and asleep), and yes I will likely look better as well (still healing from the 2nd). But the perfect bite was nonsense (for me anyway) and I was perfectly happy with how I looked.

If everything went to plan, I’d likely be singing a different tune. Most time it does go well – and way more often than not people are happy they did this. Heck, speak to me in a few years, after this is all well in my rearview, and I may have a different tune myself. My advice, know the possible outcomes and really weigh the risks. Really understand your self-confidence and/or the health reasons involved. It’s not a surgery to be taken lightly. My story is not meant to sway anyone, rather to provide another perspective and hopefully some helpful tips.

[dannyc77]

Hey thanks for a really detailed and thoughtful breakdown of your experience. Hope it's working out for you and getting better every day. I sound quite similar to you in that I'm married nearly 40 with kids. Face doesn't bother me really I suppose everyone has little things that they notice though. but I d been told that double jaw surgery the best solution to my deep overbite. They've also toldme other things about my face which kind of play on your mind once they are pointed out! Got to decide whether to go for a compromise solution or the surgery now. Btw have u got much numbness I'm concerned at my age and the fact I have a wisdom tooth right on a nerve in my lower jaw that I could have considerable permanent numbness. Good luck to you!

[iamamused]

Thanks. Glad my post was of some help.

I too had a deep over bite w/a little bit of over jet as well. Braces did correct the overjet and help to reduce the appearance of my over bite somewhat. But yes, ultimately surgery is the only way to perform the large movements required to bring the jaw into alignment.

There are alternatives for younger children. I mention this because if your kids have a similar facial structure they can avoid surgery through juvenile orthodontic treatment. While the bone is growing it can be shaped. It's something I've looked into should the time come. My children are very young, so it'll be a few years till I know what (if anything) is needed. Fingers crossed they take after my wife.

Good point on the nerve damage, I really should have mentioned it in my original post. My first surgery went very well with limited nerve injury. From day one I had normally feeling everywhere, with the exception of my lips and chin. My lips and chin had reduced sensitivity, with my lower right lip being the worse off. At the 9 month mark (start of 2nd surgery), my lower right lip was better but still off, the rest of my lips felt completely normal, and my chin was still a little off. Overall, not bad.

With the second surgery I have a lot more numbness than the first. Lips started out almost completely numb vs. the reduced sensitivity the 1st go around. Chin is the same as the first surgery. But now I also have numbness in my upper lip area (where my moustache would grow), and numbness in the tip of my nose.

Now at 6 weeks things have come back a little. They say up to a year with nerves, but I'm concerned enough that I've started acupuncture. I'll see how that goes.

Nerve damage is certainly a risk. A skilled surgeon can limit this. The only nerves that should be disturbed are those that are in the bone. And since they are in the bone, the risk of scar tissue disrupting nerve regrowth is greatly reduced. Most everyone recovers to close to pre surgery, with small pockets of permanent numbness or reduced sensitivity also common.

The greatest concern is the lingual nerve, which controls facial muscles, but a good surgeon should not even come close to this nerve. That said, I have read some horror stories, so severe nerve damage is not outside the realm of possibilities, though it is low.

My biggest worry was numbness in my lips. I wanted to be able to kiss my wife and feel it. It felt close to normal at the 9 month mark on my 1st. 6 weeks in on the 2nd, I don't feel a thing, besides perhaps some pressure. That why I'm taking a run at acupuncture.

Hope that helps.

[shortcircuit]

Great information, thanks for sharing. I'm looking at a LeFort + BSSO as well, but my case is either all or nothing, either I get surgical orthodontics or wear things as is. I have a number of functional issues, but a gradually worsening speech/pronunciation deficit is the last straw for me, the rest of it I could find a way to live with.

Question: what kind of fixation did you get (wired, rubber bands, etc.)? One of my main concerns is breathing after the surgery, I was told by one surgeon that he wires patients shut for 10 days minimum after DJS as a matter of course. Add to that a completely clogged nose and swollen lips that have to be forced/held open, and that sounds like a situation where every minute feels like an hour. If your nose was completely clogged, did you have to use something to wedge your lips open for air?

Good to hear your surgeon made things right, there is another member here who had a bad outcome from Kaiser in Oakland and instead of any help with a revision, basically got the middle finger from both her surgeon and orthodontist.

[iamamused]

I was fixated with bands for both surgeries. My surgeon utilizes plates and screws to hold the bone while it heals (unless there's a problem with plate rejection, infection, or loosening) they usually stay in for the rest of your life. My jaw was then very strongly banded to eliminate movement. There was no splint left in either. At the one week mark he typically loosens the bands, followed by a gradual loosening every two weeks until the 6 week mark where he allows my ortho to begin her work.

That's my surgeon's normal routine. Still even though it's rubber bands the initial banding is extremely tight, with no movement or ability to open. I would imagine it's similar to being wired. As I mentioned with the first surgery breathing was very difficult and the worst aspect of the ordeal because it really impacts everything else (energy, how quickly you bounce back, eating, etc). Hopefully my plan of attack will be useful to others. I had very minimal breathing discomfort the second time around.

My second surgery has been a little different, though in terms of banding. I've been close to almost fully banded for 6 weeks. There was an initial loosening at week 1, followed by another loosening at week 3. At that point I was able to open wide enough to fit a pill in, and talk relatively normal (no longer talking through clenched teeth). At week 3 of the 2nd surgery, since recovery has been going so well, I went back to work. I speak a lot in my job and the first few days over did it. I knew that over use does bring back swelling. Unfortunately I had an acute inflammatory response of hard swelling, over one of the surgical incision sites, extending to under my chin.

I went to my doctor. The worry was that I had an infection, either bacteria, or plate rejection. They ordered a CTscan which showed all the hardware looked good. I was placed on antibiotics. Honestly I never felt like my body was fighting an infection, nor has there been any drainage. It's likely I over did it, but better to be safe than not. It was especially odd how quickly the new swelling came on, where it was, and how it was harder.

As further precaution my surgeon has kept me fully banded at the level I was. Been a liquid diet for 6 weeks. But I can say with rest, both of my jaw and overall, plus the extra option of antibiotics, the swelling and the subsequent lump have considerably reduced. You can't see it, and I can barely feel it. I am much happier with my 2nd surgical outcome.

Feel free to ask any additional questions. I'm always happy to answer.

PS I think I did see that thread on the Kaiser patient, but correct me if I'm wrong, I thought it had been close to a decade since the first surgery for her? I feel for anyone who has to go through this once, let alone twice. But I know for me and my issues I couldn't wait to get them corrected.

[shortcircuit]

I was wondering how you went about selecting your surgeon, I live in a college town in a semi-rural area that is pretty far from any major population centers, and the area also has a lot of people living on a fixed income and drug problems so it's actually more likely to see people with no teeth at all than anyone with braces.

The oral surgeon that my orthodontist prefers to work with said that he does about one of these procedures a month, there are at least four oral surgeons in this area that I know of and none of them do orthognathic surgery exclusively (probably because they would starve to death if they did).

I'm consulting with a second oral surgeon later this week who is pretty new and has only been in town for a couple of years, my ortho said that I can use him if I want but he doesn't have much of a track record on these cases with my ortho yet. The new surgeon is the only one around here in-network on my dental "insurance," so if I get wisdom teeth out through him I will only have to pay 1/3 of UCR instead of the whole thing. At least that's what they told me, I should probably check and see if there is a possibility that they will deny the claim after the fact.

During the initial consult with the orthodontist, he did mention one other surgeon who has been around here for ages but he got a pretty sour look on his face at the same time, my impression was that they had had communication issues in the past.

If you were interviewing surgeons again with what you know now, what would make you decide to reject a particular surgeon and go elsewhere?

EDIT: I should mention that there are no oral surgeons in network on my insurance within 4 hours of me, the surgeon my ortho prefers working with did tell me that he doesn't balance bill for the surgery fee and just takes what he can get from the insurance as a favor to the ortho because they've been working together for x number of years. Good deal or red flag?

[iamamused]

I began my initial surgeon search the exact way as you. By taking recommendations from my orthodontist and following up with the insurance company for in-network doctors. My insurance is through work. Health care is provided by Cigna, and dental is by Delta Dental. My dental policy is quite limited. They provide a maximum lifetime pay out of $1500. I used this to help with braces (as well as an FSA account.) My dental coverage through Delta Dental was no where near the coverage needed for the oral surgery. My heath insurer, Cigna, covered it. At least from what I've gathered through this process and stories from others - its typically the health insurance provider that covers this surgery. Cigna did require pre-authorization, which actually made me more comfortable, knowing that I had documentation prior of approval.

What drew me to my surgeon was his experience and his approach, utilizing computer modeling. He is also both a plastic surgeon and an orthodontic surgeon, performing several surgeries a week - and the jaw surgery specifically several times per month. A few things did strike me about him though. One, he always seemed incredibly busy. I never felt rushed, and I could access him when need be, but in hindsight, what I thought was a pro (his high surgery schedule) may have been a detriment. Two, the hospital he practices in is a teaching hospital. And three, his bedside manner, though not poor or dismissive at all, wasn't very warm either. I assumed his beside manner was that of most surgeons (it likely is).

At the time I placed all my selection criteria on those "hard skills" - experience, education, license status, approach, referral feedback, etc. All of which my surgeon passed with flying colors. I still would place a high reliance on that today, but I would look a little more at the "soft skills". I can tell you that my second surgery was vastly different, in terms of recovery and outcome, than my first. I felt like a much more skilled hand worked on me the 2nd time. Whether my doctor had a residency touch me the 1st time, or was rushed through preparation, or just made an honest mistake - I'll never really know. In the end I do think he's done a great job, and I'm glad I went to someone who is also a plastic surgeon (he added fat grafts to me which helps with balance). I just wish it all went this way the first time, but in the end my surgeon did do right by me and has been greatly concerned with my well being.

My advice, definitely pull the surgeon's license and check for any issues. Most state websites allow you to do this easily online. Try to check references and get a sense for their approach to surgery. The doctor you mentioned that does 1 a month doesn't sound bad and it might be to your benefit that he has more time to devote to you.

The balance billing sounds a little funny to me, I'd keep it in the back of my mind, but it wouldn't be a complete red flag. I think these guys try to milk the insurance company as much as possible. My surgery was performed in a fairly expense part of the country. They attempted to charge close to $100k against Cigna (between hospital facility fees, and the surgeon). Ultimately it was settled for near half that. Which is still to high in my opinion. On my first surgery I paid an additional $5,000 for 1 hour of surgery to do work on the chin. My first surgery was 5 hours total. Extrapolating that out, you'd think it would be somewhere in the $25k - $30k range. Not $50k plus, and certainly not the near $100k they asked for. But that's how it is. I have heard this surgery ranges from $20k to $75k depending on many different factors (location, work performed, etc.)

Good Luck, if you have any more questions just ask. Happy to help.

[jawregret1]

Hey iamamused!

I have a few questions regarding how you went about a revision.

- Did you ever consult other surgeons?
- How did you trust your surgeon to perform a revision? Did you ask how many he's performed? I hear they're much more technically complex than a first surgery.
- Did you have any say regarding the planning for the revision? Because apart from the obvious asymmetry and off midline, they seemed to do a few things not to do with that (e.g. posterior disimpaction).
- Has your disimpaction in general remained stable? What kind of grafting material did they use?

Sorry for all the questions! I'm very likely heading in for a revision. It's rare to find someone who's gone through the process twice.

Thank you.

[iamamused]

Hi! I've tried to reply to your questions, below, in red.

Hey iamamused!

I have a few questions regarding how you went about a revision.

- Did you ever consult other surgeons?

I did for the initial surgery. For the revision I did not. I struggled with this decision. Stay with what I know, or go somewhere else? There was a concern that I was making a mistake trusting someone a 2nd time after the 1st mistake. On the flip side, I thought he would take extra care to correct it. Ultimately the concern and compassion my surgeon displayed, once he was convinced a revision was necessary, the continued follow-up, and overly detailed planning had me decide to stay with him. I believe he was genuinely sorry for what had happened and stepped up to do the right thing with the revision, both in terms of the outcome and financially. I felt he would (and did) take the extra care, where a 2nd guy may have just said, "Well I improved it" rather than shooting for the best possible outcome. My surgeon certainly did have the skill set, as exhibited by my 2nd surgical outcome, what happened the first time I'll likely never know.

- How did you trust your surgeon to perform a revision? Did you ask how many he's performed? I hear they're much more technically complex than a first surgery.

It did take a little bit to convince my surgeon a revision was required. He admitted that he's never revised his own work, but has revised others. I think initially he felt that it was unlikely, as good as he is, that there was a mistake. For several months he was convinced it was just swelling. It was the work of my ortho and me being my own advocate (I actually took pictures of myself from multiple angles, and marked them up to show the issues). From there he was sympathetic and receptive. I did not get an exact count, but he did say he's performed revisions of others and several complex surgeries. He had a good plan for the revision and was already familiar with my nerves and bones. So far (at 6 weeks) things seem to be panning out. Even if this is my final outcome (I still certainly have swelling) I'm much happier than where I was.

- Did you have any say regarding the planning for the revision? Because apart from the obvious asymmetry and off midline, they seemed to do a few things not to do with that (e.g. posterior disimpaction).

I had a say in the general movements. (Besides I wouldn't really know the minute movements or angles, I'm not the surgeon after all.) Correction of the mid-line and asymmetry where the two big issues. That's what drove me to a revision. In addition to that, I felt my jaw had a slight yaw to it, and that my chin was not advanced as far as it could be. They were secondary issues and wouldn't have been enough to push me to a revision, but hey, if you're already in there.. My surgeon then runs his 3d models through a computer program that measures facial balance. Everything from the distance between the eyes, to the nose, the jaw line, and many other angles. It creates a suggestion based on aesthetically pleasing angles and acceptable ranges. My surgeon will then tweak this. He then reviewed with me, that he was going to take my suggestions and also change the angle of my bite (from aiming downward to more flat.) In addition to correcting my symmetry, I think correcting this angle made my face look less long and tapered. Which I am happy with. Some of the other surgeons even do the computer modeling live with their patients, but mine preferred to do it alone and follow-up with his plan for further input. Once the plan is set, a lab creates the splints with 3d printers (vs. the old style models).

- Has your disimpaction in general remained stable? What kind of grafting material did they use?

So far so good. My midline has shifted a little bit between the two jaws, but my ortho is confident this can be corrected with bands. Plates held the bones in place, and fat grafting (the fat was taken from my belly, very small amounts, we're talking CCs) was used to fill in the chin and a few areas of the face that my surgeon felt could use filling in after everything was set.

Sorry for all the questions! I'm very likely heading in for a revision. It's rare to find someone who's gone through the process twice.

No worries, I know what its like and it can be hard to find info. Feel free to ask away. I was terribly "off" in terms of facial balance, with features pulled to the left. It was noticeable to others, not just me. Its hard to look at yourself in the mirror and not be happy with the face looking back.

Thank you.

[jawregret1]

Thanks for the reply! A few more questions as I come up with them...

- After your first surgery, did the 4mm anterior disimpaction result in 4mm of extra tooth show?
- Have you had a large change in your nose (widening or becoming upturned) from the downgraft and forward movement?

[iamamused]

Thanks for the reply! A few more questions as I come up with them...

- After your first surgery, did the 4mm anterior disimpaction result in 4mm of extra tooth show?
- Have you had a large change in your nose (widening or becoming upturned) from the downgraft and forward movement?

I have some strong features, as I am of Portuguese decent. I have a pretty strong nose (not quite Adrien Brody strong, but close) and thick full lips. My surgeon was targeting to show more teeth in my smile, since my lips covered up some of my teeth. To be honest I never really noticed after the first surgery if that movement succeeded in a larger smile. With everything so crooked, including my smile, it was hard to tell. Its also something that never bothered me. I felt my smile was full enough. Things are still healing, so we'll see how this 2nd time turns out. But either way, I don't have a gummy smile.

After the first surgery there was a change in my nose. It was not a large change, but it was slightly pushed over and one nostril was larger than the other. The right nostril, being the smaller one, was compressed and I had poor breathing from that one. This was due to the incorrect placement of my jaw, as it was pushing on my nose. After the second surgery, my nose has since returned to its normal look, and breathing is improved overall, including pre-all surgeries.

[jawregret1]

I also thought many surgeons wait a year before reoperating to allow proper healing and to see where the soft tissue has settled?

[improvedchin]

Hi iamamused, thanks for sharing your story. I have 2 questions.

were you active as in you worked out and exercised a lot?

if so, do you know if strenuous exercise, particularly activities that cause you to flex / tense your neck (certain weight lifting), jaw muscles can cause relapse? like a chin that was advanced can be pushed back to its original state due to the pressure / tension caused by the workouts?

[braces101]

You have some great tips here. Just adding to a few of your points:

Icing- I iced nonstop for the 5 days I was in the hospital which probably helped a lot but I feel like I could have done even better. The ice bags (the ones you tie together) were terrible because they are almost impossible to position correctly. On top of that, the ice needs to be replaced very frequently and the nurses I had just weren't staying on top of it. I later found out that my surgeon had given me better ice packs that I should have been using. They are called Halyard bilateral facial ice packs. If your surgeon will not provide them, I highly suggest buying some before your surgery. I continued using these for the weeks following to help control pain.

Eating/nutrition- your point about the calories is also very important. I cannot stomach Ensure or any other whey protein products for that matter, so I ate very little in the hospital. I'm also a very active person (200lbs, low body fat) so once I got home, I made a point to drink as many calories as possible each day. Not sugar, but by using oil and nut butters in smoothies. I was going through an almost entire 16oz container of almond butter every day. My main meal was a smoothie consisting of almond butter, spinach, almond milk and banana. By doing so, I managed to get through 6 weeks of liquid diet and only lose 15 pounds, which I consider a success. Have an idea of what you want to eat beforehand and buy a Vitamix if you don't already have one--a good blender definitely makes things easier.

Sleep- maybe I just haven't read enough people's experiences but for me personally, sleeping was incredibly difficult. I would wake up 4-5 times a night every night for the first couple weeks in pain/discomfort, would take pain killers and refill my ice pack. I think it was at exactly 3 weeks that I finally got my first full night of sleep. Since that one night, I have had no issue sleeping. I don't know that there's much else I could have done, just something to be aware of.

Nose/breathing- you mentioned having difficulty with the nose. I was able to control most of the congestion with Afrin. I did this for the first 2 weeks then switched to saline as needed. Never once had a full on nose bleed, but saw plenty of red nasty mucous and crust. For me, the mucous drainage into the throat immediately after the surgery was the most torturous aspect of this. My surgery was in the winter and one other thing I noticed was that breathing cold air made my nose hurt.

Overall- do not expect your surgeon or orthodontist to prepare you for how hard this will be. They are not in the business of freaking their patients out and they see it all the time. Looking back from where I am now, I think it was worth it, but like you, having known what I know now, I probably would have never decided to do it in the first place-- and I only had to do it once.

[iamamused]

Small update, OP here. Had my 10 month check up recently. I would say I am quite satisfied with the cosmetic outcome of the revision. I've been out of braces for about 2 months. I'd say I still have some minor residual swelling. Nothing anyone would notice. Hell, I probably wouldn't notice it myself, if I wasn't so attentive to every detail of my face after going through two surgeries.

Unfortunately a fair amount of nerve damage still remains on almost all of my lower lip and half of my upper. Kissing is no longer as enjoyable as it once was. I joke with my wife, that when I kiss her I no longer "feel anything". Which helps make some light of things, but if I'm honest I am sad about that. I also continue to bite my lips, spill water / food, and don't know when food is on my lips after eating due to the numbness. My surgeon says that it should return, and that the feelings in my chin (chin is 95% normal) are promising that much of the lip will return since they are the same nerve branch. I'm optimistic, but this is coming from the same guy that told me my slanted face was swelling - so I take it with a grain of salt. What I can say, is that acupuncture has helped, and I know that from a prior, unrelated, nerve injury - that nerve re-growth occurs at a glacial pace.

In the end, I'm glad I did the revision, if only to correct my facial imbalance that was introduced from the 1st surgery. The 2nd surgery had to be done, and the cosmetic outcome is good. That said, knowing what I know now - with the remaining nerve damage, the pain and suffering, and the cost - I would not have gone through with this endeavor. Family and friends are pushing me to look into compensation, I am unsure yet how I feel about that. Perhaps in another year the nerves will be back and this whole process will be a distant memory. But even 10 months out, I am reminded daily of my surgical outcome.

I don't want to scare anyone out of this. I have seen and heard of some truly remarkable transformations and success stories. Just know the risks and really assess the necessity of surgery. Like I mentioned in prior posts, how I looked was fine (although I am now, albeit subtlety, improved). I was sold on the "breathing aspect", which also has improved, subtlety. But neither improvement has been worth the (hopefully not permanent) nerve damage and considerable time, money and frustration.

In the end I do count my blessings. I have my health, my face back, and things could have been worse. My two cents is just a word of caution - especially since this is an elective surgery.

Anyway, on to questions!

Hi iamamused, thanks for sharing your story. I have 2 questions.

were you active as in you worked out and exercised a lot?

if so, do you know if strenuous exercise, particularly activities that cause you to flex / tense your neck (certain weight lifting), jaw muscles can cause relapse? like a chin that was advanced can be pushed back to its original state due to the pressure / tension caused by the workouts?

Do I even lift bro? Why yes, although not like I used to. I kept very much up on lifting and strenuous activity up until my late 20s. Work and family life has taken away from the ability to hit the gym as hard, long, and as often as I used to. I have never heard of lifting causing the chin to recede - pre, or post surgery. My surgeon did ask if my chin receded further with age. It may have, as I feel like I had more of a chin in high school, but he attributed that more to growing from adolescence and less to physical activity.

After these surgeries I have gotten back into mountain biking and lifting, gradually. I don't plan on changing my physical activities as these are things I enjoy.

I also thought many surgeons wait a year before reoperating to allow proper healing and to see where the soft tissue has settled?

I have seen that as well, and this was a question I posed to my surgeon but he felt comfortable going back in at the 9/10 month mark. His response was he wanted enough time for the bone to be strong enough to re-cut and that was it. So far my bone healing has been fine, with the exception of that nasty localized swelling I spoke of in earlier posts, which has resolved just fine.