Thursday, March 26, 2015

Rearrange Your Face

“Malocclusion” is a fancy word that means “doesn’t close right”. If you’ve got a closet door at your house that sticks, it’s maloccluded. If your jaw doesn’t line up, It’s maloccluded. If your lower jaw is nearly half an inch (1.2 cm) further out than your upper jaw, you’re maloccluded. Or you’re an English Bulldog. (The latter is cute.)

If you have a minor underbite (the not-so-fancy word for “malocclusion”), the answer is a surgical procedure called a “sagittal split osteotomy”. In laymen’s terms, they cut your jaw off behind your teeth, take out some bone, then reattach it so that it’s shorter. If your underbite is excessive – such as in my case – they cannot put all the correction onto one jaw, so you have to add a second procedure called a “Lefort I osteotomy”. In other words, they cut your upper jaw off along the cheek line and move it around.

As horrific as this all sounds, it’s a relatively low risk and common procedure. In fact, it’s a popular (and controversial) elective procedure in South Korea, where people are trying to get a more pronounced, “western” style face. It’s also medically necessary in cases like mine where (1) you’re unable to properly chew your food, leading to (2) poor digestive health. Granted, I was eating, but occasionally an un-chewed piece of food would get down there and I’d choke a little. The real kicker for me came when my dentist, in comparing X-Rays, told me that because of my uneven bite, the (3) bone structure of my jaw was degrading. I would slowly lose bone until it could no longer support my teeth, and eventually I would lose all of them. 3 basically combined with 1 and 2, and I decided it was time to have the surgery.

The first place I went was to the Internet, because everything you read there is true and real. I made the mistake of googling the procedure by name, and basically came up with a bunch of plastic surgeons trying to sell me on how beautiful and aesthetically pleasing my face would be after the surgery. That was going nowhere – I was already a handsome dude (at least in my own mind), and frankly wasn’t concerned with aesthetics. On a whim, I googled “double jaw surgery”, and the first thing to come up was Graham’s most excellent blog, “Double Jaw Surgery”. Graham is an excellent writer, and kept a detailed daily blog of his experiences both before and after his surgery. He also included additional information. More than anything else, this blog gave me the courage to go through with the surgery. (Being Canadian, Graham was very helpful when I contacted him, and very encouraging. Canadians – the best neighbors America could ask for.)

On February 19th, I went under the knife. I played the part of the brave person for my wife going into surgery because she was nervous. (I had been in her role twice before, so I know how brave she was being for my sake.) I came out six hours later. My recovery was actually very rapid, with few complications, and is somewhat different from Grahams. I’m very pleased with the results both aesthetically and in terms of function. In addition to being able to chew food properly, I no longer have a lisp. I no longer have to worry about accidentally spitting on anyone, either. Lastly, the popping in my temporomandibular joint is gone. In fact, I’m discovering new benefits of proper alignment every day.

That doesn’t mean it’s all sunshine and rainbows. Recovery is difficult physically as well as psychologically. You will be wired shut during the initial recovery period, and that inability to communicate verbally can be beyond frustrating. Being stuck in a chair or bed, and unable to get out and do the things you want to do is also hard. My marriage survived my recovery. My laptop screen did not. Even more psychologically difficult is your residual perception of self. Even though these are minor changes, you will look different. After a lifetime of looking at yourself in the mirror, you will suddenly find a stranger staring back at you. You may not like the change, either, and that can lead to depression, anger and other emotional problems. So if you’re thinking about getting this kind of surgery, think carefully about why you’re doing it. I would not recommend you get it for minor cosmetic reasons. However, if you have problems with bite or progressive degeneration of the jaw, you should not hesitate.

As I mentioned before, Graham was a huge help in not only my decision, but in being prepared for my recovery. Although my experience was quite a bit different from his, I think it’s fair to say that his experience is different from others. Your experience will be different from mine. Below are some notes on my recovery in Q and A format.

What was in like going into surgery?

First, I’m not going to lie. I was a little nervous. I think one thing that helped is that my surgical appointment was very early. I had to be at the hospital at 6:00 am. In the mornings, I’m largely on autopilot. The magnitude of what I was doing didn’t hit me until I was on the bed, in my gown, and waiting my surgical prep team to finish getting me ready. Up until then, my bigger concern was making sure my wife (the best wife in the world, and one who I am totally undeserving of) was okay. She had a lot of gear to pack around, and she was going to spend the next six hours alone in a strange place surrounded by strangers. So at that point, I had ten minutes to really think about what I was doing. Then my anesthesiologist came in with the “margarita” (aka midizolam), and after that it was one big damned party. Midizolam is administered to not only relieve anxiety – which can prevent anesthesia from being effective – but also to provide an amnesiatic effect so patients who wake up from surgery aren’t in a panic (being that their last memory is going to sleep unwillingly). Don’t be surprised if you don’t even remember changing into your gown. At the same time, don’t be surprised if (like me) you remember everything up to the point you go to sleep. The effect is different for everyone.


What was it like waking up from surgery?
It’s a little different from waking up in the morning. It isn’t the slow, gradual process. Instead, you wake up half way, stop there, and then usually go right back to sleep. The first thing you might try to do is scratch your nose. That’s because there is itchy surgical tape holding the breathing tube in. A portion of people try to pull this tube out, so if you’re not restrained, someone will stop you. Don’t fight them. Just go back to sleep.

Later on, when you wake up from surgery, you’ll probably be in your room, or on the way. Your head will be bandaged, and you will likely have four test tubes on your face with drain lines going into your mouth. This is to prevent fluid buildup at the surgical sites. Your jaw will be wired shut and splinted, so you won’t be able to talk or breathe through your jaw. You’ll probably be bleeding from your nose and mouth. They will give you suction to clean the blood out with. You may have an ice pack on your face to help reduce the swelling. You will probably also have an oxygen mask cupped around your face to help with your breathing.

You’ll be a little more awake and for a longer period this time. You’ll find that lethargy is part of the side effects of anesthesia. 10% of the population will also have nausea about six hours after surgery ends as your body metabolizes the propofol. This will be both unpleasant and potentially dangerous. Chances are you have some blood in your stomach from the surgery, and your body is going to want to throw this up anyway. Since your jaw is wired shut, there’s a chance you might aspirate it into your lungs if you try to stop yourself from vomiting.  It’s important that if you think you’re going to throw up, you alert someone. Sit up, lean forward, and let it happen. It will come out through your mouth, and that is fine.

Another side effect of the anesthesia is that you’ll have difficulty going to the bathroom. You may even have a full bladder and be unable to go. If you cannot go, they will eventually catheterize you (assuming they didn’t leave it in after the surgery). You will want to avoid that. Go to the bathroom, sit on the toilet, and squeeze. Concentrate. It will come out in small squirts. It will also hurt since your urethra was likely scratched by the catheter they put in during your surgery. You do not want them to give you another one, so give it your best effort.

How bad is the pain?

Surprisingly, I did not feel a lot of pain. The nerves of the jaw and face get stunned during the procedure, so I didn’t feel much of my face. Secondly, I was on an anti-inflammatory pain medication like ketorolac to reduce the swelling. Third, they had me on a morphine drip. I found I didn’t need morphine. They actually gave me injections of pain medicine that I didn’t ask for, and since most narcotics give me nausea, I specifically asked them not to, or to reduce the dose. The worst pain I had was from the muscle spasms, which started about 12 hours after surgery. They gave me a benzodiazepine to deal with those.

My worst pain was a 7 out of 10, and that quickly faded to 5 out of ten. Within a day of returning home, I cut my dose of lortab down to ¼ of the prescribed dose, and only took it at night before going back to sleep. Within a week, I discontinued it and all other pain meds entirely so my liver could have a break. Pain was 3 out of 10. I was entirely pain free after two weeks, and had discontinued all of it. However, the ibuprofen served as much to keep inflammation down as to quell the pain, so I was ordered back onto it.

At six weeks post op, the biggest pain I have is some residual pain around my upper lip from the swelling. This is also where most of the trauma was, so I am still taking ibuprofen. The pain is maybe a 2 out of 10, but because it’s in the middle of your face, it’s very annoying. This will go away gradually over the next four to six weeks (so I’m told).

Just a note: after surgery, even though there are screws and brackets in place, the bones will rub where they have been cut. It is a very tiny amount, but because it’s right next to your ear, you will hear it. You will feel it, but it will not be painful. It will freak you out a little bit. Don’t sweat it – the movement is on the scale of a fraction of a millimeter, and won’t affect your alignment. Bones will knit within a week, and the noise will be gone before then.

What can I eat with my jaw wired shut?

The answer is, just about anything. At first you’ll only have the energy and ability to take clear fluids that can seep through the teeth. That includes fruit juices, chicken or beef broth and so on. As the swelling comes down, you’ll be able to make yourself milkshakes and drink them around the teeth past the cheeks.

After about a week, you’ll get tired of chicken broth and vanilla protein shake powder. It’s a good time to mix it up – literally. You can add things to your shakes to give you more vitamins, protein, carbs and most important of all, flavor. Yogurt is a big one – the antibotics they have you on will clean you out. It’s very important that you re-establish your natural bacterial flora in your gut, or you will have epic gas. You should also add things like applesauce and fruit juices to get more vitamins in.

Pretty soon, the liquid diet will begin to feel limited. Take my advice: while still at the hospital, ask for some IV tubing. Cut an eight to ten inch length of IV tubing to attach to the end of your feeding syringe. You can pass this tube along the teeth where you should be able to find a gap between the teeth and jaw. Now you’re no longer limited to smoothies and juices, but to anything you can chop/blend/smash finely enough to fit through an IV tube. A good recipe – cook bacon until its crispy, then finely smash using a mortar and pestle. Mix in some scrambled eggs, and cook on medium heat until it congeals. If you accidentally overcook, mix in some chicken broth and butter. This you can draw into a syringe, and feed into your mouth.

The blender is also your friend. Most chicken noodle soups can be blended and strained. One thing I enjoyed was tossing a handful of doritos into the blender with a few cups of chicken brother. Blend it, then run it through a strainer. The result is actually quite delicious. Between a blender and a strainer, you can give your taste buds something to look forward to.

How can I take medications with my jaw wired shut?

You can get liquid medications for ibuprofen and Sudafed. For the rest, you can use a mortar and pestle to bash them into powder, then mix with a small amount of juice. You will need strongly flavored juices to hide the taste of things like ibuprofen. It’s bitter, with a disgusting aftertaste.

What do I need Sudafed for?

With your mouth wired shut, you will be breathing almost exclusively through your nose. Your nose will be inflamed from the trauma of the surgery, and congested with blood, snot, and various blood-snot combinations. Breathing will be difficult, and will limit your physical activity. At times, especially on the third or four day after surgery, you will feel as though you cannot breath, and might suffocate in your sleep if you try. Just relax, and you will be fine.

You will also get massive blood-clot boogers. Do not blow your nose at all for the first two weeks, as this can drive blood/snot out of your sinus and into the tissues of your face, risking secondary infections. Use the suction hose provided to get as much out as you can. After about a week, you’ll be able to gently exhale to clean your sinuses. After two weeks, you’ll be able to blow harder. You will be blowing bloody snot for three weeks or longer. At first it will be red. Then it will be dark brown. Then it will be black (old blood). Then it will be a medley of black (old blood), brown (not-as-old blood), red (recent blood), bright red (fresh blood), green (infected blood) and clear (clean snot). You will also need to go digging up there to get coagulate and dried blood out. (It’s a good idea to trim your nose hairs before you go in for surgery; it will aid in picking the blood boogers.) It’s all very disgusting, yes, but it has to be done.

Take Sudafed – real Sudafed from behind the counter – to control congestion. Nothing beats it. You will be taking a lot of Sudafed – I was taking 60 mg every 4 hours, for a total of 360 mg a day. The maximum does of Sudafed for an average adult is 240 mg/day. Sudafed will speed your heart rate up, so watch your consumption and back off if you have dizziness or racing pulse. Also, don’t be surprised if your pharmacist stops selling it to you. I recommend you stock up ahead of time, and rotate between 2-3 pharmacies. Don’t be surprised if your local authorities show up to your door.
Third, you will want to invest in breathe right nasal strips. They will add just that last bit of relief to make it feel like you can breathe. Frequent warm showers will also help with breathing, and will also help you feel better. As a last resort, I also recommend that you take a 10ml syringe and saw off the end. If breathing gets really bad, you can insert this into your cheek and get some airflow past your teeth. Have one of these handy in case your nose really does clog up.

How will I communicate?

There is no reason you should not learn basic American Sign Language. Real time communication will be frustratingly difficult. Common every day terms like “soup”, “drink”, “eat” should be in there. Also, “I love you” (which, ironically, is the sign of the goat you’ve been throwing up at motley crue concerts) and “thank you”. This is for you, and whoever will be taking care of you (spouse, significant other, parent, random homeless person, whatever).

Second, you’re going to want to get a stack of 5x7 cards and a good ink pen. Have common phrases already done on a handful of cards that you keep at the bottom of the deck. The most important one to give to anybody as soon as you see them: “my jaw is wired shut from surgery, and I cannot talk.”
Outside of that, just accept that you won’t be able to express yourself verbally. Instead, plan on using email, text and chat a lot. If you really need to communicate (such as via phone), there are text-to-speech software / shareware programs out on the internet. Using these on a computer can allow you to make some phone calls, but it will be cumbersome. Expect to get hung up on a lot.

Who should I see for my surgery? What doctor did you use?

Let me first tell you how I arrived at my first doctor: my dentist told me to go see them, and highly recommended them. This is a terrible way for you to choose your doctor. In my case, it worked out because my dentist had chosen Dr David Timmis of SouthOMS in Atlanta, GA. He is an accomplished oral and maxillofacial surgeon who has not only practiced for many years, published in peer reviewed medical journals, but has also contributed to medical associations that existed to further the field in which he specialized. He also retired more than a year before I was ready for surgery.

My next choice was someone associated with him through his practice, and I’m sure they would have been a good doctor (having worked with Timmis for years), but I would never know. The office staff epitomized the concept of incompetence. Customer no-service was the especiality. Getting a simple appointment was like pulling teeth. Actually, I was able to get my teeth pulled much more quickly and easily than to get an initial evaluation for my surgery. So I gave up on them, and set out to do my research.

After getting a list from my insurance provider of all maxillofacial surgeons in my area who did orthognathic surgeries (eg, bite alignment, not just cosmetic), I narrowed a list of about 20 down to a list of three, two of which were at Emory University in Atlanta. Both were published, and both had experience in post-trauma facial reconstructive surgery. The tie breaker came down to this: my choice – Dr Steven Roser – had been on several trips to central America and the Caribbean where he performed surgeries to repair developmental deformations of the palette for children. Later I discovered that my second choice – Dr Shelly Abramowicz – is his associate professor. I think either one would have been a good choice for my procedure.

The point here is to do your research. Look for not only ability, but dedication. Someone who publishes in peer reviewed journals is confident in their ability – confident enough to risk criticism. Someone who plies their craft where it is needed most and not simply where the money is – that is a person with heart, who truly cares about the welfare of his patients. If someone is going to cut half your face off, that’s the person you want to do it. Don’t just take what’s available, or what was recommended. Make your own decisions.

Did you have any other problems?

Most of it is listed above. The other “problem” is extreme weight loss. You will not be able to put enough calories into your face to maintain your weight. This is not a problem for me – I lost 27 lbs, and I really needed to. I could easily stand to lose 27 more. (I’m presently 260 lbs, and my healthy weight at this build is about 230 lbs.) Surprisingly, hunger is not an issue. Make sure you get plenty of healthy, natural sleep, and let your body repair itself. Make sure you’re getting ample protein as well as animal fats so your body can have sufficient raw material to rebuild itself.

The one problem I had that I wasn’t prepared for was the part about looking in the mirror and seeing someone else. After 39 years of having a very strong (protruding) jaw line, having a normally placed one actually appeared to have the opposite effect – that my chin was too small, and my jaw too weak. This isn’t helped by how my upper lip is still swollen after all the other swelling has gone done. Remember that your self image is based on years of looking at yourself and rationalizing that the image in the mirror is who you are. So when the image changes, you’re likely to reject it to matter what it changes to. Trust your aesthetician – they have studied facial proportions, and are adept at making sure everything is right. Other people are going to tell you that you look different, then follow up by saying you look good. Take their comments at face value. Most of all, focus on what’s important: healing.

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