Closure

Dr. Naples mentioned I should take a follow up sleep study to verify I was cured of sleep apnea about six months post surgery. The day after my surgery, I knew I was cured. The blue rings beneath my eyes were gone. However, I also had a nice oxygen mask probably helping that. I think the last six months, my body and mind have started to recover from a life of fighting to stay alive at night. I now dream and wake up refreshed. I wanted to close this two year chapter of my life with an official study and find out just how much better off I was.

Sleep studies are really an interesting experience. Take a ton of sticky medical tape, multiple elastic belts, a couple hundred feet of twisted wire, some plastic tubes sticking up your nose, then tape them all to your body and head, shove the wires through your clothes, and hook them all to some box near your body. After doing this, try and sleep! Good luck!


This is my third "split night" sleep study. The split night means that if they find sleep apnea, they need to put various C-pap masks on your face and dial you in until you sleep. I mentioned to the tech performing the study that if they came in the middle of the night and tried to put a C-pap mask on my face, be prepared for a fist fight. After a two year journey, three surgeries, four doctors, medications, five C-pap masks, and a lifetime of losing sleep, I wanted this done.

So here is the direct assessment from the report:

"The maxillomandibular facial surgery has done a tremendous job in reducing his AHI from 66 which is extremely severe with severe desaturations to an AHI of 5.4 with very minimal desaturations at worst. Technically, this patient has defineitely met the criteria of curative based on surgical criteria, not likely to require any treatment such as CPAP or oral appliance based on the numbers. This is a great success."

I really like the sound of that. I met with my ENT (Dr. Oscar Tamez) today to go over the results and walked out a very happy man. To get the remaining AHI down close to zero, I'll need to lose a few pounds. Time to go ride my new bike, listen to my body, and put this journey behind me. If anyone has questions, feel free to post comments or visit the Orthognathic Yahoo group.

Time Flies

Well its been awhile since I checked in. I wanted to let everyone know that I am doing well and my jaw is healing quite nicely. The only remaining part of this journey is orthodontics and waiting for the remaining numbness around my chin to go away.

I should have braces for another year and a half. Its weird as my teeth are starting to line up and I never really realized how crooked they were. I saw my orthodontist last week and he fixed four broken brackets (two from the surgery) and replaced my wires. Apparently, since they cut slightly above the roots of the teeth during this surgery, the teeth move much faster right after the surgery.

The numbness about three months out for me feels like I visited the dentist and had work done about a few hours ago. Most of the feeling is back, but I still don't feel food when its caught on my chin or lip. So you learn to wipe your mouth after every few bytes after this surgery so you don't look silly eating out with friends.

I spoke with someone I didn't know on IM today about my surgery. It reminded me there are still folks out there preparing for this surgery, with alot of anxiety, and wondering how things will turn out. They asked me if the surgery was worth it. Of course for me, the surgery was necessary as my health and well being were starting to get impacted by sleep apnea. A good friend of mine who had the surgery, and two follow up surgeries to clean up a post-op infection stated that if he had to do it all over again, he would. For my case, I almost did the surgery twice, except the second surgery didn't involve any cutting on my lower jaw. I am extremely pleased with my results and how my new jawline looks. I no longer snore and my concentration during the day has vastly improved.

Looking back, I wish I wouldn't of worried so much about the complications, insurance, how I would heal, what I would look like, what happens if something goes wrong, etc. Simply put, find a skilled, proven, and licensed Oral and Maxillofacial surgeon that has done this surgery for many years, several times a month, and its extremely likely you'll be pleased with the outcome. Get a second or third opinion from different surgeons. Could there be complications, yes. Know them, but don't let the fear of them paralyze you.

Patience

I am completely unbanded now and I am slowly progressing up through the range of soft foods to harder stuff. I pushed the envelope with some harder tortilla chips yesterday and it was rather strange to chew again. Everything in you mouth feels out of place to what you've known your whole life. In addition, your jaw muscles have moved and been banded closed for over a month. Laura observed that I look like a baby that has just been given its first cherrio and is learning how to chew food. I chew slowly and have to think about what I am doing as my jaw muscles just don't seem to be as strong as they were before.

In addition, my speech is starting to return to normal. After talking like a ventriloquist for the last month through the rubber bands, I am starting to sound more like myself. My cheeks still seem to be thick and tight, so I sound like I have a few marbles in my mouth, but it gets better day by day.

Finally, the chin is slowly progressing each day, but it is still pretty numb. I've been told it would be about a year before I would recover complete feeling in most of my chin. I just got through a very annoying stage where my chin would tingle much like your foot when its asleep or you hit your funny bone. That lasted a few weeks and I am glad that stage seems to be gone. I am getting brave with a blade razor and starting to shave most of my chin now, which is rather scary. You almost feel like you might accidentally slice into your chin and not know it.

This stage after the surgery seems to be about patience. I am still very happy with the results but I am looking forward to being my old self again.

Progression

After losing 20 pounds in a little over a month, I was permitted to eat soft foods today. In fact, it will be five weeks from my first surgery tomorrow when I last had anything other than liquid. I promptly came home from my surgeon's office and cooked up four scrambled eggs and a mound of mashed potatoes. They were delightful! However, after being tightly banded for nearly five weeks, I can only open my mouth about the width of my pinky finger. So I had to eat my food with a teaspoon which was a little slower than I wanted. I hear it will be about a month before I can open my jaws to a somewhat normal amount.

In addition, I only have to wear one rubber band on my braces, instead of five. This freedom was the best news of all. Perhaps I will start talking like a regular person instead of a ventriloquist.

Happy New Year everyone!

Reflection

If you can avoid doing this surgery right before Christmas or Thanksgiving, I would suggest it. Since I was already at my out of pocket maximum with my insurance, doing this surgery now would save me thousands of dollars. I've been tortured the last week with two family Christmas dinners, and our own Christmas dinner at our house. Food...food everywhere...and I'll I can do is drink. I've been tempted enough to rip my bands off and start eating, but I knew better than to risk another surgery. Let me tell you that honey glazed ham blended up just doesn't taste the same. I miss the texture of food, chewing food, and bread, oh do I miss bread. In a little over three weeks, I've lost over 15 pounds and 3 inches on my waste. Several people I've revealed these figures to jokingly say they need their jaws banded shut and to go on a liquid diet to lose weight. They have no clue what they are wishing for.

Travel a few weeks after this surgery, or two of them back to back, can be exhausting and at times painful. At times, I could feel bumps and vibrations from the road in my jaws and face after hours of driving. I would suggest bringing a microwaveable heating pad with you and let someone else do most of the driving. You can nuke your heating pad at a convenience stores along the way. Try to avoid over extending yourself with a ton of activities. In addition, talking can cause your jaws to become sore after awhile as your lower jaw still reflexively tries to move against the bands. Sometimes you just need to lay down, rest, and recover as your body is still healing from major trauma and stitching bones back together.

Even though I was tortured with visions and smells of good food and in pain some of the time, I have had a wonderful Christmas. I was glad to see both sides of my family. My girls got quality time and the expected spoiling with both sets of grand parents. I enjoyed a wonderful tortilla soup at a tex-mex restaurant in San Antonio. I also took little bits of fresh buttered flour tortillas, shoved them past the rubber bands and through the little gap I can open in my front teeth, and let them melt in my mouth. Yum! We also took a boat ride on the river walk through all the Christmas lights in downtown San Antonio.

We got back home on Christmas Eve to watch my girls sing in our church choir. When it came time for communion during our service, I was a bit concerned about the size of the piece of bread I would be presented with. Luckily, the assistant pastor in our church who visted me in the hospital and was aware of my condition, was infront of us. I signaled and whispered that I need a very small piece of bread. Lee presented me with a small piece of bread and smiled, "Let this tiny piece of Jesus represent his love for you...". I quietly snickered as I took communion with my tiny piece of Jesus.

I have so much to be thankful for this year. Thanks to the wonderful skills and talents of my surgeons, anesthesiologists, and nurses, I have come through three major surgeries without any serious complications. I have been cured of the very unhealthy, if not life threatening, disease of obstructive sleep apnea. I no longer have to fight with a c-pap mask and machine when I sleep. My body and mind are now recovering when I sleep rather than fighting to keep me alive. Through all of these trials, I have been reminded of how important friends and family are when they were by my side to help me and my family, when we needed it most.

Merry Christmas and Happy Holidays,
Robert

Getting back to the real world

I started back to work on Wednesday. The major reason was I was going stir crazy. Some folks might like alot of couch and TV time, but honestly, it gets old after awhile. I also have a small team at my workplace and knew they were working hard in my abscence. I needed something mentally to chew on.

This surgery typically causes you to swell up like a chipmunk at day four. The bruising that appears around this same time has been compared to the brusing you would see if a clydesdale horse had stepped on your face. If you have a greater than one piece LeFort surgery, or your upper pallette is being widened, you may be needing a splint in your mouth which inhibits communication and eating. Some pretty powerful steroids are used to counteract swelling and help your sinuses recover from upper jaw surgery. These and the anesthesia coming out of your system can make you rather emotional.

I would probably suggest a minimum of two weeks off from work after this surgery. I had a hiccup during my two weeks where a second revision surgery was done a week into my two week recovery period. My surgeon seems to have a technique that minimizes swelling and brusing. Thankfully, I didn't have a splint in my mouth. The steriods, pain meds, and anesthesia seemed like they were out of my system. I seemed like my old self except that my mouth was rubber banded shut and I now sounded like Jeff Dunham from Comedy Central.

Here are a few things to be prepared for when heading back to work. Packing for work is a bit different now. I have a bag with all the goodies needed to take care of a recovering orthognathic patient now, so you'll need one of these. People at work will be wonder what the heck happended to you after they see or hear you, so be prepared to talk. Most people have to talk in their jobs, so be prepared for your jaw to hurt. Take ibuprofen.

I'll update more later. Holiday festivities are beginning with the families in Houston.

Overcoming Fear

I think a major portion of going through with this surgery is overcoming fear. Many months prior to this surgery, I began researching it. One thing I knew is that I wasn't living healthily with severe obstructive sleep apnea. I was reflexively throwing the mask off at night in my sleep and getting very frustrated. I tried many different masks. I even saw a neurologist that put me on several different powerful medications to try to keep me down at night. They didn't seem to be helping much and these medications had pages of side effects with risk of dependency, so I eventually stopped taking them. I often spent an hour or two some nights, lying awake with the mask forcing my breathing wishing I would fall asleep. Those nights, I would throw the mask off in disgust hoping I would get some sleep, even with sleep apnea so that I could concentrate and make it through the next day. I was caught between a rock and a hard place.

At first, this surgery seemed so unnatural and like some sort of medieval torture with saws. It is literally in your face and working with bone saws. It could change your appearance, significantly. Its working around nerves and arteries. Its five plus hours long. It involves a significant recovery period where a ton of tight rubber bands are placed on your braces to keep your jaw closed and stationary. A liquid diet. Oh, and did I say it involves getting braces which is another torture (emotional and physical) in itself?

So, I was looking at untreated severe obstructive sleep apnea with likely heart disease, hypertension, and all the mental issues due to getting a fifth of the normal sleep someone gets, or what I currently saw as torture. Your not giving many options here are you? So I joined the orthognathic surgery support group at:

http://health.groups.yahoo.com/group/orthognathicsurgerysupport/

and started reading. I made appointments with a few orthognathic surgeons and started researching them. Luckily, I also had a good friend that had been through the surgery which I asked a ton of questions.

Things were a slow process at first. My surgeon generated several models and sent of a surgical plan to the insurance company to get approved. Apparently, insurance companies love to lose stuff (or say they did), ask for more data, and drag this process out for as long as legally possible. My surgeon's staff was simply outstanding at battling them so I had little involvement.
Eventually, my surgery was approved as "medically necessary" and we scheduled a date in the operating room.

Then things really started to sink in. Though all my research started to bring comfort, it began to bring awareness to what could go wrong. My friend Mike who had the surgery was now cured of sleep apnea, but he also had a nasty post-op infection due to a surgical mistake. Could my doctor make a surgical mistake? Funny thing is, Mike's sleep apnea was so bad he states he would of gone through the surgery again, knowing there were three additional surgeries to cure his infection to cure the sleep apnea. I almost felt like I was in the same place.

About a month prior to the surgery, I began to freak out. I found a paper on the internet which listed all the major complications of orthognathic surgery. I posted to the yahoo group and fired off email after email to my surgeon. Eventually, I scheduled an appointment with him and we went over the list of all my deepest fears about the surgery. For being a surgeon, he answered every question thoroughly and looked me in my eyes. Though there were no concrete promises, I realized if something were to go wrong, he would help me fix it. Trust had developed.

The only fear we have is...if the insurance company doesn't pay! With several days of hospitalization, anesthesia, surgeons fees, and OR time, this surgery is the price of an expensive luxury sports car (roughly $75,000). After my surgery was deemed medically necessary, this was not guarantee of payment. There is yet another pre-determination board this has to go before and things were ticking down to the wire. As all models were sent certified mail, we had proof that my insurance company received them. Then, they said they lost them. Then another department verbally said they found them. Then, another department said they don't have them a few days before my surgery and that I was still not pre-determined. @#$#$%$!
I envisioned the ill financially destitute crying homeless parents forced to live with their children from Michael Moore's Sicko, as Laura and I. Except, my kids are six and eight, so we were really screwed. I launched a nuclear assault of phone calls and threats at my insurance company. Hours were spent by several people in my orthognathic surgeon's office battling with the insurance company. Finally, the day before my surgery, it was approved and pre-determined. Phew!

Being on the other side now, the funny thing is I look back and laugh at all the emotional energy spent. If you think back to when you were learning how to ride a bike, or dive off the high dive, and it is the same thing. Fear can paralyze and dominate you. One of my fears was realized after my first jaw surgery. Loss of fixation occurred and I had an open bite. My trusted orthognathic surgeon quickly fixed it a week later. Fear dismissed, again.

I had eighteen printed out questions for my surgeon today. Some of them were still fears. Could we lose fixation again? When will I regain feeling in my chin? Could I still develop a post-op infection? My jaw hurts and is stiff, is it TMJ? Each were addressed. No concrete promises, still, but I am feeling much better.

Strength, Strawberry Milkshakes, and Sunshine

I decided to get off the painkillers and take just ibuprofen today. Normally, with this surgery, you are on painkillers a week, or two, if you choose. Because the reset button was pressed a week in, now I knew I would be on painkillers much longer than I had planned. My surgeon mentioned he had one patient take just ibuprofen after leaving the hospital. That is just crazy. I briefly thought about it after the second surgery, but quickly reconsidered.

I tested the waters and made it three hours yesterday under just ibuprofen. This morning, I stopped and began to manage the pain. I have a ThermiPAQ heating pad that is made of a mixture of clay and oil in a plastic bag, wrapped in another cloth bag. You heat it in the microwave and it radiates heat for along time. When the pain becomes too much for the ibuprofen to handle, I alternate with the heating pack on, and off until I can manage it. Its not that I want to suffer, I am just tired of being medicated. It feels like I am missing life and have been in a reverse time warp. Things aren't getting done and I am just zoned out watching TV.

This afternoon I was able to get out and play with Abby at her school playground. She was so happy to be able to complete this length of monkey bars by herself without me catching her if she fell. When we were driving home, we both hurt. My jaw hurt, her hands hurt. I ran in for my heating pad and Abby ran her hands under cold water.

My kids brought me home a strawberry milkshake from Sonic. I quickly devowered it in a few minutes, being careful not to get a brain freeze. I am starting to appreciate the simple pleasures again.

Before and After!

This is just a week and a half of time here. Admittedly, I shaved, got a hair cut, had two surgeries, spent a total of three days in the hospital, got cured of severe obstructive sleep apnea, and lost about ten pounds on a liquid diet. I am just amazed of the differences in my eyes, let alone my face!

A perfect revision and the strength of muscle over titanium

The word "revision" is something you don't really want to hear a week after an orthognathic surgery. It means something went "wrong" and the doctor needs to go "back in" an make an adjustment. My doctor looked closely at my face last Tuesday and said, "That's not the way I put you together on the table last week. There is no way I can sugar coat this, we are going to need to do a revision surgery". Not once did I think of using another surgeon. I put my complete faith in this man in a decision process over the last four months. I just thought of when. "How about tomorrow afternoon?", he said.

Holy shit! I just got done with mentally preparing for this and going though it. Now we are going back though it again tomorrow? The hospital, the anesthesia, the painkillers, steroids, and antibiotics all start over again. Most of all, the recovery clock when I could eat regular food again ,would be set back to zero. Instead of 5 weeks and counting to tacos, it would be six weeks plus another day!

I've been looking at that open bite all week and wondering if rubber bands and braces would really correct it over the next 18 months. Then I started wondering what went wrong because I am an engineer. My orthognathic surgeon is one of the best and I hand picked him. My ENT stated he was the best he had seen and heard nothing wrong about him. My orthodontist works closely with all the local orthognathic surgeons in the Austin area, and recommends him over the others. An OD assistant and an OD assistant's wife are having upcoming surgeries with him. You go where the mechanic takes their cars to get worked on, right? I could of gone up north and had some world renown orthognathic surgery stars work on me, but these people are also known for doing marathon surgeries that also replace jaw joints when they may not be needed to be replaced.

So what went wrong? After an orthognathic surgery, they xray you on the table to make sure everything is straight. They open your jaws, close your jaws, look at centerlines. They even have some piece of equipment that sticks a needle in the bridge of your nose and leaves a mark they line up stuff with. I know because I had that needle mark on the bridge of my nose twice. These people aren't just surgeons, they are also craftsmen making sure everything is true. Because I had a severely recessed jaw and severe sleep apnea, my lower jaw moved forward, alot. A whole 10 mm. People were surprised at this measurement on the Yahoo orthognathic group. In addition, my chin was coming out too.

In my first surgery, everything lined up under anesthesia. Sometime in recovery, my jaw muscles must of woke up and began pulling things out of place. By the time the doctor saw me in my hospital room loopy after the surgery, he didn't like what he saw. Luckily, my TMJ joints had not shifted or slipped. It appeared we needed stronger titanium plates to hold my upper palette in place. In addition, they were now thinking of wiring me shut for four to six weeks to keep those pesky jaw muscles quiet. I should of just bought stock in Ensure.

I stopped thinking of what went wrong and didn't lay blame on anyone. I started blaming those inanimate plates in my skull as they weren't strong enough to keep my palette straight. Yes I could of gone down the road of saying, why weren't stronger plates put in first, but that would get me no where.

I woke up surprised as I had very little pain, and wasn't nearly as groggy or confused as last time. I was only under a few hours instead of five, but it was almost like I took a nap. The pain started to hit soon enough, but the recovery nurse took care of that quickly and mercilessly. My jaw felt locked in place and I was worried wired me. I lifted my hand and felt the front of my braces. There was a huge mound of tight rubber bands on my braces. No wires! No having to walk around with emergency wire cutters to save me in the event I was choking! Praise God!

The last words my surgeon said to me before he left for the OR on the second surgery was "Thank you for your confidence in me". I never lost confidence in him, his staff, his anesthesiologist, or the nurses. They all are the best. You'll notice I took my orthognathic surgeons name off my blog. I am still his biggest fan and would send anyone his way. Email me if you need it. I didn't know if he wanted his name openly associated with a revision surgery listed on the internet. He has done so few compared to other surgeons that I looked at, he still has a better record in the long run. I guess statistics finally caught up with me and my freakishly strong jaw muscles. From looking at how straight my teeth line up under that mound of rubber bands, I think it was one of the best revision surgeries ever.

In the immortal words of Jeff Foxworthy, "you might have had orthognathic surgery, if you tried this.."




Unfortunately, it appears I will have a second revision surgery tomorrow at 3PM. My open bite does not appear that it can be corrected with just "creative orthodontics". Its best we get this thing right before the bones set. They will go back in under my upper lip, loosen the bolts, change the plates, and put my upper jaw back on with no open bite.

"Just when I thought I could get out...they suck me back in!" - Michael Corleone

Wish me luck.

This weekend was kind of a blur. On Saturday, I slept through most of the Alabama vs Florida game (at least 3 quarters) and most of Texas vs Nebraska (no surprise there as Texas's legendary overrated national championship offense was showing its true colors). I made progress on Sunday and spent time at church as well as started walking around the block.

I am signed up for the 2010 MS-150 Houston to Austin bike ride so I am not slowing down a bit. The thing is, no contact sports for 2 months following the surgery. Given that cycling isn't a contact sport, I'll ride on my stationary trainer as I feel able, but I sincerely want to avoid any contact with the ground that could possibly screw up my orthognathic surgeon's work.

Back at home!

Here is the best part. I got to get a new i-Cat scan at my orthognathic surgeon's office. These are pictures directly of his screen, but they are clear cut as can be as to the effect Orthognathic surgery has on widening you lower airway. I slept wonderfully last night on my back. My wife awoke several times and was marveled about how I was not snoring on my back.

New airway

Old Airway

My new optional upgrade equipment!


Last bit of torture before I go home for 5 days

More silly pictures at http://www.flickr.com/photos/cannondalerob/

A few new pics at:

http://www.flickr.com/photos/cannondalerob/

I am extremely happy to get my chin strap off, teeth brushed and a bit lighter elastics put on my braces. My lips chin and upper lip are all numb, but that feeling should come back over time. Taking the chin strap off allowed my face to deflate and the swelling to move elsewhere. Those pictures last night were scaring me!

One day out

Check out my Flickr images at:

http://www.flickr.com/photos/cannondalerob/

I have been sleeping most of yesterday. I would wake up, cough to clear my chest, hit the morpine button several times. My throat is extremely sore and I thik you reflexively move your jaws when you swallow. Drinking juice out of a syringe with a rubber tube is required as my jaw is pretty much immobilized with a head strap, tight rubber bands on my braces, and sints behind my teeth. I am talking via a notepad and pen.

Rob

Can't sleep..here are some pictures

Above are pictures of my airway, my two beautiful daughters, and my mug shot showing my recessed jaw. I am hoping my orthognathic surgeon gives me the Brad Pitt jaw and cleft chin option tomorrow :). Back to bed

Twas the night before surgery so I have to be brief. The purpose of this blog will be to guide others in the journey through Orthognathic surgery.

About a year ago, I was diagnosed with severe obstructive sleep apnea. My RDI was 66 and I have desaturations down to the high 70 percent range. This puts a significant strain on your heart while you sleep as its trying to keep you alive. My main problem is I, and my sleeping side, hate the C-pap mask with all my heart. I throw it off in the middle of the night while I am sleeping, which is not good for me.

So I am left with one final option. Change the geometry of the airway I have been given. The best way to do this is to bring both your lower and upper jaws forward using a procedure called Bilateral Sagital Split Osteotemy and Maxillary Osteotemy - Lefort I. Effectively, the doctor will saw off both my upper and lower jaws, move them forward about 10mm, and bolt them back on. Sounds Frankenstein-ish right? My thoughts exactly.

In order to do this, you really need to get braces first for at least a few months. This has been an adventure in itself. Its weird looking like a teenager again when your near 40, and its like having a prickly pear in your mouth with all the surgical hooks they like to put on the brackets.

There is also the approval process with insurance companies. Its not like you just had a heart attack and are rolling you back for a triple bypass. They try to view this as elective and grill the surgeon for bits of information for months. Luckily, I have a nasty condition which gets me a bit more sympathy than the folks who have an overbite, underbite, or open bite.

Finally, what I view is the most difficult part of this journey is the mental process. Its not often that medical procedures saw through perfectly good bone. The one I am thinking of is heart surgery where they saw through your sternum. But more often than not, that is after a heart attack where you don't have months to think about it. In addition, the surgery is through your mouth, around a bunch of sensitive facial nerves, and five hours in duration. This surgery can significantly alter your appearance.

So for the last few months to prepare for this surgery, I have been reading the Yahoo Orthognathic surgery support group everyday on my blackberry as emails have arrived. Its been extremely informative, and at times scary. I just read about some persons hematoma that formed in their face post surgery which caused blood to "spurt" out her incision! Not for me please! I have over researched this surgery on the internet, read research papers, and even attempted to watch a youtube of the surgery being performed. I bailed after the second incision knowing I wouldn't continue with the surgery if I didn't stop watching. I also drove my surgeon nearly crazy with alot "what if" questions.

So, after all this, it now comes down to game time. I check in tomorrow at 5:45AM for the five hour surgery. Wish me luck! More updates and pictures to come soon!