My Maxillomandibular Advancement Surgery

Being a  page about obstructive sleep apnea and a surgical treatment thereof

Obstructive Sleep Apnea

From Sleepnet.com: 

My Situation

I am a 51 year old male, overweight like so many of my peers. I have always been a heavy snorer, to the extent that it is the subject of several humorous stories. Photographs of me from the last 30 years show that I have usually had bags under my eyes. Though I was familiar with the concept of sleep apnea, I did not pursue treatment. 

Several years ago, my father was diagnosed with severe obstructive sleep apnea. In retrospect, this was not a surprise. For most of my life, my father would come home and sleep fitfully in a chair. He also snored heavily. As he aged, he started falling asleep at inappropriate times, sometimes in the middle of a conversation or while driving. He used a CPAP machine, but did not have good results with it. At the time of his death, his doctors were discussing whether he was good candidate for surgical solutions. Though sleep apnea was not a direct cause of his death (endocarditis), it hampered his health, dimmed his last years and scared the dickens out of me.

In the Fall of 2004, I went to my ENT. As I expected he referred me to the local sleep clinic. During an overnight sleep test (polysomnogram), my severe obstructive sleep apnea was documented. I started using a CPAP machine in December 2004. During the next 10 months I tried a number of masks, sleep aids and pressures, all without success. Even when I slept eight hours with the mask on, I still awoke drained. At that point, my sleep doctor declared me a CPAP failure and referred me back to my ENT for possible surgical options. He re-evaluated me and referred me to an Oral Surgeon (DDS) who specializes in sleep apnea surgery. He also evaluated me, looked at the X-Rays and recommended Maxillomandibular Advancement (MMA) surgery. 

This seems like a long process, but you need to go through it. If it is at all possible, make the CPAP option work. It is a pain, but it is likely to get better as technology improves. CPAP is also better than surgery, since you don't have to break anything, spend time in hospitals or wrangle with insurance companies. If you become a CPAP failure, it is important that you document the steps for the insurance companies.

Pre-Operation

• The doctor I was referred to works as part of a regional clinic that has a national reputation. In Wisconsin, they are considered right next to Mayo.  He is a former Navy DDS (that scared me since my Navy son had some bad experiences with military medicos), who has done MMAs for 10-15 years (reassured me). He is very communicative and personable. Do NOT call him. Find someone like him in your area.
• A note on your surgeon.. A few places (Stanford) have surgeons who do 100+ MMAs for sleep apneas annually, but that is like finding the next Brett Favre. In finding a surgeon: 1) They must have done a bunch of these, at least dozens if not more, and they must have done at least some of them for sleep apnea. 2) They should be in your insurance plan. No kidding, unless you have a spare $30,000. Make your insurance plan find you someone competent and experienced.  3) They should be somewhere near where you live. Doing pre-op and post-op via the airlines is crazy. If anything goes wrong and your doctor is in another state, you are screwed. 4) It is a big help if they are communicative.
• It also helps that I am a librarian and can read the professional literature if I want to. I do and am comforted by the high success rate for this operation.
• I got X-rays, dental casts, measurements and then they all went to the insurance company for pre-approval. My insurance covered it. My wife's didn't. I filed an appeal (denied) and then filed with the state Dept. of Insurance. Turns out they are self-insured and can deny coverage if they feel like it - nyah, nyah.
• I was originally scheduled for late November, but it had to be shifted to a nearby hospital to accommodate the assisting surgeon, who doesn't normally operate in my home town. No big deal, since I work in the nearby city. It did delay the surgery for four weeks. As it turned out, I was a lot better prepared four weeks later.

That smile is going into hiding for a while

Operation Day

• Not all MMA operations are the same. The protocols and procedures used by doctors differs, depending upon where and when they were trained. If they are experienced, they know what they want to do, what they expect from the patient and what result they can expect. The patient's situation can also effect how things are done. 
• The surgery by was scheduled for 08:00 so I was asked to be at the hospital by 06:30. I pre-registered a week earlier, so admissions was a breeze. In what seemed to be short order, I was talking to the anesthesiologist and getting prepped.
• The surgery team included two Oral Surgeons (DDS). 
•  Since they are operating on your mouth, a nose tube is used for respiration. Another nose tube goes to your stomach.
•  I had a hand mounted IV drip, which was used throughout my hospital stay.
•  Since this is a five hour operation, they used a Foley catheter, which was inserted and removed while I was under anesthesia. Thank you Dr. B.
•  The first real step in the operation is to install a dental arch and wire the jaw shut, matching casts that had been taken a couple of weeks before. The casts also helped the doctor plan the operation and ensure a good bite. A dental arch is like braces, but more temporary and maybe sharper. Installing, wiring and unwiring the arch takes up a good percentage of the operation.
• The operation on the upper jaw is called a Le Fort I osteotomy. The jaw is broken on a horizontal line above the teeth and below the nose. It is reset in the new location (often less than 10 mm out), bringing the upper jaw forward. It is then held in place with small metal plates on either side of the nose, which are screwed into place. The stitches will be between the upper gums and lips.
• The other half of the surgery involves breaking the lower jaw on both sides, usually at an angle, and screwing it back into place. No plates here for me, though that may not be the case elsewhere, since it is the surgeon's call. Again, a full cm (or 10 mm) is quite a ways on your face. Stitches will be near your lower molars on both sides. Some surgeons have the stitches on the outside. 
• The movement of the jaws forward expands the throat, whose blockage is the O in Obstructive Sleep Apnea.
• My surgery was done by two surgeons, one working on each side. Since most surgeons are right handed, the one on the right has it easier. It is also likely that one of them will be significantly more experienced than the other. That is how doctors learn and practice new operations.  It is quite likely that the immediate post-operative results will be better on the right, since the doctor on that side can work faster and get out sooner. This is only a temporary difference, but noticeable during recovery.
• After the two jaws are realigned to the proper bite, the jaw can be unwired and is usually rubber banded together. This is the state I was in at recovery. Some surgeons rubber band very tightly, while others leave them looser. It will depend on the surgeon and the patient's situation.
• Since MMA is an extensive (long) surgery, you will be groggy for some time. I was under anesthesia for about 5 hours. I was groggy the rest of the day. Fine with me.
• Milestone #1 - You wake up and everything went well. Rejoice, even if you are medicated.
• There is extensive swelling and numbness after the operation, but relatively little pain. Of course, they will be running pain meds through your IV to keep you comfortable.
• The hospital provided a liquid diet dinner, but I was happy to manage a little water. After anesthesia and the inevitable drainage down my stomach, I was not particularly hungry.
• I used a Jaw Bra from the start. It is a headband that makes you look like Jacob Marley and holds ice packs against your jaw. They refresh the ice often, which helped keep the swelling down. They also provided moisturized air, which helps keep the airways clear and keep the lips from further damage, though it is hard to use both at the same time.
• After the surgery, the lips are swollen and tender. Just having them wet is a comfort, since they will be stretched, dry and cracked. Since your nose will likely be clogged, you will breathe through your mouth, further drying your lips. Wash them well, get all the blood off and then moisturize. It will help the healing and you will look less ghastly.
• The surgery does not directly involve the nose, but it affects everything around it. Expect the nasal passages to be caked, the sinuses full of nasty stuff and breathing hampered by more drainage. Like the worst bloody nose you ever had - squared.
• Overnight, I didn't sleep much. Hospitals are terrible places to sleep in any circumstances and they will keep replacing your ice, checking to see if you can urinate and providing further meds. The nurses are great and are the only people providing care to you in the hospital. They are not good for your sleep, but that is not their function. They are there to make sure nothing goes wrong.
• I had one (actually two) unfortunate situations. A steroid was prescribed to speed healing. They injected it into the IV on my hand. I am either allergic to the drug (which is extremely rare) or just don't like things pushed into my hands (more likely). I threw up almost immediately both times, with the wave of nausea passing in a couple of minutes. They cancelled the third shot. It did clear my stomach of some nasty stuff though.

Post-Operative Day 1 (December 23)

• By morning, I was much improved. The anesthesia haze was gone. I used a syringe to take some water, but found a straw more useful. You can not use a straw to build any suction, since you have stitches in your mouth, but they were OK for drawing up water. Even tried a little jello.
• By noon, my wife had returned and I tried some more semi-liquid food. Green paste shaped into a pea form, gravy and fake potatoes. They did not provide me with a baby spoon, but I was able to make some progress anyway.
• The Jaw Bra continued, which felt good. The moisture mask was a pain, since it didn't fit well with the Jaw Bra. My lips remained swollen and cracked and my nose remained clogged.
• I could move my jaw a little. Mileage may vary on this, as noted above.
• About 15:30, Dr. B came in and we talked about the operation and start to process me out. Many MAA patients stay a second night, but I didn't seem to need nursing care, which is the determining factor. I just needed rest, time and nutrition.
• Before I left, they cut my rubber bands off. From information I have found elsewhere, I know that this is not how some surgeons proceed, but I was very happy. I was on my way home in a Wisconsin winter with ice on my jaw. As I rode in the car, my wife wondered why I turned the heat up.
• I also got my list of meds. Antibiotic with food three times daily. Industrial strength Ibuprofen up to four times a day for pain and inflammation. Icky stuff to rinse with. OTC Sudafed for congestion. Vicodin for more serious pain, which I used only once, at night. Saline spray for clearing the nose. Saline to rinse with when not using the icky stuff. Doctor OK'd prescription sleep aids as long as I didn't mix them with pain killers.
• Milestone #2 - You go home. Rejoice again. You are not sick enough to require hospitalization.

Post-Operative day 2 (Christmas Eve)

• Didn't sleep that long on my first night home, but the sleep I got felt great. Less bags under the eyes, though still tired and early in recovery. Take meds, drink Ensure and Boost, make a fruit smoothie.
• Did feel a bit nauseous, which my be due to a readjusted sense of smell and a newly designed airway.
• I start to think that I either have a pill stuck in the back of my throat or else stitches that are hanging down. Something is certainly hanging down and hitting the back of my tongue, triggering a swallow reflex. It happens all night long, about every 20-30 seconds. In the event, it is my uvula, which has been repositioned due to the surgery and is now causing a problem.

Are you sure the drugs have worn off?  I'm not in pain, just very swollen at this point.

Jaw Bra

Post-Operative Day 3 (Christmas Day)

• Finally, nose nose is mainly clear and what congestion there is come from normal sources and not caked blood.
• I stay away from regular foods, though the house is full of guests, and stick to Boost, Ensure and other liquid forms. Straw works fine, but the numb lips mean I now have a drinking problem.
• I am sleeping well enough, though the arches are a problem, the uvula problem wakes me early and I can only comfortably sleep on my right side. As mentioned, recovery is further along on my right side. Despite that, the sleep is good and my wife says I am breathing easier at night.

Post-operative Day 4 (December 26)

• I add real food pureed to my diet. Plus Nutella (chocolate peanut butter). My mix now includes one yogurt based smoothie (good for people on antibiotics), one Boost or Ensure (nutritionally dense), one real meal pureed (good for your digestive system), one pudding and other grazing during the day, which mainly amounts to a spoonful or two of non-chewing food like peanut butter.
• Milestone #3 - Eating real, but pureed food. Doesn't seem like much, but it is much better than Ensure. Now get out of the house and move around.
• My lips are still dry and swollen, but I talk well enough and people on the phone don't notice a problem. I am using Neosporin Lip Treatment, which helps.

A couple of days makes a big difference, though I don't look happy yet.

Post-Operative Day 5-6 (December 27-28)

• Watch TV, read a book, shave (which my wife appreciates). I can now almost pass for normal and not scare children.
• I would recommend adding Metamucil/Benefibre to your diet, since otherwise the first movement can be a real pain. You are probably short of fluids, your diet lacks fiber and you should not strain after this surgery.

Doctor's Visit at One Week (December 29)

• See the before and after X-Rays and am amazed. Almost no throat before and normal or more after. 
• Doctor confirms that the thing I feel tickling the back of my tongue is my long and floppy uvula. It might get better as the swelling goes away or might need treatment. Since this is not life threatening, it will be more difficult to get insurance coverage. 
• Everything else is on track. I should try wearing bands this week unless it gets painful. Stitches will come out next week. 
• Jaw Bra OK for up to one week, then moist heat is better.
• After one week I have lost ten pounds. This is OK with me, but I don't want to lose any more now, since I need my calories, calcium and protein for rebuilding my face.

Much better

Some bruising under the jaw

Week Two (December 30 - January 4)

• We have a houseful over for New Year's Eve, which is great. Smiling that much starts to hurt eventually, but is worth it. Everyone is surprised at how "normal" I look. Since it was a surgical break, the recovery is simpler than it would be from an accident.
• No wine for me. It just doesn't taste good. I'll save it for later.
• I am on my exercise bicycle a couple of days. I have lost some strength and stamina. Time to get it back. Walking is good too, but even though it has been warmer than usual, it is still winter in Wisconsin.
• Done with the prescription meds, since they were for the first ten days.
• Milestone #4 - Off all meds. You will still probably use some painkillers later, but OTC stuff as your jaw gets back in shape.
• Driving in to work today, just to spend an hour or two and pick up my paycheck. 
• My wife comments on my snoring - it is totally gone. I am a very silent sleeper. Before she had to worry if I would stop breathing. Now I am so quiet she can hardly tell if I am breathing at all.

Two Week Appointment (January 5)

• Got the stitches out, which was less pleasant than I thought it would be. The upper stitches are above your teeth and can be hard to reach without bending back the lip, which is still tender and does not appreciate such treatment. Still great to get them out, since it is a milestone. It will help lessen the swelling and removes a cause of infection.
• Milestone #5 - Stitches out. Rejoice again. 
• Back to rubber bands, which will help guide my bite back to where it belong. Since my left jaw is a still a little painful, I can't close my teeth yet. That's OK, since I'm on a no-chew diet anyway. 
• My weight has stabilized, which means I'm getting enough calories / nutrition and its time to start getting more exercise.
• Most of the swelling on the lower jaw is gone, with numbness limited to the lip and below on the left side. The swelling on the upper jaw is much reduced, but still noticeable. That area isn't so much numb as recovering and tender..
• Made scrambled eggs, with ham and cheese for breakfast and then put it in a blender. Added some crackers for texture and felt like I was a nearly normal person.
• My face is almost back. Bruising below the chin. Numb lip and resulting drinking problem. Swelling above my lip feels huge, but isn't that visible. The arch bars also feel huge, but I am getting used to them.
• Sleep is a little disordered, which is normal. It was so messed up, followed by extensive surgery, so it will take some time to settle down. My uvula problem may also be a factor, though it is much smaller now than it was immediately post-op.

Numbness still has some of my smile

My chin still looks very recessed, so I don't expect people will have trouble recognizing me.

Week Three Appointment (January 12)

Better now that the stitches are out, less swelling and easier to clean. Got my water pick out and cleaned everything up. Most bruising gone. Still feel puffy under my eyes, but that may be partially the continuing numbness there.

Darn arch bars make my lips feel huge and unwieldy.

Almost time for a hair cut?

Week Four Appointment (January 19)

Almost back to normal. Doc says if I were half my age, I would be considered recovered, but I should plan on another two weeks before putting any stress on the repaired breaks. Still have a drinking problem due to numb lower left lip. Have been taking dog (an Aussie) on long walks in the globally warm Wisconsin semi-winter. Been back on my exercise bike and can complete the regular 1/2 hour without blowing my heart rate above regular levels. The better breathing pipe makes it easier than before I think, though I do need to recover my stamina. Going back to work next week, though mainly half days. I could probably manage full days, but I have some vacation to burn and it makes it a lot easier to eat the many smaller meals I subsist on.  Before and after: Some change to where the nose sits on my face, since the face was rearranged, little thinner, since I lost 10 pounds, mainly right after the surgery. slightly stronger chin, but nothing extreme, smile still covered by the arch bars, which puff up my lips.

Milestone #6 - Back to work. Probably could have done 1/2 days sooner, but don't want to push it. My job is a 30 minute drive away, so if I have pain/problems, I am 30 minutes from help/relief.

Before and after shots

Nose is a little pointier, chin a little further out. The 10 lbs shows.

Week Six Appointment (February 2)

Everything looks good, though I still have a slight occlusion on the left side (i.e. the teeth don't quite meet). Probably  a fraction of  a mm, which is slight indeed, but it matters. I am now cleared to chew, since it has been six weeks since the operation. Unfortunately, my teeth have not meet in earnest in six weeks and they have been moved. Plus the arch bars have moved them a little and disrupted the natural order. The muscles will be sore for a while and I will have to work my way back. Tuna for lunch, then casseroles at a potluck for dinner. Looking forward to sandwiches, fish and maybe French Fries. No steak for some time. Smile is kind of concealed by the arch bars, which push the lips out, but the upper lip has more feeling and the drinking problem is going away.

Milestone #7 - Chewing food. Goodbye blender. Even my wife rejoices.

Week Seven (February 8)

The arch bars come off. This involves a brief operation with general anesthesia. Some doctors do this with a local, which sounds like the dentist from Little Shop of Horrors to me. Again, I am happy with the choices my doctor has made. I was walking shortly thereafter, but slept most of the afternoon. The procedure helps in several ways. I now have a better idea where everything is in my mouth and can close and open my lips without worrying about slicing them up. The bars seem to have moved a tooth out of place, but on the whole, things seem to be coming into line. Much easier to brush and keep the area clean. Plus, the dentist says that I have a much smaller level of occlusion than before (level 3 drops to level 1), which seems to be all in the overbite. Unlike most MMAs, the upper and lower jaws were moved different amounts, only by 2 mm, but enough to make dentists happier.

Week Ten (March 1)

After another three weeks, I have made slow progress. I can chew on the right side, but the left is not quite aligned and still sore. I had some ice cream with nuts and managed it, but fried chicken was too much. Baked chicken was no problem, but the fried was too tough. Went to my regular dentist and was a one day wonder. She said that my teeth felt hollow when she was cleaning them. I know what she means, since some of them are not really attached all the way. They remain loose enough so that they seem to sink into my gums when I chew and I can feel them move slightly when they are pushed with my tongue. It is likely that I will have some caps/crowns replaced at different heights to establish a new bite. No need to worry about that until the teeth settle down, which should take a couple of months.

There is a scar/bone ridge next to both lower molars. Didn't really notice this when the arch bars were in. They catch food.  I am still having some sleep problems, but not apnea. Understandably, I am trying to undo 30 years of bad sleep habits. Plus I have two sons in Iraq, one escorting convoys for a living. MMA surgery does not address stress. I view all this as part of the recovery process. If you break a leg, after you get your cast off, you don't run a marathon. I am expecting that this recovery will continue for 6-10 months, with slight improvements along the way, kind of like watching a dog grow out of being a puppy. No more photos, since I look normal now. No one knows I had surgery unless I tell them. Yes. my smile is back. I will continue this, but at longer intervals now, since there is less to address.. 

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