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Sleep Surgeon Question 27

Question 27 - What advancement is needed for MMA to be successful?

From: E. G.

Dear Doctor Li,

May I ask you a question? I am an MMA patient. I am about three weeks post op. My doctor advanced my upper airway from 1.5 mm to 5.5 mms, and base of the tongue from 3 mms to 8 mms. I had an unsuccessful UPPP surgery that caused more damage to the area than it did good. My doctor said he struck a balance between aesthetics and airway improvement.

My concerns are:

1. How far does a person need to be advanced before beneficial breathing results take place?

2. Does 5.5 mms (at narrowest point) seem like enough of an advancement to you? What is your gut reacton? Most of what I read talks about a 10-12 mm advancement.

3. What could I do if MMA fails?

4. Do you think that at this point I would continue to make gains? Do you think some of the residual apneas might go away?

5. Would it do any harm for me to use CPAP after MMA surgery?

Thanks,

E. G.

Answer Provided by Dr. Kasey Li
Nov. 22, 2007

Many patients are concerned about esthetic compromise following MMA. Clearly, the most important factor that dictates how a person will look following MMA is how the person looks before surgery. Many patients have deficiency of the upper and/or lower jaw, thus advancement of the jaws often improves facial proportions, thus improves esthetics. Many patients have signs of facial aging (sagging of the facial tissues), thus jaw advancement “stretches” the sagging tissues and patients can look more “youthful” following MMA. However, I always stress to patients that there will be a “change”.

Since beauty is in the eyes of the beholder, the “change” may be perceived as un-esthetic to the individual even though others may see an improvement. At the end of the day, there are two opposing factors in MMA surgery. Greater advancement of the jaws translates to greater changes of the face, even though the changes may not be a “bad” change. Lastly, there are also many “surgical tricks” that can be employed to “lessen” the facial changes following MMA.

I looked at some of the MMA blogs. Some patients really had very poor esthetic results and some patients really had very rough recovery course. I feel that the poor esthetics results are because the surgeons did not pay ANY attention to esthetics since the results could have been much better. In terms of recovery, the amount of operating time certainly influences recovery. A typical MMA should not go over 3.5 to 4.5 hours. The other day I heard of a MMA that took 9 hours. That is clearly way too long.

There is no “magic” number for advancement. The 10-12 mm that is typically quoted is the average amount that the jaws can be stretched. However, I have moved jaws 16-18 mm in many patients. One needs to remember that any movement would be good for the airway, but the smaller the advancement, the less improvement.

It is sort of amusing when patients and surgeons quote a number of the airway size before and after the surgery. There is no standard “normal” airway size as different people need different airway sizes to not have apnea. Additionally, measurement of the soft tissues size is extremely inaccurate and unreliable. I typically like to quote the amount of bone advancement. Even with that type of measurement, there is great variability as the location of measurement leads to different results.

I think it is too soon to determine the result of improvement after just 3 weeks. However, if there is continual sleep apnea, it is possible to resume CPAP or a revision MMA to get further advancement of the jaws.

Good Luck

KKL