Answer Provided by Dr. Kasey Li
June 24, 2007
One of the most difficult problem with sleep apnea surgery is that NO PROCEDURE is 100% successful. Patient education on the potential risks, complications as well as outocmes is crucial. Even with the best intention by the surgeon, some patients never fully understand what they are in for before the operation. I suspect that it is because some patients are so desperate for help and they are clinging on and only focusing on the chance of a "cure". As a surgeon, I sometimes see patients that I feel are not going to be a good candidate for surgery. When this happens, sometimes it is not because of any anatomic issue, but an "expectation" issue. As I stated in a past answer, there is no "free lunch" in any surgery that you go through. There are potential downsides which can counter-act the upsides of any operation. After approximately 500 MMAs, approximately 90% of the patients are significantly improved. Approximately 5% are mildly to moderately improved. However, there is that 5% that are not improved at all. Usually, significant obesity is a major contributor, but not always. Occasionally I am just left scratching my head and wonder why the procedure was not successful (in terms of apnea improvement). Finally, even when the sleep apnea is much improved, I would consider a procedure unsuccessful if there are complications that made the patient wish that he/she did not go through the operation in the first place. At the end of the day, a successful result means that the patient feels the operation was worth it after weighing the upsides versus the downsides of outcome.
This patient is clearly a surgical failure because there were complications and the symptoms did not improve. This is a difficult case because limitations were placed on the surgeon due to esthetic concerns. Because of these concerns, the extent of MMA was limited, thus the airway expansion was also limited.
When patients present with significant esthetic concerns regarding MMA, I usually try to alter how the jaw is moved. For example, an advancement/rotation of the MMA would be done which allows for less movement of the upper jaw but have a greater advancement of the lower jaw (patient usually never complain that their lower jaw is too prominent). Still, there would be changes in appearance, albeit less so. Other options including post surgical orthodontics to pull the teeth back and reduce the prominence of the upper lip/nose, or a nose job. Another associated risk of MMA is malocclusion, which is usually easily taken care with orthodontia or some dental work.
The solution for this patient is VERY limited. I feel that she has exhausted her surgical options. There are other surgical options such as genioglossus advancement, hyoid advancement, radiofrequency, Pillar implant, tongue reduction, epiglottis shaping and revision MMA. However, the most definitive surgical procedure has been done (albeit a limited one). It seems to me that although a revision MMA with further advancement can be done, I doubt that the result will be great because even with improved sleep apnea, she will be unhappy with her appearance (still, orthodontia and a nose job are possibilities). Any other options have much less success rate compared to MMA.
In this situation, my recommendation would be to try to stay with tracheotomy for a while if possible since she feels much improved symptomatically. I would actually recommend an oral appliance or revisit CPAP as I suspect that the pressure requirement would be reduced following MMA.