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My MMA operation

Posted by SleepyBadger on December 28, 2005 at 16:32:43:

Pre-Operation
· I was diagnosed with severe OSA by a sleep test at my local hospital in November 2004. I started CPAP therapy shortly thereafter. After trying numerous masks, various pressures and prescription aides (Sonata, Ambien, Lunesta), my sleep doctor declared me a CPAP failure. It is important to document this and not just say you don’t like it.
· This sent me back to my ENT (who referred me to the sleep doctor in the first place) re-evaluated me and referred me to a surgeon for MMA.
· The oral surgeon 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.
· The oral surgeon is a former Navy DDS (that scared me), who has done MMAs for 10-15 years (reassured me). He is very communicative and personable. It also helps that I am a librarian and can read the professional literature if I want to.
· I got X-rays, dental casts, measurements and then they all went to the insurance company for preapproval. My insurance covered it. My wife’s didn’t. I filed an appeal (denied) and then filed with the state Dept. of Insurance.
· 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.


Operation day
The surgery by was scheduled for 08:00 so I was asked to be at the hospital by 06:30. I preregistered a week earlier, so admissions was a breeze. In what seemed to be short order, I was talking to the anaethesiologist and getting prepped.

The surgery team included two Oral Surgerons (DDS). Dirty details which I did not witness:
· Since they are operating on your mouth, a nose tube is used for oxygen. Another nose tube went gastic.
· 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 anaethesia. 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 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 is quite a ways on your face.
· The movement of the jaws forward expands the throat, whose blockage is the O in Ostructive Sleep Apnea.
· My surgery was done by two surgeons, one working on each side. The one on the right has it easier, since most surgeons are right handed. 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 noticable 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 you will be 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 anaethesia for about 5 hours. I was groggy the rest of the day.
· 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 anaethesia and the inevitable drainage, I was not particluarly 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 moisterized 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 dry and cracked. Since your nose will likely be clogged, you will breathe through your mouth, further drying your lips.
· The surgery does not directly involove 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 steriod 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 anaethesia 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. Milage 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.
· 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 inflamation. Icky stuff to rinse with. OTC sudafed for congestion. Vicodin for more serious pain, which I used only at night. Saline spray for clearing the nose. Saline to rinse with when not using the icky stuff.

Post-Operative day 2 (Christmas Eve)
· Didn’t sleep that long 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.

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. 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 yoghurt based smoothie (good for people on antibiotics), one Boost or Ensure (nutitionally 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.
· My lips are still dry and swollen, but I talk well enough and people on the phone don’t notice a problem.

Post-Operative Day 5-6 (December 27-28)
· Go out to a movie, walk the dog, go shopping, watch TV, read a book, shave. I can now almost pass for normal and not scare children.
· I would recommend adding Metamucil 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. Nuf said.

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