Posted by sleepsurgeon on October 06, 2012 at 18:39:49:In Reply to: Re: ENT wants to do 3 procedures posted by Sandman on October 05, 2012 at 16:45:29:
There are two different views in doing revision
surgery. In my view, revision surgery is always
more difficult. The anatomy has been altered.
The nerve position is different thus the risk of
nerve injury is higher. The bone healing is
variable and sometimes the bone is softer (because
of poor healing) and is mixed with abundant scar
tissue. The scar tissue complicates the
dissection and exposure of the surgical site.
Sometimes plates and screws can cause underlying
bone resorption, thus reducing the bone volume
(making separation of the bone less predictable).
Sometimes the plates and screws are loose, causing
even more bone resorption and more scar tissue.
Sometimes artificial bone has been placed and
occupies a portion of the jaw, thus making bone
cuts more unpredictable. In sleep apnea MMA, all
of the above can limit the amount of advancement
needed in revision cases, thus reducing the
success rate. Unfortunately, a rare patient can
have all of the above.The initial consultation actually took place in
December. I had requested a CT scan at that time
to get a better view of the bone anatomy because I
saw several things on the regular xrays that
concerned me. I discussed the difficulty in
revision surgery in general terms since I needed
to look at the CT to gather more information
before discussing details. After the CT was
obtained, at least 4-5 emails and several phone
calls were exchanged regarding questions/answers
about the current situation, the risks of revision
MMA pertaining to the case and my reservations
about the revision operation, as well as
discussing opinions and techniques from other
surgeons that the patient had seen. The patient
elected to schedule the operation with me about 6
months following the initial consultation.The operation was scheduled on Wednesday at 7:30am
and the preoperative appointment took place on
Monday morning, almost 48 hours before the
operation. In my opinion, my job as a surgeon is
to provide as much accurate information as I can.
This is because I feel most patients are not
sufficiently educated about the risks and success
rate. If they don't like what they hear, they can
back out. When there is a difficult revision
case, I talk to the patient about what my thoughts
would be in each step during surgery. I spell out
what I would do depending on what I encounter and
that there is a chance that I would stop the
operation if I feel there is a high enough risk of
putting the patient in a worse situation as
compared to before the operation. The findings
that can influence my decision to continue include
abundant scar tissue encountered, very soft bone
encountered during the osteotomy, fracturing of
the bone during the osteotomy…etc. I try to let
the patient know about the worst case scenario in
each step. I tell patients in revision cases that
I cannot tell them how much I can move the jaws
forward because of the scar tissues that could
hinder the mobility of the bone. None of the bad
stuff may happen, but I hate surprises nor I want
my patients to be surprised. I’d rather have
everyone be overly prepared. May be I was too
blunt and direct or seemed uncaring and
pessimistic. I understand that it can be a turn
off and offend people. All I try to do is to
relay my thoughts and give my honest opinion,
which some may not like. However, I know that is
what I would want if I am the patient. I strongly
feel that patients deserve to know what they are
dealing with and what can happen. Obviously, I
have gone overboard in this situation. Nothing I
have said or done was intended to abuse but to
inform. I would like to apologize since it was
construed as abusive. The thing is I don’t think
I would have done it differently. It is obvious
that the delivery style should have been better
because the patient cancelled the operation the
day after the preoperative consultation, a day
before the surgery.I do think that majority of patients that I did
operate on thought that I had their well-being in
mind and took good care of them. I practice a bit
differently than most other surgeons. I don’t
have a team. I take care of my patients
throughout the entire process, which is
presurgery, during surgery, in the hospital, in
the office and after hours. I need to know how my
patients are doing and don’t trust them being
taken care of by others. That’s why I don’t
operate before I leave town, even though I have
coverage. I like to see my patients often and I
answer all my calls by myself. That is what I
would want my surgeon to do, if I needed surgery.
I believe this is the reason that most of the
patients that I did operated on feel that I gave
my best for them. It might be that they got to
know me pretty well, by seeing me so often
perioperatively.Finally, some surgeons view revision surgery being
easier as compared to routine cases. This is
because if the outcome is not good, one can always
explain to the patient after the operation that
the reason for bad outcome was because of the
first surgery. I choose to inform all I know
before the operation.
- Re: ENT wants to do 3 procedures arcticranger 05:42 10/13/12 (0)