Marc's Public Blog - OSA, Obstructive Sleep Apnea and MMA Surgery

Anyway, after having tried a bunch of other things for the last 4 years, noticing that things are getting slowly worse over time, and getting mixed results with CPAP which I just didn't want to rely on for the rest of my life anyway, MMA surgery was pretty much the only logical choice left.

Now, it is involved and one does have to look at it as an investment: 6 or so weeks with your mouth wired shut and not being able to eat any and then quite little solid foods. Oh, and there is the no talking for a while part too.

Anyway, I did look at the other options carefully, and tried most of them and after my sleep appliance, the best working one for a while started not being enough, and I started getting sick again 3 times in a row in a 6 week period of time, not counting the many days when I didn't feel rested and sharp, MMA surgery it was.

Luckily, I live 20mn from one of the best surgeons for this procedure in the US, Dr Kasey Li has actually done and written a lot of research in this domain and performed hundreds of such operations already, so I knew I'd get the best outcome possible with him. This is also when getting a PPO ended up being the correct choice over an HMO: I got to pick my surgeon and Cigna is going to pay everything (close to $100k I hear) outside of my $3k out of pocket deductible for the year. Quite frankly, for this kind of surgery, it's cheap.

So, the details on how the surgery went:

First, this I had to get braces to get my from and bottom teeth angled in a way that maximized the amount of moving the bottom jaw while moving the top one as little as possible (moving the top one too much does not look nice on your face whereas my bottom one was too far back, so moving it forward was actually a good thing).

Anyway, once the teeth had been angled enough, I went to Stanford on July 1st and was under 2.5H later, likely being hacked up somehow :)

Apparently, I'm a cheap date for anesthetics, so while I'm not quite sure what happened, after the procedure was over, I was moved directly to the ICU and by the time I came back, my intubation tube had already been removed and I had a hard time keeping my face straight and my eyes focussed (actually one of my eyes is still less open than the other, likely due to how puffed up my face is).
I could count fingers shown at me, but obviously I didn't look quite right until a bit later when I woke up a bit more an apparently regained more face/muscle control.

I was a bit surprised by how my throat was hurting almost as much as when I had had my tonsils removed 4 years prior. Apparently, the intubation got my throat very irritated and it took a bit over 24H before I could swallow liquids without taking pain meds first (not as bad as the tonsils operation though).

The first night at the ICU wasn't so great, which is understandable. I was obviously still a bit traumatized from the procedure and ICU recovery rooms are the loudest places ever: they are filled with machines that have very annoying and loud alarms of all kinds that kept going off literally all night: I've never seen anything so trigger happy and even with earplugs, it was hard to get much sleep.

The next morning, I was moved to regular care as soon as they had some room for me there. I was able to have breakfast so to speak which was really just flavoured soup, apple juice, tea, and some sherbet I had to melt before I could use the syringe push it between my teeth that were wired shut.

I guess I shouldn't have been surprised by how much my face had swollen up due to the procedure. On one side I lost about 5 pounds from little food intake and my face looks like I just gained 60lbs :)
48H later, I was home after having stopped at Dr Kasey Li's office where he examined me, cleaned my nose (he also operated on my nose to help improve the airway, why not while you're at it), and removed the couple of stitches on my cheeks after the small holes had had to make for the operation itself (they are already not visible).
I was pretty impressed how Dr Kasey Li is pretty much his own oncall over July 4th weekend and basically stays reachable himself (not some 3rd rate doctor while he's at the beach) should I require somewhat emergency help during the weekend. Mind you, I would do no less myself in his shoes, but I've found that I can't expect that level of service and dependability as much as I should be able to expect it. Therefore Kudos to him!

A few pictures of my face puffing down slowly over time:

At this point, my main issue is actually keeping my nose clear because I can't breathe through my mouth, and trying to shove food between the teeth with a syringe (Jennifer tried to make some soup, but it was too thick and its particles clogged up the few holes between my teeth and required a power water jet to clean/remove). So for now it's going to be odwala juice, slim fast shakes and protein powder shakes.

Food isn't super exciting for now

My only surprise so far is how I lost all feeling in my chin and lower lip, as if I had had a very long lasting dentist shot. Dr Li says it's normal and it takes a while to come back (while could be over a month though), but that's likely only half-surprise so far.

5 days later, I only had a single nap. My face is slowly getting back to more reasonable proportions, I can now mostly drink from a glass without having to use a syringe to squirt behind my back teeth (big plus), and the hardest part is likely for Jennifer not to be able to communicate much with me since I otherwise can't talk (I'm otherwise naturally a man of a few words and use Email and IM all day long, so I hardly noticed a difference :) ).

As days go by, Dr Li will replace the rubber bands that keep my teeth closed and allow them to open up just a bit more every time, eventually allowing for some very soft foods to go through as opposed to a 100% liquid diet for now (which strangely I don't mind too much even if it's only been 4 days so far).

Hopefully in a few weeks I'll be able to speak a little bit since for now, I can't at all due to the plastic piece between my shut teeth.

It's hard to see how much better I breathe right now since I can't breathe through my mouth, and my nose is still very clogged up due to the small operation I had in it too to improve the airway, but the few times I got a chance, I could definitely tell that the extra 1.5cm of forward room in my throat make a huge difference for the amount of air that can go through when I lie on my back. As far as I can tell, I should be just fine when everything is back to normal. Yeah!

(update1) got a followup appointment 6 days later and all the wounds are very clean. I saw an after X-Ray and it was pretty impressive to see how much moved forward. I guess that explains why my face and jaw feel so sore from being stretched forward like this (which is not like how a "normal person" would be, but I just wasn't born that way).

Anyway, after having tried a bunch of other things for the last 4 years, noticing that things are getting slowly worse over time, and getting mixed results with CPAP which I just didn't want to rely on for the rest of my life anyway, MMA surgery was pretty much the only logical choice left.

Now, it is involved and one does have to look at it as an investment: 6 or so weeks with your mouth wired shut and not being able to eat any and then quite little solid foods. Oh, and there is the no talking for a while part too.

Anyway, I did look at the other options carefully, and tried most of them and after my sleep appliance, the best working one for a while started not being enough, and I started getting sick again 3 times in a row in a 6 week period of time, not counting the many days when I didn't feel rested and sharp, MMA surgery it was.

Luckily, I live 20mn from one of the best surgeons for this procedure in the US, Dr Kasey Li has actually done and written a lot of research in this domain and performed hundreds of such operations already, so I knew I'd get the best outcome possible with him. This is also when getting a PPO ended up being the correct choice over an HMO: I got to pick my surgeon and Cigna is going to pay everything (close to $100k I hear) outside of my $3k out of pocket deductible for the year. Quite frankly, for this kind of surgery, it's cheap.

So, the details on how the surgery went:

First, this I had to get braces to get my from and bottom teeth angled in a way that maximized the amount of moving the bottom jaw while moving the top one as little as possible (moving the top one too much does not look nice on your face whereas my bottom one was too far back, so moving it forward was actually a good thing).

Anyway, once the teeth had been angled enough, I went to Stanford on July 1st and was under 2.5H later, likely being hacked up somehow :)

Apparently, I'm a cheap date for anesthetics, so while I'm not quite sure what happened, after the procedure was over, I was moved directly to the ICU and by the time I came back, my intubation tube had already been removed and I had a hard time keeping my face straight and my eyes focussed (actually one of my eyes is still less open than the other, likely due to how puffed up my face is).
I could count fingers shown at me, but obviously I didn't look quite right until a bit later when I woke up a bit more an apparently regained more face/muscle control.

I was a bit surprised by how my throat was hurting almost as much as when I had had my tonsils removed 4 years prior. Apparently, the intubation got my throat very irritated and it took a bit over 24H before I could swallow liquids without taking pain meds first (not as bad as the tonsils operation though).

The first night at the ICU wasn't so great, which is understandable. I was obviously still a bit traumatized from the procedure and ICU recovery rooms are the loudest places ever: they are filled with machines that have very annoying and loud alarms of all kinds that kept going off literally all night: I've never seen anything so trigger happy and even with earplugs, it was hard to get much sleep.

The next morning, I was moved to regular care as soon as they had some room for me there. I was able to have breakfast so to speak which was really just flavoured soup, apple juice, tea, and some sherbet I had to melt before I could use the syringe push it between my teeth that were wired shut.

I guess I shouldn't have been surprised by how much my face had swollen up due to the procedure. On one side I lost about 5 pounds from little food intake and my face looks like I just gained 60lbs :)
48H later, I was home after having stopped at Dr Kasey Li's office where he examined me, cleaned my nose (he also operated on my nose to help improve the airway, why not while you're at it), and removed the couple of stitches on my cheeks after the small holes had had to make for the operation itself (they are already not visible).
I was pretty impressed how Dr Kasey Li is pretty much his own oncall over July 4th weekend and basically stays reachable himself (not some 3rd rate doctor while he's at the beach) should I require somewhat emergency help during the weekend. Mind you, I would do no less myself in his shoes, but I've found that I can't expect that level of service and dependability as much as I should be able to expect it. Therefore Kudos to him!

A few pictures of my face puffing down slowly over time:

At this point, my main issue is actually keeping my nose clear because I can't breathe through my mouth, and trying to shove food between the teeth with a syringe (Jennifer tried to make some soup, but it was too thick and its particles clogged up the few holes between my teeth and required a power water jet to clean/remove). So for now it's going to be odwala juice, slim fast shakes and protein powder shakes.

Food isn't super exciting for now

My only surprise so far is how I lost all feeling in my chin and lower lip, as if I had had a very long lasting dentist shot. Dr Li says it's normal and it takes a while to come back (while could be over a month though), but that's likely only half-surprise so far.

5 days later, I only had a single nap. My face is slowly getting back to more reasonable proportions, I can now mostly drink from a glass without having to use a syringe to squirt behind my back teeth (big plus), and the hardest part is likely for Jennifer not to be able to communicate much with me since I otherwise can't talk (I'm otherwise naturally a man of a few words and use Email and IM all day long, so I hardly noticed a difference :) ).

As days go by, Dr Li will replace the rubber bands that keep my teeth closed and allow them to open up just a bit more every time, eventually allowing for some very soft foods to go through as opposed to a 100% liquid diet for now (which strangely I don't mind too much even if it's only been 4 days so far).

Hopefully in a few weeks I'll be able to speak a little bit since for now, I can't at all due to the plastic piece between my shut teeth.

It's hard to see how much better I breathe right now since I can't breathe through my mouth, and my nose is still very clogged up due to the small operation I had in it too to improve the airway, but the few times I got a chance, I could definitely tell that the extra 1.5cm of forward room in my throat make a huge difference for the amount of air that can go through when I lie on my back. As far as I can tell, I should be just fine when everything is back to normal. Yeah!

(update1) got a followup appointment 6 days later and all the wounds are very clean. I saw an after X-Ray and it was pretty impressive to see how much moved forward. I guess that explains why my face and jaw feel so sore from being stretched forward like this (which is not like how a "normal person" would be, but I just wasn't born that way).

The X-Rays also shows that the back teeth were moved a bit forward compared to the front, but the entire jaw was moved a lot more than just the offset change between top and bottom, as the front jaw was moved forward too (just less than the bottom since moving it too much would not be aesthetically pleasing).

does show that my upper teeth were way in front of the bottom ones (not because of the teeth as much as the jaw).

before

after (check the arrows showing where and by how much the bottom jaw was cut and moved)

It's been about 10 days, I've been feeling about as good as normal for the last 3 days:

Things that are still missing though:

Sure, I'll be happy when I can eat normal food again, but I'll have to be patient. In the meantime, I'm at least enjoying being able to work/hack again (working on home projects).

Oh, for those still wondering why one would do something as seemingly stupid as getting their jaw sawed and re-fused, this paragraph from this informative knol (article) says it all:

Untreated OSA has been estimated to cost the United States an excess of several billions of dollars per year to treat the medical complications of the disorder. Persons with OSA are considered to have an increased mortality risk associated with compromise of the cardiovascular (heart and major arteries) and cerebrovascular (major vessels of the brain) systems. The risk for suddenly dying of heart problems has been shown to be increased in OSA patients when they sleep. Further, the brain arousal which is typical of each obstructive episode causes brief sleep fragmentation which is usually unrecognized by the person suffering, but in fact can lead to a loss of restorative sleep, even though the person is in bed and "sleeping" for many hours. The combination of repeated sleep disruption and decreased oxygen to the brain during sleep likely contributes to the characteristic and sometimes severe daytime sleepiness of OSA. Associated mood changes including feeling depressed, as well as lack of energy, and failure of memory and concentration, all may occur. The poorly controllable sleepiness of untreated OSA is considered to cause the United States thousands of lives annually in motor vehicle accidents.
While all of these medical problems are most likely to be found in association with severe OSA, even mild OSA (for example, less than 10 obstructive episodes per hour of sleep) has been associated with an increased risk of having or developing some form of heart disease compared with the risk of persons without OSA.
(for reference, I was getting close to 20 obstructive episodes per hour).

The X-Rays also shows that the back teeth were moved a bit forward compared to the front, but the entire jaw was moved a lot more than just the offset change between top and bottom, as the front jaw was moved forward too (just less than the bottom since moving it too much would not be aesthetically pleasing).

does show that my upper teeth were way in front of the bottom ones (not because of the teeth as much as the jaw).

before

after (check the arrows showing where and by how much the bottom jaw was cut and moved)

It's been about 10 days, I've been feeling about as good as normal for the last 3 days:

Things that are still missing though:

Sure, I'll be happy when I can eat normal food again, but I'll have to be patient. In the meantime, I'm at least enjoying being able to work/hack again (working on home projects).

Oh, for those still wondering why one would do something as seemingly stupid as getting their jaw sawed and re-fused, this paragraph from this informative knol (article) says it all:

Untreated OSA has been estimated to cost the United States an excess of several billions of dollars per year to treat the medical complications of the disorder. Persons with OSA are considered to have an increased mortality risk associated with compromise of the cardiovascular (heart and major arteries) and cerebrovascular (major vessels of the brain) systems. The risk for suddenly dying of heart problems has been shown to be increased in OSA patients when they sleep. Further, the brain arousal which is typical of each obstructive episode causes brief sleep fragmentation which is usually unrecognized by the person suffering, but in fact can lead to a loss of restorative sleep, even though the person is in bed and "sleeping" for many hours. The combination of repeated sleep disruption and decreased oxygen to the brain during sleep likely contributes to the characteristic and sometimes severe daytime sleepiness of OSA. Associated mood changes including feeling depressed, as well as lack of energy, and failure of memory and concentration, all may occur. The poorly controllable sleepiness of untreated OSA is considered to cause the United States thousands of lives annually in motor vehicle accidents.
While all of these medical problems are most likely to be found in association with severe OSA, even mild OSA (for example, less than 10 obstructive episodes per hour of sleep) has been associated with an increased risk of having or developing some form of heart disease compared with the risk of persons without OSA.
(for reference, I was getting close to 20 obstructive episodes per hour).

I'm doing a lot better, I can now chew soft foods (quiche, soft bread (not baguette)), so I've been mostly eating unblended food for the last week. It's not super varied, mostly sandwich bread with paté, soft cheese, or fish eggs, but eh, I love that stuff anyway :)

I tried eating some pizza today and it was borderline but worked (the rule is that if I have any jaw pain or soreness afterwards, I shouldn't have done it). But that doesn't beat having been pilot in command of a small plane to fly to Mohave after just 3 weeks after surgery. I was a bit sore from talking on the radio, but it worked out.

Sleep is not perfect, but much better than it was before surgery for sure. It's supposed to improve more, so we'll see.