Consultation for Orthognathic Surgery

This afternoon I observed an orthognathic surgery consult in a high end practice. I was familiar with orthognathic surgery from Columbia’s emphasis on medicine and high reputation in oral and maxillofacial surgery. However this was the first time I had really witnessed a consultation for orthognathic surgery in a very practical setting.

A 28 year old female patient presented to the clinic because she was unhappy with her facial proportions. She had orthodontic treatment for 2 years prior, but was unhappy with her prominent upper lip, retruded lower lip, and also mentioned that she was unhappy with her nose being too wide (despite having a previous rhinoplasty).

Seeing this patient reinforced how important it is to take a good history of the patient. This patient in particular had a history of plastic surgery, included the rhinoplasty, so right away one has to be aware that she is going to be very particular about the results. Often patients like these change their minds, so even if the surgery gives her what she wants, she may be unhappy with it at a later point in time. It is important for the surgeon not to make guarantees, and to thoroughly advise the patient on their options.

The consulting surgeon was simply brilliant in the manner he conducted his consult. This oral surgeon is an attending at Columbia and I have met him before. However this was the first time I got to see the wealth of his knowledge in full action. He is a very powerful presence but he listened to the patient and all her needs and concerns. He then advised her on the possible options, however the patient was still adamant that she wanted to have her maxilla retruded. The oral surgeon was very honest with her and explained that women pay thousands of dollars to have her full look. He pointed out that if you retract the maxilla, the soft tissues will fall back as well, and she would lose that youthful look that she naturally has.

One of the most impressive parts of his consultation was that he was still very knowledgeable about general dentistry. He took two sets of impressions and was very proficient at taking them for an oral surgeon!

He found two issues from his exam and consult:

1. Deficient mandible/class II skeletal discrepancy

2. Wide alar base

His best treatment plan at this point was mandibular advancement via BSSO (bilateral saggital split osteotomy) along with an alar cinch to address the patient’s issue with the width of her nose. The alar cinch procedure was an intriguing option and gave the patient an alternative to getting another rhinoplasty. He  explained to the patient that an oral surgeon can go intra-orally with the alar cinch procedure which is more effective and does not produce the scarring that is possible from a rhinoplasty performed by a plastic surgeon. He explained that plastic surgeons are limited in what they can do because they cannot work intra-orally.

The patient finally became convinced that it was not a good idea to touch the maxilla, and mandibular advancement was the best solution. The oral surgeon didn’t shoot her down right away, and he advised her to choose between the given choices. However he took it step by step, until the patient saw the benefits of a less invasive approach.

The patient would also have a consult with the orthodontist because she would probably need brief orthodontic treatment after the surgery to adjust the bite so it is properly aligned.

R.A., Columbia University School of Dental Medicine

Categorised in: Dental Student Experiences

This post was written by Interns