Surgery: Maxillary osteotomy, Mandibular osteotomy, Genioplasty (chin), Septoplasty & Inferior turbinectomy (nose).
As I have known that surgery would be a necessary part of the work to correct my malocclusion (poor bite), I have been preparing for more than two years for this Maxillomandibular Advancement (MMA) surgery (also known as orthognathic surgery). I have great confidence in my surgeon, who has been very generous with his time, and not only patient with my many questions, but actively helping me to understand all that I can about the procedure. My history with the cleft palate and pharyngeal flap, and my high degree of interest and study as a singer, teacher of singing, and student of the body, make me a somewhat unusual patient.
At some point in the last year, I theorized (as a non-medically trained layman) that all of my facial issues, from the cleft palate, through the distorted teeth and hard palate, and through the deviated septum, were all expressions of one ‘vector of genetic mutation’ in my face. However, I now understand from my surgeon that it is common for surgeries like my cleft palate repair and pharyngeal flap creation to have an adverse impact on facial development, and that in fact my mid-face deficiency issues were probably a result of my surgeries and the resulting scar tissue.
Now, as I understand it, we are working to address some of that mis-development, and in fact this one surgery may be all that is needed. (Speaking hopefully, here.) My surgeon will be handling several procedures within this one event.
In my particular case, the pharyngeal flap complicates the MMA surgery. Note that the tissue of the flap connects to my soft palate – part of the roof of my mouth – and the back of the pharynx. As the maxilla is advanced forward, it’s going to pull on the pharyngeal flap, stretching it forward as well. At some point, the flap will not “give” any more, and may be the defining factor determining the maximum degree of the advancement. Furthermore, as the flap is stretched, it will attenuate, or narrow, in the same way a rubber band narrows as you stretch it.
This stretching effect on the pharyngeal flap is important for two reasons. First, because the flap’s function is to block (at the right times) the movement of air, food, or water into the nasal passages, the narrower the flap is, the less well it is going to perform its function. If the flap is attenuated too much, there is a risk that I will return to something like the condition I experienced when I was four years old and speaking with hypernasality, the characteristic “snuffly” quality, because air was escaping through my nose as I talked. When the speech pathologist noted then that anatomically I could not make complete closure, he was describing a condition known as VPI, or Velopharyngeal Insufficiency. In my conversations with speech pathologists, Ear, Nose, & Throat doctors, orthognathic surgeons, and a multitude of others, we have discussed at length the risk that VPI and hypernasality could result from this MMA surgery. (My career and life are based on my voice.) While making sure that I was informed about the risks, after looking at the models and CT scan, my surgeon has expressed confidence that my pharyngeal flap may tolerate the advancement well.
Still, considering the possibility that I may have VPI and hypernasal speech after this procedure, I have pursued some preparations for responses in that event. That is the reason I have worked with the UW Speech and Hearing department, recording baseline pre-surgery tests, with plans to return after surgery for follow-up testing and probably speech therapy. There is a range of possible outcomes. In one outcome I’ve hardly dreamt of (but perhaps should spend some time praying for/manifesting), my speech and singing may be improved through easier breathing and a mouth finally closer to the shape it should have developed into in the first place. Or, I may suffer from hypernasality and be required to work through speech therapy, possibly more surgery, and the emotional impacts of distorted speech. Of course, there is a range of possible results, and no predicting it now.
The other reason the stretching effect on the pharyngeal flap is important, is related to my sleep apnea. MMA surgery has been used to good effect in many cases of patients with sleep apnea, and is sometimes even described as a “cure” for it. An advancement unhindered by limiting factors like a pharyngeal flap can result in a much more open airway, resolving many breathing issues. (My first orthognathic surgeon referred me to several articles on the topic, including some exciting work being done at Stanford University.) However, for me, the pharyngeal flap almost certainly precludes the possibility of “curing” my sleep apnea through a sufficient advancement. My surgeon has said, if we can improve my Apnea-Hypopnea Index score to moderate levels, that will be a victory. But, the first priority of this surgery remains the correction of my bite so that I might keep my teeth into old age, plus a bit of improvement in my breathing.
Another ENT surgeon I consulted described my situation this way: If after recovery from this current surgery I have VPI and issues that cannot be resolved through speech therapy, he could do a further surgery to address the VPI, adjusting the airway to reduce the escaping air. However, that would most likely interfere with my breathing, and probably worsen my sleep apnea. Simply put, future surgical interventions may just be “Chasing my own tail”:
At this point, it’s still intellectual for me. Soon it won’t be! – though I wanted to be sure to get this third big blog entry posted before experiencing the surgery. I have studied and prepared, and thought about the issues. I am told to expect to spend a year recovering from the surgery, and I’ve been preparing for a pro-active recovery period for months. My team includes my counselor (therapist), and we’ve already begun to talk about how to deal emotionally with the results, whatever they may be. From here, it’s just, stepping through… Chop Wood, Carry Water.
In the hospital, and in my recovery, I’m planning on listening again to the audiobook version of The Martian by Andy Weir. I loved the movie, too, but it can’t touch the book for profundity. Each time I listen to it, I’m inspired by the patience, careful thinking, and steady optimism of Mark Watney. He’ll be in much worse straits than me! OK, sure, he’s fictional – but he’s still a hero of mine, and I think might inspire me to be a better patient, and to stay hopeful.
Thanks to stable insurance coverage that allowed me to catch up with old dental issues, and to more attentive self-care, I was ready to listen when two different sources suggested a few years ago that I might consider exploring ways to address my improperly developed facial structure. First, a dentist friend commented (most gently and diplomatically) that it might be possible for orthodontia and surgery to improve my “mid-face deficiency”, which I’ll describe in my layman’s terms as a lack of proper growth in the bony structures between my mouth and nose.
Around that time, I began working with a new and very excellent dentist, who soon informed me that without orthodontia, I was at great risk of losing my teeth in the next decade or so. Without further ado, I consulted an orthodontist about a treatment plan. My dentist also sent me to an endodontist for a root canal, and to a periodontist for a look at recession of my gums.
My new periodontist recommended two minor surgeries in preparation for the orthodontia and surgery, and for the health of my gums. First, in a frenectomy the periodontist cut a bit of tissue connecting my lower lip to the gums below my lower front teeth. Next, in an allograft, he sutured some graft tissue (I can’t recall what it was, but it looked like cooked pasta!) into place along those same lower gums below my front teeth. After a period of healing my gum recession was less pronounced in that area, though it may require another procedure after the rest of the surgery and orthodontia is complete.
At my first appointment with my new orthodontist, he took one look at me and strongly recommended that I schedule an appointment at a sleep clinic. In his words, I had the classic profile of a person who suffers from sleep apnea, or disrupted breathing during sleep. In discussing his plans for my orthodontic treatment, he also suggested that orthognathic (jaw) surgery was likely to be necessary as part of the treatment, and referred me to an orthognathic surgeon. Ultimately it took me two years and a couple of changes before I settled on a final choice for an orthognathic surgeon.
Following my orthodontist’s advice, I did consult a sleep doctor, underwent a sleep study, and was diagnosed with “severe” sleep apnea. Somewhere I came across a very helpful explanation of terms involved in sleep apnea, that drew upon the Latin roots of the words involved.
- “pnea” is related to air, breathing or breath (think about pneumatic lifts, using air to support something)
- “a” as a prefix meaning not
- “hypo” as a prefix meaning under or low
So, “a-pnea” means not breathing, and “hypo-pnea” means taking in a low or insufficient amount of air. (Pronounced APP-nee-a and hi-POP-nee-a, I believe.)
One important metric when one takes a sleep study is the Apnea-Hypopnea Index, or AHI. This is an average of the number of times per hour that one’s sleep is interrupted by either “apnea” (no breath) or “hypopnea” (insufficient breath). My AHI from my sleep study was 37 – which means that my sleep was interrupted an average of 37 times per hour in that study. On average, I never slept more than 2 minutes without interruption! This figure is well into the range considered "severe" sleep apnea.
Once I was diagnosed with Sleep Apnea, I was prescribed a CPAP (Continuous Positive Airway Pressure) device which helps me breathe more regularly as I sleep. In my particular case I must wear a “full-face mask” (which does great things for my facial skin). I’ll hope to share more on that particular aspect of the story, and my struggle to learn to “tolerate” the CPAP, which is thankfully mostly in the past. But, the happy result is that my AHI is down to around 6 or so, which is an acceptable level, and my sleep is much improved.
Returning to Orthodontia: In the fall of 2014, not long after I began using the CPAP for my sleep apnea, my orthodontist fitted me with orthodontia (braces). Certainly many people have experienced braces, and my experiences with that aren’t groundbreaking or unusual, though I do have the perspective of having braces both in the 1980s and in the 2010s. There have certainly been some improvements! As someone used to journaling, I’ve made a few recordings and journal entries along the way as I encountered new struggles and phases, such as the struggle with lingual buttons. These were poky attachments on the inner side of the lower teeth, that my tongue could not leave alone.
My tongue’s inner dialogue, when confronted with the new buttons: “What’s that? Ow! What’s that? Ow! What’s that? Ow! What’s that?…”
And, my typical dialogue with my tongue around that time. Tongue: "What's that? Ow!" Me: "OK, how about we avoid that spot?" Tongue: "What's that? Ow!". Etc.
There have also been the days when my orthodontist adjusts the tension in the braces to get the teeth moving. This results in pain that all braces-wearers know well. On the plus side of that experience, I’ve often taken the opportunity when I have mouth pain to do some exploring of how to eat when you can’t chew or swallow easily, thinking ahead to recovery from surgery. I used to think that having to squirt liquid food from a packet into one’s mouth, like an astronaut or a science fiction character, would feel unnatural or even disturbingly dystopian. Now I appreciate the convenience and ease of that kind of eating. Oh, I don’t think I’ll ever stop appreciating many foods in their best presentation, with flavor, scent, texture, and general yummy goodness that I am thankful to take in. But it’s nice to have an alternative that’s fast, doesn’t hurt, feeds me well, and leaves me satisfied. It also helps greatly having Lorraine’s expertise and exploratory spirit absorbing recipes and modifying them into more healthy – but still tasty – new versions, good for both of us.
For additional exploration of issues related to my speech pre- and post-surgery, I have also consulted with the department of Speech and Hearing Sciences at the University of Washington. We’ve taken video and various computer measurements of my speech. After my surgery, we’ll take another set of measurements, and I hope we’ll learn something interesting there. Later, I will work with a speech therapist assigned through that office. I hope to learn a lot in that process and perhaps improve my skills even beyond current levels. After all, we are hopeful that this surgery will improve my ability to breathe freely, so perhaps, eventually, I'll be able to speak more easily as well.
Along that line of thought, I have also consulted two of my teachers in the area of the Alexander Technique, asking their insights into the best Use of my Self in this process. We have discussed how I can carefully consider the steps (“means-whereby”) I’ll need to learn in self-care (such as feeding myself with a syringe and catheter), so that I can do those necessary steps with as much ease and comfort as possible. We’ve also talked about the post-surgical speech therapy I’ll be doing, and how to incorporate my study and experience with AT and body-mapping into my cooperative work with the speech therapist.
We’ve also talked about how to address one of my largest fears associated with the surgery. My surgeon is planning that I will be intubated during the surgery and overnight, mostly because of my history with sleep apnea. That is, to ensure that I breathe properly, a tube will be inserted through my nose, down my throat, between my vocal cords, and into my trachea. This is an area that makes me most nervous, both for how I will do when I wake up, and for any long-term effects on my voice. I am fearful that I will have a great impulse to talk – to phonate, making sound with my vocal cords, which will have the tube running between them – and that will in some way damage my voice. I’ve spoken to my surgeon about this concern, and feel reasonably well assured that all will be well. I'll also be speaking about this to my anesthesiologist, whom I haven't met yet, before surgery.
My Alexander Technique teachers have described this as a great opportunity to work at the AT practice of inhibition, the conscious choice not to do a certain action. In my case, as I expect to be awake for some hours while still intubated, I will practice the inhibition of all the typical actions I do that affect my vocal mechanism, including speaking, humming, clearing my throat, and others. Will those impulses to act be irresistible? What actions will I discover that I haven’t thought about now? What is swallowing going to feel like, as the larynx closes off the trachea to prevent food or liquid from going down the windpipe (but now with a tube in the way)? How patient can I remain in my wish to communicate, confined to a pen and pad? (A little too late to take up ASL.) I'll notice what I can, and report back on my experience.
This post has covered many of the different angles of study I have taken, with the help of professionals in medicine and other practices, to help me prepare for this surgery and for the recovery to follow. In my next post, I’ll talk in more detail about the surgery itself.
Next: The upcoming surgery: Maxillary osteotomy, Mandibular osteotomy, Genioplasty (chin), Septoplasty & Inferior turbinectomy (nose).
I was born September 22, 1970 with a “midline cleft of the soft palate”; i.e., a cleft palate. Thankfully, this did not extend as far as my upper lip, and only a short degree into my hard palate. In February of 1972 I had surgery at Seattle Children’s Hospital, for two purposes: 1) insertion of tubes into my ears, as I had chronic ear infections, and 2) repair of the cleft palate. At the time of the surgery, my surgeon noted that the palate still seemed a little short, and suggested that a pharyngeal flap might be necessary in the future.
After this surgery, as I began to talk, it became apparent that I had issues with Velopharyngeal Insufficiency, or VPI. This is a condition in which one cannot make proper closure between the mouth and nasal cavities, resulting in “hyper-nasal” speech. For many words I was unintelligible. So, in 1974 I had about 6 months of intensive speech therapy in Kitsap County, WA. My mother tells me that I was a dedicated patient and worked very hard. Mostly what I remember is being asked to lick peanut butter off the tip of my nose, which I didn't dislike. Still, perhaps that’s the reason I didn’t eat peanut butter for the next 40 years…
Ultimately my speech therapist advised the Maxillofacial Review Board (doctors and surgeons who reviewed my case through the “Crippled Children’s Services” program) that I would not be able to improve any further with speech therapy alone, and recommended that additional surgery be considered. Writing to the board, a speech pathologist agreed:
“At 4 years 7 months of age this boy demonstrated excellent movement of the lateral pharyngeal walls during speech with insufficient palatal length for contact with the posterior pharyngeal wall. At this point, it is unlikely that continued speech therapy will yield significant improvement without changes in the anatomical relationships of the velopharyngeal mechanism. Excellent lateral pharyngeal action makes him a good candidate for a flap procedure.”
The Board agreed, and in August of 1975 I had surgery again with the same surgeon, in which “An inferiorly based pharyngeal flap as wide as the entire posterior pharyngeal wall” was constructed – and is still in place. This tissue connects my soft palate to the back of my pharynx, essentially taking the place of the uvula I don’t have. A uvula creates closure between mouth and nose when you are drinking, eating, and making certain sounds. My pharyngeal flap provides this function, though not perfectly. I am aware of slight hypernasality in my speech at times, occasionally have food escape past the flap into my nasal areas, and cannot make closure to prevent water from coming in my nose, and so must wear a mask when underwater. Still, all the medical professionals I have seen essentially agree that my surgery was done well, that the pharyngeal flap procedure continues to be common practice and has not been replaced by anything more effective, and that they would not wish to disturb the surgical work that was done on me 40 years ago.
Following this surgery my speech improved greatly, and has never been a major impediment since, though I spent many years feeling self-conscious about it. I am aware still of incomplete closure in certain consonants, including initial [k] sounds, [m], [n], and others. However, in the last few years multiple professionals (orthognathic surgeons, ear-nose-and-throat doctors, speech therapists and pathologists, etc.) have all told me that, to their very educated and experienced ears, my speech is near "perfect". I’m not sure if I’m hearing flaws they are not (from my perspective as an experienced and educated listener myself, for vocal tone), but am beginning to think that if no one else is noticing oddities in my speech, perhaps I can just give up that particular well-trodden pathway to low self-esteem.
In the years after my surgery I went through extensive orthodontia for six years (age 10-16) and some additional oral surgery. Teeth were moved from odd positions in my mouth or extracted, and a couple of substitutions of one type of tooth for another were made. It’s not unusual for a medical professional looking in my mouth to say “Whoa!, that’s different.” (In the most professional way, of course.)
In the years following braces, I didn’t understand the need for follow-up care – particularly, wearing a retainer. Though my hygiene was reasonably good, and I was a regular tooth brusher, I didn’t floss. (Now I have seen the light, having learned from a hygienist about the life-cycle of plaque, and for several years been a confirmed flosser.) Also, I went through several years with no health care, and didn’t have basic dental care at that time, let alone guidance on the long-term health of my mouth. I don’t know how much my teeth moved in nearly three decades, but they certainly shifted away from the position my first orthodontist had reached with them.
During my twenties, in the period with little or no dental coverage, I broke all four of my largest molars. A few years later, thankfully, covered by Lorraine’s good health insurance, we were able to have those broken teeth all replaced with crowns. As he replaced them, my dentist at the time told me that due to the positioning of my teeth, my bite was such that those molars, weakened with 1970s-style metal fillings, had been taking the brunt of the pressure of my chewing. This was an early indication that I needed more attention to my teeth, and a return to orthodontia.
Next: A new dentist and a concerned friend spur a massive new Facial Reconstruction Project.
I've been working on getting this website started, waiting for that moment when I'll be "ready". Well, no time like the present. For the moment, I'm focusing this blog on my "Facial Reconstruction Project" (perhaps I'll come up with a better title), and with surgery imminent in two days, I need to get this going.
I'm starting with a few posts I've been working on for some time, which will lay out the background of my circumstances, including a partial cleft palate at birth, surgeries, speech therapy, orthodontia -- and a long and interesting career as a singer, teacher of singing, and conductor.
By finally getting this blog going, and getting those long background posts in place, I'm giving myself permission to make the shorter, (theoretically quick) posts as things strike me through the process.
Away we go!
Dr. Adam Burdick has been a professional musician for over two decades. Teaching, conducting, and performing in various music genres, he is also a perpetual student with interest in a wide range of topics. He loves to ponder and share his discoveries with anyone interested!