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.
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!