Should all jaw deformities be corrected surgically?

With the advent of the internet, awareness of surgical treatment of jaw deformities has increased. In the past, most of my patients were referred by orthodontists. Today, the majority of them come directly, seeking surgery. Patients who choose to see an orthodontist first are usually hoping for a non-surgical approach. Although skeletal deformities cannot be adequately corrected with orthodontics alone, most orthodontists do offer patients a camouflage option, i.e. masking the deformity rather than correcting it. As such, a large proportion of this group tends to not proceed with surgery, opting instead, for the camouflage orthodontic treatment. Patients who seek a surgical consultation as a first move are very keen to undergo surgery. It is important for the surgeon to resist the temptation to operate simply because we are able and the patient is willing. What are the cases that should not be operated?

1. Unrealistic expectation

In Singapore, the use of “before” and “after”photos in a clinic’s publicity material is prohibited. The Government’s rationale is that clinics will publish their best results which may not be representative of what the average results may be, thereby giving potential patients unrealistic expectations. While many surgeons disagree, the rule is not without merit. I do have patients who came in for consultation seeking the kind of results that they see on Korean cosmetic surgery clinic websites and think that they can achieve the same results. When I told them that those results did not apply to them, they did not seem convinced. These patients will rightfully seek second or third opinions but unless they moderate their expectations after hearing from several surgeons, they are poor candidates for surgery.

2. Minimal deformity

Effecting a change of facial appearance through corrective jaw surgery is an indirect approach. Jaw surgery changes facial appearance by altering the position and contour of the facial bones, which then produce the corresponding change on the skin. Dimensionally, the change is not equally proportional in all parts of the face. For example, a 5mm set back of the lower jaw bone measured on radiographs may not the same amount of set back when measured on photographs. This is because the skin, fat and muscles overlying the bone will “absorb” some of the bone movement. As such, minimal discrepancies in facial bone structures are not good indications for jaw surgery. Alternatives such as camouflage orthodontics, facial implants or dermal filler injections can be considered.

3. Multiple repeat surgeries

Over the years, I have operated on patients who have had jaw surgeries done by other surgeons. There are valid reasons why patients seek re-operations. Some had their surgery done when they were too young to be able to articulate their treatment objectives. Others may have some residual facial skeletal growth taking place after the initial surgery. There are also those who simply did not like the result of their surgery, wanting to “undo” the surgery. In undertaking repeat surgery, understanding what the patient did not like about the first surgery and whether a second surgery can achieve the stated treatment objectives is paramount. However, some patients do not have observable deformities but kept seeking surgeries. They are poor candidates for further surgery. The multiple repeat surgeries will result in a lot of scarring making further surgery and the subsequent healing more challenging. In some cases, non-union of the bones may result, leading to yet another surgery to repair the non-healing bone with bone grafting. In addition, some of these patients may have body dysmorphic disorder, a mental condition whereby the patient is obsessed with certain minor defects or flaws in the body. For this group, referral to a mental health professional will be more beneficial than another surgery.

4. External motivation

Many years ago, a patient was brought in by her husband for a consultation. The husband brought along photos of movie stars and pointed out what facial features he would like his wife to have. When I asked the patient herself, she was disinterested, leaving it to her husband to decide. This is even more complicated as she had not obvious dentofacial deformity to correct. It was a purely cosmetic change that her husband desired. This is definitely one person who should not undergo surgery. The motivation for surgery must be internal, coming from the patient herself. External influences by family and friends, no matter how close, often leads to dissatisfaction with the results and regret.

5. High surgical risk

Corrective jaw surgery treats functional deficits as well as cosmetic deformities. However, the functional deficits are rarely life-threatening. A notable exception is arguably severe obstructive sleep apnea caused by facial skeletal deformities. For most other indications, it serves to improve quality of life. The risks of surgery need to be balanced against the benefits. In patients who are medically compromised, undergoing a long surgical procedure under general anesthesia lasting several hours may be pose a significant risk to life which is higher than the normal healthy patient. In trying to improve quality of life, we must not jeopardize life itself. Patient with a high surgical risk should not be undergoing such invasive elective procedures.

Most surgical training focuses on the why, how, what and when to operate. However, knowing when not to operate and who not to operate on are just as important. This is even more pertinent in a private practice setting turning away patients means loss of income. Surgeons should not operate simply because they can and patients need to understand that surgery is an imperfect science.