A few years ago, a young patient came to my clinic two weeks after he had undergone cosmetic jaw surgery with surgeon from another hospital. He was rather distraught at the results of the surgery as it was not what he wanted. He desperately wanted to have the surgery reversed so that he could look like his old self again. While I had done many cases of re-treatment, they were usually done long after the first surgery when all the surgical wounds had already healed. What further complicated matters was the patient’s state of mind and whether I could really re-create his old look without having seen him before the surgery. So, what can we do? Can we “un-do” cosmetic jaw surgery?
The short answer is yes, we can “un-do” cosmetic jaw surgery. However, it is not the same as clicking on the undo icon on a computer. We need to look at what was the original condition, what was done, what is the current situation, and what the patient is looking for in seeking to undo the surgery. The most difficult part is last part. With emotions running high, it was not easy for the patient to describe what he really wanted except to look like his old self. However, without a clear and definite goal, it is not possible to achieve a predictable result.
Furthermore, other than the usual risks associated with cosmetic jaw surgery, there is the added possibility of non-healing of the bones and breakdown of the soft tissue cover due to repeated surgeries within a short time. In a worst case scenario, the blood supply to the segment that is being move may be compromised and that can result in necrosis, or "dying" of that segment. A second surgery should be considered even more carefully than the first due to the higher risks involve and there is still no guarantee that the aesthetic result desired by the patient can be attained.
As such, I told him that it is best to wait a few months for the swelling to subside and the wounds to heal before deciding on another surgery. It was not something he was prepared to do as he did not want to face the world looking the way he did. He eventually went overseas for the undo surgery. I saw him again recently as he needed some dental implants to replace some of the teeth that were taken out. The overseas surgeon did a great job and he is now happy and I am also very happy for her. He likes the result of the second surgery and is now a cheerful young man compared with the emotionally distraught person I saw a few years ago.
This was a valuable reminder for me that aesthetics is something very personal. Adequate time must be spent to understand the patient’s sense of what is nice and what isn’t. In my practice, I spend a long time discussing with patients about what they like or dislike. While the objective of cosmetic jaw surgery or any cosmetic surgery for that matter, is not to make one person look like another, I often ask patients to show me a photo of someone whose looks they like. I will emphasize to them that no matter what surgery is done, they will not look that their favourite celebrity. What I gather from this exercise is their aesthetic preference so that I can plan accordingly. Cosmetic surgery is part science and part art. Just like this patient who wanted to undo his surgery, the science part was ok. There were no real medical problems; the wound healing is good, the nerves are intact, the teeth are biting together fairly well even before orthodontic treatment. However, the art part was a failure.
So, what was done to reverse the surgery? By the time the patient went to this overseas surgeon, some months have passed and the wound has healed. The jaws were then ready for a second surgery. In the first surgery, four teeth were removed and the front part of the upper and lower jaws were cut and repositioned backwards. This resulted in a rather flat facial profile which the patient did not want. The objective of the second surgery then, is to bring the front part of the upper and lower jaws forward again. In general, it is always more difficult to add then to subtract. When the jaw dimensions are excessive, the excess bone can be cut and reduced. However, when they are deficient, adding bone must be done either by taking bone from the hip and grafting it to the jaw, or by distraction osteogenesis, a process of “stretching” bone.
In this case, the overseas surgeon used distraction osteogenesis. The bone cuts that were made for the first surgery were done again to mobilize the segments that were repositioned backwards in the first surgery. A distraction device is attached to the mobilized segment and the unmoved part of the jaw. This device is activated on a daily basis to push the two segments of bone apart at a rate of about 1mm a day. This technique allows new bone to form in that 1mm gap daily. It also stretches the soft tissue covering the bone gradually thus preventing tearing. After 7 days, the segments would be separated by 7mm, which is about the width of each of the tooth that was removed in the first surgery. The new bone that is form takes another 2-3 months to harden and the distractor is removed at that time. During the time of removal of the distractor, sometimes, another surgery may be needed to fine-tune the alignment of the bone.
An alternative way to do this would be to do the same surgery as if we are doing distraction but instead of using a distractor to move it gradually over a few days, the segment can be moved forward 7mm and fixed in that position with plates and screws. That resulting gap can be filled with a bone graft harvested from the hip bone.
There are pros and cons of each approach and the final decision is to be made between the surgeon and the patient, after a thorough discussion. While it is possible to undo cosmetic jaw surgery, it is best to avoid that altogether by spending more time in the consultation phase to understand the needs and desires of the patient and also for the patient to understand what can and cannot be achieved.