Cosmetic jaw surgery has come a long way. Thirty years ago, a patient undergoing a double jaw osteotomy typically have to endure eight to nine hours of surgery and thereafter monitored in an intensive care unit for one or two days. This was followed by a six weeks of having the jaws wired shut and having liquid diet through a straw. Today, things are vastly different.
Today, a typical double jaw surgery takes about four hours and two days of hospitalization in a general ward. Thereafter, the patient rests at home for two weeks and he can be back to school or work. This is possible for a variety of reasons.
- Better understanding of the science behind the surgery
Surgery involves cutting up our body’s natural anatomy and either removing it or “re-arranging” or reconstructing it. Unlike a butcher cutting up meat, a surgeon cutting a living human needs to minimize the “collateral” damage of surgery. For example, in order to get to the jaw bone to cut it, we have to go through the skin or mucosa that covers the bone. These tissues contain nerves, arteries, veins and other organs which may get in the way. The surgeon needs to be cognizant of these and design the surgery in such a way that it does not damage these structures in the process of doing the surgery. Over the years, the techniques have been refined and published and our collective understanding has improved, leading to shorter surgeries. A shorter operating time generally means a shorter and less eventful recovery.
- Better understanding of the healing of the jaw bones
Beyond minimizing collateral damage, surgeons also need to ensure that the operated jaws will heal properly. A better understanding of the healing process and factors that contribute to an uneventful healing also facilitate improvement in surgical techniques that lead to better recovery. The
- Hypotensive anesthesia
Jaw surgery, especially upper jaw surgery is bloody. Unlike many surgeries whereby bleeding can be controlled with diathermy and ligation of blood vessels, bleeding from jaw bone surgery do not avail itself to such measures. There is often a slow oozing of blood throughout the surgery which can only be controlled by pressure against the wound. The use of hypotensive anesthesia, where blood pressure is reduced during the surgery helps tremendously in reducing blood loss. This in turn contributes to a faster recovery.
Right after the surgery....
With these advances, patient can look to a relatively quicker recovery. Usually, on the day of the surgery, most patients will not eat very well. There will be an intravenous drip in place to provide the necessary hydration and for the administration of medication. I no longer wire the jaws together. The patient can usually speak and drink normally from a cup. Eating is possible from the very first day albeit restricted to soft diet. I will usually get a dietician to come in on the day after the surgery to advise the patient and family on a well balanced soft diet for the next few weeks. Swelling can be rather dramatic especially for double jaw surgeries. Application of ice packs on the face for the first few days will help to minimize the swelling.
Postop pain management....
Most patients do not complain of pain and the majority of patients can managed with just oral painkillers. For those who do feel a bit of pain, I may put some narcotic painkillers in the drip. However, narcotic painkillers tend to cause nausea and may lead to vomiting. Vomiting on the day of surgery can be rather dramatic as the stomach is usually empty except for blood that has been swallowed during the course of the surgery. As such, it would appear to be vomiting blood.
First postop day...
For lower jaw surgeries, the patient can usually be discharged on the day after the surgery. Those undergoing double jaw surgeries will usually need to stay for an additional day or two. In some cases, elastics may be tied to the braces to guide the jaw to bite into the right position as the jaw muscles are not trained to work with the new jaw position. Drains are usually placed in the wound to allow drainage of secretions. This helps to minimize swelling as well as hematoma. These drains are usually removed on the first or second day after surgery before the patient goes home.
First postop month....
I will usually review the patient in the clinic one week after the surgery and assess for any signs of infection of wound dehiscence. Postoperative x-rays are also taken at this time to assess alignment of the bone segments that has been repositioned. Oral hygiene assessment is also important to ensure that the wounds are kept clean. Such reviews are done weekly for a month after the surgery. After a month, the patient is referred back to the orthodontist for the final adjustment of the bite and teeth position.
Despite advances in orthognathic surgery, there is still significant downtime, mainly due to the swelling. For students, the surgery is usually scheduled during the school holidays. One of the most popular period for orthognathic surgery in Singapore is between the completion of “A” Level examinations and the starting of university. Working adults will have to find a time whereby they are able to take a couple of weeks off work. Depending on the kind of occupation, mandatory time away from work ranges from two to four weeks. Most patients are functional after two weeks if their work does not involve significant physical exertion. Going back to work is possible if they do not mind having a swollen face. For this group, the popular time is when they are taking a short break between jobs.