Last night, while driving home, I was listening to BBC on the radio and they were talking about President Obama replying a letter sent by a young girl who wants to pierce her nose against her parents’ wishes. Basically, President Obama told her that she should leave such decision to her parents till she has grown up. I can empathize with both the girl and her parents, as this kind of “conflict” between parent and child plays out in my consultation room regularly.
Yesterday, a young patient came for a consultation for orthognathic surgery with her parents. It is a familiar scene in my practice. The patient, a 20 year old young lady, had done her research before the visit. She checked out several sources on the internet, asked many questions, and had pretty much made up her mind that she wanted surgery to correct her underbite. She understood that it is fairly major surgery that involves hospitalization for a few days followed by a few weeks of recovery. She knew friends who had undergone the surgery before and had seen how the post-operative recovery was like. All that was left for her was to find out was what exact surgery she needs to achieve the objectives she had in mind.
While she was asking questions enthusiastically, the parents were not quite as interested. As decided as the patient was to proceed with surgery, the parents appeared equally decided that no surgery was to be done. Nevertheless, I proceeded with taking the history and doing a physical examination and then explain my findings and recommended treatment. Then comes the question, “Is it necessary?”
The answer to this question is a question, “Is it necessary for what?” Unless the patient also has obstructive sleep apnea, corrective jaw surgery is not necessary as a life-saving procedure. However, it is necessary to achieve a good bite for normal eating. At this point, the mother asked if a simpler surgery could be done to achieve that. Looking purely at function of mastication, it is possible to just do a single jaw segmental surgery to get the teeth to meet properly for mastication. However, that would result in an unaesthetic facial appearance. This then led the discussion into the cosmetic aspects of orthognathic surgery, which is always more complicated than the functional aspects of the procedure.
For most parents, it is concern about safety and the potential complications of surgery that deters them from allowing their kids to go for surgery. For some it is also a matter of values. Some have ingrained belief that vanity is bad and cosmetic surgery is succumbing to that weakness. There are a handful who are superstitious and are advised by their spiritual mentors not to allow their children to change their facial appearance. Regardless, all are valid reasons because corrective jaw surgery is not time-sensitive. As a surgeon, I can put the risk of the surgery in perspective but I do not venture into discussion on values and superstition.
I do, however, discuss the scientific aspects of cosmetic surgery. To invalidate the patient’s desire for an aesthetic enhancement is just sweeping the dirt under the carpet. There are many studies that showed the good-looking people have many advantages in life. A person who is self-conscious of his own appearance often has self-esteem issues as well. Teenage years are challenging due to physiological changes that take place along with the increased awareness of self, peer pressure, school, etc.
For this patient, having friends who have undergone the surgery with parental support made it more difficult for her to understand why her own parents are not supportive. I do not try to convince the parents to support the surgery nor do I try to persuade the patient to forgo surgery. However, I strongly advocate not doing a compromised treatment, such as camouflage orthodontics or simplifying the surgery to a single jaw surgery when a double jaw surgery is needed.
Camouflage orthodontics is moving the teeth to fit into a functional biting position without regard to the supporting jaw bone position. Some dentofacial deformities can be alleviated by camouflage orthodontics but the results are not ideal. Adult patients who understand the limitations and accept the compromises that come with such treatment are suitable candidates for camouflage orthodontic treatment. For underage patients, camouflage orthodontics will severely limit the options if they decide to opt for surgery when they grow up. Likewise, doing a single jaw surgery to correct the bite without consideration for facial aesthetics when a double jaw operation is needed is trading one type of facial deformity for another. Correcting such an iatrogenic deformity when the patient grows up is a lot more difficult.
Ultimately, my advice to the patient and parents is to not do anything at all, not even orthodontics, if they cannot come to an agreement. This keeps all options open for later, when the patient has grown up and is able to make her own decision.