I don’t know how many words this board allows, so I may be posting in multiple parts.
MY CASE STUDY: Most of you on this board are young. I am a 58 year old who has been working to correct an extreme case of microgenia (undersized mandible in all dimensions) for over 20 years. Prior to my first procedure, if you had placed a straight edge from the tip of my nose to the tip of my adam’s apple, you would not have made contact with my chin. My first procedures in ’91 involved a sagittal split and sliding geneoplasty, preceded by seven years of corrective orthodonture. A very good improvement, but still leaving me with volume deficiencies. In 2000 I had a simple neck lift which improved the jawline somewhat. In 2001, I discovered Medpor implants and found a New York doctor, Kenneth Francis, willing to place standard 11 mm angle implants and prejowl implants, which we did in Feb. 2002. The results were extremely disappointing. Despite my being clear about wanting a discernable and straight jawline, combining the prejowl with angle implants created a very unnatural deep ripple along the sides of my face, in part due to a failure to anticipate how an unnaturally shaped hard structure will project the soft tissue unnaturally as well.
The poor aesthetic result was compounded by two staph infections, due in part to my surgeon providing no follow up instructions. (Anyone contemplating surgery with intra-oral incisions PLEASE stick to a liquid diet for at least 30 days.) The second flareup was finally knocked out with 9 weeks of intravenous antibiotics and a half year of oral antibiotics.
By February ’03, I heard of Oscar Ramirez in the Baltimore area and during my first consult, he insisted that the only way to treat my case would be with custom implants. So I opted for the huge added expense of having the life-size plastic models of my face. It wasn’t until Dec. ’04 that we fashioned the clay models for the implants. During that fashioning session, I was concerned by their excessive size and more concerned that any suggestion to the process seemed to provoke Ramirez into a defiant mode of doing more of the thing I asked him not to do. (Ex. When he was building up the superior area of the chin implant—to prevent, in his mind, a “witch’s chin”—I asked him if it would not produce the far worse effect of making the front appearance of my chin round and bulbous, not square or at least oval like a masculine chin. His reaction was to the effect that I should trust him as he added more material. I turned out to be right; he turned out to be wrong.)
I had the first surgery with Ramirez in April ’05. His surgery took eight hours and didn’t allow time for the mid face lift we had planned in addition to the implants. The volume improvements seemed okay at first, but it was also immediately apparent that the right side angle implant was very skewed. Ramirez was in denial, telling me it was fine, and that my perception of the fault was “just my imagination”. Any layperson could run their fingers along the jawline and felt the way it jutted out. I was to learn later that Ramirez doesn’t use any more of a securing method than a single suture to secure these massive implants.
In time he admitted it was skewed. We planned phase 2 surgery to do the mid facelift and replace the skewed right side angle implant a few months later. Around mid-October, the left side of my jaw blew up. After seeing me, Ramirez insisted it could not be an infection but could not give an alternative explanation. Nevertheless he gave me prescriptions for antibiotics. We went ahead with plans for a mid-December surgery. A few days prior I went to my dentist for a cleaning. His hygienist saw puss coming from from the cheek and gum crease. I had emergency surgery to remove the left side angle implant performed by Kenneth Francis, my first implant surgeon, in New York. He told me he found tissue pinched in the gap between the chin and angle implant, which had to be there since placing these implants. I learned much later that Ramirez had no interest in learning what was found including a refusal to return phone calls from Dr. Francis.
Dealing with a death in my family caused me to postpone the final surgery till Aug. ’06, which now necessitated new angle implants on both sides. (right side skewed, left side removed for infection) A pre-op meeting with Ramirez revealed something shocking. He had new models of my implants made up with a deeper inner ridge creating a deeper channel for the angle implant to wrap around the mandible to prevent skewing. He expressed bewilderment about how he was going to secure the angle implants, like he had never given any thought to this in designing them in the first place. He also told me he had to use a more porous formula to speed up integration since “I was more prone to infection” reflecting an obvious unwillingness to consider that lousy surgical technique might have had anything to do with my infections) He said there might be some danger of tissue clinging to this courser porosity rather than shifting smoothly as it does against natural bone.
I left with grave misgivings but decided I must be having pre-op jitters. I had the surgery. The first thing I noticed post-op looking in the mirror was the forward portions of my ear lobes were missing. I was mortified. When I asked him why, he said he thought my lobes were too large. We had never discussed this. Had we done so, he would have learned that I thought (the one and only person who matters) my ears were just fine. When we contemplate plastic surgery, we commit ourselves to being objective about everything. There are several other things I would prefer to be different, but I always concluded a mirror session with saying to myself: Well, at least I have good ears. Ramirez helped himself to butchering my ears without even asking my permission. I suspect he was showing off techniques in front of the several student surgeons he had observing in the O.R.
Post-op there was a lot of swelling and scar tissue created, and I was holding off judgment for a long time. There was also a lot of numbness. As the months went by, the swelling subsided to where I could see and feel the apex of the angle implants. They were way further back than they should have been, clearly not flush against the vertical rise of my natural mandible. In fact they are about a whole inch out of position. Again, this is a matter anyone exercising common sense and a simple tape measure while performing the surgery could have easily detected. A blue collar carpenter will always do a final measurement and level check of a 2 by 4 placed horizontally between two studs to make sure it was done right. What kind of surgeon can not exercise a similar common sense? To not even perform a check of running a finger along the edge to make sure there is not a gap between the chin and angle implants is inexcusable.
Today, I live with a level of frequent pain and constant irritation worse than it would be if the surgery had just occurred two days ago. The area of second most intense pain is in the region of the vertical portion of the angle implants where they are not flush against the bone. Another very sensitive area is in the location of where the infection occurred, where there is now a gap. You would think he would have been extra cautious in this area given what happend. But he wasn’t. At first he denied the gap, much like the skewed implant of the first surgery, then about a year ago proposed injecting fat into the area as a solution.
The area of most acute pain occurs in the goiter like mass he created for me. Remembering what he told me during my first consult, I asked him if he can do anything to repair (I did say repair) my herniated muscle in my neck, not for anything cosmetic, but for the simple reason that muscle is not supposed to be herniated. Big mistake. I don’t know what he did, and I can’t get a straight answer out of him. His contention is that he made a cosmetic improvement. (Some improvement. I now have something that looks like a goiter.) He admits he yanked muscle up and to the posterior. On my last visit, when I emphasized that, aside from the pain, I can not lift anything heavy, as the neck muscles are involved in any heavy lift. He shrugged it off, and said the muscles will regenerate. This came as a shock to me, and I suspect it would be a shock to any athlete whose career ended on a muscle injury. Muscles may or may not heal, but they do not regenerate.
There is also a low grade pain along the entire edge of the implants. He told me after the fact that he was using a courser grade of material to hasten integration, but there would be a danger of internal irritation. Sure enough, I have it.
My ears feel always inflamed or itchy, especially with what doctors call phantom pain of the missing lobes. I haven’t had a good night’s sleep in the past six months. Any pressure on my ears, even against a pillow, creates extreme irritation.
Another area of pain is in the area at the peak of the chin implant, which I warned him against when we were designing the implants, but he pigheadedly built them up anyway.
Not capable of ever admitting he could have done anything wrong, Ramirez attributes a lot of my pain to what he describes as nerves growing into scar tissue, which can not be helped. When I told this to my neurologist, she asked if he had ever gone to medical school. Nerves don’t just grow where they want to grow. Tiny blood vessels do, but not nerves. If you have pain, it is due to grossly abnormal tissue structures, not nerves doing their own thing.
After learning of him on this forum, I visited Dr. Yaremchuk in Boston on 5/9/08. Within a few minutes I realized that this is the surgeon I should have used. He is not going to excessively bad mouth a colleague, but he was objectively critical of a lot that Ramirez did. He is not sure whether he can help me but wants me to bring him the models to do more evaluation.
