A great place to start Disorder information source Rated and Reviewed Sleep Links Entrance to all monitored Sleep Forums Search all of needsleep.net
Need Sleep Homepage

Ask the
Sleep Surgeon Question 4

Tips for better sleep
Needsleep.net's "Ask a Sleep Surgeon" does not provide medical advice, such as that provided through a direct consultation and is not intended to replace it. The responses given are only educational and informative in nature and cannot in any way be used to represent a complete analysis or diagnosis. We cannot make recommendations regarding diagnosis and therapy. Those issues should be addressed directly with your health care practitioner. Use of the "Ask the Sleep Surgeon" Q&A forum indicates your agreement with these terms. Submit a Question

Question 4 - MMA Problems

From: Kathy C..

I am 42 years old and never snored until a few years ago. I did not have any sleep issues. My snoring got worse during my pregnancy and because it was bothering my husband, I had radiofrequency treatment to my palate. The snoring did not improve but I developed sleep issues and wake up with snorting efforts. I then had an UPPP but again, no help. I had multiple sleep studies and all showed that I have lots of hypopneas. I could not use CPAP at all and it actually made my sleep worse. I saw lots of doctors and there were so many different recommendations from Pillar implants to shaving off my epiglottis.

I finally had a MMA but it did not help me. My bite is off after the surgery and the left side of the teeth do not meet properly. I don't like the way I look because my nose is now wider. I think part of the reason that MMA did not work was because I was very concerned about the way that it would change my appearance and so my surgeon only move the upper jaw 5 mm and the lower jaw 10mm. I wish that I had him move the jaw further forward and it could have helped me. But I think I would hate the way I look because I already don't like it now.

I was so desperate and my family just don't believe that there was anything wrong with me in the first place. I finally had a tracheotomy and all my symptoms went away, but I hate it and want it removed. My doctor tells me that he can try Pillar implants and shave off my epiglottis. What can I do?

Answer Provided by Dr. Kasey Li
June 24, 2007

One of the most difficult problem with sleep apnea surgery is that NO PROCEDURE is 100% successful. Patient education on the potential risks, complications as well as outocmes is crucial. Even with the best intention by the surgeon, some patients never fully understand what they are in for before the operation. I suspect that it is because some patients are so desperate for help and they are clinging on and only focusing on the chance of a "cure". As a surgeon, I sometimes see patients that I feel are not going to be a good candidate for surgery. When this happens, sometimes it is not because of any anatomic issue, but an "expectation" issue. As I stated in a past answer, there is no "free lunch" in any surgery that you go through. There are potential downsides which can counter-act the upsides of any operation. After approximately 500 MMAs, approximately 90% of the patients are significantly improved. Approximately 5% are mildly to moderately improved. However, there is that 5% that are not improved at all. Usually, significant obesity is a major contributor, but not always. Occasionally I am just left scratching my head and wonder why the procedure was not successful (in terms of apnea improvement). Finally, even when the sleep apnea is much improved, I would consider a procedure unsuccessful if there are complications that made the patient wish that he/she did not go through the operation in the first place. At the end of the day, a successful result means that the patient feels the operation was worth it after weighing the upsides versus the downsides of outcome.

This patient is clearly a surgical failure because there were complications and the symptoms did not improve. This is a difficult case because limitations were placed on the surgeon due to esthetic concerns. Because of these concerns, the extent of MMA was limited, thus the airway expansion was also limited.

When patients present with significant esthetic concerns regarding MMA, I usually try to alter how the jaw is moved. For example, an advancement/rotation of the MMA would be done which allows for less movement of the upper jaw but have a greater advancement of the lower jaw (patient usually never complain that their lower jaw is too prominent). Still, there would be changes in appearance, albeit less so. Other options including post surgical orthodontics to pull the teeth back and reduce the prominence of the upper lip/nose, or a nose job. Another associated risk of MMA is malocclusion, which is usually easily taken care with orthodontia or some dental work.

The solution for this patient is VERY limited. I feel that she has exhausted her surgical options. There are other surgical options such as genioglossus advancement, hyoid advancement, radiofrequency, Pillar implant, tongue reduction, epiglottis shaping and revision MMA. However, the most definitive surgical procedure has been done (albeit a limited one). It seems to me that although a revision MMA with further advancement can be done, I doubt that the result will be great because even with improved sleep apnea, she will be unhappy with her appearance (still, orthodontia and a nose job are possibilities). Any other options have much less success rate compared to MMA.

In this situation, my recommendation would be to try to stay with tracheotomy for a while if possible since she feels much improved symptomatically. I would actually recommend an oral appliance or revisit CPAP as I suspect that the pressure requirement would be reduced following MMA.

Good luck.

Copyright ©1995-2012 Needsleep.net., All rights reserved