I have a little more energy than I’ve had the last 2 weeks or so … which I guess is good, since I’m going back to work tomorrow. The swelling has gone down quite a bit … it was scary and a bit unnerving for awhile, especially when it was around my clavicle and around my adam’s apple (there was no swelling in between). That lasted for 2-3 days and then it started going down. Now, it isn’t all that bad.

My submandibular muscle under my chin feels like a rock and the swelling extends up the left side of the jaw (and stops where the maxilla begins), around the occlusal plane. My left cheek is hypersensitive, which makes shaving interesting – it feels like the razor is actually tearing the hairs out one by one. Even with a brand new razor.

My surgeon says that the inside wound is healing up well, the color is good and I need to stay on soft foods for awhile till the underside of the wound finishes healing. He actually said that attempting to eat solid foods could cause it to tear open and that would be the “kiss of death” to my graft.

The external incision is pretty much healed up and the scab having fallen off, with the last stitch being removed yesterday (the rest of the wound was superglued together and that became “rubbery” and eventually fell off with the scab).

I was fairly consistent about keeping my mouth clean (all things considered). Brush then rinse with peridex. I used a Crest rotating spin-brush (about $6 USD) and Colgate toothpaste with triclosan. I’d start at the midline, brush upper and lower all the way over too the right and just the upper on the left (I didn’t want to interfere with the wound). Brushing would push toothpaste through my teeth and then I’d take my tongue and rub it around on the inside of my teeth. Despite this, when unwired yesterday, I still have pieces of “unrecognized biomass” in my mouth. Yuck.

I have daily pictures and notes, which I’ll transcribe back-post later on.

I also have intra-operative surgical photos, if anybody’s interested over on Flickr. I attempted to post here, but Photobucket decided to randomly censor them … uggh. Warning, they contain everything you’d expect in a surgery … blood, muscle tissue, bone, etc. These are available here:

http://www.flickr.com/photos/atxameloguy/sets/72157617479878682

Today I had a follow-up meeting with my surgeon. I asked him for the photos from the surgery and at today’s appointment, he gave them to me.

I will try to explain what we talked about, but I am not a doctor, so if something doesn’t seem right, comment and I’ll try and correct it.

Here I am before being cut into. The lower mark is the incision. The upper mark sketches part of my jaw. I’m guessing that I’m intubated through one of my nostrils. They told me they’d also put a stomach pump down one of the other nostrils to catch any drainage.

Here you can see them opening me up. On the left field of view, you can see the cautery pencil, used to sear blood vessels shut to minimize bleeding. On the superior side of the incision, you can see three retractor forks.

Here you can see the skin pulled back, with some of the soft tissue. You can see some of my lymph nodes, some of the musculature and subcutaneous fat.

Stitching thread used to tag arteries which will be reattached upon closing (I’m guessing).

In this photo, the bone plate is fitted before the segment containing the ameloblastoma is removed. This is to ensure proper orientation. More soft tissue has been dissected.

Similar photo to the last. Left side of mandible is visible in the center of the photo. The plate was bent to bulge laterally outward a bit so my reconstructed jaw would have similar contours to my pre-surgical jaw. The pre-fitting is used to place the holes the plate through which the plate will be attached to my jaw. Four screws in the frontal part of my mandible and two screws on the condylar aspect.

Sterile plastic model of my pre-surgical jaw. The area cut between the condyle and tooth #20 was removed. The notch on the bottom of the ramus of my mandible was used as a reference. Screw hole marks are also denoted.

Notch cut in the mandible around the inferior alveolar nerve. This is needed to pull the nerve out without damaging it. My surgeon told me it took about 20 minutes to pull the nerve out of the defect. If you read the Marx book, in chapter 14, he talks about the “Nerve Pullout Approach”. This is what was being done. According to Marx, ameloblastomas lack the enzyme needed to be able to penetrate into the nerve bundle (unlike some cancers). Therefore, using the pullout

Rectangular area of bone removed, inferior alveolar nerve bundle visible.

Attaching a thread to tag the nerve (I think).

The mandible being cut through. A metal utensil is placed on the lingual side of the mandible to prevent the surgical saw from cutting beyond the mandible.

Inferior alveolar nerve, after being pulled out. It will be reanastomosed.

Resected bone segment, with margins. The superior-most section on the left side of the photo is the coronoid process, where the temporal muscle attached to. It will never be attached to anything ever again.

The reanastomosed inferior alveolar nerve.

Mandible with segment resected. Above the mandible, about mid-ways and 2/3rds up, both the buccal and lingual sides of the gum can be observed. And my maxillary molars can be observed through the opening into the oral cavity. These will be sewn back together to create a watertight seal.

Another photo of the entrance into the oral cavity.

Installing the titanium bone plate.

Titanium bone plate installed. Titanium mesh screen attached with screws to mandible, near distal end of what was the defect. This will prevent soft tissue enclosure and give the rhBMP-2 an area to regenerate bone in.

Another photo of the previous from a slightly different angle.

The distal end of the defect (near the chin) can be seen in this photo.

Hydroxyapatite splints are attached with stitches to the bone plate, near the proximal end of the defect. Eventually, this will hopefully reossify and become part of the replacement bone.

A close up of the splints attached to the bone plate.

One of the absorable collagen sponges (ACS) soaked in rhBMP2 is draped over the proximal end of the mesh and the distal end of the superior splint.

Closeup of previous photo.

Beginning to close me up.

Closed up. The marks perpendicular to the incision are used to close the incicion where it was made, to minimize scaring. The skin wasn’t stitched shut (except for the beginning near the ear), but was rather glued. This is supposed to minimize the formation of a scar.

This what I looked like when I woke up this morning around 730A.

This is the 60 mL syringe with flexible tubing that I’m using to feed myself.

This is me trying to hold my lips open so you can see my teeth. My lips are hard to control and the lower left lip and part of my chin are numb, because the inferior alveolar nerve (IAN) had to be removed to remove the ameloblastoma. It was pulled out using the “pull out” approach described by Dr. Marx in his book (see the earlier post that I’m holding the book up in).

I can feel a little bit of pressure in that part of my lip. Each side of the jaw has its own IAN, and they go through the bone and come out of the bones around the canine. There is a bit of cross over on each side, so the left innervates part of the right side and vice versa. Maybe that’s how I feel pressume? Another odd thing though is that earlier today the left lower lip and chin just below it was itching, but scratching did no good! A phantom itch? Weird.

I went back to sleep after this and work up around 1015A. This is what I had for my breakfast around 1030A this morning. I had a smooth (banana and strawberry I think), chicken broth and a glass of apple juice. All given to myself with the syringe with tubing, put to the back of the right side of my mouth (opposite). I tried to put my tongue over the left side as to not contaminate it. I rinse with peridex (chlorhexidine) after eating anyways.

And this is my IV in my left arm. It hurt going in first yesterday and there was some pinkness around the entry point, but is doesn’t bother me now.

And this is what the incision looks like with the gauss off. Doesn’t hurt just poofy.

This afternoon, I had a little blood spillage as well. This kinda freaked me out, but the nurse told me it wasn’t anything to worry about.

The braces I had on were wired shut. The front 4 teeth by default don’t have tabs. The ortho put K-hooks on the canines. Then the hooks and tab on the brackets were used to wire my jaw shut.

This is what I looked like when I showed up to the hospital today.

And a side view:

In pre-op, they put these stocking on your legs. These are supposed to decreased the odds of blog clots breaking off and traveling throughout your circuilatory system.

They hooked an IV up and then they put this sleeve around the stocking.

The sleeve is pumped rhytmically to squeeze the legs to prevent an emobolisms.

General anesthesia consisted of versed and fentanyl to start me off. These were plumbed into my IV line in pre-op. I don’t remember anything after that, but they intubated me through the right nostril and put a stomach pump to suction the stomach through the left nostril. The outer tube for intubation had a green thingy on the end. It apparently had an inner tube but that was removed in recovery.

Later on I asked the anesthesiologist what they gave me and he said in addition to the fentanyl and versed, they gave me:

• propotol – a deep sedative
• desflurane gas – used to maintain the general anesthesia
• morphine

They also have been adding cefazolin added into my IV.

The scopolamine patch that I put behind my ear (per my surgeon’s request) isn’t making me too loopy. Apparently it makes some people incredibly loopy. I’m a bit hungry, although strangely enough although I didn’t each much of a dinner later night, the hunger isn’t too bad. Neither the thirst. Before the midnight shutoff for all food and water, I had about 32 oz of water, just to make sure I didn’t dehydrate.

I tried to stay up a bit so I’d be a bit tired, but I’m actually a bit more chipper than I’d care to be.

Tried to clean my mouth as best as possible, without overdoing it, to reduce the bacterial load/plaque that could come back to infect the graft.

Here we go, trying not to think about the details.

Notice the back 2 molars are lacking a bracket (the #18 and #19). These will be removed with that part of the mandible, so they don’t need a bracket. That would probably just cause them to catch on the gum on the way out.