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Archive for March, 2009

Surgery Date!

Finally, I have a surgery date. Well, one that (hopefully) won’t change. It’s April 15th. Yes, on tax day.

I actually think this is the 4th date scheduled. It’s making me a bit crazy.

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Today, I met with my surgeon again. We talked about using rhBMP2 with absorbable collagen sponges (ACS) to fill in the defect that will exist after he removes the posterior part of my mandible.

Things we discussed:

  • This is an off-label use. BMP2 approved for orthoped, sinus lifts, not mandibular reconstruction of defects
  • Infuse Helpline that told them (huh?)
  • 2 week deadline self imposed by insurance company
  • my CT scan looked unchanged from the previous one

As a side note, I really would like a copy of my current CT scan, but sometimes surgeons take this as a “we’re breaking up” signal. I didn’t realized this until I went through it with surgeon #1, even though he went on about how open he was going to be about the whole process. Yeah, right, well it didn’t quite work out that way. I’d rather not upset the apple cart now, I’ll ask after surgery and take my DVD burner with me so I can make a copy 🙂

I also had read, maybe in Garg, that a membrane was required to keep soft tissue from growing into the graft. He said it wasn’t required with the titanium mesh he was planning to use.

We talked about recurrence some more. He said in the number of ameloblastomas resected, none have recurred.

I asked him which plate – 2.4mm or 2.7mm. He said that Synthese makes a 2.9mm plate. The “size” doesn’t refer to the plate dimensions but to the screw size. Bigger is still better. And I should be warned that sometimes plates can fracture, even after the bone has grown back. If there is bone there that can bear the stresses, they just left the plate in.

So here’s the remaining timeline:

  1. Schedule surgery
  2. Call or email my former orthodontist, which he will do – so he can put the brackets on teeth, these can go on anytime
    wait till close too surgery, better gum closure without wires around teeth
  3. have 3D model done – 1 week or two
  4. prebend plate on model
  5. do operation

He said I should bring medical power of attorney to the hospital on day of surgery.

And I should discuss the various aspects of the advance directive. Such as to ressucitate or not, full code? – in the event that heart stops – what actions to you want to be taken, worst case – anoxic brain injury, vegetable, if this happens, what would you like to do – he said attorney should
have form.

I asked if there is a denial of bmp2, can we still do surgery and I pay for it? He said he’s requested conventional surgery, resection and reconstruction and that this would cost for first day in hospital $24K, $10-11K per each additional day. He would argue the point that using this would decrease hospital stay and hip morbidity which would overall save them money. He may have to argue with their staff oral surgeon reviewer.

He said he probably see me one more time before surgery, I should bring my partner to the next meeting.
Eating – will probably rubber band or wire teeth, 1-2 weeks. More comfortable – less muscle movement,
closure of gum good, diet book he’ll give me, propped up with 4-5 pillows for first week to prevent
turning. Rinse with chlorhexidine. Liquid antibiotics, medication.

Looking 3-4 weeks, later for surgery.

We’d leave brackets on for about 6 weeks.
Needs to see me a week before surgery.
Determination for infuse, this is a reason why he’s scheduling this 4 weeks out.

And I had a preliminary surgery date of the 22nd.

They talked to my insurance, bone graft with infuse is CPT code 21215 with a modifier of -52.

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New CT Scan

Today I had a “real” CT scan. This is needed to make the 3D surgical model that they will use to plan the surgery and fit the plate.

This wasn’t like the cone-beam CT scan I had back in December. That was done in a scanner that you sat up in and it took about 40 seconds.

No, this was a traditional CT scan, where you lay down on a mechanized table and the technician moves the table in and out of the “donut” scanner.

All I have to say is that it is remarkably difficult to stay perfectly still and not swallow for 5 minutes. At least I didn’t require a contrast dye.

It was a rainy, nasty day today.

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Today I saw surgeon #3 again. And he had another option to suggest to me, rhBMP-2 with absorbable collagen sponges (ACS). He showed me a paper by Boyne and Hereford discussing their success with it (Herford AS; Boyne PJ. (Apr 2008). “Reconstruction of mandibular continuity defects with bone morphogenetic protein-2 (rhBMP-2).” J Oral Maxillofac Surg. 66 (4): 616-624.). I’m a little skeptical, I need to do some more reading, but it does sound promising. It would save the trouble with getting a hip graft, but it’s fairly new and not proven, although there appears to be enough success with it to make it plausible. But it’s an off-label use and insurance must be fought with.

It seems like a long time since the last visit with him.

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