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At the Hospital

I snapped ths on the way to the hospital. I’m smiling, so you can see the braces they put on. These will be used to close my jaw later.

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:

They also have been adding cefazolin added into my IV.

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Surgery Today

Today is surgery day. Arrive at the hospital 1.5 hours before, surgery at 1030a. Updates (and photos, unfortunately from my netbook since I left the camera on my desk at home) will follow.

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.

Braces (again)

Today, my (former and I guess now current) orthodontist put braces back on my teeth. These will be on 3-6 months. This hurts the gums less than surgical arch board, helps preserve the alignment of the teeth and will let the surgeon get better closure. Also, the arch bars would have required a band on the #20, which would have been a conduit shuttling bacteria straight in to the bone graft.

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.

Approved

Today insurance called me to tell me I was approved for reconstruction with an INFUSE bone graft. I was expecting them to blow me off, but it’s nice that the case manager actually took the time to call me back.

There is a small part of me that somehow expects this to get messed up, but we’ll wait and see. Can it be this easy?

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.

Meeting with surgeon

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.

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.