by PROFESSOR KHURSHEED MOOS
EVERY surgical specialty inevitably overlaps with another. For maxillofacial surgery that tends to be with ENT, plastic surgery, dental surgery and sometimes ophthalmic surgery.
For maxillofacial trauma, cleft lip and palate surgery and head and neck surgery (cancer), there is now little argument that it is primarily maxillofacial surgery. When the surgery requested is for facial deformity or aesthetic (cosmetic) surgery the issues are often more difficult for the patient and the surgeon.
Orthognathic surgery is widely carried out for jaw deformity by maxillofacial surgeons in the UK and Europe. The patient often presents in their late teens or in their third or fourth decade requesting surgery, following a referral by their dentist, GP, orthodontist or another specialty. In most cases the patient is fully aware of a discrepancy in jaw size and has been told that something can be done to improve their appearance, mastication, dental occlusion and sometimes minor joint symptoms.
There is usually a good reason for their referral and the patient is eager to have a significant problem corrected. There is a high chance of success with few risks or pitfalls for the experienced, well-trained surgeon.
Risks are always present and it is up to the surgeon to fully explain them, especially when there is a risk of nerve or vascular damage and a possible small risk to life from interference with the airway.
Patients frequently do not want to listen to these warnings, or that there is often a slight risk of relapse.
Only afterwards do they complain of a complication or not being entirely satisfied with the result, in spite of orthodontic preparation and careful preoperative planning using photographs, models and radiographs, all of which have been fully recorded and consented.
A very small number of patients are never satisfied and continue to demand further operations, often to make relatively minor changes. It is important to recognise the dysmorphophobic patient who will never be satisfied, who travels from surgeon to surgeon or to another specialty and eventually goes to the legal profession for help.
For the experienced orthognathic surgeon that can usually be picked up early on, and with the help of an experienced psychologist surgery can be avoided where there are unreasonable expectations.
Sometimes a surgeon from another specialty will unwittingly criticise or suggest or agree to further changes which can lead to a court action, with a forever-dissatisfied patient, and to a variety of secondary problems, scars, dental changes, pain and possibly the use of buried implants and cosmetic agents which lead to further problems, sometimes infections and a patient who ends up considerably worse off than at the start of treatment.
It is essential for the surgeon to recognise that major risk factor and not automatically think that all problems, however minor, can be solved by surgery. Hopefully then the patient will not go to law for a solution which will not solve their problem.
Similar problems can occur with cosmetic dentistry and plastic surgery when for these unfortunate patients all complaints and problems are blamed on their appearance or the consequences of surgery.
Good communication between patient and clinician and the early recognition of the warning signs of a preoccupation with detail and constantly changing demands are invaluable signs in this situation.
The expert witness, preferably from the same specialty, has a very important commitment to recognise the problems and may be able to convey that to his or her colleagues and, when necessary, to the legal profession, in the interests of the patient and to avoid encouraging in any way further surgery.