Q: Dr. Eppley, Two years ago, I had a septoplasty procedure with turbinate reduction due to a diagnosis of moderate sleep apnea. It turns out my septum was severely deviated, essentially blocking air at the back of one nostril. Shortly after surgery, I could breathe and smell things much better. Soon thereafter, everything has returned to pre-operative functionality, if not even worse. The surgeon I went to is an ENT physician, and refused to do rhinoplasty. I was advised by physicians later that a rhinoplasty procedure likely would have improved my nasal function significantly, simply by lifting the tip slightly. Would I be a candidate? I am concerned, because others have told me it’s a jaw issue and I would need orthognathic surgery.
A: The rhinoplasty procedure that you refer is two-fold and relates to the only two external (outer) nasal procedures that are known to improve nasal airway flow, spreader grafts of the middle vault and tip rotation. While both may be able to improve nasal airflow I would have no confidence that they would substantially improve sleep apnea. The only facial procedure that can reliably improve sleep apnea are jaw procedures that pull the face forward, particularly the lower jaw with the attachment of the base of the tongue, to open the posterior airway. But given the magnitude of orthognathic surgery it is understandable why other effort (nasal surgery) may be on interest to explore first.
Dr. Barry Eppley
Q: Dr. Eppley, I am in need of a sliding genioplasty to treat sleep apnea. Can a sliding genioplasty be billed to insurance at all?
A: The question that you are asking is whether insurance will pay for your sliding genioplasty as a medical necessity for your sleep apnea. That is not an unreasonable question but one that can only be determined by the submission of a predetemination letter to your insurance carrier. To do this requires the following information to be submitted:
1) Pictures (which you have)
2) Sleep study results that show you have a high AHI
3) X-rays which show a short jaw.
Once I have this information then a pre letter can be submitted. Only the insurance company can make the decision for approval or denial for the sliding genioplasty but they must have all of the required information for you to have any shot at all of potential coverage.
As an aside, I am not aware that a sliding genioplasty is a primary procedure for improving sleep apnea. It may offer some mld improvement but major skeletal advancement through maxillomandibular osteotomies is usually what is required to make a major improvement in severe sleep apnea problems. A sliding genioplasty is an anterior pull procedure while maxillomandibular osteotomies are a push procedure which is more effective for opening the airway.
Dr. Barry Eppley
Q: Dr. Eppley, I am scheduled to have a sliding genioplasty next month and I just wanted to clarify some things. Is there some sort of guarantee I get that this procedure it would improve or completelyy resolve my sleep apnea? Otherwise I don’t see any other benefit other than the profile improvement which would not be worth the surgery risk.
A: The simple general answer to your question is no. There are no guarantees in plastic surgery of any specific outcome. Any surgery is an educated guess that doing a certain maneuver will cause a specific effect. In some surgeries, experience may show that a certain outcome is very likely if not highly predictable. In other types of plastic surgery, the outcomes are less predictable and may, in some cases, be more hopeful than completely predictable.
When it comes to a sliding genioplasty, both sides of these potential outcomes are seen. It is a predictable fact that moving the chin bone forward will change one’s profile and give a stronger chin appearance. Once can debate whether the chin changes net a patient’s expectation but there is no debating that the chin position will change. When performing a sliding genioplasty to help improve sleep apnea, the results are less assured. In theory, when moving the chin forward the tongue is likewise brought forward somewhat due to the attachment genioglossus muscle between the tongue and the back of the chin bone. This is actually the basis of the historic genioglossus advancement procedure done for sleep apnea when a sliding genioplasty is not being performed. To be successful for sleep apnea improvement, the sliding genioplasty movement must usually be significant (greater than 10mms) and one should have a very short or horizontally deficient chin. (indicating there may be posterior tongue prolapse) Often a lateral cephalometric x-rays will show the position of the base of the tongue to the posterior pharyngeal wall with a narrow airway space. But because the sliding genioplasty moves the front position of the tongue more forward than the back (closer to the point of pull), the amount of chin bone movement does not translate in a 1:1 ratio to what occurs further back at the base of the tongue and the posterior airway opening. This is the anatomic variable in whether a sliding genioplasty will help improve sleep apnea symptoms.
Dr. Barry Eppley