The Check's In Mail

...or so they told me many, many times. I haven't written about the insurance company experience until now. It was almost as painful as the surgery. Just in a different way.

It's taken seven months to resolve all the appeals with my insurance company. The net result is the insurance company did the right thing - they reimbursed the procedure based on the actual amount billed by the surgeon, as opposed to the “customary” amount typically set by medicare. The surgeon was not a preferred provider under my plan. In fact, there were NO preferred providers under my plan in my area who do MMA surgeries. When everything was finally settled, the insurance company agreed that they had no preferred providers in my area who do the procedure.

I had done as much as possible to work with the insurance company in advance of the surgery. The insurance company had approved the procedure as being medically necessary, but would not commit to the amount they would reimburse until the actual procedure was performed. They gave me the names of several surgeons in my area who they claimed performed the procedure– none of these physicians performed the MMA. Upon notifying the insurance company that they had no providers who perform the procedure, they said my only option was to have the procedure with a physician of my choice and take my chances on an appeal.

I went into the surgery expecting to get very little reimbursement from my insurance company. So it was no surprise when they sent me the first reimbursement and it was less than 10% of the surgery bill. My surgeon gave me some great advice - he said be very persistent and don't give up. He was right.

I wrote multiple appeal letters. The basis for the appeal was there were no preferred providers in my area that perform the procedure. Based on the insurance company's responses, it was clear that they did not read any of the letters I sent. Each response said I should have used a network provider and told me my only recourse was to appeal to my state’s insurance board. After receiving each denial, I wrote another appeal letter. The final denial included a list of preferred physicians they claimed preformed the MMA. I called each physician – each one referred me to the surgeon who actually performed the procedure. My final letter simply stated that their preferred providers referred me to the physician who performed the procedure. They agreed.

I woke up this morning and felt OK - coincidence? Perhaps.

Old Friend Returns

In 1998, I gave up caffeine - what was I thinking???

Over the past few month's I've introduced caffeine into my diet. My delivery vehicle of choice - diet Pepsi/Coke. There's nothing quite like that early morning burn on the back of the throat to get the day going. It seems to help, particularly with the post lunch yawnies.

No real changes in my sleeping patterns. I'm still getting the usual 5-6 hours a night and that seems to be good enough. Now that it's winter time (if you can call it winter here in N. California), it's harder to get out of bed because of the cold than it is due to being too tired.

As far as the physical recovery goes, there has been some minor progress over the past month:

1. The spongy teeth feeling when I bite down is starting to diminish
2. Upper teeth and gums starting to feel less wooden
3. Upper gums and roof of mouth still numb, but some feeling starting to return
4. While I can chew most things, softer foods are easier to eat and still preferred
5. Weight returned to pre-surgery numbers (major bummer)
6. Lower lip and chin still numb.
7. Consistent "pussy" drainage in right sinus (this has been ongoing since the surgery) and does not go away with antibiotics

November Already?

Six months have passed since the surgery and what a journey!!!

The most significant question still remains to be resolved - did the surgery work? At this point, I don't know. Perhaps I'm in denial, or perhaps I need more time. While I still wake up tired, sleeping 5-6 hours a night, I do feel that I have more energy and can make it through most days without too much trouble. Yet, I still feel there is tremendous room for improvement.

During the past month, I've reintroduced both Bi-PAP and the "Silencer" oral appliance. While I could not tolerate the PAP treatment due to aerophagia, I was able to tolerate the oral appliance with minimum advancement . I worked closely with my surgeon to monitor progress. Perhaps there was some benefit, but the surgeon and I agreed that the improvement, (based solely on how I feel, not measured in the lab) was not enough to continue using either one. My surgeon has suggested focusing the next few months on the psychological recovery (relaxation, stress relief, etc.). He does not plan to do a repeat sleep study at this point since I'm not yet sleeping well enough where we will get significant data from the study. He expects a sleep study would tell us that I'm not sleeping better than before the MMA and therefore is not justified at this point in time.

I'm going to make a final attempt (at least for now) to improve my sleep by trying a device called the Aveo TSD. You can do a Google search to learn more about the product. It's basically a device used to prevent the tongue from collapsing on the airway. It looks like a big binky. We'll see how it goes...

As far as the physical recovery, here's the "latest"

1. Eating most foods, with the exception of very hard foods or foods that require significant chewing or grinding to eat
2. Upper gums still numb and limited sensation in upper teeth, but slowly improving
3. Lower lip and chin still numb. Hard to say if this has improved in the past month
4. Lower teeth and gums feel "normal"

Prior to the surgery, I had set a goal to complete a hundred mile bike ride in November. I felt having a training objective would force me to focus on the positive aspects of physical fitness and health. Along with my brothers and friend, we easily completed a 106 mile bike ride in October at 5 months post MMA.

In the above picture, we are riding in a paceline on the 106 mile ride. I'm wearing the red vest. We rode the first 23 miles in just over an hour at a pace of 19.7 m.p.h. Drafting on a bike can be quite a thrill. (Riding on a flat road helped keep the average speed high as well.) It turns out that the October century was my second 100 mile ride since the surgery. As I've posted earlier, I rode my first century 8 weeks post-MMA. Cycling is truly a great way to recover.

Could It Be?

In addition to the actual "sleep," I'm working on changing my expectations from sleep - silly things like is it reasonable to wake with the refreshed and wanting conquer the world feeling? While it would be nice to feel that way, perhaps it's just not realistic. If I ultimately get there, great, if not, it's OK too.

Last Friday, I returned to see the surgeon. He always has two questions: 1) how am I sleeping and 2) am I in pain. I reported my sleep had not improved and I was not in pain. While we knew my surgery was not a guaranteed success, we had hoped there would be some improvement. Most people at 5 months have realized some benefit. He suggested that I give CPAP a month trial, and if I wanted, I could also give the oral appliance another try. I left his office quite discouraged, knowing that both the CPAP and appliance failed pre-MMA.

That night, I dusted off the Silencer appliance, cleaned out its cob-webs and went to sleep. Over the past 5 nights, sleep seems better. I'm sleeping at least 7-7.5 hours and feel like I'm in a deeper sleep, not waking up at all. Not only have the nights been better but the days seem to be improving too! The post lunch circadian dip is lessening as well. While it's too soon to claim victory, I'm very encouraged! I'm going to continue with the appliance for a couple of days, and then give CPAP a try.

Not All the Same

Since I've had the MMA, I have become very aware of other people's facial structures, particularly the jaw & chin. I look to see if they have a very strong jaw line or a weak jaw and chin. I also look to see if their upper jaw is setback like mine had been, or more dominant like others. I then wonder, based on my non-existent medical training, if these people have had an MMA or OSA. After careful observation of the jaw, I move on to check out their noses. Are their noses flat, proportioned to their face, too big, too small, etc. If their noses are flat, I then apply my lack of medical training to assess whether or not they have had an MMA.


Yesterday I met with twenty+ people who had the MMA. While I thought that we would all have strong jaws that would appear unique, I fully expected everyone would have the MMA nose - slightly flattened at the base and wide. Much to my surprise, I couldn't tell a thing about all these people based on their appearance other than they seemed very nice. We spent an afternoon together, relating to one an other's experiences, sharing our own stories, and providing support to those who joined the gathering in advance of their own MMA.



My major takeaways from the gathering were:

1. Be patient, healing takes lots of time
2. Don't overlook the psychological healing that goes with the physical healing
3. Everyone was in agreement that they would do the MMA again. Almost everyone felt they had improved, a few of us felt they still had room for improvement (including me)
4. Many of us have had at least one other medical procedure/surgery in addition to the MMA

As far as my own recovery goes, I've been focused on the behavioral aspects of sleep. Over the years of "bad" sleep, I've developed a number of behaviors that need to be relearned. The most significant behavior I need to learn is it will be OK for my day to start after getting a few more hours of sleep. I can't be in such a rush to get things going. In fact, I'm more likely to have a great day if I allow myself to get sufficient rest.

Probably Shouldn't Write This

I'm sure by posting this update, I'm going to curse any progress I've made. While I can't offer that "Great, and I feel rested" post, I can say that the past few nights have been "better." Although I'm only sleeping 5-6 hours a night, I have felt better during the day. The headache's gone, I'm not as tired, and I'm gaining some weight :-(

As for the rest of the healing process, here's where things stand today:

1. Chin, lower lip, upper gums, and palette still numb, and improving
2. Occasional jaw popping when yawning
3. Eating many more foods, but nothing that requires serious chewing. Bread crusts still require a fair amount of effort, and usually are too hard form me.
4. Sensation returning to the teeth, but they still have that wooden feeling
5. Speech has pretty much returned to normal.
6. Jaw mobility pretty good laterally and about 30 mm vertically (I didn't measure what it was pre-MMA)
7. Strength - Slowly returning. I'm riding 2-4 times a week, and it's getting a bit easier. Prior to the surgery, I could do 7 pull-ups. Now, I'm down to 3. I'll need to start weight training.

Double Sleep

This experience was just too bizarre...

In a dream last night, I took a nap. I dreamt that I was traveling, and while on the bus I fell asleep. Not only did I fall asleep, but I overslept by two hours and missed my stop. It's enough of a challenge being tired when awake, but being tired while already sleeping is even worse!

So here I am sleeping, and in my sleep, I go to sleep. And, I got to wake up twice in the same sleep stage. First, I woke up from the nap in the dream, then, I woke up from the dream itself.

Could this double sleep be a way to to cut my sleep hours in half? Or, could it be a way to sleep the same amount and feel like I slept twice as much? Or like most dreams, mean nothing at all.

"The Usual"

I'm back to my regular lunch at the office deli - I named it "The Usual" - roasted turkey with avocado & pepperoncinis. The only unusual part about "the usual" is the bread. Wheat bread is much softer than the preferred ciabatta a roll. Some say the whole wheat bread may even be healthier.

In the past week, my diet has expanded quite a bit. I can eat most foods that don't require extensive chomping and chewing. The teeth feel stronger, and as sensation returns, I'm more comfortable trying new foods.

Last week, I checked in with the doctor as well. The good news is that he expects the surgery recovery to be 100% (pain free, numbness will go away, jaw mobility will return, etc.) The unknown remains the quality of my sleep.

Over the past week, I've read up on sleep hygiene. The basics are pretty simple:

1. Regular bedtime and wake-up time
2. Don't nap
3. Avoid alcohol
4. Avoid caffeine 4-6 hours before bed
5. Limit activities in bed to avoid reading and watching TV
6. Exercise at least 4-6 hours before bed
7. Don't worry, be happy

Most of the things on the list are pretty easy. However, the last one can be a bit tricky.

Last night, I slept for almost 7.5 hours. While I didn't feel "rested", I felt good enough to work out. I rode my bike about 45 miles at a moderate pace with some good hill intervals. When I returned from my morning workout, I felt fine. As the afternoon wore on, I became exhausted, and fell asleep for a few minutes while watching TV. The question I can't answer is was I exhausted from the workout, or from not sleep enough.

Hosehead, For a Night

Since I haven't been sleeping so well, I tried my BiPAP last night - just for fun. The results were not much different than before the MMA:

• 6 hours sleep with the help of little round blue friend
• Did not feel more (or less rested) than without the machine
• AHI of 2.5
• Major discomfort due to swallowing air, even on Auto mode with the pressure starting at 7/5
• 90% pressure was 10.5/7.5 (lower than in the past - a sign of a bigger airway)

Last week, NPR ran a segment on napping. They featured http://www.saramednick.com/ who advocates daily short naps. These short naps seem to go against what I thought were the best practices for good sleep hygiene. However, when I do take a short nap (usually 5-10 minutes - and almost never), they definitely help.

Not Getting Enough...

...sleep.

Each sleep attempt is a new adventure. While I have yet to post the "Rested" experience, I can post "Worse" and "Same." It seems like the biggest challenge is simply staying asleep long enough. When my head hits the pillow, I'm out for four to five hours, waking between 3:30 and 4:00 a.m. Rarely, I'm able to fall back asleep. When I do fall back asleep, it's very fragmented, with many awakenings. Prior to the MMA, I had the same sleep patterns. The problem still seems to be in my head. I've spent the past few weeks trying to go to bed relaxed, leaving my daily stress away from the bedroom.


Here's the latest recovery update:

1) Chin - significant numbness reduction. Lots of electrical sensations when touched
2) Teeth - more sensation on bottoms, but many teeth still lack any sensation other than pressure
3) Jaw popping - not as much. I've suspended the stretching exercises, and am trying to chew evenly on both sides
4) Gums - still pretty numb
5) Wake up with a "clenched" jaw - this one is quite strange

Eating & Popping

As my jaw recovers, I've shifted to a soft food diet. At first things seemed to be going pretty well. Now, however, I've developed a "popping" discomfort where my upper and lower jaws meet.

At this point, I've stopped taking all sleep and surgery related medications. As my body adjusts and tries to establish its natural sleep patterns, my sleep has been fragmented and interrupted. Within the next couple of weeks, I expect a normal sleep pattern to emerge and experience the benefits of a good night of sleep.

As far as the surgery healing goes, things continue to improve. My chin is still quite numb with the expected "tingles" indicating the nerves are regenerating. The chin pain is gone, but when I eat or drink anything that's not ambient temperature, my chin feels like there's some food or liquid dribbling (which turns out not to be the case). My teeth are a little sore and I have an unusual sensation where the upper brackets remain. My upper front teeth and the forward part of the roof of my mouth are still completely numb.

My speech has improved dramatically, but by the end of the day, it's quite hard to enunciate words properly. Perhaps the jaw mobility exercises will help.

More Exercise

I saw my doctor today for a quick check-in/up. He's said that it's time to start exercising my jaw muscles to improve jaw mobility. In no time at all, I should regain complete vertical range of motion. We did not discuss exercises to improve lateral movement. In addition, he said I can advance from mush/mashed foods to soft foods. While I'm not ready to give up the comfort of the Magic Bullet, its days are numbered.

PB&J

Sunday, I got a bit more adventurous with my eating. I had my first PB&J sandwich . It was so good, that I had 3 PB&J sandwiches - each one carefully cut in quarters. The crusts were more than I could handle. PB&J was one of the food highlights at the rest stops for the bike ride. The other good options were energy gels and Gatorade.

It was amazing to see all the people who battled and are battling cancer as well as those honoring and remembering those afflicted. It was beyond words as we all clawed our way up the nasty climb 70 miles into the ride.


Here's a picture of me with my new toothy grin. I'm smiling because there were many kind people on the course motivating all of the riders as well as many riders who created a nice draft to fight the head winds.







Also, thanks for all the very positive comments and support on the blog- it's very much appreciated.

Insane!!!

For all the folks following the Tour de France, what was Contador thinking on the final climb of Friday's stage??? Sure, he wants to win the race, but he can't do it without his team. Madness...

I woke up this morning with noticeably less chin numbness and pretty much pain free. It seems that the saying "three steps forward, and two steps back" really applies to MMA recovery. While the surgery healing seems to be on track, the sleep recovery has been at a standstill, and perhaps somewhat of a regression in the past few days. My sleep debt must be much bigger than originally anticipated. Using the mortgage analogy, I'm so early in the amortization schedule, that I have yet to pay down any principal and benefit from owning more sleep equity. Perhaps the recession has a bigger impact than originally anticipated, and my sleep debt is underwater, only to face foreclosure and sale to the lowest bidder.

Scrambled Eggs and Soft Ice Cream

Given all the yummy choices of airport food, the soft ice cream and scrambled eggs called to me - just not at the same airport or meal. I'm back on the road this week, and arrived at the airport really hungry. Knowing that I wouldn't be eating the peanuts on the flight, eggs seemed like the next best choice (it was mid afternoon). Upon arriving in Las Vegas to make my connection I was still hungry and knew I could manage the soft ice cream - chocolate.

A good nights sleep still eludes me - yet I'm hopeful. Similar to last week, the most significant energy changes have been related to exercise. I have more endurance, strength and quicker recovery than before the surgery. In trying to get ready for the LiveStrong ride this weekend, I've been riding about 100 miles a week for the past couple of weeks and so far so good.

Last night/this morning I woke at 4:30 a.m. and that was it for the night. There will be some good nights, and some nights that could be better. I just won't be able to predict them in advance. In general, I'm still sleeping about 7.5 hours a night.

My teeth seem to be the most noticeable in the recovery this week. I can feel both the upper and lower back teeth come together when I bite down. Sometimes the bite feels lopsided - like the right side meets before the left side. Other times, everything is normal. The less I think about what's going on, the more "normal" it feels. The front teeth are numb, and the gums are pretty sore. The good news is that the gums are regaining their sensation on both top and bottom.

The chin pain seems to be stronger at the end of the day. I thought that it was pretty much gone, but over the weekend, it increased. I'd like to believe that it's just the nerves waking up.

My speech still hasn't fully recovered. There are a few tricky sounds (mainly the "s"). By the end of the day, it's really hard to speak. I have not had too much jaw pain, just a challenge in speaking clearly. Given that the lower lip is still numb, I don't think that I have full muscle control to form all the words properly. I return to the doctor on Monday, and perhaps I'll start to do exercises that redevelop the facial muscles that atrophied.

8 Week Photos

It's hard to believe the surgery was 8 weeks ago. Notice I'm smiling. It's because those nasty arch bars are a distant memory.

Progress Comes in Unexpected Ways

Today showed signs of recovery and improvement. But not in the way I expected.

I woke up after about 7.5 hours of opiate free sleep, feeling pretty much like every other day - tired. Since I signed up to do a 100 mile Livestrong bike ride in two weeks, and my longest ride since having the MMA is 30 miles, I planned a 60 mile bike ride today. Not knowing what to expect or how far I would be able to ride without "bonking," I met one of my riding buddies and we set out on our adventure. I rode 62.5 miles and climbed about 3700 feet of elevation.

While the ride wasn't easy, it wasn't as tough as I expected. The three reasons I came up with to explain today's positive experience were:

1. Sleep is better than I realize - perhaps a sign that the MMA worked
2. My weight dropped almost 10%, significantly improving my ability to ride at the same level as before, but not requiring as much power output
3. I spent most of the ride drafting behind my friend so he worked harder than me

As far as the update on the MMA recovery, there have been several positive improvements. The chin pain is not gone, but no longer as strong. My chin "tingles" most of the time, so the nerves should be firing. However, one of my molars has become very sensitive when I bite. The surgeon says give it a few weeks for my bite to adjust. Worst case, my dentist will need to grind down the surface of tooth. (It's a crown). The gums are getting more feeling, but the teeth still have no sensation other than pressure.

On The Road

I've been on the road for work this week. Prior to leaving, I expected eating to be quite a challenge since I would be away from the Magic Bullet for the first time, and I would be eating with my colleagues from work. Both finding food to eat and eating with others turned out just fine. I've managed to find oatmeal, fish, and mashed potatoes and won't come home malnourished. In fact, I've even had ice cream with several meals to provide that extra comfort.

Eating continues to exhaust me. Taking small "bites" seems to take forever...

The recovery continues to progress. After seeing the surgeon this week, I won't need to return for another 3 weeks since the chin pain seems more manageable. The chin pain is not gone, but I'm much more comfortable. Jaw mobility is also improving as well. I can open my mouth much more than before. The numbness improvement is harder to measure. It feels like the roof of my mouth is improving, but there has been no change in the numbness on the gums or chin.


I took this picture at the airport. It's food I won't be eating for a long, long time...

(Since I didn't eat nuts before the MMA, I'm in no rush to start now)

Peanuts & Cracker Jacks - NOT

At the ball park, there's an overly abundant supply of peanuts, Cracker Jacks, hot dogs, and just about every other unfriendly food for us mush/mash diet folks. Fortunately, they had chili too.

The home team won in eleven innings with an unusual finish when the catcher let a wild pitch pass on the third strike and the third base runner scored.

The recovery improves, in particular the chin. The pain is now shifting to a very strong tingle pain. In addition my gum sensitivity improves as well.

I tried to use a "flosser" to floss, but the teeth felt too tight, and I didn't want to floss aggressively -it 's back to the water pick.

6 Weeks

It's been six weeks and a day since the surgery. Being back to work full time and speaking for a good part of the day exhausts me by the time I get home. Not a surprise. The doctor said that many of his patients find the same thing.

The chin pain has improved again. It's not bad in the morning and sometimes goes away. By the end of the day, it's worked its way up to being quite uncomfortable.

Other recovery stuff of note:

1. More feeling in a few back teeth
2. More feeling on the upper inside gums. The outer gums are still numb on the top
3. More feeling on the outer lower gums
4. Speaking is still a challenge. It's hard to enunciate words, and it sounds to me like I slur most of my speech. In addition, like many others, I've developed a slight drooling problem when speaking. As my jaw mobility improves, all these should clear up

Sleep:

I'm getting about 8.5 hours a night. Although I still wake up tired and usually without a headache, I think that I'm better off than before the surgery. Until the pain is gone and my sleep patterns are reestablished, I'm making no judgements on whether or not the surgery "worked." The way I look at it, it's worked either way.

Powerless

Or less power?

Sunday was a good day. I made it back on the bike - twice. The first ride was a regular route with a long sustained climb of 3.3 miles and 1300 feet of elevation gain. Riding about as hard as I could, I was about 10% slower than riding at a comfortable pace prior to the MMA. It's amazing how quickly my power and aerobic capacity dropped in only 6 weeks. My heart averaged 171 beats per minute for 33 minutes. At the top of the hill, with about a five minute rest, I felt like I recovered quickly, and was able to ride home at a good clip.

Later in the day, my wife and I enjoyed a date ride. The company was much better for the second ride!!!

I returned to the surgeon this morning - he's closely monitoring my chin pain and has me returning for weekly follow-up. We've increased the Neurontin dosage, and either time or the medication has improved the pain. It's still strong, but seems to "go away" more often during the day.

Better Than Yesterday

Today I feel better than yesterday. Perhaps it's syrup an chocolate chips in my pancakes spiking my blood sugar, but perhaps I'm sleeping a bit longer and starting to pay-off the sleep debt.

The chin pain continues to be strong, but slightly improved from yesterday as well.

We had a very busy day yesterday, and doing normal things and being so busy felt good. We attended a Bat Mitzvah (she was GREAT!), luncheon, and dinner party. Even with a nap between the luncheon and dinner, I was completely worn out by the end of the evening.

With a so much of the activity centered around food, I found that eating was actually harder than talking. Although I had very soft food (mashed potatoes, egg salad, tuna salad, babbaganoush , and humus), after about 10 minutes of eating, my jaw was exhausted and it was very hard to open it enough to eat. As time goes on, the jaw will get stronger and eating will get better.

Slow Changes

One of the challenges when recovering from a major procedure is that you tend not to notice the day to day improvement. Looking at things week to week or month to month, the changes are more dramatic. So when I try to evaluate how I felt today over yesterday, there's not much difference. In reading this blog, however, it appears that I've come a long way.

By the end of the work day, I'm pretty cooked and the chin pain is worse. Contrast that to the mornings, I'm not as tired and the chin tends not to bother me as much.

The biggest improvement I've noticed over the past few days is that my upper teeth don't have the "braces tightened" feeling. Occasionally, a few of the teeth feel like they are being squeezed.

On to the important update - the bike. I was able to sneak in one quick ride this week. If all goes well, I'll get back on the bike both Saturday and Sunday. I'm convinced that cycling will speed the recovery.

Almost 5 Weeks

Hard to believe that at this time five weeks ago, I was gnawing on a turkey leg and munching on peanut M&Ms. But that was the old me. Now it's strictly mush & mash.

Just a quick update on the recovery:

1. Numbness receding on the roof of my mouth
2. Sensation returning to a few of the lower back teeth
3. Chin pain about the same
4. Major tingles on lower lip and chin - a sign of nerve regeneration
5. Sleep (the magic question): no major changes although I woke up today without a headache for the first time since the surgery
6. Speech feels impaired as jaw mobility is limited
7. Mush diet easiest to manage
8. Back to work full time

Medium Soup

I'm back at work full-time. For lunch I ordered the medium soup and a tuna salad sandwich. When I picked up the meal, (I pre-order on the web and pick up my brown bag to eat at my desk), I noticed they gave me a small soup. Life's like that.

Saw the surgeon today as well. He said that the jaw alignment is exactly what it should be and all other signs of recovery are progressing as expected. We're going to increase the Neurontin dose to help with the chin pain. From last week to this week, the chin pain has improved, but it's still there.

"Don't You Have A Better 'Before' Picture?"

That was one of the questions asked by certain family members when I showed them the side by side comparisons. What could that mean????

Ultimately, the family generally agreed that after is better. It's not like the MMA can be undone...

Me - as I am now four and a half weeks post MMA. Still have swelling on left side.

Before - After

Before - After

The chin pain is about the same as yesterday, and I'm optimistic it will continue to improve.

Perhaps not medically proven, I'm convinced that my metabolism has dropped from being so idle for the past month. To pick up my metabolism, I'm trying to eat more and exercise.

I went for my second bike ride today and it felt good. My aerobic fitness has dropped significantly (my heart rate hit 178 on the hardest part of the ride) and my power seems reduced. The best way to increase metabolism, recover aerobic condition and increase power is to spend more time on the bike. I used to ride at 5:15 a.m. because I was awake. I plan to hold off on the morning rides until my sleeping patterns get established.

Back In The Saddle

...with my trusty steed.

Went for my first bike ride today. We rode 14.5 miles at a very comfortable pace. It was GREAT to get back on the bike.

The chin pain is a bit better today. In the morning it was quite mild, as the afternoon goes on, it's increasing a bit, but still better than yesterday.

Beaver Cleaver

Many years ago, we named our best chopper Beaver Cleaver. A funny story about the Beaver - the Beaver used to live in the bottom drawer of the kitchen cabinets. Shortly after our son was born, we had a party. One our our friends suggested we consider baby proofing our kitchen when his two year old pulled the knife out of the bottom drawer.

A good knife makes the post arch bar diet possible. I'm cleared to eat only soft foods. With a good knife, you can make mush out of just about anything.

Today I ate in a restaurant for the first time. There were ten of us celebrating my niece's high school graduation. I ordered salmon, potatoes (self mashed), and mushroom risotto. When the meal was served, I mashed, chopped, and mushed the food all together to make it nice and soft. It took tremendous concentration. When I finally looked up, I realized that everyone else had finished their meal, and while I had thought that I did a pretty good job finishing my portion, my son pointed out that at most, I consumed just a little bit of the meal and seemed to spend most of the time "playing and mashing" my food together. Based on the amount of food I brought home in the doggie bag, the boy was right.

As far as the recovery goes, the chin pain continues, and has improved slightly . The surgeon called me to check on the chin and said any improvement, even if only slightly is a positive step. I return to see the surgeon on Monday.

Without The Hardware

Liquid diets are easy eating - effortless. You just drink up. Now that the arch bars have been removed, eating is really quite a challenge. I've had two meals since the arch bars came off: lentil soup (not pureed) and slow cooked tri-tip with sweet potatoes and carrots mashed together. There are two major challenges with eating: the jaw muscles haven't been exercised and my mouth opens only 17 millimeters. Put those two together and eating seems like a major workout.

Here's what its' like being arch bar free for 10 hours:

1. Green light to get back on the bike. OLH Sunday morning (who's in?)
2. Lips rest comfortably against my gums
3. Lips don't feel like they are sticking out
4. Teeth more comfortable without wire anchors holding the arch bars
5. Teeth still have no sensation (like wooden teeth)
6. Gums still numb
7. Lower lip and chin still numb
8. Hard to speak due to jaw's limited range of motion
9. Upper teeth and gums feel like they are in a different spot - which they are
10. Still have chin pain in same isolated spot. We're hoping it goes away without the arch bars

The big question is has my sleep improved. It's returned to where it was pre-MMA. I'm no more tired or rested than before. I'm being cautious not to make any judgements based on a single day, but rather wait several months and see how I feel. Without the arch bars and their definite discomfort only good things will continue.

Need I Say More?

Actually, I can't say much at all since my lips and cheeks are numb from the Novocaine used to remove the arch bars. It was a 5 minute office procedure. No big deal. The surgeon cut the wire around the tooth and then removed the wire. I'm told that other surgeons perform the procedure under general anesthesia - seems a bit excessive, in my humble opinion.

And dinner from the slow cooker is looking good!!! It's got just 8 hours left to slow cook.

Yummy

My boy was at it again - this time he made chocolate chip cookies.

For some of us - me included, chocolate chip cookies taste better raw. There was absolutely no way I would even attempt to eat chocolate chip cookie dough. But, the nice thing about baking is that it's a step by step process, and the chocolate chips are the last ingredient to add. Let's just say that I found a new way to meet my daily calorie intake that's more tasty than just about anything I've had in the past 28 days. And, I didn't need to put it in the Magic Bullet with chicken broth.

Tomorrow is a big day - the arch bars come off. I expect only good things to continue from now on.

Nasty Box

Spontaneously, at 6:40 this morning, music just started coming from this strange box next to my bed. What is that box and who put it there? The worst part is the nasty box woke me up!!! What's up with that?

This is the first time in longer than I can remember where the alarm clock has actually woken me up. My previous pattern was I would set the alarm clock, and wake-up 1-2 minutes before it actually turned itself on. My internal body clock had always known what time it was, regardless of time zone and the alarm was just a back-up.

I managed about 9 hours of sleep last night (5 straight, then woke up a few more random times, taking Ibuprofen and Tylenol at 4:00 a.m.) and (complaint warning:) woke exhausted with a headache . Only sleeping 4 hours the previous night as well as the chin pain may have contributed to not feeling rested today. However, the chin pain seems continues to improve, even if just a little.

First Day Back

As I've blogged earlier, I absolutely love my job. In fact, I was so excited about my first day back at work, I woke up at 2:30 a.m. By 5:00 a.m., more sleep wasn't in the cards, so it was back to the grind. My plan is to work about half-time this week. For those of you that haven't experienced a Silicon Valley start up, half-time is about 8 hours a day...

I also had a scheduled visit to the surgeon today. Here's the medical update:

1. Arch bars come out Thursday (66 hours to go) - need I say more
2. The Neurontin seems to reduce the sharpness of the chin pain
3. All the stitches in my mouth are GONE. Since I never saw them, you have to wonder where they all went

Success - No Nap

Made it through the concert without a nap.

In fact, after the concert, Deb even pointed out that this is the first concert I've attended without a nap. In fact, I've been known to be snoozing before the first measure of the first piece.

Let's hope work goes well tomorrow... I'm going to put in half days for the coming week.

What's Left?

My son's orchestra performs this afternoon. The concert will be an unofficial test to evaluate the surgical success. I have yet to attend one of his afternoon concerts - 3 a year for the past 4 years - without falling asleep. In all fairness, I still take afternoon naps, and the concert takes place shortly after nap time. Yesterday's nap - only 20 minutes - spontaneously occurred watching the movie Doubt. Deb says that the part I missed was a bit slow.

As the recovery progresses, there are a few remaining effects of the surgery that need to resolve:

1. Chin pain - 6 on a scale of 10. Definitely improving.
2. Tight feeling on teeth at the gum line - feels like childhood braces were tightened. Likely due to arch bars
3. Grumpy, cranky, short tempered, impatient - personality flaws that existed prior to surgery - the surgeon would not agree to address these items
4. Numb lower lip and chin - common effect of surgery as are the remaining items on this list
5. Numb roof of mouth
6. No sensation in teeth - others have described this a wooden tooth feeling

If all goes well, the arch bars come off this week. My hope is that the arch bars are the root cause of the chin pain and the tight feeling at the gum line. Once these two sensations go away, I expect to be completely pain free and life will be good. Maybe #3 will change too. Soon I'll be saying "GREAT and I feel rested!"

If there would be an item 7 on the list above, it's shaving. Using a razor blade to scrape a chin with no sensation really scares me. So far, I've been lucky and it's worked out OK. So why not use an electric razor? Good question. I've actually tried one, and the added pressure from using the electric razor was uncomfortable on both my chin and near the mandible sites that were extended.

How Did You Sleep?

That seems to be the most common question I'm asked. In fact, the surgeon asks the question regularly as well.

One of these days, the answer is going to be "GREAT and I feel rested." We're not quite to that point yet. The biggest change is I'm now sleeping about 8.5 hours a night which is a HUGE increase from the 4-6 hours pre-surgery. Last night I had an uninterrupted 6.5 hour sleep run but woke up with the chin as active as ever. I took Tylenol and ibuprofen and slept on and off for another 2 hours. (3.5 hours of clock time elapsed - it took me about an hour and a half to fall back to sleep.)

I have a couple of ideas on what's preventing my getting restful sleep:

1. The strong and sharp chin pain disturbs my sleep
2. My sleep debt is so significant, it will take longer to payoff than my mortgage

Given that I have a lower AHI number than many patients who typically have this surgery, the best indicator of success will be my sleep quality and how I feel the next day. For people with severe sleep apnea and a high AHI number, success is typically measured by reducing the AHI number 50%. For someone with an AHI of 80 to go to 40, would be considered a success. From what I have read, many of the people with the 80 AHI actually end up w/AHIs of 10 or less, so they notice significant changes.

I've always been a very light sleeper. One theory, not proven medically, is that my central nervous system is very sensitive to external stimulus when sleeping, whether that stimulus is chin pain, appnea, hypopnea, or as seen in my many sleep studies, an "unexplained arrousal (sleep studies have measured 15-30 per hour in addition to appnea or hypopnea events). I believe that these unexplained arrousals are really appneas or hypopneas that aren't long enough to "officially" count as a respiratory sleep event.

So now that we've likely eliminated all the apneas, hypopneas, and unexplained arrousals, the only thing left of the list is the chin pain. Hopefully that will be gone in a few days, and I'll wake up like everyone else - well rested.

Questions Tell All

Earlier today, Deb asked if my weight had stabilized. Since I regularly update this blog with comments on my weight, it's quite apparent who reads the blog regularly. Not being able to answer her question with a simple answer as I had been doing immediately post-MMA, I reverted back to my old ways and I responded to her question with a question of my own. Perhaps the surgery has altered my appearance, but it still has not removed the character flaws from before.

Note to Deb (when/if you eventually read this): You are the most wonderful and amazing spouse. I am very luck to have married such and wonderful wife.

Nice People

I returned to the surgeon's office this morning for my scheduled visit. He readjusted some of the rubber bands and checked on the progress with the chin pain. While it's too soon for the Neurontin to kick-in, he's wants to ensure that the pain does not increase - which it hasn't. As the chin pain goes away, I will transition from the opiates -Percocet, Vicodin, and Tylenol w/codeine - to Neurontin over the next few days.

While waiting for my appointment, I met some very nice people. First, there was an infamous MMA blogger (recognizable from his pictures), just sitting in his chair waiting for his appointment as if he were a mere mortal. We had the opportunity to chat and share stories about our experiences. In many ways, we followed the same path - consultations with the amazing Stanford sleep doc, xPAP, tonsillectomy, oral appliance (same orthodontist), xPAP & oral appliance, then MMA. He mentioned that he will be looking into relaxation techniques and meditation. It might be worth a shot to check into that as well, as I've been known to be quite a "high strung" person. (In another Blog, I'll comment on my Transcendental Meditation exploration from about ten years ago),

Also waiting was a family with a teenage son who were considering jaw surgery. Hopefully they found resources like sleepnet.com and other blogs to provide them with more information from both the medical and patient point of view.

Finally, there was a patient who came in on her way home from the hospital. We did not strike up a conversation as she only stayed in the waiting room for a few minutes, and as I vividly remember, from my visit on the way home 20 days ago, all I wanted was to get home. Meeting other nice people in waiting rooms was not a priority 2 days post op. I wish her a speedy recovery.

Another Approach

The pain in my chin continues. The surgeon saw me for an unplanned visit this afternoon, took an Xray, and completed a thorough exam. Everything looked normal - which is very good; it's also a bit disappointing (in a very strange way) because there was nothing that could easily be fixed. He changed the rubber bands and evaluated my bite which "was as good as it was before the procedure." There are no plans to make make the bite better...

As a next step, the doc has prescribed Neurontin - a medication to control nerve pain. When the jaw gets moved, many of the nerves in the face get disturbed and these nerves need to reconnect as part of the recovery. For some people this can be a very painful experience - I may be one of those people.

My weight remains stable and my diet consistent. I'm still enjoying the daily walks. At this point, the walk is about 60-90 minutes through the hills of my neighborhood. It's not quite the same as climbing on a bike, but I'm glad be able to exercise.

First Book

I just finished John Grisham's The Associate. While I'm not going to offer a review, I will say that finding a book where I could pretty much turn the pages was relaxing and provided a great distraction from the discomfort.

Today is a definite improvement in comfort over yesterday. While there is still a long way to go, I'm getting more optimistic about this whole adventure shifting from the present to the past.

No major changes in diet other than I had scrambled eggs with cheese for breakfast. Eggs fit into that category of not requiring any chewing, yet flavorful with the added cheese.

Burrito vs. MMA Patient-Round 2

MMA Patient WON!!!

Eating the low carb way without the tortilla helped.

______________

Not Even Tempted

My son has become quite a good chef - he's 15. When he expresses interest in cooking and baking, we always encourage him. Last night, he decided to make cinnamon rolls for breakfast.

The rolls just came out of the oven, and the smell is overpowering. Remember the last time you walked past the Cinnabon store and just had to have one? Our kitchen smells GREAT!

Oddly enough, those yummy sweet rolls don't appeal to me. One of the strange things is that I have not had an appetite or interest in most foods. While I'm eating quite a bit, my weight continues to drop. I'm down to 158 pounds (total lost: 14).

Here's a typical day in my food intake:

• Breakfast: 1 or 2 Carnation instant breakfasts with whole milk or glass of soy milk with protein powder


• Morning Snack: 8 Oz yogurt mixed with berries and fruit juice (sometimes with protein powder added)


• Lunch: Meat based soup, thinned with broth (about 20 Ounces)


• Afternoon Snack: Yogurt Smoothie, same as morning


• Dinner: Vegetable soup AND meat based soup (24-30 ounces total)


• Plenty of water and other fluids during the day

The pain in my chin has improved only slightly. I'm continuing with the pain meds, but I can't say that I'm thrilled about staying on them. The challenge is that I'm more motivated without the pain meds, but more comfortable with them.

Walk, Hike or Both

In order to increase my energy level, I've felt like I've needed to increase my activity level. For the past couple of days, I've taken a walk that's about 1.2 miles around the neighborhood. Yesterday was no exception. I woke up and went for a walk.

A few hours later, my friend called and asked if I was up for a walk. We took a 90 minute hike on the trails near my home. It was GREAT to be outdoors. After the walk, I felt fine, and was not too exhausted. It' still a real challenge in that I would like to be engaged in conversation, but since speaking causes more pain, I've been in listening mode.

Like many others at this point in the recovery, I'm still very uncomfortable, but feel like I need to be doing something. Something needs to be a mindless activity since concentrating for long periods of time is still a challenge (movies still require too long a period of concentration). Today's mindless activity was a trip Costco. We had to have a tire fixed and my son joined me for the adventure. Since I drove, I did not take the pain killers before leaving. Fortunately, the gods of the tire center were able to complete their work quicker than planned, and we returned home safely after three hours. Immediately on our return, I took the pain meds.

More on Pain Meds

I'm told, by reliable sources, that Percocet has nasty behavior altering characteristics. While it does help the pain, it doesn't necessarily make me a nice person to be around.

During dinner last night, my kids were told "See what drugs do to your father? You don't want to be like that do you?"

What more is there to say...back to Vicoden during the day and the Perc at night.

Why No Smiles?

With all the hardware in my mouth, it's just not possible to smile. On June 4th, that should all change when the arch bars come off. Just 11 more days!!!

Most of the external swelling seems less, with just a little left around my lips and chin. In addition, all the external bruising is pretty much gone. As the bruising went away, it was like watching the fall colors change from black & blue to yellow to ugly yellow, to gone.

Internally, my lips and gums feel swollen. My chin, roof of my mouth, lower lip and gums are still numb and have little feeling. Over the next few weeks the numbness should go away.

Pictures Taken May 23, 2009, 17 Days Post Op

Drugs...

Since the pain in my chin has not improved in the past 5 days, I've switched my primary pain medicine to Percocet.

I really hate the idea of taking stronger, more addictive drugs. However, being in pain makes it harder to get rest, and if I'm not getting rest, I'm not healing.

The Silent Treatment

Since my chin is still hurts quite a bit, I've been told not to speak at all. In all honesty, I had thought that I was doing a pretty good job of keeping quiet. Apparently not. We're now back to the white board and pads of paper. Skype chatting has also been a great tool. I've had a number of phone and video calls. The person on the other end has spoken, and I've been able to respond using the text field. Prettty neat technology...

Since it's a long weekend and the kids will be home, our house will be anything but quiet.

Shades of Gray

I've been told that I don't answer questions. Making my living as a sales person, I tend to answer most questions with another question or a statement that refers to the question asked. However, I rarely provide a direct answer. When I could speak, my communication approach seemed to work out (probably for everyone but my wife). For the past several weeks, however, I've had to change the way I respond.

Here are some examples of how I might respond both before and after:

Q1: How do you feel?

Pre MMA Answer: We had a great ride this morning! Any day in the saddle is a good day. Let's do that again tomorrow.

Post MMA Answer: Fine.


Q2: Are you in any pain?

Pre MMA Answer: When you say pain, how do you mean?

Post MMA Answer: Yes


Q3: What would you like for dinner?

Pre MMA Answer: The salmon you made last night was fantastic! You really out did yourself.

Post MMA Answer: Beef stew.


You get the idea.


On Naps

Today was an improvement over yesterday. My chin is still numb and hurts, so I'm back on Vicoden full time. I also took a 90 minute nap. I woke from my 90 minute nap really tired, but feeling like I had slept. I had that groggy good feeling. Prior to the surgery, I don't remember the last time I took a nap that lasted more than 20 minutes.

Being severely sleep deprived for so long, my body would crave sleep during the day, but would only allow itself short naps when given the opportunity. So if I needed a nap, I could take a five minute nap, and then make it through the rest of the day. Even under the best of conditions, I just wouldn't nap more than a few minutes. Due to the demands of life, work and reality, I rarely took a naps.

Mug Shots...

I had hoped to start this blog with a baby picture. But, being the youngest of four, there just aren't any. Maybe some day I'll get over it...


The first two pictures were taken about a year before the MMA as part of getting fitted for a MAD (mandibular advancement device). I'm 5'9" and weigh 165. For the week prior to the surgery, I ate and ate and ate, bringing my weight up to 172. After a week, my weight dropped to 160, where it has stabilized.

ICU, just a few hours post-op (May 6, 2009)

Day 1 - I figured out how to apply ice and listen to music.

Day 2 - At Home

Day 3

Day 7 - May 13, 2009

The infamous "arch bars" and rubber bands.

And today, May 20, 2009 - Two Weeks Post Op

Due to the arch bars and wax (to protect my gums from the arch bars), my lips are still a bit "pushed" out. This seems more apparent on the "front" mug shots. It will be interesting to see how everything changes in two weeks when the bars get removed.

Managing Expectations

Taking the pain meds helped tremendously. I feel better this morning than I've felt since the surgery exactly two weeks ago today. That's not to say that I'm going to be getting on my bike and riding a century with 10,000 feet of climbing today, but at least I can now see that century in my future.

The emotional recovery is as significant as the physical recovery. There have been a number of different things that I have done to recover emotionally. The most significant was to set expectations.

Prior to the surgery, I wrote down my expectations for recovery:

1. Expect pain and embrace it as part of the recovery
2. Don't judge progress on a daily basis
3. Be thankful and appreciative to everyone, but focus all my energy on the recovery
4. Stay hydrated and nourished
5. Shower and get dressed first thing each day
6. Find a simple way to update family and friends (that's what this blog is about)

There have been a number of times where I have gone back and reviewed my list. It's helped me stay focused and look beyond the challenges of each particular day.

Medication - Or Lack There Of

I'm not a big fan of pain medication. I've always stopped taking pain medication as soon as possible. It inhibits thinking and alters moods. I've felt that the pain medication has slowed recovery from injury since I can't always differentiate the effects of the pain medication from the injury itself. The sooner I stopped taking the pain medicine, the faster I would recover - WRONG!!!

This recovery was no different. A week after surgery, I stopped taking Vicodin and thought that the Tylenol would be sufficient. I was wrong. When updating THE surgeon during the visit today, I described my pain as very significant. He asked what I was taking, and I said just Tylenol. He very kindly pointed out that perhaps I should reconsider my pain killer of choice to something a bit more powerful. He also pointed out that the greater the pain, the harder it would be for me to rest and recover. (As my kids would say - DUH!!!)

I'm now taking Tylenol with codeine and it seems to provide more relief than straight Tylenol. My plan at night is to take the Vicodin in hopes it will contribute to restful sleep. We'll see.

The decision to continue the stronger pain medication should have been obvious, and looking back, I made the wrong decision to stop. But, we are who we are. I expected the recovery to be difficult. On a scale of 1 to 10, I expected a 9. 9 turned out to be about right. I've had other rough recoveries in the past - operations, broken bones, bike crashes, etc. Perhaps those recoveries would have progressed faster by taking advantage of modern medicine.

Note and acknowledgement to female readers: I've never given birth - so any pain I've experienced is relatively minor to compared to "real" pain resulting from having enjoyed that first apple.

Music

Today's Whining

What's got to be one of my biggest challenges is the ability to focus. Most activities take more energy than I can muster - reading, TV, movies, conversation, etc. I haven't figured out if it's the discomfort or the energy level that make concentration difficult.

I've never been able to just "hang-out" and listen to music. Now, that's all changed. I've come to enjoy spending hours just lying around listening to music. With the ability to "stream" familiar music from the web, there is almost an infinite content.

To feel more energetic, I've tried to expend more energy as well. I took three 15 minute walks yesterday, and did my best to clean the kitchen after dinner. Today, I'll increase my physical activity just a bit more.