MMA Experiences

Final Update

2010-06-29T20:37:00.000-07:00

It’s been fourteen months since the MMA and it’s now time to bring closure to my sleep apnea story and blog.

Let’s start with the answer to the BIG question: how do I sleep? Somewhat better. Of course, there is still tremendous room for improvement, but I do sleep better than before. I have yet to master the art of sleeping more than 4.5-6 hours a night, but I’ll gladly take what I can get. While I still wake up tired, I no longer have a headache in the morning. In addition, it’s much easier to make it through the afternoon without wanting to take a nap. There are no plans to have another sleep study.

Since the last blog update, I worked with a sleep specialist who encouraged me to meditate. I spent a few months practicing Mindfulness Meditation. Meditating was definitely relaxing, but it didn’t improve my sleep. I haven’t incorporated meditation into my daily routine, but I do enjoy the experience.

At this point, I don’t expect my physical recovery to progress any further. Here’s the quick summary of the physical symptoms that will likely remain with me:

Numb lower lip, upper gums and the roof of my mouth
Most top teeth have the wooden tooth feeling and don’t have complete sensation
Upper gums still feel spongy when chewing
Difficult to chew very hard and crunchy foods
Weight returned to pre-surgery (bummer)

Looking back on the entire experience, I made the right decision to have the MMA – there were no other options left. While I haven’t had a breakthrough moment, I have benefitted from the surgery. I had the best surgeon do his best work and I feel somewhat better. Would I do it over again? I think so.

Glasses

2010-01-30T21:52:00.000-08:00

Thought it would be interesting to compare before and after photos...

The Check's In Mail

2009-12-22T19:03:00.000-08:00

...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

2009-12-15T20:19:00.000-08:00

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:

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

November Already?

2009-11-04T20:08:00.000-08:00

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"

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

2009-09-30T19:38:00.000-07:00

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

2009-09-13T16:21:00.001-07:00

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:

Be patient, healing takes lots of time
Don't overlook the psychological healing that goes with the physical healing
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)
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

2009-08-28T16:54:00.000-07:00

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:

Chin, lower lip, upper gums, and palette still numb, and improving
Occasional jaw popping when yawning
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.
Sensation returning to the teeth, but they still have that wooden feeling
Speech has pretty much returned to normal.
Jaw mobility pretty good laterally and about 30 mm vertically (I didn't measure what it was pre-MMA)
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

2009-08-10T19:46:00.000-07:00

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"

2009-08-07T12:53:00.001-07:00

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:

Regular bedtime and wake-up time
Don't nap
Avoid alcohol
Avoid caffeine 4-6 hours before bed
Limit activities in bed to avoid reading and watching TV
Exercise at least 4-6 hours before bed
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

2009-08-04T15:09:00.000-07:00

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...

2009-07-31T17:12:00.000-07:00

...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

2009-07-22T20:01:00.000-07:00

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

2009-07-13T20:24:00.000-07:00

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

2009-07-12T20:39:00.000-07:00

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!!!

2009-07-11T19:24:00.001-07:00

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

2009-07-06T21:06:00.001-07:00

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

2009-06-30T20:04:00.001-07:00

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

2009-06-27T19:35:00.001-07:00

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:

Sleep is better than I realize - perhaps a sign that the MMA worked
My weight dropped almost 10%, significantly improving my ability to ride at the same level as before, but not requiring as much power output
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

2009-06-23T19:27:00.000-07:00

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

2009-06-21T06:43:00.000-07:00

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

2009-06-18T07:42:00.000-07:00

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:

More feeling in a few back teeth
More feeling on the upper inside gums. The outer gums are still numb on the top
More feeling on the outer lower gums
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

2009-06-15T20:31:00.001-07:00

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

2009-06-14T07:58:00.000-07:00

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

2009-06-12T19:32:00.001-07:00

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

2009-06-10T18:23:00.001-07:00

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:

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

Medium Soup

2009-06-08T19:26:00.000-07:00

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?"

2009-06-07T15:52:00.000-07:00

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

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

2009-06-06T14:48:00.000-07:00

...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

2009-06-05T19:31:00.000-07:00

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

2009-06-04T18:28:00.000-07:00

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:

Green light to get back on the bike. OLH Sunday morning (who's in?)
Lips rest comfortably against my gums
Lips don't feel like they are sticking out
Teeth more comfortable without wire anchors holding the arch bars
Teeth still have no sensation (like wooden teeth)
Gums still numb
Lower lip and chin still numb
Hard to speak due to jaw's limited range of motion
Upper teeth and gums feel like they are in a different spot - which they are
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?

2009-06-04T10:13:00.000-07:00

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

2009-06-03T16:41:00.000-07:00

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

2009-06-02T13:26:00.000-07:00

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

2009-06-01T15:10:00.001-07:00

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:

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

Success - No Nap

2009-05-31T15:51:00.001-07:00

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?

2009-05-31T10:13:00.001-07:00

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:

Chin pain - 6 on a scale of 10. Definitely improving.
Tight feeling on teeth at the gum line - feels like childhood braces were tightened. Likely due to arch bars
Grumpy, cranky, short tempered, impatient - personality flaws that existed prior to surgery - the surgeon would not agree to address these items
Numb lower lip and chin - common effect of surgery as are the remaining items on this list
Numb roof of mouth
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?

2009-05-30T10:14:00.001-07:00

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:

The strong and sharp chin pain disturbs my sleep
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

2009-05-28T16:31:00.000-07:00

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

2009-05-28T14:31:00.000-07:00

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

2009-05-27T18:19:00.001-07:00

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

2009-05-26T14:46:00.000-07:00

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

2009-05-25T18:41:00.000-07:00

MMA Patient WON!!!

Eating the low carb way without the tortilla helped.

______________

Not Even Tempted

2009-05-25T09:25:00.000-07:00

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

2009-05-24T13:26:00.000-07:00

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

2009-05-23T09:16:00.000-07:00

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?

2009-05-23T08:53:00.001-07:00

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...

2009-05-22T14:43:00.000-07:00

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

2009-05-22T13:01:00.000-07:00

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

2009-05-21T18:32:00.000-07:00

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...

2009-05-20T15:50:00.001-07:00

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

2009-05-20T08:49:00.000-07:00

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

2009-05-19T16:10:00.000-07:00

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

2009-05-18T09:47:00.001-07:00

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.

Burrito vs. MMA Patient

2009-05-17T09:25:00.000-07:00

The Burrito Won

The burrito is the ultimate meal: lean chicken, black beans, avocado, tomatoes, wrapped in a whole wheat tortilla. What could be healthier? When the family had burritos last night, I had one too. It looked delicious with all the yummy fixings. Knowing that I would need to make mine extra "smudgy", I added sour cream and cheese (I figured the calories would be a bonus too). By adding enough chicken broth and salsa, I was in for a wonderful treat. And I was.

With the help of the magic bullet, and 14 ounces of chicken broth, I pulverized about a quarter of the burrito. It was a bit too thick. Fortunately, I have leftovers and will try again today, but without the tortilla.

Another Lazy Day

2009-05-16T11:56:00.001-07:00

It's an absolutely amazing beautiful day. Anticipating the afternoon heat, the temperatures will be in the 90s, I spent the entire morning outdoors. I took a walk and spend the rest of the morning relaxing on a lounge chair in the backyard listening to music.

Nothing remarkable with the recovery. My chin has two sensations - complete numbness on the skin, and a pressure/tingling pain on the the bone. Combined the sensations are a bit bizarre. I'm still challenged in getting sleep and wake up with headaches. I expect the sleep will continue to improve as the pain diminishes.

To My Children - I'm sorry and...

2009-05-15T17:34:00.000-07:00

... I would do it to you again the same way

That's right, I'm talking about the liquid medicines we force our children to take. I've been taking liquid Tylenol and Ibuprofen, and all I can say is that I should have tasted this dreadful stuff before having forced my children to swallow it when they were sick - YUCK!!!

On the positive food front, I've discovered how to pulverize food with the blender. I just had a savory chicken thigh. Deb decided to avoid cooking in the afternoon heat and cooked a chicken in the slow cooker all day. The house smelled delicious. So, throwing caution to the wind, I took out the Magic Bullet (a must for all MMA recoverers) tossed in a thigh (minus the skin and bone)and added some chicken broth. The first "solid" food in about 10 days. Hopefully this will create a turning point in energy as well. Getting concentrated calories will be a real plus.

More on the numbers

2009-05-15T08:12:00.000-07:00

Yesterday I was able to achieve the eating goals that I set. I consumed 2200 calories and 3 liters of fluids. It was exhausting to keep up on the food all day long. Between 6 a.m. and 7:30 p.m., I consumed 13 beverages, including 6 ensures, apple juice, orange juice, fruit replacement supplement, and lemonade. Normally it wouldn't be a big deal to drink 3 liters of fluid - I regularly consume 4-5 liters a day. The challenge in drinking so much now is that I need to sip each drink with a straw. Since my lower lip is still completely numb and my teeth are still immobilized in the "closed" position so it's too hard to use a glass and drink quickly. I would not fare well in a beer chugging contest today. Perhaps with the larger airway, I may be able to pick up a new sport...

I'm hoping to vary my diet today and introduce some soup. Any good tasting soups that fit through a strainer will make a great meal.

Today - another 2000 calories and 3 liters.

5 + 3

2009-05-14T08:12:00.001-07:00

8 hours of sleep last night. That's got to be more than the grand total of what I have slept in the prior six nights combined. Thank you Ambien and generic pharmaceutical manufacturers around the world. I did wake with a terrible headache, which I'm attributing to poor nutrition and liquid intake from yesterday. Perhaps the surgery procecure and the recovery contribute to the headache as well.

Nutrition has got to be a key part of the recovery. While I've been making efforts to drink enough, I could be doing much better. Today, my goal is to consume 2000 calories and 3 liters of fluid.

The Little Loop

2009-05-13T14:34:00.000-07:00

I just returned from a walk around the little loop - just a short 15 minute stroll through the neighborhood. It was great to get out.

We visited the doctor this morning. He cleaned things up a bit and suggested that I try to ease back into a regular sleep pattern, avoiding sleeping all day long. In my case, I'm going to avoid being a zombie all day long and try to concentrate the sleep during the night, if at all possible.

In addition, I'm going to switch to over the counter Tylenol and Ibuprofen, away from vicodin. The vicodin makes me tired, groggy and slow, none of which can be good for the healing process.

With regard to food, I'm drawn to sweet drinks (with protein powder) and ensure. Soups do not yet appeal to me, but I'm hopeful that will change soon.

Just a quickie...

2009-05-12T15:13:00.000-07:00

Sleep remains elusive (although I did have an exhausting dream during the afternoon nap) and the food hasn't really changed. I have tried to drink without the special implement and it works better sometimes than others. I had hoped to consume everything from a biking water bottle, compliments of Steve and Lance Armstrong, but it's just a bit too ambitious this early on in the recovery

Weight seems to have stabilized down at 10 pounds, and I can fit in the "skinny" pants. Fortunately, they don't make my butt look too big - a major concern for most of us males.

The Big Reveal

2009-05-11T14:44:00.000-07:00

Before

After

So there you have it - the before and after pictures. (The "bars" on the after picture are "Arch Bars." They are stainless steel braces that immobilize the jaw. Patients typically wear the arch bars for about 4 weeks.)

Today was busy. Prior to leaving for the doctor's office, I ventured on my first walk. I had a plan, and over did it. The plan was to walk 5 houses down the hill. I went 7. Upon my return, I crashed for the post walk nap. - Let's just just say that I should have stuck with the original plan. Those 2 extra houses were a killer.

The doctor visit went well. He said all looks good, and come back in a few days. On the way back from the doctor, we stopped at the grocery store to expand my diet. We settled on liquid fruit (8 Oz = 1 complete fruit). The grocery store visit was far beyond what I should have done. We came home, and I only made it as far as the couch before passing out.

In an effort to keep my energy going, I ventured out on a second walk. I had a plan, but ignored it - again. The plan was to go 7 houses up the hill. I went 11.

The weather here in the San Francisco Peninsula has been spectacular. While we drove to the doctor's office, we passed more bicyclists than I've seen in a long while. It's great to see all those people hammering hard up the hills and putting in a few miles for me.

Not the biggest loser

2009-05-10T11:54:00.000-07:00

After a quick weigh-in, it looks like I've gone below the yellow line and gained a pound since yesterday. For this competition, that's a good thing.

Two Course Breakfast

2009-05-10T09:44:00.000-07:00

Mother's Day 2009

Deb seems to get a raw deal on Mother's day. Next year, we're going to have a great day that doesn't involve any surgery recovery.

Each day continues to be a significant improvement from the previous day. I haven't hit the scales this morning, but as of Saturday, I'm down 11 pounds. Sleep remains elusive, I mainly get short naps of 30-60 minutes.

Most of my day is spent trying to acquire calories. If it comes in a clear liquid, and is the consistency of water, it's on my list. The hospital sent me home with 2 ounce syringes for feeding. As you can see in the photo below, breakfast was Ensure (vanilla-we're running low on chocolate) and Cytomax (an electrolyte mixture used when cycling - it's Sunday of course). Truth be told, I had seconds of each course. (30 cals/ounce of ensure, and 15 cals/ounce of Cytomax).

Thanks again for all your kind words an well wishes. They make each day go a bit smoother.

Home

2009-05-08T19:22:00.000-07:00

They sent me home today. Stanford's a great place for outstanding medical care. My hospital stay had me in the ICU for 1 night, and a regular room for the second. The ICU provides really outstanding care. They have you wired so well that they don't even need to wake you to take your vital signs. The have 1 nurse for every 2 patients The regular room was fine, a bit noisier, but not too bad.

I graduated from the clear liquid diet to the "full" liquid diet today. With all the liquid, I've still managed to drop 8 pounds in 2 days.

On the way home from the hospital, we stopped by the doctor's office, and he removed the nasal congestion, providing much relief and making it easier to breath. The doctor asked that we return on Saturday morning so that he can clean out the sinuses again. That doctor's visit on Saturday will be the highlight of my day.

Thanks for all your well wishes, and kind thoughts. It's nice to go through this with a wonderful community behind you.

I'll try to post more tomorrow.

2009-05-07T07:53:00.001-07:00

No pain.

Pretty amazing that I have no pain. Soon they will move me from ICU to a regular room.

Slept only 45 minutes last night.

Yum!!!

2009-05-05T19:09:00.000-07:00

And peanut M&Ms

Last Supper

2009-05-05T16:33:00.000-07:00

What would you request for your last meal?

As you would expect, the question came up. My kids were pushing for burritos or Indian buffet. Those are great choices, and certainly high on my list. But they just don't compare to the great meals Deb makes. She puts so much love and care into everything she prepares.

So when I was asked what I wanted to eat, it was an easy answer - anything Deb makes works for me. Well almost anything. For some reason, the turkey chili just doesn't do it.

The meal is still a mystery, but whatever it is, it's going to be great to sit down as a family and share our experiences from the day, tell stories and jokes, and see how the kids try to get out of doing their chores.

It's all good. I wouldn't trade with anyone.

A Bit About Me

2009-04-30T19:20:00.000-07:00

Who am I?

When I went off to college, I thought that the smart kids studied engineering. And that turned out to be true. What I didn't know was the clever kids studied finance.

Armed with an engineering degree, I began my professional adventures working for start-up and emerging companies in the Silicon Valley. Shortly after I started my first job, I realized that the world would be a safer place if I didn't practice engineering. I transitioned into a sales role and have spent the better part of my career as a serial entrepreneur working at start-up companies. I specialize in selling new technology products to emerging markets - mainly software and electronics. While there may be easier ways to make a living, I wouldn't trade what I do. Often, I joke that if I won the lottery, I would be late in claiming my prize because I wouldn't cancel my sales call the morning following the drawing.

My career has brought me around the world. The travel started the day I returned from my honeymoon in 1989, and hasn't let up since. When people describe how many miles they travelled, there are usually two descriptions: the total frequent flyer miles including bonuses and the AOS miles. It's the AOS miles that count. I've accumulated more than 1,500,000 AOS miles. For those of you that haven't figured it out, AOS=Ass On Seat.

At first, I thought that being tired all the time was the result of many flights, long days, and jet lag - not the case. It's the sleep disordered breathing that made me feel so tired.

In case your wondering about the URL name "pedal-MMA", it doesn't refer to being a peddler, but rather a pedal-er. I enjoy riding my bike. One of the benefits of not sleeping well is that I get to ride my bike early in the morning and return by 6:30 a.m. before everyone in the house wakes up.

Many people sleep late on their weekends. I ride my bike. During a good week, I'll train over 150 miles. 50+ on Sunday, 50-75 during the week, and 25 on Saturday. It's been quite a while since I've had a "good" week of training. As part of my planned MMA recovery, I'm hoping to ride the November Solvang century. Setting the goal for the 100 miles should be excellent motivation.

Reservations

2009-04-30T19:14:00.000-07:00

Will this work?

In a nutshell, that's my major concern. Most people get some benefit with either CPAP or the oral appliance. I didn't. We have not yet found any way to releive the symptoms. Just knowing that one of the other therapies had worked would give me a bit more confidence in this procedure working.

Making the MMA Decision

2009-04-29T20:10:00.000-07:00

I just want to wake up rested

You know when it's time for surgery. Why? Because you've tried everything else.

The last time I woke up rested was in December 1991, the day after my brother's wedding. It's such a vivid memory since I had the flu the weekend of the wedding, and had to drive 200 miles after the wedding in a heavy rain storm at night. I woke up the next morning after the big day thinking "what a great night's sleep."

It's that rested feeling that I'm after. Whatever it takes, I'm going to wake up rested again.

Many have asked me why is it so important to wake up rested, and why can't I just get by being tired. The answer is simple: I deserve a better quality of life. Imagine how you would feel if you only slept a few hours each night, and the hours you got, weren't that great. Basically, you wake up with a dull headache, have little energy, become grumpy and irritable, and can't wait to get to sleep that night. Some days have all these challenges and other days have only a few. But you know it could be better. Throw in the reality that you need to put all your energy into a successful work day. I put every bit of energy into work. Being too tired to work was never an option.

When you come home to your family after work, if you've got nothing left and you're snappy with the wife, short tempered with the kids, and just want to lay down on the sofa - you miss out on all the best parts of having a family. The family deserves to see you at your best, not your worst. Being tired all the time just isn't fair to the family.

The first time I seriously thought about sleep surgery was in 2007 after seeing the most distinguished sleep doc. Since he's the guy who wrote the book on sleep apnea, and if he thinks surgery is going to help me, I had to believe that he's probably right. However, in 2007, I wasn't ready to have any surgery. I knew that surgery might be part of the journey to getting a better nights sleep.

The internet became the best resource to learn about sleep surgeries. The discussion boards, blogs, and medical studies provided more details than I could consume. Reading about other people's success and failures with sleep surgery made me think that perhaps surgery could help me.

Before surgery, I had to exhaust every possible option at least one more time -CPAP , oral appliance, medication , and outstanding sleep hygiene. Having tried all these therapies multiple times, surgery became the only remaining option.

Wired for March 2009 Sleep Study

2009-04-28T11:03:00.000-07:00

Where Were We?

2009-04-27T17:47:00.000-07:00

More on the journey...

Before, during, and after the second CPAP/APAP trial, the doctor prescribed all the sleep narcotics. We started with clonazapan, moved to Norco, Halcion, Ambien, Lunesta, Rozerim, Remeron, Xyrem, and a few others. Since none of these sleep aids helped, I paid my first visit to the Stanford Sleep Clinic. I met with a sleep doc who suggested that I have a titration study. The doc also handed me a brochure for sleep surgery and suggested that I may consider seeing the local sleep surgeons who established the MMA. My impression from the Stanford doc was that the treatment plan was CPAP, surgery, next patient...

In 2004, I would not consider sleep surgery. I returned to my regular sleep doc, had the titration study (APAP @7-8), failed to get benefit, and abandoned CPAP for the second time. My sleep doc offered to write me a note to my employer prescribing daily naps - needless to say, I declined the nap pass. The doc said that I seemed highly functional and perhaps I could just keep going on as is. With no relief from my "wake up tired" syndrome, I decided to just "deal with it" and get through the days.

For the next three years, my sleep quality and quantity declined to the point where I slept four to six hours a night, woke up tired, and became even grumpier. As a last effort, I sought the advice the top doc at Stanford. It took only two days to get an appointment with the amazing physician. To make a long story short, the doc walks in the room, looks at my face, and tells me that my facial structures are all wrong, and they are going to need to break my jaw. WOW! He went on to explain that prior to surgery, there is a very specific protocol they follow - CPAP, phase I surgery, and ultimately phase II (MMA). He said the process would take several years. (He was right).

The doc ordered a titration study, and told me that he would see me the morning after the study. (Not only did he order the titration study, he walked me over to the scheduler and had my study scheduled the next week.) In addition to the sleep study, the doc also made an appointment for me to visit the the weekly surgery clinic after the sleep study.

When dealing with Stanford, prior to seeing the attending physicians on staff, you meet with a sleep fellow. The fellows are all post resident physicians, some directly from residency, others from private practice seeking advanced training in sleep medicine.

The morning after the sleep study, the fellow doc came in at 7:45 a.m. with a prescription for a bi-pap @ 15/11 and Ambien CR. By noon that day, I had my bi-pap.

I used the bi-pap with almost 100% compliance for about a year with no improvement. We regularly increased the pressure to a maximum of 21/17 with no improvement. The Stanford Doc had said that I need such high pressures since we were trying to overcome structural bone issues, and not simply splint the soft tissue in the airway. During the third PAP trial, I was able to tolerate the machine for 5-6 hours a night, but swallowed significant amounts of air. We eventually switched from straight bi-pap to auto bi-pap. The auto bi-pap didn't prevent swallowing the air.

About nine months into the bi-pap trial, I got n mandibular advancement device aka an oral appliance (the "Silencer"). The Silencer failed to improve my sleep quality and I developed TMJ like symptoms. I tried both the oral appliance along with bi-pap without success.

Not willing to give up on the promise of a good night's sleep, I made an appointment with THE sleep apnea surgeon. The surgeon suggested that I consider a tonsillectomy as the next treatment. He did not want to perform an UPPP as he felt that most OSA issues need to be treated lower in the airway. He performed the tonsillectomy. With no improvement in my sleep quality, he suggested that I try PAP treatment again. Once again, the PAP failed yet again to improve my sleep. As a next step, he referred me to another distinguished sleep doctor who was involved in a trial for the Ventus valves - a device you put over each nostril to create a positive pressure in your throat when exhaling.

More Doom and Gloom
The Ventus device failed me or perhaps I failed with the device. For another 6 months, I was resigned to being tired. Finally, determined to wake up rested, I made an appointment to return the most distinguished sleep doctor at Stanford. He suggested one last trial with APAP along with a Prilosec to prevent swallowing air.

The APAP trial failed and I returned to see THE sleep surgeon - MMA Scheduled for next week.

First Post - MMA - Scheduled, Locked and Loaded

2009-04-26T15:27:00.001-07:00

This is the beginning of my blog and MMA adventure. The date is set for early May, 2009. For those of you not so familiar with the MMA, it stands for maxillomandibular advancement surgery. In a nutshell, MMA treats obstructive sleep apnea by advancing both the upper and lower jaw to enlarge the airway. Many others have already published so much on the procedure. You can find out more with a simple Google of "MMA Surgery."

My blog has two objectives:

1. Detail the journey that led me to the MMA decision
2. Provide updates and ramblings on the recovery

Most of my entries will be short updates.

Bits of Background

A bit of my sleep history and background. After all, this blog is all about me. I've never slept well and have always been a "morning person." As early as high school, we scheduled all my academic classes in the morning. Classes after lunch might as well have been naps.

I don't recall having any major sleep issues in college, or the years following. My only sleep "problems" for most of my twenties was that I just didn't sleep that long, and would never sleep late, regardless of the time I went to bed.

Around 1995, I developed chronic sinus problems and ultimately had four functional endoscopic sinus surgeries. After the third surgery (and probably the first and second), I was always tired. I would describe the tiredness as being just as tired in the morning as when I went to bed at night. My doc sent me off for my first sleep study which indicated that I snored (which was news to my wife) and possible upper airway resistance syndrome. With the possible UARS diagnosis, I had a second sleep study with a esophageal pressure monitor (Pes). The second sleep study showed a negative pressure of -20. The sleep study report indicated "mild UARS." My doctor prescribed a CPAP trial with a pressure of 5 cm H20. Needless to say, the CPAP didn't work, and I abandoned the treatment and my pursuit of a good night's sleep.

After hearing more complaints about being tired, my ENT (who did my fourth surgery) sent me off for my third sleep study in 2002. The sleep study showed many, many unexplained arousals, possible UARS and an RDI of about 10. I followed up the sleep study with a sleep doctor. The doc tried many treatment options: sleep deprivation therapy, tennis balls to keep me from sleeping on my back, medication, medication, medication, medication, and other medication. On another blog, I'll comment on the drugs. Let's just say, if they made it, I tried it.

With no progress and many therapies, I had another sleep study with a daytime sleep test to rule out narcolepsy (which they did), and ultimately tried my second stint with CPAP/APAP.

I'm out of time, but will add to my story soon.