Jaw-in-a-Day

Dr. Hirsch pioneered Jaw-in-a-Day, which accomplishes in one surgery and in one day what used to take three surgeries over the course of months, if not years. Dr. Hirsch, welcome Dr. Hirsch: Thanks for having me Over the past decade our second guest today. Dr. Lawrence Brecht has worked with Dr. Hirsch to develop and improve and now expand access to this revolutionary procedure. He is the director of maxillofacial prosthetics for Lenox Hill Hospital, lij Medical Center and North Shore.

University Hospital. Dr. Brecht thanks for joining us. Dr. Brecht: Yeah. Thanks for having us Repairing, a jaw can involve multiple procedures and leave patients not feeling whole. Dr. Hirsch, tell us how Jaw-in-a-Day came to be. Dr. Hirsch: Jaw-in-a-Day was Dr. Brecht and I's kind of brain child. We had been doing a lot of reconstruction for patients with cancer motor vehicle accidents or any infectious process.

And we just weren't satisfied with the Reconstruction and we thought that we could deliver a better product. Originally when we would see patients. like this it would take us about a year from their initial surgery, having removal of their jaw to getting them new jaw as well as implants and finally teeth. And so we set out to figure out, is there a way we can do this in one operation, in one day? We talk about a jaw in a day. What kind of surgery is this?

Is this an all-day surgery or how many hours does it take? Dr. Brecht: First one was what? Dr. Hirsch: Yeah, used to be a Jaw-in-a-Day-and-a-half. And now it's probably I probably re-term it Jaw-in-half a day. Yeah, I think we could probably do this procedure in about six hours. And with that being said, you know, it takes about an hour to get set up before you even start surgery. And then when you're done, probably takes another 45 minutes when you're done, so we're very efficient.

It's awesome. What about the if it's taken from Different part of the body, say the the bone is taken from the leg. What kind of effect does that have on the person's walking? Or is there any effect at all? Dr. Hirsch: Yeah, I mean, when we take the bone from the leg, it's there's a there's two bones in the leg. The the larger bone is the tibia and the smaller bone is the fibula.

We use the fibula and the patients in the initial post operative period it is like they've had a broken leg but We've had we've done this on athletes, we've done this on basketball players. We've done this, some people who ski and for the most part they go back to their normal physical activity. It takes a little bit of time, but patients do remarkably well missing their fibula. Now, this is so successful that you're expanding on Long Island. What does this mean for the people in Long Island?

Dr. Hirsch: Well, more jaws in a day. Dr. Brecht: Yeah, It gets more jaws in a day. I think, you know, we were sitting around here before talking about what it was like to have to travel into the city, you know, you don't need to necessarily travel into the city to get this done. I mean procedures, we've done a number of them now out at Long Island Jewish Medical Center So yeah, I think patients of Long Island win by having this team out there. Providing the service.

After we've refined it for 10 years. I mean, as the, the dental person on this, I mean, I have the privilege to watch. Dr. Hirsch operating in usually our plastic surgery or ENT surgery, colleague working down on the leg and harvesting the leg bone.

If that's the bone that we're going to use as opposed to some other sites and I am amazed to watch how this whole thing kind of choreographs and comes together and, you know, David's really the leader of the team in the operating room and he kind of sets the standard for everybody and that kind of leads to Great results. You know, nobody wants walk out of there feeling disappointed.

So it's a wonderful orchestration of an extremely complicated set of procedures that kind of, makes it look easy when it's all pulled together And this is kind of amazing procedure and it's very we've talked before a little bit as is very well-choreographed. There's actually a couple of different surgeries happening at once tells walk us through the day of the surgery. What it's what goes on in a day, a Jaw in a day. Dr. Hirsch: Yeah, it is.

It's well choreographed and the entire procedure really is planned prior to us, going to the operating room Dr. Brecht: Right, right. It all happens before Dr. Hirsch: So, we'll spend a couple of sessions online with Dr. Brecht, myself.

And usually another surgeon. One that, as I'm removing the tumor will be harvesting from another area of the body that allows us to cut the surgery time in half, but the planning is about an hour, long, planning session, and we sit there and we look at the geometry of the jaw. The areas that need to be removed. What are the important anatomical landmarks? We have to respect and basically do a dress rehearsal prior to going to the OR. And so that's where the big thing is.

And then once we do, That when we go to the OR, we already know what each each of us are going to do and it just goes much smoother in that we thought about it We've thought about what each of our parts should be and then, you know, the easy part is actually going and doing the procedure. Tell me how technology plays a role virtual. Surgical planning, tell us about that. And how are you able to really get a great grasp of what's going on?

Through the the use of very fine Finally cuts cat-scans that are very accurate. We can translate that to a 3D image and then on a computer program we can actually plan the surgery, plan the cuts of the surgery, everything can be planned to the millimeter. Once that's done that's translated to physical product by sending all That information to 3D printers and then 3D printers will make guides for us to take to surgery.

They'll make specialized plates that are custom fit to the patient's jaw and even things down to the prosthesis and the teeth. Dr. Brecht is planning that virtually. So the entire surgery is planned on a computer and translated to the operating room using all 3D printers and that's that's pretty nice. Oval good thing about it is it can be replicated and so it's not just limited to our patient population.

This is something now that has been brought to the masses in the United States and in Europe and virtual surgical planning can be done anywhere. So we will be planning, Larry be planning in his office. I'll be in my office will have an engineer that we might be working with in Colorado. So All of the technology that's humanly possible. Is brought to these cases. Tell me who the ideal patient is for this procedure. Dr. Hirsch: That's a great question.

I mean when we initially started doing this we thought we could do this, only on select patients. So a young patient with a benign tumor that probably wasn't going to get radiation. We thought would be a good ideal patient. But at this point in time because we've been able to fine-tune everything we do there were we can do it on almost any patient that that needs a resection of their jaw. We used to think we couldn't do it because patients were going to get radiation.

But again, as we've gotten better at doing the technique and we've learned the intricacies of what works and what doesn't work. I think the really there's no limitation on who we can do it on. That's awesome. Dr. Brecht, tell us about how you fabricate teeth. Dr. Brecht: Again, technology is really the driving force here, you know, your leg bone, the fibula really looks like your jaw bone, your lower jaw bone without teeth. Like, you know, somebody wearing a denture.

If you took their lower jaw out It looks just like a leg bone. Except now we have the ability to attach the teeth - a denture - to A leg bone through these implants, we fabricate them from a very aesthetic, acrylic material, that's milled by computer starts out. As a looks like a big hockey puck, except it's tooth-colored and computer off of our planning, and our design mills out what the teeth should look like. We put those in in the operating room. We attach them to the implants.

We let the patient go through. Probably want a bit about like a three-month healing period, fine-tune it, maybe get them a second set of teeth to refine any changes that the patient really wants to have. Maybe they started out with crooked teeth. We gave them crooked teeth in the OR and they're like, you know, I really wish my teeth were straight. We make them a second set when the person is really happy with the new set of temporaries. Then we go off and make a final set.

Instead of Milling it out of acrylic. We Mill it out of this material called zirconia, which is we're familiar with their zironica as an artificial diamond and it's the same material. It's just in a different crystal structure. Instead of it being clear it has a tooth color shade or gradation between, you know, having an opacity to it to maybe as the top of your teeth, have some transparency, the very, very aesthetic, very durable. Those are long-term teeth.

We put those in patients that we've treated 10. years ago. They still have those those teeth in place. It's amazing. And how long does it take before? A person is back to, you know, a hundred percent, you know, eating talking back to work, all this stuff Dr. Hirsch: Depends on the patient, their age, but I think typical patient probably spends about five days to seven days in the hospital and then we start them eating while they're in the hospital.

We start Physical Therapy when when they're in the hospital. So, usually the first post-op visit we're trying to get them moving towards more normal everyday activities, but it does, it does take time. It's a big operation. But typically, you know, I think by three weeks we have them eating most Foods.

Dr. Brecht: Yeah. I think the remarkable thing is, you know, we started out pretty much uh, on younger patients that had a really aggressive benign tumor that was really destructive and the only way to eradicate it was to take out the entire portion of the jaw that was affected by then. And then a little more right, make sure you've got it all out. And over time as David said, realized that this the technique is applicable to, you know, even even older patients. I'm trying to think.

But the oldest patient we've done is and Dr. Hirsch: I probably early 80s. Dr. Brecht: Yeah, and you know, people are remarkably. In a grateful, it's humbling on our side. These are these are people. You know, in the dental side. I'm doing We're both doing follow-up. I tend to see people, you know, regularly probably every six months making sure everything is okay for, for a few years and then kind of like after the five-year mark.

I'm probably still the person seeing the people because I want to make sure the prosthesis is okay. I want to make sure the implants are okay, that everything is tight and you develop. A very long-term relationship with people that we put them through this experience. It's really life-transforming for them and they go about life, pretty much as normal afterward. And it's, it's very humbling on our end to do this. I mean, you know, every time I see one of these done, I'm, I'm still amazed.

I still get a rush. I'm so happy in what I've chosen to do for my life's avocation. I'm happy to be around colleagues who are really great at what they do. And after 20 years they still want to push the envelope. That's, that's the definition of being a professional. It's great. Speaking of moving out to Long Island. Your first patient was Tara Singh, and she had an amazing result and you did something a little bit different on this. Tell us a little bit about how that procedure went.

And what was the new process there. Dr. Brecht: Well, you know, my incredibly humble surgical colleague here, is I find it fascinating. I've got this picture up here on the computer screen and there's this plate here that holds all the pieces of the leg bone together to form a jaw bone. And one of the things we did on the march from a simple operation to the operation we're at now is David really was able to perfect the technology.

And the surgery, we're not just taking the leg bone and maybe breaking it into three pieces to make it look like a jaw, but maybe somebody had a bigger native jaw and needed to have more height in their leg, bone forming, their jaws. So, what he was able to design with the surgical colleagues that put it all together, but they were able to do, is they would split the leg bone put it on top of itself in. Come up with a bar design that again is custom made by computer.

You couldn't do this before that technology was around and it's called a double barrel technique. And what it is able to do is give a remarkable resemblance to a patient's, you know, pre-surgical jaw form. Dr. Hirsch: We do that quite frequently depending on where the defect in the in the jaw is. Yeah. And the outcome is so amazing because you would never think that she had surgery.

And I'm hoping that my producer, Brian Donnelly will be able to link that video in there because I think you should people should see that video and see the success that that was able to be done for her. Dr. Hirsch: Yeah, and lastly, you know, when you make the comment that they don't look like they had surgery. So one of the nice things about the virtual surgical planning, is it allows us to do somethings blindly The plate usually fits very well.

And so we used to have to get access to the entire mandible, to make sure everything was exactly where we wanted it. Now when things fit, I'm able to make smaller incisions make really small incisions in the patient's face, make the majority of my incisions inside the patient's mouth.

And so when you can make more incisions in the patient's mouth and have less scars on the face patients then really start to look like they don't have surgery, you know, if you can make a three-centimeter incision instead of a 10 centimeter incision in somebody's neck. It's a huge benefit, especially to a young patient who does not have wrinkles. You'd mentioned before that you two pioneered this, and now it's being replicated all over the country.

What about, are other Where does this go from here? Are there other applications for this? Maybe in other types of surgery. Are other people looking at your work here and seeing how they can maybe help somebody else. Maybe not a jaw, or something else? Dr. Hirsch: Yeah, I mean it's been so it has been replicated and in the field of Orthopedics.

The first oral surgical planning... they started to use it after we were doing a lot of head and neck stuff, were always asking ourselves what can we do next? And what's the next thing? We're always trying to look to to make things more efficient and come up with new ways of doing these things. That's what that's what makes all of this very I think exciting to us. What does it look like when you do these 3D images, right?

And you do these, these scans of the mouth and you're going to do this surgery. You want to go right to the letter. You want to make it perfect. And that's why you do this virtual surgical planning. When you're done you go back and look and see how exact it is? Dr. Hirsch: Yeah. And how exact is it? That's a very insightful question. So when we first started doing it, we wanted to know. Are we accurate?

Are we doing this right So every patient that we did it on, we probably did it for the first 20 patients is we got a post-operative CAT scan, and then overlay the images that we planned with what we turned up with after the operation just to see, are we close? What can we do better? And it was remarkably accurate The overlay was always within one with actually within one millimeter of what we planned and you know, that would just kind of proof of concept to us.

And that that type of accuracy, you know, we needed to prove I think in the beginning to make sure that we were doing the right things here. So we always like to end on a positive note here, on 20-Minute Health Talk And so I like to ask both of you and I'll start with you. Dr. Brecht, just tell me. What gives you hope? What gives you optimism going forward?

Dr. Brecht: I'm incredibly optimistic when I see young people being excited about techniques like this and wanting to learn and just kind of soak it up because they're the repositories for the next Innovation that's going to drive this forward. I remember when David and I started this person who trained just ahead of us and kind of was one of the pioneers of leg-to-jaw surgery we were at a talk and he came back and we asked him.

why he stopped doing the operation and he said, he couldn't figure out what the next iteration to the operation was and, you know, David and I looked at one another like, 'wow, that's, you know, how could you not see..." Right? Technology came along at the same time. So, I'm excited about technology and I do remember, when a, when a younger Dr. Hirsch came to me and said, hey, I have this idea and people told me you're the guy i need to come find.

I remember that day so clearly, and after he told me what his vision was, I said, 'this is at, this is great. I'm happy to do this with you.' So I think I'm hopeful that we've got great teachers in this system. We've got motivated, young people, and between young people and energy and technology I think things will be good Fantastic. Dr. Hirsch what gives you hope and optimism? Well, that once hard to follow For me, Northwell Health has given me a platform to do what I want to do

professionally. Allowed me the autonomy and Leadership role that I can recruit and surround myself with people who I think are great. And if I couldn't surround myself that people that are better than me and that are very bright and Excel then they make me look good. And so I'm really optimistic of what we're growing here throughout the Northwell system, at Lenox Hill, at LIJ, at North Shore.

And so for me the future is really bright because I love what I'm doing and I love who I'm doing it with. So it's pretty hard, not to be excited to come to work when when you have that situation set up for yourself. That's awesome. Well, Dr. Hirsch, Dr. Brecht Thank you so much for joining us here on 20-Minute Health Talk. And for you, the listener thank you so much for tuning in. Have a great day and stay safe.

Dr. Brecht: Thanks, Rob Get more expert Insight from some of the leading voices in health care today. Subscribe to 20-Minute Health Talk on podBean, Pandora, Spotify, iTunes, and wherever you get your podcasts.