Latest / 20-Minute Health Talk / Jaw-in-a-Day

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Jaw-in-a-Day · 20-Minute Health Talk

• 0:00
  Host: Welcome to 20-minute Health talk.
• 0:04
  I'm your host, Rob Hoell. A problem with your jaw is tough to hide
• 0:07
  while certain tumors of the jaw can be disfiguring.
• 0:10
  Left untreated traditional, surgical treatments can have a similar
• 0:13
  impact.
• 0:13
  That is where our guests come in today.
• 0:19
  line for northwell health and chair of the newly established
• 0:22
  Department of oral maxillofacial surgery
• 0:24
  at Lenox Hill Hospital.
• 0:26
  Dr. Hirsch pioneered Jaw-in-a-Day, which accomplishes in one surgery
• 0:31
  what used to take three surgeries over the course of months, if not
• 0:34
  years.
• 0:35
  Dr. Hirsch, welcome
• 0:36
  Dr. Hirsch: Thanks for having me
• 0:39
  Host: Over the past decade our second guest today.
• 0:40
  Dr. Lawrence Brecht has worked with Dr. Hirsch
• 0:42
  to develop and improve and now expand access to this
• 0:45
  revolutionary procedure.
• 0:47
  He is the director of maxillofacial prosthetics for Lenox Hill
• 0:49
  Hospital, lij Medical Center and North Shore.
• 0:52
  University Hospital.
• 0:53
  Dr. Brecht thanks for joining us.
• 0:55
  Dr. Brecht: Yeah. Thanks for having us
• 0:57
  Host: Repairing, a jaw can involve multiple procedures
• 0:59
  and leave patients
• 1:00
  not feeling whole.
• 1:01
  Dr. Hirsch, tell us how Jaw-in-a-Day came to be.
• 1:05
  Dr. Hirsch: Jaw-in-a-Day was
• 1:07
  Dr. Brecht and I's kind of brain child.
• 1:10
  We had been doing a lot of reconstruction for patients with cancer
• 1:15
  motor vehicle accidents or any infectious process.
• 1:20
  And we just weren't satisfied with the Reconstruction and we thought
• 1:24
  that we could deliver a better product.
• 1:28
  Originally when we would see patients.
• 1:29
  like this it would take us about a year from their initial surgery,
• 1:34
  having removal of their jaw to getting them new jaw as well as
• 1:41
  implants and finally teeth.
• 1:44
  And so we set out to figure out, is there a way we can do this in one
• 1:49
  operation, in one day?
• 1:52
  Host: We talk about a jaw in a day.
• 1:54
  What kind of surgery is this?
• 1:55
  Is this an all-day surgery or how many hours does it take?
• 1:58
  Dr. Brecht: First one was what?
• 2:00
  Dr. Hirsch: Yeah, used to be a Jaw-in-a-Day-and-a-half.
• 2:02
  And now it's probably I probably re-term it Jaw-in-half a day.
• 2:10
  Yeah, I think we could probably do this procedure in about six hours.
• 2:14
  And with that being said, you know, it takes about an hour to get set
• 2:19
  up before you even start surgery.
• 2:20
  And then when you're done, probably takes another 45 minutes when
• 2:23
  you're done, so we're very efficient.
• 2:26
  Host: It's awesome.
• 2:27
  What about the if it's taken from
• 2:29
  Different part of the body, say the the bone is taken from the leg.
• 2:33
  What kind of effect does that have on the person's walking?
• 2:35
  Or is there any effect at all?
• 2:38
  Dr. Hirsch: Yeah, I mean, when we take the bone from the leg, it's there's a
• 2:43
  there's two bones in the leg.
• 2:44
  The the larger bone is the tibia and the smaller bone is the fibula.
• 2:48
  We use the fibula and the patients in the initial post operative
• 2:54
  period it is like they've had a broken leg but
• 3:00
  We've had we've done this on athletes, we've done this on basketball
• 3:03
  players.
• 3:03
  We've done this, some people who ski and for the most part they go
• 3:06
  back to their normal physical activity.
• 3:09
  It takes a little bit of time, but patients do remarkably well missing
• 3:15
  their fibula.
• 3:16
  Host: Now, this is so successful that you're expanding on Long Island.
• 3:19
  What does this mean for the people in Long Island?
• 3:23
  Dr. Hirsch: Well, more jaws in a day.
• 3:26
  Dr. Brecht: Yeah, It gets more jaws in a day.
• 3:28
  I think, you know, we were sitting around here before talking about
• 3:32
  what it was like to have to travel into the city, you know, you don't
• 3:37
  need to necessarily travel into the city to get this done.
• 3:40
  I mean procedures, we've done a number of them now out at Long Island Jewish Medical Center
• 3:46
  So yeah, I think patients of Long Island win by having this team out
• 3:51
  there.
• 3:51
  Providing the service.
• 3:53
  After we've refined it for 10 years.
• 3:55
  I mean, as the, the dental person on this, I mean, I have the
• 4:00
  privilege to watch.
• 4:04
  Dr. Hirsch operating in usually our plastic surgery or ENT surgery,
• 4:09
  colleague working down on the leg and harvesting the leg bone.
• 4:13
  If that's the bone that we're going to use as opposed to some other
• 4:16
  sites and I am amazed to watch how this whole thing kind of
• 4:22
  choreographs and comes
• 4:23
  together and, you know, David's really the leader of the team in the
• 4:26
  operating room and he kind of sets the standard for everybody and that
• 4:30
  kind of leads to Great results.
• 4:32
  You know, nobody wants walk out of there feeling disappointed.
• 4:35
  So it's a wonderful orchestration of an extremely complicated set of
• 4:42
  procedures that kind of, makes it look easy when it's all pulled together
• 4:48
  Host: And this is kind of amazing procedure and it's very we've
• 4:50
  talked before a little bit as is very well-choreographed.
• 4:53
  There's actually a couple of different surgeries happening at once
• 4:56
  tells walk us through the day of the surgery.
• 4:58
  What it's what goes on in a day, a Jaw in a day.
• 5:04
  Dr. Hirsch: Yeah, it is.
• 5:05
  It's well choreographed and the entire procedure really is planned
• 5:13
  prior to us, going to the operating room
• 5:15
  Dr. Brecht: Right, right. It all happens before
• 5:17
  Dr. Hirsch: So, we'll spend a couple of sessions online with
• 5:24
  Dr. Brecht, myself.
• 5:26
  And usually another surgeon. One that, as I'm removing the tumor will be
• 5:31
  harvesting
• 5:34
  from another area of the body that allows us to cut the surgery time
• 5:38
  in half, but the planning is about an hour, long, planning session,
• 5:42
  and we sit there and we look at the geometry of the jaw.
• 5:45
  The areas that need to be removed.
• 5:47
  What are the important anatomical landmarks?
• 5:51
  We have to respect and basically do a dress rehearsal prior to going
• 5:56
  to the OR. And so that's where the big thing is.
• 5:59
  And then once we do,
• 6:00
  That when we go to the OR, we already know what each each of us are
• 6:06
  going to do and it just goes much smoother in that we thought about it
• 6:12
  We've thought about what each of our parts should be and then, you
• 6:18
  know, the easy part is actually going and doing the procedure.
• 6:22
  Host: Tell me how technology plays a role virtual.
• 6:24
  Surgical planning, tell us about that.
• 6:26
  And how are you able to really get a great grasp of what's going on?
• 6:30
  Through the the use of very fine
• 6:34
  Finally cuts cat-scans that are very accurate.
• 6:38
  We can translate that to a 3D image and then on a computer program we
• 6:45
  can actually plan the surgery, plan the cuts of the surgery,
• 6:50
  everything can be planned to the millimeter.
• 6:52
  Once that's done that's translated to physical product by sending all
• 7:00
  That information to 3D printers and then 3D printers will make guides
• 7:04
  for us to take to surgery.
• 7:06
  They'll make specialized plates that are custom fit to the patient's
• 7:11
  jaw and even things down to the prosthesis and the teeth.
• 7:16
  Dr. Brecht is planning that virtually.
• 7:19
  So the entire surgery is planned on a computer and translated to the
• 7:25
  operating room using all 3D printers and that's that's pretty nice.
• 7:29
  Oval good thing about it is it can be replicated and so it's not just
• 7:35
  limited to our patient population.
• 7:38
  This is something now that has been brought to the masses in the
• 7:41
  United States and in Europe and virtual surgical planning can be done
• 7:47
  anywhere.
• 7:48
  So we will be planning, Larry be planning in his office.
• 7:52
  I'll be in my office will have an engineer that we might be working
• 7:56
  with in Colorado.
• 7:59
  So
• 8:00
  All of the technology that's humanly possible.
• 8:03
  Is brought to these cases.
• 8:06
  Host: Tell me who the ideal patient is for this procedure.
• 8:12
  Dr. Hirsch: That's a great question.
• 8:12
  I mean when we initially started doing this we thought we could do
• 8:16
  this, only on select patients.
• 8:19
  So a young patient with a benign tumor that probably wasn't going to
• 8:25
  get radiation.
• 8:27
  We thought would be a good ideal patient.
• 8:30
  But at this point in time because we've been able to fine-tune
• 8:33
  everything we do there were we can do it on almost any patient that
• 8:40
  that needs a
• 8:41
  resection of their jaw.
• 8:43
  We used to think we couldn't do it because patients were going to get
• 8:45
  radiation.
• 8:47
  But again, as we've gotten better at doing the technique and we've
• 8:51
  learned the intricacies of what works and what doesn't work.
• 8:55
  I think the really there's no limitation on who we can do it on.
• 8:59
  Host: That's awesome.
• 9:00
  Dr. Brecht, tell us about how you fabricate teeth.
• 9:06
  Dr. Brecht: Again, technology is really the driving force here, you know, your leg
• 9:11
  bone, the fibula really looks like your jaw bone, your lower jaw bone
• 9:16
  without teeth.
• 9:18
  Like, you know, somebody wearing a denture.
• 9:20
  If you took their lower jaw out
• 9:21
  It looks just like a leg bone.
• 9:24
  Except now we have the ability to attach the teeth - a denture - to
• 9:30
  A leg bone through these implants, we fabricate them from a very
• 9:38
  aesthetic, acrylic material, that's milled by computer starts out.
• 9:43
  As a looks like a big hockey puck, except it's tooth-colored and
• 9:47
  computer off of our planning, and our design mills out what the teeth
• 9:52
  should look like.
• 9:53
  We put those in in the operating room.
• 9:55
  We attach them to the implants.
• 9:58
  We let the patient go through.
• 10:00
  Probably want a bit about like a three-month healing period, fine-tune
• 10:04
  it, maybe get them a second set of teeth to refine
• 10:08
  any changes that the patient really wants to have.
• 10:10
  Maybe they started out with crooked teeth.
• 10:12
  We gave them crooked teeth in the OR and they're like, you know, I
• 10:15
  really wish my teeth were straight.
• 10:16
  We make them a second set when the person is really happy with the new
• 10:21
  set of temporaries.
• 10:22
  Then we go off and make a final set.
• 10:25
  Instead of Milling it out of acrylic.
• 10:26
  We Mill it out of this material called zirconia, which is
• 10:29
  we're familiar with their zironica as an artificial diamond
• 10:33
  and it's the same material.
• 10:35
  It's just in a different crystal structure.
• 10:37
  Instead of it being clear
• 10:39
  it has a tooth color shade or gradation between, you know, having
• 10:47
  an opacity to it to maybe as the top of your teeth, have some
• 10:51
  transparency, the very, very aesthetic, very durable.
• 10:55
  Those are long-term teeth.
• 10:56
  We put those in patients that we've treated 10.
• 11:00
  years ago.
• 11:00
  They still have those those teeth in place.
• 11:03
  Host: It's amazing.
• 11:04
  And how long does it take before?
• 11:06
  A person is back to, you know, a hundred percent, you know, eating
• 11:09
  talking back to work, all this stuff
• 11:14
  Dr. Hirsch: Depends on the patient, their age, but I think typical patient
• 11:19
  probably spends about five days to seven days in the hospital and then
• 11:23
  we start them eating while they're in the hospital.
• 11:26
  We start Physical Therapy when when they're in the hospital.
• 11:28
  So, usually the first post-op visit
• 11:31
  we're trying to get them moving towards more normal everyday
• 11:38
  activities, but it does, it does take time.
• 11:42
  It's a big operation.
• 11:44
  But typically, you know, I think by three weeks we have them eating
• 11:50
  most Foods.
• 11:51
  Dr. Brecht: Yeah.
• 11:52
  I think the remarkable thing is, you know, we started out pretty much
• 11:57
  uh, on younger patients that had a
• 12:00
  really aggressive benign tumor
• 12:02
  that was really destructive
• 12:03
  and the only way to eradicate it was to take out the entire portion of
• 12:07
  the jaw that was affected by then.
• 12:10
  And then a little more right, make sure you've got it all out. And over
• 12:15
  time as David said, realized that this the technique is applicable to,
• 12:22
  you know, even even older patients.
• 12:24
  I'm trying to think.
• 12:24
  But the oldest patient we've done is and
• 12:30
  Dr. Hirsch: I probably early 80s.
• 12:32
  Dr. Brecht: Yeah, and you know, people are remarkably.
• 12:39
  In a grateful, it's humbling on our side.
• 12:41
  These are these are people.
• 12:43
  You know, in the dental side.
• 12:44
  I'm doing
• 12:45
  We're both doing follow-up.
• 12:48
  I tend to see people, you know, regularly probably every six months
• 12:52
  making sure everything is okay for, for a few years and then kind of
• 12:56
  like after the five-year mark.
• 12:58
  I'm probably still the person seeing the people because I want to make
• 13:02
  sure the prosthesis is okay.
• 13:03
  I want to make sure the implants are okay, that everything is tight
• 13:07
  and you develop.
• 13:08
  A very long-term relationship with people that we put them through
• 13:14
  this experience.
• 13:14
  It's really life-transforming for them and they go about life, pretty
• 13:19
  much as normal afterward.
• 13:23
  And it's, it's very humbling on our end to do this.
• 13:26
  I mean, you know, every time I see one of these done, I'm, I'm still
• 13:32
  amazed.
• 13:33
  I still get a rush.
• 13:35
  I'm so happy in what I've chosen to do
• 13:39
  for my life's avocation.
• 13:42
  I'm happy to be around colleagues who are really great at what they
• 13:47
  do.
• 13:47
  And after 20 years
• 13:50
  they still want to push the envelope.
• 13:51
  That's, that's the definition of being a professional.
• 13:56
  Host: It's great.
• 13:57
  Speaking of moving out to Long Island.
• 13:58
  Your first patient was Tara Singh, and she had an amazing result and you
• 14:02
  did something a little bit different on this.
• 14:04
  Tell us a little bit about how that procedure went.
• 14:06
  And what was the new process there.
• 14:09
  Dr. Brecht: Well, you know, my incredibly humble surgical colleague here, is I
• 14:15
  find it fascinating.
• 14:16
  I've got this picture up here on the computer screen and there's this
• 14:20
  plate here that holds all the pieces of the leg bone together to form
• 14:25
  a jaw bone.
• 14:26
  And one of the things we did on the march from a simple operation to
• 14:31
  the operation we're at now
• 14:33
  is David really was able to perfect the technology.
• 14:38
  And the surgery, we're not just taking the leg bone and maybe breaking
• 14:43
  it into three pieces to make it look like a jaw, but maybe somebody
• 14:48
  had a bigger native jaw and needed to have more height in their leg,
• 14:53
  bone forming, their jaws.
• 14:55
  So, what he was able to design with the
• 15:00
  surgical colleagues that put it all together, but they were able to do,
• 15:04
  is they would split the leg bone put it on top of itself in.
• 15:08
  Come up with a bar design that again is custom made by computer.
• 15:12
  You couldn't do this before that technology was around and it's called
• 15:16
  a double barrel technique.
• 15:18
  And what it is able to do is give a remarkable resemblance to a
• 15:23
  patient's, you know, pre-surgical jaw form.
• 15:27
  Dr. Hirsch: We do that quite frequently depending on where the defect in the
• 15:33
  in the jaw is.
• 15:34
  Host: Yeah.
• 15:34
  And the outcome is so amazing because you would never think that she
• 15:37
  had surgery.
• 15:37
  And I'm hoping that my producer, Brian Donnelly will be able to link
• 15:40
  that video in there because I think you should people should see that
• 15:42
  video and see the success that that was able to be done for her.
• 15:46
  Dr. Hirsch: Yeah, and lastly, you know, when you make the comment that they don't
• 15:50
  look like they had surgery.
• 15:52
  So one of the nice things about the virtual surgical planning, is it
• 15:54
  allows us to do somethings blindly
• 15:57
  The plate usually fits very well.
• 16:01
  And so we used to have to get access to the entire mandible, to make
• 16:07
  sure everything was exactly where we wanted it.
• 16:09
  Now when things fit, I'm able to make smaller incisions make really
• 16:15
  small incisions in the patient's face, make the majority of my
• 16:19
  incisions inside the patient's mouth.
• 16:21
  And so when you can make more incisions in the patient's mouth and
• 16:25
  have less scars on the face
• 16:27
  patients then really start to look like they don't have surgery,
• 16:33
  you know, if you can make a three-centimeter incision instead of a 10
• 16:37
  centimeter incision in somebody's neck.
• 16:39
  It's a huge benefit, especially to a young patient who does not
• 16:43
  have wrinkles.
• 16:45
  Host: You'd mentioned before that you two pioneered this, and now it's being
• 16:49
  replicated all over the country.
• 16:51
  What about, are other
• 16:54
  Where does this go from here?
• 16:55
  Are there other applications for this?
• 16:57
  Maybe in other types of surgery.
• 16:58
  Are other people looking at your work here and seeing how they can
• 17:01
  maybe help somebody else.
• 17:02
  Maybe not a jaw, or something else?
• 17:05
  Dr. Hirsch: Yeah, I mean it's been so it has been replicated and in the field of
• 17:11
  Orthopedics.
• 17:14
  The first oral surgical planning... they started to use it
• 17:17
  after we were doing a lot of head and neck stuff, were always asking
• 17:22
  ourselves
• 17:22
  what can we do next?
• 17:24
  And what's the next thing?
• 17:27
  We're always trying to look to to make things more efficient and come
• 17:30
  up with new ways of doing these things.
• 17:32
  That's what that's what makes all of this very
• 17:35
  I think exciting to us.
• 17:37
  Host: What does it look like when you do these 3D images, right?
• 17:40
  And you do these, these scans of the mouth and you're going to do this
• 17:44
  surgery.
• 17:44
  You want to go right to the letter.
• 17:46
  You want to make it perfect.
• 17:47
  And that's why you do this
• 17:49
  virtual surgical planning.
• 17:50
  When you're done you go back and look and see how exact it is?
• 17:54
  Dr. Hirsch: Yeah.
• 17:54
  Host: And how exact is it?
• 17:56
  That's a very insightful
• 18:00
  question. So when we first started doing it, we wanted to know.
• 18:04
  Are we accurate?
• 18:06
  Are we doing this right
• 18:07
  So every patient that we did it on, we probably did it for the first
• 18:10
  20 patients is we got a post-operative CAT scan, and then overlay
• 18:16
  the images that we planned with what we turned up with after the
• 18:21
  operation just to see, are we close?
• 18:25
  What can we do better?
• 18:26
  And it was remarkably accurate
• 18:30
  The overlay was always within one with actually within one
• 18:34
  millimeter of what we planned and you know, that would just kind of
• 18:39
  proof of concept to us.
• 18:42
  And that that type of accuracy, you know, we needed to prove I think
• 18:46
  in the beginning to make sure that we were doing the right things here.
• 18:52
  Host: So we always like to end on a positive note here, on 20-Minute Health Talk
• 18:55
  And so I like to ask both of you and I'll start with you.
• 18:57
  Dr. Brecht, just tell me.
• 18:57
  What gives you hope?
• 18:58
  What gives you optimism going forward?
• 19:01
  Dr. Brecht: I'm incredibly optimistic when I see young people being excited about
• 19:09
  techniques like this and wanting to learn and just kind of soak it up
• 19:13
  because they're the repositories for the next Innovation that's going
• 19:18
  to drive this forward.
• 19:19
  I remember when David and I started this person who trained just ahead
• 19:25
  of us and kind of was one of the pioneers of leg-to-jaw surgery
• 19:29
  we were at a talk and he came back and we asked him.
• 19:36
  why he stopped doing the operation and he said, he couldn't figure out
• 19:38
  what the next iteration to the operation was and, you know, David and
• 19:43
  I looked at one another like, 'wow, that's, you know, how could you not see..."
• 19:46
  Right? Technology came along at the same time.
• 19:49
  So, I'm excited about technology and I do remember, when a, when a
• 19:54
  younger Dr. Hirsch came to me and said, hey, I have this idea and people told me
• 19:59
  you're the guy i need
• 20:00
  to come find.
• 20:01
  I remember that day
• 20:02
  so clearly, and after he told me what his vision was, I said, 'this is
• 20:08
  at, this is great.
• 20:10
  I'm happy to do this with you.'
• 20:13
  So I think I'm hopeful that we've got great teachers in this system.
• 20:19
  We've got motivated, young people, and between young people and
• 20:24
  energy and technology
• 20:27
  I think things will be good
• 20:28
  Fantastic. Dr. Hirsch
• 20:30
  what gives you hope and optimism?
• 20:31
  Well, that once hard to follow
• 20:34
  For me, Northwell Health has given me a platform to do
• 20:44
  what I want to do
• 20:45
  professionally. Allowed me the autonomy and Leadership role that I can
• 20:56
  recruit and surround myself with people
• 21:00
  who I think are great. And if I couldn't surround myself that people
• 21:06
  that are better than me and that are very bright and Excel then they
• 21:14
  make me look good.
• 21:15
  And so I'm really optimistic of what we're growing here throughout the
• 21:21
  Northwell system, at Lenox Hill, at LIJ, at North Shore.
• 21:28
  And so for me the future
• 21:30
  is really bright because I love what I'm doing and I love who
• 21:34
  I'm doing it with.
• 21:35
  So it's pretty hard, not to be excited to come to work when when you
• 21:40
  have that situation set up for yourself.
• 21:43
  Host: That's awesome.
• 21:44
  Well, Dr. Hirsch, Dr. Brecht
• 21:46
  Thank you so much for joining us here on 20-Minute Health Talk.
• 21:48
  And for you, the listener
• 21:49
  thank you so much for tuning in.
• 21:50
  Have a great day and stay safe.
• 21:53
  Dr. Brecht: Thanks, Rob
• 21:58
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• 22:01
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