Maybe there's a downside to the delicate facial surgery Elexis Wathogama-Nunez underwent to fix her jaw. Now, the 2-year-old can open her mouth and really let loose.
"She could cry, but not as loud as this," her father said with a half-smile as Elexis sat wailing in his lap.
Dressed in a peach hospital gown in the Banner Children's Hospital pre-op last week, the toddler knew what was in store. She would undergo anesthesia so that Dr. Jeffrey Goldstein could use a device to stretch her mouth wide open and hold it that way for about five minutes. Then, he'd do it two more times.
All the stretching, along with outpatient physical therapy and frequent exercises at home, follows surgery in January in which Goldstein removed the part of Elexis' jaw that had fused to her skull bone and rebuilt a new ball-and-socket temporo-mandibular joint.
Before surgery, Elexis could open her mouth only slightly, about 1 millimeter wide.
Her speech was delayed, she couldn't get a toothbrush into her mouth and, in order to eat, her parents had to stuff food into the side of her mouth, which she would pocket in her right cheek like a chipmunk's until she could swallow it.
Now, she's able to fit a stack of 11 tongue depressors in her mouth. Elexis' family and Goldstein are pleased with the results.
"It's going to get better as the muscles stretch a little more," Goldstein said. "I think where we are in six months is where it's going to stay."
The craniofacial surgeon is among a growing list of pediatric specialists recently recruited to the children's hospital at Banner Desert Medical Center in Mesa, in anticipation of a $230 million expansion anchored by a seven-story pediatric tower set to open next fall.
Goldstein, who arrived a year ago, and other physicians have been instrumental in recruiting specialists by talking up the new pediatric facilities. A nationwide shortage of specialty physicians means those coming out of residency have their pick of jobs.
"It's a very competitive world out there," said Rhonda Anderson, interim CEO of Banner Desert and Banner Children's. "They can leave a legacy here. There isn't 25 years of an entrenched organization."
More than 30 pediatric specialists are on board, including a neurosurgeon who starts in July and a team of oncologists whose patients can participate in national drug trials.
"They're coming into a program that they can help shape," Anderson said.
That includes having a say about the look and feel of the new pediatric tower, from the entrance and admitting areas to the use of child-life specialists, who help kids and their families through surgery and other medical procedures.
Elexis' condition, called TMJ ankylosis, may have been present from birth or caused when she fell off a bed. The most common cause is from trauma, like a sharp blow to the chin, but Goldstein said her X-rays don't show that she had a fracture.
Her surgery was intricate. Goldstein made an incision, which now looks like a thin headband, across the top of her skull and pulled her skin down past her nose. That exposed the fused bone without risking severing the nearby carotid artery and gave the surgical team a broader, better view.
After a couple of days in the pediatric ICU, Elexis returned to her family in the Fort McDowell Yavapai Nation. Home therapy is key to the child's recovery, and four or five times a day her mom or dad wedge a stack of tongue depressors in her mouth to stretch and strengthen her muscles.
Goldstein will do the jaw manipulation four or five more times, and then follow Elexis to see how the jawbones and muscles are growing. The muscle exercises are critical since she hadn't used those muscles during her first two years of life because she couldn't open and close her mouth.
Though her mouth can open much wider, her lower jaw is set back from the rest of her face. But as the joint grows, Goldstein said, the jaw will move outward somewhat. Still, since she lost some bone growth, she may need surgery as a teenager to lengthen the jawbone.
In pre-op last week, the little girl's crying was a delight to Goldstein, who said it was the widest he'd seen her mouth open.
"She loves me," he said, as Elexis cried on.