About Dr. Stanley Liu

Medicine is built to fix a single bad moment, like a broken bone or an acute infection, and it does that well. Sleep apnea is the opposite kind of problem. It builds slowly across decades, shaped by how the face and airway grew in childhood and how they keep changing with age. On top of that, there are non-anatomic factors we are only beginning to understand. A single night's study is a cross-section through a story that has been running for years, so Dr. Liu works from the whole arc: where a patient's breathing came from, what it is doing now, and where it is headed if nothing changes. Dentofacial deformity and sleep-disordered breathing did not happen overnight. Working out how things came to be is the best way to unravel them.

Sleep surgery is best seen as restoring missed milestones in facial and airway development.

Early in his career, Dr. Liu observed a pattern. A child is born premature, then mostly bottle-fed. Frequent ear and throat infections lead to ear tubes and rounds of antibiotics. Allergy testing reveals the child is allergic to many agents, "every form of plant and rock." The child falls off the growth curve, so growth hormone replacement therapy is started. Then comes the co-diagnosis of ADHD, and the child starts on stimulants. Things seem to get better.

Then the child sees an orthodontist. A number of premolar teeth are extracted, since there is not enough room in the jaws. After two years of orthodontics, the teenager is somewhat compliant with the retainer, but the bite has opened slightly in front, causing a lisp. One side of the jaw joint begins to ache, worse in the morning and accompanied by dry mouth. The teenager struggles through high school and college, often self-medicating with recreational substances.

Had this been a young woman, she would present with fatigue but without snoring or the classic, largely male signs of sleep apnea. She is more likely to be placed on antidepressants and anti-anxiety medication than evaluated for her breathing. Part of the problem is that our AHI cutoffs and symptom descriptions are drawn largely from middle-aged men.

Earlier recognition and a sleep study might have directed the child to allergy treatment, inferior turbinate reduction, tonsillectomy and adenoidectomy, or nasomaxillary expansion. Any number of these combinations might have adequately restored sleep breathing health and prevented the story above. This scenario is not uncommon. It has become a public health epidemic.

Patients often arrive with a lot of numbers from CT scans. Those numbers stay as data until they connect to a person's history, the childhood allergies, the years of orthodontics, the bed partner who describes the snoring and the pauses. A measurement only becomes information once it is tied to a need, a mechanism, and a story that runs from the past into the future. Dr. Liu starts where the patient starts, because the account of how someone actually breathes is the most reliable instrument in the room. The best measure of nasal obstruction is not a CT scan or rhinomanometry. A nasal passage that looks wider on before-and-after CT scans does not mean the patient breathes better, unless the patient tells us.

"When a patient says they don't breathe well, they don't breathe well."

Sleep surgery is not about reconstruction. Reconstruction is when a tumor is removed with the surrounding tissue, and other tissues are used to reconstruct the defect. Sleep surgery does best when it restores form, which allows the retraining of function.