Vertical augmentation genioplasty, LeFort I advancement, malar augmentation, BSSO by Distraction Osteogenesis Surgery for Double Chin Correction
Patient who hated his small jaw presents to our hospital This young man from Australia never liked his retruded chin. It caused him to have a double chin. He had always wished to have a more prominent mandible. His quality of life was also affected by this. The patient had enquired all over Europe, but the costs there were prohibitive. Being a medical doctor himself, he researched the Internet for a quality oral surgeon. His Internet search led him straight to our hospital. He got in contact with our hospital manager who arranged for his travel to India. Treatment plan explained to the patient The patient met with Dr SM Balaji who obtained a detailed history from him. He was very particular that he wanted advancement through distractors. This was because he wanted to monitor for himself the changes as the distractors were activated each day. A treatment plan was then formulated and explained to the patient. His double chin would be corrected. He was then scheduled for surgery. Surgical jaw correction for treatment of double chin A rib graft was first harvested from the patient. A Valsalva maneuver demonstrated absence of any perforation into the thoracic cavity. The incision was then closed with sutures. Attention was next turned to the retrognathic mandible. A vestibular incision exposed the anterior mandibular bone. The chin was then placed forwards with a vertical augmentation genioplasty. Two L-shaped four holed plates were then used to fix the bones of the chin. The posterior mandible was then osteotomized for placement of the distractors. Mandibular distractors were then fixed with screws and tested. There was adequate function of the distractors. Bilateral inferior alveolar nerves were carefully protected during the entire procedure. Attention was then turned to the maxilla. Maxillary osteotomy with placement of bone grafts aided distractor placement. Similar distractors were also utilized here. The incisions were then closed with sutures. The distractors were in stable position. 1 mm distraction per day will be next performed until adequate advancement of jaws. The patient recovered from general anesthesia without any complications. The patient expressed his complete satisfaction with the results before discharge.
Single sitting simultaneous unilateral cleft palate and lip repair
A boy from Ladakh with unilateral cleft lip and palate The patient is a 10-month-old boy with unilateral cleft lip and palate deformity. He lives with his parents in Leh. His family is from a pastoral background. A Good Samaritan from Delhi happened on this little boy during a trek in Ladakh. He offered to help the child and the parents accepted his help. The Good Samaritan did extensive Internet research. This was to find the best cleft lip and palate surgeon who could perform a total cleft repair in one sitting. His search led him straight to our hospital. Treatment planning for simultaneous cleft lip and palate repair Dr SM Balaji examined the patient and ordered imaging studies. He explained to the parents that both cleft lip and repair would undergo surgery. He undertook the surgery after detailed presurgical planning. Simultaneous cleft lip and palate repair surgery performed Under general anesthesia, cleft palate repair was first undertaken. Bilateral palatal flaps were first raised based on the greater palatine vessels. The Levator palatine muscles were then detached from their abnormal positions. These were then reattached into normal position like a hammock. A two layer closure was then done. The nasal floor was first closed in a separate layer with the vomerine flap making a reverse knot. Oral layer was then sutured by vertical mattress sutures. The vertical mattress sutures produce a ridge of thick mucoperiosteum. Flaps were then approximated to each other in the midline. This technique repositions the levator muscle in a more favorable position. Greater palatine osteotomy was then done to mobilize the artery. This was from the greater palatine canal. The suction test performed at the end showed good results. Unilateral cleft lip repair was then performed with the modified Millard’s technique. This resulted in a very good lip seal producing good esthetic results. Parents satisfied with very good surgical results The parents expressed their immense gratitude before discharge from the hospital. Surgery Video
Upper jaw Advancement Surgery Unilateral Cleft Hypoplasia – Lefort 1 Advancement Surgery
Patient presents for maxillary advancement surgery This young lady had been born with a unilateral cleft lip and palate. She had undergone cleft lip repair at our hospital at the age of 2 months. Cleft palate repair was later performed at the age of 10 months. After this, she had rhBMP-2 surgery for uniting the two pieces of the maxilla into one single bone. The patient now has a hypoplastic retruded maxilla with anterior crossbite. This had been causing her cosmetic problems with a deficient upper jaw. She wanted to have this corrected through surgery. The patient has also been undergoing fixed orthodontic treatment for cosmetic teeth alignment. Le Fort 1 maxillary osteotomy planned for the patient Dr SM Balaji is a renowned cleft lip and palate patient rehabilitation specialist. He decided to perform a LeFort 1 osteotomy with maxillary advancement for the patient. Complete correction of the patient’s crossbite occlusion Under general anesthesia, a mucogingivoperiosteal flap was first raised in the maxilla. A LeFort 1 osteotomy was then performed. The maxillary bone was then advanced by 2 cm. It was then stabilized in place with four L-shaped four-holed plates. Occlusion was then checked and deemed to be in perfect alignment. The mucogingivoperiosteal flap was then sutured back in place. She would need further fixed orthodontic treatment to perfect her teeth alignment. Postoperative period was uneventful. The patient expressed her happiness at the results of the surgery before discharge.
Microtia – Ear Lobe Correction – Balaji Dental and Craniofacial Hospital, India
Expert correction of microtia done at our hospital Microtia is a congenital malformation of variable severity of the external ear. Correction of this deformity is through reconstruction surgery. Dr SM Balaji is an expert at microtia correction. This staged procedure gives the best results for microtia correction. Stage 2 microtia correction after successful stage 1 microtia surgery The patient is now 14 years old. He has already undergone stage 1 costal cartilage placement under the skin. This had recreated the form of the left pinna. Stage 2 surgery involves lifting up the reconstructed left pinna. This lies flat against the side of the head after the stage 1 surgery. His left ear lobe was also deformed with skin tags. This too needed corrective surgery. He presents now for stage 2 surgery. Lifting up of reconstructed external ear from side of head Under general anesthesia, an incision was first made around the reconstructed pinna. This was then lifted up and stabilized in position with sutures. Attention was then turned to the deformed ear lobe. A skin incision was first made in the ear lobe and adapted to give normal form to the deformed lobe. Sutures were then used to close the incision. The patient expressed his happiness at the results before discharge from the hospital.
History of RTA, Asymmetry of the nose and enophthalmos Correction Surgery
Patient with nasal asymmetry and sunken right eye presents for surgery The patient is a young man who presented to our hospital for nasal asymmetry correction. This was from a road traffic accident six months ago. The patient had already been first operated on elsewhere. That surgery had failed. He also complained of having a sunken right eye. This condition has been present for a very long time now. The treatment plan was explained to the patient Dr. SM Balaji examined the patient and formulated a treatment plan. This was then explained to the patient in detail who agreed to the surgery. Surgical correction of nasal asymmetry Under general anesthesia, intranasal incisions were first made to correct the nasal asymmetry. This would ensure the absence of any visible scar formation. Through an intercartilaginous incision, the nasal septum on either side was first exposed. The upper nasal cartilage was then identified, and interdomain ligaments split. Medial and lateral osteotomies were then done on either side. The nasal base asymmetry was thus corrected Medpor implant used to correct right enophthalmos Attention was next turned to the enophthalmos correction of the right eye. A transconjunctival incision was first made in the right eye. This allowed for access to the floor of the orbit. A Medpor implant was then shaped to fit into the floor of the orbit. The implant was then screwed in place and stabilized. This resulted in the complete correction of the patient’s enophthalmos. The transconjunctival incision was then left open for spontaneous healing. The patient now had a symmetrical face. The patient expressed his utmost satisfaction with the results before discharge.
Dental Implant Placement on Reconstructed Upper Jaw(Maxilla) and Lower Jaw (Mandible)
Dr. S.M. Balaji explains the advantage of implants to the patient: This patient presented at Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, a few months ago with multiple missing teeth in both jaws. The patient has been partially edentulous for many years now. The patient requested dental implants to replace the missing teeth. Dr SM Balaji examined the patient and ordered CBCT(Cone Beam CT Scan) diagnostic studies in order to do bone mapping of the patient’s jaws. It was found that bone had resorbed in both the maxilla as well as the mandible. It was explained to the patient that the existing bone was inadequate for fixing the implants and that bone grafting would be required to reconstruct the maxillary and mandibular alveolar ridges in order to place the implants. The patient consented to surgery and bone grafting was performed. Implants placed for the patient: The patient presents now for placement of dental implants in the reconstructed areas of the maxilla and the mandible. Midline alveolar ridge incisions were made and the reconstructed areas of the bone were exposed. Screws that were fixed to hold the grafts in place were removed since the grafts had fused to the alveolar bone. Implants were placed in the reconstructed regions of the maxilla and the mandible. The alveolar flaps were then closed with sutures. Once adequate osseointegration had taken place between the implants and the bone over a period of 4-6 months, the flaps would be raised again and the crowns would be fixed on the implants. Surgery Video
Multiple times jaw reconstruction failed, Resurgery – Reconstruction with rib graft
Patient with five previous failed surgeries elsewhere The patient is a young man who lost his right mandible due to ameloblastoma. He had ignored it for years and this resulted in extensive loss of bone from the left lateral incisor. The left side of his mandible had been absent since the ameloblastoma surgery. He has undergone five bone grafting surgeries elsewhere since then. None of the surgeries had been successful and he has extensive scarring in the region. His family conducted an extensive Internet search for the best facial reconstruction surgeon. It led them straight to our hospital. Reconstruction of right condyle, ramus and body of mandible Dr SM Balaji examined the patient and ordered a 3D axial CT scan. The scan revealed complete absence of the ramus and condyle on the right side. There was extensive bone destruction of the body of the mandible. The treatment plan was then explained to the patient who agreed to the surgery. This would be by using transport distraction and microvascular reconstruction Rib grafts obtained for reconstruction of mandible Under general anesthesia, two costochondral rib grafts were first harvested from the patient. A Valsalva maneuver demonstrated absence of perforation into the thoracic cavity. The incision was then closed in sutures. Completely reconstructed right side of mandible Attention was next turned to the mandibular reconstruction. A mucogingivoperiosteal flap was then raised from the midline of the mandible. Intermaxillary wiring was then done on the left side to stabilize the mandible. Dissection was then carried down to the mandibular remnant on the right side. A Titanium reconstruction plate was then cut and shaped to the right size. This was then screwed to the distal part of the right side of the mandible. The costochondral grafts were then cut to the right sizes for mandibular reconstruction. These were then secured to the Titanium plate with screws. The condyle, ramus and body of the mandible were then reconstructed. The incision was then closed with sutures. The patient recovered without event from general anesthesia. The next stage of oral rehabilitation would be through the use of implants. These would be on the grafted bone thus giving the patient normal dentition.
Neurofibroma bulk reduction and asymmetry correction
Presentation of neurofibroma in this young man A neurofibroma is a benign nerve sheath tumour of the peripheral nervous system. This is an inherited disorder of the nervous system. It adds to the bulk of the tissues and can be very disfiguring and distressing to the patient. This causes facial asymmetry. Patient with neurofibroma presents for bulk reduction surgery The patient here is a young man who developed this condition from birth. This had led to extensive right sided facial disfigurement of the patient. He had undergone surgeries elsewhere, which left behind residual scars. The disfigurement had reached a level where it was beginning to affect the patient’s day to day life. His parents conducted extensive Internet research for the best facial reconstruction surgeon. Their search had led them straight to our hospital. Treatment plan explained to the patient Prof SM Balaji examined the patient and ordered imaging studies. Studies revealed that the patient also needed reduction of the lateral orbital rim. It also revealed that the patient needed reduction of his chin and the maxillary bone. The patient also had ectropion of the left eye. Correction of the ectropion would be through lateral tarsorrhaphy. The patient and his parents agreed to the treatment plan. Asymmetry of ears corrected with removal of excess tissue Under general anesthesia, markings were first made on the excess ear tissue. Excision of the excess tissue would lead to symmetry of the patient’s ears. The excess tissue was first removed and the wounds were then closed with sutures. Maxillary bulk reduction with mandibular chin reduction Attention was then directed to the chin reduction procedure. The chin was next approached through a labial sulcus incision of the mandible. Dissection was then carried down to the chin. An osteotomy was then done at the lower border of the chin. The bone was next shaped and screwed back on the mandible. Incision was then closed with sutures. Maxillary vestibular incision was next done to access the hypertrophic right maxilla. Neurofibromatosis tissue was then excised and removed. The maxilla was then reduced until it was symmetrical with the left side. The incision was then closed with sutures. Ectropion correction with lateral tarsorrhaphy An incision was next made over the right eyebrow in the temporal region. Bulk reduction was then done with excision of excess tissue. The incision was then sutured. Attention was next turned to the ectropion correction. Markings were first made in the supraorbital region. This was then followed by excision of the excess tissue. The tissue was then sutured close. An incision was next made extending distal from the lateral canthus of the eye. A temporalis flap was then raised. Dissection was then carried down to the lateral orbital rim margin. The bone was then trimmed with a bur. Holes were then made in the bone for the sutures to pass for lateral tarsorrhaphy. This was to correct the patient’s ectropion. The sutures were then passed through the holes and tightened for ectropion correction. Excess tissues were then trimmed and incisions closed with sutures. The patient tolerated the procedure well and recovered from general anesthesia.
Re-surgery of old zygomatico orbital fracture, chronic diplopia and asymmetry correction
Patient with residual facial deformity from old RTA correction surgery The patient is a young man who had suffered a zygomatico orbital fracture from a road accident. He had also suffered a depressed supraorbital bone fracture over his left orbit. This had happened in his hometown two years ago. He had undergone emergent surgery at a local hospital. This surgery had left him with an asymmetric face and chronic diplopia. The chronic diplopia was the result of an orbital floor fracture that had not been set right. This had been a source of trouble for him for the last two years. He decided to get it corrected and approached a general dentist. The general dentist referred him to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai. Radiographic studies reveal extent of deformities The patient presented at the hospital and Dr SM Balaji, oral surgeon, examined the patient. He ordered 3D axial CT scans and studied them. He explained the plan of treatment to the patient. The patient was in full agreement with the treatment plan. Rib graft harvested from patient Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva test did not reveal any perforation into the thoracic cavity. The incision was then closed in layers. Diplopia correction performed and facial symmetry reestablished Attention was then turned to correction of the patient’s diplopia. A transconjunctival incision was next made to access the orbital floor fracture. The contents of the orbit were first raised and entrapped muscles were then released. A titanium mesh with Medpor implant was then shaped to fit into the orbital floor. This was then attached to the orbital rim with screws. This resulted in complete correction of the patient’s diplopia. Attention was then turned to the depressed supraorbital rim. An incision was first made in the region of the depressed orbital rim. A piece of rib graft was then shaped to fit into the depression in the bone. This was then screwed into place. This restored symmetry by correcting the depression. The incision was then closed with sutures. Supraorbital bony depression corrected with bone graft The depression in the supraorbital region was next addressed. An incision was first made in the left maxillary vestibular region. Dissection revealed the bony depression in the supraorbital region. A piece of rib graft was then crafted to fit into the bony depression. This was then screwed into place. This resulted in reestablishment of perfect facial symmetry for the patient. The patient recovered from general anesthesia without any complications. The patient expressed his utmost satisfaction with the results of the surgery. The patient expressed his gratitude to Dr SM Balaji before discharge.
Hemifacial Microsomia and Microtia with absence of condyle corrected with reconstruction of ramus and condyle
Patient with hemifacial microsomia presents for treatment Hemifacial microsomia is a congenital disorder. It affects the development of usually one side and rarely both sides of the face. One child in every 5600 children born worldwide is afflicted by hemifacial microsomia. This condition results from the abnormal development of the first and second pharyngeal arches. Ears, mouth, and lower jaw bone are most often affected. The patient here is a young girl with hemifacial microsomia. She has left microtia and absence of the left mandibular condyle. Her parents researched the Internet for the best facial reconstruction surgeon. They zeroed in on our hospital based upon the Internet search results. Growth centre transplant planned for replacing missing condyle Dr SM Balaji examined the patient and ordered 3D axial CT scans. This revealed the presence of a rudimentary left condyle. He planned reconstruction of the condyle and ramus with costochondral rib grafting. This procedure is also known as growth centre transplantation. Parents of the patient were in full agreement with the treatment plan. Costochondral rib graft with perichondrium obtained Under general anesthesia, a costochondral rib graft with perichondrium was first obtained. The incision was then closed after ensuring absence of thoracic perforation. Subcuticular sutures closed the incision for minimal post healing scar. Surgical reconstruction of missing left condyle Following this, markings were then made over the mastoid region. This was to map out the distorted anatomy of the underlying structures. An incision was first made followed by dissection down to the condylar region. Facial nerve and parotid duct were duly protected throughout the surgery. The rudimentary condyle was present below the ear tag. The pterygomandibular raphae was then stripped off. The costochondral graft was then positioned in the posterior ramus. Upper part of the growth centre transplant was then positioned in the glenoid fossa. This was then fixed with screws. The incision was then closed in layers using subcuticular sutures. The patient recovered well from general anesthesia. The patient presented later at our hospital and expressed complete satisfaction. Surgery Video