Successful Correction of Primary Incomplete Cleft Lip Defect
A 3-months-old baby girl from Delhi was brought to our hospital. The parents complained about her deformed lip, nose and requested to correct the same. They were worried about their baby girl’s appearance. The baby was diagnosed with incomplete cleft lip. Maxillofacial Surgeon Dr. S.M. Balaji planned to correct the lip and nose defect surgically. The primary cleft lip repair was done using modified Millard’s technique. Primary rhinoplasty was also done. The baby’s appearance improved greatly. Her parents were overjoyed to have the defect treated with negligible scar formation.
Unilateral Cleft Lip Correction Surgery – Dr. SM Balaji, Maxillofacial Surgeon, India
Baby boy is born with a unilateral cleft lip and palate: This baby boy is the grandson of a famous merchant in Bangalore, Karnataka. He was born with a severe form of unilateral cleft lip and palate. There was a wide cleft space with ill developed segments. Balaji Dental and Craniofacial Hospital, a world-renowned cleft surgery centre: The family searched far and wide for the best cleft surgeon in India. They made enquiries all over the country, including all metro cities. Friends too joined in the search for the best hospital. One friend finally zeroed in on Balaji Dental and Craniofacial Hospital in Chennai. Further enquiries revealed it to be a world-renowned centre for cleft correction. The parents then made discreet enquiries about the hospital. Once satisfied, they presented at our hospital for repair of the cleft deformity. Dr SM Balaji, Cranio-maxillofacial surgeon, examined the baby. He decided to perform a modified Millard’s Technique to repair this baby’s cleft lip defect. Dr Balaji explained this to the parents in detail. The parents consented to the operation. Perfect adaptation of the cleft halves of the upper lip: A modified Millard’s technique leads to less scarring. It also gives better functional and esthetical results. Customization of the approach depends upon the degree of cleft and muscular involvement. Being ambidextrous (the ability to work with both hands) is an advantage for this surgery. A modified Millard’s flap was first employed. The C flap was then used to recreate the nasal sill while the M flap was next used to create the floor of the nose. All tissues were well used in the reconstruction and there was no tissue wastage. There was a perfect adaptation of the two halves of the cleft. Need for further surgeries explained to the parents: The need for further surgeries was then explained to the parents. This would be necessary for the complete rehabilitation of the baby’s deformities. Surgery Video
Medial Tarsorrhaphy of the eye for Ptosis
[et_pb_section fb_built=”1″ _builder_version=”3.22″][et_pb_row _builder_version=”3.25″ background_size=”initial” background_position=”top_left” background_repeat=”repeat”][et_pb_column type=”4_4″ _builder_version=”3.25″ custom_padding=”|||” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.9.4″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” hover_enabled=”0″ sticky_enabled=”0″] Prof SM Balaji plans ptosis surgery for the patient A patient is a young man who was unable to close his left eye due to ptosis. This was leading to continuous drying of the eye with the potential for damage to the cornea. He presented to Dr. SM Balaji, Craniofacial Surgeon, Chennai, for correction of his problem. Dr. Balaji decided thttps://smbalaji.com/dr-sm-balaji/o proceed with a medial tarsorrhaphy. Successful surgical correction of the patient’s ptosis An incision was first made inferior to the left eyelid margin. This was medial to the punctum and through the skin and orbicularis muscle. This incision was then extended to the medial canthus. It was then continued along the upper eyelid. This was in a similar fashion such that it presented as a sideways V-shaped incision. Dissection was then carried out between the anterior and posterior lamella. This was along the length of the incision. The posterior lamella of the upper and lower eyelid was then sutured together with interrupted sutures. Care was always taken to ensure that the canaliculus was not damaged by the sutures. The anterior lamella was then sutured together with Vicryl sutures. These anterior lamellar sutures should not be too far medial. This is to avoid formation of a webbing deformity in the region. The patient tolerated the procedure well. Surgery Video [/et_pb_text][et_pb_video _builder_version=”4.9.4″ _module_preset=”default” src=”https://www.youtube.com/watch?v=bma_uFiiTyw” hover_enabled=”0″ sticky_enabled=”0″][/et_pb_video][/et_pb_column][/et_pb_row][/et_pb_section]
Velopharyngeal insufficiency (Hypernasality) Nasal Speech Correction Surgery for Cleft Palate- Pharyngoplasty with positive suction test
Initial Presentation This young man from Yangon, Myanmar, had been born with a cleft lip and palate and had undergone cleft repair as an infant. He had subsequently developed velopharyngeal incompetence, where there is escape of air through the nose during speech. This had lead to him having difficulty pronouncing certain words well and he also had a nasal twang to his voice. He had very limited mouth opening. He presented to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai for surgical correction of his speech difficulties. He had been referred to a speech pathologist who advised him for a sphincter pharyngoplasty surgery to correct his velopharyngeal incompetence/hypernasality. Treatment Planning and Surgery Dr SM Balaji, Cranio-Maxillofacial Surgeon, examined him and advised him that he needed a pharyngoplasty surgery for correction of his problem. The patient agreed to this and was scheduled for surgery. This surgery is performed for the creation of a dynamic sphincter in the pharynx by repositioning of the palatopharyngeus muscle. The patient was taken to the operating room and underwent general anesthesia without complications. Incisions were made to release the posterior faucial pillars, including the palatopharyngeus muscle. These were then crisscrossed and sutured together on the posterior pharyngeal wall. This formed a sphincter along with the formation of a small opening or “port” for the patient to breathe through his nose. Though his mouth opening was very limited, his sphincter pharyngoplasty was very successful. Successful Positive Suction Test Demonstrates Successful Surgery Successful demonstration of a positive suction test at the completion of the surgery revealed a dynamic velopharyngeal sphincter action thus indicating successful correction of his velopharyngeal incompetence. The patient was then extubated and recovered from general anesthesia without complications.
Prof SM Balaji receives the highest scientific award at the World Cleft and Craniofacial Congress, Germany
Prof SM Balaji has been honored with the highest scientific “ Prof David Precious Award ”. This was at the 12th World Cleft and Craniofacial Congress held in Leipzig, Germany. He is the first Indian to receive the honor on such a platform. The award comes with a citation, plaque and a cash award of US $1000.00. Prof Kenneth Salyer, the world-renowned Craniomaxillofacial surgeon, presented him with the award. He is the President of the International Cleft Lip and Palate Foundation. Congress President, Prof Alexander Hemprich was also present. Prof Marie Tolarova, Member, Board of Trustees, ICPF spoke a few words about Dr. S M Balaji‘s achievement. This award is the highest award of the International Cleft Lip and Palate Foundation. Achievements of International Cleft Lip and Palate Foundation The International Cleft Lip and Palate Foundation (http://www.icpfweb.org) is a thirty-year-old forum. It is multidisciplinary with members including all stakeholders involved in orofacial cleft rehabilitation. This is a non-profit organization. It promotes service to humanity and the dissemination of scientific knowledge. The ICPF coordinates volunteer surgical missions in underdeveloped and developing countries. It sponsors surgeries in Vietnam, Cambodia, Tunisia and various other developing countries. They teach the local surgeons and cleft teams about cleft rehabilitation. The ICPF has its headquarters in Japan and has over 3000 members from over 60 nations across the world. Prof David Precious, Cleft Lip and Palate Specialist One of the founding Presidents of ICPF was Prof David S Precious. Prof David Precious resided, taught and served in Halifax, Canada. He was a notable Cleft surgeon who trained under Prof Delaire. Prof Delaire was the founding father of Craniomaxillofacial and Plastic Surgery. Dr. Precious established a Cleft Surgery unit in Canada. Prof Precious also continued research into Cleft treatment. He had many publications to his credit. In 2015, Prof David Precious passed away after a brief illness. The ICPF decided to instate a Scientific Award in his honor. It was in recognition of his immense scientific contributions to Orofacial Cleft rehabilitation. This is the highest Scientific Award of this noted International Organization. International Recognition for Prof SM Balaji’s Ground-Breaking Research Prof SM Balaji conducts research in Protein Guided Tissue Regeneration. He uses this for surgical cleft correction. The award is for these groundbreaking studies. Scientific merit was the basis of selection for this award. The selection panel consisted of world-renowned cleft rehabilitation surgeons. Prof SM Balaji’s pioneering work removed the necessity of a second surgery and more bone grafts. This led to great improvement in the quality of life of the patients. It also avoided a lot of complications associated with synthetic substances.
Periapical Cyst Enucleation, retrograde filling with MTA and defect filling with Bio-Oss
Presence of periapical cyst The patient is a young man who presented at Balaji Dental and Craniofacial Hospital, Chennai, with pain in the upper left central incisor, which had previously undergone root canal treatment elsewhere. Radiographic investigations conducted revealed a periapical cyst in relation to the tooth. Dr S M Balaji, Cranio-Maxillofacial Surgeon, decided to perform enucleation of the periapical cyst followed by retrograde filling of the root apex with Mineral Tri-Aggregate (MTA) and filling of the bony defect with Bio-Oss. Cyst removal with filling of defect The patient was taken to the operating room and a mucogingival flap was raised to the level of the root apex. A window was created in the bone and the cyst was removed in its entirety. The root apex was cut (apicoectomy) and removed following which the stump was retrograde filled with MTA. The bony defect was then closed with Bio-Oss and the flap was sutured back into anatomical position. Successful resolution of infection The patient underwent regular post-operative checkups over a period of six months and x-rays showed complete resolution of the infection with filling in of the bony defect with new bone.
Facial Paralysis – Reanimation by Temporalis and Fascia lata Dynamic Sling Surgery
Indian Academy of Maxillofacial Surgeons’ Advanced Craniofacial Surgery Workshop The Indian Academy of Maxillofacial Surgeons conducted their Advanced Craniofacial Surgery workshop on “Current Advances in Cranio-Maxillofacial Surgery” at Hitkarini Dental College and Hospital & Jabalpur Hospital and Research Centre, Jabalpur, on February 15-18, 2018. Many leading Cranio-Maxillofacial surgeons from around the world participated in this workshop. The programme director was Prof. J.N. Khanna and the programme coordinator was Dr. Rajesh Dhirawani. Foreign Faculty at the Workshop Prof. G. E. Ghali, Chancellor and Dean, LSU Health Sciences Center and Gamble Professor and Chairman, Oral and Maxillofacial Surgery -Shreveport, USA and his entire team of key opinion leaders played the role of mentors for this huge workshop. Other foreign faculty who were present at the workshop were Dr. Andrew Meram, Dr. Mary Laura Hastings, Dr. Ahmed Tamim and Dr. Hendell Nealy. Dr. S.M. Balaji Invited for Demonstration of Congenital Facial Palsy Correction Surgery Prof. Dr. S. M. Balaji was invited as a key operating faculty for this workshop. A case of congenital facial palsy was allotted to Prof. Dr. S. M. Balaji to demonstrate the facial reanimation procedure. Planning for the Dynamic Temporalis Sling Surgery The patient was a middle-aged male who had congenital facial palsy and facing a lot of health and social issues due to the facial palsy. Due to case selection and studies were performed. Considering all clinical and anatomical factors, a dynamic facial reanimation using Tensor fascia lata along with partial Tarsorrhaphy (surgery for joining of part of the upper and lower eyelids so as to partially close the eye) was planned. There were about 200 postgraduates and young oral surgeons from across India as the audience. The surgery was planned as an interactive session where the audience asked questions to operate faculties. Live Surgical Demonstration with Commentary by Prof. S.M. Balaji The patient suffered from a congenital lower motor neuron type of paralysis. To correct this condition, a strip of fascia lata from the vastus lateralis was first harvested. The next step of the surgery was performed through a combined preauricular and intraoral approach. The insertion of temporalis into the coronoid process was released at the infratemporal area. The zygomatic arch was carefully cut and pushed down to free the temporalis muscle. Care was taken to preserve all the vital structures such as the parotid duct and gland in this area. This action was carried out without disturbing the deep temporal artery and nerve. Then through careful manipulation, the lower end of temporalis was identified to which an end of the fascia lata was attached. Through a nasolabial incision, the modiolus was identified. The free end of fascia lata was split into three parts – the lower part was connected to muscles of the lower lip, the middle part to the modiolus and the upper part to the upper lip. The connections were checked and ensured that the muscle attachments were secured and the dynamic facial reanimation was confirmed by the action of the muscles. To take care of the improper eye closure, a partial lateral tarsorrhaphy was performed. The patient recovered well. Post-surgical Conference by Dr. S.M. Balaji Prof. S. M. Balaji cleared doubts from the audience regarding the surgical procedure and carefully mentioned the tips for this kind of surgeries that he has learned over the years. The surgery was well-received by all at the workshop.
Orbital Blowout Fracture, Enophthalmos and Diplopia Correction Surgery
The patient’s facial deformities from fracture reduction after a road accident A patient is a young man employed in the UAE. He got involved in a road traffic accident a little over three years ago. This resulted in fractures to the facial bones on the right side. It also included a floor of the orbit blowout fracture. The patient was first treated as an emergency at the time of the accident. This left him with residual deformities from the fracture correction surgery. The patient developed diplopia and enophthalmos as a result of the surgical correction. The patient presents for consultation with Dr. S M Balaji The patient had been searching far and wide for the right surgeon to correct the deformities. He was then referred to Dr. S M Balaji, Cranio-Maxillofacial Surgeon by an oral surgeon in the UAE. The patient first contacted the hospital manager at our hospital. She requested the patient to mail all pertinent medical records to the hospital. Dr Balaji studied the medical records in depth including all imaging studies. He informed the patient that his facial deformities could be set right. The patient presented at Balaji Dental and Craniofacial Hospital’s Trauma care unit. All preoperative investigations were then performed. The surgery was then scheduled for the patient. Successful surgical correction of the patient’s fracture Under general anesthesia, a maxillary vestibular incision was first made. The site of the zygomatic fracture repair on the right side was then accessed. The plates from the previous surgery were then removed and the area refractured with a drill. An incision was next made extending from the outer canthus of the right eye. The plate from the previous surgery was then removed and the area refractured. This was next followed by a transconjunctival incision. The site of the orbital floor fracture repair was then accessed. All refractured segments were next brought into proper alignment. A Titanium mesh with Medpor coating was then shaped to align with the floor of the orbit. This was then placed on the floor of the orbit and screwed to the lower orbital wall. Transconjunctival incision was then closed with sutures. Refractured segments of the zygomatic bone were then replated and the incision sutured. The outer canthal incision was then closed with sutures. The patient recovered without an event from general anesthesia. The patient returns back to the UAE The patient expressed complete satisfaction at the time of discharge from the hospital. There were no noticeable facial scars from the surgical procedure. He was very happy with the results of the surgery.
Direct Sinus Lift Surgery with Allograft for Dental implant placement in Upper jaw
Dr. S.M. Balaji explains the Sinus Lift Procedure to the Patient The patient presented to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai for treatment. He was seeking replacement of missing right upper molars with implants. Dr. S.M. Balaji, Cranio-Maxillofacial Surgeon, examined the patient and ordered radiographic studies. There was inadequate bony height in the posterior maxillary region. This would lead to unsuccessful placement of dental implants by the conventional method. The patient then enquired if there were alternative treatments for implant placement. Dr. Balaji then explained the sinus lift procedure to the patient. It would done by placement of an allograft, Bio-Oss through a window in the bone. This would become consolidated into new normal bone over a period of time. The new bone would serve as foundation for loading of normal biting forces on the implants. He was in total agreement with this treatment plan and agreed to surgery. Successful Sinus Lift Procedure through Bony Window with Placement of Bio-Oss Allograft Material After infiltration of local anesthesia, a window was then made in the bone with a round bur. The window was in the lateral wall of the maxillary antrum. This wall forms the boundary of the right maxillary sinus. The sinus floor was then lifted taking care not to damage the Schneiderian membrane. This membrane is the lining of the sinus. Implants were then placed in the bone. These implants will mimic the roots of natural teeth. Allograft mixture was then prepared using approximately 1.5 mL of the patient’s blood and Bio-Oss. This was then packed into the sinus pocket tucked below the sinus lining. The height and width of the implant bearing bony area would thus increase. With time, there would be consolidation of the allograft into new bone. This new bone will provide a good bony foundation for the implants. Success of the implant treatment depends on this. The flaps were then closed with sutures. Future Placement of Ceramic Prosthesis on Implants: His next visit would be after three months. After confirmation of proper osseointegration, ceramic prostheses would then be attached to the implants. This would complete the patient’s rehabilitation process.
Unilateral Condylar Fracture (jaw Joint) Open Reduction and Plate Fixation Surgery
The patient is a teenage boy from north India. He had a road traffic accident. This lead to development of pain and swelling in the left preauricular region. He also demonstrated deviation of his mouth to the left upon mouth opening. His parents took him to a hospital for radiographic studies. The doctor who examined him explained to them that he had a fracture of the left condyle. He added that this needed surgical correction. Since this was a difficult surgery to perform, he said it needed expert care. He then referred the patient to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai. This is one of the leading Cranio-Maxillofacial Superspecialty Surgical Hospitals in India. Dr. S.M. Balaji, Cranio-Maxillofacial Surgeon examined the patient. He then ordered 3D axial CT scans. It revealed the fractured left condyle of the mandible. Dr. S.M Balaji then explained to the parents that the fracture was in a region that was difficult to approach. He said that the conventional method would not work. Only the modified preauricular incision approach would work, he explained. The parents were in agreement with the treatment plan. The patient was then scheduled for surgery. Treatment was by open reduction and internal fixation of his left condylar fracture. General anesthesia was first induced. Then Dr. S.M Balaji marked the proposed modified preauricular incision with a marker. The incision was then made with great care. This was to avoid injury to vital structures in the region. The facial nerve and the parotid gland were thus protected. Dissection was then carried down to the region of the fracture of the condyle. The fractured condyle was then plated. Plate fixation check for stability was positive. The incisions were then closed in layers with sutures. The patient recovered without event from general anesthesia. He was then scheduled for suture removal in seven day’s time. The patient presented on the seventh day after surgery for suture removal. He then demonstrated the ability to open his eyes wide, shut his eyes tight and open his mouth wide without pain. This demonstrated absence of any damage to the facial nerve. There was complete preservation of function with no neuropraxia or other neurological deficits.