The occurrence of craniofacial abnormalities in infants
A small percentage of infants are born with craniofacial anomalies. The frontal, parietal, sphenoid, occipital and temporal bones comprise the bones of the skull. The joint between these bones are called sutures. Infants born with trigonocephaly have a noticeable ridge running down the middle of the forehead. The old terminology for this defect was metopic craniosynostosis.
These birth defects are corrected by a surgery comprising of a team of neurosurgeons, plastic surgeons and craniofacial surgeons. This also comes under the purview of plastic surgery as there is esthetic improvement in the shape of the baby’s skull. Cleft lip surgery is an example of plastic surgery where there is functional as well as esthetic improvement through surgical intervention. Advent of the CT scan has enabled the development of such complicated surgeries to have a high degree of success.
Young child with metopic synostosis and trigonocephaly
The patient is a 6-month-old boy who was born in Punjab, which is the agricultural heartland of India. His parents noticed that his head was abnormally triangular in shape when viewed from above. There was also a prominent bony ridge on his forehead. Alarmed about this, they approached a local neurosurgeon. Suspecting that the patient had premature fusion of the metopic suture, the neurosurgeon obtained x-rays and diagnosed metopic synostosis with trigonocephaly.
Referral to our hospital from World Craniofacial Foundation
He got in touch with the World Craniofacial Foundation (WCF), which is an organization that helps with complete surgical rehabilitation of children born with prematurely fused cranial bones and other craniofacial deformities. Dr Kenneth E Salyer, Founder and director of WCF then referred the patient for surgery to Balaji Dental and Craniofacial Hospital (BDCH) in Chennai. Having identified BDCH as a center of excellence for craniofacial surgery in India, WCF had made the Balaji Craniofacial Foundation its Asian affiliate partner for referring such cases to our hospital.
Confirmation of diagnosis at our hospital
Dr SM Balaji, craniofacial surgeon, examined the patient and ordered 3D CT and other comprehensive imaging studies for the patient. These confirmed that the patient had metopic synostosis with trigonocephaly. This is a condition that arises from the premature fusion of the metopic suture of the skull. This results in the triangular shape to the skull.
A 3D stereolithographic model of the skull was obtained. In consultation with the neurosurgical team, a mock surgery was performed on this skull. Meticulous treatment planning was done and explained to the parents of the boy. They gave their consent and the child was scheduled for surgery.
Surgical correction of craniofacial deformity
Under general anesthesia and with the entire neurosurgical team in attendance, marking were made on the scalp and a bicoronal flap was raised to expose the trigonocephaly deformity on the frontal bone. Following this, bur holes were made on the frontal bone and a frontal bone osteotomy was performed using the craniotome. The frontal bone was then gently lifted out.
Fixation with sonic welding of the resected bones
Next, beginning at the pterion, a bone cut was made at the frontozygomatic suture and extended through the roof of the orbit to the frontonasal suture. This was then extended to the contralateral side. This resulted in complete detachment of the supraorbital bar from the skull. The metopic ridge on this segment was then trimmed. This was then advanced anteriorly by around 3-5 mm and fixed using sonic welding.
Advantages of using sonic welding over conventional titanium screws
Sonic welding consists of a polymer implant, which is picked up by the hand piece tip and inserted into the predrilled hole in the bone. When an ultrasonic sound wave is generated at the tip of the hand piece, the resultant vibration causes friction between the bone and the implant. This melts the polymer and makes it flow into the surrounding trabeculae of the bone. The polymer hardens once the hand piece is removed. This stabilizes the segments of the bone and holds it in place. The polymer slowly dissolves by the time bone healing is completed, thus making another surgery for removal of the implants unnecessary.
The metopic ridge on the frontal bone was also trimmed. Barrel stave osteotomy cuts were then performed on the frontal bone in order to create space for the growing brain. Following this, the frontal bone was placed back in position and fixed with sonic welding and dural hitch sutures.
The bicoronal flap was then brought back into position and closed with staples. The patient recovered well from general anesthesia and was taken to the recovery room in stable condition. Skull anatomy was observed to be normal and the parents of the baby were extremely satisfied at the results of the surgery.
Complete recovery during the postoperative period
On the fourth postoperative day, the drains from the surgical site were removed and the patient was back to baseline behavior. The staples were removed on the 12th postoperative day and there was good healing of the bicoronal flap. The patient was later feeding normally in the ward and was observed to be playing with his elder sibling.
Etiology of cleft lip and palate deformity formation
Cleft lip and palate deformity is the second most common congenital deformity in the world. The first is Down’s syndrome. Cleft lip and palate formation can be genetic, environmental or idiopathic. There is a higher chance of a baby with cleft being born to parents with cleft lip or palate. However, the gene responsible for cleft formation is yet to be identified.
Environmental factors include smoking, exposure to excess second hand smoke, alcohol intake and usage of certain illicit drugs. A clear link has been demonstrated between these factors and increased risk for cleft lip and palate formation.
Cleft lip correction is performed at 3 months of age and palate correction is undertaken at around 10-12 months of age. The lip repair is an intricate surgery performed by the cleft lip surgeon. The upper lip consists of three segments, which fuses in utero to form the upper lip. A split lip occurs when fusion of these segments does not happen. The lip tissues consist of the epithelium and underlying dermis muscles. Cleft palate surgery is performed when there is a hole connecting the oral cavity with the nasal cavity in the roof of the mouth.
A lip correction surgeon has to perfectly align these three elements of the upper lip. Perfect fusion results in minimal scar formation, which slowly fades away with time. When this alignment is less than ideal, it leads to thickened scar formation and muscle contracture of the lips. This causes a lack of full lip seal and poor esthetics. Scar revision surgery is performed to remove any unsightly hypertrophic scar tissue. This plastic surgery is performed keeping in mind the tissue planes of the lip.
History of cleft lip surgery in the olden days
There was a period in human history where babies born with a cleft were considered to be evil and were abandoned and left to die. This was brought about by mainly superstition and ignorance. Such practices were the norm for many babies born with deformities during that period. It was only after science began taking roots within human society that superstition and ignorance were overcome by humans and people began looking for ways to alleviate human suffering.
Ancient China boasted of a remarkable degree of scientific knowledge compared to most other parts of the world. The world’s first cleft lip repair was performed in China even before the advent of Christianity in the world. Greek and Egyptian medicine was also remarkably advanced for the times, but records from that period of human history have unfortunately been lost.
Cleft lip closure was performed successfully essentially because it involved only the soft tissue. Any involvement of the bone automatically rendered the process very difficult and prone to failure. It was because of this that the first successful cleft palate closure was accomplished only sometime during the eighteenth century.
Patient with a history of cleft lip and palate surgery referred to our hospital
The patient is a young man of 22 years of age who had undergone lip and palate repair as an infant. He also has a history of undergoing pharyngoplasty surgery and repair of the soft palate. He now feels that his upper lip is too long and there is insufficient show of upper teeth during smiling. This had left him feeling despondent and withdrawn. The patient also felt that his upper lip lacked adequate fullness. His parents had presented to a local plastic surgeon in their hometown who felt that he needed cosmetic lip surgery. He then referred them to our hospital for surgical correction of his complaints.
Initial examination with treatment planning explained to the patient
Dr SM Balaji, cosmetic lip surgeon with over 27 years of experience in cleft lip and cleft palate repairs, examined the patient and ordered biometric studies. This revealed that the patient had a long upper lip without adequate fullness. The surrounding skin tone and texture was also noted. Patient expressed his desire for fuller lips. This called for lip augmentation or lip enhancement surgery.
He explained the treatment plan to the patient and his parents, which involved obtaining a fascia lata graft from the thigh region followed by a bullhorn incision to the upper lip at the base of the nose to shorten the upper lip. It was felt that artificial lip implants would not give optimal results in this case and there could also be adverse side effects.
The patient and his parents were in agreement with the treatment plan and consented to surgery. It was ascertained that the patient had no allergic reaction to any of the medications that would be used during and after surgery. The patient would be prescribed hyaluronic acid after surgery to improve healing of the wounds.
Surgical correction with bullhorn incision and fascia lata graft
Under general anesthesia, the patient was prepped and draped for lip scar revision surgery. Markings for the bullhorn incision were made under the nostrils and extended downwards to include the scar from the previous cleft lip surgery. Incisions were then made along the markings and the hypertrophic tissue excised.
The fascia lata graft was then inserted into the upper lip to increase the fullness of the lip. Upper lip was then sutured back in a slightly superior position. This resulted in a lip length that was proportionate to the rest of the face.
Healing proceeded uneventfully with minimal residual scar formation. The patient and his parents expressed complete satisfaction at the results of the surgery before final discharge from the hospital.
The nose is the most prominent feature in the human face. Evolution down the ages had resulted in a wide variation to human facial features. This ranges from the color of the skin to the shape of the nose or the shape of the chin being different although the DNA is the same.
Environmental factors, diet and a few other factors had influenced this. For example, people from very cold places that received very little sunlight developed light skin and aquiline noses. This served an evolutionary function as less body heat was lost through lighter skin and passage of cold air breathed in through long noses resulted in adequate humidification and warming up of the air as it passed into the trachea.
Likewise, people in hotter regions of the earth developed darker skin and noses with wide open nostrils. This enabled easier cooling down of the body as well as cooling down of the air as it passed in through the broader nostrils.
Functional versus cosmetic rhinoplasty
Functional rhinoplasty is performed when the patient is having problems with breathing or if the deformity of the nose is to a degree that it is affecting their normal functioning in society. This can range from anything from a deviated nasal septum to reconstruction of the nose affected by a cleft lip deformity. A functional rhinoplasty correction also invariably results in improvement in the cosmetic appearance of the nose.
Cosmetic rhinoplasty is performed when the patient has no functional difficulties, but is simply dissatisfied with the appearance of the nose. This is a completely elective procedure and is performed by either plastic surgeons or oral and maxillofacial surgeons. Surgeons from both these specialties undergo years of extensive training in this procedure.
Young woman with a previous history of cleft lip and palate repair
The patient is a young woman from Jharkhand who had undergone repair of her cleft lip and palate as an infant. She had however always had a nasal deformity with a flattened bridge of the nose and a collapsed columella. She had also had nasal breathing problems and snoring during sleep. She desired to undergo cosmetic surgery by a facial plastic surgeon to correct this. This variety of plastic surgery is also performed by oral and maxillofacial surgeons.
Cleft rhinoplasty elsewhere with unsatisfactory results from the surgery
She underwent a rhinoplasty elsewhere two years ago, but was very unhappy with the results of the previous rhinoplasty. She felt that the bone grafting to augment the bridge of her nose was too bulky and her breathing difficulties had worsened. Bone grafting had also been performed to a bony deficiency in the left anterior alveolar region.
Patient referred to our hospital for revision rhinoplasty surgery
She and her parents presented to a local plastic surgeon who advised revision cleft rhinoplasty surgery to correct her problem. He referred them to our hospital as this required a redo rhinoplasty surgery. This redo rhinoplasty required advanced techniques as the primary rhinoplasty procedure had been improperly performed. The graft placed in the previous surgery had to be removed followed by placement of a newly harvested bone graft. This rhinoplasty procedure is best performed by an experienced rhinoplasty surgeon.
It is only board certified oral and maxillofacial surgeons who perform this surgery in developed countries like the US, UK, Germany and Japan. The nasal bones could have been deformed by the previous surgery. Formation of excess scar tissue could cause this sort of deformity. The nose had to be brought into perfect alignment with the facial features.
Initial examination and treatment planning of the patient
They presented for consultation with Dr SM Balaji, rhinoplasty specialist, who examined the patient and ordered imaging studies. This revealed that the patient had a collapsed columella and the graft at the augmented bridge of the nose had shifted. Merits of an open rhinoplasty versus closed rhinoplasty were considered for the patient. He explained to the patient and the parents that he needed to harvest new bone grafts to correct this deformity. The patient and her parents were in agreement with the treatment plan and consented to surgery.
Harvesting costochondral rib grafts for the surgery
Under general anesthesia, an incision was made through the old scar from the site of the previous bone graft. Two costochondral rib grafts were harvested and a Valsalva maneuver was performed to ensure patency of the thoracic cavity. The incision was closed in layers after confirming this.
Cleft rhinoplasty with placement of columellar strut graft
Attention was next turned to the revision cleft rhinoplasty nose surgery. A vestibular incision was made in the anterior maxilla and the bone graft used to augment the bony depression in the anterior maxilla was exposed. The titanium screw used to fix the screw was removed and the region was further augmented with a rib graft shaped to fill the bony depression in the region.
Attention was next turned to the revision rhinoplasty portion of the procedure. The costochondral grafts were contoured to the correct shape. The previously placed rib graft was removed. An intranasal incision was then made and a graft was tunneled in to give perfect form to the bridge of the nose.
The second costochondral rib graft was then used as a strut graft to raise up the collapsed columella. This was tunneled into the columella through an intraoral approach and secured in place with sutures. This gave perfect form and symmetry to the nose.
The vestibular incision was then closed with sutures and the patient extubated from general anesthesia. Patient and her parents expressed complete satisfaction at the results from the surgery before final discharge from the hospital.
This baby boy from Assam was born with a cleft. He is about one year of age. The incidence of cleft lip and palate in newborns is comparatively higher in Assam. The baby had a split upper lip. He also had a hole in the roof of his mouth which affected his feeding. An ultrasound test during development in the womb revealed that the developing baby had a cleft.
There is a history of clefts running through the family. Even though the parents were aware of the right time to perform the surgery, they were hesitant and brought the baby only at about one year of age. They, however, requested for simultaneous cleft lip and palate correction.
Unilateral cleft lip and palate
Unilateral cleft lip is a congenital split in the upper lip on one side. It is often associated with cleft palate. The cleft palate refers to a hole in the roof of the mouth. It usually involves the soft palate and hard palate. Babies with cleft lip and palate have difficulty in feeding. They have nasal regurgitation. Cleft babies may develop various problems as they continue to grow.
They develop dental problems which require corrective treatments. The dental problems may require surgical and non-surgical intervention. They also have an increased risk of middle ear infections which may lead to hearing problems. Babies born with clefts may have speech problems. Thereby requiring a speech therapist opinion.
Pre-operative view showing unilateral cleft lip and palate
Pre-operative view showing cleft palate
Post-operative view following cleft palate repair
Post-operative view following unilateral cleft lip repair
Post-operative view immediately after suture removal showing an enhanced appearance of the baby
Types of clefting
There are various types of clefting which may involve oral and nasal cavities. They are
Incomplete
Unilateral and
Bilateral
Cleft lip and palate surgery in India
The parents were very depressed with their baby’s condition. They were very concerned about her future. They were searching through the internet for the best cleft lip surgeon in India. They were referred to our hospital by a local physician. Dr.S.M.Balaji one of the leading cleft lip and palate surgeon in India examined the patient.
He agreed to correct the cleft lip and palate simultaneously. The oral and nasal cavities had to be closed also.
Cleft palate repair
Cleft palate repair was to be done first. The abnormal palatal musculature was to be corrected during the surgery. The cleft palate repair was done using Veau Wardill Kilner’s technique.
Primary cleft lip repair
Corrective lip repair was also of utmost importance. Cleft lip and palate surgeon Dr. S.M. Balaji also performed cleft palate repair at one year of age. Unilateral cleft lip repair is done using Modified Millard’s technique. The upper lip musculature was also corrected during the surgery.
Surgery outcome:
The result of the surgery was as expected. He looked normal unlike any other child of his age with minimal to no scar. The parents were pleased with the outcome of the surgery.
Future surgical corrections:
Bone grafting is to be done at 3 and a half to 4 months of age thereby promoting bone growth. Speech correction / Pharyngoplasty may be necessary at 3-4 years of age. Further surgical corrections will be carried out at later date.
Presentation of antimongoloid slant and its occurrence
A downward slant from the medial canthus to the lateral canthus of the eye is termed as an antimongoloid slant. It is the direct opposite of the mongoloid slant where the downward slant is from the lateral to the medial canthus of the eye. It can be idiopathic in nature or can occur as a part of a syndromic presentation including as a part of Treacher-Collins syndrome and Franceschetti syndrome. An eyelid surgery is performed to correct this.
Characteristics of the antimongoloid slant in eyes
Patients who have an antimongoloid slant to their eyes have no functional deficits to their eyes. It is only when patients are uncomfortable with the esthetic appearance of their eyes do they opt for surgical correction of this condition.
Subtle body language cues that can alter the very meaning of spoken words
Human communication can be divided into two components. One is verbal and the other is nonverbal cues. You would notice that when a person talks to another, they use their mouth to articulate the words, but special emphasis is laid to nonverbal communication through the use of hand movements and eye movements. Subtle differences brought about by nonverbal cues can change the entire tone of the communication even if the words remain unchanged.
Rationale behind opting for cosmetic eye surgery in the modern world
When one feels uncomfortable with the appearance of their eyes, this makes them feel very self conscious. This immediately leads to a sense of awkwardness that impedes effective communication. Communication is the tool through which we make a mark on the world around us. When this is affected by any factor, our very growth and integration into the community around us, whether at home or at the workplace is affected.
Care has to be taken by the surgeon to ensure that the functional integrity of the eyes is not compromised by this surgery. This is a completely elective eye surgery on the patient’s part to undergo this surgical procedure. Removing excess skin is performed in case of wrinkles in the skin in older patients in order to make the skin tauter.
Procedural description of corrective eye surgery
A form of brow lift is performed for this correction. Excess skin muscle if present is carefully excised before taking deep bites from the eyelid and eyebrow and suturing to the periosteum. Sagging skin under the eyes is also tightened as a secondary benefit arising from this procedure. The appearance of having droopy eyelids is corrected completely giving the patient a completely level gaze. Care should be taken to not impair vision in any way.
Lateral canthopexy surgery is one of the most commonly performed procedures of blepharoplasty in India. This is classified under brow lift surgery procedures. Cosmetic surgery is undergoing a boom throughout the world. India in particular is fast turning into a hub for cosmetic eye surgery, cosmetic nose surgery and overall cosmetic face surgery in the world.
Patient with antimongoloid slant is referred to our hospital for cosmetic eye surgery
The patient is a young man with idiopathic antimongoloid slant of the eye. He hated the way his eyes appeared. His marriage got fixed recently and he finally decided to get the slant corrected. He approached a local plastic surgeon at a cosmetic eye center in his hometown who referred him to our hospital for correction of his antimongoloid slant as we are a specialty center for cosmetic eye surgery in India.
Initial examination and treatment planning for the patient
Dr SM Balaji, cosmetic eye surgeon, examined the patient and ordered detailed biometric studies including measurements for the golden ratio. He explained to the patient that he needed a lateral canthopexy for correction of his antimongoloid slant. This is a procedure that has the approval of the American Society of Plastic Surgeons for the correction of antimongoloid slant.
The patient was in agreement with the treatment plan and consented for surgery. He explained that this procedure gave the best results for correcting the antimongoloid slant. The patient was informed that the decision might be made to remove excess skin if the need arose during surgery.
Surgical correction of antimongoloid slant of the eyes
Under general anesthesia, the patient was prepped and draped for surgery. Cosmetic eye correction surgery for antimongoloid slant of the right eye was performed first. An incision was made at the lateral canthus and extended outwards. The incision was then extended along the margins of the upper eyelid and also the lower eyelid.
A suture was passed through the edge of the lower eyelid and secured to the periosteum of the orbital margin. The incision was then closed in layers using sutures to ensure minimal scar formation. This resulted in bringing the medial and lateral canthal margins to the same horizontal plane.
Good esthetic results with symmetry of repositioned eyelids
The same procedure was next performed on the left eye. Perfect symmetry of the eyes was ascertained at the end of the procedure. Care was taken to ensure that the eyes were never dry during any portion of the procedure. General anesthesia was reversed and the patient recovered without incident after the surgery. The patient expressed complete satisfaction at the results of the surgery before final discharge from the hospital.
Most scientific advances are made through accidental discoveries. For example, Dr Alexander Flemming had left a few bacterial culture dishes unattended over a period of time and had observed a fungal growth in the dishes that had inhibited bacterial growth. This had led to the discovery of penicillin, which had directly led to the birth of modern medicine as we know it.
The same way, Dr Per Ingvar Branemark had been conducting experiments with placement of titanium inserts into the bones of rabbits. Upon completion of the experiments, he had tried to retrieve the inserts as they were expensive. It was then that he discovered that the titanium inserts had completely fused with the bone. This is the phenomenon of osseointegration where the titanium and bone become one without any distinguishable joint.
Later research by Dr Branemark had led to dental implants and he founded Nobel Biocare for the manufacture of implants. Constantly evolving research has led to the development of various types of dental implants. The first dental implants were single tooth units, which were used to replace a single missing tooth. We now had special dental implants such as All-on-4 dental implants and zygoma implants. These implant systems utilize a minimal number of implants to rehabilitate an entire edentulous arch.
Dental implants come closest to natural teeth when it comes to its ability to bear biting forces and esthetics. Just like natural teeth require a lot of care to last a lifetime, dental implants too require a lot of care to last a lifetime. This involves the maintenance of scrupulous oral hygiene through not only tooth brushing, but also through the use of dental floss and mouth washes. Implant failure rate is also very low when all the instructions are followed for their upkeep by the patients.
Patient with missing right maxillary molar teeth
The patient is a young man who had prematurely lost the right molars in his upper jaw due to dental decay. This partially edentulous state had led to a lot of difficulty with chewing food along with entrapment of the tongue during chewing and speech. He had started chewing mainly with the left side of his jaw.
He had visited a local dental clinic for information regarding dental implant surgery in India. He had felt apprehensive as this is a surgical procedure. The local dentist had also advised him to go for dental implants considering his young age. He had also informed the patient that sinus augmentation might be required due to the length of time the patient had been edentulous. It was also explained to the patient that he needed to go to a specialty treatment center for dental implants. The patient was then referred to our hospital for dental implant surgery.
India is a major hub for medical tourism from all parts of the world. Many patients come to India because of the high quality of care allied with the low cost of treatment here. Our country boasts of a very well developed infrastructure for the delivery of quality healthcare. Chennai is considered to be the healthcare capital of India.
Patients seeking the services of a quality dental implant surgeon in India form a major part of medical tourism to our country. There has been a profusion of dental implant clinics lately because of this. Edentulous mandibles are more often encountered than edentulous maxillae. Reasons for this can be varied and can depend upon food habits and diet.
Initial examination and treatment planning
Dr SM Balaji, director, Balaji Dental and Craniofacial Hospital, examined the patient. He ordered CBCT for treatment planning. Our hospital was the first in South India to acquire the CBCT imaging system. CBCT enables the best treatment planning for placement of maxillary dental implants and mandibular dental implants. Soft tissue contour and the maxillary sinuses are well visualized in CBCT images.
The patient was informed that bone height was inadequate in the maxilla for implant placement. It was explained that the sinus lift surgery would enable building up the bone height in the maxilla for implant placement. Bio-Oss would be used to enable the sinus lift procedure. This is close to being the ideal bone graft material for maxillary bone augmentation.
Bone grafts from the ribs would be required in cases where there is bone loss in the mandible. The patient readily agreed to the procedure. A presurgical systematic review was conducted after obtaining consent from the patient.
Importance of adequate maxillary bone height
Adequate bony height of the maxilla is very essential for long term success of the implant. The Schneiderian membrane, which lines the maxillary sinus should not be perforated during implant fixation. Perforation of this membrane would lead to long term sinus problems with maxillary sinusitis and chronic maxillary sinus infection. Sinus lift procedure increases the height of the bone of the maxilla, thus making is possible for implant fixation in the maxilla.
Bone height begins to reduce within six months of extraction of maxillary teeth. This is more pronounced in the case of loss of maxillary molars. The use of Bio-Oss provides quick formation of new bone by means of consolidation of the Bio-Oss placed through the lateral window created in the maxilla.
Implant placement and Maxillary sinus lift procedure
Under general anesthesia, a mucogingivoperiosteal flap was first raised in the right posterior maxillary region. Following this, a lateral window was then made in the maxillary bone using a surgical bur. The Schneiderian membrane was then gently separated from the floor of the maxillary sinus. A space was soon created between the floor of the maxillary sinus and the membrane. Extreme care was taken during to procedure to ensure that there was no tearing of the membrane. The ensuing space between the Schneiderian membrane and maxillary bone was then densely packed with Bio-Oss.
This Bio-Oss would soon consolidate into new bone and this would serve as bony support for the implant. A dental implant was then placed in the maxilla in the molar region. Our hospital is a specialty center that has been certified as such by Nobel Biocare for the placement of dental implants. Following this, the flap was then closed with sutures. An implant supported artificial tooth or dental crown would be fixed to the implant in 4-6 months after adequate bony consolidation of the Bio-Oss.
The patient tolerated the procedure well and recovered uneventfully from general anesthesia.
