Re-alveolar bone graft Surgery, Fistula Closure and Cleft Rhinoplasty Surgery

Re-alveolar bone graft Surgery, Fistula Closure and Cleft Rhinoplasty Surgery

This young girl had been born with a left-sided cleft lip, alveolus, and palate. She had undergone repair of her cleft lip as an infant with an alveolar rib graft, but the graft hadn’t fused with the bone and had been a failure. She had developed an asymmetry of her nose because of this and a deficiency in the development of the cartilaginous part of her columella, which had lead to a collapsed left nostril. This had made her very quiet and withdrawn, isolating herself from her peers at school. The alveolar cleft in the region of her left lateral incisor was causing a direct communication with her nasal cavity through an oronasal fistula, which was leading to regurgitation of fluids from her mouth into her nasal cavity. Her parents had been enquiring everywhere as to where her defect would be best set right and had finally been referred to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai. Dr. S. M. Balaji, Cranio-Maxillofacial Surgeon, examined the patient thoroughly and ordered comprehensive imaging studies including a 3D axial CT scan. He then explained the treatment plan in detail to the parents of the patient and they expressed their desire to go ahead with surgery.

After satisfactory induction of general anesthesia, two costochondral rib grafts were obtained from the patient. The wound was then closed in layers after ascertaining patency of the pleural cavity through the positive pressure ventilation test. Following this, mucogingival and palatal flaps were raised on the left side of the patient’s maxillary region at the region of the alveolar cleft defect. Costochondral rib grafts were shaped and crafted to fit into the area of bony defect and fixed with screws. Attention was next turned to the collapsed columella. A costochondral rib graft that had been shaped to precisely fit into the columella was inserted along the length of its base and stabilized in place with sutures. This lifted up the collapsed columella of the nose and set right the deformity to the left nostril. The palatal and the mucogingival flaps were then closed with sutures and the patient recovered uneventfully from general anesthesia.

The patient expressed her happiness to Dr. Balaji for setting right the deformity to her nose and her parents expressed their gratitude to Dr. Balaji for enabling an improvement in the aesthetic as well as functional quality of life for the patient.


Cleft Rhinoplasty- Nasal Augmentation and Buckling Correction Surgery

Cleft Rhinoplasty- Nasal Augmentation and Buckling Correction Surgery

The patient is a young girl who was born with a left-sided unilateral cleft lip defect. She was operated upon as an infant at an outside hospital, but that correction had left her with an unsightly residual scar. She had slight lip incompetency on the left side in association with the scar tissue. There was also a buckling of the left nostril. This had lead to taunts and jibes at school from other children, which lead to her becoming withdrawn and quiet. Her worried parents brought her over to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, where she was thoroughly examined by Dr. S. M. Balaji, Cranio-Maxillofacial Surgeon, who suggested a minor scar revision procedure and nasal augmentation with buckling correction surgery. He explained to them that this involved harvesting a costochondral rib graft from the patient to be used to augment the bridge of the nose and her parents were in full agreement with that.

Upon induction of adequate general anesthesia, a costochondral rib graft was harvested and the wound was closed in layers with sutures. Following this, the minor scar revision surgery was performed with release of fibrous bands from the scar tissue, which lead to improvement in the patient’s lip incompetency. Next an intranasal incision was made at the region of the lateral crus and a tunnel was created extending up to the bridge of the nose. The cartilaginous rib graft was then manipulated into position resulting in a straighter profile to the nose along with correction of the nasal buckling of the left nostril. The incision was then closed with sutures.

The patient was overjoyed at the results of the surgery and couldn’t stop smiling, thanking Dr. Balaji profusely for the way he had set right her problem.


Velopharyngeal insufficiency (Hypernasality) Cleft palate- Pharyngoplasty Surgery(Nasal Speech Correction)

Velopharyngeal insufficiency (Hypernasality) Cleft palate- Pharyngoplasty Surgery(Nasal Speech Correction)

This young man had difficulty pronouncing certain words well and had a nasal twang to his voice. He had been born with a cleft lip and palate and had undergone repair as an infant. He had subsequently developed velopharyngeal incompetence, where there is escape of air through the nose during speech.

He presented at Balaji Dental and Craniofacial Hospital, Teynampet, Chennai for correction of his problem. Dr. S. M. Balaji, Cranio-Maxillofacial Surgeon, examined him and explained to him that he needed a pharyngoplasty surgery for correction of his problem. The patient was in agreement with this and was scheduled for surgery. The aim of this surgery is to create a dynamic sphincter in the pharynx by repositioning the palatopharyngeus muscles.

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 muscles, which were then crisscrossed and sutured together on the posterior pharyngeal wall to form a sphincter leaving a small opening or “port” for breathing through the nose. A positive suction test was performed after completion of the surgery and showed new dynamic velopharyngeal sphincter action indicating successful correction of velopharyngeal incompetence. The patient recovered from general anesthesia without complications.


TMJ Ankylosis Gap Arthroplasty Surgery with Coronoidectomy and temporalis interposition Surgery – Sleep Apnea and Snoring

TMJ Ankylosis Gap Arthroplasty Surgery with Coronoidectomy and temporalis interposition Surgery – Sleep Apnea and Snoring

This young lady was involved in a road traffic accident many years ago in her hometown. First aid had been administered immediately after the accident, but a minor injury to her right TMJ went undiscovered at that time because there were no good diagnostic facilities in her hometown. This resulted in ankylosis of her right TMJ with resultant retarded growth of the mandible on the right side with deviation of the mandible to the right. She developed snoring and sleep apnea over the years and this had now been troubling her for a long time. She had undergone ankylosis release surgery multiple times elsewhere but without much success. Her parents finally brought her to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, for definitive surgical correction.
Dr. S. M. Balaji, Cranio-Maxillofacial Surgeon, examined the patient and ordered diagnostic studies including a 3D axial CT scan. A diagnosis of right-sided ankylosis of the TMJ was made and he explained the surgical procedure in detail to the patient and her parents. They were in complete agreement with the proposed treatment plan and the patient was scheduled for surgery.

The patient was taken to the operating theatre. Anesthesia was administered via fiberoptic nasal intubation because of the patient’s inability to open her mouth. This was done to avoid performing a tracheostomy. A submandibular incision was then made just below the margin at the angle of the mandible on the right side to access the TMJ and a gap arthroplasty was performed. The ankylosis was released and a temporalis muscle interpositioning procedure was performed to prevent reankylosis of the joint to the glenoid fossa. Attention was next turned to the left side where the coronoid process was accessed through an intraoral approach. A coronoidectomy was performed to negate the action of the left temporalis muscle and enable increased mouth opening. Full mouth opening was established at the end of the procedure. The incisions were closed with sutures and the patient recovered uneventfully from general anesthesia.

The joint was mobilized within a week’s time and the patient was able to slowly begin eating solid foods again. She did not demonstrate any sleep apnea or snoring after the surgery while in the hospital. The patient and her parents expressed their happiness at the results of the surgery before being discharged from the hospital.

Surgery Video


Simultaneous Maxillo Mandibular Distractor Removal with Lateral Defect Augmentation With Rib Grafts

Simultaneous Maxillo Mandibular Distractor Removal with Lateral Defect Augmentation With Rib Grafts

The patient is a young woman with distortion of her lower face due to mandibular asymmetry. This had lead to her socially isolating herself due to people staring at her and passing comments since she was a little girl. She presented to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, for correction of her condition. Dr. S. M. Balaji, Maxillo-Craniofacial Surgeon, viewed her 3-D axial CT scans and decided to perform simultaneous maxillomandibular distraction for the patient to correct her vertical mandibular deficiency and occlusal cant on the right side. Maxillomandibular distraction was successfully performed and her facial asymmetry was set right, but there was a persistent bone deficiency in the right side of her mandible. She now presents for removal of her distractors as well as for placement of rib grafts for correction of her bone defect.

The patient was taken to the operating theatre where general anesthesia was induced. Two rib grafts were taken from the right side for filling in the bony deficiency on the right side of her mandible and the incision was closed in layers with sutures. A right-sided submandibular incision was made and dissection was carried down to the level of the distractor. The distractor was then unscrewed and removed uneventfully. The rib grafts were then shaped and screwed in place to fill in the bone deficiency in the mandible.

The patient presented to Dr. Balaji a few months after the surgery and expressed her delight at the way he had given her a new lease of life by setting right her facial asymmetry.

Surgery Video