Patient born with unilateral cleft lip and palate

The patient is a 25-year-old female from Ongole in Andhra Pradesh, India. She was born with a unilateral cleft lip and palate. Her parents had been advised that she needed to undergo cleft lip repair at 3 months and cleft palate surgery at 8 months of age. The hole in the roof of her mouth was successfully closed through cleft palate repair.

She had subsequently undergone both surgeries at a local hospital. A cleft alveolus reconstruction had been performed at 4 years of age. This is the correct recommended timetable to undergo surgery for these congenital defects.

Teeth can be missing in the region of the cleft in the alveolus. These are replaced through the use of artificial teeth attached to implants. Meticulous gum tissue health is necessary for success of implants.

Dissatisfaction with appearance while growing up

The patient developed a flat and bulky nose over time. She also had a very prominent scar from her cleft lip surgery. This had made her feel very self conscious. Her self confidence level was also low because of her facial deformities. She had always desired to have a sharp prominent nose. The nose consists of both bone and cartilage tissue.

The patient and her parents had visited a local cosmetic surgeon who examined her. Realizing the extent of correction required, he had referred them to our hospital. Our hospital is a premier center for cosmetic nose surgery in India. Results over the years stand testimony to the level of care at our hospital for cosmetic rhinoplasty.

Initial presentation at our hospital for management

Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained relevant diagnostic imaging studies. The patient’s chief complaint was a depressed nose and lip scar. Columellar collapse had resulted in the depressed nose.

She also complained of mobility of her upper front teeth. This was found to be retained deciduous lateral incisors. The patient stated that her nose looked bulky and this made her feel uncomfortable. She requested for a symmetrical nose with prominent tip. The patient was also found to have a depressed left anterior maxilla.

Treatment planning formulated and explained to the patient

A complete treatment plan was formulated for the patient. It was decided to extract the mobile retained deciduous lateral incisors. This would be replaced with dental implants. It was also decided to augment the left anterior maxillary defect with a rib graft. This would result in elevation of the base of the nose. Our hospital is a specialty center for cosmetic surgery procedures.

A costochondral graft would then be used to perform nose correction of the depressed bridge. This would give the patient a prominent bridge of the nose. The patient consented for cleft rhinoplasty with dental implant surgery.

Successful surgical correction of the patient’s complaints

Under general anesthesia, an incision was made in the right inframammary region. Dissection was carried down to the ribs. A costochondral rib graft was then harvested. This was followed by a Valsalva maneuver to ascertain that there was no perforation into the thoracic cavity. The wound was then closed in layers with sutures.

Attention was then turned to lip scar revision surgery. Once this had been successfully performed, the two retained deciduous teeth were extracted. Nobel Biocare dental implants were then placed at the extraction sites.

Attention was then turned to the depressed region of the left anterior maxilla. A flap was elevated and the area was augmented using the rib graft. The graft was then fixed using titanium screws. This would slowly integrate with the maxillary bone over time to form a defect free maxilla.

A transcartilagenous incision was next made in the right nostril. Dissection was then done down to the lateral nasal cartilages, which were excised. Following this, the nasal dorsum was augmented using the costochondral rib graft. This resulted in a prominent sharp nose for the patient.

Patient satisfaction at the results of the surgery

Cosmetic improvement from the surgery was immediate. The patient was very happy with the outcome of the surgery. She now had a symmetrical and prominent nose without the lip scar. Her parents also expressed their happiness at the results of the surgery.

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