Patient born with unilateral cleft lip and palate deformity
The patient is a 24-year-old female from Mannargudi in Tamil Nadu, India. She was born with a cleft lip and palate deformity on the left. Her unilateral cleft lip and palate deformity greatly distressed her parents. They were extensively counseled by the doctors soon after the birth of the child.
They had referred the parents to a local dental surgeon. He had examined the patient and had referred them to a hospital in a nearby city for surgical correction. Many cleft patients have a split roof of the mouth.
Her parents had presented at the hospital. As instructed by the surgeon, the patient had undergone cleft lip surgery at 3 months of age. This had been followed by cleft palate surgery at 8 months and cleft alveolus surgery at 7-1/2 years of age. She had satisfactory functional and cosmetic results from the surgery.
Development of progressive nasal deformity with growth
The patient began noticing the gradual development of a deformity of her nose with time. Her nasal tip was depressed and this too added to the compromise in her facial esthetics. There was also a sunken appearance to her left nostril. Her upper lip however was cosmetically acceptable.
She became very self-conscious about her appearance and became withdrawn. Around two years ago, her worried parents took her to the same hospital for consultation. The surgeon had examined the patient. He then explained that she needed to undergo a closed rhinoplasty procedure or a nose job.
Previous rhinoplasty correction with unsatisfactory cosmetic results
The patient had subsequently undergone nasal deformity correction with the utilization of costochondral grafts. She was however dissatisfied with the results and remained withdrawn. Improper positioning of the graft had led to increased deviation to her nose. This had resulted in increased worsening of the esthetic appearance of her nose.
Her parents made the decision to get this addressed and made extensive enquiries regarding the best treatment options available. They had subsequently been referred to our hospital for her secondary rhinoplasty correction. Our hospital is also a specialty center for revision rhinoplasty.
A specialized cleft team consists of professionals from varied specialties. Facial plastic surgeons also perform this surgery in Europe and America.
Initial presentation at our hospital for nasal deformity correction
Dr SM Balaji, the cleft rhinoplasty surgeon, examined the patient and obtained imaging studies. Her nose was depressed on the left side with compromise in both esthetics and function. There was also an asymmetry to the left alar base region. She expressed her desire to have a well-defined and sharp nose.
It was explained to her that an autologous costochondral cartilage graft would be used to augment her nose. The Z-plasty surgery for correction of her alar base region was also explained to her. She was in complete agreement with the treatment plan and consented to surgery.
Surgical correction of her nasal deformity with closed rhinoplasty
Under general anesthesia, an incision was placed over the old incision in the right inframammary region. Costochondral rib graft was harvested from the patient. Following this, a Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures.
A Z-plasty was then performed to correct the depressed and asymmetric left alar base. This was followed by an intercartilaginous incision to the right nostril with partial excision of the lateral nasal cartilage
Dissection was then done up to the nasal dorsum and the nasal bridge was augmented using the costochondral graft. The closure was done intranasally using resorbable sutures. General anesthesia was then reversed without any complications.
The patient expressed complete satisfaction with the results of the surgery
The patient was very happy with the outcome of the surgery. She now had an elevated and sharp nose that was also symmetrical with a good profile. Her nasal function was also improved. She said that her breathing was unobstructed with free flow of air now.
She expressed that her levels of self confidence have improved significantly after surgery. Her parents too expressed their thankfulness before final discharge from the hospital.
The patient is a 11 months old baby boy from Jammu who was brought to our hospital seeking treatment for cleft lip and palate. A pre-natal diagnostic scan (Ultrasound of abdomen) had been done at the end of the first trimester in his hometown. It was then that the deformity was discovered and the parents were informed that their baby would be born with a cleft lip.
Search for renowned cleft lip and palate repair center
The parents were aware that their child would be born with this deformity. They therefore educated themselves about this condition. However, they were not very keen on getting the surgery done for their baby until he was about 10 months of age.
They had also made widespread inquiries about the best hospital for cleft lip repair. Their inquiries led them to Balaji Dental and Craniofacial Hospital, which is a premier center for cleft lip and palate repair in India.
The parents got in touch with our hospital when the baby was about 10 months of age. Detailed explanation was given regarding the treatment. Books authored by Dr SM Balaji providing comprehensive information about cleft lip and palate deformity and repair were also mailed to the parents.
Initial presentation at our hospital for consultation and treatment planning
Parents brought the child to our hospital at 11 months of age. Dr SM Balaji, Cleft Repair Specialist, examined the baby. He advised the parents regarding the need for lip repair surgery.
Unilateral cleft lip in a 11 months old baby boy
Primary cleft lip repair following Modified Millard’s technique
Immediately after suture removal following seven days of surgery
showing enhanced appearance
Successful rehabilitation following cleft lip surgery performed at our hospital
The patient underwent cleft lip repair surgery using the modified Millard’s technique. Suture removal was done after a period of seven days. Surgery was a resounding success and the baby’s appearance was greatly improved.
His parents were overjoyed that the defect had been corrected with no visible scar formation. He looked like every other infant, gurgling and smiling spontaneously.
The patient will undergo cleft palate surgery after a period of one or two months followed by alveolar cleft defect reconstruction at 3 and a half years of age. Parents expressed understanding of the same and expressed complete satisfaction at the time of discharge from the hospital.
Dr SM Balaji hosts Professor Mark Boyd and Dr Nikolina Vlatkovic of Merseyside Head and Neck Oncology Research Group
Professor Mark Boyd, Professor of Molecular Oncology, Department of Molecular and Clinical Cancer Medicine, University of Liverpool and Dr Nikolina Vlatkovic, Director of PGR Studies, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, visited Dr SM Balaji at Balaji Dental and Craniofacial Hospital during their recent visit to Chennai.
Dr SM Balaji honours Professor Mark Boyd, Professor of Molecular Oncology, Department of Molecular and Clinical Cancer Medicine, University of Liverpool
Dr SM Balaji welcomes Dr Nikolina Vlatkovic, Director of PGR Studies, Department of Molecular and Clinical Cancer Medicine, University of Liverpool
Key research into tumor suppression in the head and neck region
Dr SM Balaji conducted a guided tour of the facilities for Professor Mark Boyd and Dr Nikolina Vlatkovic, including the dental clinic
Professor Boyd heads the Merseyside Head and Neck Oncology Research Group. The two visitors are key members of the P53/MDM2 Research Team, which specializes in research related to tumour suppression through the reworking of biochemical pathways, prognosis of tumours and individualized treatment plans for best treatment outcomes. They were accompanied by Dr Sundarraj Lakshmiah who is also a member of the research team.
Discussion about ongoing research into craniomaxillofacial anomalies
Dr SM Balaji warmly welcomed the visitors to the hospital and gave them a guided tour through the facilities, including ward rounds. He explained ongoing research projects in the hospital, particularly those related to craniofacial distraction osteogenesis. The visitors met with some of the patients currently being treated at the facility.
Professor Boyd and Dr Vlatkovic listen intently as Dr SM Balaji explains the treatment planning protocol undertaken for distraction osteogenesis
Dr SM Balaji explaining the preoperative findings and the innovations undertaken to obtain ideal postoperative results for the patient
Dr SM Balaji sharing insights from his landmark ‘Clinical Craniomaxillofacial Surgery’ book with the distinguished visitors
He also shared insights with the visitors from his ‘Clinical Craniomaxillofacial Surgery’ book, which is a compilation of the landmark cases from his 30 years as a craniomaxillofacial surgeon. This book serves as a reference book for postgraduate students and practicing oral and maxillofacial surgeons.
Difficulties relating to cutting edge research in a third world limited resources setting
Dr SM Balaji related to them his experiences as a researcher over the past three decades and related significant breakthroughs that had enabled improved and better surgical outcomes. He also spoke about the various obstacles that had to be overcome over the course of his career in a limited resources setting.
The visitors thanked Dr SM Balaji for his invitation to visit the hospital and sharing valuable insights into conducting research in a third world country. They appreciated the innovations adopted by him to advance the cause of research in the craniomaxillofacial region.
Patient diagnosed with fibrous dysplasia through genetic testing
The patient is a 26-year-old man from New Delhi in India. He had been fine up until age 12 when he started developing right sided facial asymmetry. This had progressively gotten worse with gross deformity of the face. His parents had taken him to a leading facial plastic surgeon.
Extensive testing had been performed on the patient. Genetic testing had been ordered with results positive for fibrous dysplasia with associated neurofibroma. Implications of the diagnosis had been explained to his parents in detail. It was explained that the only treatment was surgical management.
Symptomatology and implications of fibrous dysplasia
Fibrous dysplasia is a rare genetic disorder. It is abnormal growth of fibrous tissue that replaces normal bone tissue. This results in asymmetrical enlargement of the affected region, which leads to gross deformity. This condition needs facial plastic surgery for reestablishment of esthetics.
There can be spontaneous remission of the condition. Fibrous dysplasia of the face leads to gross disfigurement. Surgical intervention is the only available treatment for management of fibrous dysplasia. Constant medical surveillance is advised in order to ensure that it does not affect any vital functions.
Patient undergoes surgical intervention of his condition
The patient has undergone two surgeries thus far for treatment of his condition. Both surgeries had been performed in New Delhi. Unfortunately, the results had been catastrophic for the patient. It had led to a dramatic decrease in the quality of his life.
Incisions had been poorly designed in the first surgery. This had lead to unsightly scar formation. Excess fibrous tissue had been poorly contoured leading to worsening of his facial asymmetry. The patient had undergone a second surgery a few years later, which did not lead to any significant improvement.
The patient has been depressed for a few years now over his condition. Seeing this, his parents had made enquiries about the best facial cosmetic surgeon in India. They had finally decided to come to our hospital for surgical management of his condition. Board certified plastic surgeons also perform this surgery in the European countries.
Initial examination at our hospital along with treatment planning
Dr SM Balaji, facial deformity surgeon, examined the patient and ordered for radiological studies including a 3D CT scan. This revealed overgrowth of fibrous tissue that had replaced bone on the right side of the facial skeleton. The patient had extreme facial asymmetry because of this. This was diagnosed as neurofibroma with fibrous dysplasia.
The surgical procedure was explained to the patient and his parents in detail. They were in agreement with the treatment plan and consented to undergo surgery for facial asymmetry correction.
Successful surgical removal of excess tissue for improving esthetics
The patient was administered anesthesia through bronchoscopic intubation. A nasolabial incision was then made to expose the fibrous tissue. Excess tissue was removed using a mallet and burr through the stamp cut technique. Once adequate reduction had been obtained, the incision was closed with sutures.
Attention was next turned to the right lower border of the mandible. An incision was made through a preexisting scar from a previous surgery. The lower border of the mandible was trimmed until it was symmetrical with the left side of the mandible.
The incision was closed in layers once adequate reduction had been obtained. The patient and his parents were very happy with the results of the surgery. They stated that the patient was very happy with the facial form after surgery. They expressed their total satisfaction before final discharge from the hospital.
Patient born with Crouzon syndrome with typical facial features
The patient is a 23-year-old female from Manapparai in Tamil Nadu, India. She was the product of an uneventful pregnancy. Her abnormal facial features were first noted at the time of birth.
She had been referred for genetic testing and had been confirmed to have Crouzon syndrome. Her parents had been extensively counseled regarding the condition and its implications.
What is Crouzon syndrome and what are its manifestations
Crouzon syndrome is a genetic disorder which is characterized by craniosynostosis. Deformities can be classified into congenital and acquired deformities. This comes under the category of congenital deformities. Treacher-Collins syndrome is another example of a congenital condition causing deformities.
Craniosynostosis denotes the premature fusion of some of the skull bones. This early fusion leads to abnormal development of the skull, leading to deformities of the skull and face.
Patients with this syndrome have abnormal looking faces and skull shape. There are however no soft tissue abnormalities. The eyeballs are extremely protuberant because of a deficiency in the orbital bones. There is marked regression of the midfacial region.
There is also strabismus due to the eyes being displaced within the orbits. Patients also have a beaked nose along with a prominent nasal bridge. Their intelligence is however completely normal.
Parents decide to seek surgical consultation for correction of facial and skull deformities
The patient had a difficult childhood because of constant bullying at school. She has very few friends and avoids socializing because of her facial deformities. As she has become an adult now, her parents decided to get this addressed surgically.
A local oral surgeon had examined her and had referred her to our hospital for management. Plastic surgeons do not perform surgery for correction of deformities arising from Crouzon syndrome.
Our hospital is a superspecialty center for craniomaxillofacial surgery in India. We perform syndromic facial deformity correction at our hospital. There are two modern operating theaters equipped with the latest medical technology. Orthognathic surgery is also another specialty procedure that is performed in our hospital.
Patient presents at our hospital for surgical correction of her craniofacial deformities
Dr SM Balaji, oral and craniofacial surgeon, examined the patient and obtained comprehensive radiographic studies including a 3D CT scan. He also ordered for 3D stereolithographic skull models for the patient.
Upon examination, the patient had protruding eyeballs due to bony deficiency in the orbital region. This gave her an abnormal facial appearance. There was also retrusion of her midfacial region. He performed mock surgery on the 3D models and meticulously planned the surgery.
It was decided to do midfacial advancement for the patient using distraction osteogenesis. This would be facilitated by a Le Fort III surgery of the midfacial region. The internal distractors would be in place for a period of three months. Bony distraction of 15 mm would be performed for correction of her midfacial deformity.
Successful surgical correction of the facial deformities from the Crouzon syndrome
Of note, hair was not shaved prior to surgery as this is a female patient. Under general anesthesia, a bicoronal flap was first raised to expose the patient’s frontal and facial bones. Bony cuts were marked and the zygoma was cut. This was followed by 180-degree bone cuts to the lower part of the orbital bone.
The bone was then disjointed and bilateral internal distractors were fixed in place. Trial distraction was then performed to ensure that distraction resulted in adequate bony separation.
The frontal bone was reduced with a burr and smoothened to reduce the prominence of her forehead. Once hemostasis had been confirmed, muscle flaps were placed back in position and the bicoronal flap was closed with staples.
Initiation of internal distraction osteogenesis for correction of midface retrusion
A latency period of around ten days was allowed for settling down of the operative site. Bilateral distraction of 1 mm was performed every day until there was good midfacial advancement. This also resulted in correction of the patient’s strabismus.
The distractors would be left in position for three months. This would allow bone formation and consolidation at the sites of distraction. Radiographic imaging would then be obtained to confirm consolidation following which the distractors would be removed.
Complete satisfaction at the results of the surgery
The patient and her parents expressed understanding that they will return in three months for removal of the distractors. They expressed their happiness with the results of the surgery. She would now have the confidence to face the world and take on the everyday challenges of life.
Patient develops a painful swelling in her right lower jaw region
The patient is a 55-year-old female patient from Thane in Maharashtra, India. She began noticing a progressively enlarging swelling in the right mandibular region. There was also development of progressive mobility of teeth in the region.
This greatly alarmed the patient and her family. They had presented to a local surgical hospital for consultation. This was a multispecialty surgical hospital, which also offered oral surgery services.
Initial presentation at a local hospital for surgical correction
The oral surgeon at the hospital had examined the patient and ordered radiographic studies. Biopsies had been obtained, which returned with a diagnosis of ameloblastoma. The patient had been counseled regarding the diagnosis and treatment planning had been explained to her in detail.
She had subsequently undergone ameloblastoma resection and reconstructive surgery with rib grafts and mandibular reconstruction plates. A few months after surgery, she developed pus discharge from the surgical site and underwent reoperation.
There was also gum tissue inflammation at the site overlying the previous operation. The rib graft, which had become infected, was removed along with the reconstruction plate. There was no plate exposure in this case.
What is an ameloblastoma and what are its implications?
Ameloblastoma is a benign or cancerous tumor of the odontogenic epithelium. The tumor occurs more commonly in the lower jaw than the upper jaw. This tumor was first named ameloblastoma in 1930 by Ivey and Churchill.
Ameloblastoma are rarely malignant or metastatic. They however progress relentlessly and result in severe abnormalities of the face and jaw causing severe disfiguration. Treatment involves utilization of wide surgical excision in order to ensure that it does not recur. If left untreated, it ultimately results in obstruction of nasal and oral airways.
Patient diagnosed with recurrence of ameloblastoma at the site of the previous surgery
The patient had severe facial asymmetry after removal of the infected bone grafts and reconstruction plates. Speech and eating also became very difficult for the patient. In the meantime, there was also recurrence of swelling in the region of the right first mandibular molar. This was diagnosed as recurrence of the ameloblastoma.
Alarmed at this, the patient and her family made widespread enquiries about the best ameloblastoma surgery hospital for her treatment. They were subsequently referred to our hospital for surgical management of her condition
Initial presentation at our hospital for treatment of her ameloblastoma
Dr SM Balaji, mandibular reconstruction surgeon, examined the patient and ordered comprehensive radiological studies including a 3D CT scan. Radiological studies revealed recurrence of ameloblastoma at the region of the lower right first molar with lingual perforation of the cortex.
Treatment planning was explained to the patient and her family in detail. This would involve segmental resection of the right mandible. Resection would be followed by reconstruction with rib grafts and reconstruction plate and screws.
It was explained that dental implant surgery with placement of crowns would complete rehabilitation of the oral cavity. Removable dentures are rarely used in modern dentistry. The patient was in agreement with the treatment plan and consented to surgery.
Surgical resection of the mandible with reconstruction of the bony defect
Under general anesthesia, a right inframammary incision was made and a costochondral rib graft was harvested. A Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures.
Attention was next turned to the right mandibular region. A midcrestal incision was made followed by elevation of a flap to expose the mandibular bone. This was followed by segmental resection of the right mandible.
The region of bony defect following the resection was reconstructed using rib grafts and mandibular reconstruction plates and screws. Hemostasis was achieved and closure was done with sutures.
Successful reconstruction of mandible with further instructions to patient
There was good restoration of mandibular contour following surgery. The patient understood that she would need to return after bony consolidation of the implants in six months. Dental implants would then be placed followed by placement of ceramic crowns.
The patient and her family expressed their satisfaction with the results of the surgery. They stated that they would return in six months for dental implant surgery. The patient stated that she was very happy and relieved with successful completion of her surgery.
