The patient is a 13-year-old boy from Chittoor in Andhra Pradesh, India. He had been born without external ears. There were only rudimentary structures present at the site of bilateral ears.
He had been diagnosed with hemifacial microsomia with bilateral microtia. There was also gross asymmetry of his face.
The patient had faced constant bullying over the years in school. He had very few friends and had slowly grown depressed about the appearance of his face. Approximately a year ago, he had refused to go to school until his ear deformity had been corrected. He stated that he wanted big prominent ears.
His parents had approached a cosmetic surgeon in a nearby city who had examined the patient. He had weighed all treatment options. Realizing that the patient needed microtia correction surgery, he had presented the treatment plan to the parents.
They had consented to the surgery. He had been admitted to the hospital and had subsequently undergone surgery. However, the patient and his parents were not satisfied with the results of the surgery.
There had been slight asymmetry of the cartilaginous form of the external ears. There were also hypertrophic scars, which were unsightly. They felt that the scar tissue needed to be addressed. It however did not involve a large area of skin.
Realizing that this needed to be corrected, parents had made wide enquiries regarding the best hospital to get the problem addressed. They had subsequently been referred to our hospital for his correction surgery. Our hospital is a renowned center for facial cosmetic surgery in India.
Cosmetic correction of deformities involving both bone and soft tissues are addressed at our hospital. Facial asymmetry correction surgery is a specialty at our hospital. Jaw deformity correction, ear deformity correction, scar revision surgery, cosmetic rhinoplasty and cleft deformity correction surgery are routinely performed here.
Initial presentation at our hospital for treatment
Dr SM Balaji, microtia correction surgeon, examined the patient and obtained a detailed history. The patient’s parents explained their anxieties and fears regarding the failed surgery. A complete clinical examination was performed and comprehensive radiographic studies including a 3D CT were ordered.
It was determined that there was deficiency of cartilage that had been placed in the first surgery. The patient and his parents were reassured and counseled extensively.
His 3D CT scan revealed the presence of an anatomically patent, middle ear, inner ear and ear canal. Clinical examination also revealed facial asymmetry on the left side. Auditory testing was also performed for the patient. This revealed that he had about 70-80% hearing in both the ears despite the absence of external ear structures
A brief introduction to microtia and its etiological factors
Microtia is a congenital deformity where the pinna is underdeveloped. Complete absence of the external ear is referred to as anotia. Because microtia and anotia have the same origin, the complex can be referred to as microtia-anotia.
Microtia can be either unilateral or bilateral. It occurs approximately in 1 out of every 8000–10000 live births. The right ear is more commonly affected in cases of unilateral microtia.
Microtia may occur as a complication of taking Accutane (isotretinoin) during pregnancy. The etiology of microtia in children however remains uncertain. It is suspected to be genetic in origin along with being a complication of gestational diabetes. Risk factors also include very low birth weight.
Treatment planning explained to the patient and his parents in detail
It was planned to correct the asymmetrical form of bilateral ears from the previous surgery. This would be followed by a subsequent stage at a later date where the ear structures would be elevated followed by creation of the ear lobule in the final stage of the surgery. They were in agreement with the treatment plan and the patient was scheduled for surgery.
Harvesting of rib graft and placement at the site of bilateral ear deformity
Under general anesthesia, a left inframammary incision was made and dissection was performed down to the ribs. Costochondral grafts were harvested and Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The wound was then closed in layers with sutures.
This was followed by incisions performed over the asymmetrically constructed ear structures. The costochondral grafts were shaped and tunneled to ensure that the resultant ear form was symmetrical and esthetically pleasing. Incisions were then sutured using nonresorbable sutures.
Parents express their satisfaction with the cartilaginous ear framework
The patient and his parents were very happy with the esthetic outcome of the corrective surgery. There was a well defined and symmetrical cartilaginous framework to the ears bilaterally. They could clearly visualize the ear taking shape.
Parents expressed that the patient had definitely cheered up following the surgery. They stated that he was looking forward to the subsequent stage of the surgery. The ear elevation surgery using skin graft will be performed after about 6 months.
The patient is a 29-year-old patient from Theni in Tamil Nadu, India. He was born with a cleft lip, palate and alveolus deformity. His parents had been advised of the correct time schedule for surgical correction of his deformities. The birth had been uneventful and without any complications.
As advised at the time of his birth, he had undergone cleft lip surgery at 3 months and cleft palate surgery at 9 months. Alveolar cleft surgery had been performed at 3-1/2 years. All surgeries had been performed elsewhere. He had subsequently developed acceptable feeding and speech patterns with acceptable esthetics.
Increasing degree of facial deformity with the passage of time
As he grew older, the degree of facial deformity gradually increased. He had been bullied a bit while in school and in college. The deformity had been bothering him a lot lately and he discussed this with his parents. They then decided to get it surgically corrected.
He had made extensive enquiries and had been referred to our hospital by multiple sources. Our hospital is a specialty center for facial deformity surgery. Many patients who are dissatisfied with their appearance have undergone facial cosmetic surgery at our hospital.
International recognition of our hospital by premier organisations
We are a recognized referral center for the Japan-based International Cleft Lip and Palate Foundation (ICPF). The US-based World Craniofacial Foundation (WCF) has also named us as its affiliate in the Southeast Asian region.
Initial presentation at our hospital for lip deformity surgery
Dr SM Balaji, lip reconstruction surgeon, examined the patient and obtained a detailed history. The patient complained of a deformed upper lip and he felt that it was also very thin and asymmetrical. The patient also stated that speech and word formation was always difficult due to the lack of bulk in his upper lip. He desired to have a full upper lip that was in harmony with the rest of his face.
Treatment planning formulated for correction of thin lip deformity
A complete clinical and radiological evaluation was performed on the patient. It was decided to harvest a strip of fascia lata tissue from the patient’s thigh to augment the thin lip. The treatment planning was explained to the patient in detail.
All his doubts regarding the surgical procedure were answered to his satisfaction. The patient then consented for surgery and was scheduled for reconstruction of his thin lip deformity.
Successful surgical reconstruction of his thin upper lip
Under general anesthesia, two linear vertical incisions were first placed over the lateral aspect of the right thigh. Dissection was then done up to the vastus lateralis muscle and the fascia lata was identified. A strip of fascia lata was then separated from the muscle and harvested. The incisions were then closed using sutures.
Incisions were then made over the previous surgical scars in the upper lip. Tunneling was done up to the commissures of the upper lip bilaterally. The thin lip was then augmented using the fascia lata graft. The incisions were then sutured using nonresorbable sutures.
Complete patient satisfaction with results of surgery
There was excellent esthetic result from the lip reconstruction surgery. The degree of upper lip fullness from the surgery was in perfect harmony with the rest of his face. He said that he was very happy with the result of the surgery.
His parents were also very happy with the result of the surgery. They mentioned that this will help him regain his self confidence. The patient also expressed complete satisfaction before final discharge from the hospital.
The patient had always felt that the bridge of his nose was depressed and that his nose was broad. The patient had been born with a left sided cleft lip and palate deformity. His parents had been advised of the right time schedule for him to undergo cleft lip and palate repair.
He had subsequently undergone cleft lip and palate surgery in his home state of Kerala, India when he was three months and eight months old respectively.
This had resulted in significant improvement in esthetics and function. He had been able to feed well and his BMI had always been within normal limits for age. However, children with this deformity tend to have exacerbation of the defect as they grow up. Facial morphology changes rapidly with growth and any residual bony defect from the cleft palate gets amplified.
Depressed and lacking self confidence because of the nasal deformity
He is now 24 years old and quite depressed about the appearance of his nose. The bridge of his nose was depressed leading to the nose appearing excessively broad for his face. The patient was worried that his nose was looking very big and ugly. The nose was also depressed on the left side. He has a typical cleft lip nasal deformity now.
Because of the above factors, the patient desired to get his facial deformities corrected. He and his parents had made widespread enquiries regarding the best cleft rhinoplasty hospital in India. They had subsequently decided to come to our hospital for his nasal deformity surgery. Plastic surgeons and oral and maxillofacial surgeons perform cosmetic rhinoplasty.
Initial presentation at our hospital for his corrective surgery
Dr SM Balaji, cleft rhinoplasty surgeon, examined the patient. The left side of his nose was depressed because of his cleft lip and palate deformity. He explained the treatment plan to the patient and his parents.
Nasal bridge augmentation would first be performed with a costochondral rib graft harvested from the patient. This would be followed by alar web correction surgery in the left nostril. Lateral osteotomy surgery would then be performed bilaterally resulting in correction of his broad nose deformity. The patient consented to the treatment plan.
Surgical correction of the patient’s complaints
Under general anesthesia, a right inframammary incision was made and a costochondral rib graft was harvested. The incision was then closed in layers with sutures.
Attention was next turned to the nasal bridge augmentation surgery. An intercartilaginous incision was made in the left nostril. The lateral nasal cartilage was excised partially. Dissection was done up to the nasal bridge, which was augmented using the costochondral graft.
Alar web correction surgery was then done in the left nostril. Bilateral lateral osteotomy was then performed following which closure was done intranasally using resorbable sutures.
Total patient satisfaction at the results of the surgery
The patient and his parents were very happy with the esthetic results of the surgery. He now had an elevated, more symmetrical, narrow, and prominent nose. This was in complete harmony with the rest of his facial features. He stated that his self confidence levels had soared up before final discharge from the hospital.
Patient with pain and swelling in the posterior left mandible
The patient is a 25-year-old female from Kumbakonam in Tamil Nadu, India. She had developed severe pain and swelling on the left side of her mandible. The patient had a grossly decayed left third molar. There was also severe trismus with limited mouth opening due to the presence of the infected tooth.
Inferior alveolar nerve passing through impacted mandibular molar
The patient had presented at a nearby dental clinic for management of her problem. An OPG had been obtained, which revealed bilaterally impacted mandibular third molars. The left third molar was grossly infected. The right third molar was completely submerged within bone and the inferior alveolar nerve was passing through the tooth.
Upon viewing this, the doctor had realized that this was a complicated extraction that needed to be performed by an experienced oral and maxillofacial surgeon. He had subsequently referred the patient to our hospital for extraction of her impacted mandibular molars.
Our hospital is a specialty center for complicated extractions. Molar impactions present at the lower border of the mandible are addressed here. Simultaneous extractions of bilaterally impacted maxillary and mandibular molars are routinely operated in our hospital.
International acclaim from world renowned organizations
Our hospital is also renowned for complex craniofacial surgery in India along with facial trauma surgery and facial cosmetic surgery. It has been widely decorated by many acclaimed international organizations.
They include the World Craniofacial Foundation founded by Prof Kenneth Salyer and the International Cleft Lip and Palate Foundation founded by Prof Nagato Natsume.
Initial presentation at our hospital for management of her problem
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detail history. He also ordered 3D CT scan and other pertinent imaging studies. The patient stated that she had severe pain and swelling in left mandibular molar region for one week.
The 3D CT scan revealed bilaterally impacted lower third molars. The left molar was grossly decayed. The inferior alveolar nerve which provides sensation to the lower lip was passing through the root of the impacted right third molar.
Treatment planning was explained in detail to the patient and her parents. The importance of preventing any injury to the inferior alveolar nerve was explained in detail to them. They were in agreement with the treatment plan and consented to surgery under general anesthesia.
Successful surgical removal of the third molar teeth
Under adequate general anesthesia, atraumatic extraction of the maxillary third molars were done. Modified Ward’s incision was utilized for extraction of the lower third molars.
A flap was first raised on the left side and bone was reduced around the carious third molar tooth. This was followed by transalveolar extraction of the grossly decayed tooth.
Bone was reduced to expose the submerged right third molar tooth. The tooth was then sectioned taking great care to ensure there was no damage to the inferior alveolar nerve.
The sectioned parts of the tooth were then carefully extracted to prevent any damage to the nerve. The flap was then sutured using resorbable sutures.
Complete patient satisfaction with resolution of pain and swelling
Nerve function tests were performed and all nerve functions were fully intact. The patient was very happy that a potentially complicated problem had been solved with such ease. She did not experience any numbness and had no postoperative complications following the removal of her third molars.
Patient involved in an accident while on a holiday
The patient is a 28-year-old male from Chennai, Tamil Nadu, India. He was recently holidaying with his family in Rajasthan when he was involved in a motor vehicle accident. A camel had suddenly strayed onto the path of his car, which had resulted in a collision. His face had violently impacted on the steering wheel causing fractures (broken bones) to his orbit and zygomatic bone.
Emergency treatment at a nearby city hospital
He did not lose consciousness following the injury; however, there was significant double vision. The patient was rushed by his family to a nearby hospital where his right upper eyelid soft tissue laceration was sutured.
Imaging studies were also obtained, which revealed fractures to the right side of the face. He was advised surgery, but declined as he wished to undergo surgery at our hospital.
Our hospital is renowned for facial trauma surgery arising from road accidents. The facial cosmetic surgery services available at our hospital provide very good esthetic outcome for the patient. We have a dedicated facial trauma care unit that caters to such cases.
Patient presents to our hospital for surgical management of fracture
Dr SM Balaji, facial trauma surgeon, examined the patient and obtained a detailed history. He then ordered a 3D CT scan and other pertinent imaging studies. The patient complained of a depression on the right side of the face and double vision in the right eye. Clinical examination revealed depressed right zygoma and double vision.
Radiographic examination revealed a shattered zygoma and orbital floor with a midpalatine suture split. There was evidence of subconjunctival hemorrhage in the right eye as a result of the trauma. The patient was experiencing severe discomfort and difficulty with viewing due to his double vision.
Treatment planning presented to the patient in detail
It was explained to the patient that he needed fixation of the midpalatine suture split. He also needed lateral orbital wall fracture fixation and right orbital floor reconstruction with a titanium Medpor implant. Zygoma fracture elevation and fixation would be performed through an intraoral approach to avoid external scar formation.
It was also explained that he needed to stay on a liquid diet for about one to two weeks following surgery. The patient and his parents were in complete agreement with this surgical plan and consented for surgery. Presurgical anesthetic evaluation was completely normal for the patient. This was performed per American Board certified presurgical protocols.
Successful surgical reduction of multiple facial fractures
Under general anesthesia, a sulcular incision was made in the left anterior maxilla and mucoperiosteal flap raised. The dentoalveolar fracture and midpalatine suture split was reduced and fixed using titanium plates and screws. This was followed by a vestibular incision that was made in the right posterior maxilla. A flap was raised and the fractured segments of the zygoma were visualized.
Eye lid surgery followed with placement of a lateral canthal incision. The lateral orbital wall fracture was then reduced and fixed using titanium plate and screws. Following this, the comminuted right zygoma fracture segment was reduced, elevated and fixed using titanium plates and screws.
A transconjunctival incision was then made and the inferior orbital wall fracture was visualized. Orbital contents were elevated. Herniated periorbita was released from the orbital floor.
The floor of the orbit fracture was then reconstructed using a Titan Medpor implant. Closure of incisions was done using resorbable sutures intraorally and non resorbable sutures extraorally.
Total patient satisfaction following surgery
Surgery was successful with no complications. Results were immediate with restoration of previous facial esthetics. The patient and his family were fully satisfied with the outcome of the surgery.
There was no depression and his face was now symmetrical on both sides. His double vision was also corrected following orbital floor reconstruction.
Patient with asymmetrical nose and prominent lip scar
The patient is a 22-year-old male from Kasargod in Kerala, India. He had been born with a cleft lip, palate and alveolus deformity. Surgical repair of his deformities had been performed at the correct prescribed times at a local hospital. The patient had subsequently developed normally with good speech and nutrition.
However, there had always been residual facial and nasal deformity from the surgery. This had led to a degree of bullying during his schooling. As the patient grew older, the amount of nasal deformity had gradually increased. Nasal deformities usually involve both bone and cartilage.
There was also some hypertrophic scarring at the site of the lip correction. About two years ago, the patient and his parents had visited a nearby city for consultation regarding corrective surgery. This is one of the treatments that would be addressed by a cosmetic surgeon in India. Facial plastic surgery will correct this esthetic shortcoming.
Initial presentation for facial deformity correction surgery
Upon viewing the patient’s deformity, the surgeon had recommended rhinoplasty with costochondral graft placement. The patient and his parents consented and surgery was performed; however, they were highly dissatisfied with the results of the surgery. The lip scarring had worsened and he had also developed breathing problems after the surgery.
His breathing problems worsened considerably to the point where they visited a cosmetic surgeon in their hometown. After examining the patient, the surgeon realized that he needed to be operated at a specialty center. He had therefore referred him to our hospital for correction of his complaints.
Our hospital is a specialty center for facial cosmetic surgery in India. We are also a reputed center for cosmetic rhinoplasty, cleft rhinoplasty, jaw reconstruction surgery and facial trauma surgery. Our hospital is a world renowned center for craniofacial surgery. Scores of children with craniofacial deformities have been rehabilitated in our hospital over the years and now lead normal lives.
Initial presentation at our hospital for corrective surgery
Dr SM Balaji, Cleft Rhinoplasty Surgeon, examined the patient and obtained a detail history. The patient complained of a depressed nose. He also said that he had developed breathing difficulties after his first surgery.
The patient stated that the scar on his lip had also worsened after the previous surgery. He said that he desired to surgically have his nose and lip scar addressed.
Treatment planning was explained in detail to the family. This would first involve harvesting a costochondral graft from the patient. This would be followed by lip scar revision with correction of vermillion notching and rhinoplasty correction.
A strut graft would be used to correct the columellar deformity. The patient and his parents were in complete agreement with the treatment plan and consented to surgery.
Various nasal shapes and deformities of the nose
Shape of the nose varies widely due to differences in the shape of the nasal bone. This gives rise to the shape of the bridge of the nose. Nasal form was first classified by Eden Warwick in 1848. Nasal deformities include broad, narrow, crooked, saddle nose etc.
Some birth defects such as Down’s syndrome manifest a small nose with a flattened nasal bridge. This can be due to the absence of one or both nasal bones, shortened nasal bones or unfused bones in the midline.
Successful surgical correction of facial deformities
Under general anesthesia, the previous surgical scar in the right inframammary region was excised. A costochondral graft was then harvested. The lip scar was excised and lip revision was done. The notching on the vermillion was also corrected.
This was followed by a transcartilagenous incision to the right and left nostril. A strut graft was placed to elevate the columella. Closure of the incision was done intranasally using resorbable sutures.
Total patient satisfaction at the results of the surgery
The patient and his parents were very pleased with the surgery. He now had a symmetrical and prominent nose. There was also establishment of a perfect Cupid’s bow lip form. He said that he could now face social situations with complete confidence.
