The patient is a 19-year-old young girl from Mathura in Uttar Pradesh, India. She was born with a cleft lip, palate and alveolus. Her parents were counseled extensively after her birth. They were advised to get her deformity repaired at the appropriate ages.
She first underwent cleft lip surgery at 3 months of age. This was followed by cleft palate repair at 9 months of age. Cleft alveolus repair was then performed at 4 years of age. This resulted in overall improvement in her oral health. It was advised that she would need orthognathic surgery at a later date.
The degree of her facial deformity progressively increased as she grew up. It has now reached the point where she is finding it hard to bite on foods. Her upper teeth are placed inwards in relation to her lower teeth. She also said that this made her look ugly and unattractive. They realized that she would need corrective jaw surgery. This does not come under the purview of facial plastic surgery.
Deciding to get this corrected, her parents took her to Kolkata to seek the advice of an Oral and Maxillofacial Surgeon. The surgeon had examined the patient and obtained radiographic studies. Upon viewing it, he realized that the degree of correction required was enormous. He then counseled the parents that this needed to be performed at a specialty jaw surgery center.
The patient and her parents were then referred by him to our hospital for surgical correction of her problem. Our hospital is a premier center for jaw deformity surgery in India. Jaw correction surgery is a specialized services offered by our hospital. We are a premier center for jaw advancement surgery in India. Surgical crossbite and open bite correction is routinely performed at our hospital.
Initial presentation and examination at our hospital
Dr SM Balaji, jaw correction surgeon, examined the patient and obtained a detailed history from her parents. He then ordered for comprehensive imaging studies for the patient.
The patient had an increased crossbite in the anterior region. Her maxilla was also positioned backwards in relation to her other facial bones. Radiological examination confirmed maxillary hypoplasia.
Maxillary Hypoplasia in cleft lip and palate patients
Underdevelopment of the maxillary bones, which results in midfacial retrusion is known as maxillary Hypoplasia. This condition creates the illusion of protuberance of the mandible. The size of the mandible though is normal.
It is associated with Crouzon syndrome, Angelman syndrome and fetal alcohol syndrome along with many other syndromes. This can also be a byproduct of cleft lip and palate deformity.
Development of treatment planning for the patient
It was planned to correct the retrognathic maxilla by pulling it outwards using the Le Fort 1 surgical technique. This surgical technique is a complex one that is performed by only experienced surgeons. Results from this surgery provide good esthetic and functional correction of the patient’s problems.
Successful surgical correction of the retruded maxilla
Under general anesthesia, a sulcular incision was made in the maxilla. A mucoperiosteal flap was then elevated to expose the maxillary bone. Le Fort I bone cuts were made and the maxilla was separated. The separated maxillary segment was then pulled forward until there was proper occlusion of the teeth. Following this, the maxilla was stabilized and fixed using titanium plates and screws. Closure was then done using resorbable sutures.
Total patient satisfaction at the outcome of the surgery
The patient and her parents were extremely happy with the esthetic results of the surgery. Improvements in the functional aspects were also explained to them. It was explained to them that she could eat a more varied diet because of normalization of her occlusion.
They expressed understanding of this. The patient said that she could not face the world with self confidence because of her improved appearance.
A 23-year-old girl from Guntakal with facial deformity
The patient is a 23-year-old female from Guntakal in Telangana, India. She had fallen down and injured her jaw while playing with friends as a little girl. The patient had landed on her chin and had cried incessantly for a few days.
Her parents had taken her to a nearby hospital where they had prescribed her analgesics. She soon returned to her normal playful ways once the patient had subsided.
As the patient grew up, her parents began noticing that her lower jaw growth was lagging. It soon reached the point where she had gross deformity of her lower jaw. Her mouth opening was also very much reduced and she began to have difficulty eating and with speech. There was rigidity to the position of her lower jaw.
TMJ ankylosis surgery of her jaw joint
Her parents had taken her to an oral surgeon in Hyderabad for consultation. He had diagnosed the patient to have left-sided TMJ ankylosis. There was a deviation of her mandible to the left side. He had recommended surgical release of her ankylosed joint. Her parents had consented to surgery and she had undergone TMJ ankylosis surgery.
She now had a degree of facial asymmetry that interferes with her activities of daily living. She has lost all self confidence and rarely leaves the house. This had worried her parents endlessly and they had presented to a local oral surgeon for consultation regarding her problem.
Upon examining the patient, he had realized the degree of correction needed for the patient was extreme. Explaining this to the patient, he had explained the mechanism of distraction osteogenesis surgery to them. He had then referred them to our hospital for facial asymmetry surgery to correct her facial deformity.
Our hospital is a specialist center for facial deformity correction in India. Hundreds of people with facial deformity are rehabilitated in our hospital through distraction osteogenesis and Le Fort osteotomy surgery. Many patient have provided testimony about how surgery at our hospital has completely transformed their lives.
Initial presentation and examination at our hospital
Dr SM Balaji, facial deformity surgeon, met with the patient and her parents and obtained a detailed history from them. This was followed by a thorough clinical examination of the patient’s lower face. He then ordered comprehensive imaging studies for the patient including a 3D CT scan.
The patient was diagnosed with a mandibular asymmetry caused by the TMJ ankylosis. This had caused a shift of the mandible to the left side. There was also an obvious facial asymmetry as a result of this. The patient had minimal mouth opening with poor oral hygiene.
There was also an obvious occlusal cant that had resulted from the long standing ankylosis. Imaging studies revealed that the right side of the mandible was longer than the left side.
Treatment planning explained in detail to the patient
The patient would need treatment on the left side even though the defect was on the right side. This correction would be achieved through mandibular distraction on the left side. A mandibular ramus distractor would be fitted on the left side of the mandible. The patient and her parents expressed understanding of the treatment and consented to surgery.
Successful correction of the facial asymmetry through distraction
Under general anesthesia, an incision was made in the left mandibular retromolar region with elevation of a mucoperiosteal flap. Bone cuts were then made to the outer cortex of the ramus of the mandible. This was followed by fixation of the mandibular ramus distractor using titanium screws.
The inner cortex of the mandible was then cut to facilitate movement of the proximal bone segment. Extreme care was taken throughout to prevent any injury to the inferior alveolar nerve.
A sulcular incision was then made in the maxilla. This was followed by Le Fort I osteotomy. The maxilla was then mobilized and the posterior end of the left maxilla was fixed using transosseous wires. Hemostasis was achieved and closure was done.
Postsurgical treatment phase for the patient
Interarch wiring was done to stabilize the maxillary segment. A latency period of about six to seven days was then given. Following completion of the latency period, the distractor was activated by 1 mm every day.
After achieving the desired increase in length of about 23 mm, the distraction process was stopped. Two weeks after this, a straight plate was fixed to the left posterior maxilla to prevent further downward movement.
There was complete correction of the occlusal cant at the end of this procedure. Radiographs were then obtained after a period of about four months. This revealed complete consolidation of bone at the distraction site in the mandible.
Radiographic evaluation revealed complete bone formation with a patent nerve canal. It was then decided to remove the distractor.
Removal of distractor after bony consolidation
Under general anesthesia, an incision was made followed by elevation of a flap. The distractor was then exposed and successfully removed without incident. The flap was then closed using sutures and the patient recovered from general anesthesia without incident.
Return of self confidence and confidence following successful surgery
The patient and her parents were very happy with the outcome of the surgery. She now had a very pleasant face with symmetrical profile. Her self confidence levels had improved dramatically within a short period of time. She said that she could now face the world bravely and expressed her thankfulness for restoring normalcy back to her life.
The patient is a 20-year-old female from Kottayam in Kerala, India who has a disproportionately large lower jaw. This problem manifested at an early age in the patient. She said that she has always had a very long lower jaw, which had gradually worsened with time. Her parents had sought a consultation with a local oral surgeon who had advised surgical correction after completion of her growth.
Thumb sucking habit results in the exact opposite of this. It causes maxillary prognathism and a class II skeletal malocclusion. It is essential that habits like thumb sucking are broken at the earliest to avoid later problems with the jaw bones and teeth. The tongue posture is itself changed by such habits.
Effects of adverse effects on future treatment needs for the patient
This leads to requiring extensive treatment to obtain normally positioned permanent dentition. Such treatments could include both surgery as well as orthodontics. Treatment can be initiated during the mixed dentition phase.
The patient is now 20 years old and had approached him again. Seeing the degree of correction needed for the patient, he had referred them to our hospital for correction of her problem. The patient did have an extreme degree of mandibular prognathism.
Her mandibular prognathism is so extreme that she is unable to close her mouth. She also has a lot of difficulty with chewing and speech. Our hospital is a premier center for corrective jaw surgery in India. Both jaw reduction surgery and jaw advancement surgery are done at our hospital. Her mandibular plane would also be normalized by this surgery.
Distraction osteogenesis is the treatment of choice for increasing jaw size. Reduction of mandibular size is through bilateral sagittal split osteotomy.
Occurrence of mandibular prognathism with possible etiology
Prognathism in humans can be due to normal variation among phenotypes. In humans, prognathism may be a malformation, the result of injury, a disease state or a hereditary condition. It is considered a disorder only when it affects mastication, speech or the ability to function normally in a social setting.
Mandibular prognathism is a protrusion of the mandible in relation to the rest of the face. Pathologic mandibular prognathism is a potentially disfiguring genetic disorder where the lower jaw outgrows the upper jaw resulting in a protruding chin and anterior cross bite. Facial asymmetry surgery would address all of the patient’s problems.
Initial presentation at our hospital for mandibular prognathism
Dr SM Balaji, facial asymmetry surgeon, examined the patient and obtained comprehensive imaging studies. The patient had a skeletal class III malocclusion and an anterior open bite. He explained that the patient first needed to undergo fixed orthodontic treatment for straightening of her lower anterior teeth. This was to ensure proper alignment of the upper and lower anterior teeth following surgery.
He then explained the surgical details of bilateral sagittal split osteotomy to the patient. All the aspects of the treatment plan were presented to them. The patient and her parents were in agreement with the proposed treatment plan and consented to surgery.
Successful surgical correction of her mandibular prognathism
Under general anesthesia, incisions were first placed in the mandibular retromolar region bilaterally. Flaps were then elevated to expose the mandibular bone. Bone cuts were then made and bilateral sagittal split osteotomy was performed using the Obwegeser’s technique. The mandible was pushed posteriorly ensuring proper occlusion of the teeth.
This was then fixed in place using titanium plates and screws. Extreme care was taken throughout the procedure to ensure protection of the inferior alveolar nerve during mobilization of the proximal segment. All incisions were then closed with resorbable sutures.
Complete patient satisfaction with the outcome of the surgery
Results of the surgery were immediately evident to the patient and her parents. They were very happy with the outcome of the surgery. The patient’s occlusion was completely normal and she had an esthetic facial profile. She would need to undergo continued orthodontic treatment to bring her teeth into perfect alignment, thus obtaining good facial symmetry.
The patient expressed her happiness and said that this would transform her life completely.
The patient is a 12-year-old girl from Guwahati in Assam, India. She was born with a cleft lip and palate along with a cleft alveolus. Cleft lip surgery had been performed at 3 months of age. This was followed by cleft palate surgery at 9 months of age and cleft alveolus surgery at 4 years of age.
Progressive development of facial deformity with growth
As the patient grew up, her nose began to get progressively deformed and flat. There was also a hypertrophic scar from the cleft lip repair. This detracted from the appearance of her face and she felt self-conscious because of this. Her nasal tip was also flattened. She said that the left side of the face appeared different from the right side of the face.
Cleft lip deformities are considered to be facial deformities and not craniofacial deformities. Facial palsy is never present in cleft lip and palate patients. Bell’s palsy is a variant of facial palsy.
She began to get constantly bullied at school. This led to a lot of social problems with the patient isolating herself and withdrawing from everyone. She had very few friends in school and rarely went out of the house. The bullying reached the point where the patient refused to go to school.
Her alarmed parents decided to get her condition corrected and approached a local plastic surgeon. Following a detailed examination, the surgeon realized the complexity of the patient’s presentation. He referred the patient to our hospital for correction for facial deformity correction.
Premier centre for facial cosmetic surgery in India
Our hospital is a premier centre for facial deformity surgery in India. Facial cosmetic surgery is performed for correction of all deformities. Our hospital is one of the few to perform facial reanimation surgery in India. Extensive deformity correction with reestablishment of facial asymmetry is a specialty at our hospital.
Initial presentation at our hospital for treatment planning
Dr SM Balaji, cleft rhinoplasty surgeon, examined the patient and studied all her old case records. She had an obtuse nose with a short prolabium and nearly no columella, which is a typical presentation of bilateral cleft lip and palate patients.
The patient desired to have a normal nose and upper lip. It was advised for her to undergo nose correction through open rhinoplasty through rearrangement of nasal cartilage and lip correction using lower lip Abbe flap technique. Reconstruction of the columella of the nose and the prolabium will also be done using this technique.
The two stages of the surgical procedure
The surgery is usually done in two stages. In the first stage, an incision is placed in the upper lip and the tissue is mobilized to create a new columella. This stage is a columella reconstruction surgery. Nose correction is also done at this stage.
Following this initial procedure, a portion of tissue from the lower lip is transferred to the upper lip with its base still attached to maintain vascularity. This will be used to create the prolabium.
A period of about three weeks is allowed for new blood supply to establish from the upper lip to the tissue transferred from the lower lip. Once adequate vascular supply has been established, the pedicle will be separated from the lower lip. The donor and recipient sites are then sutured. This will enable restoration of normal lip anatomy.
Successful completion of the first stage of surgery
Under general anaesthesia, the first stage of the aforementioned surgical technique was successfully performed. The columella of the nose was successfully created along with the prolabium. Patient will be on a liquid diet for a period of 21 days until division of the flap is done. It was explained to the parents that scrupulous hygiene is very essential during this 21 day period.
Division of the pedicle flap and separation from the lower lip was performed after 21 days. The patient and her parents were very happy with the results of the surgery. They expressed that she will gain more self-confidence from the normal appearance of her lips after the surgery.
The patient is a now 24-year-old girl from Ranchi in Jharkhand, India who was born with near total absence of her external right ear. She had just a peanut like wedge instead. There was also absence of an external ear canal and eardrum.
Her marriage had been fixed three years ago and they had approached a local plastic surgeon. Upon examining the patient, he had realized that she needed to get it addressed at a specialty center. He had then referred them to our hospital for treatment.
Our hospital is a premier surgical center for microtia surgery in India. Many patients have been rehabilitated here and are leading completely normal lives today. Our hospital is a premier center for facial plastic surgery in India.
Initial presentation and consultation at our hospital
Dr SM Balaji, ear reconstruction surgeon, examined the patient and conducted a detailed evaluation. He explained to the patient the processes involved in ear reconstruction surgery.
Microtia surgery is performed in three stages. The first stage involves reconstruction of the ear using rib cartilage. A skin pocket is first created at the site of the missing external ear. The cartilage is then banked in the skin pocket created at this location.
The patient has already undergone this stage of the surgery two years ago at our hospital. Lobule shifting had also been completed. She now presents for the second stage microtia surgery.
Presentation and classification of microtia ear deformity
Microtia is a congenital deformity where the external ear is underdeveloped. Complete absence of the external ear is referred to as anotia. Microtia can be unilateral or bilateral and occurs in around 1 out of about 8,000–10,000 births. The right ear is more commonly affected than the left ear.
Unilateral microtia is more common than bilateral microtia. Microtia is graded according to its severity. In grade I microtia, there is a less than complete development of the external ear with identifiable structures and a small but present external ear canal. Grade II microtia manifests a partially developed ear with an underdeveloped upper half. The external ear canal is closed leading to conductive hearing loss.
Grade III microtia is more severe with near complete absence of the external ear with just a small peanut-like structure along with the absence of the external ear canal and ear drum. This is also the most common form of microtia. Grade IV microtia denotes the complete absence of the external ear.
Second stage microtia surgery for ear reconstruction
After a clinical evaluation, the second stage surgery for ear elevation was scheduled for the patient. Under general anesthesia, the banked cartilage was first removed. This was followed by excision of the scar in the inframammary region where the graft for the first stage had been harvested. A full thickness skin graft was then obtained from the hip region and right ear elevation was done using the banked graft and the full thickness skin graft.
Successful completion of the second stage microtia repair
The ear was successfully elevated, but constant monitoring was needed to ensure that the site of the graft did not develop an infection. Routine check-up was performed for a period of about one month. The patient and his parents were very happy with the results of the surgery.
The patient is a 12-year-old boy from Vizag in Andhra Pradesh, India who was born with bilateral cleft lip and palate. Parents were counselled extensively regarding their child’s condition. The roof of the mouth had a hole in it.
As per the recommendations made, he underwent cleft lip surgery first at 3 months of age. This was followed by cleft palate surgery at 9 months of age and cleft alveolus surgery at 4 years of age. These are as per the guidelines followed by the American Association of Oral and Maxillofacial Surgeons in the United States of America.
As the patient grew up, he gradually developed a flat nose deformity. There was also a prominent scar in his upper lip from the cleft lip repair. This had led to considerable bullying at school. The patient was becoming combative and rebellious because of all these factors. There was also flattening of the nasal tip from the surgery.
His worried parents had consulted a facial cosmetic surgeon who had suggested getting these deformities corrected. Due to the nature of these defects, he had referred them to our hospital for surgical management of his problem. The lip and nasal deformities will be addressed by the surgical repair.
Initial presentation and treatment planning at our hospital
Dr SM Balaji, cleft rhinoplasty surgeon, examined the patient and reviewed all his old surgical records. He observed that the patient had an obtuse nose, a short prolabium and a near absent columella, which is typical of bilateral cleft lip and palate deformity. A treatment plan was then formulated for the patient. It was advised that the patient undergo nose correction through open rhinoplasty and philtral reconstruction using an Abbe flap technique from the lower lip. The columella of the nose will be reconstructed using the philtrum of the nose.
Description of the surgical procedure
This surgery is done in two stages. In the first stage, an incision is placed in the upper lip and prolabium is mobilized. This is then utilised to create the columella. Nose correction is also done at this stage. The next step involves mobilization of a portion of the lower lip that is then transferred to the upper lip with its base still attached to maintain vascularity. This is used to create the philtrum.
Following a period of approximately 21 days, the second stage of the surgery will be performed. This period is given to allow the flap to establish vascular supply from the surrounding tissues in the upper lip. Once this has been established, the pedicle will be divided and the donor and recipient sites sutured. The lip anatomy will thus be completely restored.
Successful surgical reconstruction of the upper lip deformity
Under general anesthesia, the columella of the nose was successfully created along with the prolabium. The patient will have to be on a liquid diet for a period of 21 days until division of the flap is done. Maintaining hygiene is very essential during this period.
The parents and the patients were extremely pleased after division of the pedicle after the 21-day waiting period. The cosmetic results were excellent and there was also an improvement in lip function. Normalcy was restored to the appearance of the nose and lip of the patient. Parents stated that the child would now be able to face life with self-confidence and hope.
