by smbalaji | Sep 11, 2019 | Surgery
History of a fall on her chin as a little girl
The patient is an 18-year-old young girl from Guntur in Andhra Pradesh, India. She has a history of a fall at the age of two when she fell off the bed and landed on her chin. This had resulted in pain and difficulty with chewing for a few days. She soon became pain free and her parents did not follow up with the doctor.
As she grew up, it became evident that her lower jaw was not growing normally. There was also difficulty with chewing and mouth opening. They had taken her to a local oral surgeon who had obtained imaging studies of her mandible. He explained to them that she had ankylosis of bilateral TMJ and had advised release of her ankylosis. She had subsequently undergone TMJ ankylosis surgery for release of her jaw joints.
However, her parents soon realized that her mandibular deformity was getting progressively worse as she grew up. Her mandible was extremely retruded in relation to the rest of her face. She was having problems with both chewing and speech and had minimal mouth opening.
History of breathing problems leading to chronic tiredness
The patient has also had breathing problems for a long time and complained of feeling tired all the time. Her parents said that she woke up regularly in the middle of the night with a loud gasp. She was also constantly drowsy throughout the day.
Her parents took her to an oral surgeon in Hyderabad for a consultation. He realized that the patient had micrognathia and needed distraction osteogenesis with internal devices for lengthening of her mandible. Explaining the situation to them, he informed them that there were only a few specialty hospitals that performed this surgery in India. He then referred them to our hospital for management of her problem.
Initial presentation at our hospital for consultation and treatment planning
Dr. SM Balaji, Distraction Osteogenesis Surgeon, examined the patient and observed that she appeared pale. Her skin was cyanotic and he ordered sleep studies. Pulse oximetry revealed decreased oxygen saturation levels in her red blood cells due to sleep apnea. He explained the condition in detail to the parents and advised them of the proposed treatment plan. It was explained that the patient needed to undergo a tracheostomy before distraction osteogenesis surgery for her micrognathia correction. This was also because of the patient’s restricted mouth opening. The parents expressed understanding and consented to surgery.
Successful surgical correction of micrognathia
Under general anesthesia, the patient first underwent a tracheostomy. This was followed by bilateral incisions in the mandible with elevation of mucoperiosteal flaps. Vertical bone cuts were first made on the outer cortex of the mandibular body bilaterally. Univector mandibular body distractors were then fixed with the activating arms exiting outwards. The inner cortex was broken following fixation of the distractors.
Total duration of the distraction osteogenesis treatment
The tracheostomy would remain in place throughout the entire distraction treatment phase. Activation of the distractors would begin after a latency period of five days following surgery. Distraction of 1 mm would be performed every day until a total distraction of 25 mm had been achieved.
After sufficient increase in length of the mandible has been achieved, the distraction would be stopped. The distraction devices would however remain in place for a further period of four months. Once sufficient consolidation of bone is demonstrated at the site of distraction, this would be followed by another surgery for removal of the distractors. The patient would have full function of the lower lip including sensation due to reformation of the nerve canal.
There would be an increase in the parapharyngeal space following completion of the treatment. This would enable the patient to breathe normally. Blood oxygen levels would return to normal. Her facial appearance would also be greatly improved with the increase in the size of the lower jaw. The parents expressed their gratitude to Dr. Balaji following surgery.
Surgery Video
by smbalaji | Sep 10, 2019 | Surgery
A fall from bed as an infant with resultant chin injury
The patient is a 4-year-old boy from Chennai in Tamil Nadu, India who rolled off his crib as an infant. He had landed on his chin and had cried a lot due to the resultant pain. His worried parents had taken him to a nearby hospital where the duty doctor had examined him and prescribed analgesics.
The child soon returned to his normal playful self though he had developed difficulty chewing. Parents soon noted that his facial structure was slowly changing with his chin getting retruded progressively. He also developed progressive breathing difficulties.
The parents then had taken him to an oral surgeon who diagnosed bilateral ankylosis of the TMJ. He advised release of the ankylosis, which had been done. However, the patient still had difficulty with mouth opening and his breathing difficulties were also worsening. It was then that he was referred to our hospital for management of his difficulties.
Our hospital is a premier center for TMJ ankylosis surgery in India. Jaw deformity surgery is routinely performed in our hospital. Distraction osteogenesis surgery is a specialty at our hospital. We were one of the first centers in India to offer this specialized jaw treatment.
Initial presentation at our hospital for consultation
Dr SM Balaji, Jaw Lengthening Surgery specialist, examined the patient and obtained a detailed history from the parents. They complained that he was always feeling drowsy and tired. He was listless and had difficulty breathing, particularly during sleep.
Dr SM Balaji noted that the patient looked very pale and had mild cyanosis of the skin. The patient also had a backwardly positioned lower jaw. He immediately ordered for pulse oximetry and oxygen saturation tests, which revealed extremely reduced blood oxygen levels in the red blood cells.
It was decided to do an emergency tracheostomy to relieve this and the patient’s skin tone immediately returned to normal. The parents were counseled that the tracheostomy needed to be in place during the entire period of jaw lengthening through mandibular distraction osteogenesis.
It was explained to them that the tracheostomy needed to be retained for about 4-5 months during the entire duration of distraction treatment. Mandibular lengthening through distraction device fixation would lead to increased airway space, thus facilitating improvement in his breathing. Parents were in agreement with the treatment plan and consented to surgery.
Successful completion of mandibular distraction osteogenesis
Under general anesthesia, incisions were placed in the mandible bilaterally and mucoperiosteal flaps raised. Vertical bone cuts were made in the mandibular body bilaterally following which mandibular body distractors were fixed bilaterally with the activating arms exiting outwards.
After a period of about five days, distraction was started by turning the distractors clockwise. The Univector distractors were distracted bilaterally by 1 mm daily for a total of 20 mm in three weeks to compensate for deficiency in growth of the mandible.
Distractors retained during the period of bony consolidation
The distractors were left in place for a latency period of four months. The distractors were removed once adequate bony consolidation was seen at the site of the distraction. Oxygen saturation tests were then performed to check the patient’s oxygen levels. Once it was seen to be normal, the tracheostomy was removed with complete restoration of normalcy in the patient’s life.
Lower lip function including sensation was intact with complete reformation of the nerve canal. This was documented radiographically. The patient’s facial profile was also normal with lengthening of the mandible.
His breathing had returned to normal following the increase in his parapharyngeal space. He was once again a very active young boy. The parents expressed their gratitude to Dr. Balaji as their child was breathing well during sleep without any signs of obstructive sleep apnea.
Surgery Video
by smbalaji | Sep 7, 2019 | Surgery
Young man involved in a road traffic accident
The patient is a 24-year-old male from Surat in Gujarat, India. He had been involved in a road traffic accident while riding his bike. A collision with another two wheeler had resulted in his motorcycle skidding and he had landed hard on his chin. This had immediately resulted in difficulty opening his mouth and speaking.
His parents had taken him to a local hospital where emergency treatment was administered. Wound debridement had been done for his superficial lacerations along with dressing. An x-ray taken at the hospital revealed a left-sided condylar fracture.
The radiologist had explained to the patient that this needed to be addressed surgically at a specialty center. Due to its complicated presentation, the patient had been referred to our hospital for surgical management.
Initial presentation at our hospital for treatment planning
Dr SM Balaji, mandibular fracture surgeon, examined the patient and ordered an orthopantomogram and 3D CT scan to visualize the fracture. The patient was in a considerable amount of pain and had difficulty opening his mouth. He also had vertical shortening of the lower face along with a posterior open bite. There was also mild facial asymmetry with deviation of the mandible to the left side. Both the OPG as well as the 3D CT scan clearly revealed a displaced left-sided condylar fracture.
It was explained to the patient that he needed condylar fracture surgery with open reduction and internal fixation along with plating to stabilize the fracture. He would also be placed in Intermaxillary fixation to promote healing of the fracture site. The area of the stylomastoid foramen in the temporal bone was not involved in the fracture.
A liquid diet would be needed during the period of Intermaxillary fixation, which would be for a period of 2-3 weeks. This would be followed by a period of semi-solid diet. The patient and his parents were explained the rationale behind the treatment planning and consented to surgery.
Successful surgical management of the condylar fracture
Under general anesthesia, a modified Alkayat-Bramley incision was made on the left side of the face. This was just anterior and superior to the pinna of the ear. A flap was then elevated and dissection was carried out until the fracture site was identified. The displaced condylar fracture was then reduced followed by a check for normal occlusion.
Once it had been determined that the fracture had been adequately reduced, it was then fixed using titanium plates and screws. Extreme care was taken to ensure that the facial nerve was adequately protected throughout the procedure. Intermaxillary fixation was applied to the jaws and the patient was instructed to follow all the postoperative instructions. The patient demonstrated full function of the facial nerve in the immediate postoperative period including furrowing of the brow and eye movements. Bite was also normal.
Patient satisfaction at the results of the surgery
The patient returned after a period of two weeks for removal of his Intermaxillary fixation. Facial asymmetry had been reestablished and there was no difficulty with opening his mouth. Pain was also absent and the patient demonstrated full facial nerve function without any compromise. Parotid gland function was also completely normal. There was no alteration in the taste sensation.
The patient and his parents were very relieved that he had gained complete function without any sequelae from his road traffic accident. They expressed their complete satisfaction at the results of the surgery.
Surgery Video
by smbalaji | Sep 6, 2019 | Surgery
Road traffic accident from a two wheeler
The patient is a 45-year-old woman from Chennai in Tamil Nadu, India. She was involved in a road traffic accident while crossing the road as a pedestrian. A speeding motorcycle knocked her down with her chin impacting the asphalt. The biker had immediately left the scene and she had been taken to a nearby hospital by onlookers. The patient suffered no external injuries from the impact. Her jaw was slightly displaced to the right side.
Referral to our hospital for treatment of her fractures
She complained of pain and difficulty opening her mouth upon initial presentation at the hospital. Imaging studies had been taken at the hospital and had revealed that she had fractured the right condylar head of the mandible. She had undergone condylar fracture surgery, but it had resulted in a malunited fracture due to the pull of the lateral pterygoid muscle.
Faced with eating and speech difficulties, the patient had presented again at the hospital. Realizing the complexity of the treatment involved to correct the malunited fracture, the doctor had immediately referred her to our hospital for management. Our hospital is a premier center for jaw fracture surgery in India. Even complicated comminuted jaw fractures are addressed at our hospital with excellent results.
Initial presentation at our hospital for management
Dr SM Balaji, jaw fracture surgeon, examined the patient and ordered comprehensive imaging studies including a 3D CT scan. Imaging studies revealed a displaced malunited condylar fracture on the right. The displacement was due to the pull of the lateral pterygoid muscle. Treatment planning was then done after ascertaining the extent of injuries. The patient had deviation of the mandible to the right side along with a right-sided posterior open bite.
It was explained to the patient that she would need re-fracture of the malunited fracture. This would be followed by internal fixation using titanium plates and screws. She would also need to stay on a liquid diet for about two to three weeks. This would be followed by a semi-solid diet for another week to ten days. The patient and her husband were in agreement with the treatment plan and consented to surgery.
Successful surgical reduction and stabilization of the fracture
Under general anesthesia, a modified Alkayat Bramley incision was made on the right side of the face. A flap was then elevated following which the malunited fracture site was exposed. The region of malunion was then refractured. This was followed by reduction of the displaced condylar segment. Occlusion was then checked and found to be perfect. The fracture was stabilized and fixed using titanium plates and screws. It was now resting stable within the glenoid fossa.
Special care was taken to ensure that the facial nerve was not damaged during the procedure. Facial nerve paralysis is a complication that could arise from the surgery. This is usually caused by intraoperative damage inflicted upon the facial nerve from its point of exit in the temporal bone during surgery. Care also has to be taken to not cause any injury to the parotid gland.
Complete patient satisfaction at the outcome of the surgery
Immediate postoperative check for facial nerve function showed normal facial nerve function. The patient was able to furrow the forehead and open and close his eyelids. There were no complications arising from the surgery. Results were apparent immediately after the surgery. The patient was satisfied with the outcome of the surgery. She was able to open and close her mouth again with no pain or discomfort. There was also complete restoration of normal occlusion following surgery.
Surgery Video
by smbalaji | Sep 5, 2019 | Surgery
Patient born with a cleft lip and palate deformity
The patient is a 25-year-old female from Jaipur in Rajasthan, India who was born with a cleft lip, palate and alveolus. A cleft palate defect results in a hole in the roof of the mouth. This results in regurgitation of fluids from the mouth through the nose. Cleft palate repair would result in closure of this communication between the oral cavity and the nose.
She had undergone cleft lip surgery at 3 months of age and cleft palate surgery at 9 months of age. This had been followed by cleft alveolus surgery at 4 years of age. These had been performed at the correct recommended times for these surgeries.
The patient however developed a crooked nose with growth and age. She had always felt that her nose was asymmetrical and not in harmony with her face. This made her feel self conscious and depressed.
Another complaint the patient had was about the facial scar on her upper lip as well as a few missing teeth. She has already been operated twice for the nose and multiple times for the lips. A request was made for nose reshaping surgery. Plastic surgeons also perform this surgery.
She had approached a local cosmetic surgeon who had thoroughly examined the patient. He had advised her that she needed to see a cleft rhinoplasty surgeon. The patient had then been referred by him to our hospital. Our hospital is a premier center for cleft rhinoplasty surgery in India.
Initial presentation at our hospital for treatment planning
Dr SM Balaji, nose correction surgeon, examined the patient and studied her old medical records. She was a case of left sided unilateral cleft lip and palate. Her nose appeared bulky. There was no symmetry in the upper lip. The vermillion border was uneven.
There was lack of sufficient alveolar bone in relation to the left lateral incisor for placement of a dental implant. Bone grafting would need to be performed at this site of implant placement at a later date. Decision was made to harvest the graft from the retromolar region. It was explained to the patient that she needed lip scar revision surgery as well as nose correction with bilateral lateral osteotomy and removal of the medial crus of the nose.
A bone graft would be utilized to reconstruct the defect in the alveolar bone. This would be followed by dental implant surgery after consolidation of the alveolar bone graft. He also explained that no grafting of skin or skin flaps will be required for these procedures.
Successful surgical correction of the facial deformities
Under general anesthesia, lip revision surgery was first performed followed by closure of the incision with sutures. A bone graft was next harvested from the left retromolar region. This was then used to reconstruct the patient’s alveolar defect.
Nose correction was performed next. An incision was made in the right nostril and medial nasal cartilage was excised. Lateral osteotomies were then performed bilaterally. Intranasal and intraoral incisions were then closed utilizing resorbable sutures.
Complete patient satisfaction at the results of the surgery
The results of the surgery were visible immediately. The patient was very happy with the outcome of the surgery. She no longer had a bulky nose and had a more symmetrical nose. The result of her lip revision surgery was also very pleasing to her.
She expressed her happiness to the surgeon and thanked him for helping her to regain her confidence.
by smbalaji | Aug 31, 2019 | Surgery
The 13th ICPF World Congress in Japan
Dr SM Balaji attended the 13th ICPF (International Cleft Lip and Palate Foundation) World Congress in Nagoya, Japan. He is a member of the Board of Trustees of the ICPF as well as Editor-in-Chief of the ICPF newsletter. The ICPF Board of Trustees comprises of the premier cleft lip and cleft palate surgeons in the world who come together at the yearly world congress to assess the work done in the previous year and to formulate plans for the upcoming year.
The Board of Trustees meeting discussed ways of incorporating various allied fields into the ICPF to address the pressing needs of patients with various birth defects. The meeting was helmed by Dr Nagato Natsume, Secretary-Treasurer, who is also the founder of the ICPF and Prof Kenneth Salyer who is the President of the ICPF. Prof Salyer holds the distinction of having performed the first successful separation of conjoined twins in the world.
Dr SM Balaji is a premier Chennai-based cleft lip and palate surgeon whose surgical innovations have been widely adopted throughout the world by other surgeons. His surgical flap designs have resulted in improved esthetics and function for the patient.
Widening the scope at the 13th Congress of the ICPF at Nagoya
The ICPF was founded in 1997 as a humanitarian, nonprofit organization whose aim was to address the sufferings of patients born with cleft lip and palate deformities. It has exponentially grown over the years and now conducts surgical missions to poor underdeveloped countries around the world for the rehabilitation of cleft lip and palate patients.
This year’s congress was held in conjunction with the 59th Annual meeting of the Japanese Teratology Society at the picturesque city of Nagoya in Japan. This is in lieu with the decision of the Board of Trustees of the ICPF to address a greater number of birth defects that plague humanity. The vision of the ICPF is to completely eliminate the occurrence of cleft lip and palate through genetic studies aimed at identifying the genes responsible for cleft formation.
Participation of the American Society of Teratology at the congress
This year’s congress saw the participation of the American Society of Teratology for the first time at the ICPF congress. It was represented by the President, Dr Elise M Lewis who spoke at length about the increase in the incidence of birth defects around the world. She spoke about the challenges facing the medical field in this regard.
Dr SM Balaji and Dr Elise Lewis held discussions about collaborations between India and the United States of America towards addressing this problem. They agreed that environmental factors were increasingly becoming a factor in the occurrence of birth defects.
Dr SM Balaji’s keynote lecture at the conference
The topic of Dr SM Balaji’s keynote lecture at the conference was the “Management of Orbital Dystopia.” He presented cases from his over 25 years of surgical experience in correcting this deformity. His lecture was followed by a lively Question and Answer session in which he addressed a variety of queries posed by the distinguished audience. Dr SM Balaji received a Certificate of Appreciation from Dr George Sandor at the end of his keynote lecture.
Dr SM Balaji meets Dr Akiro Yamada at the congress
Dr SM Balaji attended the microtia workshop conducted by Dr Akiro Yamada. He held discussions with Dr Yamada regarding the various surgical techniques utilized for ear reconstruction. They discussed about the morphological differences in the human ear found in people around the world. The workshop was a resounding success with contributions from leading microtia surgeons from around the world.
This year’s congress concluded on a positive note with the decision to include a greater number of birth defects under the ICPF umbrella being lauded by all those in attendance. Everybody pledged their commitment towards the ideals of the ICPF of alleviating suffering cause by birth defects and other genetic anomalies.
