Patient with long standing dissatisfaction over the structure of his face
The patient is a 25-year-old male from Haridwar in Uttarakhand, India. He states that he had always had a small lower half of face. Both his maxilla and his mandible were extremely retruded. The patient had always disliked his facial structure because of this. He stated that he has no history of childhood trauma or any other issues that could have caused it.
His maxillary and mandibular retrusion were not only esthetically compromising, but also compromised function. He had been troubled with breathing problems since he was a little boy. His sleep had been disturbed and he would often wake up gasping for air. He had always had daytime somnolence and this had caused a lot of trouble with his teachers in school.
These problems had persisted all through his life. It was only about two years ago that a colleague had suggested that this could be corrected through surgery. The patient and his parents immediately fixed an appointment with a facial cosmetic surgeon in a nearby city.
Sleep study with resultant diagnosis of obstructive sleep apnea
A sleep study had been obtained with the diagnosis of obstructive sleep apnea. They had been advised that he needed jaw advancement surgery. The patient and his parents had consented to the proposed treatment plan. Subsequently, the patient had undergone bijaw surgery with advancement of both his maxilla and mandible.
The patient had been sorely disappointed with the results of the surgery. He still felt that the lower third of his face was disproportionately small compared to the rest of his face. His sleep apnea problems had also not been resolved. He still woke up tired from a full night’s sleep.
Determined to get relief from the problems that had troubled him all his life, he started making enquiries regarding corrective surgery. It was at this point that he met an old friend who had got full relief from similar problems. This friend who had been plagued by sleep issues had been operated in our hospital.
Referred by his friend, the patient immediately got in touch with our hospital manager. He was asked to send his imaging studies following which an appointment was fixed for him to come for consultation.
Patient presents with comprehensive records at our hospital
Dr SM Balaji, jawline correction specialist, examined the patient and ordered imaging studies including a 3D CT scan. This revealed that the patient had very short bilateral rami. It was explained to the patient that he had reduced airway space because of this. This was causing his tongue to fall back into the throat, causing the nighttime awakening.
A sleep study was performed, which revealed very poor oxygen saturation levels. This revealed that the previous surgery had done little to relieve the patient’s obstructive sleep apnea.
Treatment planning was then explained to the patient in detail. Bilateral mandibular distraction osteogenesis would be performed for the patient. This would result in lengthening of the bilateral rami. Lower facial height would also be increased thus improving esthetics.
Successful bilateral internal mandibular distractor fixation surgery performed
Under general anesthesia, bilateral mandibular vestibular incisions were made with dissection down to the ramus. Old plates were then unscrewed and removed from the body of the mandible. Bone cuts were made to the ramus followed by fixation of the internal mandibular distractors. Distraction function was checked and found to be optimal. Incisions were then closed with sutures.
A maxillary vestibular incision was then made followed by removal of all the plates fixed at the previous surgery. The maxilla was then disjointed followed by intermaxillary fixation. This would ensure that the patient had perfect occlusion.
A latency period of five days was allowed following placement of distractors. Bilateral ramus distraction of 1 mm was performed per day after completion of the latency period. A total of 18 mm of distraction was done over a period of 18 days.
Resolution of obstructive sleep apnea with resultant increased oxygen saturation
There was dramatic improvement in the quality of the patient’s sleep after completion of the distraction. He also expressed his happiness with his facial esthetics. It was explained to the patient that the distractors will remain in place for a period of four months. This would allow for consolidation of new bone formed at the site of distraction.
The patient was instructed to return after four months for distractor removal surgery. He expressed understanding of the instructions and expressed his satisfaction at the results of the surgery.
Patient with lower facial asymmetry manifesting at birth
The patient is a 7-year-old female from Hastinapur in Uttar Pradesh, India. She had a minor degree of facial asymmetry at birth. This gradually worsened with age. It soon became apparent to her parents that there was an abnormality underlying her condition.
Worried over the turn of events, when she was around three years old, they had taken her to a local hospital.
Suspecting this to be the result of a genetic abnormality, they had been advised gene testing. Gene testing had revealed that the patient had the genetic abnormality linked to hemifacial microsomia.
Hemifacial microsomia explained to allay fears of the parents
The process causing hemifacial microsomia usually begins by the first trimester. It is still unclear as to the exact cause behind this condition. One probable cause could be disruption of vascularity to the face of the developing fetus. Though it usually manifests unilaterally, it can also occur bilaterally.
No external causes have been identified that lead to hemifacial microsomia. These include mother’s diet, metabolic conditions like diabetes or other such factors.
Parents were extensively counseled regarding the condition. It was explained to them that she had unilateral hemifacial microsomia, which involved her left lower face. There was also a minor deformity to the pinna of the left ear. They were informed that this would require cosmetic ear surgery at a later date.
Patients with hemifacial microsomia do not have prominent ears. Plastic surgeons perform ear reconstruction in most western countries.
The parents were advised that surgical correction of the deformities would be required for the patient at the appropriate ages. This would also include reconstruction of the affected side of the mandible.
Parents decide to seek consultation for correction of facial deformity
Deciding to get her condition corrected surgically, parents made widespread enquiries regarding the best surgeon to address this problem. They finally decided to come to our hospital for surgical management. Our hospital is a specialist craniofacial center with a dedicated craniofacial team.
Our hospital is a renowned center for facial asymmetry correction. Facial asymmetry arising from varied causes such as cancer, trauma and congenital causes are corrected surgically in our hospital. Facial reconstructive surgery is a specialty feature that has won accolades through our craniofacial program.
Initial presentation at our hospital for treatment of hemifacial microsomia
Dr SM Balaji, hemifacial microsomia surgery specialist, examined the patient and obtained comprehensive imaging studies including a 3D CT scan. This revealed that ramus and condyle were missing on the left side. There was no TMJ structure present. The patient had deviation of the mandible to the left side.
A comprehensive treatment plan was formulated and explained to the patient’s parents. It was explained that distraction osteogenesis cannot be performed due to insufficient bone. A costochondral rib graft with perichondrium would be harvested from the patient.
Harvesting with the perichondrium would enable lengthening of the ramus through growth as the patient grows up. In case growth of the ramus does not occur, ramus lengthening surgery through distraction osteogenesis would be performed.
The patient would also need TMJ reconstruction surgery at a later date. Parents expressed understanding of the treatment plan and consented to surgery.
Successful surgical placement of rib graft to posterior ramus
Under general anesthesia, an inframammary incision was made and a costochondral rib graft was harvested. This was followed by a Valsalva maneuver to ensure that there was no perforation of the thoracic cavity. The incision was then closed in layers with sutures.
Attention was next turned to the left ramus region of the mandible. An incision was made to expose the underdeveloped left ramus. The mandible was then pulled down and the costochondral graft with perichondrium affixed to the posterior ramus using titanium screws.
This resulted in improvement in facial symmetry for the patient. The wound was then closed with sutures.
It was explained to the parents that the patient would require further surgeries for complete rehabilitation of her facial deformity. Parents expressed understanding of the information and expressed their thankfulness before final discharge from the hospital.
Patient involved in a minor road traffic accident as a child in her hometown
The patient is a 23-year-old female from Mallapuram in Kerala, India. She had been involved in a minor road traffic accident when she was a little girl. Her father had been riding his motorcycle with her seated in front of him. A cyclist had abruptly cut across their path, which had resulted in them skidding and falling down.
There were only minor bruises and scrapes resulting from the accident. She had complained of a mild pain on the left side of her face upon opening her mouth. This had however soon resolved. The patient and parents had completely forgotten about it and had got on with their lives.
Her parents gradually began noticing the development of a mild deviation of her lower jaw to the left. This progressively worsened until it became evident to even a casual observer. Worried about this development, her parents fixed an appointment with an oral and maxillofacial surgeon in a nearby city.
Failed temporomandibular ankylosis release with damage to facial nerve
The surgeon examined the patient and obtained imaging studies of her temporomandibular joint. This revealed that there was ankylosis of the patient’s left jaw joint. He explained to them that this was most probably caused by an injury to the joint at the time of the accident.
The parents were counseled that the patient needed temporomandibular joint ankylosis surgery. They consented to the treatment plan and the patient underwent surgery. This surgery was however a failure and the patient began complaining of an altered taste sensation following surgery.
Feeling despondent over these developments, they sought the advice of a family friend who was a medical professional. She made thorough enquiries regarding hospitals where the patient’s condition would be adequately treated. Deciding that our hospital met all the criteria listed by her, she referred them to us for surgical management.
Facial plastic or cosmetic surgery is routinely performed in our hospital. Distraction devices are used for gradually lengthening the bone through osteogenesis of the mandible. Mouth opening is enhanced through this procedure. Upper airway obstruction due to small lower jaw is also relieved through distraction. Cleft palate surgery is a superspecialty feature of our hospital.
Initial presentation at Balaji Dental and Craniofacial Hospital for consultation
Dr SM Balaji, temporomandibular joint ankylosis surgeon, examined the patient. He then obtained imaging studies including a 3D CT scan. The patient also demonstrated a significantly skewed occlusal cant.
The patient was informed her altered taste sensation was from facial nerve damage. This had been caused by her previous surgery. He advised that the patient undergo left TMJ gap arthroplasty with interpositioning of temporalis muscle.
This would be followed six months later by unilateral mandibular distraction and Le Fort I surgery. He also advised advancement genioplasty for overall good cosmetic results. The patient and her parents consented to the treatment plan and the patient had successful release of her joint ankylosis. They now present for the second stage of surgery.
Patient and her parents present for second stage of surgical correction
Dr SM Balaji, facial asymmetry correction surgeon, examined the patient and there was good movement of her previously ankylosed left temporomandibular joint. It was then decided to proceed with the next step of surgery. There would be correction of the mandibular asymmetry and the skewed occlusal cant following this surgery.
A left mandibular vestibular incision was first made following which a bone cut was made to the ramus. Mandibular distraction osteogenesis was then made with good demonstration of distraction upon activation of the device.
Interdigitation of the occlusal plane with good facial asymmetry
Attention was next turned to the Le Fort I osteotomy of the maxilla. The maxillary segment was disjointed. This was followed by advancement genioplasty, which gave the patient an esthetically pleasing chin. Transosseous wiring was then performed to fix the maxilla on the right side.
This was followed by intermaxillary fixation of the jaws. A latency period of five days will be allowed following which distraction will be initiated. It was planned to perform a total of 12 mm of mandibular distraction over a period of 12 days. The distractor will be left in place for four months for good bony consolidation at the site of distraction.
Complete patient and parental satisfaction at the results of the surgery
There was good establishment of facial asymmetry after completion of the distraction. The patient and her parents expressed their complete satisfaction with the results of the surgery. They expressed understanding of the instructions and will return in four months for distractor removal surgery.
Patient with facial deformity since a very young age
The patient is a 12-year-old female from Guntur in Andhra Pradesh, India. She was around two years old when she tripped on a step and landed quite heavily on her chin. Her parents immediately rushed her to a local doctor who had prescribed analgesics for the pain.
The pain subsided a few days later and the patient returned to her normal playful self. Her parents however did not seek any further medical attention for this.
It was soon evident that her lower jaw growth was not keeping pace with the rest of her face. Her facial esthetics began to decline gradually. By the time she was around 8-10 years of age, there was an obvious retrusion of the mandible.
Beginning of breathing difficulties caused by lower jaw deformity
It was around this time that her breathing difficulties began. She would gasp for air in the middle of the night in her sleep. Her sleep was interrupted by episodes of sudden awakening. She would complain of feeling extremely tired despite a full night’s sleep.
Her lower jaw retrusion had become esthetically compromising by this point and she had “bird facies.”
This was making the patient extremely frustrated and was affecting every aspect of her life. It was at this point that her parents decided to seek medical intervention for her condition. They met with an oral and maxillofacial surgeon at a local hospital who examined the patient.
Diagnosis of bilateral TMJ ankylosis from the childhood injury
He had obtained imaging studies for the patient, which revealed bilateral TMJ ankylosis. Oral and maxillofacial surgery planning was performed. The patient had subsequently undergone bilateral TMJ ankylosis release surgery, which had enabled increased mouth opening. The patient however continued to suffer from the breathing difficulties and daytime somnolence.
They had been counseled that she would need mandibular distraction surgery for resolution of her breathing difficulties. It was explained to them that this was a specialized surgery performed by only a few select surgeons in India. He had then referred them to our hospital.
Our hospital is a premier center for internal distraction osteogenesis in India. Facial asymmetry correction is enabled through this advanced surgical technique. Lower jaw asymmetry correction has helped scores of patients to lead completely normal lives.
Parents bring the patient to Balaji Dental and Craniofacial Hospital for consultation
Dr. SM Balaji, distraction osteogenesis specialist, obtained a detailed history. He also ordered imaging studies including a 3D CT scan. The patient had a bird face appearance. A review of the CT scan revealed that the patient had an extremely micrognathic mandible along with the absence of condyle and coronoid.
He also ordered sleep studies for the patient because of the history of nighttime awakening along with excessive tiredness. This confirmed the diagnosis of obstructive sleep apnea with very low oxygen saturation rates.
Dr. SM Balaji explained to the patient and her parents that obstructive sleep apnea was caused by the micrognathic mandible. This was causing the tongue to fall back into the throat thus obstructing her breathing during sleep.
He explained that the patient needed distraction osteogenesis with forwarding advancement of the mandible. This would result in increased airway space for the patient, thus correcting her sleep apnea.
He also explained that the patient would need mandibular condylar reconstruction with bone grafts at a later date. The parents were in agreement with the treatment plan and consented to surgery. Mandibular condyle reconstruction is performed with the use of autologous bone grafts.
Successful mandibular advancement through internal distraction osteogenesis
The patient underwent placement of bilateral internal mandibular distractors. Following a latency period of five days, a total mandibular distraction of 10 mm was performed. This resulted in a gain of sufficient length of the mandible.
It was explained to them that the distraction device will be left in place for four months. This would be the consolidation phase to allow for new bone formation at the distracting site.
There was an immediate improvement in the patient’s breathing following the completion of the distraction. She was able to sleep the whole night without any episodes of awakening. The patient also related that she felt refreshed and did not experience any daytime tiredness.
Patient returns after four months for removal of distractors
The patient and her parents returned to our hospital after four months for distractor removal surgery. This would be the completion of the distraction process. The transformation in the facial esthetics of the patient was very pleasing to the eye. The interincisal opening had become uniform without any tilt.
They related how the quality of her life had improved significantly following surgery. The esthetics of her face was also greatly improved. She was now able to be more active and involved with all the activities of daily living.
Surgical removal of bilateral internal mandibular distractors
The patient was taken to the Operating Theater and general anesthesia was induced following bronchoscopic intubation. Sulcular incisions were placed and the distractors were removed without incident. The incisions were then closed with sutures.
Her parents were counseled on the need for further coronoid and condyle reconstructive surgery. They expressed their understanding of the instructions and thanked the surgical team before their final discharge from the hospital.
The patient is a 19-year-old college student from Guwahati in Assam, India. He was born with a bilateral cleft lip and palate defect. His parents had been extensively counseled regarding the condition. They were educated about the need to follow the correct schedules for surgical repair.
The patient had first undergone cleft lip surgery at 3 months of age. This had been followed by a cleft palate repair at 8 months of age. The two surgeries had been performed at a medical center in a city near his hometown. He had however never undergone a cleft alveolus repair, which is normally performed at 3-1/2 years of age.
There was a good esthetic result from the surgery with minimal scarring of the upper lip. Plastic surgeons also perform this cosmetic surgery in many countries.
Increasing difficulty with speech with the passage of time
The patient has always had problems with clear word-formation since childhood. He has always had difficulty with the pronunciation of certain sounds. His parents felt that there was a nasal quality to his voice. It sounded like he was talking through his nose at times.
The patient had faced a lot of difficulties during his school days. Teachers had constantly complained that they could not understand his speech. He had also been subjected to teasing by his peers. All these factors made him withdrawn and he had very few friends.
Initial visit to a local hospital for surgical consultation
His parents had been counseled by well wishers of the family to get this speech problem addressed. They had visited a local hospital where they were informed that the patient needed surgical repair of his palate.
The mechanism of the velopharyngeal insufficiency was explained to them in detail. They understood that the communication between the oral cavity and nose due to VPI was causing air to escape into his nose during speech. Following this, they had made widespread enquiries regarding the best hospital to get this corrected.
They were then referred to our hospital for surgical management of his condition. Our hospital is a premiere center for speech correction surgery in India. We are a referral hub for palatal defect surgery and jaw reconstruction in India. Our hospital is credited with many surgical innovations in cleft lip and palate rehabilitation.
Velopharyngeal insufficiency and its influence on word formation during the speech
When a patient has velopharyngeal incompetence/insufficiency, the soft palate does not contact the back of the throat. This is mandatory for the creation of certain sounds. Air exits through the oral cavity during the creation of certain sounds. This air escapes into the nasal cavity when there is velopharyngeal insufficiency. The nasal quality to the speech arises because of this escape of air into the nasal cavity.
Initial presentation at our hospital for surgical correction of the palate
Dr SM Balaji, palate repair surgeon and sphincter pharyngoplasty specialist, examined the patient. He noted the quality of speech and explained the causes to the patient and his parents. It was explained to them that the velum was not occluding and this was resulting in the nasal speech.
The patient was then referred to a speech pathologist for assessment was carried out. He was diagnosed with velopharyngeal insufficiency (VPI).
Treatment planning is done and explained to the patient in detail
It was explained to the patient and his parents that the palate surgery also needed to be redone. The palatal repair would be followed by a sphincter pharyngoplasty. This would result in complete normalization of the patient’s speech. Both procedures would be performed in a single surgery.
Successful surgical correction of the velopharyngeal insufficiency
Under general anesthesia, a palatoplasty was first performed using Veau-Wardill Kilner’s technique. The levator palati muscle was joined in the middle. This resulted in a good roof of the mouth palatal repair for the patient.
This was followed by the sphincter pharyngoplasty. Flaps were raised from the palatopharyngeus muscle. These were then attached to the posterior wall of the pharynx. The attachment was at the level of the adenoids in the form of a posterior pharyngeal flap. This resulted in complete correction of the velopharyngeal insufficiency.
A small central opening or “port” was left in the middle for breathing. A suction test was performed at the end of the surgery, which demonstrated good movement of the soft palate. A positive suction test indicates that the patient would have normal speech after rehabilitation following surgery.
Total satisfaction with the results of the surgery
The patient and his parents were very happy with the outcome of the surgery. His parents stated that there was considerable improvement in the quality of his speech following surgery. They were extensively counseled regarding the need for speech therapy for the patient. Speech therapists play an integral role in the successful rehabilitation of these patients.
The patient and his parents expressed a complete understanding of the instructions. His parents stated that this surgery would help the patient gain self-confidence and develop a more active social life.
Patient with facial asymmetry from a very young age in life
The patient is a 23-year-old female from Hubli in Karnataka, India. She had developed right-sided facial asymmetry from a very young age in life. Her parents had taken her to a local hospital where genetic testing had been performed. It had returned with the diagnosis of hemifacial microsomia.
Her facial asymmetry had gotten progressively worse with the passage of time. The right side of her mandible was extremely hypoplastic. She had problems with speech and eating due to this. Upper lip and lower lip function have always been normal. External ear deformity can also occur with hemifacial microsomia.
The patient had also faced significant bullying in school and college. She has always been introverted and considered books to be her best friends.
What is hemifacial microsomia and how is it corrected?
Hemifacial microsomia is a congenital disorder that affects the development of the lower half of the face. It most commonly affects the ears, mouth and mandible. There is marked facial asymmetry with resultant disfigurement of the face.
Hemifacial microsomia is the second most common birth defect of the face after cleft lip and palate deformity. Craniofacial microsomia involves structures of the upper cranium along with the usual facial involvement. Deformities related to children with cleft lip never overlaps hemifacial microsomia.
Parents decide to obtain surgical correction of her facial asymmetry
Around a year ago, her parents began making extensive enquiries regarding the best treatment center to address her problems. They were finally referred to our hospital for surgical management of her problem.
Hemifacial microsomia surgery is performed by only a few hospitals in India. Hemifacial microsomia correction requires years of highly specialized surgical training and experience.
Initial presentation at our hospital for management of her problem
Dr SM Balaji, hemifacial microsomia surgeon, examined the patient and obtained pertinent imaging studies including a 3D CT scan. It revealed that the patient had an extremely hypoplastic mandible including condyle, coronoid process and ramus. Meticulous treatment planning was made for the patient.
Treatment planning explained to the patient and parents in detail
It was explained to the patient and her parents that she needed to undergo a two-stage surgical correction of her facial asymmetry. The first stage would include mandibular condylar reconstruction along with coronoid and ramus reconstruction. This would be performed through utilization of bone grafts harvested from the patient.
This would be followed by a period of six months for full bony consolidation of the grafts. Mandibular distraction osteogenesis would then be performed along with maxillary Le Fort I surgery for facial asymmetry correction. This would be through lengthening of the ramus. The patient was in agreement with the treatment plan and consented to surgery.
The patient underwent the first stage of surgical treatment. She was discharged home with instructions on postsurgical care and to return in six months for the second stage of surgery.
Patient presents for placement of internal distractor and Le Fort I surgery
The patient returned to the hospital for placement of mandibular ramus distractors and Le Fort I osteotomy. Radiographic imaging of her right mandible including a 3D CT scan was obtained. This demonstrated a well-formed right condyle, coronoid and ramus.
Successful surgical correction of her facial asymmetry
Under general anesthesia, an incision was placed in the right submandibular region. Dissection was performed down to the right mandibular ramus. The plates from the previous surgery were removed. This was followed by a horizontal bone cut to the ramus.
The mandibular ramus distractor was then fixed using titanium screws. Distraction function was checked and was optimal.
Attention was next turned to the maxilla. A sulcular incision was placed in the vestibular region and Le Fort I osteotomy was performed.
This was followed by mobilization of the maxilla. The posterior end of the left maxilla was fixed using transosseous wires. This would ensure that the occlusal cant was corrected. Hemostasis was achieved and closure was done.
Postsurgical phase of the hemifacial microsomia correction
A latency period of six to seven days was given following surgery. The distractor was then activated by 1 mm each day for a total distraction of around 14 mm. This resulted in achieving a satisfactory increase in the length of the ramus. A plate was fixed to the right posterior maxilla to prevent further downward movement.
The final phase of the surgery in three to four months for distractor removal
The patient was very happy with the cosmetic results of the surgery after completion of the distraction phase of the treatment. She and her parents were instructed to return in three to four months for removal of the distractor. This would result in the complete rehabilitation of the patient after surgery.
