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.
A certain proportion of the human population has always been affected by disabling facial asymmetry. This could be congenital as a result of developmental anomalies or birth injuries or acquired as a result of disease or trauma. Once of the most common causes of facial asymmetry is trauma. This trauma could either be accidental or inflicted during interpersonal conflicts.
Human history is strewn with wars. Most major wars lead to landmark changes in the course of history. However, war has also extracted a horrific price from many soldiers. For example, trench warfare during World War I had an unnatural number of soldiers suffering serious facial injuries followed by lifelong facial deformities. A special unit was in operation in France during the war that crafted lifelike masks for soldiers with horrific facial deformities.
Importance of facial symmetry
No human face is truly symmetrical. Perfect symmetry is unnatural. There is an imperceptible degree of facial asymmetry present in each face. This small degree of facial asymmetry is what adds to the beauty of the face. When facial symmetry is 100%, it will look unnatural and unreal. However, this asymmetry should be imperceptible and not noticeable on first glance. When this facial asymmetry becomes too obvious, it becomes a social handicap leading to the person withdrawing from social contact. Surgery is needed to correct facial asymmetry. Surgical correction of facial asymmetry requires an artistic touch in addition to surgical skills. This is a requisite for good plastic surgery results.
Surgical specialties that deal with facial asymmetry correction
The services of a plastic surgeon or an oral and maxillofacial surgeon would be required for correction of facial asymmetry. They would be the equivalent of system administrator in the team that performs this surgery. Facial asymmetry commonly is a result of road traffic accidents. Horizontal osteotomy surgery is one of the treatments available for correction of mandibular asymmetry. Facial asymmetry correction surgery is performed by board certified surgeons who are well versed in their craft. There are various degrees of facial asymmetry, ranging from the very mild to extreme asymmetry.
Functional difficulties caused by facial asymmetry
Jaw discrepancies can lead to functional problems. These are corrected through orthognathic surgery. The degree of asymmetry determines the approach that is taken to correct it. Reconstructive surgery frequently uses bone grafting for correction of defects that cause facial asymmetry.
Kashmiri man with facial asymmetry referred to our hospital
The patient is a 26-year-old Kashmiri man with facial asymmetry. He has a distant history of trauma to the chin. Wishing to have his facial asymmetry corrected, he visited a local oral surgeon who explained to him that he needed reduction of the right side of the mandible and maxilla to correct his asymmetry. It was further explained to him that facial asymmetry correction surgery in India was performed only at a few specialty surgical centers. He was then referred to Balaji Dental and Craniofacial Hospital for surgical management of his facial asymmetry.
Treatment planning explained in detail to the patient
Dr SM Balaji, facial asymmetry correction surgeon, examined the patient and ordered 3D CT scan and other imaging studies. This revealed that the patient had a hyperplastic right mandibular condyle. As a result, the right side of his mandible was bigger than the left and he has a downward left to right occlusal cant. Using facial biometrics to study the skull, he explained the treatment planning in detail to the patient and the patient consented to surgery.
Le Fort I osteotomy correction of maxillary occlusal cant
Under general anesthesia, a maxillary vestibular incision was made in the sulcus and a Le Fort I osteotomy was performed. The right maxilla was disjointed and a 10-12 mm segment of bone was removed from the region. This resulted in correction of the maxillary occlusal cant and the maxilla was stabilized and fixed with titanium plates and screws. This resulted in an open bite on the corrected side. This will be corrected by the bilateral sagittal split osteotomy (BSSO) of the mandible.
Bilateral sagittal split osteotomy of the mandible for occlusal cant correction
Following this, a right sided buccal vestibular incision was made in the mandible for the bilateral sagittal split osteotomy. This was repeated on the left side. BSSO was performed with an uplift of 10-12 mm of mandibular bone on the right side. This resulted in correction of the occlusal cant with establishment of perfect occlusion. The mandible was then stabilized and fixed with titanium plates and screws.
Sliding genioplasty for restoration of full facial symmetry
However, it was noticed that the chin was still skewed after the jaw surgeries. So attention was next turned towards correction of the chin. A reciprocating saw was used to perform an osteotomy and the chin was repositioned with a sliding genioplasty and fixed with titanium plates and screws. This resulted in complete correction of the patient’s facial asymmetry. All incisions were then closed with sutures and the patient taken to the recovery room in stable condition. The patient expressed his full satisfaction with the results of surgery before final discharge from the hospital.
Patient with extreme double chin presents for surgical correction
This middle aged man is from Latur in Maharashtra. He is a chronic snorer and has suffered from disturbed sleep for a long time. He has retrognathia and excessive neck fat. This had combined to give him an extreme double chin. His dissatisfaction with his appearance had led him to become withdrawn. He had searched far and wide for the best cosmetic surgeon to correct this. Word of mouth references from local dentists had led him straight to our hospital.
The patient examined and treatment plan explained in detail
Dr SM Balaji examined the patient and ordered lab and radiologic studies. Radiographic studies revealed impaction of left second and third molars. The patient also had a retrognathic mandible. Treatment planning included advancement genioplasty and neck fat removal. This surgery would result in increased pharyngeal airspace. It would also result in tauter musculature. This would relieve his snoring and sleep difficulties. The patient was in agreement with the proposed treatment planning.
Advancement genioplasty and impactions performed
Under adequate general anesthesia, markings were first made on the chin for reference. Advancement genioplasty was first performed. A vestibular incision was first made in the anterior mandible. The chin was then exposed and osteotomy performed. Chin was then brought forward and stabilized with two four-holed L-shaped plates. Attention was then turned to the two molar impactions. These were then extracted without event. The incision was then closed with sutures.
Neck fat removal surgery with good results
Attention was next turned to the neck fat removal surgery. An incision was then made below the chin and dissected to the region of fat deposits. Adipose tissue was then dissected in a meticulous manner. After adequate removal of fat tissue, the incision was then closed with sutures.
The patient was very satisfied with the results of the surgery. He expressed his happiness before discharge from the hospital.
The patient is a young man who presented to our hospital for facial feminization surgery. He had zeroed in on our hospital after extensive Internet research. Dr SM Balaji is a member of the W-PATH. This organization dedicates all its efforts toward improving transgender healthcare. It aims to provide accessible healthcare for persons with different gender identities. The patient had a hypertrophic masseter.
Diagnostic studies performed for treatment planning
A 3D axial CT was first obtained for treatment planning. This planning proceeded after obtaining his biometrics. The patient agreed to the treatment plan and was then scheduled for surgery.
Facial feminization surgery with good esthetic results
Under general anesthesia, a right mandibular vestibular incision was first made. The bone at the gonial angle was then reduced to reduce its prominence. Excess masseter muscle was then excised and removed. The same procedure was then performed on the left side with symmetrical results.
Bimaxillary setback surgery was then performed through an osteotomy of the maxillary bone. Advancement genioplasty was next performed. Osteotomy was then performed with good cosmetic results. Occlusion was perfect at the end of the two procedures. All incisions were then sutured close.
The patient expressed his satisfaction at the results before final discharge.
