Rhinoplasty and Abbe Flap Reconstruction – Cleft Nose Repair
The patient is a 21-year-old female from Ongole in Andhra Pradesh, India. She was born with a bilateral cleft lip, palate and alveolus defect. There was an oronasal communication through the roof of the mouth.
Redo Rhinoplasty – Removal of Mobile Silastic Graft
Patient with a history of cleft lip, palate and alveolus surgery The patient is a 22-year-old female from Kanpur in Uttar Pradesh, India. She was born with a cleft lip and palate deformity. Doctors had counseled her parents about what to expect with cleft children. They had also presented them with a schedule for surgical correction of her deformities. Past history of surgical correction of her cleft deformities She had undergone cleft lip surgery at 3 months of age and cleft palate surgery at 8 months old. Cleft alveolus surgery had been performed at 4 years of age. All these surgeries were performed in a neighboring state at the same hospital. Her parents had been satisfied with the results of the surgery. The hole in the roof of the mouth had been completely closed and the patient had no feeding or speech problems. However, as the patient grew up, her nasal deformity had gradually worsened. Her nostrils were asymmetrical and she had a collapsed bridge of the nose. She had a saddle nose deformity with gross nasal asymmetry caused by a depressed left nostril. This caused her to become depressed and they decided to get this addressed at a nearby city. Failed primary rhinoplasty with mobile silastic graft She underwent a primary rhinoplasty about two years ago for correction of her nasal deformities. This had been performed utilizing a silastic graft to lift up the dorsum of her nose. Nasal tip had also been enhanced by the surgery. All deformities of the nose involve components of bone and cartilage. The graft however never stabilized and remained mobile. This has made the patient very self conscious and withdrawn. It finally reached the point where she decided to get this addressed. The patient and her parents made extensive enquiries regarding the best rhinoplasty hospital in India. They were repeatedly informed that we were the best hospital in India or rhinoplasty correction. She discussed this extensively with her parents and they decided to come to our hospital for her surgery. The best rhinoplasty surgeons in India come to our hospital for regular workshops. India is a top destination for medical tourism from around the world. Nose reshaping through cosmetic surgery is one of the most commonly desired procedures by such patients. The cost in India is also just a fraction of what it costs in the developed countries. Surgical results though are on par with the results obtained in the Western world. Initial visit for consultation and treatment planning at our hospital Dr SM Balaji, cosmetic rhinoplasty surgeon, examined the patient and obtained a detailed history from her parents. He also ordered pertinent imaging studies including a 3D CT scan. The patient said that the graft on her nasal dorsum was mobile. This caused her to become extremely self conscious. She had also begun to withdraw socially because of this. Examination of her nose revealed an extremely mobile nasal bridge. This was the result of the infected silastic nasal graft. There was a depression of the left side of the nose from the cleft lip deformity. The left nostril was also considerably smaller in size along with a noticeable depression in the left anterior maxillary region. Rationale behind treatment planning explained to patient and parents It was explained that the silastic graft needed to be removed. A costochondral graft would be utilized for nose correction. The grafts would be harvested from the patient at the beginning of the surgery. Successful surgical correction of maxillary depression and nasal deformity Under adequate general anesthesia, an incision was made in the right inframammary region. A costochondral rib graft was harvested. Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The wound was then closed in layers with sutures. A transcartilagenous incision was made in the right nostril. This was followed by dissection and removal of the infected silastic graft. The nasal dorsum was then augmented using the costochondral graft along with a strut graft to elevate the left nostril. Patient expresses happiness at the results of the surgery The patient was extremely happy with the results of the surgery. Her nose now had a more symmetrical and prominent profile. It was in complete harmony with her face with equal nostril size. She said that this would help her gain more self confidence and participate in social events without feeling self conscious. Surgery Video
Cosmetic Rhinoplasty – Bulky Nose Reduction Surgery
Young man with a strong dislike for his nose The patient is a 19-year-old male from Wandiwash in Tamil Nadu, India. He had developed a strong dislike for the shape of his nose since very young. The appearance of his nose had resulted in a bit of bullying during his school days. There have however never been any breathing and feeding difficulties. He had always wished to have a narrower and sharper nose. The form of his nose, he felt, was very broad for his face. It appeared very bulky. There were no deformities involving the roof of the mouth or the nasopharyngeal airway. The only complaint that the patient had was with the shape of his nose. Seeing the degree of unhappiness the patient had over his nose, a friend had suggested that he undergo cosmetic nose surgery. He also said that the patient needed to visit a facial plastic surgeon. The patient also like the idea of a nose job and convinced his parents about it. After making enquiries about the best hospital for the procedure, they decided to come to our hospital for consultation. Our hospital rigorously follows surgical protocols laid down by the American Association of Plastic Surgeons. Initial examination upon presentation at our hospital Dr SM Balaji, Cosmetic Rhinoplasty Specialist, examined the patient. He ordered for comprehensive imaging studies. Clinical evaluation revealed a bulky nose without a prominent tip. There was also excess soft tissue over the nasal bridge, thereby causing the nose to appear shapeless. Treatment planning was explained to the patient in detail. Excess soft tissue would be removed to reduce the nasal bulk first. This would be followed by augmentation of the nasal dorsum using a costochondral graft that had been harvested from the patient. Our hospital is renowned for cosmetic rhinoplasty in India. Both bone and cartilage contribute to the shape of the nose. Open rhinoplasty can lead to visible scars while no visible scars will result from a closed rhinoplasty. This aspect of the surgery was very appealing to the patient. The patient was in agreement with the treatment plan and consented to surgery. Types of shapes of the nose Nasal shapes vary according to the structure of the underlying bone and cartilage. Nasal shapes have been classified under aquiline, broad and flat. Aquiline is found in the Caucasians, flat in the mongoloids and varying degrees of broad in the rest. Nasal deformities can appear in the form of crooked nose deformity, saddle nose deformity, dorsal hump, parrot beak deformity and hooked nose deformity. Certain conditions such as Pierre-Robin syndrome manifest a hooked nose. Cosmetic rhinoplasty is the surgery of choice for correction of these nasal deformities. Successful surgical correction of the bulky nose deformity Under general anesthesia, a right inframammary incision was made followed by harvesting a costochondral graft. A Valsalva maneuver was next performed to ensure patency of the thoracic cavity. The incision was then sutured close in layers. Attention was next turned to the nose. A transcartilagenous incision was first placed in the right nostril and dissection was done up to the nasal dorsum. Excessive soft tissue was identified and excised. This was followed by augmentation of the nasal dorsum using the costochondral graft. Closure of the wound was then done using resorbable sutures. The patient was extubated and brought to the recovery room in stable condition. Total patient satisfaction with the results of the surgical procedure The patient and his parents were very happy with the results of the surgery. He liked his new nose immensely. His nose was now narrower, more symmetrical and had an elevated dorsum. He expressed that he would now be able to face life with a greater degree of confidence. Surgery Video
Unilateral Cleft Rhinoplasty and Cupid’s Bow Lip Surgery
Patient born with unilateral cleft lip and palate deformity The patient is a 26-year-old female from Thalassery in Kerala, India. She was born with a unilateral cleft lip and palate deformity. Her parents had been counseled extensively at the time of birth. A plastic surgeon had given them a timetable for the surgeries required by the patient. Parents had rigorously followed the doctor’s advice. The patient underwent cleft lip surgery at 3 months of age and cleft palate surgery at 9 months of age. There was complete closure of the communication with the nasal cavity at the roof of the mouth. This had been followed by cleft alveolus surgery at the age of 4 years. The three surgeries had been performed at a nearby city. Immediate period after initial surgical correction of deformities Her parents had been satisfied with the immediate results of the surgery. The patient had been able to feed well and her speech also developed within normal limits; however, as she grew up, the deformity became more pronounced and evident to others. She had also developed a degree of breathing difficulty and snoring. Her facial deformity had always drawn unwelcome attention from others. She had faced a certain degree of bullying while in school and college. The patient had always been an extrovert and had excelled in studies and co-curricular activities. She had met all her milestones appropriately and had always been a happy child. Considering surgical correction of her facial deformities The patient has been mulling surgical correction of her deformities over the past few years. She and her parents had visited a local facial cosmetic surgeon. He examined her and said that there would be cosmetic and functional improvement with the surgery. The patient and her parents had therefore decided to go forward with getting her deformity corrected. Her parents persevered to find the best hospital for the surgery. They had made extensive enquiries regarding the best surgeon for this surgery. Our hospital had been widely recommended by many specialists with whom they enquired. They therefore decided to visit our hospital and fixed an appointment. Initial Consultation and Examination at our Hospital Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained a detailed oral history. He then ordered pertinent imaging studies for the patient including a 3D CT scan. Clinical examination revealed that there was a depression on her left nostril. It was also considerably smaller than the right. Imaging studies revealed a depression in the left anterior maxillary region. The patient also had a congenitally missing left lateral incisor. Augmentation of the maxillary defect would result in elevation of the base of the nose. This would result in proper form to the nose. The left side of the lip was slightly uneven at the site of the left vermilion border. It was at the site of the previous cleft lip repair. This resulted in a slight asymmetry of the upper lip. Her lips also had some scarring from the previous surgery. Treatment plan formulated for addressing her complaints It was explained to her that she would need closed rhinoplasty with insertion of a costochondral cartilage graft. This would result in symmetry of both sides of her nose. An open rhinoplasty was not chosen as it would result in visible scarring at the site of surgery. It was also explained that the lip revision surgery of the vermilion would establish the Cupid’s bow form to her lips. Cupid’s bow lip surgery would help establish perfect lip contour for the patient. The patient and her parents expressed understanding of the same and consented to surgery. Surgical correction of the nasal and lip deformities Under general anesthesia, an inframammary incision was made following which a rib graft was harvested. An intranasal transcartilaginous incision was then made. Rhinoplasty was next performed followed by insertion of a costochondral graft for cosmetic nose correction. This was followed by augmentation of the maxillary defect with the rib graft, which was fixed with titanium screws. Lip correction of the vermilion border was performed next. Incisions were made followed by excision of the scar tissue and suturing to establish the Cupid’s bow. Anesthesia was reversed and the patient was extubated and brought to recovery room in stable condition. Successful outcome of surgery with good cosmetic results The patient and her parents were very happy with the results of the surgery. Her parents stated that her nose and lips were in perfect harmony with her face. It was explained that they should return in 3-4 months for dental implant surgery for replacement of her missing lateral incisor. An artificial tooth would be placed over the implant at a later date. They expressed their understanding and gratitude to the surgical team. Surgery Video
Cosmetic Rhinoplasty – Tip, Alar base and Root of the Nose Narrowing Surgery
Evolution of nasal forms down the ages The shape of the nose evolved over millions of years as humanity first spread out from its origins in the African continent. This gradual migration of human beings led them to regions with widely varying climates. Human beings colonized all the continents except for the Arctic and Antarctic. These were too hostile for habitation by humans. Those who migrated to cold regions slowly evolved long thin aquiline noses, which helped heat up the air as it entered the respiratory passages and those who migrated to hot climes evolved broad noses with wide open nostrils that helped cool down the air as it entered the respiratory passages. These noses also evolved to esthetically suit the facial forms from each region. Therefore, a Chinese nose would not be the best fit for a European face and vice versa. Surgeons also need to keep this in mind before proceeding with cosmetic nose correction and should counsel the patients before surgery. Patient very conscious of his nasal structure This is a 24-year-old male from Jodhpur in Rajasthan, India who had always felt self conscious of the shape of his nose. He had always felt that his nose had a very broad base along with a bony hump on the dorsum of the nose. This had lead to him desiring to undergo a nasal hump reduction surgery for a long time. The patient felt that his nose was too big for his face and this had subsequently led to the patient avoiding social interactions at work and at home. He had visited a plastic surgeon at his hometown who had advised an open rhinoplasty for the patient. The patient however did not undergo the recommended surgery as it would result in a visible scar on his face. He then visited a cosmetic surgeon who had examined the patient and had referred him to our hospital for surgical management. Our hospital is renowned for rhinoplasty surgery in India. Our hospital is a premier centre for facial cosmetic surgery in India. Plastic surgery in India has increased greatly and is sought after by many patients for cosmetic correction. There was a time in the past when cosmetic surgery was very expensive and only the rich and the famous could afford it; however, with the rising income levels in the country after opening up of the economy to direct foreign investment, the number of people opting for cosmetic surgery has vastly increased. Board certified cosmetic surgeons perform this procedure in western countries. A deviated nasal septum is also corrected through rhinoplasty surgery and can result in subtle nose reshaping. Hump removal can drastically improve the profile of the face. Patient presents to our hospital for initial consultation Dr SM Balaji, rhinoplasty surgeon, examined the patient thoroughly and obtained a detailed history. Our hospital is one of the renowned centres for nose surgery or ‘nose job’ in India. This falls under the purview of facial plastic surgery. The patient explained that he was dissatisfied with the appearance of his nose and wanted correction of the same. He said that he did not want any visible scarring from the surgery. Following this, detailed biometric measurements were then obtained for the patient’s face along with complete radiographic evaluation. It was explained to the patient that a closed rhinoplasty could be performed to correct his nose. Role of the upper lateral cartilages in the appearance of the nose was explained to the patient. The patient expressed understanding of the surgical procedure and signed the informed surgical consent. Surgical correction of his nasal structure General anaesthesia was induced and orotracheal intubation was done. Following this, through an intranasal approach, transcartilaginous incisions were placed on both sides and the nasal mucosa was dissected. The lateral cruces of the lower lateral cartilages were excised bilaterally for aesthetic correction of his nose. The nasal mucosa was then dissected up to the dorsum of the nose. His nasal hump deformity on the dorsum of the nasal bone was then rasped and the nasal bridge was given a straight profile. Following correction of his nasal hump deformity, bilateral Weir excisions were performed at the alar base. The wide alar base was then reduced to narrow the root of the nose. Closure was the incisions were then done using resorbable sutures. The patient was then extubated without incident. Patient fully satisfied with the outcome of his surgery Postsurgical swelling subsided in two weeks and the patient returned for a check up. He expressed complete satisfaction at the results of the surgery and said that the nasal form was perfect and that this would help him regain his self confidence. Surgery Video
Revision Rhinoplasty Surgery with Scar Removal in the Chest
Increasing numbers of revision rhinoplasty surgery in India A revision rhinoplasty is performed when a patient is not satisfied with the results obtained from the original rhinoplasty surgery. It is also performed when there is a functional compromise from the original rhinoplasty. This could be worsening difficulty with breathing or snoring from a deviated nasal septum. A revision rhinoplasty is more difficult that a rhinoplasty as it has to offset the damage arising from the previous rhinoplasty. An inexperienced rhinoplasty surgeon might remove more bone or cartilage than necessary thus causing serious damage to the nasal structures. The initial surgery is known as primary rhinoplasty and the revision rhinoplasty is known as secondary or corrective rhinoplasty. Indications for rhinoplasty surgery or nose surgery A rhinoplasty procedure or nose job is advised when a patient has breathing difficulties or excessive snoring during sleep. This can be due to a deviated nasal septum. A nasal septum deviation could be congenital or could be caused by trauma to the nasal bone. This results in a deviation in the nasal passage, thus obstructing the clear passage of air during breathing. A rhinoplasty procedure needs to be performed to rectify this. Rhinoplasty surgery restores the function of the nose back to optimal levels. Principal qualities of a good rhinoplasty surgeon An experienced rhinoplasty surgeon instinctively diagnoses the cause for the problem and the degree of correction required in each case. There is no unnecessary excision of tissue or removal of bone. This ensures that optimal results are obtained with maximum cosmetic as well as functional benefit to the patient from the surgery. It always results in an improvement in facial features. Rhinoplasty surgery is not just purely a cosmetic surgery. It also results in relieving a person’s breathing difficulties. Facial plastic surgeons as well as oral and maxillofacial surgeons perform rhinoplasty procedures. Different categories of nasal deformity corrected by rhinoplasty surgery Rhinoplasty surgery is a form of facial plastic surgery. There are many kinds of nasal deformities that are addressed by a rhinoplasty. These include parrot beak deformity, flat nose deformity, hooked nose deformity, dorsal nasal hump, saddle nose deformity, broad nose deformity, crooked nose deformity and asymmetrical nose deformity. A rib cartilage is often used as a graft to enhance the bridge of the nose in case of a flattened nose. The protocol followed for rhinoplasty is the same as for other surgery procedures. Cleft rhinoplasty is a highly specialized field. Only the most experienced of surgeons excel in this corrective procedure. It is a highly complex procedure and complete mastery over all the basic sciences of medicine is a prerequisite to master this. Rhinoplasty surgery used to be confined to the rich and the famous in the past, but the number of rhinoplasty procedures has drastically increased leading to the increase in the number of hospitals offering this service to patients. A rhinoplasty surgery requires extreme finesse and precision to give the best esthetic results. It takes years of training under an experienced surgeon to master this. When an inexperienced surgeon performs this surgery, chances of patient dissatisfaction with the results is high and this automatically leads to an increase in the number of revision surgeries being performed. Patient dissatisfied with previous rhinoplasty surgery The patient is a young girl who had undergone rhinoplasty elsewhere with placement of a rib graft to augment the bridge of her nose. She had also had placement of a graft to the tip of the nose. Over a period of time, she felt that the bridge of her nose was too broad and the tip of the nose was very pronounced. She desired to have a narrower bridge of the nose and a less pointy tip of the nose. She had presented to a plastic surgeon in her hometown to enquire about surgeons performing rhinoplasty surgery in India and also scar revision surgery in India. He referred her to our hospital. She therefore presented to our hospital requesting corrective surgery as it was a failed rhinoplasty and revision was advised. Patient presents at our hospital for revision rhinoplasty Dr SM Balaji, a well known rhinoplasty surgeon in India, examined the patient and ordered imaging studies. As the outcome of the initial rhinoplasty was not satisfactory to the patient, she was a little apprehensive and enquired about the revision rhinoplasty swelling timeline. It was explained to the patient that the recovery period would be for a period of one to two weeks and that she would need to stay home for the first ten days following surgery. The splint that would be placed on her nose after the procedure would be removed at this point. He explained that the graft to the bridge of the nose would need to be shaped to a finer form during the revision rhinoplasty surgery. The patient also complained of an unsightly scar at the site of the bone graft harvest from the previous surgery. It was decided to perform a scar revision surgery at that site during this surgery. The scar revision procedure would involve closure of the wound in several layers for minimal residual scar formation. Harvesting of bone graft for nasal bridge rhinoplasty augmentation Under general anesthesia, a rhinoplasty incision was placed in the columella and the bone graft was taken out. It was then reshaped to form a finer bridge of the nose. It was placed again at the bridge of the nose. The tip of the nose was also shaped to be less pronounced. Incision was then closed with sutures. Scar revision surgery performed with optimal results Attention was then turned to scar removal from the chest wall. An incision was made at the old chest incision scar site. The unsightly scar tissue was excised completely. A Valsalva maneuver was then performed to ensure that there was no accidental perforation into the thoracic cavity. The incision was then closed in layers. The patient’s revision nose surgery was meticulously documented in her medical records. Surgery Video
Successful nose correction with no scars | Rhinoplasty Surgery in India
A 22 year old girl from Mumbai visited our hospital with complaint of broad and bulky nose. She was very unhappy with her nose and had inquired about her nose with a local surgeon who referred her to our hospital. She requested for a narrow nose with a sharp tip. Maxillofacial surgeon Dr.S.M.Balaji examined the patient. She had a broad dorsal base with bulky nasal tip. He planned to correct the nose by closed rhinoplasty technique. The lateral nasal cartilages were removed by transcartilaginous incision. Lateral osteotomy was done bilaterally. The patient was overjoyed with the results and expressed her joy to the surgeon.
RTA 5 months old Fracture Malunion of Upper jaw Resurgery with Rhinoplasty
Emergency surgery after RTA results in open bite and flattened bridge of nose This young lady is from Salem, Tamil Nadu. A road traffic accident five months ago resulted in fractures to her maxilla and a comminuted nasal bone fracture. Emergency surgery elsewhere left her with a flattened bridge of the nose and an open bite. Feeling very dissatisfied, she approached a local surgeon who referred her to us. Le Fort I osteotomy surgery planned to correct open bite Dr SM Balaji, nose correction and facial deformity correction specialist, examined the patient. He ordered imaging studies for the patient. He decided on a LeFort I maxillary osteotomy for the open bite correction. Treatment plan was then explained to the patient in detail. The patient was in agreement and consented to surgery. Open bite surgery and rib graft for correction of flattened nose Under general anesthesia, a rib graft was first harvested. A Valsalva maneuver demonstrated a patent thoracic cavity. The incision was then closed with sutures. Attention was next turned to the maxilla. A vestibular incision was then made exposing the maxillary bone. Plates used in the previous surgery were then removed. A LeFort I maxillary osteotomy was next performed. Arch bars were next wired to both jaws for stabilization. Following this, the vestibular incision was then closed with sutures. The flattened bridge of nose was then addressed. The rib graft was first crafted to the right size. It was then tunneled to the bridge of the nose through a transcartilaginous incision. This resulted in a straight profile to the patient’s nose. The incision was then closed with sutures. The patient expressed complete satisfaction before discharge from the hospital. Surgery Video
Successful Flat Nose correction with CC graft
A patient of age 35 years presented to our hospital with a complaint of flat nose. He was very unhappy about his nose and requested for a prominent nose. Maxillofacial Surgeon Dr.S.M.Balaji planned to correct the nose by closed rhinoplasty. The nasal bridge height increased using cc graft harvested from the right inframammary region. Lateral osteotomy done bilaterally. Columellar strut graft placed to raise the height of the nose. Weir excision done to decrease the alar width. The patient had a very esthetic and pleasing appearance post surgery. He expressed his happiness and appreciated Dr SM Balaji and his team for the skillful correction.
Nose Defect – Augmentation with Rib Cartilage graft
A patient presents for broad nose correction This young man from Arani in Tamil Nadu never liked his nose. He had already undergone rhinoplasty elsewhere. They had used cartilage graft from the ear. Following surgery, he still felt that his nose was very broad and flat. He desired corrective surgery and presented to our hospital for management. Patient consents to surgery after treatment plan explained Dr SM Balaji, rhinoplasty specialist examined the patient. He explained the treatment plan in detail to the patient. This involved harvesting a rib graft. The patient consented to surgery. Harvesting of rib grafts for nasal bridge augmentation Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva maneuver was then performed to confirm patency of the thoracic cavity. The incision was then closed in layers. Correction of saddle nose deformity through rhinoplasty Attention was then turned to the saddle nose deformity. A transcartilaginous incision was first made. Tunneling was then done to the bridge of the nose. The rib graft was then inserted to augment the bridge of the nose. Attention was next turned to the broad ala. An elliptical incision was then placed in the right alar crease. Excess tissue was next excised from this region and the incision sutured. The patient expressed complete satisfaction at the results of the surgery.