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 His dissatisfaction with his appearance had led him to become withdrawn.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.
Crouzon syndrome is an autosomal dominant genetic disorder. The first brachial arch is the affected arch. The brachial arches are also known as pharyngeal arches. This syndrome results from a mutation in chromosome 10. The name of this syndrome is derived from Octave Crouzon. He is the one who first described this condition. This syndrome is always manifested by premature closure of the cranial sutures.
A 10 month old boy presents for Crouzon syndrome surgical correction
The patient is a 10-month-old boy with premature closure of cranial sutures. He had the typical presentation of bulging eyes (exophthalmos). His parents brought him to our hospital for definitive treatment. Dr SM Balaji and the neurosurgical team examined the patient. Extensive investigative studies were then ordered for the patient. A 3D CT revealed premature fusion of the bilateral occipitoparietal sutures.
The exophthalmos in his case arose from shallow orbital cavities. Parents were then counseled about his condition. The premature closure of the sutures would cause increased intracranial pressure. This would result in impaired brain development. Complications that could arise from this were also explained to the parents. The parents agreed to the surgery. A 3-D stereolithographic model was then obtained for performing mock surgery.
Intricate interdisciplinary surgery performed with great success
The entire neurosurgical team was present for the surgery. This surgery would be a multidisciplinary undertaking. Under general anesthesia, markings were first made on the scalp for the incisions. A bicoronal incision was then made and scalp reflected. A craniotome was then used to make the bone cuts. The craniotome utilizes a clutch that stops it after penetration through the bone. The meninges are thus protected from damage. Our hospital was one of the first in India to get a craniotome. This was way back in the early 2000s. The different sections of the skull bones were then removed and barrel stave cuts made in them. This was to accommodate the growth of the brain.
Bone segments fixed with resorbable Sonic Weld
It was planned to fix the bony segments with sonic weld. It is used with resorbable plates. A galvanic current passes through the screwdriver that is utilized to fix the sonic weld. This melts the screws thus making it flow into the trabeculae. The screws and plates hold the bones together for a period of three months. They resorb after three months thus allowing for normal bone development. Adequate barrel stave relief cuts were then made in the sections of the skull bones.
The frontal bone was then fixed back again using resorbable plates with sonic weld. Each bone section was then sutured to the duramater using resorbable Vicryl sutures. This was for added stability of the bone. These sutures and the sonic weld will completely dissolve on their own. This would make it unnecessary to perform a second surgery to remove them.
The bones were then checked to ensure correct placement. Sonic weld was perfect. The bicoronal flap was then placed back into anatomic position. Closure was then done using surgical staples.
The patient recovered well from general anesthesia without event.
Successful surgical result for boy with Crouzon syndrome
The patient was playful and happy a few days after surgery. He was interacting in his usual friendly way with the staff in the hospital. His parents expressed their gratitude to the whole surgical team. Their son would develop as a normal boy.
Parry Romberg syndrome is a rare neurocutaneous syndrome of unknown origin. It causes progressive hemifacial atrophy. This is often sporadic in its course. It leads to shrinkage of tissues underneath the skin. Only one side of the face is often affected. It also rarely extends to other parts of the body. Females are most commonly affected by this disease. Onset is often between 5 to 15 years of age. Other associated morbidities include those of a neurological, ocular and oral nature. Severity of this condition varies between patients.
Patient with Parry Romberg syndrome referred to our hospital
This middle aged male from Tirupati presented to our hospital for management. He has undergone previous surgeries elsewhere. The patient presented with nose, lip and chin asymmetry. He desired establishment of symmetry to the face.
Treatment planning and surgery explained to the patient
Dr SM Balaji examined the patient and ordered diagnostic studies. He explained that fascia lata graft from his thigh needed to be harvested for this surgery. The patient agreed to the treatment planning and consented to surgery.
Successful surgical correction of the patient’s facial asymmetry
Under general anesthesia, an S shaped incision was first made on his lateral thigh. The incision was then closed after harvesting a fascia lata graft. Attention was next turned to the chin asymmetry. A vestibular incision first made in the anterior mandibular region. Dissection was then carried down to the chin and an osteotomy done. The osteotomized piece of chin bone was then repositioned and screwed in place. This resulted in establishment of chin symmetry. The incision was then closed with sutures.
Attention was next turned to the upper lip. A midline incision was then made on the inner aspect of the lip. The fascia lata strip was then tunneled from the corner of the lip on the left to the midline incision. This was then sutured and secured. This resulted in establishment of lip symmetry.
Attention was then turned to the nasal asymmetry. Intranasal incisions ensured absence of any visible scars. Lateral osteotomies were then performed of the nasal bone. The medial cartilage was then partially excised from the nasal septum. This resulted in good nasal symmetry.
The patient recovered from general anesthesia without event. He expressed his happiness at the results before final discharge from the hospital.
Crouzon syndrome is a rare genetic disorder with premature fusion of a few skull bones. This fusion prevents the skull from growing in all three dimensions. The shape of the head and face is most affected by this along with the mid-facial structures. This leads to wide-set, bulging eyes due to shallow eye sockets. The retruded middle part of the face results in an abnormal appearance. Surgery is the only treatment modality for adult patients.
Patient with retruded midface presents for surgery
This is a 15-year-old from Ajmer, India. He had undergone surgery for craniosynostosis elsewhere at 10 years of age. He presented to our hospital for facial reconstruction. His midface retrusion was causing him breathing and eating difficulties. Dr SM Balaji examined the patient and ordered diagnostic studies. He explained his proposed treatment plan to the patient. This would involved a Le Fort III advancement. The patient and his parents agreed to the treatment plan.
Midface advancement from skull for Le Fort III
Under general anesthesia, an incision was first made over the old scar. A bicoronal flap was then raised. The scalp was then dissected till the glabella and supra-orbital notch. Plates from the previous surgery were first removed. Careful bony cuts were next placed in four regions. These were the zygomatic arch, frontozygomatic sutures, floor of orbit and nasion. In the midline, the vomer and the ethmoid bone were then separated from the cranial base. Pterygomaxilary dysjunction was first done through the intraoral approach. His entire midface was now detached from the skull.
Kawamoto distractors placed for midface advancement
Attention was next turned towards placement of the Kawamoto distractors. First, the right temporalis muscle was dissected to gain access to the area. The distractor was then fixed with the help of screws to the skull and to the orbital border. Distraction was next tested and found to be perfect. The same procedure was next performed on the left side. After surgery, a latency period of six days was then given for bone stabilization. Distraction of 1 mm each day will be performed until adequate advancement of the midface. A total of 18 mm distraction was planned for this patient to be performed over a period of 18 days. The patient recovered from general anesthesia without event.
The distractor will be kept in place for three months for bony consolidation. It will then be removed to be followed by orthodontic treatment.
Postsurgical results were very satisfying for the patient and his family. He and his family expressed their gratitude before discharge from the hospital.
This patient is a 30 year old native of Shimla. He was born with a bilateral cleft lip and palate. The patient has undergone primary cleft lip and palate surgery elsewhere when he was as an infant. He complained about nongrowth of hair in the center of the lip(prolabial region). The patient now has a depressed dorsum of the nose. The nose is at an obtuse angle.
The patient was very specific about his appearance. He said this caused him to lack self confidence
Rhinoplasty nose deformity specialist Dr SM Balaji planned the surgery. He planned to correct both the nose and lip defects using open rhinoplasty and Abbe flap.
The columella of the nose was constructed using prolabium. The raw surface of the upper lip was then corrected by using a switch flap. The base of the flap was then kept attached to the lower lip for retention of blood supply. Once blood supply has been re-established in the upper lip, the flap division was then done. The defective upper lip and nose now had a more natural and esthetic appearance. The patient was very satisfied with the results.
Pre-operative facial view showing defective lip and nose due to bilateral cleft lip and palate
Worm’s eye view showing depressed dorsum of nose and illdefined columella
Intra-operative view showing raised columella of nose
Immediately after suturing using Abbe flap technique
Immediately after suture removal showing enhanced appearence of the nose and upper lip
This is a 3-month old baby girl from Jammu. She was born with a unilateral cleft lip & palate. Her parents brought her to our hospital for treatment. An Internet search pointed to our hospital as being the best center for cleft repair.
Maxillofacial Surgeon Dr. SM Balaji examined the patient. He performed the primary cleft lip repair surgery using Modified Millard’s technique. Following surgery, the baby’s appearance became normal. The parents were very happy with the results as she hardly had any post-surgical scars. Cleft palate correction surgery will be at a later date.
A 3-month-old baby born with unilateral cleft lip and palate
Primary cleft lip repair done using Modified Millard’s technique
Immediately after suture removal showing improved appearance
