Facial Asymmetry Correction by distraction of reconstructed bone along with Plate removal Surgery

Occurrence of facial asymmetry is very common

No human face is truly symmetric. A mild degree of facial asymmetry is always present, but not easily spotted by the naked eye. Only when this asymmetry is easily noticeable does it require surgical correction. Distraction devices are commonly employed in the correction of facial asymmetry. The distraction devices are first fitted. This is followed by distraction. Consolidation of the distracted bone segment is allowed before removal of the distraction device. The bones heal and soft tissue remodeling occurs during this period of consolidation.

Correction of hemifacial microsomia and temporomandibular joint surgery also come under corrective jaw surgery. There are many surgical techniques that are employed for correction of facial asymmetry. All these are technique sensitive and are best performed by experienced surgeons.

Guidelines for surgical correction of orofacial deformities

The American Association of Oral and Maxillofacial Surgeons has laid down guidelines for all surgical procedures of the oral and facial regions. Bone grafts are advised in certain cases where distraction is contraindicated. Distraction osteogenesis and orthognathic surgery are two arms of facial asymmetry correction. Mandibular distraction osteogenesis is more common as mandibular asymmetry occurs more commonly than maxillary asymmetry.

Patient with a history of surgery for ameloblastoma

The patient is a 24-year-old male from Vandavasi in Tamil Nadu, India. He had developed a left lower jaw swelling around two years ago and visited a local hospital. Tests had been performed by an oral surgeon at the hospital. The patient had then been diagnosed with ameloblastoma of the left mandible. A left partial mandibulectomy had been performed followed by reconstruction with a rib graft and reconstruction plate. The patient had been left with a severe facial asymmetry with the right side of the mandible being longer than the left. This had depressed the patient to a degree that he refused to go outside. His career had suffered as a result and this alarmed his worried parents.

They had consulted with the oral surgeon again who realized the severity of the problem. The parents and the patient were informed that this could be addressed only at a specialist oral and maxillofacial surgery hospital. He had then referred them to our hospital for management of the patient’s facial asymmetry.

Our hospital is renowned for facial asymmetry surgery. Jaw reconstruction surgery is performed routinely at our hospital. Facial asymmetry resulting from trauma to congenital deformities of the jaws is addressed at our hospital.

Initial presentation at our hospital

Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. The patient’s old medical records pertaining to the ameloblastoma surgery were studied in detail. He then ordered comprehensive imaging studies for the patient including a 3D CT scan. The patient was noted to have a deficient left mandibular body. Right side of the mandible was longer than the left. Mandibular ramus was also found to be defective.

Treatment planning presented to the patient and his parents

It was advised that the patient undergo mandibular ramus distraction osteogenesis on the left side. Removal of the reconstruction plate would be followed by mandibular ramus distractor fixation on the left side. The patient and his parents expressed understanding of the surgical procedure and consented to surgery.

Successful surgical correction of facial asymmetry

Under general anesthesia, an incision was first made through the previous surgical scar in the left submandibular region. Dissection was done down to the mandibular reconstruction plate and screws. These were then removed. An incision was then made in the left mandibular retromolar region. A flap was elevated following which bone cuts were made. Mandibular ramus distractor was then fixed on the left side using titanium screws. The activating arm of the distractor was brought out through the left submandibular incision.

Following the fixation of the distractor in the mandible, a sulcular incision was made in the maxilla. Le Fort I bone cuts were then made and the maxilla was mobilized. The posterior end of the left maxilla was fixed using transosseous wires. Hemostasis was ensured following which closure was done using sutures.

Distraction osteogenesis of the mandible to establish facial symmetry

Interarch wiring was done following the surgery. A latency period of about 6-7 days was allowed for stabilization of the surgical site following which the distractor was activated. Two clockwise turns of the distractor were performed everyday for a resultant distraction of about 1 mm. A total of 18 mm distraction of the mandibular bone was achieved at the end of the treatment. A plate was then fixed to the left posterior maxilla to prevent further downward movement.  The distractor will be removed after a period of about 3-4 months once adequate consolidation of the bone in the distracted segment is seen.

Complete patient satisfaction at the results

The patient started noticing the change during the distraction phase itself. Result was obvious at the completion of 18 mm of distraction. The patient was very happy with the outcome of surgery. He expressed his satisfaction at the final outcome of the surgery. The patient also added that he would be able to start leading a normal life again

Surgery Video