Mandibular Distraction for Facial Asymmetry Surgery
Patient with facial asymmetry The patient is a 30-year-old male from Jamshedpur in Jharkhand, India. Growth of his facial bones was normal until he became a teenager. It was around that time that the right side of his lower face began to develop an asymmetry. This slowly but gradually worsened to the point where he now has gross asymmetry of his face. Eating most foods had also become very difficult because of an increasing left posterior open bite. He also soon developed pain in his right temporomandibular joint. These two issues have been present for over 10 years now. He had also faced significant bullying during his school and college days. This has made him an introvert. Initial surgery for correction of asymmetry in a nearby state Desiring to get this treated, he had approached a maxillofacial surgeon in a neighboring state for consultation. A detailed examination had been performed and he had been advised surgery. He had subsequently undergone reduction of the mandibular angle and shortening of the ramus on the right side. A piece of the ramus had been removed and the ends brought together with titanium plates and screws. The patient however was greatly disappointed by the results of the surgery. He was left with an unsightly scar on the right side of his face due to the extraoral approach adopted by the surgeon. The patient also realized that his chewing problem and pain remained the same. There was also an increase in the muscle mass on the right side of the face. There was also an increase in his facial asymmetry. He had approached another oral and maxillofacial surgeon who had advised bone grafting from the iliac crest(hip bone graft). The patient’s mandibular deficiency caused by the first surgery was addressed through the use of this graft, but this led to compromised facial esthetics for the patient. Referral to our hospital for treatment of his facial deformity Feeling despondent by the turn of events, he had approached a local surgeon in his hometown. Upon examining the patient and realizing the magnitude of damage caused by the first two surgeries, the surgeon had immediately referred the patient to our hospital. Our hospital is renowned for facial asymmetry correction in India. Facial asymmetry surgery is routinely performed utilizing distraction osteogenesis surgery. Initial presentation for treatment at our hospital Dr SM Balaji, facial asymmetry surgeon, examined the patient and obtained a detailed oral history. He also ordered for comprehensive imaging studies including a 3D CT scan. It was clear that this was a case of idiopathic hyperplastic right mandibular ramus. Clinical examination revealed an open bite on the left side and increased muscle mass on the right side of the face; however, OPG revealed that the right mandible was short by 10 mm. The 3D CT scan also revealed defective mandibular ramus length on the right side as well. Iatrogenic damage from the previous surgeries was also clearly visualized in the imaging studies. Treatment planning explained in detail to the patient Dr SM Balaji explained that correction of his asymmetry required right mandibular ramus distraction osteogenesis. A distraction of about 10 mm was planned for the patient. Subsequent rib grafting was planned for correction of the iatrogenically induced mandibular angle defect. Distraction devices can be classified into external devices and internal devices. Oral and Maxillofacial Surgery predominantly uses internal devices. Orthopedic surgery however mainly relies on external devices. Completion of the distraction process is always followed by the consolidation phase. This is for the bone at the surgical site to be strengthened. Successful placement of the Univector mandibular distractor Under general anesthesia, an incision was first placed in the right mandibular posterior region. This was followed by elevation of a flap. Horizontal bone cuts were then made and the Univector mandibular ramus distractor was fixed using titanium screws. Distractor function was checked and was found to be optimal. Following the placement of the distractor, a sulcular incision was placed in the maxilla. Le Fort 1 bone cuts were made and the maxilla was mobilized. The posterior end of the left maxilla was fixed using transosseous wires. This would enable correction of the occlusal cant. Hemostasis was achieved and closure was done using resorbable sutures. Postsurgical distraction performed for asymmetry correction Interarch wiring was done. A latency period of about 6-7 days was allowed for settling down of the surgical site. Following the latency period, the distractor was activated by 1 mm each day. After achieving a satisfactory increase in length of 10 mm, the distraction was stopped. Two weeks following completion of distraction, a straight plate was fixed to the left posterior maxilla to prevent further downward movement. Total patient satisfaction with the results of the surgery The patient was extremely satisfied with the results of the surgery. His facial asymmetry had been corrected and his entire face was in harmony. The patient’s parents were also very happy with the results and said that the patient had become noticeably happier following surgery. They were instructed to return after a few months for removal of the distractor after bony consolidation had been demonstrated at the surgical site. The patient and his parents expressed understanding of the same.
Bilateral (TM Joint) Condylar and Symphyseal Fracture Surgery
Patient involved in a road traffic accident The patient is a 28-year-old male from Vaniyambadi in Tamil Nadu, India who was riding his motorcycle to work. Of note, he was not wearing a helmet. A pothole in the road had caused him to brake suddenly. This caused a car that had been behind him to collide with his motorcycle. The impact had thrown him off his motorcycle. He had subsequently landed very hard on the asphalt surface, impacting on his chin. The fall was hard enough to result in broken bones. Bilateral fractures of the condyle commonly occur with falls on the chin. There were also a few soft tissue bruises on his body from the fall. Bystanders had rushed him to a nearby hospital where first aid had been administered and bruises debrided clean. Diagnosis of fractures and referral to our hospital The patient had demonstrated difficulty with mouth opening and speech. An x-ray obtained at the hospital demonstrated multiple mandibular fractures. Fractures of the mandible are most common with two wheeler accidents. The duty doctor had instructed the patient and his parents to immediately present at our hospital for management of his injuries. Parents immediately transported the patient to our hospital. Initial presentation at our hospital for management Dr SM Balaji, facial fracture surgeon, examined the patient and ordered comprehensive imaging studies. An OPG and a 3D CT of the patient’s facial region were obtained. Imaging demonstrated a mandibular symphysis fracture well as displaced bilateral condylar fractures. Treatment planning was formulated and explained to the patient and his parents in detail. It was explained that open reduction and internal fixation of the fractures using titanium plates and screws needed to be performed. Our hospital is a renowned center for facial fracture surgery. The patient and his parents expressed understanding of the treatment plan and consented to surgery. They were also informed that intermaxillary fixation may be necessary to promote healing. He was also advised to take liquid diet for about two to three weeks followed by a semi-solid diet. Surgical reduction and fixation of the mandibular fractures It was decided to utilize a modified Alkayat-Bramley incision using an end aural approach to expose the fracture site. This was followed by elevation of a flap and identification of the condylar fracture. The condylar fracture was reduced, occlusion was checked and the fracture fixed using titanium plates and screws. Great care was taken throughout the surgery to ensure that there was no damage to the facial nerve. Facial nerve function was demonstrated to be preserved at the end of the surgery. Following fixation of the left condylar fracture, a sulcular incision was made in the mandible. This was followed by elevation of a mucoperiosteal flap. Next, the symphysis fracture was exposed and identified. This was then reduced and fixed using titanium plates and screws. Successful stabilization of the multiple fractures Anesthesia was reversed and the patient was extubated. Results of the surgery were immediate. The patient was very happy with the outcome of the surgery. He was able to open and close his mouth freely without pain. His occlusion was also completely normal. It was explained to the patient that a full face helmet would have prevented his jaw fracture. 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 – Broad Nose Correction
Young patient dissatisfied with the shape of her nose The patient is a 22-year-old female from Ongole in Andhra Pradesh, India. She had always disliked the shape of her nose. Her dissatisfaction with the shape of her nose has increased lately. She had felt that her nose was too broad for her face and had a blunt tip. There was also an element of difficulty breathing due to nasal obstruction. Her friends too had recommended that she get it corrected through a nose job. Desire for cosmetic nose surgery She had presented with her parents at a local cosmetic surgery hospital. The surgeon had examined her and performed detailed biometric analyses. It was explained to them that this could not be performed as an outpatient procedure. He had then referred her to our hospital for correction due to the complexity of the correction. Our hospital is a premier center for cosmetic rhinoplasty in India. Rhinoplasty procedures performed at our hospital Every variety of nasal deformity correction is performed here. Saddle nose correction, hooked nose correction, nasal hump reduction and crooked nose correction are a few examples. Many celebrities have undergone nasal correction at our hospital. Some of them have even seen their career graph rise steeply as a result of the improved esthetics. Broad classification of nasal deformities The shape of the nose varies widely due to differences in the nasal bone shapes and formation of the bridge of the nose. Deviation of the nasal septum is present in most deformities of the nose. Eden Warwick first classified the nose in 1848. Nasal deformities can be broadly classified as broad, narrow, crooked, saddle nose, hook nose, parrot peak etc. Certain birth defects such as Down’s syndrome commonly present a small nose with a flattened nasal bridge. This can be due to the absence of one or both nasal bones, shortened nasal bones or nasal bones that have not fused in the midline Initial presentation at our hospital Dr SM Balaji, nasal deformity surgeon, examined the patient in detail and obtained a detailed oral history. He then ordered imaging studies for her nose. She stated that she was worried that her nose looked ugly. This had been an issue with her for a long time now. She had become very self conscious because of this and had started avoiding social functions. The patient stated that she wanted a narrow and elevated nose with a prominent tip. She said that shape of nose would be in harmony with the rest of her face. Biometric studies were obtained for her face. The best nasal form for her face without compromising function was determined for her face. Surgical correction of her nose with cosmetic rhinoplasty Under general anesthesia, a transcartilaginous incision was placed in both nostrils. Bilateral lateral nasal cartilages were partially excised. The lateral nasal cartilages were then sutured together to augment the tip of the nose thereby creating a prominent tip. Lateral osteotomy was then performed bilaterally. Closure of the incisions was performed intranasally with resorbable sutures. Complete patient satisfaction from the surgery Esthetic improvement from the surgery was immediate. The patient expressed her happiness at the result of the surgery. She said that her nose now suited her facial form perfectly. Her breathing function was also at optimum levels. The patient said that she already felt more self confident to face the world. Her parents also expressed that her overall persona had become happier and expressed their satisfaction at the results of the surgery. They said that all their apprehensions were gone after viewing the final results of the surgery. Surgery Video
Periapical Jaw Cyst Surgery with Rib Graft
Patient develops a swelling in his anterior upper jaw This is a 24-year-old patient from Mysore in Karnataka, India. He had developed caries in his maxillary front teeth. These included the upper right central incisor, left central and lateral incisors and the left canine. This was approximately 7-8 years ago. Having neglected it, he developed pain and ultimately required root canal treatment of the four teeth. His symptoms had subsided following the root canal treatment. A ceramic bridge had been placed over the crowns of the four teeth. Over the last three to four months, the patient had developed a swelling in relation to the four teeth. This swelling had slowly grown in size. There was no pain associated with the swelling. He had however developed mobility of the involved teeth. Alarmed at the prospect of losing his teeth, he had presented at a local dentist. The local dentist had examined the patient and ordered for x-rays. An x-ray had been obtained, which revealed radiolucency in relation to the four involved teeth. Realizing that this was an extensive periapical cyst, the dentist had explained the treatment needed to the patient. He had then referred the patient to our hospital for treatment. Specialty center for various cyst surgeries in India Our hospital is a specialist center for cyst surgery in India. We are a renowned center for dentigerous cyst surgery in India. Scores of patients have undergone odontogenic keratocyst surgery at our hospital. Jaw reconstruction surgery is a specialty offering at our hospital. Initial presentation and evaluation at our hospital Dr SM Balaji, facial reconstruction surgeon, examined the patient and obtained a detailed history. He ordered comprehensive imaging studies for the patient including a 3D CT scan. This revealed a radiolucency extending from maxillary right central incisor to the left canine. These were the teeth that had undergone root canal therapy many years ago. Treatment planning for total removal of the cyst The swelling involved the anterior maxilla and palate. There was also evidence of buccal and palatal perforation along with a communication with the left maxillary sinus. A biopsy was done, which confirmed the diagnosis of a periapical cyst. It was decided to do a complete cyst enucleation along with extraction of the involved teeth. The involved teeth had grade III mobility. This would result in a large bony defect, which would be reconstructed using a costochondral graft. Dental implant surgery would be performed after complete consolidation of the grafts with the surrounding bone. Ceramic or zirconia crowns would be placed on the dental implants after osseointegration of the implants with the bone. Successful surgical rehabilitation of the patient Under general anesthesia, a right inframammary incision was made followed by dissection down to the ribs. A costochondral rib graft was then harvested. This was followed by a Valsalva maneuver, which demonstrated a patent thoracic cavity. The incision was then closed with sutures. Attention was then directed towards the periapical cyst surgery. A crevicular incision was placed in maxilla in relation to the defect. This was followed by elevation of a mucoperiosteal flap. The cystic lesion was surgically identified. Complete cyst enucleation was done along with removal of involved teeth. Bleeding in the cavity was controlled with the use of electrocautery. This was followed by flushing of the cystic cavity with an antibiotic solution. The previously harvested costochondral grafts were then used to reconstruct the bony defect. These costochondral grafts were fixed using titanium screws. Hemostasis was achieved and wound closed with resorbable sutures. The patient was then extubated and taken to the recovery room in stable condition. Postoperative instructions for complete rehabilitation The patient was advised to return in 3-4 months for placement of dental implants. This would later be followed by placement of dental crowns for esthetic and functional rehabilitation. The patient expressed understanding of the instruction and was happy with the surgical results. Surgery Video
Jaw Reconstruction with Rib Graft after Dentigerous Cyst Surgery
Patient with pain in her right mandibular first molar The patient is a 21-year-old girl from Kottayam in Kerala, India. She had started noticing a swelling on the left side of her mandible over the last few months. Pain had also developed along with the swelling. This had rendered her unable to chew anything. Her taste sensation had also become altered along with the other presenting symptoms. Her parents had become very alarmed by this development. Upon consultation with their family doctor, he had referred them to come to our hospital. He explained to them that our hospital was the premier center in India for treatment of jaw cysts. Initial presentation at our hospital for diagnosis and treatment Dr SM Balaji, jaw reconstruction surgeon, examined the patient. He then ordered comprehensive imaging studies including an OPG and a 3D CT scan. This revealed a cystic lesion in the left posterior mandibular region, which extended well into the ramus region. A biopsy was obtained from the cystic lesion, which revealed it to be a dentigerous cyst. Treatment planning explained to the patient in detail It was explained to the patient that the cystic lesion needed to be enucleated in toto. The patient was also informed that the bony defect that would result from the surgery would have to be reconstructed. It was further explained that rib grafts harvested from the patient would be used for the jaw reconstruction surgery. Dental implants would then be placed after complete bony consolidation of the bone grafts with the mandibular bone. This would be followed by placement of crowns after osseointegration of the dental implants with the surrounding bone. The patient discussed this with her parents and signed the informed consent for the surgery. What is a dentigerous cyst? A dentigerous cyst is an odontogenic cyst, which is associated with the crown of an unerupted or partially erupted tooth. Based on radiological presentation, dentigerous cysts can be classified into central type, lateral type and the circumferential type. The most common dentigerous cysts are those that are associated with mandibular third molars followed by maxillary canines. They are rarely found in association with deciduous teeth and occasionally with odontomas. Treatment of dentigerous cyst is through enucleation of the cyst followed by extraction of the associated tooth. Surgical enucleation of the dentigerous cyst Under general anesthesia, a right inframammary incision was made and costochondral rib grafts were harvested. This was followed by a Valsalva maneuver to ensure that there was no perforation into the thoracic cavity. The incision was then closed in sutures. A crevicular incision was next made in the left mandible followed by elevation of a mucoperiosteal flap. This was followed by extraction of the three left lower molars. Complete cyst enucleation was then performed and electrocautery was applied followed by antibiotic flushing. The resultant bony defect was then packed with rib grafts, which were contoured to fit into the defect. These were then fixed with titanium screws and the flap was closed with sutures. Results: The patient and her parents were extremely relieved after the successful completion of the surgery. They were very happy that the dentigerous cyst had been treated with such good results. It was explained to them that they would need to return in a three months for dental implant surgery. Artificial teeth would be fixed to the dental implants. This would offer complete rehabilitation after the surgery. This would be in the form of a fixed ceramic bridge. Removable dentures are normally not advised for patients. Maintenance of gum tissue health is imperative for success of dental implants. Surgery Video
Cosmetic Rhinoplasty with Rib Graft for Nasal Deformity Correction
Broad nose deformity in a young man The patient is a 22-year-old male from Gudiyattam in Tamil Nadu, India. He had always felt that his nose did not suit his face. His main complaint was the lack of harmony between his nose and his face. He had always desired to get it corrected. This had even impeded his soto that the patient that he neededcial interactions over the years. Deciding to get this corrected, he and his parents had made extensive enquiries regarding the best hospital for this treatment. They had been referred to our hospital at multiple places and had finally decided to get this corrected at our hospital. Premier center for cosmetic rhinoplasty in India Our hospital is a world renowned facility for cosmetic rhinoplasty. Broad nose deformity, flat nose deformity and saddle nose deformity are some of the nasal deformities corrected at our hospital. We are pioneers in cleft rhinoplasty correction and our hospital is credited with many surgical innovations. Many of these innovations have been adopted as surgical protocol throughout the world. Our hospital is a preeminent referral center for the World Craniofacial Foundation in this part of the globe. Initial presentation and examination at our hospital Dr SM Balaji, cosmetic rhinoplasty surgeon, examined the patient and obtained a detailed history. The patient stated that he had always disliked his bulky nose and that it made him feel unattractive. He said that he always desired to have a narrow and elevated nose with a prominent tip. The patient also complained of significant snoring during sleep. Examination revealed that the patient had a significant nasal septal deviation. What is a deviated nasal septum? A deviated septum occurs when the dividing wall between the nostrils is displaced to either the left or right side. In many people, the nasal septum is off-center thereby making one nasal passage smaller. When a deviated septum is severe, it can block one side of the nose. This will directly result in reduced airflow and cause difficulty breathing. A nasal blockage or congestion can occur from a deviated nasal septum. It can also result from swelling of the tissues lining the nose. Both these conditions can also exist concurrently. Treatment planning for correction of the broad nose deformity It was explained to the patient that he needed nasal bridge augmentation with costochondral graft placement. He would also require a medial osteotomy and a left lateral osteotomy to correct the nose. This would be followed by a tip graft for creation of a prominent tip. The patient and his parents were in complete agreement with the proposed treatment plan and consented for surgery. Successful surgical correction of the patient’s complaints Under general anesthesia, an incision was made in the right inframammary region and a costochondral rib graft was harvested. Attention was next turned to the broad nose surgery. An intercartilaginous incision was first made. This was followed by placement of a tip graft to elevate the tip. A medial osteotomy was then performed followed by a left lateral osteotomy. Dissection was done following which the nasal bridge was augmented using costochondral graft. This resulted in complete correction of his broad nose deformity. Closure was finally done intranasally using resorbable sutures. Total patient satisfaction at the results of the surgery The patient and his parents were extremely pleased with the results of the surgery. They felt that this had drastically improved the esthetics of the patient’s face. The patient said that he now had a nose that was in harmony with the rest of his face. He said that he would now have new levels of self confidence to face the world. Surgery Video
Facial Asymmetry Surgery for Hemifacial Microsomia with Mandibular Distraction
Patient struggling with facial asymmetry deformity The patient is a 16-year-old male from Secunderabad in Telangana, India. His parents state that he had been born with a deformity of the mouth with a right lateral facial cleft. This is commonly known as macrostomia. He had undergone surgery for correction of his microstomia during his childhood. The parents stated that the patient has always had residual scarring from that surgical procedure. A gradually developing facial asymmetry was soon noted by the parents with the passage of time. There was underdevelopment of the right side of the face, which was becoming worse. The patient had undergone testing, which had returned with the diagnosis of hemifacial microsomia. It has now reached the point where the patient’s face demonstrated extreme asymmetry of the two sides. The patient had become completely dejected and depressed by this progressive development of facial deformity. He had faced a tremendous amount of bullying at school, which had made things worse for him. It has now reached the stage where he is refusing to attend school or at times even leave the house to attend social gatherings. The parents then began their quest at finding the right hospital for their son’s treatment. They had made enquiries all over the country. These enquiries had finally led them to our hospital. Our hospital is a premier center for hemifacial microsomia surgery in India. Scores of patients have been successfully rehabilitated in our hospital and are now leading normal lives. Hemifacial microsomia and lateral facial clefts Hemifacial microsomia is a congenital disorder that affects the development of the lower half of the face. It most commonly affects the ears, the mouth and the mandible. It usually occurs on one side of the face, but rarely involves both sides. When severe, it may result in breathing difficulties due to obstruction of the trachea, which might even require a tracheotomy. Incidence of hemifacial microsomia is in the range of 1:3500 to 1:4500 live births. This is the second most common birth defect of the face after cleft lip and cleft palate. Lateral facial clefts arise from the failure of the maxillary and mandibular prominences to fuse at the lateral commissure. This gives rise to macrostomia. Initial presentation and consultation at our hospital Dr SM Balaji, facial asymmetry surgeon, examined the patient and ordered for comprehensive imaging studies. The patient had a noticeable scar on his right cheek from the lateral facial cleft correction. There was also a gross facial asymmetry on the right side. The patient also had an occlusal cant due to his mandibular deformity. A 3D CT scan revealed a deformed right mandible with a hypoplastic ramus. It was explained that he needed to undergo mandibular ramus distraction osteogenesis surgery. This would be on the right side and would correct his facial asymmetry. A Le Fort I maxillary osteotomy was also planned for correction of the asymmetry and the occlusal cant. Facial symmetry is established when it is used for correction of asymmetrical mandible. Clinical application of distraction osteogenesis covers the entire skeleton. It is used for limb lengthening in case of limb length discrepancy. This is very safe and the resulting bone structure is both stable and strong. Soft tissue molding also happens concurrent with the bone lengthening. Bone grafts are unnecessary for this procedure. Successful surgical correction of hemifacial microsomia deformity Under general anesthesia, an incision was first made in the right submandibular region. Dissection was done up to the right mandibular ramus. This was followed by horizontal bone cuts to the outer cortex following which the mandibular ramus distractor was fixed using titanium screws. The inner cortex was then separated. Extreme care was taken to protect the inferior alveolar nerve throughout the procedure. Following this, a sulcular incision was made in the maxilla followed by a Le Fort I osteotomy. The maxilla was then mobilized. Hemostasis was achieved and closure was done using resorbable sutures. Interarch wiring was then done to stabilize the surgical site. Postsurgical phase of the treatment A latency period of about six to seven days was allowed after surgery for stabilization of the surgical site. Following the latency period, activation of the distractor was begun. This was by 1 mm every day for a period of 25 days to achieve a total mandibular advancement of 25 mm on the right side. Distraction was stopped after this period. A period of two more weeks were allowed before fixation of a straight plate to the left posterior maxilla to prevent further downward movement. Successful completion and rehabilitation of the patient After a period of about four months, radiographs were obtained to evaluate the site of distraction. This revealed complete consolidation of the bone with a reformation of a patent inferior alveolar nerve canal. The patient was extremely happy with the esthetic results of the surgery. He had a symmetrical face as well as normal occlusion with stabilization of the occlusal cant. Surgery Video
Segmental Osteotomy for Rapid Palatal Expansion and Closed Rhinoplasty
Patient with cleft lip and palate deformity undergoes surgery The patient is a 20-year-old female from Udupi in Karnataka, India. She was born with a unilateral cleft lip and palate defect. Her parents had been extensively counseled at the time of her birth. The surgical schedule of cleft repair was explained to them. The deformity involved both bone and cartilage as well as skin and tissue. She had subsequently undergone cleft lip surgery at 3 months of age. This had been followed by cleft palate surgery at 9 months of age. Cleft alveolus surgery was at 4 years of age. All these surgeries had been performed at our hospital. She had also undergone bone grafting at the site of the alveolar cleft. Increasing concern from the facial deformity As the patient grew up, her nasal deformity gradually increased. There was also inadequate development of the left maxilla. Her midface region had a depressed appearance. This resulted in a worsening facial asymmetry. Cleft lip and palate is the most commonly occurring of all birth defects. The patient had always faced a degree of bullying while in school. She had also become very self conscious of her appearance and had become withdrawn. Her parents had always been very worried about her and desired to do something to correct her facial deformity. They brought her again to our hospital for initial consultation and further management. Our hospital is a premier center for facial deformity surgery in India. Nose jobs are routinely performed at our hospital. Plastic surgeons also specialize in such surgeries. Initial presentation at our hospital for surgical correction Dr SM Balaji, facial deformity surgeon, examined the patient. He ordered extensive imaging studies for the patient. The patient expressed the opinion that her nose was ugly. She said that this made her feel very self conscious and made her withdraw from social contact. Her desire was to have a symmetrical nose with a prominent tip. She also complained of malaligned teeth in left back upper jaw region. Findings upon examination of the patient Examination revealed a repaired cleft lip and cleft palate on the left side. The left side of the nose was depressed along with a smaller nostril. She also complained of snoring during sleep. The left maxillary bone was also underdeveloped and constricted. Treatment planning for surgical correction It was explained to the patient and her parents that she would need orthodontic treatment before and after surgery. This would involve a period of six months of fixed orthodontic treatment before surgery. Surgical treatment would comprise of a segmental Le Fort I osteotomy of the left maxillary bone for correction of the posterior crossbite. This would enable maxillary correction through rapid palatal expansion in the postsurgical period. It was also planned to obtain a costochondral graft for cosmetic rhinoplasty of her depressed nose. The treatment plan was explained to the patient and her parents in detail. They expressed complete understanding of the treatment process and gave their consent to undergo facial asymmetry surgery for correction of the patient’s facial deformity. Successful surgical correction of the patient’s complaints Under general anesthesia, an incision was made in the right inframammary region and a costochondral cartilage graft was harvested. A Valsalva maneuver was then performed to rule out any perforation into the thoracic cavity. The incision was then closed in layers using sutures. This was followed by the maxillary osteotomy. An incision was made intraorally and a flap was raised to expose the underdeveloped maxilla. Segmental Le Fort I osteotomy cuts was then made and the maxillary segment mobilized. The vertical cut was made through the previously placed bone graft anteriorly. Cosmetic rhinoplasty was performed next. A transcartilagenous incision was first made in the right nostril. Dissection was then performed and the nasal dorsum was augmented using the costochondral graft. A tip graft was also placed followed by a strut graft to elevate the left nostril. Total patient satisfaction at the outcome of the surgery The patient and her parents were very happy with the results of the surgery. Her nose now appeared normal and there was better symmetry of the two halves of the face. It was explained that there would be even greater improvement following rapid palatal expander treatment. The change in her personality was immediate. She expressed that she would now face life with renewed confidence as a result of the surgery. Surgery Video
Maxillary reconstruction surgery for cleft palate
Patient born with cleft lip and palate The patient is an 18-year-old male from Erode in Tamil Nadu, India. He had been born with a left-sided cleft lip and cleft palate deformity. There was a hole in the roof of the mouth from the cleft palate deformity. Cleft lip and palate deformity does not lead to an open bite. Psychological counseling was provided for his parents on how to care for a baby with cleft lip and palate. They were also educated on the challenges that the child would face at every stage in life. It was explained that he needed the services of a good cleft team.. He was referred to our hospital for treatment. As advised by Dr SM Balaji, the patient had undergone cleft lip surgery at 3 months of age. This had been followed by cleft palate surgery at 9 months of age. He also underwent cleft alveolus surgery at 7 years of age. This was to unite the split in the maxillary bone with a bone graft. Gradual development of midfacial deformity As the patient grew up, his parents began to develop a noticeable facial deformity. His upper jaw demonstrated deficient growth and soon became retruded in relation to the rest of his face. The lip and nose were a part of the facial deformity. He also developed a cross bite of his anterior teeth due to the backward positioning of his upper jaw. This led to difficulties with speech and eating. The patient also experienced bullying at school. This was making the patient combative and belligerent. Initial presentation and treatment planning at our hospital His worried parents approached our hospital again. Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed oral history. He then ordered comprehensive imaging studies for the patient. After studying the case, he explained to the patient that he had maxillary hyperplasia. It was explained to the patient that he would need orthodontic treatment. This would help correct the malaligned teeth. Orthodontic treatment would be followed by forward positioning of the maxilla through a Le Fort I osteotomy. The patient and his parents expressed understanding of the treatment plan and consented to surgery. Our hospital is a premier center for orthognathic surgery in India. Jaw advancement surgery and jaw reduction surgery are performed routinely at our hospital. Scores of patients who had undergone jaw deformity correction at our hospital are leading completely normal lives now. Many of them had undergone complex jaw reconstruction surgery at our hospital. Maxillary hypoplasia explained in detail This condition is the underdevelopment of the maxillary bones, which produces midfacial retrusion and creates the illusion of protuberance of the lower jaw. This is a very common finding in patients with cleft lip and palate deformity. Plastic surgeons do not perform bony jaw corrections. It is also seen in Crouzon syndrome, Angelman syndrome and fetal alcohol syndrome as well as many other syndromes. Traumatic extraction of anterior teeth with resultant bone loss can also lead to this condition Successful surgical correction of the maxillary hypoplasia Under general anesthesia, a sulcular incision was placed in the maxilla. A mucoperiosteal flap was then elevated. This was followed by Le Fort I bone cuts with separation of the maxillary bone. The maxillary segment was then pulled forwards, occlusion was checked and the maxilla was stabilized and fixed using titanium plates and screws. Flap closure was then done using resorbable sutures. Complete patient satisfaction at surgical results The patient and his parents were completely satisfied with the results of the surgery. His maxilla had been brought forward with establishment of a pleasing facial profile. The patient was extremely happy with the outcome of the surgery and expressed the same to the surgical team. He said that this was a life changing event in his life. His parents expressed that the patient had become self confident as a result of this surgery. Surgery Video