Facial Asymmetry Correction Surgery Simultaneous Maxillary & mandibular Distraction
[vc_section content_layout=”full” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=””][vu_heading style=”2″ heading=”Patient with long standing facial asymmetry due to hemifacial microsomia” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]The patient is a young man from Thrissur, Kerala with hemifacial microsomia. His parents had slowly begun noticing a facial asymmetry as he grew up. The left side of the jaw was shorter than the right side as the corpus of the mandible was not growing normally and there was also a deformity of the left maxilla. He had also progressively developed difficulty chewing and with his speech. They approached a local oral surgeon for diagnosis and treatment. It was explained to them that the patient had a high degree of facial asymmetry with a skewed occlusal cant. The surgeon had then informed them that facial asymmetry surgery in India was performed only in a few specialty centers. The patient and his parents were then referred by him to Balaji Dental and Craniofacial Hospital in Chennai.[/vc_column_text][vu_heading style=”2″ heading=”Treatment planning explained and consent obtained for distraction osteogenesis” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Dr SM Balaji examined the patient and ordered detailed imaging studies including a 3D CT scan. Facial biometrics were then obtained, which revealed a 10 cm shortening of the ramus on the left side when compared to the right. It was decided to proceed with simultaneous maxillary and mandibular distraction for the patient. The treatment planning was explained in detail to the patient and his parents who consented to the surgery.[/vc_column_text][vu_heading style=”2″ heading=”Sagittal split osteotomy of the mandible” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Under general anesthesia, a sagittal split osteotomy was performed on the left mandibular ramus. A Univector ramus distractor was then fixed with screws to the distracted segments of the mandible. Functioning of the distractor was checked before the incision was closed with sutures. Attention was next turned to the maxillary distraction. A vestibular incision was performed followed by a Le Fort I maxillary osteotomy. Dysjunction of the maxilla was then performed on the left side followed by stabilization of the distracted segments.[/vc_column_text][vu_heading style=”2″ heading=”Establishment of facial symmetry through distraction osteogenesis” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Distraction osteogenesis of the mandible would be performed after a latency period of seven days to allow for stabilization of the distracted site. This will be followed by a distraction of 1 mm everyday for a total of 10 mm of distraction in ten days. The distractors would be left in place for a period of three months for new bone to consolidate at the distracted site. This would result in establishment of facial symmetry for the patient. The patient and his parents expressed their satisfaction at the results of the surgery before final discharge from the hospital. [/vc_column_text][vu_heading style=”2″ heading=”Surgery Video” subheading=”” alignment=”left” custom_colors=”” class=””][vc_video link=”https://www.youtube.com/watch?v=Wd-OX3yGbEE”][/vc_column][/vc_row][/vc_section]
Jaw reconstruction surgery with bone graft after removal of odontogenic keratocyst
Genesis and characteristics of an odontogenic keratocyst A cyst is essentially a sac of membranous tissue that can occur anywhere in the body. They normally contain fluid, but other substances can also be found inside them on occasion. Cysts are benign and not cancerous growth. There are many kinds of cysts. They include epidermoid cyst, sebaceous cyst, pilonidal cyst, ovarian cyst, chalazion of the eyes, popliteal cyst and pilar cyst amongst others. Varieties of common cystic lesions Treatment of cysts includes excision and careful enucleation of the cystic lesion including the membranous lining of the cyst. Any remnants left behind during enucleation can lead to recurrence of the cyst. Care has to thus be taken to ensure complete removal of the contents of the cystic cavity. Some of the more common cysts include the sebaceous cyst, the chalazion, and the epidermoid cyst. Cysts can turn painful when they occur in a confined space or get infected. Epidermoid cysts are slow growing cysts that are the result of keratin buildup under the skin. They can get infected easily as they are very close to the surface of the skin. Sebaceous cysts occur when sebum glands get clogged leading to a buildup of sebum. This too can get infected easily. Surgical excision is the treatment of choice for both these cysts. A pilonidal cyst occurs at a hair follicle and is said to occur due to a combination of hormonal changes, friction or prolonged pressure to that region. It can be quite painful and there is a foul smelling discharge from the cyst. A hair follicle is also present in association with the cyst. Treatment is curettage and enucleation along with removal of the associated hair follicle. Etiology and pathogenesis of odontogenic keratocyst An odontogenic keratocyst is a very rare benign developmental cyst that is very aggressive. It results in extensive destruction of the bone. It is most commonly seen in the posterior mandibular region in the third decade of life. The PTCH1 gene, which leads to the occurrence of odontogenic keratocyst has also been linked to the occurrence of ovarian cysts and ovarian cancer. Differential diagnoses for odontogenic keratocysts can include epidermoid cysts though these are completely different in their origin. Recommended treatment protocol for odontogenic keratocysts Treatment of the odontogenic keratocyst involves meticulous resection to completely remove the lesion followed by reconstruction of the jaw with bone grafting. Implant surgery for the placement of dental implants is performed after full bony consolidation of the bone grafts to complete full oral rehabilitation for the patient. This is the treatment protocol that is recommended by the American Association of Oral and Maxillofacial Surgeons. The patients thus properly cared for can go on to lead a completely normal life. Use of dental implants for oral rehabilitation from destructive jaw lesions The advent of dental implant treatment has enabled complete rehabilitation patients with odontogenic keratocyst. Implants enable replacing missing teeth. Success rates are extremely high for patients rehabilitated with dental implants. This is because dental implants mimic tooth roots and are able to bear occlusal loads that are borne by natural teeth. Before dental implant treatment became a part of routine surgical protocol, postsurgical dental rehabilitation was through the use of removable dentures. This was highly unsatisfactory for the patient. The patient faced a lot of difficulty with both chewing and speech. Dental implants have enabled the complete rehabilitation of both the upper and lower jaws. Proper maintenance of dental implants aided by following instructions of the implant surgeon meticulously is essential for the success of dental implant treatment. Patient develops pain and swelling in the left posterior mandibular region The patient is an 18-year-old female who had slowly developed a soft tissue swelling of the left posterior mandible with pain for the last six months. She had consulted a local dentist who noticed that the patient’s left third molar was missing from the oral cavity. Suspecting the swelling to be a dentigerous cyst, he had referred the patient to our hospital for management. Our hospital is a renowned center for jaw reconstruction surgery. Implants will need to be placed to complete oral rehabilitation after jaw reconstruction surgery. Examination of the patient at our hospital with subsequent investigations The patient presented at our hospital for management of the pain and swelling in her left posterior mandibular region. Dr SM Balaji, an oral and maxillofacial surgeon and jaw reconstruction surgeon in Chennai, examined the patient and ordered imaging studies and a biopsy of the lesion. The biopsy results returned as odontogenic keratocyst. Imaging studies revealed a radiolucent lesion in relation to the left mandibular molars and a horizontally impacted third molar. Treatment planning for the management of the odontogenic keratocyst was explained to the patient in detail. She was advised to undergo cyst removal surgery and was in total agreement with surgical management of the lesion. Bone graft harvested from the patient for jaw reconstruction Under general anesthesia, rib grafts were first harvested from the patient. The rib grafts will be used to reconstruct the jaw after resection of the odontogenic keratocyst. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. Following this, the incision was then closed in layers with sutures. Resection of the odontogenic keratocyst from the left posterior mandible. A mucogingivoperiosteal flap was raised in the left posterior mandibular region. This exposed the area of the odontogenic keratocyst. The cystic lesion was exposed and then completely resected. Great care was taken to ensure that there were no cystic remnants left behind in the bony cavity. The rib grafts were then carefully shaped to fit into the bony defect left behind by the lesion. Titanium screws were used to fix the rib grafts into the bony defect in the jaw to reconstruct the jaw. Once adequate jaw reconstruction had been achieved with the rib grafts, the flap was then closed with sutures. The healing process along with bone remodeling of the grafts to merge
Metopic synostosis – Trigonocephaly – Anterior Calvarial Reconstruction with Fronto Supraorbital Remodeling
The occurrence of craniofacial abnormalities in infants A small percentage of infants are born with craniofacial anomalies. The frontal, parietal, sphenoid, occipital and temporal bones comprise the bones of the skull. The joint between these bones are called sutures. Infants born with trigonocephaly have a noticeable ridge running down the middle of the forehead. The old terminology for this defect was metopic craniosynostosis. These birth defects are corrected by a surgery comprising of a team of neurosurgeons, plastic surgeons and craniofacial surgeons. This also comes under the purview of plastic surgery as there is esthetic improvement in the shape of the baby’s skull. Cleft lip surgery is an example of plastic surgery where there is functional as well as esthetic improvement through surgical intervention. Advent of the CT scan has enabled the development of such complicated surgeries to have a high degree of success. Young child with metopic synostosis and trigonocephaly The patient is a 6-month-old boy who was born in Punjab, which is the agricultural heartland of India. His parents noticed that his head was abnormally triangular in shape when viewed from above. There was also a prominent bony ridge on his forehead. Alarmed about this, they approached a local neurosurgeon. Suspecting that the patient had premature fusion of the metopic suture, the neurosurgeon obtained x-rays and diagnosed metopic synostosis with trigonocephaly. Referral to our hospital from World Craniofacial Foundation He got in touch with the World Craniofacial Foundation (WCF), which is an organization that helps with complete surgical rehabilitation of children born with prematurely fused cranial bones and other craniofacial deformities. Dr Kenneth E Salyer, Founder and director of WCF then referred the patient for surgery to Balaji Dental and Craniofacial Hospital (BDCH) in Chennai. Having identified BDCH as a center of excellence for craniofacial surgery in India, WCF had made the Balaji Craniofacial Foundation its Asian affiliate partner for referring such cases to our hospital. Confirmation of diagnosis at our hospital Dr SM Balaji, craniofacial surgeon, examined the patient and ordered 3D CT and other comprehensive imaging studies for the patient. These confirmed that the patient had metopic synostosis with trigonocephaly. This is a condition that arises from the premature fusion of the metopic suture of the skull. This results in the triangular shape to the skull. A 3D stereolithographic model of the skull was obtained. In consultation with the neurosurgical team, a mock surgery was performed on this skull. Meticulous treatment planning was done and explained to the parents of the boy. They gave their consent and the child was scheduled for surgery. Surgical correction of craniofacial deformity Under general anesthesia and with the entire neurosurgical team in attendance, marking were made on the scalp and a bicoronal flap was raised to expose the trigonocephaly deformity on the frontal bone. Following this, bur holes were made on the frontal bone and a frontal bone osteotomy was performed using the craniotome. The frontal bone was then gently lifted out. Fixation with sonic welding of the resected bones Next, beginning at the pterion, a bone cut was made at the frontozygomatic suture and extended through the roof of the orbit to the frontonasal suture. This was then extended to the contralateral side. This resulted in complete detachment of the supraorbital bar from the skull. The metopic ridge on this segment was then trimmed. This was then advanced anteriorly by around 3-5 mm and fixed using sonic welding. Advantages of using sonic welding over conventional titanium screws Sonic welding consists of a polymer implant, which is picked up by the hand piece tip and inserted into the predrilled hole in the bone. When an ultrasonic sound wave is generated at the tip of the hand piece, the resultant vibration causes friction between the bone and the implant. This melts the polymer and makes it flow into the surrounding trabeculae of the bone. The polymer hardens once the hand piece is removed. This stabilizes the segments of the bone and holds it in place. The polymer slowly dissolves by the time bone healing is completed, thus making another surgery for removal of the implants unnecessary. The metopic ridge on the frontal bone was also trimmed. Barrel stave osteotomy cuts were then performed on the frontal bone in order to create space for the growing brain. Following this, the frontal bone was placed back in position and fixed with sonic welding and dural hitch sutures. The bicoronal flap was then brought back into position and closed with staples. The patient recovered well from general anesthesia and was taken to the recovery room in stable condition. Skull anatomy was observed to be normal and the parents of the baby were extremely satisfied at the results of the surgery. Complete recovery during the postoperative period On the fourth postoperative day, the drains from the surgical site were removed and the patient was back to baseline behavior. The staples were removed on the 12th postoperative day and there was good healing of the bicoronal flap. The patient was later feeding normally in the ward and was observed to be playing with his elder sibling. Surgery Video
Lip Scar Revision and Removal of notching with Lip bulk increasing Surgery
Etiology of cleft lip and palate deformity formation Cleft lip and palate deformity is the second most common congenital deformity in the world. The first is Down’s syndrome. Cleft lip and palate formation can be genetic, environmental or idiopathic. There is a higher chance of a baby with cleft being born to parents with cleft lip or palate. However, the gene responsible for cleft formation is yet to be identified. Environmental factors include smoking, exposure to excess second hand smoke, alcohol intake and usage of certain illicit drugs. A clear link has been demonstrated between these factors and increased risk for cleft lip and palate formation. Cleft lip correction is performed at 3 months of age and palate correction is undertaken at around 10-12 months of age. The lip repair is an intricate surgery performed by the cleft lip surgeon. The upper lip consists of three segments, which fuses in utero to form the upper lip. A split lip occurs when fusion of these segments does not happen. The lip tissues consist of the epithelium and underlying dermis muscles. Cleft palate surgery is performed when there is a hole connecting the oral cavity with the nasal cavity in the roof of the mouth. A lip correction surgeon has to perfectly align these three elements of the upper lip. Perfect fusion results in minimal scar formation, which slowly fades away with time. When this alignment is less than ideal, it leads to thickened scar formation and muscle contracture of the lips. This causes a lack of full lip seal and poor esthetics. Scar revision surgery is performed to remove any unsightly hypertrophic scar tissue. This plastic surgery is performed keeping in mind the tissue planes of the lip. History of cleft lip surgery in the olden days There was a period in human history where babies born with a cleft were considered to be evil and were abandoned and left to die. This was brought about by mainly superstition and ignorance. Such practices were the norm for many babies born with deformities during that period. It was only after science began taking roots within human society that superstition and ignorance were overcome by humans and people began looking for ways to alleviate human suffering. Ancient China boasted of a remarkable degree of scientific knowledge compared to most other parts of the world. The world’s first cleft lip repair was performed in China even before the advent of Christianity in the world. Greek and Egyptian medicine was also remarkably advanced for the times, but records from that period of human history have unfortunately been lost. Cleft lip closure was performed successfully essentially because it involved only the soft tissue. Any involvement of the bone automatically rendered the process very difficult and prone to failure. It was because of this that the first successful cleft palate closure was accomplished only sometime during the eighteenth century. Patient with a history of cleft lip and palate surgery referred to our hospital The patient is a young man of 22 years of age who had undergone lip and palate repair as an infant. He also has a history of undergoing pharyngoplasty surgery and repair of the soft palate. He now feels that his upper lip is too long and there is insufficient show of upper teeth during smiling. This had left him feeling despondent and withdrawn. The patient also felt that his upper lip lacked adequate fullness. His parents had presented to a local plastic surgeon in their hometown who felt that he needed cosmetic lip surgery. He then referred them to our hospital for surgical correction of his complaints. Initial examination with treatment planning explained to the patient Dr SM Balaji, cosmetic lip surgeon with over 27 years of experience in cleft lip and cleft palate repairs, examined the patient and ordered biometric studies. This revealed that the patient had a long upper lip without adequate fullness. The surrounding skin tone and texture was also noted. Patient expressed his desire for fuller lips. This called for lip augmentation or lip enhancement surgery. He explained the treatment plan to the patient and his parents, which involved obtaining a fascia lata graft from the thigh region followed by a bullhorn incision to the upper lip at the base of the nose to shorten the upper lip. It was felt that artificial lip implants would not give optimal results in this case and there could also be adverse side effects. The patient and his parents were in agreement with the treatment plan and consented to surgery. It was ascertained that the patient had no allergic reaction to any of the medications that would be used during and after surgery. The patient would be prescribed hyaluronic acid after surgery to improve healing of the wounds. Surgical correction with bullhorn incision and fascia lata graft Under general anesthesia, the patient was prepped and draped for lip scar revision surgery. Markings for the bullhorn incision were made under the nostrils and extended downwards to include the scar from the previous cleft lip surgery. Incisions were then made along the markings and the hypertrophic tissue excised. The fascia lata graft was then inserted into the upper lip to increase the fullness of the lip. Upper lip was then sutured back in a slightly superior position. This resulted in a lip length that was proportionate to the rest of the face. Healing proceeded uneventfully with minimal residual scar formation. The patient and his parents expressed complete satisfaction at the results of the surgery before final discharge from the hospital. Surgery Video
Cleft Rhinoplasty – Nose Correction Surgery
Different nasal forms and the human face The nose is the most prominent feature in the human face. Evolution down the ages had resulted in a wide variation to human facial features. This ranges from the color of the skin to the shape of the nose or the shape of the chin being different although the DNA is the same. Environmental factors, diet and a few other factors had influenced this. For example, people from very cold places that received very little sunlight developed light skin and aquiline noses. This served an evolutionary function as less body heat was lost through lighter skin and passage of cold air breathed in through long noses resulted in adequate humidification and warming up of the air as it passed into the trachea. Likewise, people in hotter regions of the earth developed darker skin and noses with wide open nostrils. This enabled easier cooling down of the body as well as cooling down of the air as it passed in through the broader nostrils. Functional versus cosmetic rhinoplasty Functional rhinoplasty is performed when the patient is having problems with breathing or if the deformity of the nose is to a degree that it is affecting their normal functioning in society. This can range from anything from a deviated nasal septum to reconstruction of the nose affected by a cleft lip deformity. A functional rhinoplasty correction also invariably results in improvement in the cosmetic appearance of the nose. Cosmetic rhinoplasty is performed when the patient has no functional difficulties, but is simply dissatisfied with the appearance of the nose. This is a completely elective procedure and is performed by either plastic surgeons or oral and maxillofacial surgeons. Surgeons from both these specialties undergo years of extensive training in this procedure. Young woman with a previous history of cleft lip and palate repair The patient is a young woman from Jharkhand who had undergone repair of her cleft lip and palate as an infant. She had however always had a nasal deformity with a flattened bridge of the nose and a collapsed columella. She had also had nasal breathing problems and snoring during sleep. She desired to undergo cosmetic surgery by a facial plastic surgeon to correct this. This variety of plastic surgery is also performed by oral and maxillofacial surgeons. Cleft rhinoplasty elsewhere with unsatisfactory results from the surgery She underwent a rhinoplasty elsewhere two years ago, but was very unhappy with the results of the previous rhinoplasty. She felt that the bone grafting to augment the bridge of her nose was too bulky and her breathing difficulties had worsened. Bone grafting had also been performed to a bony deficiency in the left anterior alveolar region. Patient referred to our hospital for revision rhinoplasty surgery She and her parents presented to a local plastic surgeon who advised revision cleft rhinoplasty surgery to correct her problem. He referred them to our hospital as this required a redo rhinoplasty surgery. This redo rhinoplasty required advanced techniques as the primary rhinoplasty procedure had been improperly performed. The graft placed in the previous surgery had to be removed followed by placement of a newly harvested bone graft. This rhinoplasty procedure is best performed by an experienced rhinoplasty surgeon. It is only board certified oral and maxillofacial surgeons who perform this surgery in developed countries like the US, UK, Germany and Japan. The nasal bones could have been deformed by the previous surgery. Formation of excess scar tissue could cause this sort of deformity. The nose had to be brought into perfect alignment with the facial features. Initial examination and treatment planning of the patient They presented for consultation with Dr SM Balaji, rhinoplasty specialist, who examined the patient and ordered imaging studies. This revealed that the patient had a collapsed columella and the graft at the augmented bridge of the nose had shifted. Merits of an open rhinoplasty versus closed rhinoplasty were considered for the patient. He explained to the patient and the parents that he needed to harvest new bone grafts to correct this deformity. The patient and her parents were in agreement with the treatment plan and consented to surgery. Harvesting costochondral rib grafts for the surgery Under general anesthesia, an incision was made through the old scar from the site of the previous bone graft. Two costochondral rib grafts were harvested and a Valsalva maneuver was performed to ensure patency of the thoracic cavity. The incision was closed in layers after confirming this. Cleft rhinoplasty with placement of columellar strut graft Attention was next turned to the revision cleft rhinoplasty nose surgery. A vestibular incision was made in the anterior maxilla and the bone graft used to augment the bony depression in the anterior maxilla was exposed. The titanium screw used to fix the screw was removed and the region was further augmented with a rib graft shaped to fill the bony depression in the region. Attention was next turned to the revision rhinoplasty portion of the procedure. The costochondral grafts were contoured to the correct shape. The previously placed rib graft was removed. An intranasal incision was then made and a graft was tunneled in to give perfect form to the bridge of the nose. The second costochondral rib graft was then used as a strut graft to raise up the collapsed columella. This was tunneled into the columella through an intraoral approach and secured in place with sutures. This gave perfect form and symmetry to the nose. The vestibular incision was then closed with sutures and the patient extubated from general anesthesia. Patient and her parents expressed complete satisfaction at the results from the surgery before final discharge from the hospital. Surgery Video
Simultaneous Unilateral Cleft Lip and Palate Repair
Baby boy from Assam This baby boy from Assam was born with a cleft. He is about one year of age. The incidence of cleft lip and palate in newborns is comparatively higher in Assam. The baby had a split upper lip. He also had a hole in the roof of his mouth which affected his feeding. An ultrasound test during development in the womb revealed that the developing baby had a cleft. There is a history of clefts running through the family. Even though the parents were aware of the right time to perform the surgery, they were hesitant and brought the baby only at about one year of age. They, however, requested for simultaneous cleft lip and palate correction. Unilateral cleft lip and palate Unilateral cleft lip is a congenital split in the upper lip on one side. It is often associated with cleft palate. The cleft palate refers to a hole in the roof of the mouth. It usually involves the soft palate and hard palate. Babies with cleft lip and palate have difficulty in feeding. They have nasal regurgitation. Cleft babies may develop various problems as they continue to grow. They develop dental problems which require corrective treatments. The dental problems may require surgical and non-surgical intervention. They also have an increased risk of middle ear infections which may lead to hearing problems. Babies born with clefts may have speech problems. Thereby requiring a speech therapist opinion. Types of clefting There are various types of clefting which may involve oral and nasal cavities. They are Incomplete Unilateral and Bilateral Cleft lip and palate surgery in India The parents were very depressed with their baby’s condition. They were very concerned about her future. They were searching through the internet for the best cleft lip surgeon in India. They were referred to our hospital by a local physician. Dr.S.M.Balaji one of the leading cleft lip and palate surgeon in India examined the patient. He agreed to correct the cleft lip and palate simultaneously. The oral and nasal cavities had to be closed also. Cleft palate repair Cleft palate repair was to be done first. The abnormal palatal musculature was to be corrected during the surgery. The cleft palate repair was done using Veau Wardill Kilner’s technique. Primary cleft lip repair Corrective lip repair was also of utmost importance. Cleft lip and palate surgeon Dr. S.M. Balaji also performed cleft palate repair at one year of age. Unilateral cleft lip repair is done using Modified Millard’s technique. The upper lip musculature was also corrected during the surgery. Surgery outcome: The result of the surgery was as expected. He looked normal unlike any other child of his age with minimal to no scar. The parents were pleased with the outcome of the surgery. Future surgical corrections: Bone grafting is to be done at 3 and a half to 4 months of age thereby promoting bone growth. Speech correction / Pharyngoplasty may be necessary at 3-4 years of age. Further surgical corrections will be carried out at later date.
Cosmetic eye surgery with lateral canthopexy for antimongoloid slant correction
Presentation of antimongoloid slant and its occurrence A downward slant from the medial canthus to the lateral canthus of the eye is termed as an antimongoloid slant. It is the direct opposite of the mongoloid slant where the downward slant is from the lateral to the medial canthus of the eye. It can be idiopathic in nature or can occur as a part of a syndromic presentation including as a part of Treacher-Collins syndrome and Franceschetti syndrome. An eyelid surgery is performed to correct this. Characteristics of the antimongoloid slant in eyes Patients who have an antimongoloid slant to their eyes have no functional deficits to their eyes. It is only when patients are uncomfortable with the esthetic appearance of their eyes do they opt for surgical correction of this condition. Subtle body language cues that can alter the very meaning of spoken words Human communication can be divided into two components. One is verbal and the other is nonverbal cues. You would notice that when a person talks to another, they use their mouth to articulate the words, but special emphasis is laid to nonverbal communication through the use of hand movements and eye movements. Subtle differences brought about by nonverbal cues can change the entire tone of the communication even if the words remain unchanged. Rationale behind opting for cosmetic eye surgery in the modern world When one feels uncomfortable with the appearance of their eyes, this makes them feel very self conscious. This immediately leads to a sense of awkwardness that impedes effective communication. Communication is the tool through which we make a mark on the world around us. When this is affected by any factor, our very growth and integration into the community around us, whether at home or at the workplace is affected. Care has to be taken by the surgeon to ensure that the functional integrity of the eyes is not compromised by this surgery. This is a completely elective eye surgery on the patient’s part to undergo this surgical procedure. Removing excess skin is performed in case of wrinkles in the skin in older patients in order to make the skin tauter. Procedural description of corrective eye surgery A form of brow lift is performed for this correction. Excess skin muscle if present is carefully excised before taking deep bites from the eyelid and eyebrow and suturing to the periosteum. Sagging skin under the eyes is also tightened as a secondary benefit arising from this procedure. The appearance of having droopy eyelids is corrected completely giving the patient a completely level gaze. Care should be taken to not impair vision in any way. Lateral canthopexy surgery is one of the most commonly performed procedures of blepharoplasty in India. This is classified under brow lift surgery procedures. Cosmetic surgery is undergoing a boom throughout the world. India in particular is fast turning into a hub for cosmetic eye surgery, cosmetic nose surgery and overall cosmetic face surgery in the world. Patient with antimongoloid slant is referred to our hospital for cosmetic eye surgery The patient is a young man with idiopathic antimongoloid slant of the eye. He hated the way his eyes appeared. His marriage got fixed recently and he finally decided to get the slant corrected. He approached a local plastic surgeon at a cosmetic eye center in his hometown who referred him to our hospital for correction of his antimongoloid slant as we are a specialty center for cosmetic eye surgery in India. Initial examination and treatment planning for the patient Dr SM Balaji, cosmetic eye surgeon, examined the patient and ordered detailed biometric studies including measurements for the golden ratio. He explained to the patient that he needed a lateral canthopexy for correction of his antimongoloid slant. This is a procedure that has the approval of the American Society of Plastic Surgeons for the correction of antimongoloid slant. The patient was in agreement with the treatment plan and consented for surgery. He explained that this procedure gave the best results for correcting the antimongoloid slant. The patient was informed that the decision might be made to remove excess skin if the need arose during surgery. Surgical correction of antimongoloid slant of the eyes Under general anesthesia, the patient was prepped and draped for surgery. Cosmetic eye correction surgery for antimongoloid slant of the right eye was performed first. An incision was made at the lateral canthus and extended outwards. The incision was then extended along the margins of the upper eyelid and also the lower eyelid. A suture was passed through the edge of the lower eyelid and secured to the periosteum of the orbital margin. The incision was then closed in layers using sutures to ensure minimal scar formation. This resulted in bringing the medial and lateral canthal margins to the same horizontal plane. Good esthetic results with symmetry of repositioned eyelids The same procedure was next performed on the left eye. Perfect symmetry of the eyes was ascertained at the end of the procedure. Care was taken to ensure that the eyes were never dry during any portion of the procedure. General anesthesia was reversed and the patient recovered without incident after the surgery. The patient expressed complete satisfaction at the results of the surgery before final discharge from the hospital. Surgery Video
Upper jaw Sinus Lift Surgery for immediate dental implant placement
An introduction to dental implants Most scientific advances are made through accidental discoveries. For example, Dr Alexander Flemming had left a few bacterial culture dishes unattended over a period of time and had observed a fungal growth in the dishes that had inhibited bacterial growth. This had led to the discovery of penicillin, which had directly led to the birth of modern medicine as we know it. The same way, Dr Per Ingvar Branemark had been conducting experiments with placement of titanium inserts into the bones of rabbits. Upon completion of the experiments, he had tried to retrieve the inserts as they were expensive. It was then that he discovered that the titanium inserts had completely fused with the bone. This is the phenomenon of osseointegration where the titanium and bone become one without any distinguishable joint. Later research by Dr Branemark had led to dental implants and he founded Nobel Biocare for the manufacture of implants. Constantly evolving research has led to the development of various types of dental implants. The first dental implants were single tooth units, which were used to replace a single missing tooth. We now had special dental implants such as All-on-4 dental implants and zygoma implants. These implant systems utilize a minimal number of implants to rehabilitate an entire edentulous arch. Dental implants come closest to natural teeth when it comes to its ability to bear biting forces and esthetics. Just like natural teeth require a lot of care to last a lifetime, dental implants too require a lot of care to last a lifetime. This involves the maintenance of scrupulous oral hygiene through not only tooth brushing, but also through the use of dental floss and mouth washes. Implant failure rate is also very low when all the instructions are followed for their upkeep by the patients. Patient with missing right maxillary molar teeth The patient is a young man who had prematurely lost the right molars in his upper jaw due to dental decay. This partially edentulous state had led to a lot of difficulty with chewing food along with entrapment of the tongue during chewing and speech. He had started chewing mainly with the left side of his jaw. He had visited a local dental clinic for information regarding dental implant surgery in India. He had felt apprehensive as this is a surgical procedure. The local dentist had also advised him to go for dental implants considering his young age. He had also informed the patient that sinus augmentation might be required due to the length of time the patient had been edentulous. It was also explained to the patient that he needed to go to a specialty treatment center for dental implants. The patient was then referred to our hospital for dental implant surgery. India is a major hub for medical tourism from all parts of the world. Many patients come to India because of the high quality of care allied with the low cost of treatment here. Our country boasts of a very well developed infrastructure for the delivery of quality healthcare. Chennai is considered to be the healthcare capital of India. Patients seeking the services of a quality dental implant surgeon in India form a major part of medical tourism to our country. There has been a profusion of dental implant clinics lately because of this. Edentulous mandibles are more often encountered than edentulous maxillae. Reasons for this can be varied and can depend upon food habits and diet. Initial examination and treatment planning Dr SM Balaji, director, Balaji Dental and Craniofacial Hospital, examined the patient. He ordered CBCT for treatment planning. Our hospital was the first in South India to acquire the CBCT imaging system. CBCT enables the best treatment planning for placement of maxillary dental implants and mandibular dental implants. Soft tissue contour and the maxillary sinuses are well visualized in CBCT images. The patient was informed that bone height was inadequate in the maxilla for implant placement. It was explained that the sinus lift surgery would enable building up the bone height in the maxilla for implant placement. Bio-Oss would be used to enable the sinus lift procedure. This is close to being the ideal bone graft material for maxillary bone augmentation. Bone grafts from the ribs would be required in cases where there is bone loss in the mandible. The patient readily agreed to the procedure. A presurgical systematic review was conducted after obtaining consent from the patient. Importance of adequate maxillary bone height Adequate bony height of the maxilla is very essential for long term success of the implant. The Schneiderian membrane, which lines the maxillary sinus should not be perforated during implant fixation. Perforation of this membrane would lead to long term sinus problems with maxillary sinusitis and chronic maxillary sinus infection. Sinus lift procedure increases the height of the bone of the maxilla, thus making is possible for implant fixation in the maxilla. Bone height begins to reduce within six months of extraction of maxillary teeth. This is more pronounced in the case of loss of maxillary molars. The use of Bio-Oss provides quick formation of new bone by means of consolidation of the Bio-Oss placed through the lateral window created in the maxilla. Implant placement and Maxillary sinus lift procedure Under general anesthesia, a mucogingivoperiosteal flap was first raised in the right posterior maxillary region. Following this, a lateral window was then made in the maxillary bone using a surgical bur. The Schneiderian membrane was then gently separated from the floor of the maxillary sinus. A space was soon created between the floor of the maxillary sinus and the membrane. Extreme care was taken during to procedure to ensure that there was no tearing of the membrane. The ensuing space between the Schneiderian membrane and maxillary bone was then densely packed with Bio-Oss. This Bio-Oss would soon consolidate into new bone and this would serve as bony support for the implant. A dental implant was then placed in the
Mandibular prognathism Correction (Long Lower jaw) Surgery BSSO Bilateral Sagittal Split Osteotomy
Mandibular prognathism arising from an excessively large mandible When the lower jaw is disproportionately larger than the upper jaw in size, this condition is known as mandibular prognathism. When the upper jaw is normal in size and the lower jaw is disproportionately larger than normal, it is called true mandibular prognathism. Correction of this condition involves reduction in the size of the mandible. This is achieved through surgical correction. Benefits from the development of modern medicine and dentistry to humanity Modern dentistry has come to the aid of many conditions that caused great suffering in the past. There was a time when even the most minor of dental ailments could even turn life threatening. Alveolar abscesses that are so easily controlled today through the use of antibiotics and root canal treatment could lead to the death of the individual 150 years ago. Mandibular prognathism during olden days would have caused an extreme degree of distress to the individual with regards to eating and speech. Anterior crossbite is present in mandibular prognathism. Difficulty with chewing food would have caused intake of insufficient nutrition that could lead to malnutrition. Historical occurrence of mandibular prognathism Mandibular prognathism was a feature that was common among the von Habsburgs of Austria. The Habsburgs were the dynasty that ruled the Austro-Hungarian empire before World War I. Most of the male members of this dynasty demonstrated a marked mandibular prognathism. A prognathic mandible is also called a Habsburg jaw or lantern jaw. The Habsburg jaw was an extreme manifestation of mandibular prognathism because of many generations of inbreeding. What must have been present as mild mandibular prognathism in the first generation had become accentuated to an extreme degree through the inbreeding. It was so extreme in some of them that they were unable to chew food because of the prognathism. There was no treatment to correct jaw prognathism prior to the advent of modern dentistry. Jaw deformities are a common occurrence in case of extensive inbreeding. Many breeds of dogs that are inbred to retain the bloodline exhibit severe jaw deformities. This is because inbreeding is against the laws of nature and is something that is unique to human beings. Surgical technique used for correction of mandibular prognathism A bilateral sagittal split osteotomy is performed to reduce the size of the mandible and bring it into correct alignment with the maxilla. An illusion of mandibular prognathism can occur when there is a retruded maxilla and a normal mandible. Correction of this condition is through forward movement of the maxilla through distraction osteogenesis. This corrects the relationship between the maxilla and mandible and brings the two jaws into correct alignment. Surgeons advice diagnosis or treatment planning in several steps using various diagnostic protocols. They look for excessive wear of the teeth in the molar region. This surgery is contraindicated in patients who have undergone treatment for oral cancer as per the American Association of Oral and Maxillofacial Surgeons. Patient with mandibular prognathism referred to our hospital for surgical correction The patient is a young woman from Kurnool, Andhra Pradesh. She has had long standing problems with anterior crossbite due to mandibular prognathism. This had led to her feeling very self conscious because of the cosmetic aspect of her prognathism. She had always desired to undergo corrective jaw surgery for her problem. Parents and patient referred to our hospital for surgical management Her parents decided to seek the upper and lower jaws and teeth correction treatment advice from an oral surgeon in their hometown. She and her parents approached a local oral surgeon to seek the advice regarding the details about surgery. He said to them that this was not conducive for maintaining good oral health and referred them to Balaji Dental and Craniofacial Hospital for corrective orthognathic surgery. He explained to them that this is a specialty maxillofacial surgery center for jaw reduction surgery in India. Jaw reduction surgery requires extreme precision in measurements to achieve the best results. Mandibular prognathism is a condition that is present in 0.35% of the Indian population. This condition completely alters the jaw line. Correction of this condition is done by jaw reconstruction surgeon in India. A bilateral sagittal split osteotomy is performed to reduce the size of the lower jaw and make it proportionate with the upper jaw. Benefits of undergoing surgical correction of mandibular prognathism It is common to see many people with mandibular prognathism who have not even considered the option of surgical correction. They have to be educated regarding the benefits of undergoing surgical correction of their condition. This would include improvement in speech and eating habits along with the improvement in esthetics. It is mostly those with pronounced functional disruption who voluntarily seek help for their condition. Tooth extraction is never a part of this surgery as it is performed posterior to the tooth bearing section of the mandible. This can also be considered a cosmetic surgery or plastic surgery as it results in dramatic improvement in facial appearance of the patient. Soft tissues automatically mold themselves once this surgery is complete and there is no need to do any soft tissue correction as part of this surgery. Initial examination and treatment planning explained to the patient and her parents Dr SM Balaji, oral and maxillofacial surgeon, examined the patient and ordered radiographic studies. The patient had anterior and right-sided posterior crossbite. Presurgical planning was meticulously carried out on the patient. He explained that orthognathic surgery is performed for correction of this condition. The patient was in agreement with the treatment plan and consented to surgery. Surgical correction of mandibular prognathism with very good results Under general anesthesia, bilateral sagittal split osteotomy was performed. The anterior segment of the mandible was then positioned posteriorly to align correctly with the maxilla. Great care was taken to protect the exposed inferior alveolar nerve during this segment of the surgery. Intermaxillary fixation was then applied. This was followed by removal of a 5 mm wide piece of bone from
Successful cleft lip repair for unilateral cleft lip
Baby girl from Mathura This little baby girl from Mathura was born with a cleft. She is now 3 months of age. Mathura accounts for a higher than average number of babies born with a cleft. Her upper lip was split into two. This is known as a cleft lip. She also had a hole in the roof of her mouth which affected her feeding. The patient’s mother was also operated for a cleft lip and palate as an infant. An ultrasound test during pregnancy revealed the baby’s cleft. There was also a familial history of clefts running through the generations. Unilateral cleft lip Cleft lip is a congenital split in the upper lip on one side often associated with cleft palate. The cleft palate usually involves the soft palate and hard palate. Babies with cleft lip usually have difficulty in feeding. Cleft babies may develop various problems as they continue to grow. They have dental problems which require corrective treatments. The dental problems require surgical and non-surgical intervention. They have an increased risk of middle ear infections which may lead to hearing problems. Babies born with clefts may have speech problems. Thereby requiring a speech therapist opinion. Cleft lip surgeon in India Though aware of the condition the parents were very depressed. They were very concerned about her future. They were searching far and wide for the best cleft lip surgeon in India. A local physician referred them to our hospital. Dr.S.M.Balaji one of the leading cleft lip and palate surgeon in India examined the patient. He planned to correct the cleft lip at 3 months of age. Primary cleft lip repair Corrective surgery to repair the lip is required. Cleft lip and palate surgeon Dr. S.M. Balaji planned to perform primary lip repair at 3 months of age. Unilateral cleft lip repair is done using Modified Millard’s technique. The upper lip musculature is also corrected during the surgery. Surgery outcome The result of the surgery was as expected. She looked like any other baby girl of her age with minimal to no scar. The parents were very pleased with the results. Future surgical corrections Cleft palate repair will be done at about 9 months of age. Bone grafting is to be done at 3 and a half to 4 months of age. Speech correction / Pharyngoplasty may be necessary at 3-4 years of age. Further surgical corrections will be carried out at later date. The mouth palate must be repaired within 10 months of age.