TMJ reconstruction surgery with costochondral graft for hemifacial microsomia
Hemifacial microsomia and the manifestations of the condition Hemifacial microsomia is a congenital condition where one side of the face is underdeveloped with the eyes, ears, cheekbone and mandible being affected. The lower half of the face is affected the most by this condition. Underdevelopment of the mandible includes underdevelopment of the TM joint. Hemifacial microsomia always results in TMJ disorders. This can result in serious structural and functional disorders of the TMJ. One manifestation of this condition is extreme facial asymmetry. Normal alignment between the upper and lower jaws is also lost. Other symptoms of hemifacial microsomia include an extremely wide mouth, skin flap present over an underdeveloped external ear and growths around the eye on the affected side. Normal and abnormal relationship between the upper and lower jaws Normal alignment of the teeth is called normal occlusion. Normal occlusion of the teeth signifies normal alignment of the maxilla and the mandible. Normal alignment of the jaws can also be present in cases of abnormal relationship between the teeth of the upper and lower jaws. This is called dental malocclusion and correction of this is through fixed orthodontic treatment. Dental malocclusion can also result when there is abnormal alignment between the two jaws. This is known as skeletal malocclusion. Skeletal malocclusion can only be corrected through surgery. Surgery that is performed to correct the relationship between the two jaws is known as orthognathic surgery. Manifestations and etiology of hemifacial microsomia TMJ symptoms begin to manifest early in life for these patients. There is also a lot of TMJ pain. Most cases of hemifacial microsomia occur as the result of a combination of genetic and environmental factors. It causes serious problems with the patient’s general health as well as oral health. Relaxation techniques do not help with pain arising from this condition as it is caused by a structural deformity. Clinical trials are constantly being performed around the world to help alleviate the symptoms in the long term. The temporomandibular joint is the only movable joint in the skull. It is the point of contact between the mandible and the skull. The joint has a cartilaginous capsule that provides synovial articulation between the glenoid fossa of the temporal bone and the mandible. There are a variety of disorders that lead to disruption in the functioning of this joint. Fractures of the TMJ are very common as any blow to the chin is directly transmitted to the joint. The condylar fractures of the mandible are amongst the most common facial fractures. Only nasal bone fractures occur in greater numbers. Common causes of condylar fractures are road traffic accidents and interpersonal assaults. Classification of disorders of the TMJ There are many conditions that lead to disorders of the TMJ. They can be broadly classified into congenital, traumatic, idiopathic, degenerative and inflammatory disorders. Congenital disorders include absence of the joint at birth, smaller than normal or larger than normal joint and abnormally developed joint. Traumatic disorders include dislocation, subluxation and fracture. An idiopathic disorder of the TMJ is defined as one where there is pain and dysfunction of the joint without any identifiable cause for the symptoms. Inflammatory disorders include myositis, capsulitis and synovitis. Degenerative disorders include rheumatoid and osteoarthritis. Benefits of surgery in patients with temporomandibular joint disorders Oral and maxillofacial surgeons always recommend surgery for this condition. There is overall improvement in the patient’s health once surgery is performed. Physical therapy in the form of jaw exercises has to be performed regularly to maintain good joint health following surgery. Surgery for hemifacial microsomia however is not an orthognathic surgery or corrective jaw surgery. This can be categorized under temporomandibular disorders that require TMJ reconstruction surgery. Patient with hemifacial microsomia with worsening mandibular deviation The patient is an 8-year-old girl with right-sided hemifacial microsomia. She also has microtia of her right ear and underdevelopment of her mandible with deviation to the right side. She had first undergone right-sided jaw reconstruction surgery elsewhere when she was 3 years old. However, over the course of time, her right-sided mandibular deviation had gotten worse with development of an open bite and her parents consulted with a plastic surgeon. Referral to our hospital by a plastic surgeon in her hometown The plastic surgeon examined the patient and explained to the parents that the patient needed TMJ surgery for temporomandibular joint reconstruction, which came under Oral and Maxillofacial Surgery. He explained that the American Association of Oral and Maxillofacial Surgeons (AAOMS) had developed a protocol for surgical treatment of this condition. Only certain hospitals in India met the stringent standards prescribed by the AAOMS for TM joint surgery. The patient was thus referred by him to Balaji Dental and Craniofacial Hospital. It was explained to the parents that the cost of temporomandibular joint reconstruction surgery in India was a fraction of what it cost in other countries with an excellent infrastructure for healthcare. Examination and treatment planning at our hospital Dr SM Balaji, an experienced temporomandibular joint reconstruction surgeon, examined the patient. He then ordered a 3D CT scan and other pertinent imaging studies. This protocol is standard for determining the best treatment option for the patient. These diagnostic studies revealed that the patient had extreme resorption of the costochondral rib grafts that had been placed during the previous surgery. Detailed treatment planning was done and it was decided to reconstruct the temporomandibular joint with rib grafts. This was explained to the parents of the patient in detail and they consented to the proposed treatment plan. Dr. SM Balaji is an experienced TMJ surgeon who has published many articles on the jaw joint surgeries performed by him in many international scientific journals. Many cases of hemifacial microsomia have been surgically rehabilitated at our hospital. Postsurgical follow up of over ten years has shown excellent results with the patient leading active lives that were fully integrated into their society. Harvesting rib grafts for jaw reconstruction surgery The patient was taken to the operation theater where she was
One stage microtia ear reconstruction surgery
Microtia deformity correction surgery The congenital underdevelopment of the external ear is defined as microtia. A completely undeveloped external ear is known as anotia. Anotia is the most extreme manifestation of microtia. Microtia is one of the birth defects that can appear in isolation or in conjunction with a syndrome. Some common syndrome that present with microtia include hemifacial microsomia, Treacher-Collins syndrome, Franceschetti syndrome and Goldenhar syndrome. Prosthetic fabrication of external ears for microtia patients Unilateral microtia is more common although occurrence of bilateral microtia is also recorded. The right ear is more commonly affected than the left ear. Fabrication of prosthetic ears using latex was in vogue in the early 1900-30s though esthetic results were not as satisfactory. Silicones are used currently for fabrication of prosthetic ears now and these ears offer satisfactory esthetic results for the patient. Studies to evaluate prospects of hearing ability It is important to determine as early as possible if the patient’s hearing can be restored through surgery. A CT scan is performed at around the age of 5-6 to determine the degree of development of the external auditory canal. Placement of cochlear implants can be considered in cases of complete lack of development of the external auditory canal. This will restore normal hearing for the child. Cosmetic aspects of microtia deformity Microtia is cosmetically disfiguring for the patient and can lead to a lot of distress for the patient and his family. Such deformity correction is performed by ear deformity correction specialists. Correction of this deformity is through the use of rib cartilage grafts and is done in three stages when the deformity is severe. Preauricular skin grafting is utilized in cases of deficiency of skin cover for the rib graft Modes of sound wave propagation Sound waves are transmitted to the inner ear through two modes. One is air conduction and the other is bone conduction. What we know as normal hearing is through air conduction. This is much clearer and the sounds are much sharper. The sound waves are propagated through the external auditory canal and strike the ear drum in this case. The second mode of propagation of sound waves is through bony conduction. When we have a severe respiratory illness or an ear infection, the external auditory canal gets blocked. Though we are still able to hear sounds, it sounds muffled and has a vibratory quality. This is because the sounds we hear are reaching the eardrum through the bone. This is known as bony conduction. Grades of microtia deformity There are four grades of microtia. Grade I microtia features a less than complete development of the external ear. This external ear has a shape and form of a near normal external ear. A fully functional external auditory canal is also present. Grade II microtia features a partially developed ear where the top of the external ear is affected. This is informally known as a lop ear. It has a closed external auditory canal but the ability to hear is retained in these patients and it is through bony conduction of sound waves. Grade III microtia features a tiny remnant of the external ear that resembles an ear tag. This is the most common form of microtia. Grade IV microtia features the complete absence of an external ear. Severe microtia is also accompanied by complete lack of an external auditory canal. This causes severe hearing impairment. It is very rare that a patient without an external auditory canal has the ability to ear through bony conduction. It is very important that good blood supply is maintained when surgical reconstruction of microtia defect is performed. Gradual loss of blood supply to the cartilage graft over a period of time was the main reason for the failure of other microtia surgery technique. Loss of blood supply can lead to gradual withering of the reconstructed external ear. Alternative techniques of microtia reconstruction A few other reconstructive techniques were utilized for microtia reconstruction in the past although they have been discontinued to lack of good long term results. Treating microtia is also a form of plastic surgery. Cosmetic ear surgery requires the surgeon to have an artistic vision of the final surgical outcome. When the reconstruction is unilateral, the surgeon should be able to visualize the process through which symmetry of the ears will be achieved. An ear framework template or cartilage framework is first constructed and the cartilaginous rib grafts that are harvested from the patient are crafted to suitable size and shape. The reconstructed ear should be symmetrical to the normal ear. This surgery can also be done in a single stage when the deformity is not extreme as illustrated in the case described below. Young boy with microtia desires to undergo surgery This is a young boy with microtia in the form of a congenitally deformed right external ear. He is now 8 years of age. Teasing at school by other children was causing great distress to him. His concerned parents consulted a local surgeon to enquire about ear reconstruction surgery in India. He explained to them that a good ear reconstruction surgeon would be able to correct his ear deformity. Cost of microtia surgery in India Cost of ear reconstruction surgery in India is only a fraction of what it costs in developed countries. The results are however as good as in any western country. He made extensive enquiries and referred them to Balaji Dental and Craniofacial Hospital. The patient and her parents subsequently presented at our hospital. Patient presents at our hospital for microtia surgery Dr SM Balaji, ear deformity correction surgeon, examined the patient. He ordered facial biometrics for both the deformed ear and the normal left ear.This would ensure that the reconstructed right ear was symmetrical to the normal ear. Biometric studies revealed this to be a constricted ear. Detailed planning for the surgery was done. Usual microtia ear reconstruction surgery is normally performed in three stages.He decided to do a single stage deformity correction
Revision Rhinoplasty Surgery with Scar Removal in the Chest
Increasing numbers of revision rhinoplasty surgery in India A revision rhinoplasty is performed when a patient is not satisfied with the results obtained from the original rhinoplasty surgery. It is also performed when there is a functional compromise from the original rhinoplasty. This could be worsening difficulty with breathing or snoring from a deviated nasal septum. A revision rhinoplasty is more difficult that a rhinoplasty as it has to offset the damage arising from the previous rhinoplasty. An inexperienced rhinoplasty surgeon might remove more bone or cartilage than necessary thus causing serious damage to the nasal structures. The initial surgery is known as primary rhinoplasty and the revision rhinoplasty is known as secondary or corrective rhinoplasty. Indications for rhinoplasty surgery or nose surgery A rhinoplasty procedure or nose job is advised when a patient has breathing difficulties or excessive snoring during sleep. This can be due to a deviated nasal septum. A nasal septum deviation could be congenital or could be caused by trauma to the nasal bone. This results in a deviation in the nasal passage, thus obstructing the clear passage of air during breathing. A rhinoplasty procedure needs to be performed to rectify this. Rhinoplasty surgery restores the function of the nose back to optimal levels. Principal qualities of a good rhinoplasty surgeon An experienced rhinoplasty surgeon instinctively diagnoses the cause for the problem and the degree of correction required in each case. There is no unnecessary excision of tissue or removal of bone. This ensures that optimal results are obtained with maximum cosmetic as well as functional benefit to the patient from the surgery. It always results in an improvement in facial features. Rhinoplasty surgery is not just purely a cosmetic surgery. It also results in relieving a person’s breathing difficulties. Facial plastic surgeons as well as oral and maxillofacial surgeons perform rhinoplasty procedures. Different categories of nasal deformity corrected by rhinoplasty surgery Rhinoplasty surgery is a form of facial plastic surgery. There are many kinds of nasal deformities that are addressed by a rhinoplasty. These include parrot beak deformity, flat nose deformity, hooked nose deformity, dorsal nasal hump, saddle nose deformity, broad nose deformity, crooked nose deformity and asymmetrical nose deformity. A rib cartilage is often used as a graft to enhance the bridge of the nose in case of a flattened nose. The protocol followed for rhinoplasty is the same as for other surgery procedures. Cleft rhinoplasty is a highly specialized field. Only the most experienced of surgeons excel in this corrective procedure. It is a highly complex procedure and complete mastery over all the basic sciences of medicine is a prerequisite to master this. Rhinoplasty surgery used to be confined to the rich and the famous in the past, but the number of rhinoplasty procedures has drastically increased leading to the increase in the number of hospitals offering this service to patients. A rhinoplasty surgery requires extreme finesse and precision to give the best esthetic results. It takes years of training under an experienced surgeon to master this. When an inexperienced surgeon performs this surgery, chances of patient dissatisfaction with the results is high and this automatically leads to an increase in the number of revision surgeries being performed. Patient dissatisfied with previous rhinoplasty surgery The patient is a young girl who had undergone rhinoplasty elsewhere with placement of a rib graft to augment the bridge of her nose. She had also had placement of a graft to the tip of the nose. Over a period of time, she felt that the bridge of her nose was too broad and the tip of the nose was very pronounced. She desired to have a narrower bridge of the nose and a less pointy tip of the nose. She had presented to a plastic surgeon in her hometown to enquire about surgeons performing rhinoplasty surgery in India and also scar revision surgery in India. He referred her to our hospital. She therefore presented to our hospital requesting corrective surgery as it was a failed rhinoplasty and revision was advised. Patient presents at our hospital for revision rhinoplasty Dr SM Balaji, a well known rhinoplasty surgeon in India, examined the patient and ordered imaging studies. As the outcome of the initial rhinoplasty was not satisfactory to the patient, she was a little apprehensive and enquired about the revision rhinoplasty swelling timeline. It was explained to the patient that the recovery period would be for a period of one to two weeks and that she would need to stay home for the first ten days following surgery. The splint that would be placed on her nose after the procedure would be removed at this point. He explained that the graft to the bridge of the nose would need to be shaped to a finer form during the revision rhinoplasty surgery. The patient also complained of an unsightly scar at the site of the bone graft harvest from the previous surgery. It was decided to perform a scar revision surgery at that site during this surgery. The scar revision procedure would involve closure of the wound in several layers for minimal residual scar formation. Harvesting of bone graft for nasal bridge rhinoplasty augmentation Under general anesthesia, a rhinoplasty incision was placed in the columella and the bone graft was taken out. It was then reshaped to form a finer bridge of the nose. It was placed again at the bridge of the nose. The tip of the nose was also shaped to be less pronounced. Incision was then closed with sutures. Scar revision surgery performed with optimal results Attention was then turned to scar removal from the chest wall. An incision was made at the old chest incision scar site. The unsightly scar tissue was excised completely. A Valsalva maneuver was then performed to ensure that there was no accidental perforation into the thoracic cavity. The incision was then closed in layers. The patient’s revision nose surgery was meticulously documented in her medical records. Surgery Video
Facial Reconstruction Surgery of Upper Jaw after Treatment of Fungal Infection Followed By Dental Implant Surgery
History of maxillary rhinosporidiosis with pain and drainage This patient had been having undiagnosed pain and swelling for two years when he first came to our hospital. He had been referred here by a surgeon in his hometown after several doctors in various dental clinics had been unable to diagnose his condition. He even visited a few oral surgery implants clinics without any solution. He was examined by Dr SM Balaji, oral and maxillofacial surgeon, who ordered a 3D CT scan and biopsy. Cultures of the biopsy specimen were done and revealed rhinosporidiosis infection of the maxillary sinus. Surgery was performed and all infected bone had been removed. This had lead to a maxillary bone deficiency. A jaw reconstruction surgery was indicated for the patient. Jaw reconstruction surgery in India is very affordable compared to western countries. A jaw reconstruction surgeon in India undergoes years of rigorous training. The patient had lost most of his natural teeth in the maxilla and was partially edentulous. The jaw joint was however not compromised by this. There were no retained tooth roots and the health of the soft tissues were not compromised. Only two wisdom teeth were present in his mouth, his left mandibular third molar, which was impacted, and his right maxillary third molar. Dental work following surgery would be the placement of implants followed by dental rehabilitation with crowns. The patient complained of excessive daytime sleepiness, but there was no suspicion of sleep apnea. The patient was advised to come back to the hospital after adequate healing of the maxillary surgical site. Bony rehabilitation of the lower and upper jaws is also treated by plastic surgeons. Principles of orthognathic surgery are not used in these cases although this is also corrective jaw surgery. Surgery for maxillary augmentation with bone grafts The patient presented after the surgical wounds had healed completely. A biopsy obtained from the maxilla revealed complete resolution of his maxillary rhinosporidiosis. Augmentation of his maxillary bone had been performed with bone grafting for placement of dental implants at a later date. The patient presents now for placement of dental implants. Nobel Biocare implants are very commonly used for dental implant surgery in India. Almost every implant surgeon in India uses this. Implant surgery is a component of maxillofacial surgery. History of modern dental implants It was Dr Per-Ingvar Branemark who first discovered osseointegration of titanium with bone. During the course of his research into factors that influence bone healing, he inserted titanium rods into rabbit leg bones. When he later tried to retrieve it, he discovered that the titanium rod had completely fused with the bone and the two had become indistinguishable. The structure of the bone was not affected in any way and bony strength to withstand stresses was also normal. This later led to the development of dental implants by Dr. Branemark. He is considered to be the father of dental implantology. This led to the formation of Nobel Biocare and he continued to research ways to improve dental implants. Advantages of dental implants over other dental prostheses Titanium is very light and completely fuses with the bone. The joint between the bone and the titanium implant is virtually indistinguishable and very strong. It can withstand occlusal loads comparable to that of natural teeth. Constant research into dental implants has led to different implant designs to cater to individual patient needs. The most common type of implant is the single tooth dental implant. The crown fixed to this type of implant can either be a single crown or a crown that is a part of a bridge. The number of implants used to fix a bridge depends upon various factors. Factors such as the amount of occlusal load the implant will have to bear determine this. Different types of dental implants systems in use today All on 4 implants utilize the placement of tilted dental implants for the rehabilitation of an entire arch. Placement of the teeth prosthesis, typically a bridge, can be done within 24 hours. It is very convenient for the patient and the postoperative recovery phase is the shortest for this implant. Patients thus rehabilitated are able to eat all varieties of food and the occlusal loads borne by these implants are equal to that of natural teeth. Long-standing edentulous condition of the maxilla can lead to severe resorption of the maxillary bone. This can be to a degree that cannot support most implant systems. This lead to the development of zygoma implants. Dental implants are directly fixed to the zygomatic bone. The zygomatic bone is a very strong bone and serves as an ideal foundation to soak up occlusal forces that are exerted upon these implants. Factors behind the long term success of dental implant surgery The success rate of dental implants is very high. It ranges from 98% to 99.5%; however, it needs to be reiterated that the patient needs to take good care of the implants to enable long-term success of the implants. The habit of smoking greatly reduces the success of implant placement. The patient also needs to maintain meticulous oral hygiene with the use of aids such as dental floss and special mouthwashes that will be prescribed to the patient. Maintenance of poor oral hygiene will definitely lead to failure of the implant system. The dental implant surgeon will have to ascertain the patient’s levels of motivation before going ahead with the placement of dental implants. Periodic checkup of dental implants needs to be done by the surgeon to ensure that the right conditions are being maintained in the oral cavity to ensure long term success of the dental implant treatment. Placement of maxillary dental implants A mucogingivoperiosteal flap was raised in the maxilla to expose the augmented maxillary bone. Screws used to fix the bone grafts to the maxilla during the previous surgery were removed. The bone grafts were seen to be fully integrated with the maxillary bone. Implants were then fixed in the maxilla. A total
Cosmetic Eye Surgery for Bilateral Antimongoloid Slant Correction
Occurrence of antimongoloid slant of the eyes The shape of the eye and the eyelids is heavily influenced by genes. Each race is characterized by a particular eye and eyelid form. When the nasal corner of the palpebral fissure is higher than the temporal corner, it gives rise to an antimongoloid slant to the eyes. This is a genetic feature and is heavily influenced by hereditary factors. It is manifested by a slight downward slant to the lateral upper eyelids. This gives the eyes the typically narrow appearance. Mongoloid slant to the eyes explained in detail It is the opposite of the mongoloid slanting of the eyes where the temporal corner of the palpebral fissure is at a higher level than the nasal corner. This is a racial characteristic that is found amongst the Chinese, Japanese, Malay and other similar races. Mongoloid slant to the eyes is a prominent finding in Down’s syndrome. Down’s syndrome is also known by the term mongolism. The other features of Down’s syndrome include short stature, flat face and mental retardation. Down’s syndrome is not a genetic disorder, but occurs due to a random mutation during the cell division phase of fetal development. Certain syndromes that have a presentation of antimongoloid slant to the eyes also feature mental retardation amongst the constellation of symptoms associated with it. Syndromes associated with antimongoloid slant to the eyes Certain syndromes give rise to an antimongoloid slant of the eyes. These include Tarsal Tunnel, Cri Du Chat, gigantism, Curry Hall, Weaver, Waisman, Pallister, Noonan, Charge and Treacher-Collins syndromes. Antimongoloid slant of bilateral eyes appears as one amongst a constellation of features in these syndromes. However, this patient did not display any syndromic presentation. His antimongoloid slant of the bilateral eyes occurred in complete isolation. This could be due to an isolated genetic mutation or could be the result of hereditary transference from a distant ancestor. Patient with the complaint of antimongoloid slant to the eyes This patient had an antimongoloid slant due to the downward slant of his bilateral lateral eyelids. This led to a myopic or drooping appearance to his eyes. He felt uncomfortable with his appearance because of this. A friend recommended that he undergo cosmetic eye surgery to correct this. The patient presented to a local board certified plastic surgeon who referred him to our hospital. Presentation at our hospital for cosmetic eye surgery for antimongoloid slant correction Our hospital is a well known center for facial reconstructive surgery in Chennai. Dr SM Balaji examined the patient and explained that the patient needed plastic surgery similar to a brow lift procedure. He explained that the principle was the same as breast augmentation surgery. The technique used would be the same that was used to make sagging skin taut. The difference was that the tautening the skin involved removing excess skin. This however was not a case of excess eyelid skin. This was an anatomical variation that presented in approximately 0.5% of the population. He said that droopy eyelids involved both upper and lower eyelids. It was illustrated to the patient that a downward tilt of the lateral upper lids of the eyes gave the antimongoloid appearance. This is a purely cosmetic procedure and has no functional aspect to it. Principles of cosmetic eye surgery explained to the patient The principle behind face lifts would be utilized to correct the antimongoloid slant. He said that the patient needed a facial cosmetic surgeon and referred him to our hospital. The cost of facial cosmetic surgery in India is very economical compared to the developed countries in the west. Facial plastic surgery in India is highly developed and very advanced due to the high demand. These surgery procedures are very commonly performed nowadays. It is a combination of these factors that had led to the explosion in medical tourism to India. Cosmetic surgical procedures feature at the top of the list for medical tourism to India. Highly skilled medical professionals allied with excellent infrastructure provide very good results for the patients. Patient presents for facial cosmetic surgery Dr SM Balaji, a well known facial cosmetic surgeon in India, next ordered a series of biometric studies as these surgical procedures demand a high degree of precision. Decision was made to perform cosmetic eye surgery. He made detailed measurements of the needed corrections. The surgery was then explained in detail to the patient. Patient agreed to the surgery and provided his consent. Surgical correction of antimongoloid slant of the eyes Under conscious sedation, a right lateral upper eyelid crease incision was first made. A fine Prolene suture was then used to suture the underlying tissues of the eyelid to the periosteum of the lateral orbital bone. Elevation of the lateral eyelid resulted in correction of the antimongoloid slant of the eye. Same procedure was then repeated on the left eye with similar results. The patient expressed total satisfaction at the results of the surgery. Surgery Video
Facial cosmetic surgery for abscess sinus tract removal and extraction of abscessed tooth
Dental caries and periodontal disease Dental caries result from the demineralization of teeth structure by acids that are formed through the degradation of food in the mouth. This leads to the breakdown of the hard structure of the tooth ultimately leading to the loss of the tooth. Teeth are attached to the bony socket with the aid of periodontal ligaments. Periodontal disease or gum disease leads to the loss of periodontal ligaments and supporting bone. This leads to the tooth becoming mobile due to loss of bony support. This also ultimately leads to the tooth falling out. Neglect of a carious tooth with consequent abscess formation Dental caries is treated through restorations. When dental caries perforates into the pulp chamber within the tooth, it leads to infection of the pulp tissue. When this is not treated appropriately with root canal treatment, it will ultimately lead to necrosis of the pulp and abscess formation. When a tooth abscess is not attended to and becomes a chronic problem, it will ultimately lead to a sinus tract formation to enable pus drainage. Chronic draining sinus on the left cheek The patient had a carious left lower first molar filled a few years ago. Filling was improperly done with progression of the caries deeper into the tooth structure. The caries ultimately reached the pulp chamber leading to infection of the pulp. An abscess soon developed in relation to that tooth. The patient neglected the tooth for a long time. Symptomatic relief through the use of antibiotics and pain killers ensured that he never underwent any proper treatment. The pain and swelling kept recurring on and off in relation to the lower-left permanent first molar. A draining sinus to his left cheek with granulomatous tissue soon formed at the site with chronic pus drainage. He presented to our hospital for surgical excision of the sinus through the utilization of facial cosmetic surgery techniques. This would ensure that no unsightly scar tissue would be left behind at the site of the sinus opening. Results for facial cosmetic surgery in India are on par with the best in the world. A facial cosmetic surgeon in India undergoes years of rigorous training. Initial examination of the patient at our hospital Dr SM Balaji, facial cosmetic surgeon, is vastly experienced in cosmetic surgeries. He examined the patient and ordered a 3D CT scan of the left jaw. It revealed a sinus tracking from the distal root of the left lower first molar and opening onto the left cheek. He explained the surgical procedure to the patient who consented to surgery. He said surgical removal of the sinus was very important as it can lead to the formation of unsightly hypertrophic scars if not excised. Plastic surgery with the utilization of skin flaps would be required for the excision of such scar tissues. Categorization of scar tissue for scar revision surgery Different types of scars require different types of scar revision. One such cosmetic procedure would be tissue expansion. Tissue expansion is most commonly utilized for breast augmentation. Excision of extensive scar tissue requires reconstructive surgery by a plastic surgeon. These surgery procedures come under the category of facial plastic surgery. Each layer of skin is carefully sutured to avoid unsightly scar formation. This is the principle behind face lifts. The ideal approach would be to avoid extensive scar tissue formation by meticulously closing the wound through layered suturing using resorbable sutures for the deeper layers and nonresorbable suture material for closure of the skin. Surgical excision of draining sinus tract Under general anesthesia, a mucogingivoperiosteal incision was first made mesial to the molar. This would help expose the site of abscess formation at the distal root of the molar tooth. A flap was next raised to expose the sinus tract. The tooth was then extracted. All granulation tissue at the apical region was debrided thoroughly. This was followed by tunneling an artery forceps through the sinus tract until it reached the facial surface. Care was then taken to fully excise the sinus tract and the incisions were sutured. Adoption of facial cosmetic surgery techniques resulted in no scar formation for the patient. The patient tolerated the procedure well and recovered well from general anesthesia. Postoperative instructions were given to the patient. The patient was instructed to keep the area clean and dry and to not pull at the scab formed at the area. It was explained that this was necessary to avoid any scar formation at the site of the sinus opening on the left cheek. The patient presented a few weeks after surgery for a checkup. There was no visible scar formation from the surgery. This ensured that there would be no necessity for scar revision surgery in the future. Surgery Video
Lower Lip Reduction Surgery – Best Result for thick lips
[et_pb_section fb_built=”1″ _builder_version=”3.22″][et_pb_row _builder_version=”3.25″ background_size=”initial” background_position=”top_left” background_repeat=”repeat”][et_pb_column type=”4_4″ _builder_version=”3.25″ custom_padding=”|||” custom_padding__hover=”|||”][et_pb_text _builder_version=”3.27.4″ background_size=”initial” background_position=”top_left” background_repeat=”repeat”] Importance of lip size on facial esthetics – Lip Reduction Surgery Lip size is very important for correct facial esthetics. Surgical correction of lip size comes under cosmetic surgery. Lips that are too big or too small for the face need corrective surgery. The relationship between the sizes of each lip is also important or lip reduction surgery correct the difference in size of the lips. Lips exercise undue influence over how we look. Upper and lower lip size should match. The lips should blend into the patient’s skin tone. This will enhance the patient’s facial features. Lips smaller than normal give a pinched look to the face. Patients with large lips, bigger than normal, desire a lip reduction procedure. Cost of lip surgery in India Lips surgery cost in India is much lesser than it is in the developed western countries. How to reduce lip size has to be decided on before surgery. Oral and Maxillofacial surgeons and plastic surgeons perform this procedure in India. The former also perform cosmetic plastic surgery on the face. Minor corrections can also be done under local anesthesia. Patients with complicating medical conditions need to undergo a thorough checkup before surgery. This will prevent any undue side effects from medications used for surgery. Patient with disproportionate upper lip presents at our hospital This patient is from Kurnool, Telangana. He was born with a large lower lip, which was also everted. This affected his speech to an extent. He felt that it was also difficult to keep the lips apposed. His search for the best lip reconstruction surgeon in India brought him to us. He thus presented to our hospital for lower lip reduction surgery. He desired surgery for reducing lip size. Initial Examination and biometric analysis for treatment planning Dr SM Balaji, a premier cosmetic lip surgery specialist in India, examined the patient. He used biometric analyses to study the patient’s lips and face. His treatment plan for the patient was cheiloplasty. He then explained the exact extent to which the lower lip needed reduction. The surgical procedure was then explained in detail to the patient who gave consent. Reducing the size of the lip was then planned. This is a common surgery performed by both plastic and maxillofacial surgeons. Surgical reduction with removal of excess tissue from the upper lip General anesthesia was first induced. The region of the lower lip that needed reduction was then identified. Markings were then made on the lip. An incision was then made along the markings made on the lip. Dissection was then carried down into the submucosal region. Excess tissue was dissected and excised from the region. Vermillion borders of the lip incision were then closely reapproximated with sutures. The patient expressed complete satisfaction at the results of the cosmetic lip surgery. Surgery Video [/et_pb_text][et_pb_text _builder_version=”4.9.0″ _module_preset=”default”] Lower Lip Reduction Surgery [/et_pb_text][et_pb_text _builder_version=”4.9.0″ _module_preset=”default”] Importance of lip size on facial esthetics – Lip Reduction Surgery Lip size is very important for correct facial esthetics. Surgical correction of lip size comes under cosmetic surgery. Lips that are too big or too small for the face need corrective surgery. The relationship between the sizes of each lip is also important or lip reduction surgery corrects the difference in the size of the lips. Lips exercise undue influence over how we look. Upper and lower lip sizes should match. The lips should blend into the patient’s skin tone. This will enhance the patient’s facial features. Lips smaller than normal give a pinched look to the face. Patients with large lips, bigger than normal, desire a lip reduction procedure. Cost of lip surgery in India Lips surgery cost in India is much lesser than it is in the developed western countries. How to reduce lip size has to be decided on before surgery. Oral and Maxillofacial surgeons and plastic surgeons perform this procedure in India. The former also perform cosmetic plastic surgery on the face. Minor corrections can also be done under local anesthesia. Patients with complicating medical conditions need to undergo a thorough checkup before surgery. This will prevent any undue side effects from medications used for surgery. Patient with disproportionate upper lip presents at our hospital This patient is from Kurnool, Telangana. He was born with a large lower lip, which was also everted. This affected his speech to an extent. He felt that it was also difficult to keep the lips apposed. His search for the best lip reconstruction surgeon in India brought him to us. He thus presented to our hospital for lower lip reduction surgery. He desired surgery for reducing lip size. Initial Examination and biometric analysis for treatment planning Dr SM Balaji, a premier cosmetic lip surgery specialist in India, examined the patient. He used biometric analyses to study the patient’s lips and face. His treatment plan for the patient was cheiloplasty. He then explained the exact extent to which the lower lip needed reduction. The surgical procedure was then explained in detail to the patient who gave consent. Reducing the size of the lip was then planned. This is a common surgery performed by both plastic and maxillofacial surgeons. Surgical reduction with removal of excess tissue from the upper lip General anesthesia was first induced. The region of the lower lip that needed reduction was then identified. Markings were then made on the lip. An incision was then made along the markings made on the lip. Dissection was then carried down into the submucosal region. Excess tissue was dissected and excised from the region. Vermillion borders of the lip incision were then closely reapproximated with sutures. The patient expressed complete satisfaction with the results of the cosmetic lip surgery. Surgery Video [/et_pb_text][et_pb_video src=”https://youtu.be/XbgaH5rmnck” _builder_version=”4.9.0″ _module_preset=”default”][/et_pb_video][/et_pb_column][/et_pb_row][/et_pb_section]
RTA, Coronoid Zygoma Malunion, Trismus Corrective Surgery
Patient with inability to open mouth following depressed zygoma fracture The patient is a middle-aged man from Hassan, Karnataka. He suffered a comminuted zygoma fracture from a road accident. Improper reduction elsewhere had left him with a depressed zygoma and trismus. The depressed zygoma led to facial asymmetry and impingement of the coronoid process. This resulted in a mouth opening of only 1 cm for the patient. The patient had complaints of inability to eat well as well as impaired speech. He was becoming withdrawn and avoiding social interaction. This became a hindrance to normal functioning in day to day life. His friends searched for the best hospital to get his asymmetry corrected. They took him to a local oral surgeon who studied the case in depth. Findings were somewhat complicated and needed an experienced surgeon. He was then referred to our hospital for correction of his complaints. Various aspects of correction of facial asymmetry No human face has perfect symmetry. Perfect symmetry is impossible in biological organisms. There is always a small degree of asymmetry present in all structures. The human face is no exception to this law of nature. This facial asymmetry is imperceptible in 99.90% of the population. It is only in a small minority that there is noticeable asymmetry. This asymmetry could be congenital or acquired. Congenital facial asymmetry could be the result of birth defects or injuries. Improper use of forceps during delivery can result in facial asymmetry. Cleft lip and palate deformities result in severe facial deformities. Correction of this requires the services of an experienced cleft surgeon. The majority of acquired facial asymmetry is through trauma. An asymmetrical face can lead to psychological problems. The patient becomes very self conscious and withdraws from social interactions. Types of presentation of asymmetry of the face Facial asymmetry can involve the soft tissues alone or can involve the hard tissues also. Treatment options depend upon the location and degree of asymmetry. The main aim of treatment is to restore facial symmetry. We are one of the premier hospitals for facial asymmetry correction in India. Correction of the asymmetry of his face will undergo correction here. Jaw surgery is among the most common asymmetry correction surgeries performed in India. Orthognathic surgery can also correct facial asymmetry. Both maxillofacial as well as craniofacial surgeons perform these surgeries. Treatment planning explained to the patient in detail for correction of problems Dr SM Balaji, a premier facial deformity correction surgeon in India, examined the patient. He specializes in all manifestations of facial asymmetry. A world renowned cleft surgeon, all types of facial asymmetry undergo correction here. Facial asymmetry due to paralysis is also corrected at our hospital. Patients undergoing rehabilitation are able to lead a completely normal life after surgery. Their ability to smile restored, they are able to face life with dignity and self confidence. Clinical examination revealed impingement of the left coronoid process during mouth opening. The patient had a mouth opening of only 1 cm. There was a depressed left zygoma with resultant facial asymmetry. He explained the treatment planning to the patient, which included a left coronoidectomy. This would enable good mouth opening again for the patient. The patient was in agreement and consented to the facial deformity correction surgery. Left coronoidectomy performed on the patient to enable mouth opening The patient underwent fiberoptic bronchoscopic intubation for general anesthesia. This was due to his inability to open his mouth for oral intubation. A tracheostomy would have to be performed otherwise. Once under satisfactory general anesthesia, a left retromolar incision was first made. The coronoid process was then accessed. A coronoidectomy was next performed and the coronoid process removed. The patient’s mouth opening was then demonstrated to be about 5 cm. This falls within the parameters of normal mouth opening. The incision was then closed with sutures. Depressed zygoma elevated and fixed with plates for facial asymmetry correction The depressed zygoma was next addressed. It was impinging on the coronoid process during mouth opening. This was preventing full opening of the mouth. Zygomatic bone was then approached through two approaches. They were through the maxillary vestibular incision and lateral canthal incision. The zygoma was first refractured to set right the depression. It was then fixed in an elevated position with the use of plates. Both incisions were then closed with sutures. The patient expressed his total satisfaction at the results of the surgery. Surgery Video
Fracture of the lower jaw open reduction and fixation surgery
Open bite from displacement of reduced fracture This young man is from Chennai, Tamil Nadu. He had a bike accident a week ago. Direct impact to his mandible resulted in a fracture of the mandible. He sustained facial injury as a result of this accident. This resulted in inability to close his mouth with an open bite. There were no soft tissues injuries from this accident. The patient never lost consciousness. He remained lucid during the immediate period after the fracture. Examination by a neurologist revealed no signs of head injury in the patient. The neurologist explained to the family that the helmet had saved the patient’s life. He explained through charts how the injuries would have been very severe if the patient had not been wearing his helmet. Presentation at our hospital for management of fracture His family wanted the best treatment for his jaw fracture. They made enquiries about the best jaw fracture surgeon in India. He was then brought to our Balaji Dental and Craniofacial Hospital for treatment. Our hospital is a premier hospital for jaw fracture surgery in India. Success rate of surgery for mandibular fractures at our center is amongst the best in India. Our hospital is a specialty maxillofacial surgery center. We deal with cases of maxillofacial trauma on a daily basis. Our center is a top referral center among city plastic surgeons. Special training through workshops are a regular feature at our hospital. Many oral and maxillofacial surgeons undergo this training. Fractures of the bones of the face are a common feature at these workshops. Injuries to the face are a common occurrence in the city. Treating these injuries needs the utmost care. Treatment plan presented and consent obtained from patient Dr SM Balaji, facial trauma surgeon in India, examined the patient. He obtained imaging studies for the patient. There was no fracture involvement of the eye sockets. There was no involvement of other facial bones or soft tissue. Any dental implants along the fracture line would need removal if present. Fracture was only at the left mandible. This came under the classification of facial fractures. There had been no facial lacerations from the accident. Location of the fracture determined his treatment plan. Rigid fixation was essential for fracture stability. Fracture treatment would be through open reduction and internal fixation. This decision was based upon his experience with jaw fractures correction. The patient consented to the treatment plan. All appropriate consents were next signed by the patient and surgery scheduled. Open reduction versus closed reduction Open reduction and closed reduction are two ways of setting a fractured bone. The fractured segments of the bone stay reduced when it is a favorable fracture. The anatomy of the fracture ensures this. Certain fractures can be reduced without any skin incisions. These stay in place without displacement with plaster casts alone. This is a closed reduction. The break has to be clean without comminution of the fracture. Fractures that do not stay reduced need open reduction and internal fixation. An incision is first made to gain access to the fracture site. Titanium plates and screws are then used to fix the fragments of bone to each other. This results in stabilization of the fracture. Incisions used to access the fracture are then closed with sutures. This is then followed by a period of immobilization for consolidation of bone. A closed reduction is possible only in a favorable fracture. All other fractures need open reduction and internal fixation. Fractures of the mandible can be favorable or unfavorable fractures. Favorable mandibular fractures stay stabilized with closed reduction and intermaxillary wiring. Care should be taken to maintain proper occlusion of the teeth. These fractures heal without any further intervention. Unfavorable mandibular fractures can comprise of several fracture segments. These do not stay stabilized with closed reduction. They need correction through stabilization with titanium plates and screws. An incision is first made to access the fracture site. The fracture fragments are then brought together into proper anatomical alignment. Titanium plates and screws are then used to stabilize the fracture. Occlusal harmony of the teeth should be ensured before final closure. The patient needs to return for periodic checks for a prescribed period of time. Full bone consolidation at the fracture site ensures complete healing of the fracture. The number of plates used for fracture reduction would increase with fracture severity. Successful open reduction and internal fixation of the fracture Under general anesthesia, a left vestibular incision in the mandible exposed the fracture. The fracture segments were then brought into correct alignment and occlusion checked. The fracture was then stabilized with plates and screws. Incisions were then repaired by suturing. The patient expressed his satisfaction at the results of the surgery before discharge. He was able bring his teeth together. The open bite had undergone complete resolution. Facial esthetics was also perfect and there was no residual asymmetry. Surgery Video
Recurrent odontogenic keratocyst total enucleation and reconstruction surgery
Patient treated elsewhere for bilateral OKC four years ago with enucleation and resection This patient is from Hyderabad, Telangana. He had undergone surgery elsewhere four years for bilateral mandibular odontogenic keratocysts. These cysts form in the bones of the jaws. This type of cyst has to be surgically removed. They are not like sebaceous cysts, which are minimally invasive. These cysts are comparable to polycystic ovaries in nature. Polycystic ovary syndrome converts the ovaries into fluid filled sacs. Ovarian cysts are always removed with care taken to preserve all surrounding internal organs. The patient carries the diagnosis of Gorlin-Goltz syndrome. Occurrence of many odontogenic keratocysts is a feature of this syndrome. This is very uncommon and is an autosomal dominant inherited disorder. The patient underwent bilateral enucleation and reconstruction of his mandible. Oral and maxillofacial surgeons remove these cysts. Patient returns with pain in the left side of his mandible Four years later, the patient noticed a swelling with pain in his left lower jaw. The patient was then referred to our hospital for treatment of his condition. Dr SM Balaji, an expert in mandibular reconstruction in India, examined the patient. Balaji Dental and Craniofacial Hospital is a premier center for mandibular cyst removal surgery in India. He ordered diagnostic studies including a 3D CT scan. This revealed recurrence of the odontogenic keratocyst on the left side. He explained that total enucleation was the best way for removing the cyst. The patient consented to surgery after a detailed review of this. Enucleation of OKC followed by reconstruction with rib grafts The surgical procedure commenced after general anesthesia. Rib grafts were first obtained through the old inframammary scar. A Valsalva maneuver confirmed patency of the thoracic cavity. The incision was then closed with sutures. Following this, a left sided vestibular incision was next made. The OKC was then thoroughly enucleated from the mandible. The cyst wall lining was carefully removed completely from the lingual surface of the mandible. Care was taken to ensure there were no remnants of cyst wall lining left behind. The mandible was then reconstructed using the rib grafts, titanium plates and screws. The incision was then closed with sutures. The patient recovered well from general anesthesia. The patient will need periodic checkups over the next few years. This will be to ensure that there is no recurrence of the OKC. The patient’s facial reconstruction surgery had good results. Surgery Video