Maxillary augmentation, nasal notch correction and alar web correction surgery
A brief introduction to Tessier’s facial cleft and their management Tessier’s facial clefts are of 14 types. They can extend from the hairline above the forehead to the mandible. These malformations can be debilitating for the patient and distressing for the family. It requires extensive surgical correction to rehabilitate these patients. Tessier’s facial clefts can also include malformations of the brain. A patient with Tessier’s facial cleft presents to our hospital This young man was born with Tessier’s facial cleft. He has already undergone innumerable surgeries elsewhere in the past. A doctor in his hometown referred him to our hospital for further management. Dr SM Balaji, facial reconstruction specialist, examined the patient and ordered radiographic studies. The patient needed maxillary augmentation, nasal notch correction and right alar web correction. He explained that rib grafts were mandatory for this surgery. The patient and his parents consented to the surgery. Surgical correction of labial and infraorbital defect with rib grafts Under general anesthesia, rib grafts were first harvested from the patient. A Valsalva maneuver demonstrated a patent thoracic cavity. The incision was then closed in layers with sutures. Attention was next directed to the patient’s labial defect. There was heavy scarring of the buccal vestibular mucosa from the previous surgeries. Incisions were made in the vestibular region. A costochondral graft was then shaped and placed in the anterior maxillary region. Rib grafts were then used to augment the remaining maxillary defects. The grafts were then fixed with screws. Sutures were then used to close the incisions. Attention was next turned to correction of the nostrils. Notching on the left nostril was then corrected followed by right alar web correction. The incisions were then closed with sutures. The patient recovered without event from general anesthesia. The patient and his parents expressed their complete satisfaction at the results. Surgery Video
Upper Lip Reduction Surgery – Dr. S.M Balaji, Balaji Dental and Craniofacial Hospital, India
Patient with disproportionate upper lip presents at our hospital This patient is from Rohtak, Haryana. He was born with congenital disproportion between the size of his lips. His upper lip has always been everted and large. This had begun affecting his social life and his work life. He presented to our hospital for lip reduction surgery. Initial Examination and biometric analysis for treatment planning Dr SM Balaji, cosmetic lip surgery specialist, examined the patient. He obtained biometric measurements of the patient’s lips and face. Using various analyses, he determined the exact extent the upper lip needed reduction. He explained the surgical correction procedure in detail to the patient. The patient consented for surgery. Surgical reduction with removal of excess tissue from the upper lip Under general anesthesia, the region of lip that needed reduction was marked out. An incision was then made along the marking on the lip. This was then extended down into the submucosal region. Excess tissue was then dissected and excised from the region. The vermillion borders of the incision were then reapproximated with sutures. A two week postoperative visit was scheduled at the hospital. The patient expressed complete satisfaction at the results of the surgery. Surgery Video
Road Traffic Accident (RTA) Upper Jaw (Maxilla) defect, Reconstruction for dental implant surgery
Patient with partial edentulousness presents for implants at our hospital This young man is from Ranchi, Jharkhand. A biking accident resulted in direct trauma to his jaws and oral cavity. He suffered fractures to both jaws as well as to many teeth. Fracture fixation and fractured teeth extraction was first performed elsewhere. This surgery resulted in a bony defect in the left maxilla. He desired complete oral rehabilitation with implant placement for missing teeth. Treatment planning presented to the patient after diagnostic studies The patient presented to our hospital for oral rehabilitation. Dr SM Balaji, Implant specialist and facial trauma specialist, examined the patient. He ordered a 3D CT scan and other imaging studies. This revealed a bony defect in the left maxilla. There was also a periapical cyst in the remaining left upper central incisor. He explained to the patient that the tooth needed to be extracted. Rib graft was necessary for implant placement in that region. The patient agreed to the treatment plan and consented for surgery. Successful left maxillary defect augmentation with rib graft Under general anesthesia, an inframammary incision was made to harvest a rib graft. A Valsalva maneuver was then performed to ensure patency of the thoracic cavity. The incision was then closed. Following this, a maxillary flap was then raised and the central incisor extracted. The periapical cyst associated with the tooth was then enucleated. Rib graft was then used to augment the left maxillary defect. It was crafted to the correct size and fixed with screws. Implants will be placed around six months after fusion of the rib graft to the underlying bone. Successful implant placement in edentulous regions of the oral cavity The edentulous regions of the oral cavity were then addressed. Implants were then placed. A bone graft was then placed in the anterior mandible to stabilize the anterior implants. Crown placement will be done in three month’s time after osseointegration is complete. All plates and screws from the previous surgery sites were then removed. All incisions were then closed with sutures. The patient recovered well from general anesthesia.
Craniosynostosis – Scaphocephaly Surgical Correction of the Frontal Bone and Bitemporal Compression
Child with scaphocephaly referred to our hospital for craniosynostosis surgery The patient is a 1-year old boy from Jaisalmer, Rajasthan with scaphocephaly. This is the simplest form of craniosynostosis. It involves fusion of the sagittal suture. His mother became very worried after observing an abnormal shape to his growing head. A consultation with a local neurosurgeon confirmed the diagnosis of scaphocephaly. This doctor referred them to our hospital for surgical management of the child. Patient scheduled for surgery after obtaining parental consent for surgery Dr SM Balaji, Craniosynostosis surgery specialist, examined the child along with his team of neurosurgeons. He ordered a 3D CT scan and other imaging studies. This confirmed the earlier diagnosis of scaphocephaly. He explained the effects and potential complications to the parents. There could include increased intracranial pressure, visual impairments, seizures and skull deformities. They were advised that these needed immediate treatment. The child’s parents were in complete agreement and consented to surgery. Mock surgery performed on 3D stereolithographic model of the patient’s skull A 3D stereolithographic model was first obtained of the patient’s skull. The anatomy of the patient’s skull was studied and a mock surgery performed on this model. Craniosynostosis surgery performed with adequate relief provided for growing brain The neurosurgical team was present and assisted throughout the entire operation. Under general anesthesia, a bicoronal flap was first raised and skin clips used to hold the flap. Markings were then made on the bone and a craniotome used to section the skull. The bone along the edges of the cut skull sections was removed. This would provide adequate relief for brain growth. Barrel stave cuts were then made on the bony sections to provide further relief. This would ensure development of the brain to its full size. Vicryl sutures were then used to hold the various bony sections in their correct place. The bicoronal flap was then closed using surgical staples. Vital signs were closely monitored throughout the surgery and were normal. Uneventful postsurgical course after craniosynostosis surgery on the child The child’s postoperative course was uneventful. He was very active and playful the day after surgery. They were then discharged with instructions to present in 12 days for staple removal. Normal parameters observed at the 12th day postsurgical appointment At the 12th day recall appointment, the patient’s postsurgical healing was normal. The surgical staples were then removed and the patient discharged. The patient will be monitored at regular intervals to ensure normal growth of the brain.
Bilateral Ear Reconstruction – Microtia – 1st Stage
Microtia deformity of the external ears Microtia is a congenital condition in which there in poor development of the ears. Correction involves staged reconstruction of the ear using autogenous costal cartilages. A template is utilized to create the form of the proposed external ear. Three surgeries complete reconstruction of the microtia affected ear. Patient presents to our hospital for specialized microtia surgery This is a young 13-year-old boy from Tirupati, Telangana with microtia. His parents brought him to our hospital for bilateral microtia repair. Dr SM Balaji, microtia repair specialist, explained the surgery to them. They agreed to proceed with surgery. Microtia surgery of bilateral ears performed for young boy from Tirupati After general anesthesia, rib grafts were first harvested. Grafts obtained were from the fourth, fifth and sixth ribs. A Valsalva maneuver was then performed. This was to rule out accidental perforation into the thoracic cavity. Using a metal template, the sixth rib graft was first carved and sculpted to form the external ear framework. This was done for both the right and the left sides. The other graft pieces were then fixed and secured with nonresorbable sutures. Care was taken to maintain symmetry between the frameworks of both ears. The skin of the right ear was first incised and underlying tissues dissected to create a pocket. The framework of ribs was then tunneled into the pocket. Skin was then sutured and surgical drain placed at the site. This step will help adapt the skin to the cartilage framework. The left ear was then addressed. Second stage repair will be after about 3 months. This will be for elevation of the framework inserted in the first stage.
Nose Defect – Augmentation with Rib Cartilage graft
A patient presents for broad nose correction This young man from Arani in Tamil Nadu never liked his nose. He had already undergone rhinoplasty elsewhere. They had used cartilage graft from the ear. Following surgery, he still felt that his nose was very broad and flat. He desired corrective surgery and presented to our hospital for management. Patient consents to surgery after treatment plan explained Dr SM Balaji, rhinoplasty specialist examined the patient. He explained the treatment plan in detail to the patient. This involved harvesting a rib graft. The patient consented to surgery. Harvesting of rib grafts for nasal bridge augmentation Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva maneuver was then performed to confirm patency of the thoracic cavity. The incision was then closed in layers. Correction of saddle nose deformity through rhinoplasty Attention was then turned to the saddle nose deformity. A transcartilaginous incision was first made. Tunneling was then done to the bridge of the nose. The rib graft was then inserted to augment the bridge of the nose. Attention was next turned to the broad ala. An elliptical incision was then placed in the right alar crease. Excess tissue was next excised from this region and the incision sutured. The patient expressed complete satisfaction at the results of the surgery.
Unilateral Cleft Lip & Palate Rhinoplasty Surgery
Patient presents to our hospital for nose asymmetry correction The patient is a young man who had undergone cleft surgery in our hospital as an infant. He now presents for correction of nasal asymmetry and scar revision surgery. Treatment planning explained in detail to the patient Dr SM Balaji examined the patient and explained the treatment planning to him. He explained that harvesting a rib graft was necessary for this surgery. The patient consented to this and agreed to the surgery. Successful rhinoplasty and cleft lip scar revision surgery Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva maneuver was then performed and demonstrated a patent thoracic cavity. The incision was then closed in layers. Attention was next turned to the rhinoplasty surgery. Intranasal incisions ensured absence of visible scar formation. Medial osteotomy of the nasal bone was then done. The spreader graft was then placed. Following this, the rib graft was then shaped and tunneled to the bridge of the nose. This established symmetry of the nose. Attention was next turned to the scar from the previous cleft lip surgery. The scar was then incised and skin edges sutured using fine sutures. The patient expressed his satisfaction at the results before final discharge. Surgery Video
Reconstruction of Upper Jaw After Resection for Fungal Infection with Associated Osteomyelitis
Patient with deficient maxilla presents for augmentation surgery The patient is a middle aged man from Waltair. He had undergone an endoscopic surgery for clearance of maxillary sinus rhinosporidiosis. A complete maxillary resection was performed previously at our hospital to remove all affected bone and bone affected by osteomyelitis. A reconstruction was done using the remaining bone. This resection however led to a maxillary bone deficiency, causing problems with nutrition and speech. He was then sent for a course of medical treatment of his rhinosporidiosis with complete resolution of his infection. He then presented to our hospital for definitive management of his problems. Rhinosporidiosis treated with full resolution Dr SM Balaji, facial reconstruction specialist, examined the patient. A biopsy was first obtained from the mucosa. Once it was confirmed that there was complete resolution of his fungal infection, the patient was then scheduled for surgery. Maxillary augmentation surgery performed with bone grafts Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva maneuver was then performed to confirm patency of the thoracic cavity. The incision was then closed in layers. Successful completion of maxillary augmentation surgery Attention was next turned to the maxilla. A mucoperiosteal flap was then raised and plates from the previous surgery removed. Pieces of rib graft were then fixed at the deficient regions. This aided in augmenting the deficient maxillary bone. Once adequate augmentation was performed, the flap was then closed using sutures. Implants at a later date will complete oral rehabilitation of the patient. The patient expressed his happiness at the progress of his treatment. He expressed his gratitude at the successful completion of the first phase of treatment.
Long standing lower motor neuron facial paralysis correction by static suspension with fascia lata
The various causes that lead to partial or complete facial paralysis Facial paralysis means loss of facial movements due to nerve damage. It usually affects only one side of the face. The muscles on that side weaken and appear to droop. Causes of facial paralysis include infection, injury, tumor or stroke. Patient presents to the hospital for treatment of long standing facial paralysis This lady from Kurnool has had drooping of the left side of the mouth for a long time now. This caused problems with both eating and speech. There has also been constant drooling of saliva on that side. Her family’s search for the best facial reanimation surgeon led them to our hospital. The patient examined thoroughly and treatment planning explained Dr SM Balaji examined the patient. Diagnosis was lower motor neuron facial paralysis of the left face. Treatment planning was then explained to the patient. This would involve static reanimation using fascia lata sling graft. The patient agreed to the treatment plan and was then scheduled for surgery. A fascia lata sling operation is a static procedure done to improve the symmetry of the mouth. It is the most preferred material for sling because it is tough enough to support the mouth. More than one strip can be also taken for creation of different vectors to aid in suspension. Surgical procedure of static suspension with fascia lata strip for facial reanimation Under general anesthesia, a fascia lata strip was first harvested from the thigh. The incisions were then closed with sutures. An elliptical incision was then made in the right nasolabial fold. Another small incision was then made on the right zygomatic arch. A tunnel was then created below the skin. The fascia lata strip was then tunneled through to the zygomatic arch. It was then sutured to the atrophic orbicularis oris to act like a sling for the modiolus. Lateral tarsorrhaphy also performed to establish good facial symmetry This procedure created symmetry of the lips, corners of the mouth and laugh lines. Lateral tarsorrhaphy was then done to for partial closure of the eyelids. This would ensure that the patient was able to close her eyelids. Good facial symmetry resulted from these procedures. The patient expressed her happiness at the results before final discharge from the hospital.
Large Salivary Stone (Calculi) Removal Surgery
Patient with painful lumps under his tongue presents for treatment The patient is a middle aged male from Cuttack. He stated that he had felt two hard lumps under his tongue. This has been causing pain for around two years now that increases while eating. He presented to our hospital for definitive management and treatment. A diagnosis of sublingual salivary calculi confirmed through studies Dr SM Balaji examined the patient and ordered diagnostic studies. A 3D sialogram and OPG demonstrated presence of two sublingual salivary duct calculi. Palpation of the region revealed two hard masses in the left sublingual duct. Treatment planning was then explained to the patient who agreed to the surgery. Successful removal of salivary calculi with uneventful healing Under adequate general anesthesia, the opening to the Wharton’s duct was first identified. Gentian violet was then injected into the duct to fix the position of the calculi. The calculi were first palpated to confirm their location. A small incision was then made at the orifice of the salivary duct. The two calculi were then manipulated and teased out of the duct. This would ensure uninterrupted flow of saliva after healing. The patient recovered from general anesthesia. Postoperative healing was uneventful and salivary flow was normal and at optimal level. The patient expressed his gratitude before final discharge from the hospital. Surgery Video: