Neurofibroma bulk reduction and asymmetry correction
Presentation of neurofibroma in this young man A neurofibroma is a benign nerve sheath tumour of the peripheral nervous system. This is an inherited disorder of the nervous system. It adds to the bulk of the tissues and can be very disfiguring and distressing to the patient. This causes facial asymmetry. Patient with neurofibroma presents for bulk reduction surgery The patient here is a young man who developed this condition from birth. This had led to extensive right sided facial disfigurement of the patient. He had undergone surgeries elsewhere, which left behind residual scars. The disfigurement had reached a level where it was beginning to affect the patient’s day to day life. His parents conducted extensive Internet research for the best facial reconstruction surgeon. Their search had led them straight to our hospital. Treatment plan explained to the patient Prof SM Balaji examined the patient and ordered imaging studies. Studies revealed that the patient also needed reduction of the lateral orbital rim. It also revealed that the patient needed reduction of his chin and the maxillary bone. The patient also had ectropion of the left eye. Correction of the ectropion would be through lateral tarsorrhaphy. The patient and his parents agreed to the treatment plan. Asymmetry of ears corrected with removal of excess tissue Under general anesthesia, markings were first made on the excess ear tissue. Excision of the excess tissue would lead to symmetry of the patient’s ears. The excess tissue was first removed and the wounds were then closed with sutures. Maxillary bulk reduction with mandibular chin reduction Attention was then directed to the chin reduction procedure. The chin was next approached through a labial sulcus incision of the mandible. Dissection was then carried down to the chin. An osteotomy was then done at the lower border of the chin. The bone was next shaped and screwed back on the mandible. Incision was then closed with sutures. Maxillary vestibular incision was next done to access the hypertrophic right maxilla. Neurofibromatosis tissue was then excised and removed. The maxilla was then reduced until it was symmetrical with the left side. The incision was then closed with sutures. Ectropion correction with lateral tarsorrhaphy An incision was next made over the right eyebrow in the temporal region. Bulk reduction was then done with excision of excess tissue. The incision was then sutured. Attention was next turned to the ectropion correction. Markings were first made in the supraorbital region. This was then followed by excision of the excess tissue. The tissue was then sutured close. An incision was next made extending distal from the lateral canthus of the eye. A temporalis flap was then raised. Dissection was then carried down to the lateral orbital rim margin. The bone was then trimmed with a bur. Holes were then made in the bone for the sutures to pass for lateral tarsorrhaphy. This was to correct the patient’s ectropion. The sutures were then passed through the holes and tightened for ectropion correction. Excess tissues were then trimmed and incisions closed with sutures. The patient tolerated the procedure well and recovered from general anesthesia.
Re-surgery of old zygomatico orbital fracture, chronic diplopia and asymmetry correction
Patient with residual facial deformity from old RTA correction surgery The patient is a young man who had suffered a zygomatico orbital fracture from a road accident. He had also suffered a depressed supraorbital bone fracture over his left orbit. This had happened in his hometown two years ago. He had undergone emergent surgery at a local hospital. This surgery had left him with an asymmetric face and chronic diplopia. The chronic diplopia was the result of an orbital floor fracture that had not been set right. This had been a source of trouble for him for the last two years. He decided to get it corrected and approached a general dentist. The general dentist referred him to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai. Radiographic studies reveal extent of deformities The patient presented at the hospital and Dr SM Balaji, oral surgeon, examined the patient. He ordered 3D axial CT scans and studied them. He explained the plan of treatment to the patient. The patient was in full agreement with the treatment plan. Rib graft harvested from patient Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva test did not reveal any perforation into the thoracic cavity. The incision was then closed in layers. Diplopia correction performed and facial symmetry reestablished Attention was then turned to correction of the patient’s diplopia. A transconjunctival incision was next made to access the orbital floor fracture. The contents of the orbit were first raised and entrapped muscles were then released. A titanium mesh with Medpor implant was then shaped to fit into the orbital floor. This was then attached to the orbital rim with screws. This resulted in complete correction of the patient’s diplopia. Attention was then turned to the depressed supraorbital rim. An incision was first made in the region of the depressed orbital rim. A piece of rib graft was then shaped to fit into the depression in the bone. This was then screwed into place. This restored symmetry by correcting the depression. The incision was then closed with sutures. Supraorbital bony depression corrected with bone graft The depression in the supraorbital region was next addressed. An incision was first made in the left maxillary vestibular region. Dissection revealed the bony depression in the supraorbital region. A piece of rib graft was then crafted to fit into the bony depression. This was then screwed into place. This resulted in reestablishment of perfect facial symmetry for the patient. The patient recovered from general anesthesia without any complications. The patient expressed his utmost satisfaction with the results of the surgery. The patient expressed his gratitude to Dr SM Balaji before discharge.
Hemifacial Microsomia and Microtia with absence of condyle corrected with reconstruction of ramus and condyle
Patient with hemifacial microsomia presents for treatment Hemifacial microsomia is a congenital disorder. It affects the development of usually one side and rarely both sides of the face. One child in every 5600 children born worldwide is afflicted by hemifacial microsomia. This condition results from the abnormal development of the first and second pharyngeal arches. Ears, mouth, and lower jaw bone are most often affected. The patient here is a young girl with hemifacial microsomia. She has left microtia and absence of the left mandibular condyle. Her parents researched the Internet for the best facial reconstruction surgeon. They zeroed in on our hospital based upon the Internet search results. Growth centre transplant planned for replacing missing condyle Dr SM Balaji examined the patient and ordered 3D axial CT scans. This revealed the presence of a rudimentary left condyle. He planned reconstruction of the condyle and ramus with costochondral rib grafting. This procedure is also known as growth centre transplantation. Parents of the patient were in full agreement with the treatment plan. Costochondral rib graft with perichondrium obtained Under general anesthesia, a costochondral rib graft with perichondrium was first obtained. The incision was then closed after ensuring absence of thoracic perforation. Subcuticular sutures closed the incision for minimal post healing scar. Surgical reconstruction of missing left condyle Following this, markings were then made over the mastoid region. This was to map out the distorted anatomy of the underlying structures. An incision was first made followed by dissection down to the condylar region. Facial nerve and parotid duct were duly protected throughout the surgery. The rudimentary condyle was present below the ear tag. The pterygomandibular raphae was then stripped off. The costochondral graft was then positioned in the posterior ramus. Upper part of the growth centre transplant was then positioned in the glenoid fossa. This was then fixed with screws. The incision was then closed in layers using subcuticular sutures. The patient recovered well from general anesthesia. The patient presented later at our hospital and expressed complete satisfaction. Surgery Video
Facial Feminization – Hairline Reduction, Frontal bossing Correction surgery and Reduction genioplasty
Patient with failed facial feminization surgery elsewhere The patient is a young man from England. He had always felt that he was a woman trapped in a man’s body. It took him a while, but he finally decided to go ahead with his decision of becoming a woman. His parents were very supportive of his decision. He had undergone reduction genioplasty surgery. The results left him disappointed. Internet search leads the patient to our hospital It was then that they decided to research the Internet. Together, they searched for a good surgeon for facial feminization surgery. The patient had typical male frontal bossing and a prominent chin. He also desired for hairline reduction. Their search led them to our hospital. Treatment planning explained to the patient Dr SM Balaji examined the patient and obtained detailed biometric studies. After detailed analyses of these studies, he explained his treatment plan. He explained that the previous surgery was inadequate and had to be redone. The patient was in complete agreement with his treatment plan. Patient undergoes facial feminization surgery Under general anesthesia, markings with scalloped borders were first drawn for hairline reduction. The scalloped borders would enable perfect alignment of the skin margins. Attention was next turned to the frontal bossing. This was after incising the superior margin of the markings. A forehead flap was first retracted to expose the frontal bone. The frontalis muscle was then sectioned and retracted. Prominences over the frontal bone were then reduced to an adequate level. This resulted in a sloping feminine forehead. The skin was then reapproximated over the new frontal bone. Incision was then made over the inferior marking and the excess skin excised. This resulted in perfect approximation of the flap over the frontal bone. The muscle and skin flap was then sutured close. This resulted in complete feminization of the patient’s forehead. Successful facial feminization surgery performed Attention was then turned to the reduction genioplasty. A vestibular incision was first made in the anterior mandibular buccal sulcus. Dissection of the tissues exposed the genial tubercle. The patient’s genial tubercle had a typical prominent masculine structure. The plates from his previous surgery were first unscrewed and removed. Osteotomy was then performed with an oscillating saw. The chin was then fixed again with plates after adequate removal of bone. Four holed Y shaped plates were then used to aid to stabilize the osteotomy site. The fixation was very stable. This resulted in good genial reduction. Incisions were then made in the posterior region of the mandible. Plates from the previous surgery here were then removed. Bone obtained from the reduction genioplasty was then screwed in place here to obtain a good gonial angle. All incisions were then closed with sutures. The patient recovered well from general anesthesia. Surgery Video
History of RTA operated elsewhere with secondary deformity, DNS correction performed
History of malunited facial fractures after RTA surgery elsewhere This young man had suffered injuries to his face with fractures from a motor bike accident. This happened in his hometown a few years ago. He had undergone emergent surgery, which resulted in a malunited nasal bone fracture. His nasal septum was also deviated to the left side. He has been suffering from breathing problems and snoring since then. He decided to get this corrected. A general dentist in his hometown referred him to our hospital for correction of his problem. Treatment plan explained to the patient The patient presented at our hospital for management of his multiple facial deformities. Dr. SM Balaji, Cranio-Maxillofacial surgeon examined the patient. He explained the treatment plan to the patient. This also involved harvesting a rib graft from the patient. The patient was in full agreement with the treatment plan. Deviated nasal septum set right to correct breathing problems Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva test demonstrated patent thoracic cavity. The incision was then closed in layers. Attention was then turned to the nose. The deviated nasal septum was first refractured. A nasal speculum was then used to widen the nasal choanae. Intranasal incisions were then performed to avoid visible scarring. Hardware from previous surgery removed Attention was next turned to the zygomaticomaxillary bone. Maxillary vestibular incisions were then made in the buccal sulcus region. Old hardware from the previous surgery was exposed and removed. Sutures were then used to close the incisions. Augmentation rhinoplasty performed The rib graft was next crafted to fit into the bridge of the nose. Graft was then placed through the intranasal incision to fit into the bridge of the nose. This augmented the nasal bridge with precision. All incisions were then sutured. Nostril breadth reduction surgery performed Attention was next turned to the nostril reduction procedure for the patient. Crescent shaped incisions were then marked out at bilateral alar bases. The tissue was next incised and removed. The alar bases were then sutured closer to the midline. This resulted in narrowing of the nose. The patient expressed his utmost satisfaction to Dr SM Balaji before final discharge. He said that his nasal form was back to its original shape.
Cleft Palate Surgery, 2 Times Failed – Re-surgery Successful
World-renowned surgeon for cleft lip and palate repair Dr. SM Balaji is a world renowned expert on cleft lip and palate surgical correction. He has over 30 years of experience operating on cleft cases. Many cases of cleft repair done elsewhere, which have failed are often referred to him. His many innovations to existing cleft surgical procedures have to lead to better results. These have become standard operating protocols worldwide. Young boy with two failed cleft repair surgeries elsewhere This is a case of a young boy who had undergone cleft surgeries twice elsewhere. Both surgeries had not resulted in closure of the cleft. This had been a cause of anguish to his parents as his food intake was very impaired by the cleft. They had been searching for a long time for a cleft surgeon who could repair their son’s cleft. This search for the best cleft surgeon led them to Dr. SM Balaji. The treatment plan explained in detail to parents The patient was first examined and the treatment plan was explained to the parents. The parents agreed to the surgery. Veau-Wardill-Kilner technique with Orticochea pharyngoplasty General anesthesia was first administered. The Veau-Wardill-Kilner palatal pushback technique and Orticochea pharyngoplasty were then performed. This resulted in complete closure of the cleft defect. A positive suction test was then demonstrated at the end of the surgery. This would ensure proper speech for the patient. The patient’s parents presented to Dr SM Balaji six months post-surgery for a checkup. The cleft remained closed and the patient’s speech was much improved. His parents expressed their extreme gratitude. Surgery Video
Unilateral Cleft Maxillary (Upper jaw) advancement. LeFort I Osteotomy with Dental Implant Surgery
The patient is a young woman who had been born with a unilateral right sided cleft lip and palate. She had undergone cleft lip repair as a 2-month infant at Balaji Dental and Craniofacial Hospital. Second surgery was for repair of cleft palate. Stage 3 surgery involved the placement of a bone graft for closure of her alveolar bone cleft. The patient now presents for a LeFort I osteotomy for advancement of her retruded maxilla and for placement of implants for replacement of her missing maxillary teeth. An implant was first placed for replacement of her right maxillary canine. This was then followed by placement of an implant for replacement of her missing first molar. Attention was next turned towards the LeFort I osteotomy of her maxilla. A gingival mucoperiosteal flap was first raised up to the buccal sulcus. A LeFort I osteotomy was then performed. The entire maxilla was then advanced by 2-3 mm. This resulted in establishment of a Class I occlusion along with correction of her anterior crossbite. The maxillary segment was then stabilized in position with the use of three plates with four screws to each plate. This would aid in stability of her plates during the healing period. Her occlusion was then checked and the teeth were found to be in perfect alignment. The flap was then sutured in place. She recovered well from general anesthesia and was in stable condition. The patient was very happy with the results of the surgery and expressed the same to Dr SM Balaji. Surgery Video
Comminuted zygoma fracture reduction and relief of infraorbital nerve compression
Facial numbness due to nerve entrapment in fracture fragments This young man fell down a flight of stairs and ended up with pain and swelling on the left side of his face. He was experiencing numbness in the infraorbital region for the last three months. He came to our hospital to address this. Dr SM Balaji, oral and maxillofacial surgeon, examined the patient. Then he ordered a 3-D axial CT scan for the patient. It revealed the infraorbital numbness was due to nerve entrapment in the fracture. Treatment plan was then explained to the patient. He was in complete agreement with the proposed treatment plan. Surgical correction with release of entrapped nerve The patient underwent uneventful induction of general anesthesia. A left maxillary vestibular incision was first made to visualize the fracture site. This revealed the comminuted zygomatic fracture. There was a fracture fragment that was rotated in the medial direction. This was first elevated and fixed with plates and screws. The entrapped infraorbital nerve was then released from the fracture. This resulted in perfect alignment of the various segments of the fracture. The maxillary vestibular incision was then closed with sutures. The patient expressed his gratitude before discharge from the hospital.
Cleft Orthognathic Surgery, LeFort I Advancement for Bilateral Cleft Lip and palate Surgery
Young Nepali girl with extreme crossbite of the jaws This teenage girl from Kathmandu, Nepal was born with a bilateral cleft lip and palate. Her parents brought her to our hospital for correction of her deformities. She had undergone cleft lip repair at two months of age and cleft palate surgery at 10 months of age. She had surgery with rhBMP-2 for repair of her cleft alveolar bone at 4-1/2 years. This was to repair and unite the maxilla, which was in three segments. She had developed an anterior crossbite due to deficient growth of the maxilla. As a result, she has had difficulty with eating and speech all her life because of her crossbite. Her parents decided to get her problem corrected through surgery. They then brought her back again to our hospital for correction of her problem. Treatment planning for crossbite correction Prof SM Balaji, Cranio-maxillofacial surgeon, examined the patient. The patient was very familiar to him as he was her surgeon since her infancy. He ordered a 3D axial CT scan and other pertinent studies. Once he had decided on the treatment plan, he explained it to the parents and the patient. They were in complete agreement with his plan of treatment. Surgical correction of the patient’s crossbite A maxillary vestibular incision was first made after induction of general anesthesia. A maxillary osteotomy was then performed. The osteotomized maxilla was then advanced forwards to correct the anterior crossbite. This was done utilizing two plates on each side with four screws per plate. It was for stabilizing the maxillary bone during the healing period. The bite was then checked and there was complete correction of the crossbite. Incisions were then closed with sutures. The patient expressed complete satisfaction with the results of the surgery. Surgery Video
Cosmetic Rhinoplasty – Nasal Bridge Augmentation & Alar Base Reduction Surgery
Searching for the best rhinoplasty surgeon in India The patient is a young woman who always wanted a sharp nose with a straight bridge. She had always felt that her nostrils were too wide for her face. A doctor in her hometown suggested that she undergo rhinoplasty. She and her parents searched for the best rhinoplasty surgeon in India. They finally decided to come to our hospital for surgery. Treatment plan explained to the patient Dr SM Balaji, Rhinoplasty specialist, examined the patient upon arrival at the hospital. He explained to the patient and her parents that she needed a rib graft. The patient and her parents were in agreement with the treatment plan proposed by him. Rhinoplasty procedure performed on the patient Under adequate general anesthesia, a rib graft was first obtained from the patient. A Valsalva test was then performed to confirm that there was no perforation of the thorax. Attention was next turned to the nose. An intranasal incision ensure that there would be no external scar formation. The bone graft was then tunnelled through the incision to lift up the bridge of the nose. Alar reduction was then performed to reduce the width of the patient’s nostrils. The patient and her parents expressed their happiness at the results of the surgery.