Orbital Blowout Fracture, Enophthalmos and Diplopia Correction Surgery
The patient’s facial deformities from fracture reduction after a road accident A patient is a young man employed in the UAE. He got involved in a road traffic accident a little over three years ago. This resulted in fractures to the facial bones on the right side. It also included a floor of the orbit blowout fracture. The patient was first treated as an emergency at the time of the accident. This left him with residual deformities from the fracture correction surgery. The patient developed diplopia and enophthalmos as a result of the surgical correction. The patient presents for consultation with Dr. S M Balaji The patient had been searching far and wide for the right surgeon to correct the deformities. He was then referred to Dr. S M Balaji, Cranio-Maxillofacial Surgeon by an oral surgeon in the UAE. The patient first contacted the hospital manager at our hospital. She requested the patient to mail all pertinent medical records to the hospital. Dr Balaji studied the medical records in depth including all imaging studies. He informed the patient that his facial deformities could be set right. The patient presented at Balaji Dental and Craniofacial Hospital’s Trauma care unit. All preoperative investigations were then performed. The surgery was then scheduled for the patient. Successful surgical correction of the patient’s fracture Under general anesthesia, a maxillary vestibular incision was first made. The site of the zygomatic fracture repair on the right side was then accessed. The plates from the previous surgery were then removed and the area refractured with a drill. An incision was next made extending from the outer canthus of the right eye. The plate from the previous surgery was then removed and the area refractured. This was next followed by a transconjunctival incision. The site of the orbital floor fracture repair was then accessed. All refractured segments were next brought into proper alignment. A Titanium mesh with Medpor coating was then shaped to align with the floor of the orbit. This was then placed on the floor of the orbit and screwed to the lower orbital wall. Transconjunctival incision was then closed with sutures. Refractured segments of the zygomatic bone were then replated and the incision sutured. The outer canthal incision was then closed with sutures. The patient recovered without an event from general anesthesia. The patient returns back to the UAE The patient expressed complete satisfaction at the time of discharge from the hospital. There were no noticeable facial scars from the surgical procedure. He was very happy with the results of the surgery.
Direct Sinus Lift Surgery with Allograft for Dental implant placement in Upper jaw
Dr. S.M. Balaji explains the Sinus Lift Procedure to the Patient The patient presented to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai for treatment. He was seeking replacement of missing right upper molars with implants. Dr. S.M. Balaji, Cranio-Maxillofacial Surgeon, examined the patient and ordered radiographic studies. There was inadequate bony height in the posterior maxillary region. This would lead to unsuccessful placement of dental implants by the conventional method. The patient then enquired if there were alternative treatments for implant placement. Dr. Balaji then explained the sinus lift procedure to the patient. It would done by placement of an allograft, Bio-Oss through a window in the bone. This would become consolidated into new normal bone over a period of time. The new bone would serve as foundation for loading of normal biting forces on the implants. He was in total agreement with this treatment plan and agreed to surgery. Successful Sinus Lift Procedure through Bony Window with Placement of Bio-Oss Allograft Material After infiltration of local anesthesia, a window was then made in the bone with a round bur. The window was in the lateral wall of the maxillary antrum. This wall forms the boundary of the right maxillary sinus. The sinus floor was then lifted taking care not to damage the Schneiderian membrane. This membrane is the lining of the sinus. Implants were then placed in the bone. These implants will mimic the roots of natural teeth. Allograft mixture was then prepared using approximately 1.5 mL of the patient’s blood and Bio-Oss. This was then packed into the sinus pocket tucked below the sinus lining. The height and width of the implant bearing bony area would thus increase. With time, there would be consolidation of the allograft into new bone. This new bone will provide a good bony foundation for the implants. Success of the implant treatment depends on this. The flaps were then closed with sutures. Future Placement of Ceramic Prosthesis on Implants: His next visit would be after three months. After confirmation of proper osseointegration, ceramic prostheses would then be attached to the implants. This would complete the patient’s rehabilitation process.
Unilateral Condylar Fracture (jaw Joint) Open Reduction and Plate Fixation Surgery
The patient is a teenage boy from north India. He had a road traffic accident. This lead to development of pain and swelling in the left preauricular region. He also demonstrated deviation of his mouth to the left upon mouth opening. His parents took him to a hospital for radiographic studies. The doctor who examined him explained to them that he had a fracture of the left condyle. He added that this needed surgical correction. Since this was a difficult surgery to perform, he said it needed expert care. He then referred the patient to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai. This is one of the leading Cranio-Maxillofacial Superspecialty Surgical Hospitals in India. Dr. S.M. Balaji, Cranio-Maxillofacial Surgeon examined the patient. He then ordered 3D axial CT scans. It revealed the fractured left condyle of the mandible. Dr. S.M Balaji then explained to the parents that the fracture was in a region that was difficult to approach. He said that the conventional method would not work. Only the modified preauricular incision approach would work, he explained. The parents were in agreement with the treatment plan. The patient was then scheduled for surgery. Treatment was by open reduction and internal fixation of his left condylar fracture. General anesthesia was first induced. Then Dr. S.M Balaji marked the proposed modified preauricular incision with a marker. The incision was then made with great care. This was to avoid injury to vital structures in the region. The facial nerve and the parotid gland were thus protected. Dissection was then carried down to the region of the fracture of the condyle. The fractured condyle was then plated. Plate fixation check for stability was positive. The incisions were then closed in layers with sutures. The patient recovered without event from general anesthesia. He was then scheduled for suture removal in seven day’s time. The patient presented on the seventh day after surgery for suture removal. He then demonstrated the ability to open his eyes wide, shut his eyes tight and open his mouth wide without pain. This demonstrated absence of any damage to the facial nerve. There was complete preservation of function with no neuropraxia or other neurological deficits.
Cleft Palate – Velopharyngeal Incompetence – Hypernasality Speech Correction Surgery – Pharyngoplasty
A patient with velopharyngeal insufficiency presents to Dr SM Balaji The patient had been born with a cleft lip and palate. This had been set right as an infant. She later developed velopharyngeal incompetence. This is where there is escape of air through the nose during speech. It also manifested as difficulty pronouncing certain words well. This also added a nasal twang to her voice. She searched far and wide for the right cleft lip and palate surgeon to correct her problem. The patient was then referred to Dr SM Balaji. He is a world renowned cleft lip and palate surgeon. Surgery planned for the patient Dr SM Balaji, Cranio-Maxillofacial Surgeon, examined her. He explained to her that she needed a pharyngoplasty surgery to correct this. The patient was in agreement with this and was then scheduled for surgery. Aim of this surgery is to create a dynamic sphincter in the pharynx. Repositioning of the palatopharyngeus muscles achieves this. The surgical procedure The patient was then taken to the operating room. She then underwent general anesthesia without complications. Incisions were then made to release the posterior faucial pillars. This included the palatopharyngeus muscles. These muscles were then crisscrossed and sutured together on the posterior pharyngeal wall. A sphincter was thus formed here. This left a small opening or “port” for breathing through the nose. Successful positive suction test A positive suction test was then performed after completion of the surgery. This demonstrated a new dynamic velopharyngeal sphincter action. Correction of the patient’s velopharyngeal incompetence was thus completed. The patient expressed total satisfaction with the results of the surgery. She was then discharged from the hospital.
Unilateral Cleft Lip Correction Surgery – Suture Removal on 7th day
Initial Presentation: This is a 2-month-old baby boy from Sri Lanka who was born with a unilateral cleft lip and palate defect. His parents related that his elder sister had also been born with the same condition. She had been operated on elsewhere in India, but the surgery had left behind ugly residual scars. So when their son too had been born with a similar deformity, they wasted no expense in searching far and wide for a cleft lip repair specialist. They finally zeroed in on Balaji Dental and Craniofacial Hospital, Teynampet, Chennai after extensive research done over the Internet and meeting parents of previous patients. Dr. S. M. Balaji, Maxillo-Craniofacial Surgeon, explained to them that the child needed primary cleft lip repair surgery using the modified Black’s technique in order to recreate a tight lip seal. A modified Black’s technique cleft lip repair was done. Suture Removal: Seven days after the surgery, the parents presented with the boy at the hospital for suture removal. There was perfect vermillion border approximation, good columellar form and good overall appearance. There was negligible scar formation, which would slowly fade away over time. The baby was also feeding well. Both esthetic as well as functional outcomes of the surgery were good. Complete Rehabilitation: It was explained to the parents of the boy that he would need further surgeries in the future, which would have to be planned out in a phased manner for further correction of his cleft defects.
Dr. S.M. Balaji invited as key operating faculty to the Advanced Craniofacial Surgery Workshop of the Indian Academy of Maxillofacial Surgeons
Indian Academy of Maxillofacial Surgeons’ Advanced Craniofacial Surgery Workshop The Indian Academy of Maxillofacial Surgeons conducted a workshop in Jabalpur. It was an Advanced Craniofacial Surgery workshop. Topic was “Current Advances in Cranio-Maxillofacial Surgery”. Hitkarini Dental College and Hospital & Jabalpur Hospital and Research Centre were the hosts. Duration of the workshop was from February 15-18, 2018. Many leading Cranio-Maxillofacial surgeons from around the world participated in this workshop. Prof J N Khanna was the programmed director. The programme coordinator was Dr Rajesh Dhirawani. Foreign Faculty at the Workshop Prof G E Ghali, Chancellor & Dean, LSU Health Sciences Center was the chief mentor at the workshop. He is the Gamble Professor and Chairman, Oral and Maxillofacial Surgery -Shreveport, USA. Dr Ghali was present with his entire team of key opinion leaders at this huge workshop. Other foreign faculty were also present at the workshop. Prof Andrew Meram, Dr Mary Laura Hastings, Dr Ahmed Tamim and Dr Hendell Nealy were also present. Dr S M Balaji Invited for Demonstration of Congenital Facial Palsy Correction Surgery Prof S M Balaji was a key operating faculty at this workshop. His surgery was a case of congenital facial palsy. He taught the audience the finer aspects of the facial reanimation procedure. Planning for the Dynamic Temporalis Sling Surgery The patient was a middle aged male. He had congenital facial palsy and was facing a lot of health and social issues due to the facial palsy. Due case selection and studies were exacting and precise. Study of all clinical and anatomical factors was the basis of treatment planning. Inference was that a dynamic facial reanimation surgery would provide best results. This would be by means of using a Tensor fascia lata graft along with a partial Tarsorrhaphy. Surgery would join a part of the upper and lower eyelids. This would close the eye to a certain degree. About 200 postgraduates and young oral surgeons presented for the workshop. They were from all over India. The surgery was a live demonstration. There was constant interaction between the surgeons and the audience. Audience would ask questions while the surgery was in progress. The operating faculties would immediately answer them. Live Surgical Demonstration with Commentary by Prof S M Balaji The patient suffered from a congenital lower motor neuron type of paralysis. Planned correct of this condition was via a strip of fascia lata. This was first harvested from the vastus lateralis. Next step of the surgery was by the combined preauricular and intraoral approach. Release of the temporalis from the coronoid process insertion was then performed. This was in the infratemporal region. The zygomatic arch was then cut and pushed down to free the temporalis muscle. Care was then taken to preserve all vital structures such as the parotid duct and gland in this area. Meticulous dissection ensured no damage to the the deep temporal artery and nerve. Through careful manipulation, the lower end of temporalis was then identified. One end of the fascia lata was then attached to it. Access to the modiolus was through a nasolabial incision. Free end of the fascia lata was then split into three parts. The lower part was then connected to the muscles of the lower lip. This was then followed by attaching the middle part to the modiolus and the upper part to the upper lip. Dynamic facial reanimation check ensured proper connections and secure muscle attachments. This was through the action of the muscles. Movements were satisfactory. The connections were then checked again. Muscle attachments were secure and dynamic facial reanimation was fine. Confirmation of this was through the action of the muscles. A partial lateral tarsorrhaphy was then performed to correct improper eye closure. The patient recovered well. Post-surgical Conference by Dr S M Balaji: Prof S M Balaji’s interaction with the audience was educational and informative. The audience had a lot of questions about the procedure. The surgical tips he gave the audience about the case were very useful and practical. The audience was appreciative and the surgery was well received by all at the workshop. Dr Ghali and Dr Dhirawani giving Dr S M Balaji a warm send off at the end of the workshop.
OKC – Odontogenic Keratocyst Hemimandibulectomy with total Reconstruction of Jaw (Ramus & Body of Mandible)
The patient’s presentation and history: This young 13-year-old Northeastern girl was brought to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, by her parents for treatment of a painless swelling involving the right side of her lower jaw that had been present for over a year. Her parents had not taken this slowly developing swelling seriously for a very long time and had neglected going to a doctor. It was only when it had grown to a very large size that they decided to seek medical help for their daughter. Search for a good surgeon: They had approached many hospitals throughout India, including premier surgical centers in other metropolitan cities, but had been turned away because of the extent of the lesion in her mandible. It was only after many months of futile search that they were finally referred to Balaji Dental and Craniofacial Hospital in Chennai for management of their daughter’s condition. Initial visits with Dr SM Balaji: Dr SM Balaji, Cranio-Maxillofacial Surgeon, examined the patient and ordered extensive investigations including 3D axial CT scans. Radiographic studies revealed the presence of an odontogenic keratocyst in the right side of the mandible, which involved both the ramus and the body of the mandible. It had spread so extensively that it had completely breached through the cortical bone of the ramus of the mandible into the soft tissues surrounding it. Dr. Balaji explained to the patient and her parents that except for the condylar region, the right side of the mandible would have to be completely removed because of the extent of the lesion. He further explained that the mandible would then be reconstructed using a titanium plate with costochondral rib grafts obtained at the same surgery. The parents were in full agreement with this treatment plan and the patient was scheduled for surgery. Obtaining Rib Grafts: After the successful induction of general anesthesia, two costochondral rib grafts were harvested from the patient. The incision was then closed in layers after a Valsalva maneuver demonstrated absence of perforation into the thoracic cavity. Reconstructive Surgery: A right sided mucogingival flap was then raised and reflected down to the vestibular sulcus. The flap was reflected until the affected areas involving the body of the mandible was exposed. An extraoral incision was then made at the region of the angle of the mandible and dissection was carried down to the ramus. The bone in the affected regions was extremely soft and friable. A hemimandibulectomy was then performed with complete removal of the affected segment of the mandible. Reconstruction of the mandible was then performed with use of the costochondral rib grafts and the titanium plate. The incisions were then sutured close and the patient recovered uneventfully from general anesthesia. Postoperative Period: The patient and her parents expressed their thankfulness to Dr SM Balaji before being discharged from the hospital. Surgery Video
Bilateral cleft lip correction surgery suture removal on 7th day
Surgical Planning: This is a 2-month-old baby girl from Bahrain was born with bilateral cleft lip and palate. Her parents were referred to Balaji Dental and Craniofacial Hospital, by a close friend of theirs whose daughter had been operated upon by Dr. Balaji with very good results. Dr. S. M. Balaji, Maxillo-Craniofacial Surgeon, explained to them that the goal of this primary surgery is to recreate the lip seal. The parents consented and the child was scheduled for surgery. A modified Black’s technique cleft lip repair was done. Suture Removal: Seven days after the surgery, the parents presented with the baby for removal of sutures. There was very good approximation of the vermillion, structural appearance of the columella and nice overall appearance to the nose. She was taken to the operating room where the sutures were removed. There was very negligible scar formation and the final appearance of the baby girl was good with satisfactory functional outcome. It was explained to the parents that subsequent phased surgeries will have to be done for correction of the other defects.
Testimonial – Mr. Taha from UAE is a case of Zygomatico-orbital Fracture
My name is Taha. I am working in the UAE. I have been following Dr. S.M. Balaji since three years. Actually before three years, I met with an accident. I had emergency surgery, but I was never satisfied with the result. I kept on searching every doctor, every possible things I could search for my betterment, but the satisfactory answer I got was in Dr. S.M. Balaji Hospital, Chennai. Sir told me yes brother, your condition will be improved. So I planned everything, I came, and I got operated with Dr. S.M. Balaji. Now my diplopia has been corrected and he did so well that I cannot even see a scar on my face. So really, really, I am so grateful and very thankful to Dr. S.M. Balaji. Thank you sir, thank you very much.
Primary cleft lip repair for a child with unilateral cleft lip and palate
A Baby with Unilateral Cleft Lip and Palate A 3-month old baby boy born with unilateral cleft lip & palate was brought to our hospital by his parents seeking the best treatment for cleft lip and palate. The parents were greatly disturbed on seeing their firstborn son’s condition. Primary cleft lip repair Maxillofacial Surgeon Dr. S.M. Balaji performed the primary repair surgery for unilateral cleft lip using Modified Millard’s technique. Following surgery, the baby appeared to be like any other baby of his age with minimal to no scar. The parents were overjoyed with the results. Consecutively cleft palate correction surgery will be done at a later date.