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Lip lift surgery using bullhorn technique without any visible scar

29/6/2016

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A 24 year old girl from Dubai, a known case of unilateral cleft lip and palate reported to our hospital seeking for lip correction. Primary cleft lip repair was done elsewhere resulting in thinning of upper lip. Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected this defect using bullhorn lip lift technique.

There are different types of lip lift surgery. The most commonly used lip lifting technique is known as the ‘bullhorn lip lift’. Pre-operative markings on the skin ensure the lip lift is approximately symmetric. Advancement of the inferior edge of skin directly beneath the nasal base lifts the lip, producing more visible vermilion and about 3 mm of teeth show at rest. The position of the final incision is such that it is located within the shadow of the nose. Meticulous technique produces an almost invisible scar. The amount and width of skin excised is individualized depending on the desired aesthetic goals. Lip lifts using this technique provide an immediate, dramatic, and permanent result.
Thin upper lip due to secondary cleft lip defect
Using Bullhorn technique the skin along with subcutaneous tissue excised to raise the lip
Immediately after suturing by raising the inferior border of the incision to the base of the ala raising the vermillion
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Successful correction of disproportionately long lower jaw without any scars

27/6/2016

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A 26 year old man reported to our hospital seeking to correct his long lower jaw. This gave him an aged appearance and he was not happy with his facial profile.
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Maxillofacial Surgeon Dr. S. M. Balaji expertly planned to correct his lower jaw protrusion by using bilateral sagittal split osteotomy technique (Obwegeser sagittal Split osteotomy). Intraorally a cut was made bilaterally in the lower jaw bone in the ramus region, excess bone was removed and the segment was set back to its correct position and thus correct dental occlusion was achieved. Results are immediate and the patient was happy to have his lower jaw bone correction done without any scars on the face. His profile also improved dramatically giving him a renewed confidence.
Preoperative facial view showing long face with disproportionately large lower jaw
Profile view showing disproportionately long lower jaw giving asymmetric appearance
Intraoral view showing reverse bite
Complete reverse bite with midline shift
Intraoperative view - Sagittal split on right side
Intraoperative view - Sagittal split on left side
Mandibular nerve traced from foramen ovale and saved
Excess bone removed from buccal cortex to setback the mandible
Excess bone separated from mandible to correct the length
Bone plates fixed to stabilize the segments after achieving proper occlusion
Proper occlusion achieved and segemnts stabilized with bone plates
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Complete removal of huge infected cyst involving entire anterior maxilla followed by reconstruction

26/6/2016

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A 26 year-old boy form West Bengal came to our hospital with a complaint of swelling with occasional pain in his upper jaw. A digital X-ray took revealed a large cystic lesion extending anterior teeth to premolar of the maxilla with complete erosion of the labial plate.
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Histopathological examination of the specimen showed it to be a huge infected dental cyst due to continuous trauma from occlusion resulting from anterior deep bite. Maxillofacial surgeon Dr. S. M. Balaji successfully removed the entire cystic lesion along with the lining in toto. Followed by defective region of the upper jaw was reconstructed using costochondral rib graft. Following surgery the wound healed well and the patient was happy to be cured of his ailment. After complete bone formation, fixed dental replacement of the missing teeth will be done using dental implants. 
Preoperative digital orthopantomogram showing huge osteolytic lesion in anterior region of maxilla
Preoperative 3DCT view showing huge osteolytic lesion involving entire anterior and extending to the molar region of upper jaw
Axial view showing expansile osteolytic lesion involving entire left side of maxilla
Sagittal view showing buccopalatal expansion of cyst with bodily displacement of involving teeth
Costochondral graft obtained from 7th rib to reconstruct the defective portion of upper jaw
After raising gingivomucoperiosteal flap elevated and cystic lesion exposed
Removal of infected cyst in toto
After removal of cyst bone cavity debrided and diathermy applied
Costochondral graft used to augment the defective portion of upper jaw
Immediately after suturing
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Surgical correction of telecanthus due to naso-orbito-ethmoidal fracture without any scars

25/6/2016

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A 16 year old boy from Nepal reported to our hospital with the complaint of cosmetic defect near the left eye, continuous tearing of eyes. His history revealed that he had sustained a blunt injury in the upper half of the face due to road traffic accident and he was primarily treated elsewhere 6 months back.
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On clinical examination there was increased canthal distance in the left side from midline and obliteration of the canthal bay and caruncle. Lacrimal punctum did not dip into the lacrimal lake, thereby causing epiphora.  3DCT revealed an old medial wall fracture with minimal difference in skeletal intra orbital distance at the posterior poles of the globes. Hence the unilateral telecanthus was entirely soft tissue in origin and in this case, due to the faulty reattachment of the medial canthal ligament.

Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected this defect using modified miniplate technique for the reattachment of the medial canthal ligament. Results were immediate and patient feels very happy to have the entire correction of eye defect along with epiphora correction without any visible scars on the face.
Preoperative view showing increased canthal distance from midline on the left side
3DCT view showing minimal difference in skeletal intraorbital distance
CT view showing canthal difference
Bicoronal access to the medial canthal region and removing the hyperostotic bone in the medial canthal region
Medial canthal ligament suspended to the long arm of teh Y- plate
Stent-stay suture placed on the medial canthal region
Postoperative radiograph showing Y-plate in position
Postoperative view after 6 months
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Growth centre transplantation using costochondral rib graft for correction of hypoplastic ramus of mandible

21/6/2016

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​A 12 year old girl was brought to our hospital with a complaint of facial deformity. No history of trauma elicited by her parents. Extra oral examination revealed retruded mandible, deviation of chin towards left side.
3DCT revealed obliterated left joint space elongated coronoid process, reduced ramal height and prominent antegonial notch. The case was diagnosed as hypoplastic ramus on left side with developing secondary facial deformity. Maxillofacial Surgeon Dr. S. M. Balaji successfully performed left condylar component reconstruction using 7th costochondral rib graft (CCG).
Postoperative mouth opening was adequate. Over 6 years follow up; CCG was favorable where it acts as a growth centre to induce bone growth and thus facial asymmetry was corrected without any visible scars on her face.
Preoperative facial view showing asymmetrical appearance with deviation of chin towards left side
Preoperative bite showing occlusal cant towards left side
Preoperative mouth opening
3DCT scan showing short left ramus with deviation of chin towards left side
Short left side ramus
Left side short ramus with altered condylar morphology
Costochondral rib graft obtained with the junction to correct the ramus length
Intraoperative view showing fixation of costochondral rib graft on left side ramus
Postoperative digital PA view showing fixation of costochondral rib graft to the left ramus
After 6 years followup showing enhanced appearance with symmetrical facial profile
Corrected bite and occlusal cant
Costochondral junction induced natural growth of the ramus of mandible
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Successful cleft nose and lip correction using Abbe flap technique

15/6/2016

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A 16 year old boy born with bilateral cleft lip and palate came to our hospital for expert cleft treatment. He was operated elsewhere for primary cleft lip and palate. He had a thin upper lip and broad flattened nose for which he sought treatment.
Maxillofacial Surgeon Dr. S.M. Balaji performed the specialized Abbe flap technique to correct the upper lip. A flap of tissue was taken from the lower lip and used to reconstruct the upper lip with the base of the flap still attached to the lower lip. Once blood supply was established, the flap will be divided giving the upper lip a more natural, improved form.
Simultaneously, the broad nose was reshaped to make them more proportionate and balanced. Following surgery, the nose appeared sharp & defined with more proportionate profile.
Preoperative view showing broad flat nose with defective upper lip
Profile view showing ill defined columella of nose with depressed nasal tip and defective upper lip
Columellar view showing ill defined columella and depressed dorsum of nose with defective upper lip
Immediately after suturing showing raised defined dorsum with corrected lip alignment
Postoperative profile view showing enhanced appearance
Postoperative view showing enhanced appearance of nose and lips without much visible scars on the face
Postoperative profile view following 1 week after suture removal showing enhanced appearance
Columellar view showing corrected dorsum and alar shape with defined columella of nose
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Successful correction of low lying upper eyelid without any visible scars

14/6/2016

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A 16 year old girl reported to our hospital with the complaint of inability to open her right eyelid completely. On examination,  history of blepharoptosis of right eye since birth was seen with no other functional or ophthalmic complications.
Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected this defect without any visible scar on her face. Resection and advancement of levator aponeurosis was the technique used in correction of blepharoptosis. Patient feels very happy to have corrected eye lid function without any scar on the face. 
Preoperative view showing ptosis measuring 2mm in right eye with good levator function
Preoperative view showing ptosis measuring 2mm in right eye with good levator function
Preoperative view showing ptosis measuring 2mm in right eye with good levator function
Resection of 11mm of levator palpeberal superioris muscle in accordance with preoperative calculation
Postoperative view showing equal palpeberal fissures of 10mm at rest
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Successful surgical repair of incomplete cleft lip

6/6/2016

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A 3 month old baby girl was born with unilateral incomplete cleft lip. Her parents brought to our hospital for surgical management.
Maxillofacial Surgeon Dr. S.M. Balaji successfully performed the cleft lip repair using modified Millard’s technique. Following suture removal 7 days after surgery, the baby’s appearance was greatly enhanced. The baby’s parents were very happy to have the cleft lip defect corrected with very negligible scar.
Baby having incomplete cleft lip defect
Primary cleft lip repair using modified Millards technique
After suture removal showing good healing and no scar
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Ear reconstruction for microtia 

4/6/2016

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A 24-year old female from Mumbai born with a deformed right ear, sought the expertise of Maxillofacial Surgeon Dr. S.M. Balaji for reconstruction of her ear defect. Previously, in some other hospital elsewhere, multiple attempts to reconstruct the ear were done but she was not satisfied with the results. Hearing was normal.
Dr. Balaji employed the Limberg’s flap to successfully reconstruct the ear lobule. Followed which stage wise complete ear lobe reconstruction done using costochondral rib graft. Costal cartilage was harvested; external framework was carved and tunneled to reconstruct the external ear.
 After suction, the skin was seen getting adhered to the cartilage.  This was followed by the second-stage surgery to elevate the newly formed ear from the side of the head using split skin graft obtained from right thigh region. Thus, entire shape and size of the ear was reconstructed with enhanced appearance without much visible scars.
Appearance of right ear deformity
Cartilage graft harvested and carved to form ear framework
Framework placed beneath the skin to reconstruct the ear
Limberg flap raised
Earlobe reconstruction using Limberg flap
Immediately after suturing
Skin graft used to complete the elevation giving the ear a normal, raised appearance
Postoperative view following complete ear reconstruction giving enhanced appearance
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Primary cleft lip repair for 6 months old baby girl with unilateral cleft lip and palate

4/6/2016

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​A 6-month-old baby girl born with unilateral cleft lip and palate was brought to our hospital by her parents for specialized treatment of the cleft defect.
Maxillofacial Surgeon Dr. S.M. Balaji successfully performed the primary cleft lip repair using modified Millard’s technique.  Right away after surgery the baby’s appearance was remarkable improved and she was able to feed well. Her parents were very happy to have the cleft lip treated with negligible scar formation. After few months cleft palate repair will be done.
Preoperative view showing unilateral cleft lip and palate defect in a 6 months old baby girl
Immediately after cleft lip suturing using modified Millard's technique
Immediately after suture removal following seven days after surgery showing negligible scar
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Successful removal of huge dentigerous cyst involving entire left side of lower jaw without any scars

2/6/2016

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​A 25-year-old woman reported to our hospital with a complaint of swelling with pain in her left side of lower jaw. A digital X-ray took revealed a large cystic lesion extending entire ramus and angle and part of the body of the mandible involving the molar teeth.
Histopathological examination of the specimen showed it to be a chronic infected dentigerous cyst. Maxillofacial surgeon Dr. S.M. Balaji expertly removed the entire cystic lesion along with the lining with affected teeth in toto. Following surgery the wound healed well and fixed molar teeth given using dental implants in the newly formed bone with good retention, patient was happy to be cured of her ailment and to have fixed teeth.
Preoperative intraoral view
Preoperative digital orthopantomogram showing huge osteolytic lesion involving left side of mandible
Intraoperative view showing complete distruction of the bone due to cystic lesion
Removal of cyst lesion along with the involved tooth in toto
Postoperative digital orthopantomogram showing complete removal of cyst and new bone formation
Dental implants fixed in the newly formed bone with good retention
Digital orthopantomogram showing implants fixed in newly formed bone
Cosmetically well blended fixed ceramic prosthesis loaded on to the dental implants
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Facial asymmetry correction without scars

1/6/2016

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​A 19-year-old boy came to our hospital seeking to correct his facial asymmetry that gave unpleasant appearance. The boy was very anxious & wanted a cosmetic correction to enhance his appearance without any scars.
Maxillofacial Surgeon Dr. S.M. Balaji diagnosed that the asymmetrical face was due to unilateral masseter hypertrophy. Masseter muscle is mainly responsible for the movements of the lower jaw & plays an important role in facial aesthetics. When the muscle becomes enlarged or thickened, it gives the lower third of the face a wide, square-shaped appearance.
Maxillofacial Surgeon Dr. S. M. Balaji surgically reduced the bulk of the enlarged Masseter muscle from within the mouth itself so there were no scars. Along with the muscle, the buccal surface of the gonial angle of the mandible was also trimmed. Immediately after surgery the lower jaw appeared more proportionate and his appearance greatly improved. The boy and his family were very happy to have a more attractive, natural look.
Preoperative view showing asymmetry due right masseter hypertrophy
Preoperative worm's eye view
Preoperative OPG depicting asymmetry
Repositioning of the muscles following removal of hypertropied mass
Debulking of the masseter muscle
Suturing done
Postoperative 3 months review
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Ala of nose reconstruction using forehead flap

1/6/2016

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A young man reported to our hospital seeking the expertise of Maxillofacial Surgeon Dr. S.M. Balaji for the cosmetic correction for his nose defect. He had met with an accident and he had a defect in the left nostril (loss of tissue). It was decided to do a nose reconstruction using forehead flap. The advantages of a forehead flap is that the skin color closely matches that of the nose and the harvest site is very close to the surgery site.
Alar base reconstruction was done using forehead flap. Step one was done where the forehead pedicle flap was rotated and attached to the existing ala maintaining good blood supply and following 21 days, second step of flap division was done where exact shape and size of left ala was created without any visible scar and skin discoloration.
Preoperative view
Preoperative worm's eye view
Forehead flap design
Forehead flap pivoted
Stage 2 preoperative state
Adequately formed pedicle
Division of the pedicle
Suturing done after division
Postoperative view after suture removal
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