Patient with long standing facial asymmetry due to hemifacial microsomia

This young man who is from a small town in Maharashtra first began noticing a gradually developing facial asymmetry for a few years now. He also began noticing that it was progressively becoming difficult to chew and speak compared to a few years ago. This had led to him developing avoidance behavior with regarding to meeting people and eating certain classes of foods. His day to day functioning was becoming affected by this and he was becoming very worried by this problem.

This asymmetry also made him develop the habit of tilting his head until it nearly touched his shoulders to conceal this facial asymmetry from casual observers. He developed severe neck spasms as a result of this debilitating habit of tilting his neck. This neck pain was keeping him up at night and this lack of sleep was making him irritable. He was also feeling chronically angry at this turn of events in his life. This problem was slowly beginning to consume his thought process and affect every aspect of his life including his professional life.

Deciding that something had to be done about this, he and his parents met an oral surgeon to get to the root of the problem and also to find out the cause of the severe neck pain. The surgeon explained that the patient had very prominent facial asymmetry and that his occlusal cant was also askew. His diagnosis for the patient was hemifacial microsomia. He said that the patient required facial asymmetry correction surgery.

​He educated them on the various aspects of treatment available to the patient and said that they needed to go to a specialty center for facial asymmetry surgery in India. The patient and his parents were thus referred to Balaji Dental and Craniofacial Hospital in Chennai, India for definitive surgical management of his problem

Treatment planning explained and consent obtained for distraction osteogenesis
Dr SM Balaji met with the patient and obtained a detailed history. This was followed by detailed imaging studies including a 3D CT scan. Facial biometric scan was also obtained in order to make treatment planning easy. This revealed a ramus that was shorter by 10 cm on the left side when compared to the right. Planned surgical intervention would be through simultaneous maxillary and mandibular distraction for setting right the problem for the patient. The rationale behind treatment planning was fully explained to the patient and his parents who expressed understanding and agreed to surgery.

Bilateral sagittal split osteotomy of the mandible
Sagittal split osteotomy was performed on the left mandibular ramus after successful induction of general anesthesia. A Univector ramus distractor was then utilized for the distraction osteogenesis. This was fixed with screws to the two side of the distracted segments of the mandible. Distraction functioning was deemed to be adequate after a thorough check and the incision was then closed with sutures.
Maxillary distraction followed mandibular distraction. A Le Fort I maxillary osteotomy was performed through a vestibular incision. Left sided dysjunction of the maxilla followed by stabilization of the two distracted segments was performed.

Establishment of facial symmetry through distraction osteogenesis
A latency period of seven days would be followed by distraction osteogenesis of the mandible. This period was for stabilization of the distracted site. A distraction of 1 mm would be performed each day for a total of 10 mm of distraction in ten days. The distractors would then be left in place for a period of three months for the new bone to consolidate at the distracted site.
This would result in establishment of facial symmetry for the patient. The patient and his parents expressed their satisfaction at the results of the surgery before final discharge from the hospital.

This is a case of a 22 year old male patient who reported to us for the surgical correction of asymmetry over the left side of the face. Facial asymmetry may be present in cases of hemifacial microsomia, TMJ ankylosis or may have resulted following condylar fractures. This patient had a madibular deficiency at the ramus level and deficiency measured almost 17mm with a resultant occlusal cant. Hence a maxillomandibular distraction was planned using internal distraction osteogenesis to lengthen the ramus and to correct the occlusal cant as well.   

Under nasoendotracheal intubation, general anaesthesia was induced.  Paragingival incision was placed over the left angle region along the anterior border of ramus. Full thickness mucoperiostal flap was reflected buccally and bone exposed. Reflection of the lingual tissues done minimally to protect the inferior alveolar nerve. Horizontal osteotomy done inferior to the anti lingula over the buccal cortex. The direction of the osteotomy cut and positioning of the distractor is the most important as it determines the vector of distraction.  The vector determines the direction of the bone growth. The distractor device positioned and fixed using screws. Osteotomy is then completed along the medial cortex. Distractor device checked and wound closure done. Le Fort I osteotomy completed in maxilla. Patient extubated, recovery spontaneous and uneventful.  After a latency period of 5 days, IMF was done and distraction at the rate of 1 mm per day was accomplished. Over correction of about 21 mm was done so as to compensate for any relapse that may occur. The post-operative CT image demonstrating the correction achieved.