Home     About Her     Contact Her     Services     Photo Gallery
  Press & Media New  |  Testimonial  
 

Orthognathic Surgery in Chennai -Surgery on facial bones to improve appearance

 
 

These are highly specialized Cosmetic surgeries done to correct the facial bones. Commonly these procedures are done to improve the smile, excess protrusion of facial bones, correction of facial profile and correction of any facial asymmetry.  These procedures may need some orthodontic treatment before and after surgery.

Who needs corrective surgery?
How the surgery is performed?
Details of surgery
Risks of Surgery

Introduction:

Maxillo-Mandibular Surgery is the correction of deformities of the upper and lower jaw by cutting bones and adjusting their position. It aims to improve facial appearance and get correct occlusion of teeth.

Who needs corrective surgery?

People with the following conditions would benefit from corrective surgery

a. Mandibular Prognathism
This condition is caused by the protrusion of lower jaw and is very visible from the side. This results into protrusion of the lower part of the face and particularly the lower lip. When seen from the front, however, the patient may seem to have a normal facial width. The upper lip may appear to be thinner. There is a group of patients who may have asymmetric jaw. Aside from the deformity in the patient's appearance, problems with speech and mastication are also noted in certain cases. Although it is quite a common deformity, the etiology of this condition remains unclear but it has been observed to have a partly genetic cause.

b. Bimaxillary Protrusion
This condition caused by protrusion of both jaws, resulting into "gummy smile", with excessive show of front teeth. Because the patient has difficulty in closure of his lip, they have difficulty in concealing their front teeth. The patient often compensates by trying to hide this deformity with a tight lip closure, making their lips appear small and constricted. The treatment is different according to age and degree of protrusion. Generally, during the teenage to young adult years, the patient may undergo orthodontics to correct the condition. In the older age group, however, this can be treated with combination of orthodontics and surgery on the front part of the jawbones.

c. Maxillary Retrusion
This condition is caused by less or restricted growth of the upper jaw and is more commonly seen in cleft lip and palate patients and following trauma of the upper face. Due to the poor growth and development of the upper jaw, these individuals may appear to have mandibular prognathism even if their mandible growth is normal. However, the nostrils and nostril base are setback.

d. Mandible retrusion
Patients with mandibular retrustion appear to have a small and/or underdeveloped lower jaw. In some cases, even the whole face may appear short. Patients often have mouth opening problems or open bite. Surgical correction is usually the only solution for open bite. Other associated complications are temporo-mandibular joint problems and breathing problem during sleep.

<Back to the top>

 
Patient - I
(Mandibular Excess)
   
Before

After

 
   
Xray Before Surgery

Xray After Surgery

   
   
Patient - II
(Maxillary Deficiency & Mandibular Excess in Cleft)
   
   
Before

After

   
Xray Before Surgery

Xray After Surgery

 


How the surgery is performed?

a. Bilateral Sagittal Split Osteotomy - The mandible or the lower jaw bone is detached from its attachment to the skull by splitting the tooth bearing lower arch away from the condyle or joint. The split is made on both the left and right side of the lower jaw. It is then repositioned by moving it front or back and/or rotated left or right to the correct or optimum occlusion with the maxilla. Once the acceptable occlusion is achieved, titanium screws and plates are used to secure the cut segments together.

b. Wassmund procedure- Anterior Subapical Osteotomy - is for the upper jaw. In this procedure usually, the first pre-molars of the upper jaw is removed. Then the excess bone is removed and anterior part of jaws is set back.

c. Kole procedure - It is similar to the Wassmund procedure, however, it is used for the lower jaw. The first pre-molars are also removed and the bone underneath is removed to allow backward movement of the front segment of teeth.

d. Le Fort 1 Procedure - This is for the upper jaw. The lower maxillary segment and the alveolus are separated from the rest of the maxilla. Then the detached segment is repositioned and fixed with titanium plates. With this procedure, the middle part of the face may be shortened, or pulled forward, or moved to the left or right.

These four procedures may be used individually or in combination. The treatment is based on a discussion between the patient, the orthodontist and the plastic surgeon. However, the orthodontist does the major part of the planning, and then it is the plastic surgeon that carries out the procedure.

<Back to the top>

 

 

Preparations for surgery:

When you have decided and prepared for surgery, the plastic surgeon will set a date for your admission and day of surgery. He will also arrange for the pre-operative blood storage. You will need to arrange with your dentist or orthodontist for pre-operative dental work. Before you are admitted, the plastic surgeon will discuss with you the planned procedures.

Admission:

Hospital stay usually lasts for 3-6 days. Some patients feel well on the first post-operative day and may be discharged soon after. However, a majority of the patients would like to rest a bit longer and are discharged on the second post-operative day.

Anesthesia and Procedure:

General anesthesia is needed for the surgery. The operative time is related with the complexity of the surgery. Simple procedures usually take 2 to 3 hours. Complex ones take 8 to 9 hours.

Important Points in Postoperative:

Tubes and Lines - After surgery, the intravenous line may be removed once the patient is feeding well, usually on the afternoon of the day after surgery. The urinary catheter also helps during the immediate post-operative period to aid you in emptying your bladder without the need to get out of bed. This is usually removed on the next day after surgery.

Post-operative food and drink - Because of the use of titanium plates for bone fixation, maxillo-mandibular fixation with wire is not usually needed. You will then be able to freely open your mouth. Once you regain consciousness, you may try drinking water and clear liquids. With the decrease in swelling and the new occlusion, you may gradually try soft food that does not need chewing, such as porridge, pudding, and steam or poach egg. It is important to brush your teeth and rinse your mouth after eating to maintain oral hygiene. Bone healing occurs after six weeks and you need to take soft diet. After six weeks, the bone can withstand the bite force, you may then gradually return to your regular diet.

Oral Hygiene and Care - The wound is inside the mouth. Because of the oral flora, the infection risk of intra-oral wounds tends to be higher. Therefore, it is important to maintain good oral hygiene. The intra-oral wound will have some blood oozing and in addition teeth will have orthodontic wiring. The wiring and the oral cavity will have blood clots and bloodstains causing halitosis and might cause wound infection. Therefore, after the operation it is imperative to start oral hygiene (brushing of teeth and mouth rinse). The patient must adhere to the oral hygiene regimen every 2 to 4 hours regardless whether he/she has taken food or not. Obviously if you have taken food you have to wash again. On the first post-operative day it will be more painful and uncomfortable, however, to decrease the rate of infection, the patient must bear the pain of brushing his/her teeth with the soft brush provided by the orthodontist. The earlier one brushes, the easier to keep the mouth clean. Rinsing is not enough.

Warm and Cold compress - During the first 3 days, the patient may use cold towel, ice pack or compress on both cheeks/jaw area as well as the sides of the nose. After three days, the patient may shift to warm towel or compress to decrease swelling.

Going Back to Your Normal Routine - You are encouraged to get out of bed and back to your regular daily activities. This will enable to you to recover faster and regain your former strength and well-being. You will get back to normal faster after sufficient rest. (You must remember that if you are recuperating at home and have begun to regain your strength, you are advised not to overindulge in videotapes, electronic or computer games, or the internet as these may affect your post-operative recovery.) VII. Orthodontics After operation, the patient must still undergo a period of orthodontic work to provide better tooth alignment. Orthodontic adjustment starts 4 weeks after surgery. The period of orthodontics vary depending on the individuals ranging from 6 months to 18 months.

<Back to the top>

 

 

Common Morbidities

  1. Inferior alveolar nerve injury - The inferior alveolar nerve supplies sensation for the skin of the lower jaw. Because of the nerve is located right at the site of the sagittal split and the traction and pressure of the instruments on the area, the nerve may get some bruising or temporary injury causing insensitivity to the lower jaw. The probability of this happening is 10%. Approximately 90% of the patients who have nerve injury will recover in 3 to 4 months after surgery. A small percentage never gains full recovery with the insensitivity of the lower lip becoming persistent. However this numbness does not affect daily life, does not affect the movement of the lower lips nor it cause drooling of saliva.

  2. Hemorrhage after surgery, or hematoma after surgery - During surgery of cutting the bones, some bleeding may occur causing an expanding hematoma or accumulation of blood clots. This may occur in 20 to 30 percent of cases. A majority does not lead to serious complications and will spontaneously resolve. A very small group may have large hematomas or may have continuous bleeding at the operative site, and in these cases the patient might need to undergo emergency operation resolve these problems.

  3. Post-operative Infection - All operations have a risk for infection. These surgeries are intra-oral operations therefore if the patient's oral hygiene is poor; the risk for infection will increase. Likewise if the patient's immune condition is weak the chances of infection will also increase. Overall, there is a 3% risk of infection. The majority of cases with infection only require outpatient follow-up and treatment with antibiotics. Some may require opening of the wound to drain the bacteria and pus with the purpose of better healing. A very small number may require longer hospital stay to have intravenous antibiotics or undergo surgery to clean the wound.

  4. Exposure of the plates - In principle, the titanium used for the surgery is non-reactive to human body tissue. Once fixed, they do not need to be removed. However, due to infection or poor healing of bone, the titanium plates may become exposed. In these cases, the patient may need to undergo removal of the plates under regional anesthesia. Removal is usually done after 6 months after surgery once there is evidence of bone union.
  5. Trauma to skin (usually at the corner of the mouth) - Because the operation is done intra-orally, all the surgical instruments have to reach areas inside the mouth. The skin around the mouth has to be stretched to accommodate these surgical tools. There may be some abrasions or oral fissures in 7 to 10 percent of cases. These will heal spontaneously after 1 to 2 weeks and not leave any scars.

  6. Preparations for auto-transfusion - Bilateral Sagittal Split Osteotomy and LeFort1 Osteotomy usually have more blood loss. To prevent excessive bleeding and the risks associated with transfusion, the patient is encouraged to arrange for auto-transfusion. The patient must donate 250cc and the hospital will store this in the blood bank. The patient may then have his own blood transfused back when he/she requires during surgery. Consequently, the risks, infections or morbidities associated with transfusion will also be avoided.

  7. Psychological Effects After Surgery - After surgery, the unique features of the face will change dramatically. The operation will alter the ratios of the face to more normal and pleasing proportions. Some patients may have problems with self-image. Friends, family and colleagues may not be able to recognize the new face. Others may even have unintentional negative comments regarding the change in appearance. These may create some psychological pressure and adjustment difficulties. Generally students and young adults (patients in their late teens and early and late twenties) have an easier time adjusting and have a better outlook. But for individuals 30 years and above, or those who successful, famous, well recognized; they may have more psychological problems or difficulty in adjustment. Some may require up to half a year to regain their self-confidence. Before the operation, it is highly suggested that these patients have a good relationship with their doctor and referral to a psychiatrist may even be advised.

Other Common Problems

  1. Swelling After the Operation - There will always be swelling after the surgery. The more complex the procedure, the greater the number of combination of procedures, the longer the surgery, the worse the swelling will be. Within the first week, there may be edema and face may not be what the patient expects. After the first week however, the swelling will go down. The patient is advised not to engage in any strenuous activity during this first week. In the second week, the swelling will markedly subside. In the third or fourth week, the puffiness will not be as obvious, but the patient may feel a bit puffy, tight and discomfort. In the following weeks, the edema will continue to subside becoming minimal after two or three months.
  2. Numbness of the gums - during BSSO (Bilateral Sagittal Split Osteotomy), there may be temporarily injure the nerve, and cause numbness on the anterior gums.
  3. Difficulty in speech: After the operation the teeth may not yet be aligned properly. There may be gaps between the teeth, and may be even bigger than before the operation. The pronunciation of words may be affected to varying degrees. During the post-operative period, after further orthodontic treatments and the occlusion is realigned and the speech return to normal. The patient needs to re-learn and to adjust to this new jaw, tongue and gum relationship. Speech will return to normal within a month or two.
  4. Post-Operative Recurrence - The soft tissues of the face (skin, muscles, and tendons/ligaments), still exert some force even after you have moved the bones. After a long period of time, the patient might regain some of the pre-surgery facial deformities, because of the effects of the pulling of the soft tissue. Although some recurrence may happen, the big majority will still retains the normal facial and dental relationship and appearance. A very small percentage might need re-operation.

Special Attention for Cleft Patients

Velopharyngeal Insufficiency - For patients with a history of cleft lip/palate surgery, undergoing Le Fort 1 operation may bring out velopharyngeal insufficiency and result in hypernasal speech. Hypernasality may impair the patient's ability to communicate properly. If the Le Fort 1 advancement is more than 1 cm. then the hypernasality will more likely occur. Majority will recover, but some will require additional surgery to correct the VPI problem.

<Back to the top>

 

Home    |    About Her   |    Contact Her    |    Services
 
  Copyright © AETHETIC SURGERY AT CHENNAI 2009. All Rights Reserved                                                                 Created By : SRIRAM SOFT TRADE SOLUTIONS