Facial Asymmetry Correction

Facial Asymmetry Correction by BSSO Surgery

by smbalaji | Mar 28, 2021 | Facial Asymmetry Correction, Surgery

Facial Asymmetry Surgery by bilateral sagittal split osteotomy (BSSO)

Patient with a Progressive Increase in Lower Jaw Size

The patient is a 21-year-old male from Durgapur in West Bengal, India. He has always had a very large lower jaw in comparison to his upper jaw. There was also a slight deviation of the lower jaw to the right. This resulted in a mild asymmetry of his lower face.

A bilateral sagittal split osteotomy (BSSO) is the surgery of choice for reducing a large lower jaw. A receded lower jaw is advanced using distraction osteogenesis. Internal distraction is safer and preferred over external distraction. The open bite caused by upper jaw abnormalities is corrected through maxillary osteotomy.

Size discrepancy between the jaws can lead to a lot of functional difficulties. Speech is altered and eating patterns are also altered. Left unaddressed, this could possibly also lead to problems with the temporomandibular joint (TMJ). Cosmetic compromise is another important aspect that could lead to issues with self-esteem and self-confidence.

Associated Difficulties Caused by his Jaw Asymmetry

He has also faced speech and eating difficulties throughout his life. Of note, his brother also has a large lower jaw. He had presented to a surgeon in his hometown. Realizing that this was a complicated presentation, he was referred to us for surgery for jaw and chin correction.

The mechanism behind Perception of Jaw Size Discrepancy

The disparity in jaw size is a common cause of facial deformity and asymmetry. Either the lower jaw or the upper jaw can be larger than the other jaw. This could be a result of either a large jaw or a small jaw. A small upper jaw could make a normal lower jaw appear large.

Correction of this deformity could either be through jaw reduction or jaw augmentation. Le Fort I maxillary setback reduces the size of a large upper jaw. Bilateral sagittal split osteotomy reduces the size of a large lower jaw. An increase in the size of the lower jaw is through distraction osteogenesis.

Le Fort I osteotomy is the technique of choice for upper jaw advancement. Jaw reconstructive surgery helps correct a variety of deformities, both congenital and acquired. Facial plastic surgeons also perform these surgeries in Japan and other developed countries.

Initial Presentation for Jaw Correction Surgery at our Hospital

Dr. SM Balaji, facial asymmetry surgery specialist, examined the patient. The patient had mandibular prognathism as well as lower facial asymmetry. Treatment planning was formulated and explained to the patient. He was in agreement and consented to jaw reduction surgery.

Specialty Surgical Procedures Performed at our Hospital

Our hospital is a specialty center for facial cosmetic surgery. Facial plastic surgery in our hospital has transformed many lives. Scar revision surgery for burn scars is performed through tissue expansion. We are a specialty center for cosmetic nose surgery in India.

Successful Surgical Correction of Jaw Deformity

Bilateral bone cuts were first made in the mandible. The nerve was safely mobilized with the distal segment. This allowed for free manipulation of the proximal segment. Extreme care was taken to preserve the inferior alveolar nerve during surgery.

A slice of bone 14mm in thickness was removed from the left side. This was followed by a smaller slice of 12 mm being removed from the right to set right the asymmetry.

Occlusion was checked and was found to be normal. The mandible was then stabilized with plates and screws. His facial appearance was transformed following the surgery. He was very happy with the results of the surgery.

His family thanked the surgical team before discharge from the hospital.

5 Points on Facial Asymmetry Surgery – Facial Cosmetic Surgery

A Minor Degree of Facial Asymmetry is Completely Normal

Both sides of the face are near mirror images though it is never a perfect match. There is a minor degree of facial asymmetry even in normal faces. This is how nature works. There is never perfect symmetry of the face or the body. It is this minor asymmetry that adds to the attractiveness of the individual. This asymmetry is however not evident to common people.

Purely Cosmetic Deformity Versus Function Affecting Deformity

It is only when this degree of asymmetry is present to a degree where it is clearly noticeable that it becomes a problem that needs to be addressed. There are two components to the problems caused by this. One is pure cosmetic where it is only the appearance that is affected and not the function. The second is when normal function is affected by the asymmetry.

Procedures for Cosmetic Facial Asymmetry Correction

Procedures like cosmetic rhinoplasty help correct minor imperfections in the face and enhance the appearance of the individual. Many high visibility celebrities undergo such procedures to enhance their facial features for greater career opportunities.

Facial asymmetry normally manifests itself early in life whether it is idiopathic or caused by a medical condition like hemifacial microsomia. Injuries or infections to the developing baby during pregnancy can also result in facial disfigurement.

It can however occur at any stage in life too as a result of trauma or diseases like cancer. Facial asymmetry is very distressing to the affected individual and leads to associated psychological effects like depression and becoming introverted with self-isolation.

Struggles of Mankind through the Ages for Restoring Normal Facial Appearance

Mankind has tried to address this over the ages through various means. For example, World War I was the first truly global war that led to unprecedented levels of facial mutilation. A special unit was created to help individuals who suffered from facial asymmetry due to injuries sustained in war. Facial Plastic Surgery developed rapidly through the efforts of such units.

The Development of Modern Surgical Techniques

Modern surgery has come a long way in addressing the issue of facial asymmetry. Oral and Maxillofacial Surgery as well as Craniofacial Surgery deal extensively with the correction of facial asymmetry and restoration of normal facial features. An example is the treatment of burns scars. Facial scar revision surgery cost depends upon the extent of scarring.

Surgical techniques such as distraction osteogenesis, bone grafting, sagittal split osteotomy, utilization of biocompatible implants and soft tissue remodeling help restore normalcy in the lives of those afflicted with facial asymmetry.

The cost of facial asymmetry correction surgery varies a lot depending upon the severity of the presentation. It can cost anywhere from INR 1-2 lakhs for minor procedures to INR 3-4 lakhs for major facial deformity corrections.

Video [Facial Asymmetry Surgery]

Facial Asymmetry Correction– Mandibular Distractor Surgery

by smbalaji | Feb 18, 2021 | Facial Asymmetry Correction

What is Facial Asymmetry?

Facial asymmetry is characterized as a condition where one-half of the face is different from the other half. Minor asymmetries are very normal and can be minor anomalies that distinguish the face, offer uniqueness and make it fascinating. However, large variations in contours are readily identifiable and frequently viewed as influencing the appearance of the aesthetic.

There are many options to treat facial asymmetry, including fat transfer, facial boost operations, soft tissue adjustment, lipodermal grafting, personalized implants, craniofacial architecture correction, or nerve and muscle function alteration. The goal of the procedure is to strengthen the equilibrium between the two facial halves.

Patient born with hemifacial microsomia affecting the right side of the face

The patient is a 23-year-old male from Guntur in Andhra Pradesh, India. He was born with a major asymmetry of the right side of the face. Genetic testing for hemifacial microsomia was performed for the patient with confirmation of the diagnosis.

Incidence of hemifacial microsomia and probable causes for the condition

Hemifacial microsomia is the condition where one side of the face is smaller than the other. It is an autosomal recessive trait. Though most commonly unilateral, it can on rare occasions be bilateral. Facial nerve dysfunction is underdiagnosed because of the magnitude of other deformities.

There might also be involvement of the external ear. It might manifest as congenital absence of ear canal in severe cases. Microtia surgery is required when there is deformity of the pinna of ear.

Craniofacial microsomia is another term used to describe hemifacial microsomia. Signs and symptoms usually manifest at the time of birth. Jaw correction is through orthognathic surgery. The rehabilitation process is prolonged with several surgeries needed for complete rehabilitation.

A lot of research has been devoted to the study of hemifacial microsomia. It is felt that there could also be a vascular component to the development of hemifacial microsomia. This is usually manifested in the first trimester of pregnancy.

The patient faces worsening of hemifacial microsomia with growth

The patient’s condition gradually worsened as he grew up. His right cheekbone was also affected. There was complete hypoplasia of the right side of his mandible. The body and ramus were grossly underdeveloped leading to gross facial asymmetry.

He had faced considerable bullying while in school. This had caused him to be quiet and have few friends. His parents had always been worried about how he would adapt to his problems.

Decision made to undergo corrective facial surgery for hemifacial microsomia

The patient informed his parents that he wanted to undergo surgery once he finished his studies. He said that he wanted to begin his work life only after the corrective surgery. His parents began making inquiries regarding hospitals that performed hemifacial microsomia surgery.

A distant acquaintance whose son had undergone reconstructive facial surgery at our hospital had recommended our hospital. She said that her son who had been born with facial deformities had been restored to normalcy at our hospital. The patient’s parents got in contact with our hospital manager and fixed an appointment.

Initial consultation at our hospital for hemifacial microsomia correction

Dr. SM Balaji, hemifacial microsomia surgeon, examined the patient and obtained imaging studies. Examination revealed that the patient had gross asymmetry of the face. There was an extreme deviation of the mandible to the right side. Intraoral examination revealed that the patient had an occlusal cant.

Treatment planning explained in detail to the patient and his parents

Imaging studies revealed that the patient had a shortening of the ramus of the mandible. There was also a hypoplastic body and ramus. They were informed that ramus height needed to be increased through internal distraction. A total of 25 mm of distraction needed to be performed to establish symmetry of the ramus on either side.

A maxillary Le Fort I osteotomy also needed to be performed to ensure that his occlusal cant was corrected. This would also help prevent the occurrence of an open bite on the contralateral side. The patient and his parents expressed understanding of the treatment plan and consented to surgery.

Successful completion of the distraction osteogenesis phase of treatment

Under general anesthesia, the patient underwent placement of the right internal ramus distractor followed by the maxillary Le Fort I osteotomy. Following a latency period of one week, distraction of the right ramus was begun. A total of 25 mm of distraction was performed.

There was symmetry established to the patient’s lower third of the face. The mandibular deviation to the right was also corrected. It was explained to the patient that he needed to return in six months for distractor removal. This would allow for complete bony consolidation at the site of distraction.

Patient returns for internal distractor removal surgery

As per instructions, the patient returns for removal of the internal distractor device. A posterior crevicular incision was made followed by unscrewing of the distractor using an angled screwdriver. The incision was then closed with sutures.

The patient was instructed that he would need bone graft placement to the hypoplastic ramus and body of the mandible. This would result in the completion of his rehabilitation. He expressed understanding of this and said he would return for further surgery in six months.