Plastic and Reconstructive Surgery Procedure

Jaw Surgery Or Orthognathic Surgery: A Part Of Craniofacial And Plastic Surgery

Jaw surgery or Orthognathic surgery is a part of Craniofacial and Plastic surgery where the bones of the upper or lower jaw or both are moved to either realign the position of teeth or improve the appearance of the face.

The main specialists involved in orthognathic surgery:

• Craniofacial & Plastic surgeon
• Orthodontist
• Speech pathologist

Common reasons to undergo Orthognathic surgery:

1. To correct malocclusion of teeth – There are many types of malocclusion. It could be where the upper teeth are far ahead of lower teeth which are commonly referred to as ‘Overbite’. It could be where the lower teeth are far ahead of upper teeth which are commonly referred to as ‘Underbite’. There could be a gap between the upper and lower teeth which is commonly referred to as ‘Open bite’.
2. To improve the appearance of face – Most commonly people seek orthognathic surgery for facial deformities like ‘Dish face’ where the upper jaw is far behind the lower jaw, ‘Weak chin’ where the lower jaw is far behind the upper jaw, ‘Strong chin’ where the lower jaw is far ahead of the upper jaw causing a masculine appearance in a female patient etc.
3. To improve the smile – People who have ‘Gummy smile’, ‘Excessive teeth show’ etc. also benefit from orthognathic surgery.
4. Cleft lip and palate deformities – People with cleft lip and palate usually have a ‘Dish face’ deformity and benefit tremendously from orthognathic surgery.
5. To improve snoring and sleep apnoea – People with snoring and sleep apnoea issues who have failed all previous medical and surgical management can potentially benefit from orthognathic surgery.

Investigations required prior to Orthognathic surgery:

X-ray Lateral Cephalogram – This is an X-ray of the facial bones showing the profile view of the patient. This helps in assessing the actual deformity (Bony and soft tissue).

CT scan, Virtual surgical planning, Splints and 3D models – CT scans of the facial bones are taken and then surgical planning is carried out online with special software which helps the surgeon in planning the actual cuts on the bone, moving the bones to the right position and then fixing the bone with plates and screws. Surgical splints and 3D models are also prepared using virtual surgical planning. 

Speech assessment – Moving the jawbones can have an impact on speech and hence a speech assessment before surgery and possible speech therapy after surgery will help in optimizing the result.
Routine blood tests before anaesthesia.

Approaches in Orthognathic surgery:

Orthodontics first approach – This will involve the application of braces and orthodontic dental treatment for a period of 6 months to 1 year followed by surgery. During the orthodontic treatment period, all the compensations of the teeth that are present due to the malocclusion are removed (Decompensation). During this period, you may notice that the deformity of the teeth is getting worsened, but in reality, it is just going back to where it is supposed to be. And once the surgery is done, the alignment of teeth will be normal. Some amount of orthodontic treatment is sometimes required even after surgery.
Surgery first approach – Here the jaw surgery is done first. It is then followed by orthodontic treatment for 6 months to 1 year.
Both approaches are available at Sakra World Hospital.

Types of surgeries:

1. Lefort I osteotomy – In this operation, cuts are made in the upper jaw (maxilla) and the bone is moved forwards, backwards, upwards or downwards depending upon the deformity and then fixed with titanium plates and screws in the new position.
2. Bilateral sagittal split osteotomy of the mandible (BSSO) – In this operation, cuts are made in the lower jaw (mandible) and the bone is moved forwards, backwards, sideways or rotated upwards depending on the deformity and then fixed with titanium plates and screws in the new position. 
3. Double jaw surgery – It is a combination of the above procedures which involves surgery on both maxilla and mandible. 
4. Genioplasty – In this operation, cuts are made in the chin (central) region of the lower jaw and the bone moved forwards, backwards, upwards or downwards depending upon the deformity. 

All surgeries involve cuts on the inside of the mouth, which means ‘NO EXTERNAL SCARS”!

What does the surgery involve?

• Consultation with craniofacial & plastic surgeon, orthodontist and speech pathologist.
• Investigations and planning – Takes 4-5 days for surgical planning and preparation of splints and models.
• Admission on the day of surgery.
• Blood tests and reserving blood for blood transfusion.
• Surgery 2-3 hours under general anaesthesia.
• Recovery room 2-3 hours.
• One night ICU stay which might also involve blood transfusions. ICU stay is for monitoring of the airway and breathing issues.
• Shifted to ward and ward stay for 2-3 days.
• Rubber bands applied to braces.
• Discharge 
• Soft or semi-solid diet for 3 weeks.
• Follow up with Craniofacial & plastic surgeon, orthodontist and speech pathologist.
• Return to normal activities after 1 week. Strenuous physical activity after 6 weeks.

Complications expected:

• Orthognathic surgery is very safe with the best surgical and anaesthetic practices. In spite of all safety measures, there might be a few complications which need to be understood by the patient.
• Blood loss – Blood transfusion is sometimes required.
• Breathing difficulties – ICU stay for one night is advised to monitor breathing issues.
• Infection – Very rare to have infections due to titanium plates and screws. In case there is an event like that, the plates and screws can be removed easily.
• Swelling and bruising – The patient will have a lot of swelling and bruising in the first 48 hours. The swelling and bruising will slowly reduce over a period and completely disappear by 6 weeks’ time.
• Numbness and paraesthesia of lips – Some amount of numbness and altered sensation on the lips are present due to impact on the nerves due to surgery. This is usually temporary. In a worst-case scenario, it can take 1-2 years for the sensations to come back.
• Loss of tooth – Due to loss of blood supply to the teeth. In such cases, dental rehabilitation is required. This is also a very rare complication.

Whom to contact for further questions?

• Dr Rajendra S Gujjalanavar – Rajendra.sg@sakraworldhospital.com 
• Dr Vybhav Deraje – Vybhav.deraje@sakraworldhospital.com

Craniofacial Surgery

What is Craniofacial surgery?

Craniofacial surgery is a branch of Plastic and Reconstructive surgery which specifically deals with correction of deformities of the face and skull.

What conditions are treated by Craniofacial surgery?

1. Craniosynostosis - Nonsyndromic (Metopic, Coronal, Sagittal, Lambdoid, Multisuture) and syndromic (Apert, Crouzon, Pfeiffer, Muenke, Saethre-Chotzen)

2. Facial clefts - Cleft lip, Cleft palate, Cleft lip and palate, Submucous cleft palate, Rare facial clefts

3. Craniofacial trauma - Facial and skull fractures, injuries

4. Vascular anomalies - Haemangiomas, arterial and venous malformations, AV malformations, Lymphangiomas

5. Jaw deformities (Orthognathic surgery) - Overbite, Underbite, Crossbite, Small chin, Flatface

6. Cosmetic - Rhinoplasty, Blepharoplasty, Facelift, Necklift, Prominent ear correction, Hair transplant, Filler and Botox

7. Head and neck cancer reconstruction

8. Facial palsy

9. Snoring and Obstructive sleep apnoea

10. Other conditions - Neurofibroma, Encephalocoeles, Fibrous dysplasia, Craniofacial microsomia, Romberg's disease, Dermoids

Who are the doctors involved in craniofacial surgery? Does Sakra World Hospital have all the specialists required?

1. Craniofacial surgery is teamwork. The specialists involved in Craniofacial surgery are:

2. Craniofacial & Plastic surgeon

3. Neurosurgeon

4. Ophthalmologist

5. ENT surgeon

6. Dentist & Orthodontist

7. Speech pathologist

8. Paediatric & Neuro anaesthetist

9. Paediatrician

10. Neuropsychiatrist

11. Specialist Plastic surgery nurse

All the above specialists are available at Sakra World Hospital and work in a coordinated manner to provide the best services to you and your children.

Is Craniofacial and cleft surgery safe in children?

Yes. Cleft and craniofacial surgery are absolutely safe in children due to advances in Anaesthetic practices, well organized Paediatric and Neuro Anaesthesia teams and excellent Paediatric ICU services. These surgeries can be done in babies as young as 3 months of age onwards.Plastic surgery consultants

What options are available to treat Craniosynostosis (premature fusion of growth plates of the skull)?

Sakra World hospital is a pioneer in minimally invasive or keyhole surgery for Craniosynostosis. All children who present to us below the age of 6 months are offered minimally invasive (keyhole) endoscope- assisted surgery followed by helmet therapy. Children above 6 months of age are offered open surgery for remodelling of the skull. The advantages of minimally invasive procedures are smaller scar, shorter stay in the hospital, lesser need for blood transfusion, shorter operation and quick recovery.

How many surgeries does a cleft lip and palate baby need and when?

Typically, the cleft lip operation is done at 3-6 months of age. The cleft palate surgery is done at 9-12 months of age. Alveolar bone grafting to the upper jaw is done at 9-10 years of age. Jaw surgery to correct jaw deformities followed by rhinoplasty and touch up procedures are done at adolescence (14-18 years of age). Some children might require additional procedures like surgery to correct speech issues, ventilation tube insertion to ears and dental extractions.

How many days do I need to stay in the hospital for Facial Cosmetic procedures?

Most of the cosmetic procedures can be done as Daycare procedures. In some cases, you might need to stay overnight depending on convenience. 

Will I have pain during and after Craniofacial surgery?

Most surgeries are done under safe general anaesthesia and you will not experience any pain during the procedure. After your procedure, our acute pain service team will make sure that you are on the right pain killer to alleviate any pain issues.

What is the recovery time after Craniofacial surgery?

It depends on the type of procedure you have undergone. But generally, if you have undergone a daycare procedure, the recovery time is short and you might be able to go back to normal activities in a couple of days time. Please ask our specialists for procedure-specific downtime.

How safe will my surgery be? And what about the privacy of my data and pictures?

Sakra World Hospital is a NABH accredited hospital and adheres to all the safety and quality guidelines prescribed by the board. Your data and pictures will be confidential and no part of it will be shared or displayed in the public domain without the written consent from you.

I have a few questions. Whom do I address it to?

Our Plastic surgery consultants are happy to address any of your questions and concerns. You can call them on their phone numbers during working hours (0900-1600). You can also email them any queries and they will get back to you as soon as possible.

Dr Rajendra S Gujjalanavar - Ph No +919986447732 email rajendra.SG@sakraworldhospital.com

Dr Vybhav Deraje - Ph No +919958731986 email   vybhav.deraje@sakraworldhospital.com

Tendon transfer surgery, puts commander from Yemen back on his feet

Mr. Mohammed Saeed Ahmed from Yemen is a 42-year-old man who is the principal of the local high school.  He was a history teacher prior to his appointment as the headmaster.  He became the commander of the people in Yemen when the Civil War broke out in Yemen in 2015. The Yemeni Civil War is an ongoing conflict that began in 2015 between two factions claiming to constitute the Yemen government, along with their supporters and allies. Mr. Ahmed helped the people of his town defend their land acquisitions and it was during the process that he was shot in the spine.  He was bound to a wheel chair and was unable to undergo treatment because of the ongoing war in the country. 

He came to India in the hopes for treatment in 2016 and visited two top hospitals in India, both of whom were speculative in treating his condition effectively.  He came to Sakra World Hospital in the month of September 2016 and post consultation with Surgeons team at Sakra World Hospital lead by Dr. Maheswarappa B.M. Head of Physical Medicine, Rehabilitation & Sports Medicine along with Dr Derick Mendonca, Head of Plastic Surgery, he was reassured of the treatment.  Post his surgery on the 9^th of September, Mr. Ahmed underwent extensive physiotherapy sessions which has now enabled him to walk on his own once again. 

Mr. Ahmed is extremely grateful to the doctors, nurses, and staff at Sakra Hospital for the constant support and care during his treatment.  He speaks highly of the international patients’ cell of the hospital, for helping him with translators which made caregiving simpler. 

“I was told by many that my condition was permanent and that I shall never again be able to stand on my own feet.  But in this age and time, I knew that there would be a cure for my condition. Dr. Maheswarappa and Dr. Derick at Sarka World Hospital showed me the ray of hope and it is with the help of the team at Sakra and God Almighty that I am once again back on my feet.  I cannot express my gratitude to them in words.” said, Mr. Mohammed Saeed Ahmed

I conducted the operation three months ago, during which we rearranged the tendons in his foot. The surgery is suggested to patients suffering from nerve damage,” said Dr. Mendonca, senior consultant, plastic surgery, Sakra World Hospital.

Post-surgery, Mohammed was tended to by the physical medicine department. Dr Maheshwarappa BM, senior consultant and head of physical medicine rehabilitation and sports medicine, said: “He has been undergoing physiotherapy for three months.” He will return home soon.

As published in The Times Of India on 20th Jan 2017

Dr. Maheswarappa B.M.
Senior Consultant & HOD - Physical Medicine, Rehabilitation & Sports Medicine

Rhinoplasty

What is Rhinoplasty? 
Often known as the “Nose Job”, rhinoplasty is a plastic surgery procedure which involves reshaping, resizing or reconstruction of the nose in order to either enhance esthetics or restore the form and function of the nose.

What does a Rhinoplasty procedure do?
Rhinoplasty involves correction of:
   1. Length of the nose
   2. Width of the nose
   3. A deformity in the tip or bridge of the nose, like drooping tip or visible humps and depressions in the bridge of the nose
   4. Shape of the nostrils
   5. Nasal blocks due to septal deviation
   6. Correction of irregular dorsum e. g. Humps/ deviations
   7. Nasal asymmetry
   8. Obstruction in airway or breathing
   9. Congenital deformities

Types of Rinoplasty
Reduction Rhinoplasty - this type of rhinoplasty is primarily to alter the size of the nose, correction of width of the nose or a bridge bump, or altering the nostril size and shape to bring them in proportion to the rest of the face.
Augmentation Rhinoplasty – this type involves increasing the dimensions of the nose by adding structural material or grafts for aesthetic and functional enhancement purposes. 
Post-traumatic Rhinoplasty – as the name suggests, this type deals with the post- traumatic deformities of the nose, like deviation, asymmetry or even obstruction in airway and breathing. 
Ethnic Rhinoplasty - The Ethnic Rhinoplasty takes into consideration the particular nasal characteristics based on the patient’s ethnicity. In a way all of the rhinoplasties can be considered as ethnic rhinoplasties as a special care is always taken towards maintaining the ethnic features of the face while correcting any kind of nasal deformity.

Who is the right candidate for a Rhinoplasty?
A person can be considered as an ideal candidate for Rhinoplasty if he/she has:
   1. Good general health 
   2. Full grown facial features, except for cases where breathing is impaired and in trauma cases.
   3. Any breathing or airway problems
   4. Any kind of aesthetic nasal deformity 
   5. Realistic expectations from the cosmetic treatment

Who is the right person to perform a Rhinoplasty?
A perfect rhinoplasty is said to be done when post- surgery, people know there is an appealing change but are unable to point at the actual spot. Such an outcome is possible only when surgery is performed by the right person.
A cosmetic surgeon, who has the essential qualification, knowledge, acumen and the experience for doing such a technique sensitive surgery is the ideal person to put one’s trust in. It is not a piece of wardrobe that one can discard if it does not look good. One can play with clothes and colors but not with body parts. 

Pre- surgery precautions
A rhinoplasty must always be considered as any other surgery of the body and requires similar precautions and care from the doctor as well as the patient.
The patient must explain his expectations clearly to the doctor but at the same time keep them realistic.
The preparation for this surgery will also require complete medical history, examination and essential investigations to be conducted.
 Photographs may be taken to assessment of existing facial features and comparison post operatively.
Cessation of all certain medication and smoking will be required at least 4 weeks prior to the surgery.

The procedure
An average procedure takes 2-3 hours except complex or multiple surgeries which may take longer.
It can be done using local or general anesthesia.
Generally done as an OPD/ Day care procedure but may occasionally require hospitalization for a day. 
Rhinoplasty can be done as an open procedure where the incision is made outside of the nose across the columella or a closed procedure where the incision hides inside the nose. The incision helps to raise the skin over the nasal bone and cartilage to have access to the desired location that requires alteration.
Depending on the desired result, some bone and cartilage may be removed, or tissue may be added (either from another part of the body or using a synthetic filler). After the surgeon has rearranged and reshaped the bone and cartilage, the skin and tissue is closed over the structure of the nose. A splint is placed outside the nose to support the new shape of the nose as it heals.

Risks involved in Rhinoplasty
Rhinoplasty carries the same risks as any other surgery. Bleeding, infection, and reactions to medications or anesthesia are possible side effects of rhinoplasty surgery. Rarely one might need a second procedure at some point in the future to rearrange the tissues this is especially true in cleft deformities corrected at younger age as the nose tends to grow with age.

What to expect after surgery?
Similar to any other surgery, rhinoplasty also requires good post op care. Generally it takes about 2 weeks to heal completely even though the patient can resume his daily activities within 4-5 days. 
Mild pain, and discomfort is common after the surgery and can be controlled by medication.. Black eyes are not unusual especially after bony reshaping. 
Swelling and discoloration in the operated area can remain for few days which can be minimized with cold compression. 

Liposuction

What is Liposuction? 
Liposuction is an invasive surgical procedure done primarily to improve the body contours and proportion by removing excess fat deposits between the skin and muscle. The focus areas usually involve tummy, hips, thighs and arms which are often resistant to diet and exercise.

What does a Liposuction procedure do?
Liposuction techniques may be used to reduce localized fat deposits of the:
   1. Thighs
   2. Hips and buttocks
   3. Abdomen and waist
   4. Upper arms
   5. Back
   6. Inner knee
   7. Chest area
   8. Cheeks, chin and neck
   9. Calves and ankles

The main aim of the procedure is to reshape the problem areas of the body as mentioned above, and not merely to reduce weight. In men these areas mostly include the waist and back and outer thighs and hips for women.
Apart from this, liposuction is also used in treating some medical conditions like:
   1. Lipomas - Benign fatty tumors 
   2. Abnormal enlargement of the male breasts (gynecomastia or pseudogynecomastia)
   3. Metabolic disorders causing deposition of fat in the body

Although, Liposuction is a successful procedure with many positive outcomes both aesthetically and medically, it is important to understand that liposuction does not help in treating obesity, cellulite, stretch marks or sagging skin. It is simply not a substitute for diet and exercise to reduce weight.

Types of Liposuction Techniques
    1. Tumescent liposuction. This technique uses a local anesthetic solution containing lidocaine and epinephrine to numb the area where the suction tube is to be inserted and liposuction is done through the traditional approach. 
    2. Ultrasound-assisted liposuction. This technique uses ultrasound to liquefy the fat, which makes it easier to remove. This technique may be particularly helpful in removing fat from the upper abdomen, sides, and back.
    3. Laser-assisted liposuction. This technique uses low-energy waves to liquefy the fat, which is removed through a small cannula.

Who is the right candidate for a Liposuction?
   1. Patients with the following conditions are considered to be suitable for this procedure:
   2. Area with excess fat resistant to “diet and exercise”
   3. Adults within 30% of their ideal weight who have firm, elastic skin and good muscle tone
   4. Non-smokers
   5. Healthy individuals, without any life-threatening illness or medical conditions that can impair healing
   6. Individuals with a positive outlook and specific goals in mind for body contouring
   7. Liposuction is equally effective for both men and women

Who is the right person to perform a Liposuction?
The surgeon has to be a qualified and certified cosmetic surgeon and along with good sculpting and suctioning skills for performing a flawless liposuction. The result of liposuction depends a lot on the doctor’s experience and acumen in sculpting and suctioning.

The procedure
Liposuction removes fat from your body using suction. During liposuction, small, thin, blunt-tipped hollow tubes called - cannulas are inserted through tiny cuts in the skin. Fat is suctioned out through these tubes using vacuum – a process known as suction assisted liposuction (SAL), as the doctor moves the tubes around under the skin to target specific fat deposits. Often this process can be assisted by a motor in order to oscillate the cannula for dislodging fat and sculpting the area. This is known as power assisted liposuction (PAL). Similarly other techniques involving sound waves or laser etc. may be used for breaking down fat cells.

Risks involved in Liposuction
Liposuction is one of the commonest procedures performed and associated risks are very infrequent. Some of the complications include – bleeding, infection, changes in sensation, scarring, allergic reactions, damage to underlying structures, unsatisfactory results possibly necessitating additional procedures in some cases which is why it is very important to choose a certified plastic surgeon only.

Recovery after Liposuction
Post- surgery, patient is kept in recovery for a few hours before giving discharge. A compression garment is generally worn by the patient to help shrink the skin and aid in healing
Patient must rest and avoid any kind of strenuous work after the surgery except slight activity inside the house for the next few days. Pain, fever, swelling and bruising are common in the postoperative period. Swelling generally subsides within 48 hours.

Breast Augmentation

What is Breast Augmentation?
Breast augmentation also known as Breast Implants or Augmentation Mammoplasty is the surgical enlargement or modification of the breasts either using fat or implants, to increase the size of breasts or restore breast volume that has been lost after weight reduction, pregnancy or due to aging. 

What does a Breast augmentation procedure do?
    1. Enhances self-confidence and self-image.
    2. Increase fullness and projection of breasts
    3. Alters shape or texture of breasts 
    4. Breast implants are also used for breast reconstruction after mastectomy or injury

Breast augmentation does not correct severely drooping or sagging breasts, for which a breast lift may be required in conjunction with breast augmentation or separately.

Types of Breast Implants
    1. Silicone/Gel
    2. Saline
    3. Fat 

Who is the right candidate for Breast Augmentation?    
You are a suitable candidate for this procedure if you have:
    1. Good general health 
    2. Fully developed breasts
    3. Asymmetrical breasts
    4. Been bothered by the feeling that your breasts are too small
    5. Been dissatisfied with your breasts losing shape and volume after pregnancy, weight loss, or with aging
    6. Underdeveloped or abnormal development of one or both breasts 
    7. Realistic expectations from the cosmetic treatment

Who is the right person to perform a Breast Augmentation?
Apart from choosing a board-certified plastic surgeon for your breast augmentation surgery, it is very important to understand that the surgeon's experience with breast implants and your comfort with him or her are also equally important.