Friday, August 31, 2012

Asiatic Aesthetic Series 172:Tragedy of an unusual orbicularis- canine duo

Human bite left ear: using a sliding posterior auricular perforator flap with cartilage transfer-case report    
** This was a short and unusual report on traumatic ear biting which is a somewhat common pastime of  the nikushoku male prototype who is  unenviably endowed with an overactive orbicularis muscle and aggressive dental faculties... 

Yemen Smile Charity 


Intro:  We present a case of human bite of the left ear leading to a partial defect of the ear. The patient was a twenty five year old lady from Djibouti who was referred to our clinic in Sana’a. Her acquaintance had bitten off her left ear for undisclosed reasons.  One could only speculate that the perpetrator who probably suffered from some sort of Para Freudian delusional disorder also had a penchant for nibbling off ladies ears.  The defect was successfully repaired with a posterior auricular sliding flap based on random perforators.

 Technique: On examination, the left ear was partially bitten off and some of the cartilage had been lost as well. The ear was repaired with a posterior auricular perforator flap and some ipsilateral conchal cartilage was used for part of the missing framework. The flap was not detached but allowed to slide along with the perforators to the desired position and sutured to form the new ear. The post op was uneventful and the patient was satisfied with the results.

Discussion: Partial loss of the ear and helical rim has been successfully reconstructed by many others using various methods.1,3,4 In this case, it was quite successfully repaired using the posterior auricular flap without any tube pedicle or detachment. The results post op are quite reasonable and we would recommend this method for similar defects because of the easy technique involved and good post op results.

Pic: human bite left ear

 ** accepted as an abstract at the Taipei Grand Hotel, 7th Asian Pacific Craniofacial and 6th
International Surgical Simulation Conference 2008 Oct

Suggested reading:

1. Reconstruction of non-marginal ear defect by a postauricular wedge

transposition flap B. van der Lei and C. A. Spronk , British Journal of Plastic Surgery (1998), 51, 14–16

2. Ear recon and salvage Steven P Davidson Georgetown Med Univ,e med /ear July 2006

3. The bi-pedicle post auricular tube flap for recon of partial ear defects Mohd G E BJPS 2003 56, 593-598

4. The acquired ear deformity, A systemic approach to its analysis and reconstruction Brent B PRS 59: 475 , 1997

5. Fascial feeder and perforator based V Y flaps in the recon of lower limbs NS Niranjan BJPS v. 53 : 8, 2000

Asiatic Aesthetic Series 173:45 minutes as the crow flies?

**45 minutes as the crow flies ?- revisiting the popular myth in Speedy Gonzales cleft lip surgery

I wrote this article several years ago when I felt that cleft lip surgery takes much longer than 45 minutes;a few years down the smile lane and I realised that one has to rapidly adapt and shift gears when it comes to operating large volumes in poor nations. How times have changed! Sometimes I take as little as 15 minutes for a reasonably good cleft lip surgery.At other times ,when the load is much less,the time required is longer because I can work at my own pace.Others painstakingly redesign the smile taking several hours for a magnificent work of art. The times,they are a changin'....

Yemen Smile Charity 

Intro: Cleft lip conditions present themselves in many different ways; no two cleft lip patients are alike. In developing countries where the bulk of cleft patients come from, the problems are even more complicated because of the absence of prior orthodontic treatment for most of the cases. In fact, the smaller cleft lips seemed to take more time and expertise because of the delicate nature of the work. The larger and wider cleft lips which require even the inferior turbinate flap plus alar corrective surgery in some cases definitely take more than an hour at the least, even in experienced hands. So why is it so important to say that cleft lip surgery takes as little as 45 minutes when most of us who have operated hundreds of cleft children do not seem to be able to subscribe to this view? We undertook many cleft lip operations to see if the surgery could be done in 45 minutes and came up with some interesting conclusions.

Methods: Over a period of five years, several hundred cleft lip patients were operated at our safari smile camps using well established methods of Millard and Mohlers C flap with nasal correction and the inferior turbinate flap. The tissue dissection was kept to a minimum and the main focus was on accurate muscle approximation. In all the cases, the cleft lip surgery took and average of one to two hours depending on the complexity of the problem. None of the cases could be completed in as little as 45 minutes. Trainee surgeons took even longer to complete the procedures because of their inexperience. All the patients were operated on successfully and there were no mortalities.

Discussion: Some of us even feel that the more experienced we become, the slower we get because we realize how many mistakes we have made in the past because of Speedy Gonzales cleft surgery. For instance, if we were to make all the measurements prescribed by the cleft guru Prof. Sam Noordhoff, the measurements themselves take quite a bit of time especially for the younger cleft surgeon. And to make the inferior turbinate flap also takes quite some time; extra time is spent cauterizing the bleeders in raising the inferior turbinate flap. It might seem plausible to perform a very quick surgery given the horrendous working conditions in some safari missions where the patient has been knocked out by a cocktail of ketamine and other drugs and out of sheer fear and nervousness, the cleft surgeon slashes through the tissues and just wants to get it over with as fast as possible. In some countries, the surgeons would use only one packet of four zero silk sutures per cleft lip which is sure to lessen the operation time significantly. Others who painstakingly use the excellent Noordhoff modification of the C flap would need to use seven zero sutures for the mucosa flaps and skin. Imagine making the C flap, adjusting the tension, making the white roll zee flap, designing the triangular mucosal flap, raising the inferior turbinate and M and L flaps of mucosa.This takes a lot more time than one can imagine. A careful observation of excellent cleft surgeons like Philip Chen at others at the Chang Gung hospital in Taipei proves this point over and over again that cleft lip surgery takes quite a bit of time and effort. Perhaps one would need to rephrase the sentence as “Good cleft lip surgery takes approximately forty five minutes plus the extra twenty to thirty minutes to make the final fine adjustments”. This might go down better with the increasing number of incredulous spectators, patients, patient anesthetists, and especially plastic surgeons who have to deal with cleft patients on a regular basis.

Pic: Using the C flap with white roll flap, triangular mucosal cheiloplasty, and alar adjustment.

Time required for fine surgery approximately over one hour in experienced hands.

Pic: bilateral cleft lip op time is almost two hours in experienced hands

 **  accepted as an abstract at the Taipei Grand Hotel, 7th Asian Pacific Craniofacial and 6th
International Surgical Simulation Conference 2008 Oct


Suggested reading: Smile train DVD –virtual surgery videos cleft : 45 minutes cleft surgery

Asiatic Aesthetic Series 174:observations under the tip of the cleft iceberg

**Some rare craniofacial disorders in Yemen :observations under the tip of the cleft iceberg

Intro: Yemen in south Arabia till today does not have a proper record of the types or number of cleft anomalies. In our safari smile camps across the country over a period of a few years, some rare craniofacial anomalies were encountered. Craniofacial patients cannot even hope to receive any treatment for the time being till some drastic changes occur in the country’s bad economy and health care system. We came across eleven cases  with Hemifacial microsomia, hypertelorism, traumatic clefts of the face and nose following a rare neurosensory disorder, cleft nose with intranasal dermoid, cleft with Binderoid syndrome, Aperts,familial Tessiers Kartagener, Pierre Robin sequence, craniofacial cleft, frontonasal dysplasia  and Binder syndrome with absent columella.

Discussion:This was the initial observation made of rare craniofacial disorders in Yemen ; we believe this is the next big challenge lying dormant under the tip of the cleft iceberg since more and more craniofacial cases are being brought from the distant villages to the cleft camps. This report is more of an appeal to craniofacial centres around the world to take a close look at a nation in need and to offer training or help for this group of unfortunate patients.

Response:  We are thankful that as a result of the appeal, Prof John B Mulliken of the Childrens Hospital Boston offered his services to consult online all the difficult Plastic surgery cases and also offer training at his unit for team members.

Pics of patients:

Cases: Midline binderoid cleft type 0 pic 1

         a flat nasal dorsum and a well-defined groove between the 2 alar domes. The width of the osseocartilaginous framework of nasal pyramid was increased, leading to orbital hypertelorism 1a Her nose was relatively short. The anterior edge of the nasal septum was thick and separated in the shape of a “Y,. The philtrum was quite large.. The cleft was located between 2 central incisors and the base of the pyriform aperture in 1962, von Binder described a syndrome consisting of a short nose with a flat bridge, absent frontonasal angle,absent anterior nasal spine, limited nasal mucosa,short columella and acute nasolabial

         angle, perialar flatness, convex upper lip, and a tendency to class III occlusion.1

Pic 2: Absent columella Binderoid median cleft (repaired) Type 0

          slumped/hypoplastic  alar dome, short labial elements with thin vermilion midfacial retrusion.Wide alveolar cleft(not shown) Midline deformities of the upper lip and nose are included in the No. 0 cleft (Fig). Midline cleft may be accompanied by either a deficiency of tissue or an excess of tissue. When hypoplasia is the dominant theme, portions of these structures can be missing. Examples are a false median cleft lip and an absent columella. The skeletal deficiencies are reflected by the absence of the premaxilla and nasal septum

Pic 3 :Frontonasal dysplasia (CFND) : with midline partial cleft palate 

           * a rare familial craniofacial syndrome, first described by Cohen 2

         the frontonasal ‘dysplasia’ is manifested as hypertelorism and a broadened nose,frequently with a bilid nasal tip.High arched palate

         Dd- craniofrontonasal dysplasia

Pic 4: Cleft nose and lip type 13 with frontal encephalocele3

          The No.13 cleft is the cranial prolongation of the No. 1 cleft. In its paramedian location, Hypertelorbitism is a constant feature with the cleft traversing the nasal bone ,ethmoidal labyrinth and olfactory groove. The cribriform plate is widened

Pic 5: Craniofacial cleft right :type 4

          begins lateral to the cupid’s bow and skirts around the nose to end in the lower eyelid medial to the punctum rare (less than 0.25 percent among all facial clefts)

Pic 6: Aperts
         Incidence 1:160,000 5 Bilateral coronal synostosis with brachycephaly

         Shortened anterior cranial base Severe midface hypoplasia Exorbitism

         Down slanting palpebral fissures High arched palate Increased facial width with some hypertelorism Four limb syndactyly Ankylosis of joints Developmental delay Behavioral disturbances

Pic 7: Nasal cleft with intranasal dermoid ,hydrocephalus

           The No.13 cleft7 is the cranial prolongation of the No. 1 cleft. In its paramedian location, it lies medial to the eyebrow; Hypertelorbitism is a constant feature with the cleft traversing the nasal bone ethmoidal labyrinth and olfactory groove. The cribriform plate is widened

Pic 8: Kartagener syndrome

          Dextrocardia Situsinversus,bronchiectasis,sinusitis ciliary dyskinesia 9

Pic 9: Traumatic clefts fol absence of sensation lip,nose

Pic 10.Familial Tessier

 ** ** accepted as an abstract at the Taipei Grand Hotel, 7th Asian Pacific Craniofacial and 6th
International Surgical Simulation Conference 2008 Oct


         1a Tessier 0 cleft with bifid nose: Turkaslan et al Annals of Plastic Surgery • Volume 54, Number 2, February 2005

         1b  BINDEROID COMPLETE CLEFT LIP/PALATE John B Mulliken, Plast. Reconstr. Surg. 110: 1714, 2002

         2. Craniofrontonasal dysplasia D. J. A. Orr, S. Slaney, G. J. Ashworth and M. D. Poole British Journal of Plastic Surgery  50, 153-161,1997

         3. A new technique for the repair and reconstruction of frontoethmoidal encephalomeningoceles by medial orbital composite-unit translocation S. Boonvisut, S. Ladpli, British Journal of Plastic Surgery (2001), 54, 93–101

         4.The Spectrum of Orofacial Clefting Barry L. Eppley, M.D., D.M.D., John A. van Aalst, M.D., PLASTIC AND RECONSTRUCTIVE SURGERY, June 2005

         5. Scott P. Bartlett and Greg J. Mackay Aperts Syndrome: Grabb and Smith 5th Edn

         6. Craniofacial Microsomia Joseph G. McCarthy Grabb and smith 5th edn

         7.Craniofaciaf clefts Henry Kawamoto  Grabb and Smith 5th Edn

         8. Pierre Robin Sequence P. Craig Hobar, Donnell F. Johns Grabb and Smith 5th edn

         9.William Friedman Congenital heart disease –Kartagener syndrome ,Harrison Internal Medicine  15th edn

Asiatic Aesthetic Series 175:Simple minor variations on a theme of the C flap

*The unilateral cleft lip-“Simple minor variations on a theme of the C flap “
Techniques evolve over a period of time and there are many variations on a theme of the C flap;these days my methods are simpler and do not even include flaps

Yemen Smile Charity 

Intro:  The C flap repair for cleft lip deformities with it’s modifications gives some of the most accurate alignments for unilateral cleft lip defects that have been treated by prior orthodontics. With the extensive experience and large series presented by Noordhoff et al in their classic Chang Gung  series on correction of unilateral cleft lip deformities, there is not much that one can add to the existing techniques described in great detail by the authors. However, we believe that there still might be some harmonic mechanisms that one could add to the cleft armamentarium, as there are in classical themes. In this paper, we drew a helpful analogy from Fernando Sor’s Variation on a Theme of Mozart where the guitar maestro describes several variations on the main theme in E major. The classic paper by Noordhoff remains unchanged, but there are some mild variations which one can play with when faced with unilateral cleft lip defects.

Technique : When faced with a moderately sized partial defect we found it useful to use Variation 1 where we use a small but slightly broad C flap near the columella line to fit snugly into the slightly wider “inverted V” defect along with the usual white roll baby flap but the tissue in between is only de epitheliazed and not discarded ; in a very small partial defect we found it unnecessary to use the white roll flap and could get a reasonable adjustment with a Variation 2 flap where we tuck in the similar C flap close to the columella base line alone .

Discussion: So far, these two minor variations have proved to be quite easy to execute even for the less experienced cleft surgeons and the overall results are pleasing to all. The techniques are quite easy to learn and saves us quite a bit of operating time as well.We recommend these minor variations for achieving a harmonious aesthetic balance in milder forms of clefts.

Sample pics: variations on a theme of the C flap for unilateral cleft lip defects

Pic 1: Le mini  C flap variation

Pic 2:Le micro mini c flap variation

 ** accepted as an abstract at the Taipei Grand Hotel, 7th Asian Pacific Craniofacial and 6th
International Surgical Simulation Conference 2008 Oct

Suggested reading:

  1. Unilateral cleft lip repair: a 33 year experience Ken Salyer ,Journal of Craniofacial Surgery, vol 14:4,July 2003
  2. Mohler’ s  technique   M Samuel Noordhoff ,NCF Taipei 1997
  3. Primary repair of an incomplete unilateral cleft lip: avoiding an elongated lip and achieving a straight suture line  T Nakajima BJPS 51: 511-516,1998
  4. Smile  Train DVD 2006 unilateral cleft lip repair

Asiatic Aesthetic Series 176:The innovative V -2 zee triad concept flap for the neglected very wide cleft lip

*The innovative V -2 zee triad concept flap for the neglected very wide cleft lip

This was an earlier technique tried out in our camps for very wide complete cleft lip defects;these days I use lip adhesion as a prelim measure and complete the repair at a later stage after the gap is much smaller.Although the technique described worked in some cases,an easier alternative is two staged repair.

Yemen Smile Charity, 

Intro: The very wide neglected cleft lip presents a difficult challenge for the primary cleft surgeon. In this case report, we present a wide cleft lip approximately 4cm wide with a short cleft side and large nasal deformity. The traditional C flap is not suitable for such a defect and the Millard with the usual back cut is sometimes used with an extra baby flap below to increase the length of the lip.We present here an innovative concept based on the musical triad .A triad is the simplest form of the chord-three notes. It can be used in any degree of a major or minor scale. A triad consists of the 1st-root or the degree on which it is based, the 3rd which is the major or minor above the root and
the 5th which is the perfect, diminished or augmented, above the root. In this concept which we named the V-2 zee triad flap repair, the V is the main flap like the C flap i.e.” the root flap” and the two zee baby flaps are the 3rd and 5th  minor flaps around the triad to give the flap the desired length. When sounded together these three flaps provide a somewhat harmonious result. Using this concept, one is able to work around the basic framework of the root flap and augment or diminish the smaller flaps to produce aesthetically pleasing results in the wide cleft lip. The root C flap like the middle C in music remains the same throughout, but with various harmonic mechanisms in technique, one is able to make minor adjustments to achieve the most out of the surgical procedure.


The patient was a five month old with a wide neglected left cleft lip. The V flap was raised on the cleft side and tucked into a slit in the inner part of the alar base so that it was hidden quite well. The upper baby zee flap was placed close to the columella base line and the lower baby zee near the white roll. The nose was released from the pyriform aperture and adjusted; two small mucosal zee flaps on the lip were added. The immediate post operative result was satisfactory and the patient had good oral function

Discussion: Correction of the very wide cleft which has been neglected or where there are no orthodontic services can be quite a tricky challenge for plastic surgeons. Various methods of repair have been tried by many surgeons and some get good results in a cleft team. In this case of neglected wide cleft,the  above design proved to be quite useful.We would like to recommend it for surgeons who work in difficult conditions where specialist services are not easily available.

Pic 2: V-2 zee triad concept flap

* accepted as an abstract at the Taipei Grand Hotel, 7th Asian Pacific Craniofacial and 6th
International Surgical Simulation Conference 2008 Oct

Suggested reading:

  1. complete unilateral cleft lip –nasal deformity : M Samuel Noordhoff,Yu Ray Chen et al Op Tech PRS vol 2 no. 3 ,Aug 1995, 167-174
  2. Cleft lip : unilateral primary deformity –James  DB. Steve Byrd PRS March 2000 105:3
  3. Millard repair of unilateral cleft lip -25 yrs follow up,Magnus Becker ,Scand Journal Plastic recon Surgery 32: 387-394 , 1998
  4. The Smile Train DVD 2006 , cleft lip repair

Asiatic Aesthetic Series 177:Crooked nose rhinoplasty in the cleft patient

The crooked nose deformity is quite common in the Arab world where there are several aberrations in the nasal anatomy .This makes rhinoplasty in some of the cleft patients even more tricky because of the extra challenges for the plastic surgeon.

The common observations one might make in such cleft nasal deformities are

1.       bulbous tip

2.       deformed alar cartilage

3.       drooping tip with an abnormal naso labial angle

4.       loss of columella support

5.       caudal septal devation
All the above problems cause separate problems for the rhinoplasty surgeon and each problem has to be addressed during the management of cleft rhinoplasty.
Case example: This 20 year old  female cleft patient  was operated at our unit in Badan village
The cleft patient presented with midface dysplasia,cleft nasal deformity with a  deflected  septum to left,bulky tip, ala and hanging columella deformity,crooked nose

 Pic 1:Stage one osteotomy of bony septum, correction of caudal deviation,caudal septal resection and Tajema were done along with correction and defatting of the tip,lip adjustment.The alar cartilage discrepancy was adjusted and ala domal sutures placed after minimal resection of the lateral domes to narrow the nose.The extra cartilage from the septum and alar region was used to strut the columella.Parts of the medial crura and lateral crura were fixed to the septum with fine non absorbable sutures.

Pic 3: the naso labial angle was also adjusted in the process; a separate low to low nasal osteotomy will be done at a later stage

Suggested reading:
          Suture algorithm for the bulbous nasal tip: Ronald R Gruber PRS 110:7 Oct 2001
          Diced cartilage rhinoplasty RK Daniel PRS  113:7 June 2002
          The deviated nose :optimizing results using a simple classification and algorithmic approach  Rod JR  PRS 110:1509,Nov2002
          Nasal Osteotomies: A Clinical Comparison of the Perforating Methods versus the Continuous Technique Joe M. Gryskiewicz, M.D. PRSVol. 113: 5 April 2004
          Understanding the Nasal Airway: Principles and Practice Brian K. Howard, M. D., and Rod J. Rohrich, M. D PRS 109: 1128,March 2002
          The Role of Septal Surgery in Management of the Deviated Nose Hossam M. T. Foda, M.D.Plast. Reconstr. Surg. 115: 406,Jan2005
          Silicon augmentation rhinoplasty in Orientals Colin Tham, MB, ChB (Aberdeen), FRCS,Yung-Lung Lai, MD,Chau-Jin Weng, MD,and Yu Ray Chen MD Annals of Plastic Surgery  54: 1, January 2005
**Post Traumatic  Rhinoplasty for the Arab crooked nose deformity
**YS,Bona Sept 2008, abstract accepted for the 7th Asian Pacific and 6th International Surgical Simulation Conference,Taipei Grand Hotel Oct 2008

Thursday, August 30, 2012

Asiatic Aesthetic Series 178:less is MORE

 K  I  S  S

Keep  ISimple and  Straightforward  in large volume unilateral partial cleft lip surgery

(..less is more)
 I often perform large volume unilateral cleft lip surgery in mission camps, and over the years have redesigned the C flap technique to include a simple "crescent moon incision cheiloplasty" to address the problem of big numbers in cleft lip surgery mission camps. The basic Millard principles of cleft lip repair remain unchanged but there are a few helpful modifications in technique,including an added advantage over the C flap .
In crescent moon incision cheiloplasty ,the crescent is drawn from the midcolumella point to the peak of the proposed Cupid bow on the cleft side . The corresponding measurement from the broadest point of the non cleft side is made and joined to the tip of the other side. The orbicularis is dissected for a distance of about 2 mm and closed from the top to bottom; an extra suture is placed on the pars marginalis to prevent a lip notch in the late post operative period.To equalize the philtral heights a skin hook is used to pull down the curved flap by the assistant while the surgeon does the closure. For a mucosal cheiloplasty, I use a triangular Noordhoff flap/one to two small z plasties. The whole technique takes me about 15 to 20 minutes only and our team in Yarim  is able to complete the large list of upto ten cleft lip operations in one day's list. However, these days we limit our numbers to about 7 a day so that we can rest adequately in between.Large volume cleft lip surgery is common only in very poor countries where there are no regular sevices.
On the flip side,one can get burnt out very easily in this given situation. Our most recent experience was a mega smileathon during the Arab uprisings in the Yemen where thousands were being massacred across the nation and the already failing health services came to a virtual standstill. Many cleft children were stranded in the villages and so we operated hundreds in a very short period of time.All other expat NGOs had fled the country because there were terrorists and gunslingers everywhere. It was very difficult for me to do this but I went ahead and operated the entire list .

Thankfully it went well for my anesthetist Wahed and me and many children were helped(although we both almost did not make it back to Sana after the camp in Yarim when  rogue military units went to war suddenly in Sana using heavy artillery).The whole experience skewed up my mind and I wrote "Psychedelic Zombie" as a result of my first hand experience with the horrors of the Arab Uprisings when the streets of Sana and elsewhere  were  strewn with bodies of massacred individuals  some of whom had their entire faces blown off by rocket launchers and machine guns. A terrible tragedy of holocaust proportions. 

I honestly admit that as an aesthetic surgeon, I would much rather do my aesthetic cleft surgeries at a slower pace in a normal hi tech cleft unit where everything works smoothly and there is not the extra burden of large numbers of impoverished patients who travel days to get to the cleft mission camps.
This technique is useful mostly for the unilateral 1/3 or 2/3 cleft lip and the narrow to moderate complete unilateral defects.The mucosal flaps in complete cleft lip take some extra time for closure.Wider cleft lips usually require the C flap with an extra z plasty near the white roll. A very thinned out vermillion may even require three mucosal z plasties for adjustment.The technique is useful only if there is no corresponding alar deformity which usually requires extra time for correction.
Remarks: The results are comparable to other methods like the C flap repair and it's modifications ,or the fairly recent straight line closure methods used by some plastic surgeons.The only advantage over the C flap is the absence of nasal sill retraction with this method. The technique is fairly simple,given the plastic surgeon's vast experience and can be used especially in large volume cleft surgeries.I would like to add that cleft lip surgery is not as simple as it sounds but requires many hours of study and practice before using such a method.I have done over a thousand five hundred similar cases over fourteen years before designing this easier alternative using a simplified approach.
Pics and comparison with the C flap
Patient 1: using a modifed C flap procedure with mucosal zee cheiloplasty

 Patient 2: using the above mentioned Yemeni crescent moon cheiloplasty method;an undersurface mucosal zee was added here to adjust the discrepancy in size(some swelling of mucosa immediate post op due to injection of mucosa).The patient did well post op.
Suggested reading:                 
Unilateral cleft lip nose repair: a 33 year experience -Ken E Salyer: JCF Surg vol14:4 July 2003
The Surgical technique for unilateral cleft lip –nasal deformity : M Sam Noordhoff: Taipei 1997, NCF ;
The Smile Train Virtual Surgery Videos: Unilateral cleft lip
  2001,NY The Smile Train US

* *

a.The innovative V -2 zee triad concept flap for the neglected very wide cleft lip
**b.The unilateral cleft lip-“Simple minor variations on a theme of the C flap

**YS,Bona Sept 2008, abstracts accepted for the 7th Asian Pacific and 6th International Surgical Simulation Conference,Taipei Grand Hotel Oct 2008

Asiatic Aesthetic Series 179:Speechless in Cincinnati

                                                pic:artist impression of Tower of Babel

Everybody’s talking...I can’t hear the words they’re sayin’

The war is over and won. Loopalazoo has been enshrined in the hearts of millions of Americans as the shibboleth of a new world order. The formula works once in a lifetime and only for a chosen few. The same would have had disastrous consequences in the war between the Koreas. The defeated Japanese have since reinvented themselves  into one of the most sophisticated and noetic societies on planet earth.No more guns and roses. Success is redefined by sushis and geisha nites .So like the French who don’t care how you pronounce it as long as you do it.La vie en rose et je ne regrette le rien. Others of the enlightenment  have been discussing themselves almost to hellinistic extinction.Words are cheap and the end result is grinding poverty and angst.The root end paradigm of an enormous EU crisis of biblical proportions.It is impossible to bring  the lost Ephraimites back to life again.

One has to come up with more novel ideas than kalavachi lollipops and ying yang loopalazoos to ensure another mega power ball win. Obamanomics may prove to be the right way forward only if he wins a second majority.If he loses,he will be mercilessly relegated to the minority report shelves of Abu Hussein by etymologists of a rapidly diminishing minority matrix . Thankfully, he has the majority of the other world on his side, at least for now. Is it  time to cash in on aliens ,including all these illegal immigrants by offering them chocolate coated sweeteners? Ying and Yang. The world is getting flatter by the hour since India and China are no longer forgotten civilizations, but incredibly powerful and corrupt allies to reckon with even by the likes of Bernie Madoff and Libor.Money talks,the rest walk. No one cares these days if New Yorkers speak  Hindlish or Chinglish.Business is brisk and the kitty is always filled to the brim at the end of the day. Old world skeptics are speechless, to say the least.

It is now March 2012, well past the midnight hour in Cincinnati, Ohio . Ann Kummer has  given up trying to get plastic surgeons and speech experts to speak a common language. Neo solipsism is the eulogistic buzz word across the universe and people just aren’t listening anymore to each other .

“The agenda has not changed over the decades! Many experts still talk about 'better', 'improved' speech but not many refer to 'normal' speech in post palatal surgery.It still strikes me that surgeons just stick to their 'techniques', with less acceptance of others, and use their own criteria in justifying this. If you only have a hammer, then everything looks like a nail! One glove does not fit all...especially in clefts! Enough of this personal 'soap box'....” (comments from Harley Str, London 2012)

The world which was at your doorstep is now within your living room.The speaking tree and ying yang control vast areas of an overburdened capitalistic system that can no longer sustain itself for too long. Chasing that dream can often lead to nightmares. The only precarious consolation lies in an intractable last ditch that both are surreal. Deterministic changes could be made in space time history before the emperor’s last sigh.

Will there be an age when people speak the same language that can be understood by one and all? Perhaps  nyet. The tower of Babel has fallen and it will never be the same again for mankind.

“Therefore, there cannot be much

progress in improving speech outcomes until there is a

reliable way to actually compare outcome results through

an ‘‘apples to apples’’ comparison”*…or did I just hear Banta Singh’s “ Applay!” to Yu Rong’s “AppBrrrr?”

*Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals

Ann W. Kummer, Ph.D., C.C.C.-S.L.P., Stacey L. Clark, M.D.,Cleft Palate–Craniofacial Journal, March 2012, Vol. 49 No. 2

Saturday, August 25, 2012

Asiatic Aesthetic Series 180:One note samba gone wrong

"The ability to convert has to be elegant *”
Some years ago, my dear Singaporean friend and Intl Patron of Yemen Smile Mission, *Raymond Wah, former vice president of HP's Personal Systems Group (PSG),advised me to leave behind a smile legacy in Yemen .That comment made me focus on standardized techniques in cleft surgery so that all could benefit from the work in future. I thank Ray ,who is now the new VP of Samsung, ( for his support over the years, including his generous gifts of two HP Compaq laptops for the mission in Yemen.

An elderly woman’s do-it-yourself restoration project has potentially ruined a 19th-century Spanish fresco.

"Experts are now trying to salvage the painting of Jesus Christ in a crown of thorns, known as “Ecce Homo,” or “behold the man.” The terribly botched restoration has been jokingly dubbed “Ecce Mono,” or “behold the monkey” for the new painting’s striking similarity to what BBC called "a crayon sketch of a very hairy monkey in an ill-fitting tunic.”

As numbers of primary cleft surgeries increase across the developing world ,one of the worrying trends is an increase in the percentage of iatrogenic deformities. More often than not, the cleft deformity is replaced by another equally grotesque deformity( done by inexperienced surgeons).
There are numerous complaints from host countries about the quality of work done by safari smile missions who bring in inexperienced residents to do the surgery while their big bosses are out sightseeing or playing golf in the resorts.
Updates on China cleft missions where there are many spoilt cleft cases by visiting expat plastic surgery teams..
" It is sad that most of the so-called plastic surgeons do not have much clue about managing cleft lip/palate programmes and hence messed up a lot of the cases. They have no patients in their homeland and when they see the crowd of such patients they become frantic and like sharks starting attacking them surgically. Of course we can predict the results. I had seen many such patients with previous repair - some with cutaneous-mucosa fistulas. One had just the lip repaired below the protruding pro-labium and with the maxillary protrusion above it recently. They have no clue of repairing the bi-lateral cleft and took the most convenient way out. Very sad indeed.
So please educate the people that not all the so-called charity doctors or experts are humane and provide the best service. They can be crooks in disguise trying to get a big name for themselves.
 When I went there they showed me some of the post-operative results. I just could not comment. Now they want me to go to the source in Fugong to operate on them" (views of a prominent consultant plastic surgeon)

feedback on the above comment:

“RE: “Humanitarian” missions by non-practicing cleftlip/palate surgeons. I have written several times about this problem.  It is obviously unacceptable.  None of them repair cleft lip/palate at home.The photographs of their results are unacceptable. I’m certain their fistula rate is over 50%, just as in published outcomes. They are incapable of training local surgeons and setting up a sustainable center.  They use these trips for advertising in local newspapers. I cannot simply ask them to stop these trips; only the surgeons in the country can do that.” ( a world leader in plastic surgery)

Harsh words to some, but sometimes one has to speak up despite criticisms from offended do gooders because they are sincerely wrong.And the mess left behind can be almost impossible to correct at times ( like a huge palatal fistula).
 The timeless message to plastic surgeons by their teachers  is very straightforward .."if you do not do it in your own home country,please do not try it on poor patients outside". Good advice.
The other issues  raised are..if one is eager to start cleft lip and palate work,be sure you have the background experience and not just a  degree from a good Univ etc.
I agree  a 100%  after correcting hundreds of spoilt cleft lip and palate cases by well meaning but insufficiently trained expat humanitarian plastic surgeons in the Yemen. The same would never do it in their own home countries.

One of the guiding  principles for most plastic surgeons performing cleft surgery  is," Do the surgery as if the kid was your own child".That is what plastic surgery should be like.

Some German Universities refuse to allow their max facial and plastic surgery trainees to get involved in humanitarian cleft missions till the plastic surgeons have at least ten years of practical experience to prove they are capable enough to perform the tasks. A good move in the right direction to prevent iatrogenic deformities.

Mr Smile maker, have pity on cleft children in a poor country!
Some advice to cleft mission aspirants:
1. how many standardized procedures have you done in the past before you think you should lead a cleft team?
2. do you have tangible proof that your results are good..photographs etc?Do other plastic surgeons with expertise in this area agree with your results?
3. do you feel the need to teach? . If so, how many secondaries have you corrected successfully?
If one is hesitant to answer these questions,then it is better to wait and humbly accept one's postion as a team member with others who have the required level of expertise in such work. These days,cleft patients are more well informed and may not forgive the attending surgeon so easily.Also, local news channels, physicians groups and news papers may report the outcomes of such cleft missions and thereby tarnish the reputation of the mission or visiting Univ hospital teams.

 It takes time and real effort to make a smile .The learning process continues because many questions still remain unanswered even for the seasoned aesthetic cleft surgeon.Expertise in aesthetic cleft surgery is not an innate gift but a result of countless hours of hard work and study with people who are experts in the field. I am not a "self styled BB King of cleft surgery".It took me nearly ten years to learn **aesthetic cleft surgery and other sophisticated **techniques in plastic surgery with my Singaporean and Taiwanese friends.They in turn have standardized their techniques over the years under other experts in the field.

Yeap: “   We should always try to get it right the first time because subsequent surgeries are difficult. The exact measurements are so important in aesthetic surgery.” 

Taipei Chang Gung2006 @ Philip Chen’s Unit

“ Watch the measurements carefully because it is important. I did  not always take this very seriously in the past during my early years with Sam Noordhoff ,but Sam always stressed the importance of accurate measurements in cleft surgery. It took us over twenty years to standardize the procedures for unilateral cleft lip surgery”
Sam Noordhoff 2006 @ NCF Office, Taipei
" When I first started out as a cleft surgeon in Taiwan it was not easy. I had to go back to America to train with good people so that I could do a better job in Taiwan."
"Doing a bad job on a cleft child is worse than doing nothing at all" Sam Noordhoff, Taipei 2006