Sunday, September 30, 2012

Asiatic Aesthetic Series 165:Aesthetic lip defatting in cleft lip surgery

As a very large volume mission plastic surgeon,I often come across cleft lips which appear bulky and difficult to adjust with the  conventional cheiloplasty methods. Quite often I have had to painstakingly adjust mucosal flaps using the double zee or Noordhoff traingular flap with variable results.Some of the results I got were superior to others.This was mainly because of the presence of a thick lip on one side,making aesthetic adjustments more complicated for the plastic surgeon.
The technique is frustrating for my cleft and plastic surgery trainees who have to figure out the exact adjustments without much success ,mainly because of their inexperience in plastic procedures.

Recently, I devised a simple aesthetic technique where i use very fine sharp scissors to remove some of the fat lobules in the thicker lip which considerably reduces the bulk of the affected lip .I then perform the usual cheiloplasty zee or traingular flap as before.
The final aesthetic outcome is a huge improvement to previous methods of correction and these days I prefer to perform this simple method of aesthetic lip defatting in most of my cleft lip repairs.
The overall results are good and patient satisfaction with this new method are quite high.

 sample pics:


Saturday, September 29, 2012

Asiatic Aesthetic Series 166:Prelim lip adhesion for the asymmetrical bilateral cleft lip

These days I prefer to do a prelim adhesion for the asymmetrical cleft lip because of the better outcome following a staged repair.
It is often difficult and time consuming to repair the asymmetrical cleft lip and some plastic surgeons prefer to use this staged procedure for better results.
During my visit this year @ John Mulliken's Unit at Childrens Boston,John showed me a child where he had done the first stage adhesion for an asymmetrical bilateral cleft lip.
The first stage adhesion more or less equalizes the vertical lengths making it a lot easier for the surgeon to perform a proper symmetrical closure at a subsequent date.
The technique is simple and gives much better outcomes.I also add a floor of nose recon during the procedure.



The second stage of lip recon is much easier with this methods because the lines can be drawn accurately and the overall outcome is much better.Below are some samples of the 2nd stage. Finer adjustments like nose correction,cheiloplasty modifications are done at a later stage after the functional and aesthetic correction.





Asiatic Aesthetic Series 167:The problem case-unoperated older cleft palate patient

One of the many challenges we face in rural cleft missions is the unoperated cleft palate in older patients.
This week, we saw a 25 year old male with an unoperated cleft palate.
On examination, he had a complete cleft palate,which was asymmetrical ;the patient also had severe VPI. The lateral pharyngeal wall movements were good and strong on direct vision.

An initial stage soft palate closure with  levator repositioning was done. In addition we added closure of a few cm of the posterior pillars to decrease the gap.
He did well post op and will come back after a few months for the hard palate closure.

Questions asked: How old should the cleft patient be before the plastic surgeon feels that the patient is "too old for any useful procedure".The repair was done in this case because the patient had good pharyngeal wall movement with a mobile soft palate type 1/2 and might benefit from a staged corrective procedure.
Many questions remained unanswered in the older cleft palate patient with VPI because there are not too many long term studies done in this group of patients.

Asiatic Aesthetic Series 168:an unusual cause of premax deformity in the bilateral cleft lip



This 5 year old cleft child with a bilateral cleft lip deformity had been operated earlier by a surgeon in Sana'a and was later referred to our free camp at Yarim hospital. The child presented with a badly repaired bilateral lip and a protruberant left premax.
At surgery,we noticed a smooth swelling on the left premax which turned out to be an inclusion cyst.After lateral premax osteotomy,the cyst with a tooth inside the cavity was removed and an initial lip  and nose adhesion was performed.
The child did well post op and will attend a follow up surgery camp for the revision cheiloplasty and floor of nose recon.

Remarks: Premaxillary protrusion is a common problem in many bilateral cleft lip presentations and we usually perform some form of setback using reduction and k wiring,thumb pressure reduction, and in this case, removal of the cyst which made closure possible.

Friday, September 7, 2012

Asiatic Aesthetic Series 169:More with less...the concept of aesthetic palatoplasty

The main goal for every plastic surgeon practising cleft palate surgery is normal speech,although this is hard to fulfil in some patients with varying degrees of VPI.
Aesthetic palatoplasty aims at achieving a marked improvement in speech using relatively simpler methods of palate repair with minimal scarring.
In this method , I repair the complete cleft palate in two stages. Stage one consists of saline hydrodissection,and hamulus fracture using a small lateral button hole incision and muscle medialization.The levators are dissected for some distance from medial to lateral using sharp scissors and retropositioned for a  distance of about one cm. The uvula is 2/3 retropositioned and an occasional zee plasty is added to the upper 3rd of the uvula to allow it to fall back posteriorly.The nasal layer is always closed and there are no raw surfaces.This prevents post op palatal scarring which affects speech.
The 2nd stage includes repair of the hard palate defect using a modified hemipalatal flap where I hinge the flap on superior and inferior attachments and "bowstring"the flap to fill the defect without any tension. The flap is elevated in the mid portion where there is less bleeding and fixation.Surgical gel is used to fill the raw area laterally and the flap is fixed to the lateral wall to decrease movement and post op pain.

Pic1: stage one palate closure leaving a hard palate defect which is closed with a hemipalatal flap after 4-5 months

Remarks: easy to perform technique and good results post op;the chances of a junctional fistula with this method are very low.

suggested read:

1. Islanded hemipalatal flap Vijay K et al, PRS July 2008 122:1 ,232-239
2. Soft palate mucosal adhesion T Oyama et al, PRS Aug 2006 118:2, 469-475


Asiatic Aesthetic Series 170:Taking the “A” Train in cleft palate speech


Trying to speak good..small beginnings in Yarim Village ,Yemen

Problems: No speech services in this impoverished nation. Use of a cost effective method to record speech using a high resolution Samsung wifi smart camera with 18x zoom and ultra sensitive inbuilt microphone. We use a multi lingual strategy using various languages which are difficult even for normal people!

So you think you can speak?
For eg. try ” otsi tso tso ha?” in Lotha Naga or “ ni jiao shama ming tse ”in Chinese ,”kacha pappar,pakka pappar”in Hindi, “Opposite of Rangasawme in Gumudipundee simply is Ranga did not saw me” in Hinglish, and “Inspector Clouseau’s pink panther NYC run on “ ayyy voooold lick to bay ayy yam bugga!” eet eees ay shallanze,mon dieu! ..bon chance…

Patient one:
Hana 11 yr old cleft palate pre op  near normal speech-


Hana is from Dhale village in Yemen; she was not sent to school because of her cleft palate defect. She is learning to speak in English and Arabic   at Yarim hospital cleft centre. Despite her complete wide soft palate cleft and 2/3 hard palate cleft she has near normal speech.
Stage one done this week after speech trial : hamulus #, muscle reposition and soft palate closure
Remarks: Motivated young girl who is making rapid progress. Expect a good outcome soon.
Follow up speech clip later this month. Ward nurse Tahira will help her with reading and speaking lessons.

Patient 2:

Ali Raja Saed 6M  from nearby Taiz with a complete cleft palate .
Stage one soft palate and muscle reposition done 4 mths ago-Ali is keen to speak well.He has moderate VPI which should improve with closure of the stage 2 hard palate cleft and some training. In this clip Ali speaks in Arabic, Hindi,Lotha Naga,Italian,Chinese,English ,Frenchlish .Good one!
2nd stage done this week for hard palate cleft closure with our modified  hemi palatal flap where the entire flap is hinged above and below and made to “bow string” across to fill the defect. The chances of a fistula this way are minimal.


Remarks: Moderate VPI but motivated young child who wants to overcome his speech problems. Expect very positive outcome soon because his parents are equally motivated to get him speaking good. Follow up speech clip later this month.

Asiatic Aesthetic Series 171:The Early Years ...




Establishing

 An

 International Cleft and Aesthetic Recon Mission

For

 A

 developing country in Arabia : lessons from a 5 year experience (2003 June -2008 May)

accepted for a 6 minute presentation @
The Asian Pacific Craniofacial and Surgical Simulation Conference, Taipei Grand Hotel October 5-8 2008

  

Abstract

Many patients in developing countries do not have ready access to aesthetic and reconstructive services. The Republic of Yemen is a poor Middle Eastern country with a population of approximately 23 million people. The population is predominantly Arab with a few Jews and Africans. Health services in most parts of the country are either substandard or non existent. There are no established cleft or aesthetic recon services and many patients have to live with their deformities for the rest of their lives. As a compassionate response to the needs of plastic surgery patients in Yemen, some expats along with HMA Frances Guy, UK Res got together in a very informal manner  and formed a small support group called Yemen Smile in June 2003.The Smile Train USA with the help of Melody Farrin, Michele Sinesky and Delois Greenwood offered  support for ten cleft patients in 2003.Later on, the Yemen Smile Trust was included as a worldwide partner of the Smile Train and two training sponsorships were given for the Taipei 2006-2007 cleft conferences to help the charity improve its existing services in Yemen. Over a period of two years, the founder along with two UK embassy leaders , the expat corporate sector (DNO Norway with Partners and Total E&P France  plus others) , a few expat volunteers both in Yemen and overseas began serious work on establishing an International Aesthetic and Reconstructive Mission for the country of Yemen.Guidlines on Intl NGO charity formation were studied by taking examples from the London Charities Commission with the help of HMA Mike Gifford, UK Residence/FCO London and a governing document was formulated that would be presented to the Ministry of Planning and International Cooperation. The late Dr. Hugh Philips, President of the Royal College of Surgeons very kindly wrote an official letter to the charity, offering to help the charity when he was contacted by HMA Mike Gifford in 2005. After his sad demise a few years later, Mr.Martyn Coomer from the Royal College of Surgery reiterated the support of the Royal College of Surgery for the charity. The principal cooperation agreement between the Government of the Republic of Yemen and the Yemen Smile Mission Trust was formally signed in April 2007.In March 2008, the Ministry of Planning officially accepted the back up medical team along with the support of CL Yeap, Aesthetic Recon Consultant Mount Elizabeth Singapore, Rodney Lim Laser Specialist, Medline Tech Singapore and others. A few months later,two prominent Consultants offered to help with difficult consultations. An e clinic was started and Prof John B Mulliken ,Director of the Craniofacial centre Childrens hospital Boston and Tony Moss offered to advise in diagnosis and treatment. Dalia Nield of the London Clinics offered her journals and also some instruments.

This team would be responsible for coordinating services as well as networking with other expat specialists for the benefit of Yemeni cleft and other plastic surgery patients..

 A locally grown International Aesthetic and Recon Mission  dedicated to providing cleft care was thus formally established with the main office at the home of HMA Mike and Trish Gifford in London for the benefit of the cleft and plastic surgery patients of Yemen. This would serve for many years as the country’s main Plastic Surgery support foundation for the patients in this country. During the period of formation of the International NGO, several hundred patients received free consultations and treatment for cleft and other plastic surgery deformities. Because of the success of the cleft and other plastic surgeries on hundreds of Yemeni patients, Yemen Smile was officially given the status of the country’s only International Aesthetic and Recon Mission with the full support of the Government of Yemen to continue the work in all the governorates of Yemen. According to Chief International Patron of the charity, HMA Frances Guy, the long term goal would be to train Yemeni technicians and surgeons to carry on the mission work for the benefit of Yemeni patients.


Introduction

From 2003 June till March 2008 efforts were made by some expats to help Yemeni cleft and plastic surgery patients. The initial challenges were mainly because of   the poor health infrastructure across the country and unsafe medical practices in many of the country’s hospitals. A few visiting European plastic surgeons visited the country about once in two years to help some of the patients ,but similar to many developing countries1 there were no established cleft or aesthetic recon services for the patients. Several visits were made across the major governorates of the country by our medical team to assess the needs for cleft and aesthetic recon services. The services were non existent in all the hospitals we visited. Over a period of three to four years ,basic improvements were made in these target hospitals to build up a safe infrastructure for the cleft and other patients. The units were equipped with proper anesthesia machines, multiparameter patient monitors, suction, lights,  and bipolar cautery units. Local staff were encouraged to participate in the programme and community participation was also encouraged. Some of us from the expat medical team were actively involved in the main camps and training of local surgeons.Fortunately, the local Yemeni nurse anesthesia expert in our team had a very good safety record and  he performed all the OT procedures without any morbidity or mortality. Over 550 patients received consultations for cleft lip, palate and other plastic surgery deformities and over 544 were successfully treated. The work was appreciated by the Govt of Yemen who encouraged us to start an International cleft and aesthetic charity for the benefit of their citizens. Today, Yemen Smile is an officially registered UK Trust with the Ministry of Planning and International Cooperation for the cleft and other plastic surgery patients of Yemen.


Materials and methods

In order to meet the growing needs of cleft and other plastic surgery patients in Yemen, a small team of volunteers worked on the following to establish an International charity NGO for the patients:

1.Formulating a Governing document . This was very kindly prepared by HMA Mike Gifford, UK Res and his team of expat Trustees using some helpful guidelines from the London Charities Commission.2 A website www.yemensmiletrust.org explaining the aims and objectives of the charity was designed by Stan Hazell (ex Senior journalist of ITV, UK).The aim would be to help cleft and other plastic surgery patients and offer training to local surgeons. This was presented to the Ministry of Planning and International Cooperation who were very kind to allow the team to start an International NGO without any obstacles in the process.

Governing Document:

The work would be presented as the Yemen Smile charitable trust, run by volunteers, which would provide free or low cost medical services, primarily to children and young people in Yemen, in particular, provision of cleft lip and palate and other reconstructive plastic surgery. It would also provide training in cleft surgery and other medical techniques to selected doctors and other medical personnel in Yemen, with a view of increasing the availability and expertise of such services in the country.

The charitable trust would be administered by a group of trustees.

Application of income would be in furthering the following objectives:

a. to provide free or low cost medical services, primarily to children and young people within the republic of Yemen, in particular, provision of cleft lip, palate and other reconstructive plastic surgery

b. to provide training in cleft lip and palate surgery and other medical techniques to selected doctors and other medical personnel within the Republic of Yemen, with a view of increasing the availability of and expertise in reconstructive plastic surgery within the Republic of Yemen.

At their discretion, the trustees may spend all or part of the capital of the charity in furthering the objectives.

Powers:

The Trustees would exercise any of the powers in order to further the objects:

a. to raise funds. In exercising this power, the Trustees must not undertake any substantial permanent trading activity and must comply with any relevant Yemeni or British statutory regulations

b. to buy, take or lease or in exchange, hire or otherwise acquire property and to maintain and equip it for use.

c. to sell, lease or otherwise dispose of all or any part of the property belonging to the charity. In exercising this power, all of the trustees must agree

d. to co-operate with other charities, voluntary bodies and statutory authorities and to exchange information and advice with them

e. to support any charitable trusts, associations or institutions formed for any of the charitable purposes included in the objects

f. to create such advisory committees as the trustees think of it

g.to employ and remunerate such staff as are necessary for carrying out the work of the charity

h.to do any other lawful thing that is necessary or desirable for the achievement of the objectives


Delegation:

i. the trustees may delegate any of their powers or functions to a committee of two or more trustees. A committee must act in accordance with any directions given by the trustees. It must report its decisions and activities fully and promptly to the trustees. It must not incur expenditure on behalf of the charity except in accordance with a budget previously agreed by the trustees.

ii. the trustees must exercise their powers jointly at properly convened meetings except where they have:

A.delegate the exercise of the powers under this provision or made some other arrangements, by regulations under this governing document.


The first trustees:

The first trustees and their respective terms of office are listed below:

1. Michael John Gifford       one year

92 North Block County Hall

5 Chiclehey Street

London SE 17PN


2. Patricia Anne Gifford        one year

92 North Block County hall

5 Chicheley Street

London SE17PN


3.Colin Kramer       Five years

DNO Yemen PO Box 16133

Sana’a Republic of Yemen


4. Andre Armand Jean Louis Lamy       two years

Total E&P Yemen

PO Box 842

Sana’a Yemen


5. Vilvanathan         Five years

DNO Yemen PO Box 16133

Sana’a Republic of Yemen

6. Stanley Hazell            Three years

36 Abbotsford Road

Redland Bristol

BS6 6HB


7. Jill Hazell                Three years

36 Abbotsford road

Redland Bristol

BS6 6HB


The founder later started the medical support section of the charity .


Duty of care and extent of liability:

When exercising any power in administering or managing the charity, each of the trustees must use the level of care and skill that is reasonable in the circumstances, taking into account any special knowledge or experience that he or she claims to have.

No trustee, and no one exercising powers and responsibilities that have been delegated by the trustees, shall be liable for any act or failure to act unless, in acting or failing to act, he or she has failed to discharge the duty of care.


Appointment of Trustees:

i.

There must be at least three trustees. Apart from the first trustees, every other trustee must be appointed by a resolution of the trustees passed at a special meeting under the clauses of the governing document

ii. in selecting trustees, the trustees must have regard to the skills, knowledge and experience needed for the effective management of the charity.

iii. the trustees must keep a record of the name and address and the dates of appointment,re-appointment and retirement of each trustee.

iv. The trustee must make available to each new trustee, on his or her appointment:

a. a copy of this document and amendments made

b.a copy of the charity’s latest report and statement of accounts



Eligibility for Trusteeship:

i.no one shall be appointed as a trustee if he or she is under the age of 18

ii.no one shall be entitled to act as a trustee whether on appointment or in any re-appointment as trustee until he or she has expressly acknowledged ,in whatever way the trustees decide, his or her acceptance of the office of trustee of the charity.


Termination of Trusteeship:

A Trustee shall cease to hold office if he or she:

i. becomes incapable by reason of mental disorder, illness or injury of managing his or her own affairs

ii. is absent without the permission of the trustees from all meetings held within a period of six months and the trustees resolve that his or her office be vacated

iii. notifies to the trustees a wish to resign

iv. is, in the view of a majority of the remaining trustees, disqualified from remaining as a trustee by willfully breaking the terms of this document and/or by his or her actions or behavior bringing Yemen Smile into disrepute.


Vacancies:

If a vacancy occurs the trustee must note the fact in the minutes of their next meeting. Any eligible trustee may be re-appointed. So long as there are fewer than three trustees, none of the powers or discretions conferred by this document or by law on the trustees shall be exercisable by the remaining trustees except to appoint new trustees.


Ordinary meetings:

The trustees must hold at least two ordinary meetings each year. One such meeting in each year must involve the physical presence of those trustees who attend the meeting. Other meetings may take such form, including videoconferencing, as the trustees decide provided that the form chosen enables the trustees both to see and hear each other.


Calling meetings:

The trustees must usually arrange at each of the meetings, the date time and place of the next meeting, unless such arrangements have already been made. Reasonable notice of meetings must be given to all trustees.


Special Meetings:

A special meeting may be called at any time by the person elected to chair their meetings. The person elected shall always be eligible for re-election. If that person is not present within thirty five minutes after the time appointed for holding the meeting, or if no one has been elected, or if the person elected has ceased to be a trustee, the trustees present must choose one of their number to chair the meeting.


Quorum:


i. Subject to the following provision of this clause, no business shall be conducted at a meeting of the trustees unless at least one third of the total number of trustees at the time, or two trustees are present throughout the meeting.

ii. The trustees may make regulations specifying different quorums for meetings dealing with different types of business.



Minutes:

 The trustees must keep minutes, in such form as the trustees decide, of the proceedings at their meetings. In the minutes the trustees must record their decisions and where appropriate, the reasons for these decisions. The trustees must approve the minutes in accordance with the procedures, laid down in regulations.


General power to make regulations:

The trustees may from time to time make regulations for the management of the charity and for the conduct of their business, including:

i. the calling of meetings

ii. methods of making decisions in order to deal with cases or urgency when a meeting is impractical

iii. the deposit of money in a bank

iv. the custody of documents and

v. the keeping and authenticating of records


Accounts and annual report:


The trustees must comply with the following:


i.                    the keeping of accounting records for the charity

ii.                  the preparation of publicly –available annual statements for the charity

iii.                the auditing of the statements of accounts of the charity

iv.                the preparation of publicly available annual report on the activities of the charity.


Bank Accounts:


Any bank or building society account in which any of the funds of the charity are deposited must be operated by the trustees and held in the name of the charity. Unless the regulations of the trustees make other provision, all cheques and orders for the payment of money from such an account shall be signed by at least two trustees.


Trustees not to benefit financially from their trusteeship:


a. No trustee may receive any remuneration for any service provided to the charity and no trustee may acquire any property belonging to the charity or be interested in any contract entered into by the trustee otherwise than as a trustee of the charity.

b. Any trustee who is a solicitor, accountant or engaged in any profession may charge and be paid all the usual professional charges for business done by him or her firm, when instructed by the other trustees to act in a professional capacity on behalf of the charity. However, at no time may a majority of the trustees benefit under this provision and a trustee must withdraw from any meeting of the trustees at which his or her own instruction or remuneration or performance, or that of his or her firm ,is under discussion.


 Insurance and indemnity:


The trustee shall ensure that any person or company employed by or delegated to carry out work for the charity in pursuit of the objects of the charity, particularly medical operations, shall be fully insured and indemnified against any claim of liability. The trustees will use their duty of care to ensure that medical operations carried out within the Republic of Yemen by the charity or its agents are in accordance with the laws of the Republic of Yemen.


Expenses:

The trustees may use the charity’s funds to meet any necessary and reasonable expenses which they incur in the course of carrying out their responsibilities as trustees of the charity.


Dissolution:

The trustees may dissolve the charity if they decide that it is necessary or desirable to do so. To be effective, a proposal to dissolve the charity must be passed at a special meeting by a two thirds majority of the trustees. Any assets of the charity must be given to another charity with objects that are no wider than the charity’s own or to any other medical charity operating within Yemen.


2. Funding for the projects through locally based expat companies and other donors; the main donors were DNO Norway and France’s Total E&P Oil Company along with other smaller donors. An approximate budget was planned for a 4-5 year programme and the expat corporate sector made pledges to run a transparent accounts section through the Norwegian Oil DNO Head office in Sana’a in order to ensure a steady flow of funds for the programmes across Yemen. Trish Gifford of the UK Residence very kindly offered the use of her home in London as a temporary office for the charity so that other well wishers in the UK and Europe could support the work in Yemen.




3.Forming a medical support team that would address the cleft and other plastic surgery problems; a locally based team as well as an international online consultation service . This was much appreciated and accepted by the Govt of Yemen. The Smile Train USA very kindly offered support for ten cleft patients in 2003 as well as two conference sponsorships at Chang Gung Taipei in 2006 and 2007.




A forum was started with the help Nigel Mercer of the Frenchay Unit and Tony Moss of Saint George’s Tooting to discuss a proper primary cleft protocol .The goal was not to reinvent the wheel but to refine and improve the present concepts with more useful techniques which some world leaders found useful in their practice3. Nigel Mercer gave some helpful methods from the Frenchay primary cleft protocol which they had used very successfully for many years. Many important lessons were learnt during the course of discussions on management of cleft patients. A few newer cleft concepts were also added by Philip Chen of Chang Gung Craniofacial Taipei. Dr. Dalia Nield, Aesthetic and Reconstructive Consultant of the London Clinics/Saint Andrews Hospital Plastic Surgery also helped the team by donating many of her research journals for the work in Yemen.

For aesthetic recon patients ,CL Yeap Aesthetic and Recon Consultant, Mount Elizabeth Singapore very kindly offered hi tech training and donated implants plus hi tech equipment for the consultancy so that more patients could be helped. Rodney Lim of Medline Tech Singapore also very kindly offered a carbon dioxide repeat and superpulse laser along with Total E&P well as other items for the consultancy.


4. Patient database system: Presently the Govt and private hospitals have their own database system in Arabic where patient records are kept for further use; the medical team of Yemen smile works closely as facilitators of the work with the Yemeni hospital network and as result all the hospital data are recorded by the Yemeni hospitals for their patients. In order to have a proper clinical research service and quality control on cleft care the Health system will need to have a countrywide register in the near future4


5. Cleft Forum to improve the services for our cleft patients:

To provide improved services to the cleft population of the country, a forum was introduced with the helpful input of Nigel Mercer, Tony Moss, and others who shared their personal experiences (Yemen Smile Cleft Forum with the Royal College of Plastic Surgery, UK).

Mr. Nigel Mercer suggested the use of vomer flaps in the primary repair because they significantly reduce the cleft width. He also mentioned that the Langenbeck type will give a lower fistula rate. Hamulus fracture is not indicated any more. The anatomical studies show that it has very little effect on the tensor or the palatine aponeurosis.In the Frenchay series they have 10% with some delayed healing and a 5% rate of fistula repair using Langenbecks.  He stressed that one should not lengthen the columella at any stage. The primary problem lies in the position of the medial crura of the alars and the domes.

He corrects these later with a tip rhinoplasty when the child can cooperate.  For the retracted premax in some kids  they need othodontics when the adult teeth are through. For the alar cart on the affected side ,repair is done later, after the bone graft. If the alar is raised when the alveolus is open it will just be pulled back by scarring no matter what. 

Tony Moss shared his experience with the Millard forked flaps for columella lengthening.  It is okay in babies but awful in the adult, therefore many have abandoned this procedure. His personal preference for the columella would be to do a nasal tip projection procedure later.The retracted maxilla needs Osseo distraction or maxillary advancement, with prior orthodontics. If the hospital does not have this service, then one can try soft tissue augmentation, eg Abbe flap.


As a result of several discussions on cleft lip and palate management protocols, a useful and standardized primary lip and palate cleft protocol was followed in our camps with some modifications in techniques. The lip was generally repaired at 3months of age and the palate at about 18 months. Some had gingivo periosteoplasty at 3-4 months at the time of lip repair. All procedures mentioned in the excellent Smile Train USA DVD 2007 video5 were carefully analyzed. Some, however were viewed with skepticism, especially the premaxilla surgical procedure which would cause retrusion later, external incisions over the nose which leave ugly tell tale scars especially in darker skin types, alar base incisions with bad scarring and fixation of the orbicularis to the anterior nasal spine in the unilateral cleft because which would inevitably cause lip shortening later. We were also of the opinion that cleft lip surgery in the hands of experts do take more than one hour (eg. the famous cleft surgeon, Dr. Philip Chen CGMH Taipei) even in partial unilateral cleft lip repair because of the finesse required in making a beautiful smile. The ones done in 45 minutes or less more often than not have to be redone because the results are often unacceptable. One cannot remain complacent with “quickies “in the aesthetic and recon world. Alveolar bone grafts were not done in the safari camps because of the unclean surroundings in most places. Secondary nose corrections were done in the late teens. Under the present circumstances in the country, it was not advisable to venture into the other aspects of cleft care. Several hundred patients benefited from this treatment plan.




Chart: Cleft patient list from 2003 June to April 2008:

Number of cleft groups: 291    Males 167 (57.4%), females 124(42.6%) median age: 5 yrs

Min age: 1mth oldest: 35 yrs (Syndromic cleft patients 3: Kartagener, Pierre Robin sequence

and Binderoid)




















Table 2: Types of cleft procedures used:

Diagnosis
Procedure
1. Unilateral cleft lip
Millard rotation, Mohler C flap modifications, inferior turbinate flap,Tajema (3 months),V-2 zee flap (Xfactorteam)
2.Bilateral cleft lip
Columella elongation flap (3mths)
3. Cleft palate
Langenbeck, NV bundle flap, Furlows (12-14mths)
4.Palate fistula
NV bundle flap, half meat roll flap, buccal mucosa flap
5.Alveolar clefts
Bone graft (none) 9yrs
4.Anterior palate cleft
Primary vomer flap (3-4mths)
5.older patient VPI
Superior based
6.Secondary nasal deformity
Rhinoplasty/silicon implant/cartilage (late teens)
7.Pre maxillary protrusion
Only manual pushback/no resection/orthodontics
8.Maxillofacial deformities
None yet
9.Secondary lip
Revisions
10.Thin lip
Fascia filler
11.Wide bilateral lip with premax
Lip adhesion initial stage or elastic traction (first month)




Table 3:  Other aesthetic and plastic surgeries (178 pts)

Type
1.Burns     30
2.Lasers 45
3.Implants nasal 7
4. Aesthetic facial rejuv. facelift       4  b.perioral rejuv  4 c.laser rejuv  7
5.Rhinoplasties   15
6. Breast (gynaecomastia) 1 ptosis 4
7.Nasal reconstruction   9
8. Eyelids a.ptosis  2   b.blepharoplasty  3
8.Ear reconstruction(defects)     6
9.Other minor plastic procedures(scars, GCA peels,dermabrasion  etc) 18
10. Tumors face  4
11. Vascular malformations face/lip  7
12.Tattoos body  2
13. Scalp  defect   2
14. Other congenital problems: a. syndactyly, CTEV     4
15.trauma
Face/limbs  4
16.Lipoplasty,lipoaugmentation   4







Total number of patients: 469   clefts: 291 others: 178(number by March 2009=540)

Mortality

1         Local hospitals :  3 where local untrained staff wrongly administered drugs without supervision /on their own

2        In Yemen Smile camps with Yemen Smile anesthetist : no mortality

Medico legal cases: none

                                                         Total number: 2003- 2008


Case  /Year
Region
Cause due to surgery
Cause due to anesthesia
Medical error
1.1mth M cleft lip complete 2003
Saadah hospital
Not operated
Wrong anesthesia methods
Local hospital staff anesthesia technicians
2. 2004
Adult 21M complete cleft palate
Seiyun hospital
Adult palatoplasty
Overdose of anesthesia drugs
Anesthesia technician wrong doses
3. 2008
14F
TMJ ankylosis
Taiz Karama hospital
Not operated
Wrong drugs administration by untrained staff
Local hospital untrained staff technician administration of anesthesia drugs











RW Pigott very aptly stated it in his famous speech “Speak ye comfortably”5 that it takes years for the weight of unsatisfactory results to dent one’s ego
Challenges faced during the period: We faced immense challenges during the initial period because most hospitals and patients were not familiar with the concept of cleft care; despite the initial success with primary surgeries, there were also some unsatisfactory results later on in the numerous camps across the country because of the poor post operative follow up system where patients were at the mercy of doctors who were not familiar with this type of surgery. RW Pigott very aptly stated it in his famous speech “Speak ye Comfortably”6 that it takes years for the weight of unsatisfactory results to dent one’s ego. Some of our senior Plastic Surgery colleagues had already learnt their harsh lessons in cleft care and advised others to study the changes in patients over the years before writing glowing statistical reports. Some large cleft groups that were publicizing their impressive reports should have also mentioned that many of their post surgery results were less than optimal to the naked eye, and that some cases obviously needed   serious remedial work. This would present a more realistic picture to patients and other specialist plastic surgeons.The other problem we faced were the great distances of the villages from the primary hospitals in the cities. Because of the distances of Yemeni villages from the main cities, many patients could not receive adequate treatment. As a result, the team introduced the Smile Cell concept for Yemen where rural patients could receive help regularly like in some developing countries elsewhere 7. Along with the help and cooperation of Yemeni govt. authorities, several target units were chosen across the country for the development of small smile cells. 






The Smile Cell Concept

          Many cleft and other plastic surgery patients in developing countries who live far away from main hospitals cannot afford the costs involved in cleft treatment.

          The Smile Cell Concept was introduced in Yemen, a poor developing country8, to address the problems faced by these patients.

          Over a period of five years, several smile cells were established in different parts of the country in order to meet the needs of cleft and other plastic surgery patients. These Smile Cells are target units which are close to the villages where  patients come from and are easily accessible.

          As a result, many patients in Yemen are now able to receive free or very low cost treatment for their  problems at these primary centres.

          The most important requirements for a Smile Cell are:

          A local hospital unit with a trained  surgeon, anesthetist, nurses and medical technicians

          Basic medical equipment for the surgery which include: anesthesia machine, monitor, cautery machine, sterilizers, OT table, suction units, plastic surgical instruments and adequate lighting.



From 2003 June till March 2008 over 550 patients were able to attend our clinics and by March 2009 over 544 patients were successfully treated for clefts and other plastic surgery problems; a few local and expat surgeons were trained in the process. Improvements are still being made in the work with the help of other visiting specialists from overseas. Our main goal is to ensure  safe and effective plastic surgery services for the Yemeni patients and also provide some long term support .We are thankful that our child and adult anesthetist Dr. Wahed Nazir from Yemen  performed his duties to the best of his abilities and that in his hands there were no morbidities or mortalities in any of the cases. Unfortunately this was not the case in other units which we visited earlier with other doctors  where local untrained staff  gave wrong treatments to their patients and  as a result there were three deaths due to wrong anesthesia techniques.



Discussion:


It may well be considered normal routine to perform delicate procedures in a sophisticated suite, whereas the same might pose some inherent risks when pursued with a similar passion in the bush.
Providing aesthetic and reconstructive services in a poor developing country till today remains a formidable challenge. It may well be considered normal routine to perform delicate procedures in a sophisticated suite, whereas the same might pose some inherent risks when pursued with a similar passion in the bush.  A routine surgery in a well developed hospital unit in a rich country or mega city unit with adequate facilities can be a nightmare in a safari mission setting. Some of our friends from sophisticated units in their own home countries realize how difficult it is  to do a simple cleft lip repair in countries where anesthesia facilities are non existent or dangerously substandard. Patient morbidity and even mortality may be unacceptable high in these spartan settings.


The other need is for training local personnel. Many controversies still surround the surgical

management of unilateral cleft lip and cleft lip nose repair.9  For palate closure, we could not follow the recommended  timing  and chose to operate at 18mths because of pediatric anesthesia problems here. The recommended sequence involves closure of the soft palate at 3 to 6 months of age, with secondary closure of the residual hard palate at 15 to 18 months of age 10.Doctors in Yemen are willing to learn newer and improved methods of patient care and surgery but few have the privilege of traveling to other sophisticated hospitals overseas because of language, visa and financial problems. The most useful solution to this chronic problem would lie in training local medical personnel. This takes time and dedicated effort. Over a period of five years we observed some encouraging results of the work; many of the hospitals were upgraded to provide better services and  local staff became more motivated to change the working system for the better.

We are thankful that the Govt leaders in Yemen as well as the medical community and patients believed in what we were trying to do for their country. Many of them lent a helping hand with the safe and effective implementation of the projects across the country. As a result, hundreds of patients can now benefit from the existing services.

The problem of funding most of the country’s aesthetic reconstructive programme was solved by the corporate sector who donated generously both in medical equipment and funding for the programmes. Another encouraging development was the willingness of patients and their families to pay for some of the costs (which were kept at a minimum).This significantly reduced the need for large scale funding of the camps and projects.

To safeguard the interests of the charity mission, our policy was to handle only cases that we were familiar with so that there would be fewer complications;fortunately,there were only a few minor wound infections and most of the patients were satisfied with the treatment.

It has been a useful learning curve for those of us interested in helping communities with low cost plastic surgical care. Till today there are no Plastic Surgery training centres in Yemen and some locals attend short term courses at overseas hospitals.



We are thankful that our work was successful and that the people of the host country were not only kind and hospitable but willing to support such a programme for the benefit of their fellow citizens.





               



Yemeni Smile Units 2008


From September 2008 , several Yemeni Smile cleft lip and palate units  across the country have taken on the full responsibility for helping cleft patients at a discounted price. The smile cell units are small local government hospitals with basic infrastructure units which are equipped to handle the primary lip and palate surgeries.

As a result, more  local patients are now able to afford low cost treatment for their cleft and other problems.

The smile cell units are now found in the governorates of Saadah in the north, Sana'a city, Jibla in the central region,Taiz city,Aden in the south,Seiyun and Mukalla in the Hardamout regions,and Hadibo hospital in Socora island.

Yemeni cleft lip and palate trainees


1.      Dr.Mohammed Alawi Aidaroos-surgeon, Seiyun General hospital

2.      Dr.Khalid- surgeon,Ibn Sina Mukalla,Hadramout University

3.      Dr.Yasser Bal Fakhy- orthodontist, Mukalla city,Hadramout

4.      Dr.Abdulla Matary-surgeon, Jibla hospital, Ibb

5.      Dr.Omer Bawaseer, ENT surgeon Ibn Sina,Mukalla City Hadramout

6.      Dr.Ton K Fahim,surgeon  Saadah Republican hospital

7.      Dr. Rana ,surgeon Aden Republic Hospital

8.      Dr.Muasalem ,surgeon Hadibo hospital Socotra island

9.      Dr.Khalid Mohd Taiz

















References:


1. A rural cleft project in Uganda Andrew Hodges BJPS    2000, 53, 7–11

2 .London Charities Commission: Charity Guidelines (Google search engine)

3. Unilateral cleft lip nose repair: a 33 year experience –Ken Salyer, JCF Surg 14:4, July 2003

4. Computing data about patients with cleft lip and palate Magnus Becker, Henry Svensson Scand J Plast Reconstruct Hand Surg 33: 203–208, 1999

5. The Smile Train Virtual Surgery Videos 2007 NY www.smiletrain.org  

6. Speak Ye Comfortably RW Pigott   BJPS 2000 53, 641-651                                                                                                                                                                                                                                                                                                                                          

7. Development of a network system for the care of patients with cleft lip and palate in Thailand Bowornsilp Chowchuen1 and Keith Godfrey Scand J Plast Reconstr Surg Hand Surg 2003; 37: 325–331

8. Yemen, a UNICEF guide April 1992

9. Cleft Lip: unilateral deformities James D. Burt, M.B.B.S., and H. Steve Byrd, M.D.  PRS 105: 1043, 2000

10. Optimal Timing of Cleft Palate Closure Rod J. Rubric, M.D., Edward J. Love, M.D., H. Steve Byrd, M.D., and Donnell F. Johns, Ph.D. PRS Vol. 106, No. 2 Aug 2000