Friday, October 26, 2012

Asiatic Aesthetic Series 160:In the Mood...jazz fingerstyle and cleft surgery improvisations

Plastic surgery is mostly about innovation and improvisation .Some techniques sell,others do not.
As a fingerstyle guitar soloist, I like to study jazz fingerstyle scores of famous American jazz guitar players. Some of the pieces have a basic 2-5-1 pattern and the improviser usually takes off on different tangents from there, making beautiful licks in the process.

There is not too much one can add to Millard's superb techniques in the art of cleft lip surgery. Modifications have been made to his classic presentation over the years by many plastic surgeons like Noordhoff and others .But all innovations are based on the basic principles of Millard.

In cleft palate surgery,there are numerous claims and counter claims .The time tested two flap procedures with Langenbeck variants,muscle repositoning methods used by famous plastic surgeons in the past have not changed  much.The basic principles remain the same,more or less. The desire to re invent the wheel goes on and on.Not many extraordinary answers to  old questions but many new players in the process. Many years ago, I met a young man who was treated by a famous Frenchay plastic surgery consultant for his complete cleft lip and palate speech.The surgeon had done a tremendous job. The boy had perfect speech and looked really handsome without any tell tale scars. That was nearly 19 years ago. Not many of us can get such results,despite massive technological advances since that time. That was the beginning of my journey in cleft missions.

As I sit in my office reading an amazing 7 page score by a former GIT (Music Institute, CA) teacher on the improvised version of Glen Miller's famous hit,"In the Mood"  I notice that the basic 4/4 rhythm pattern  is still the same,the introduction riff cannot be replaced by any other arrangement because it is the core essence of this famous jazz piece. The standard jazz walking bass line progression accompanying the score cannot be changed because it is tailor made for the song. The basic intro riff includes a simple progression using Ab7-Db7-Eb7. In the earlier years, this song was played by the Shadows and other old timers using basic chord patterns with wonderful results.
The US improviser in this  newer and "jazzier" version adds some sophisticated progressions with a "Tuxedo Junction" thrown in. So you have  Ab13-Ab0-Bbmi7-Ebsus4 and so on. It sounds great to the listener but one cannot help notice that the improviser has to return to the original score to get the real punch effect. Without it,the magic is gone and the riffs remain anonymous licks from progressive jazz improvisations.

I wonder where we guys would be today without Glen Miller and Ralph Millard? 

The new US national anthem ,"In the Mood" is being improvised in some remote shangrila today...but the basic principles will always remain the same... :-)

Saturday, October 20, 2012

Asiatic Aesthetic Series 161: Hope to thousands of Yemeni cleft children

Since January 2010,  940 cleft lip and palate patients have benefited from the charity support of the United States Smile Train
Most of these kids come from the impoverished villages of  Yemen where plastic surgery patients live with their deformities for life.
When the cleft lip and programme was launched in Yarim Cleft Centre for these poor families,many did not believe that government hospitals in Yemen could offer such services.
Today the US Smile Train has touched the lives of thousands of poor Yemeni families across the nation of Yemen and many continue to register at the Yarim and Baadan health centres for their free surgeries.

My message to our Yemeni friends in the government hospitals was simple-guys take this opportunity to help your nation .The US Smile Train is willing to help every cleft child in your villages and towns. They got the message and some friends who own major GSM companies sent out 3 to 4 million text messages to every village and town in the nation. The idea of mobile networking for cleft lip and palate missions was born in Yemen and is being used in other nations now.

pic:                                  41 Madison Avenue,Smile Train HQ New York

Wednesday, October 17, 2012

Asiatic Aesthetic Series 162:Tackling the thorn in the flesh:the junctional fistula

The junctional fistula is one of the commonest problem one faces in cleft palate surgery.
This is most probably due to the thin nasal mucosal layer at this junction and also because of the sometimes wide cleft which makes closure difficult.
To prevent the problem ,I have tried some of the following:

1. Two stage repair where I close the soft palate in stage one and the hard palate after six months.The chances of a fistula are generally lower in a narrow defect. Of course,technical finesse adds to fistula prevention.
2. To decrease the tension during the 2nd stage,I often make a button hole release of the mucoperiosteum during stage one on one side of the hard palate.This eases soft tissue distraction over the months,making closure tension free.

One of the useful methods I use in closing the fistula is to use two lateral Langenbeck type relaxing incisions on both sides of the defect to create a tension free repair;the technique is relatively simple to learn and is used successfully for closure of  this type of fistula.

Sample pic: using the lateral release incisions for fistula closure

Sunday, October 14, 2012

Asiatic Aesthetic Series 163:soft tissue distraction palatoplasty

Older cleft palate patients tend to bleed more during surgery and  also experience more pain post op .
I usually perform adult palatoplasty in two stages for the complete cleft palate .
In stage one, I close the soft palate and also make a button hole over the hard palate rugae to insert a fine dissector and release the mucoperiosteum.This allows soft tissue distraction over time and decreases the hard palate defect considerably.
Rapid distraction of the hard palate has been tried in some European centres using  osmotic expanders (*1) but the technique remains controversial and is not popular anywhere else in the world.
The second stage hard palate repair can then be closed after six months using a hemi palatal flap.

sample pic: stage one soft palate closure with  unilateral button hole palate release over the hard palate.

Reading: *1 Cleft palate repair with the use of osmotc expanders- KF Kobus, Poland JPARS 60,414-421 Year 2007

Monday, October 8, 2012

Asiatic Aesthetic Series 164:Button hole palatoplasty concepts

In a complete cleft of the soft palate I use a button hole to fracture the hamulus and medialize the levators which are then retro positioned by detaching them from their abnormal insertions.
Very often ,in a cleft of the soft palate, the upper third extends into the hard palate and as a result I make a lateral button hole midway ,close to the hard palate rugae and lift the entire mucoperiosteal flap thereby making tension free closure possible. I have found this innovation to be useful in these select cases.
sample pics: