Tuesday, November 27, 2012

Asiatic Aesthetic Series 152:Smilemakers of Arabia Felix


                            Smilemakers of Arabia Felix

A short documentary film on poor Yemeni cleft kids produced by aesthetic plastic surgeon and fingerstyle guitarist Bona Lotha in Yemen.A tribute to the United States Smile Train www.smiletrain.org for helping a nation in desperate need.Over 830 cleft children have been helped in approx 207 operating days since 2010 January through the Smile Train USA charity programmes in the Republic of Yemen. Yemeni familes convey their respect and gratitude to the Smile Train USA and bless the ones who care about their cleft children.



Standard YouTube License

Monday, November 26, 2012

Asiatic Aesthetic Series 153:Solving the problem of the fatty cleft lip

I often come across cleft lips that are fat and require additional aesthetic makeovers in the process.So I developed the concept of aesthetic lip defatting where i use fine sharp scissors to remove numerous fat lobules as an adjunctive procedure in aesthetic cheiloplasty.The overall results are very pleasing to the eyes and patient satisfaction with this new procedure is high. 
One of my main areas of interest in the field of cleft lip and palate surgery is to develop finer and newer additions to existing procedures so that the end result is more remarkable. As a result as I research newer aesthetic procedures I try to modify each concept by fine tuning it.
No matter how nice the plastic surgeon's repair is,if the fatty lip is not dealt with,the results will not be good.As a result, you see a lot of good repairs but abnormally thickened lips which causes psychological problems for the kid.
I use this new concept on most of my cleft lip patients ;similarly in cleft palate surgery, I have developed the  technique of aesthetic button hole palatoplasty where I make a tiny incision over the hamulus to fracture it and shift the muscle complex medially after which I retroposition the levators about 7-10mm.The results on follow up are excellent and patients do pretty well with their speech outcomes.

Friday, November 9, 2012

Asiatic Aesthetic Series 154:The happy cleft child

Nothing better for a plastic surgeon than to see a happy cleft patient smiling after the surgery! Little Shams was two years old when we saw her at a cleft camp.The other photos were taken two years later .

Wednesday, November 7, 2012

Asiatic Aesthetic Series 155:Useful tips in palatoplasty

Tips on muscle reconstruction in palatoplasty

Levator muscle dissection and retropositioning remains the mainstay in cleft palate surgery. Although I seldom practice radical muscle dissection and prefer a modified lesser approach where I retroposition the muscle by 7mm-9mm,the technique of radical dissection could come in useful for severe VPI problems.

Some useful tips in radical palatoplasty: 1*
Complete dissection of the levator from the oral and nasal lining (upto hamulus and sometimes upto the medial pterygoid plate);incise the tensor aponeurosis from medial to lateral,following it to the point where it hooks round the hook of hamulus;detach levator  from the tensor aponeurosis
Transversely orient the levator after dissection and suture with appropriate tension- too tight=apnoea,too loose=VPI
NOTE: In Pierre Robin sequence the patient has an isolated cleft palate with macroglossia and micrognathia and sleep apnea- be very careful of this. Also take a history of sleep apnea in all cleft palate patients and take extreme care because the of a stormy post op period and respiratory /oxygen saturation problems.
Close oral mucosa with vertical mattress
In this radical muscle surgery ,note- place a tongue stitch for 24 hours for emergency airway control, monitor oxygen saturation continuously during hospitalization.
Discharge 2 days post op after ruling out breathing and eating problems.

Technical details of a moderate palatoplasty

: 2* Ken Salyer uses a different approach for palatoplasty. However, I do not agree with him when he mentions the T shaped vomer incision to tether the repair to a "more anatomical" position because this invariably causes nasal obstruction later. The procedure was abandoned later when he noted the complication of this innovation.

Dissection of the abnormal attachments of the velar musculature and retro positioning to create a functional sling is key and must be performed in all clefts regardless of severity
the mucoperiosteal flaps are elevated starting at the lateral edges and proceeding to the cleft edge to ensure there is adequate mucosa for closure of the nasal lining before incising the edge of the cleft hard palate
in dissecting the uvula, most of the tissue is left on the nasal side and closed with mattress sutures; this creates a bulky pad and enhances the contact between the velum and the posterior pharyngeal wall, contributing to velopharyngeal closure
the neurovascular bundle is mobilized to improve the mobility of the mucoperiosteal flap-the cone of periosteum at the base of the bundle is incised with a fine blade and two parallel incisions are made 2mm from the bundle-a right angled forceps loosens the bundle 
using a palate elevator ,release the aponeurosis from the posterior edge of the palate and divide the levator muscles with a fine scissor/scalpel ,up to the hamulus
incise the tendon of the tensor as it hooks around the hamulus-this facilitates the medial mobilization of the muscle complex
the anterior vomer flap ,starting at the anterior edge of the cleft and extending to the junction of the hard and soft palate ,is used in almost all cases to close the nasal lining-this minimizes tension and less oral mucosa needs to be turned in for the lining
In approximately 70 % cases, the vomer extends beyond the junction of the hard and soft palate, back to the adenoid tissue. In these cases the vomer is incised all the way back to the junction of the adenoid tissues, where it is back cut in both directions as a “T “ and sutured to the nasal lining: it tethers it up to a more functional position
Never transact the nasal mucosa (Onizuka) because it leads to scarring

pics:1* artist impression of  palate repair showing the technique of levator repositioning to a more anatomical level

1*  The importance of radical intravelar palatoplasty during two flap palatoplasty PRS Vol 122:no 4  page 1121 Oct 2008  John H Grant MD

2*  Two flap palatoplasty: 20 year experience and evolution of surgical technique PRS
P191:vol118 number1 July 2006 Ken Salyer, 

Tuesday, November 6, 2012

Asiatic Aesthetic Series 156:Has the cleft surgery world finally gotten FLAT?

As we look at the phenomenal way in which cleft lip and palate surgery missions has changed, especially in the last decade or so, it is becoming  increasingly clearer that the answer lies not in expat humanitarian plastic surgery missions but in discovering and supporting homegrown expertise. Developing nations like India and China are no longer at the mercy of " medical mission compound" care for their cleft patients. However,the west does have a huge advantage in terms of resources and what we now see is a symbiotic relationship where the rich west handles the financial and other logistical support, wheras the real work is done by local plastic surgery teams in these countries.Their results are often remarkable and comparable to the best, if not better than those seen in the developed world. How much has changed in less than a decade! It is mind boggling to see the cleft surgery numbers churned out in these countries.India alone operates over 50,000 cleft lip and palate patients in a year with the help of the US Smile Train financial support.Most of them with fairly reasonable results.

As incomes grow in India and China, I do hope that the nouveau rich will understand and practice corporate social responsibility to overtake their western counterparts in generous giving for cleft missions and not expect Americans and Western Europeans to foot the bill for their cleft lip and palate children who are often ostracized by their own home societies. This will take a miracle in both countries through a complete overhaul of the prevailing mindset.
In the past,foreign mission workers called all the shots,often providing questionable medical care to poor people and messing up many cases in the process. Most of these medical workers had no previous experience or expertise in their home countries. Good intentions just aren't enough in cleft lip and palate missions. I have served in med missions for many years  with western expat med teams and gained valuable firsthand experience with the inexperience of such missions in poor nations.The number of iatrogenic problems is unacceptable.This is mainly because of the background inexperience of the expat volunteers who feel they need to save the "poor natives".Good intentions that have led to hellish outcomes for many patients.Mercifully,such work is being phased out in many countries now. India and China are leading examples of such progress .Both have seen miraculous advances in the science of technology and hi tech medicine and even cater to medical tourists from the US and EU countries. This was something unheard of in the 1990s.

Sam Noordhoff put it very aptly," I did not consider myself good enough to do a reasonable job on cleft children in  Taiwan when I first started out as a medical missionary surgeon to the Taiwanese in the 1960s. I knew I had to return to the USA and train under good plastic surgeons who taught me what I needed to know in this field."
Those of us who have studied at the world famous Chang Gung Craniofacial Centre know what a huge difference Sam's decision to help Taiwanese patients has made in the nation's medical history. He built a system out of nothing at all during his time at the Dansui clinic where he saw his first few patients.
Prior to his arrival,the great Canadian pastor and social worker Rev Mackay had successfully pulled out twenty thousand Taiwanese teeth!
 Sam cast his bread upon the waters.Today thousands of plastic surgeons from across the world train at the legacy he left behind in Taiwan.(pic)
pic: A legacy of obedience -the  world famous Chang Gung Memorial Hospital that Sam Noordhoff and his Taiwanese friends built

Well, to give you all a very honest opinion I think the world has gotten a lot flatter for plastic surgeons across the world because these days,well trained plastic surgery specialists in developing nations who toil for poor cleft children  are able to prove their mettle to the entire world. Their efforts and results are amazing.Thanks of course, to the generous support of the US Smile Train,without which this work would not be possible.

But has our world gotten flatter in terms of giving to the poor?I think not, because the bulk of support for cleft lip and palate missions still comes from the United States which has a tremendous track record in terms of generous giving to charity missions worldwide.
People who have never learnt to give,will probably never be givers in their lifetime no matter how much new wealth they may accumalate. That is the reason why you see the filthy rich in Indian cities in their multimillion dollar homes,even the world's first billion dollar home in Mumbai, with slum dwellers as their unfortunate neighbours, without even the basic necessities of life .  China is no better when it comes to cleft lip and palate missions because despite the country's enormous wealth in the last decade,the nation still depends on rich and middle class Americans to foot the bills for their cleft lip and palate children.As a result,there are millions in the country who remain untreated for years, or even a lifetime.
And so the story goes on and on. Many are called and yet few are chosen to give and be blessed in the process. Takers may receive a blessing but givers are the more blessed.
It will take a miracle leap for the cleft lip and palate mission world to become FLAT ..when people who have made their riches also learn to give like their generous predecessors in the richer western world.

Monday, November 5, 2012

Asiatic Aesthetic Series 157:Smile Beatitudes

Blessed are the givers of smiles
May they be blessed by many across the miles
Blessed are those who feel the cleft children's sadness and pain
May they always walk tall  be it sunshine or rain
Blessed are the kind and generous at heart
May their world never fall apart
Blessed are those who give cleft kids a second chance at life
May they live long without contention and strife
Blessed are those who make cleft children smile
May they always be glad they walked that extra mile
Blessed are those who have helped many a cleft child
They have saved those in a cruel world who are oft reviled
Blessed are the smilemakers
They will be loved by all
Blessed are those who toil to make cleft children find happiness
They have discovered a universe filled with eternal joy and bliss

A tribute to all the great guys who think about the welfare of cleft children worldwide

Asiatic Aesthetic Series 158:Cleft photojournalism- every smile tells a story

Every smile tells a story...