Tuesday, February 26, 2013

Asiatic Aesthetic Series 125:A smile legacy in Arabia

The only way to ensure long term sustainability for any smile mission is to train local surgeons in the art of cleft surgery so that they in turn help their own citizens.
As the time for us to leave Yemen is nearing, I realize that there is much that one can do to help others through regular cleft blogging.As a result,many local surgeons are able to learn the proper techniques and approaches to cleft lip and palate problems.
It has a been an interesting teaching experience for me and I look forward to my next assignment in other nations.



Monday, February 25, 2013

Asiatic Aesthetic Series 126:The Singapore smile support team

Feb 2013-visit to the island city of Singapore to catch up with smile supporters from 2013- 2012. An amazing miracle as a result of friends and wellwishers.
More than 5700 Yemeni familes with plastic surgery needs were helped across the nation since 1998 Jan.

Yeap CL,Mount Elizabeth Aesthetic Recon


James and Tang Shin Yong

KO Lee,NUH

Rodney Lim LAC


Georgie Ong and friends SPC




Saturday, February 9, 2013

Asiatic Aesthetic Series 127:Neo concept palatoplasty: Minimal blood loss


Neo concept 2012: minimal blood loss palatoplasty
(this concept is quoted in our US task Force paper for late palate repair for www.cleft2013.org @Orlando,Disneyworld,Fla and will be published in July)



Palate distension by the tumescent method for cleft palate repair was a technique described in Haifa by a group of plastic surgeons in October 1997 6. They found that the technique allowed easy closure with good post op and speech outcomes, although they did not operate on the levator sling in their study and used only mucosal adhesion.
Over the years, I have modified this tumescent technique by reducing the amount of adrenaline from 1:200,000 to 1:500,000 and also adding levator retropositiong,button hole fracture of the hamulus,incision of the tensor tendon and uvular 2/3 retropositioning. A minimal incision technique4 was  used for all stage one cases and complete soft palate clefts.The technique of saline hydro dissection was used in order to reduce operating time as well as blood loss in older cleft palate patients.


Patients:

86 cleft palate patients between the ages of 2- 14 years of age were operated between Jan 2012 and Jan 2013 using the modified saline hydro dissection method. There were 50 males patients and 36 female patients, with a mean age of 6.3 years. 49 had a complete cleft palate deformity (unilateral) and 37 had a complete soft palate, whereas one 4 year old girl had a submucus soft palate cleft.
An extra 4 adult male patients between the ages of 21 and 37 were also treated by the same method, for their complete cleft palates, using a 2 stage approach, 6-10 months apart.

Techniques used:

The complete cleft palate was operated in 2 stages, 6-10 months apart. Stage one closure included levator and uvular repositioning .as well as button hole fracture of the hook of hamulus, and soft palate closure.The submucus cleft was closed with levator retropositioning.
In this method, I use a relatively bloodless method using 1:500,000 saline  adrenaline hydro dissection by mixing 1mg adrenaline in 500 ml saline, which makes tissue dissection very easy.20-30ml may be enough for smaller palates
Using fine scissors, I dissect the levators from their insertion on the palatal aponeurosis / bony hard palate and reposition the muscles in a transverse position for about 7-10mm;the uvular is 2/3 retro positioned
I also add a small button hole incision over the hamulus to fracture the bone, incise the tensor and medialize the muscles. A button hole incision medial to the max tuberosity identifies the hook of hamulus quite easily.
The surgery takes 20-25 minutes and is very safe; the blood loss may be less than 10ml in this method
The complete palate is closed in 2 stages-  stage one includes soft palate closure with levator repositioning; the stage 2  minimal incision palatoplasty is done after 6 months to a year.





Observations:
There was no mortality or morbidity with this method. The low dose anaesthesia we used ensured a quicker recovery for the patients post op.All patients were monitored for 12 hours in the ICU by our team of nurses and they did well after the procedure. There was minimal bleeding intra operatively and the operating time was short (20-25 minutes for the soft palate) and about 30-35 minutes for the second stage hard palate closure.
The second stage repair to close the hard palate defect was done quite easily using the innovative hinge uni palate flap developed here.(pic A) All the patients did well post operatively. Two of the children with complete soft palate cleft had post op breakdown because of negligence and poor follow up, one child developed a tiny junctional fistula because of stitch infection and one had a 1 cm soft palate fistula which was successfully closed later. All the others did well at follow up and healed well without significant palatal scarring.
Pic A: hinge flap palatoplasty stage 2



Discussion:

        Older palates tend to ooze and bleed and this technique helps reduce the problem significantly. From Jan 2012-Jan 2013, 90 cleft palates were operated using this technique for late repairs (after 2-2.5 years). The blood loss was minimal and post op recovery excellent in all the cases without any major discomfort since all flaps were fixed and there was hardly any bleeding. The two stage method also seems to be a good alternative for prevention of junctional fistulae .However long term follow up is needed to study the effects on speech (which was not included here).Compared to other methods of palatoplasty1,2,3,5,this technique is simpler and safer, with an easy learning curve.
*This study was done mainly to develop a method for decreasing blood loss during palate repair using the above mentioned method. We found it quite useful especially for the older cleft patients where bleeding can be troublesome for the plastic surgeon.




Reading:
1. cleft palate repair by double opposing z plasty: LT Furlow:Op Tech in Plastic Surgery 2:4 223-232 1995
2. Two flap palatoplasty: J Bardach Op tech Pl Surg 2:4 211-214 1995
3. Smile Train Virtual surgery video:Langenbeck and other cleft palate repairs 2001:NY The Smile Train USA
4. 7.minimal incision palatoplasty  Anthony Vu MD

ACPA 69th Annual Conference April 17-21,2012 San Jose April p 58:3

5. Addition of Radical Intravelar palatoplasty significantly improves speech outcomes and reduces re operation rate in primary palatoplasty John H Grant MD, UAB,Division of Plastic Surg,Birmingham,AL -ACPA 69th Annual Conference April 17-21,2012 San Jose April, p112:276
6. Intraoperative expansion of the palate by the tumescent technique , Issac J et al, Haifa Israel,PRS vol 100:1 July 1997 p 100  (Ideas and Innovations)


Friday, February 8, 2013

Asiatic Aesthetic Series 128:Unoperated cleft palate with near normal speech




One of the baffling clinical curiosities is the cleft palate patient who has near normal speech despite the wide palate defect,which should normally lead to speech defects.
This is an area where one needs to do some research to find out why such patients with such defects speak normally.

video: this 11 year old girl with a complete cleft soft palate and an incomplete hard palate cleft had near normal speech



Asiatic Aesthetic Series 129:940 new smiles across Yemen from the Smile Train








From Jan 2010- August 2013,  940 cleft lip and palate children in Yemen received the gift of smiles from the US Smile Train across the nation of Yemen.
Many of these families were too poor to even afford the costs of travel to the various camp centres.
Some of the patients had waited almost a lifetime for their surgeries.

The problems of cleft children in this country are worse in remote regions where there are often no roads or electricity. As a result many do not even hear about the charity camps.

Many Yemeni families are thankful that the Smile Train USA helped them at a time of desperate need in their lives.
Several local surgeons and others have been trained in the process and are able to perform some simpler surgeries for the rural children.

Wednesday, February 6, 2013

Asiatic Aesthetic Series 130: Yemeni and expat well wishers over the years


HMA  Frances Guy launching the charity Yemen Smile in June 2004

Frances Guy is now the UN Rep for Women in Iraq.



Yemeni and expat well wishers across the years..having fun and making everyone smile :-)




Fundraiser night at Sana International School 8th March 2008 for cleft kids
"Buy a child a smile concert" that raised $7,200 from donors and friends











Many wellwishers joined hands,donated generously and traveled to remote regions to help the plastic surgery patients of Yemen
The charity programmes were successful as a result of the joint efforts to help familes across the country
These days, most of the work is carried out by local doctors who continue the good work among poorer sections of Yemen.