Wednesday, April 24, 2013

Asiatic Aesthetic Series 89: US miracle..Changing faces worldwide

Sometime in August 1999, an incredible charity was started in the US which would later change the lives of over 850,000 cleft children worldwide in over 80 countries...the Smile Train has been helping poor cleft children for over twelve years now.Many families with cleft children can now hope for a better chance at life because of this amazing miracle charity for cleft

Tuesday, April 23, 2013

Asiatic Aesthetic Series 90:Mission Plastic Surgery 2013

Mission plastic surgery is a growing popular concept to help aesthetic  and reconstructive patients with state of the art hi tech innovations that can change a person's life forever.
There are millions of plastic surgery patients across this world who cannot even dream about life changing surgery for their deformities because they are too poor to  consult a plastic surgeon.
While there are some plastic surgeons whose chief goal in life is to get as much money as they possibly can from their prospective clients, by promoting unethical advertsing methods like ," we offer you a discounted divorce package"etc.. to vulnerable sections of society,not every plastic out there has ulterior motives for mastering the art of this sub speciality.
I am thankful to have learnt many useful techniques from famous plastic surgeons who care about the ordinary patient or help those who have nothing to offer for their advanced services (in poor nations) .
Mission plastic surgery is not going to be phased out anytime soon by greedy wannabes in the speciality.
There is hope for millions of patients because this speciality art will continue to grow  over the next few years.

Monday, April 22, 2013

Asiatic Aesthetic Series 91:Local problems,local solutions

Cleft lip and palate problems in poor developing nations are best managed by well trained local medical personnel.
Expat medical missions might be able to train and equip local medical teams,but  long term solutions are best understood and managed by local teams.
Yemeni medical teams have received sample training at the hands of experts from different countries over the last 15-20 years and are fairly confident to handle most of the common medical problems by their own medical teams.
Teach a person to fish , to ensure a long lasting legacy in any country..

Asiatic Aesthetic Series 92:Dilemma: replacing one deformity with another..

This 37 year old male patient had a bilateral cleft lip messed up by an untrained surgeon when he was 9 years old
He had been living with this iatrogenic deformity since
Thankfully,the first stage reconstruction of his entire lip and nose went well and he will return for fine adjustments at a later date

Asiatic Aesthetic Series 93:the tricky wide cleft palate

The wide cleft palate is quite difficult to close and one can get into problems if the width of  the nasal layer flap is not accurately measured  before the surgery ,making closure almost impossible
this young girl had an incomplete ,3.5cm wide cleft palate
surprisingly,her speech was good without any nasal emissions

1. a two flap procedure was planned with complete skeletonization of the neurovascular bundle to increase flap mobility
2.the nasal mucosal flaps were drawn a few mm wider than  usual  to ease closure
3.the hook of hamulus was fractured and the levators retro positioned without tight closure because this patient has an isolated cleft palate with a large tongue;too tight a closure might lead to airway problems post op;her mandible was normal

The operation went smoothly;the palate was fixed with sutures and hemostatic gel
broad spectrum antibiotics were given post op and the patient kept nil orally for 24 hours

Friday, April 19, 2013

Asiatic Aesthetic Series 94: 18.04.2013..With God, there is hope even in the most hopeless situation ...

“Spring is the time of year when God reminds us that things are not always as they seem. Over the course of a few short weeks, what appears hopelessly dead comes to life. Bleak woodlands are transformed into colorful landscapes. Trees whose naked arms reached to heaven all winter, as if pleading to be clothed, suddenly are adorned with lacy green gowns. Flowers that faded and fell to the ground in surrender to the cold rise slowly from the earth in defiance of death.
From Bleak To Beautiful  April 18, 2013 — Julie Ackerman
Dear God, we pray for faith anew,
For greater trust in all we do,
For hope that never knows defeat,
For victory at Thy mercy seat. —Brandt
With God, there is hope even in the most hopeless situation.

(our prayers for all those who suffered in the Boston attacks of April 2013)

pics: visit to J B Mulliken, 2012 Childrens Boston to discuss advances in cleft surgery in our mission to impoverished cleft children from Arabia Felix .One of the most beautiful aesthetic cleft lip and palate design protocols was as a result of JB Mulliken's contribution of 15 years of his research work on clefts to our charity .

Childrens Hospital Boston

Longwood Avenue,Boston

with Prof JB Mulliken,Childrens Hospital Craniofacial,Boston 2012

Tuesday, April 16, 2013

Asiatic Aesthetic Series 95:Hands on Workshops in Primary Cleft Lip and Palate Surgery

Several hands on training workshops in cleft lip and palate advances 2013 were held for the benefit of local surgeons.
The goal of these workshops is to ensure accurate and safe methods of cleft lip and palate management without blood loss and tedious operations ,using our 2013 innovations for short and accurate techniques of repair,allowing us to perform very large volume surgery in a precise and accurate manner.
Using these guidelines, we have operated over 900 cleft lip and palate surgeries in approx 225 working days.


1. Anatomical considerations and unilateral cleft lip repair using the 2012 innovation-crescent incision cheiloplasty.The procedure takes about 15-20 minutes,allowing us to operate about 10-12 patients in one day
2. Principles of bilateral cleft lip repair-lessons from JB Mulliken ,Childrens Boston
3. Anatomical considerations in cleft palate surgery and the 2013 neo concept aesthetic button hole palatoplasty- a relatively  bloodless procedure.

Sunday, April 14, 2013

Asiatic Aesthetic Series 96:Helping thousands of global cleft palate surgeons with a safer method

Over the last 15 years,I have been developing newer and improved techniques of plastic surgery, especially on the safer repair of cleft palates. One of the exciting innovations was the relatively bloodless method of saline hydrodistension and easy dissection.
I have made some short clips of these easy methods on you tube for the benefit of readers,patients and surgeons alike.I am glad to say that there are over 12,000 readers in the last 7 months alone since i started blogging ,including thousands of  doctors across the world reading these innovations. The end result is a safer and user friendly  "windows" version of cleft palate surgery.
I am grateful to friends in the US for including these palate repair innovations in the upcoming world congress in Disneyworld ,Flordia 
As long as poor patients across the world benefit from these innovations, i think my goal of reaching out to the masses is somewhat achieved. I believe tens of thousands of cleft palate patients of all ages will soon benefit from this addition by an unknown smile mariachi.

Links: Using saline hydrodistension and easy dissection of cleft palates

Wednesday, April 10, 2013

Asiatic Aesthetic Series 97:Hands on workshop demo of cleft palate surgery for OR trainees

Thanks for inviting me to show your surgeons how I perform modifications in cleft palate surgery; I will be demonstrating the techniques on some of the patients here.
An easy way of extending the neck is to place a ring rest below the head and a sandbag between the scapulae. However,take care not to use this if the patient has neck pain, or antanto axial instability.
One also has to take care when operating the isolated cleft palate in a patient with Pierre Robin sequence, or in those with micrognathia. Airway obstruction is common post operatively,and so the levators should not be tightly approximated ; sometimes,a tongue stitch may be needed for the next 24 hours to prevent the large tongue from falling posteriorly and causing airway obstruction. Radical muscle dissection in such patients may cause a lot of post op airway problems and hypoxia so be aware of this problem.

In this patient with a complete wide cleft of the soft palate,  the first step is to identify the hook of hamulus by making a mini incision on the medial edge of the maxillary tuberosity.The tensor tendon is divided and the hamulus fractured so that the entire muscle bundle is moved medially and divided from its aponeurotic insertion on the palatal bone,using a medial incision .There is no important structure and so I generally use a blind method with curved sharp scissors after dividing the attachments to the posterior nasal spine.The procedure is easy and causes very little bleeding ,which is easily controlled with a bipolar cautery.
The levator is 7-9mm retropositioned and sutured to the opposite muscle ,bringing the muscle to a more infero transverse position .Since this muscle forms approx 50% of the muscle bulk,the procedure inproves speech considerably.
The nasal layer is closed first with interrupted sutures as you can see here,the muscle approximated and the final closure done with 4 0 vicryl.

Patient 2 has a similar problem but here the lower 3rd of the hard palate also has a cleft;the procedure is similar but i add a hinged hemipalatal mucoperiosteal flap to close the hard palate defect.The neurovascular bundle is mobilised to make the repair tension free.
The palate is fixed with hemostatic gel and the edges closed with 4 0 chromic.

You note that patient 3 (below) has already had a stage one soft palate closure; the hard palate defect is closed using two parallel incisions.

A useful method of raising the mucoperiosteal flaps is to identify the site of the first incision;I choose a relatively loose and avascular area around the upper palatal rugae to raise the flaps from that incision.The vascular bundle is released completely to make a tension free closure.
The way to approach the medial nasal flaps is to incise the lateral flaps first ,and  the medial incisions next.The uvularis fibres are divided from their insertion on the posterior nasal spine.
This way ,I use a fine palate dissector to sweep the entire nasal mucosa off the palatal bone in a gentle but firm manner,starting from the lower end and ascending all the way to the anterior palate.Stay on the bone at all times and you will not make any holes,like you see here.Use a very sharp fine knife to divide any stubborn fibrous attachments.
The rest of the repair is straight forward- use chromic 4 0 catgut for nasal mucosal sutures with the knots facing the nasal surface (though not completely essential).
The flaps are gently approximated without tension,gel foam is applied and the palate edges fixed in a routine manner with 4 0 vicryl or chromic.
The patient is kept nil orally for 6-8 hours and shifted to the ICU for further management.Nursing is done in a left lateral position with regular fine suction and oxygen via a mask. Regular mouthwashes and broad spectrum antibiotics  are given for the next 4-5 days.

Asiatic Aesthetic Series 98:masterclass in bilateral cleft lip repair methods

This is a hands on operating session on the repair of bilateral cleft lip
The patient had a previous adhesion for his bilateral cleft lip deformity. You note a few deformities-

1.the upper lip is abnormally long  and distorted
2.the philtrum and Cupid bow elements have to be reconstructed
3.the abnormal bulges on the lateral edges are caused by the abnormal orbicularis oris muscle which has to be reconstructed in the midline
4.the nose looks ok so there is no need for a cheilo septorhinoplasty in this incision; we can use it if the nose is deformed


The neo philtrum is designed by marking the bases of the columella on the right, left and centre.
The Cupid's bow is designed using a skin flap minus the median turbercle so that there is no whistle deformity post op after several months.The median tubercle is reconstructed using lateral lip elements as you can see here.
One has to play by ear when reconstructing the philtrum and Cupid's bow in the older patient; the lower end of the flap is about 2.5 mm wide from the centre and the upper about 2mm on each side of the columella midpoint.
The flap is raised to a moderate thickness to prevent necrosis, and the lateral lip elements trimmed after making equal measurements;the orbicularis is released from its abnormal attachments for a few mm.
The muscle is joined with 4 0 vicryl in the midline; the marginalis is approximated to prevent a lip notch.
The mucosa over the muscle is released for a few mm and the lip elements reconstructed to form a new Cupid's bow that should look attractive;i use vertical matress sutures using 4 0 chromic catgut for the lateral lip elements so that the  lip is slightly everted and over corrected by about 15%.This will stretch over the next few months giving a pleasing aesthetic appearance in the long term.
Since the philtrun in a normal person is slightly depressed, I use the "double eyelid stitch" where a deep stitch is taken through the neo philtrum and a corresponding superficial stitch on the lateral edge so that the lateral edge is slightly raised.
Sometimes , a z plasty can be added to the mucosal midline to thicken the lip.It is not needed in all cases.
An undersurface cross shaped incision over the lip mucosa releases tension on the repair and the mucosa is closed with interrupted sutures.

Monday, April 1, 2013

Asiatic Aesthetic Series 99:A Tribute to Her Majesty's Smilemakers


There is nothing as beautiful as a pure London Charity in this world,because there are no hidden agendas in the process of running such a charity. Now that we have come to the close of our ten year stint as a locally registered British Charity in Yemen and it is time to move on to other things ,there are certain things that one can learn about the beauty of a true Brit Charity:

The golden rule that we followed :

Keep it clean from the start to the finish. HMA France Guy protected the small charity till the very end and as a result many were able to understand how a pure British charity really works,even under the most difficult of circumstances.She stayed with us as Patron even after her tenure in Yemen as the Queen's Ambassador.God bless her! She is now the UN Rep for Women in Iraq.

Because of her direct involvement with an unknown ,small charity,no one dared to openly trouble the work for fear of being embarrassed in the higher society circles . Some unwittingly dragged their feet into the mud by making false allegations about the business interests of those of us involved,but they were completely silenced  by the direct involvement of the US state department leaders who openly praised the work and donated very generously to equip the units and camps.In all this, we kept plodding on and on and did not allow ourselves to bear grudges or make unhelpful comments to any rumour monger.

 I will never forget the words of Trish Gifford ,spouse of HMA Amb Mike Gifford,the present Amb to Pyongyang, N Korea  ," All I ask is that we keep everything above board. We can use my place in Chicheley Street London as a temporary office for the charity".Later on, Stan and Jill Hazell moved the office to their home in Henleaze, Bristol. Stan is the former Senior Journalist of Britain's regional ITV office in Bristol.The Yemen Office was adopted by the DNO Yemen AS team under Colin Kramer and Vilva.Total France,Sabafon and others supported the work for a few years.

At the end of our time here, all the smile units we sponsored across Yemen were equipped with medical equipment donated by our wellwishers,including some local business friends. The charity does not have any items left to give away. The bank accounts are almost empty except for a few hundred pounds which Stan Hazell,our contact in Bristol will pass on to other charities when we move on this year. There is no compensation of any sort,be it in kind or cash for any of us who gave our time and effort to save the lives of deformed plastic surgery patients in the impoverished regions of  Yemen. Even the Royal College Plastic Surgery Journals and other Intl Plastic surgery journals gifted by Dalia Nield of the London Clinics have been donated to a local institution for the benefit of local surgeons who wish to use the resources.

"We started with a shoebox,and left ...minus the shoebox"

Lessons learnt from this: make sure you have a good plan B for your own financial support if you run a charity, because one still has to pay bills!  I am thankful I could use my skills as a plastic surgeon to make enough to pay the bills  and enough to help others in need.I also thank my parish friends in Singapore who stood in the gap during our early years by their generous support for my work.All the other friends in the charity were well established professionals and gave their free time to help run this work over a few years.They have moved on since.

It was indeed a mammoth challenge that some of us undertook to help this nation,but looking back,we can only say that we tried our best under the given circumstances and were not unduly daunted by threats from misguided troublemakers who acted in connivance with some corrupt officials;there were some instances when they tried to harm us and the beneficiaries.We were the only charity that helped the nation during the Yemen massacres which took place in the war of 2011 when thousands were gunned down mercilessly.Needless to say,there were those moments of despair when we wondered why we ever chose to tread a path where even angels would fear to tread.

All in all, the work was successful and we are thankful for all who participated in this grand charity programme for people who would otherwise never have a chance. In the last 3-4 years, the work received a major boost from the US State Dept of  Sana and the US Smile Train.The Smile Train offered long term support for cleft children and also covered some of our our expenses.Sadly,the situation deteriorated across the nation making it impossible for expats to live and work for prolonged periods of time in Yemen ,and hence the work was sporadic at best.Moreover, the threats of violence were too high and most of the work was suspended indefinitely as a result.

I myself have been blessed and privileged to participate in the mission, and even spearhead this unusual outreach to plastic surgery patients in a poor country that needed help for poor patients.Who would have imagined that an unknown smile mariachi would walk into a Brit Pub and launch a plastic surgery charity for thousands of patients with some simple lead riffs? But this sort of thing happens only once in a lifetime.