Wednesday, December 31, 2014

Smilemaker..all about a SMILE

As a smilemaker,I often come in contact with people who ask me what I do for a living. This season was exciting because I had the opportunity to travel to Doha and India where some folks asked me about the work I was involved in.
I spent about 15 minutes at an immigration counter in Doha,Qatar ,with a young immigration officer who was very interested in the smile work ;he asked for the website link, to learn more about cleft children.

Later, during the week, I met some friends who had traveled all the way to the Indo Myanmar border villages,close to the north eastern part of India  . Many of these villages in Myanmar have seen severe conflict,neglect and poverty for hundreds of years. Thankfully, with the cooperation of the new govt in Myanmar, and the opening of  new international border trading posts with neighbouring India,some aid workers can now freely visit some of these remote villages.
Life in these villages is very harsh,without roads,transport,water supply or electricity. The villagers mostly live on a diet of yam and corn. Some mission posts have been built over the last two years by some of our friends,but there are no clinics or hospitals because it is impossible to ferry heavy equipment to these zones.  The only way to help cleft children from these regions is to sponsor their travel and treatment at govt hospitals in the neighbouring northeast of India where donors and volunteers from local church missions, and govt agencies  are willing to accommodate such patients and offer free services.
Some medical volunteers have already begun some basic health services in these villages and the work is growing.More help will be needed in the future to ensure a sustainable health delivery system to these target regions in Myanmar through hospitals and govt centres in neighbouring India.

Logistical challenges for smile missions in remote regions of the world

Many poor cleft children often find it impossible to reach the nearest cleft centre for help because their regions have no roads,electricity or transport. Some live on islands where the only way to reach a cleft centre is by air.This makes it impossible for them to travel for treatment.
The only way to offer sustainable smile services to some remote regions is to identify and equip the nearest hospital and register patients in those areas.  Some of these patients may live many hours or even days from the nearest treatment centre.In conflict zones,the problem is even worse because of the dangers of getting maimed or even killed during the fierce gun battles between warring factions.

Training sessions: basic concepts in cleft palate speech

Those of us who are involved in palate surgery wpould need some basic knowledge of cleft palate speech. Althpough this is not our specialty,it is useful to know some concepts in this complicated field.

Goals of palate surgery:
To facilitate normal speech
Normal hearing

Minimal or no  mid facial growth interference

Normal speech mechanisms:
Velopharyngeal closure refers to the normal apposition of the soft palate(velum) ,with the posterior and lateral pharyngeal walls.
The main mover of the soft palate is the levator veli palitini muscle which makes up about 50% of the soft palate bulk
Movement of the pharyngeal component depends on the contraction of the superior constrictor muscles and the palatopharyngeal muscles
The levator moves the soft palate upwards and backwards ;this is coupled with the mesial movement of the lateral pharyngeal walls and slight anterior movement of the posterior pharyngeal walls at the level of the C1 vertebra
As a result, the oral cavity is separated from the nasal cavity during speech and deglutination

VPI: velopharyngeal incompetence
Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination
After primary palatoplasty,up to 20% have VPI and require secondary management
With early recognition and intervention,the chances for normal speech and hearing are increased
Structural defects of the velum or pharyngeal walls at the level of the nasopharynx
Tissue deficiency
Submucus cleft palate
Short or immobile cleft palate
Unoperated cleft palate
Palatal fistula
Large and deep nasopharynx

Speech assessment should always be done by an experienced speech therapist at a sp[eech centre  where facilities are available and results interpreted accurately.This enables the palate surgeon to choose the right procedure for correcting speech defects.

Happy 2015 to all

Happy 2015 to all my viewers

Appreciate the support and comments;i have tried to answer some of your queries online and will continue to answer questions on clefts and aesthetic  medicine.

Thanks to all of you who have been supporting the cleft lip and palate projects across several countries.

Many more children are smiling again,thanks to people who donate and make a difference. Our community fundraiser for Tibet cleft children received some more donors this season.The support for these programmes will continue through 2015.

We hope there will be more support for upcoming cleft camps in the Indo Myanmar border regions and elsewhere this coming year.

Tuesday, December 30, 2014

Training sessions :Aesthetic Rhinoplasty in cleft nose deformities

Aesthetic rhinoplasty in cleft lip patients is a challenge even for the most experienced aesthetic rhinoplasty surgeon, because of the distorted anatomy

Observations in most cleft patients:
Bulbous tip
Deformed right ala cartilage
Drooping tip
Bulky nose
Loss of columella support
Caudal septal deviation to the left
Loss of nasolabial angle



Plan of treatment:
Correction of bulbous tip with interdomal sutures
Augmentation of nose and columella support with a cartilage/silicon implant
Tip graft with conchal cartilage
Debulking fibrofatty tissue of the nose
Resection of the caudal septum and after scoring it ,use it as an overlay graft for the right ala cartilage
Augment the deficient upper lip with posterior auricular fascia to improve the naso labial angle

after a conchal graft rhinoplasty

Training sessions: anatomical considerations in cleft palate surgery

1.The levator sling is created : the muscles are detached from their abnormal insertions on the palatal bone and retro positioned to make them meet in the midline at a distance of 7-10mm
2.A button hole incision below the middle of the maxillary tuberosity identifies the hamulus which is fractured to medialize the muscle complex

3.The tensor tendon is incised as it hooks around the hamulus process of the sphenoid bone
4.The palatal aponeurosis formed by the levator and tensor insert on the posterior surface of the palatal bone;this is incised with a sharp blade to release the muscle fully
5. the elevation of hard palate mucoperiosteum is made in the middle zone near the palatal rugae where the attachment is looser.
The neuro vascular bundle lies a few mm medial to the 2nd molar –care is taken to  dissect this structure so that the flap can be moved easily to the midline
* submucus cleft palate may be diagnosed by bifid uvula,zona pellucida due to muscle deficiency in the midline and osseous notch on the hard palate

Training sessions: know your lip landmarks before cleft surgery

Orofacial clefts which includes cleft lip and palate, are the most common craniofacial deformities ,occuring in 1:800 live births worldwide

Causes include genetic and environmental factors like smoking,alcohol and folic aid use in the first trimester of pregnancy

Training sessions:Some useful tips in unilateral cleft lip repair

•The Cupid’s bow is pulled up and the edge of
• the cleft lip is often thinned out because of the
• vermillion deficiency
•The orbicularis oris muscle in the lateral lip element ends upward at the margin of thecleft to insert into the alar wing.
•There are fibrous adhesions under the mucosa. The musculature between the philtral midline and the cleft is hypoplastic
•The philtrum is short and the ala cartilage on the cleft side is deformed .Two-thirds of the Cupid’s bow, one philtral column, and a dimple hollow are preserved
•The inferior edge of the septum is dislocated
•out of the vomer groove and presents with
•the nasal spine in the floor of the normal
•1. Bring the Cupid’s bow to a more horizontal level
•2. Make both sides of the lip equal in size and length
•3. Exact placement of the stitch on the white roll
•4. Correct the alar defect as much as possible
•5. Eliminate the lip notch by a Z
•plasty/triangular mucosal flap after approximating the orbicularis marginalis area.

Training sessions: Revision-*5 Principles of bilateral lip repair

• The secret of success in the field of
aesthetic cleft lip surgery:
• 1.Symmetry
• 2.Primary muscle continuity
• 3.Proper philtral size and shape
• 4.Formation of the median tubercle
from lateral labial elements
• 5.Primary positioning of the lower
nasal cartilages to form the nasal tip
and columella.

• *J B MullikenCurrent Surgical management of bilateral
cleft lip in North America, Childrens Boston,
PRS129:1347, 2012 June
• Prof John B Mulliken, Harvard
Childrens Hospital MA

Waiting for a miracle smile 2015

Just returned from a short trip overseas, where some friends who had heard about our smile work presented some  of the smile needs in a remote region of Myanmar where there are no roads,no power or water supply.
The only mode of transportation in those impoverished areas are old Chinese made motorbikes which ferry people across villages,at an exorbitant cost.
There are several cleft lip and palate children in those regions ,and most have to live with their deformities for life, because they do not even know that treatments are available for free.
The task of transporting such underprivileged cleft patients will be a mammoth challenge ,because there are no roads.
2015 presents itself with newer frontiers and challenges.There are many requests and enquiries from developing regions where cleft children live in isolation and shame.
The smiles must go on and on...till every cleft child is smiling again

Sunday, December 28, 2014

Training sessions: minimal incision palatoplasty with levator repositioning

2012 minimal incision palatoplasty with levator repositioning

In this method, I use a relatively bloodless
minimal incision method using 1:500,000
saline adrenaline hyrdro dissection by mixing
1mg adrenaline in 500 ml saline
Starting from the medial minimal incisions,using
fine curved sharp scissors,I dissect the
levators from their insertion on the palatal
aponeurosis / bony hard palate and
reposition the muscles in a transverse
position;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.
The surgery takes 20-25 minutes and is very safe
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
Ongoing study:over 270 cases,no intra/ post op
bleeds or hypoxia in any
• The levator repositioning improves
• The nasal flaps are best approached
from the lateral side to prevent
• It is easier to raise the mucoperiosteal
flaps from the mid palate where the
tissue is loose and less vascular
• Palatal fistula is usually due to wrong
technqiue and too much tension on
the flaps and ,wound infection.

Friday, December 12, 2014

Patient number 1371 this December @Smile Train Yarim programmes

This week,the Smile Train  sponsored programmes operated patient number 1371 at Yarim hospital under the local medical team .
Patients from across the nation,Saadah,Sana,Jowf,Taiz,Ibb,Aden, Hodeidah and other regions reularly register at Yarim govt hospital for their free surgeries.
The local medical team is confidently able to help all Yemeni citizens at this hospital because of their years of experience and friendly relations with the villages and tribes across Yemen.

Thursday, December 11, 2014

Taking the measurements before cleft lip surgery

Pic 1: surgery done by an untrained surgeon using no landmarks ,corrected this week;she will need nasal correction later

Pic : below-what you can expect after taking correct  measurements,using landmarks

Handle with care-the large tongue in isolated cleft palate

The large tongue in isolated cleft palate can cause problems post operatively,so this had to be handled with care by the cleft palate surgeon. It is not a good idea to reposition the levator under tension in this case because it is sure to cause post op airway problems. I encountered one post op probems many years ago in such a case,and the patient had to be observed in the ICU for 48 hours post op.Thankfully, her airway problems  got better after the first 24 hours.The receovery was stormy in the initial 8-20 hours post op,but subsided after that period.
These days, I do a loose approximation of the levators in similar cases and do not face the same problems.

Monday, December 8, 2014

Dermal fillers for fine wrinkles


a 70 year old lady type 3 FP after intradermal injection of collagen for wrinkles ;the results are good post op and lasts for six months.

The perfect filler is non allergenic,has no down time and looks and feels natural.

Beauty and the beast: Challenges in aesthetic clinics

*Challenges in aesthetic clinics:

1. unrealistic expectations
2. obsessive compulsive behaviour
3.whims and fancies
4.indecisive patients
6.over flattery
7.overly familiar
8.unkempt patient
9.imagined deformity
10.careless historian
11.VIP patient
12.uncooperative patient
13.overly talkative
14.plastic surgeon shopper
16.plastic surgicoholic
17.price haggler
18.patient involved in litigation
19.patient you or your staff dislike

"better safe than sorry"
the worst nightmare for any plastic surgeon is to have a once friendly,chatty patient who wants the money back later even if a procedure is done accurately without complications,all because the patient wants more!

read: Tardy ME Face lift variations; Dermatology Surgery,NY 1988,p 1249

Fillers vs PRPM face lift?

With an increasing number of  men and women in their early thirties to forties opting for minimal down time,minimally invasive facial rejuvenation ,the number of patients lining up for PRPM facial rejuvenation using micro needles is on the rise.But it is not a completely painless procedure.One can expect some discomfort,depending on the pain threshold.
It is not difficult for a good aesthetic physician to separate the platelet rich plasma from about 8 ml of the patients own blood; used alone, or with a matrix former like calcium chloride,the results are obvious in a few days time and get better over the next few weeks.
You can expect the effects to remain for about a year.A revisit and re injection is usually necessary after a year.Patient selection is important-those with more advanced wrinkles would do better with a proper facelift.
Autologous filler materials always have an advantage over commercial fillers because there is no reaction to one's own tissue. This is not to say that HLA fillers are inferior.Cross linked HLA can give very good results and last for up to one year. The aesthetic physician should be well trained at a reputable institute and not work on one's own.
The advantages of using PRPM are manifold,promoting new collagen formation and wound healing among a few.This is what makes the face look a lot younger in a few weeks time.