Tuesday, April 26, 2016

Network strategy in medical outreach missions

Network outreach in medical mission outreach across a nation is an effective way of helping larger sections of underprivileged populations .



In our work, the outreach was fairly successful in regions where local teams warmly welcomed us and participated  fully in implementing projects.



We scaled back in areas where there was active opposition or suspended  projects in volatile and dangerous locations.

From 2015 March  till the present,all medical outreach across the volatile nation of Yemen Arabia was abandoned by expat doctors because of the extreme violence and dangers involved for all medical personnel.

A useful strategy we followed was:

1. Preliminary visit to discuss possibilities of medical workshops and camps

2. Visiting  local medical units and completing a checklist for operations

3. Conducting a few  hands on sessions and training modules

4. Based on the response and success,further work continues in target areas

5. Leaving a sustainable legacy for local teams to continue the work


Monday, April 25, 2016

Smiles@Singapore -Need smiles,got smiles so just GIVE SMILES la!

Having spent so many years in Singapore,I was amazed at the efficiency of the system .Singaporean friends laid the groundwork for this miracle smile mission in Arabia.

That is because when they see a need, they JUST DO IT! No questions asked.

No lengthy rhetoric.No discussing patients to death,trying to figure out often complicated and meaningless diagnoses.

The result?-  a nation receives free smiles and plastic surgery for thousands









US paper California @ Yemen Smile Charity



72nd Annual Meeting of the American Cleft Palate-Craniofacial Association being held April 22-25, 2015 at the Westin Mission Hills Resort in Palm Springs, California, USA.



ID #: 1784

Title: KISS SMILEATHONS IN A VOLATILE ME COUNTRY


Introduction: Cleft lip and palate humanitarian missions in volatile regions are filled with dangers for visiting expat smile teams. From January 2010 till March 2015, one thousand four hundred and ninety cleft lip and palate children were operated under our Smile Train charity sponsored programmes for underprivileged cleft children in Yemen Arabia by a single plastic surgeon. The work came to a near standstill for almost one and a half years in between, following violent clashes and massacres during the Arab uprisings of 2011.There was a near total breakdown of all services. From security roadblocks, tribal blood feuds, threats of terrorist attacks and bottlenecks in local corrupt medical systems, the uphill task seemed insurmountable. Had it not been for the unwavering support of local medical heroes who were determined to rebuild from the rubble and ashes of a system near ground zero, these 1490 children in Yemen would not be smiling again for the first time in their lives.
Since the work was done by a single expat mission plastic surgeon in a nation where most expat workers had fled, an innovative KISS megasmileathon had to be improvised and played locally by ear, to clear the huge backlog of smile operations. The improvisations and variations of the KISS theme worked and today the list is a lot smaller and easier to handle. Thanks for all those who made smiles happen for underprivileged cleft children in a troubled country.


The Asian Pacific Craniofacial and Surgical Simulation Conference, Taipei Grand Hotel October 5-8 2008





The Asian Pacific Craniofacial and Surgical Simulation Conference, Taipei Grand Hotel
   October 5-8 2008 ( 8 scientific papers)
   Delegates: USA, Japan, Latin America , Middle East, Asia, Europe

Paper and posters:  Yemen Smile  Number: 8



Establishing an International Cleft and Aesthetic Recon Mission for a developing country in
Arabia: lessons from a 5 year experience (2003 June -2008 May)
Cleft Charity: Yemen Smile
Many patients in developing countries do not have ready access to aesthetic and
reconstructive services. The Republic of Yemen is a poor Middle Eastern country with a population of approximately 23 million people. The population is predominantly Arab with a few Jews and Africans. Health services in most parts of the country are either substandard or non existent. There are no established cleft or aesthetic recon services and many patients have to live with their deformities for the rest of their lives.
The Yemen Smile Mission Trust was formally signed in April 2007.In March 2008, with the Ministry of Planning and International Cooperation.
A locally grown International Aesthetic and Recon Mission dedicated to providing cleft care was thus formally established.

The long term goal would be to train Yemeni technicians and surgeons to carry on the mission work for the benefit of Yemeni patients.

2. Approaches to difficult post trauma nasal deformities in Yemeni Arab patients: case reports
Septo rhinoplasty and camouflage silicon implants: Lessons learnt
The post trauma deformed nose presents several challenges for the rhinoplasty surgeon because of functional and aesthetic problems .The severely injured nose often presents with bony as well as septal aberrations.The aesthetic goal is to straighten the dorsum which is often very difficult in the post trauma nose, to modify the nasal bones, to adjust the tip cartilages and iron out the irregularities in the nose.

3. Some rare craniofacial disorders in Yemen :observations under the tip of the cleft iceberg

Yemen in south Arabia till today does not have a proper record of the types or
number of cleft anomalies.In our safari smile camps across the country over a period of a few years, some rare craniofacial anomalies were encountered.
We came across eleven cases with Hemifacial microsomia, hypertelorism, traumatic clefts of the face and nose following a rare neurosensory disorder, cleft nose with intranasal dermoid, cleft with Binderoid syndrome, Aperts, Kartagener, Pierre Robin sequence, craniofacial cleft,frontonasal dysplasia and Binder syndrome with absent columella.

4. Human bite left ear: using a sliding posterior auricular perforator flap with cartilage
transfer-case report
We present a case of human bite of the left ear leading to a partial defect of the ear. The
patient was a twenty five year old lady from Djibouti who was referred to our clinic in Sana’a.
Her acquaintance had bitten off her left ear for undisclosed reasons. One could only speculate that the perpetrator who probably suffered from some sort of Para Freudian delusional disorder also had a penchant for nibbling off ladies ears. The defect was successfully repaired with a posterior auricular sliding flap based on random perforators

5. 45 minutes as the crow flies ?- revisiting the popular myth in Speedy Gonzales cleft lip
surgery

Intro: Cleft lip conditions present themselves in many different ways; no two cleft lip patients are
alike. In developing countries where the bulk of cleft patients come from, the problems are even
more complicated because of the absence of prior orthodontic treatment for most of the cases. In
fact, the smaller cleft lips seemed to take more time and expertise because of the delicate nature
of the work. The larger and wider cleft lips which require even the inferior turbinate flap plus alar
corrective surgery in some cases definitely take more than an hour at the least, even in
experienced hands. So why is it so important to say that cleft lip surgery takes as little as 45
minutes when most of us who have operated hundreds of cleft children do not seem to be able to
subscribe to this view? We undertook many cleft lip operations to see if the surgery could be done
in 45 minutes and came up with some interesting conclusions.

6. Two thumb pressure reduction of the protuberant pre maxilla in bilateral cleft lip patients i

Intro: We present a method of reducing the protuberant premaxilla in bilateral cleft
patients using pressure reduction with the thumbs. The neglected protruding premaxilla in bilateral cleft patients poses a big challenge for the primary cleft surgeon because of the difficult closure. Attempts have been made by many surgeons in the past to reduce the premaxilla but with disappointing results

7. The unilateral cleft lip-"Simple minor variations on a theme of the C flap "
Intro: The C flap repair for cleft lip deformities with it’s modifications gives some of the most accurate alignments for unilateral cleft lip defects that have been treated by prior orthodontics.In this paper,we drew a helpful analogy from Fernando Sor’s Variation on a Theme of Mozart where the guitar maestro describes several variations on the main theme in E major. The classic paper by Noordhoff remains unchanged, but there are some mild variations which one can play with when faced with unilateral cleft lip defects

8. The innovative V -2 zee triad concept flap for the neglected very wide cleft lip

Intro: The very wide neglected cleft lip presents a difficult challenge for the primary
cleft surgeon. In this case report, we present a wide cleft lip approximately 4cm wide
with a short cleft side and large nasal deformity. The traditional C flap is not suitable for
such a defect and the Millard with the usual back cut is sometimes used with an extra
baby flap below to increase the length of the lip.We present here an innovative concept
based on the musical triad .A triad is the simplest form of the chord-three notes. It can be
used in any degree of a major or minor scale. A triad consists of the 1st-root or the degree
on which it is based, the 3rd which is the major or minor above the root and
the 5th which is the perfect, diminished or augmented, above the root. In this concept
which we named the V-2 zee triad flap repair, the V is the main flap like the C flap i.e.”
the root flap” and the two zee baby flaps are the 3rd and 5th minor flaps around the triad
to give the flap the desired length. When sounded together these three flaps provide a
somewhat harmonious result. Using this concept, one is able to work around the basic
framework of the root flap and augment or diminish the smaller flaps to produce
aesthetically pleasing results in the wide cleft lip. The root C flap like the middle C in
music remains the same throughout, but with various harmonic mechanisms in technique,
one is able to make minor adjustments to achieve the most out of the surgical procedure







MCQ Primary Cleft Course for international trainees



MCQ Primary Cleft Course
Smiles 4 All

A charity project of www.smilemakernyc.com

A free primary cleft training resource for primary cleft trainees





1. ALL OF THE FOLLOWING ARE FEATURES OF THE UNILATERAL CLEFT LIP DEFORMITY -
•a.The Cupid’s bow is pulled up and the edge of the cleft lip is often thinned out because of the vermillion deficiency b.The orbicularis oris muscle in the lateral lip element ends upward at the margin of thecleft to insert into the alar wing. c.There are fibrous adhesions under the mucosa. The musculature between the philtral midline and the cleft is hypoplastic d.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.
•A.true
•B.false

2. IN UNILATERAL CLEFT LIP, THE SUPERFICIAL PART OF THE ORBICULARIS ORIS LOCATED IN THE VERMILION
•a. Is distorted along with the deep portion
•b. Inserts into the alar base
•c. Is simply interrupted without distortion
•d. Is hypoplastic and cannot be identified
•e.all of the above
•f. b
•a.true
•b.false

3. Our goal in cleft lip surgery is -
•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
a. All of the above
b.None of the above
c. 1,2 and 3 only


4.In unilateral cleft nasal deformity, 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 nostril.
•A.true
•B.false
5. Our goal in cleft lip surgery is -
•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
a. All of the above
b.None of the above
c. 1,2 and 3 only

6.In unilateral cleft nasal deformity, 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 nostril.
•A.true
•B.false

7. The following picture represents the anatomical markings of a normal lip
a.true b.false


8.The levator veli palatini muscle has a tendinous origin from inferior aspect of the petrous part of the temporal bone, on the proximal part of the apex just antero medial to the entrance into the carotid canal.Fleshy origins are from the tympanic part of the temporal bone and from the cartilage of the auditory tube
•a. the above statement is true
•b.false

9.The main function of the levator muscle is to a. tense the palate b. elevate of the soft palate
•a. the answer is a
•b. both a and b
•c.the correct answer is b

10.Both levator veli palatini and tensor veli palatini insert into the palatine aponeurosis
•a.true
•b.false

11. The greater palatine, gingiva,glands artery enters the palate through the greater palatine foramen and passes anteriorly on the lateral aspect of the hard palate to supply the palatal mucosa, and then proceeds to anastomose with the nasopalatine artery in the incisive canal
•a.true
•b.false

12. The bony part of the hard palate is covered by a specialized mucoperiosteum on both its oral and nasal surfaces.The posterior border possesses the palatine aponeurosis for attachment of the muscles of the soft palate
•a.true
•b.false

13. The muscles of the soft palate include Levator veli palatini ,Tensor veli palatini ,Musculus uvulae ,palatoglossus ,palatopharyngeus.
•a.true
•b. false

14. The pterygoid hook of the hamulus lies lateral to the maxillary tuberosity.
•a. true
•b. false, it is medial to the maxillary tuberosity

15. The soft palate’s anterior portion near its junction with the hard palate is almost fully mobile , whereas its posterior –most extent, the uvula is capable only of minimal movement.
•a. true statement
•b. false statement ; the soft palate junction with hard palate is immobile and the uvula is capable of great extension.

16. In cleft palate surgery ,levator muscle retropositioning is an essential step to ensure good speech outcomes.
•a.true
•b.false

17.The nasal lining is dissected from the palatal shelves during palatoplasty.During this procedure great care should be taken so that-
•a. the friable mucosa is not torn by rough handling
•b. the greater palatine artery is not injured in the process
18. Dissection of the anterior soft palate mucosa from the underlying levator muscle cause bleeding in younger patients due to
•a. abnormal blood vessels
•b. the presence of numerous gland which have a rich blood supply

19. It is best to raise the mucoperiosteal flap of the palate from-
•a. the midportion of the palate where the tissue attachment is looser and less vascular
•b. it does not make a difference

20. The nasal mucosal flaps during palate surgery are best raised- •a. from a lateral mucoperiosteal approach ,to avoid tearing the mucosa
•b. from a medial incision over the nasal mucosa

21.The common causes of palatal fistula are
•a. infection
•b. wrong technique with increased tension on repair
•c. all of the above

22. Submucus cleft palate is characterised by
•a.bifid uvula
•b.deficient midline muscle with zona pellucida
•c.osseous notch of the hard palate
•1. a and b
•2.all of the above

23. Following palatoplasty,the patient position post operatively is
1. supine
2.prone
3.lateral ,tonsillar position

A. It does not matter B. 3 is correct C. supine position is the best

24.The bulk of soft palate muscle is formed by the following muscle
•Tensor veli palatini
•Uvularis
•Levator veli palatini

25.Velopharyngeal closure is primarily due to the the action of the:
•Uvularis
•Palatoglossus
•Palatopharyngeus
•Superior constrictor
•Tensor veli palatini
•Levator veli palatine

26.Normal speech production requires the velopharyngeal port coupling of the nasal and oral cavities.
•a.true
•b.false

27.After primary palate repair and muscle repositiong ,all patients have satisfactory speech.
•True
•False

28.The functional goals of cleft palate surgery are-
•a.facilitate normal speech
•b.normal hearing
•c.minimal facial growth disturbance
•d.all of the above
•e.none of the above
•f.only a and b

29.The causes of VPI are the following:
•a.structural deficits
•b.neurogenic impairment
•c.mechanical interference to velopharyngeal closure
•d.all of the above
•e.only a and b

30.Severely hypertrophied tonsils should be removed before cleft palate repair in order toremove the mechanical obstruction and interference with velopharyngeal port closure.
•a.true
•b.false

31.The three common speech characteristics secondary to increased transmission through the nasal cavity are hypernasality, nasal emission,reduced aspiration and frication.
•a.true
•b.false

32. Velopharyngeal incompetency can be evaluated by-
•a. clinical evaluation
•b. instrumental evaluation
•c. all of the above
•d. only b

33. Inaudible nasal emission during vowel production can be diagnosed by
•a. electromyography
•b. the mirror test
•c. tissue paper test
•d.all of the above
•e. b and c

34. Plosive is a consonant sound made by closing the air passage and the releasing the air in a way that can be heard eg.p,t and top.
•a.true
•b.false

35. A consonant sound made by forcing breath out through a narrow space in the mouth with lips,teeth,tongue in a certain position eg. v,z is called
•a.voiced fricative
•b.voiceless fricative

36. A consonant sound made by forcing breath out through a narrow space in the mouth with lips,teeth,tongue in a certain position eg. F,s,h is called
•a.plosive
•b.voiceless fricative
•c.voiced fricative

37.Craniofacial clefts occur in 0.075-3.1 % of cleft births and include facial cleft deformity which involves
•a.the eye,
•b.the zygoma,
•c. the tm joint,
•d.the cranium
•e.all of the above

•38. Theories of causes for craniofacial cleft include focal fetal dysplasia,amniotic bands,chromosomal arrangements
•a.true
•b.false

•39.Oblique facial clefts -
•1. include Tessier clefts 3-5(lips) and 9-13(orbit region)
•2. may involve soft tissue and bone
•a.1and 2
•b.only 1

•40. Median cleft lip is also known as Tessier 0 -
•a.involves the lips and sometimes also the premax and nasal skeleton
•b.may be associated with a bifid nose and double frenulum
•c.some may have severe brain deformity and hypotelorism
•d.none of the above
•e.all of the above
•f.only a is correct

•41. Tessier 7 cleft is
•a. the same as lateral cleft lip and mostly unilateral
•b.the patient has macrostomia
•c.it is rare and occurs in 1:80,000 live births
•d.may occur with hemifacial microsomia
•e.can be repaired by a simple straight line closure of muscle and skin and a vermillion mucosa flap for the commisure
•f.all of the above

42.Topical tetracycline in cleft lip surgery is effective against methicillin resistant staph aureus and also streptococci pneumoniae,e coli and klebsiella pneumoniae
•a.true
•b.false

•43.Platelet rich plasma -
•a. is rich in growth factors,and is useful for restoring damaged tissues
•b.contains platelet derived growth factor which promotes collagen formation and cell growth
•c.fibroblast growth factor useful for tissue repair and collagen formation
•d.promotes wound healing through angiogenesis through endothelial growth factor
•e.enhances growth of epithelial cells through transforming growth factor TGF-B1
•f.helps in generation and growth of new keratinocytes through KGF keratinocyte growth factor

•44. Microneedling using 1.0mm microneedles is useful for
•a. remodelling of the skin by causing thousands of microscopic channels in the skin
•b. increases new tissue formation
•c.both are correct

•45.Platelet rich plasma is prepared from the patient’s own blood
•a.true
•b.false
•c.is artificially manufactured

46. The following challenges can occur in cleft palates
1.large and deep nasopharynx
2.short and immobile palate
3. very wide palate
A. true B. False C. Only 2 and 3 are correct

47. Both Furlows and Intravelar veloplasty for cleft palate have-
1.low morbidity rates
2.improved speech scores
3. low re operation rates
4.both present an advantage over potential airway obstruction procedures like the pharyngeal flap.
A. all of the above B. None of the above 3. Only 1 and 3 are correct

48. The following statement is wrong, “ Late repair of palate always means bad speech outcomes”
A. True B. False
49. Fracture of the hook of Hamulus-
1. causes mid ear effusion and hearing problems
2. it should be avoided
3. studies have shown that it is a safe and useful procedure in palatoplasty

A. All are correct B. Only 3 is correct C. Only 1 and 2 are correct

50. Complete cleft palate repair in 9-11 month old babies causes
1. post operative hypoxemia
2. bronchospasm
3. should be done as a two stage procedure to avoid potential complications
A. All are incorrect B. Only 1 and 2 are incorrect C. 3 is correct

Cleft operations sponsored by Yemen Smile and Smile Train ,Yemen 2010- March 2015




Cleft operations  sponsored by Yemen Smile and  Smile Train ,Yemen 2010- March 2015 


Hospital Units :


1 .Jibla Hospital Ibb

2. Taiz Karama 

3. Badan Hospital

4. Yarim Hospital

5. Ras  Morbat Aden

6. Mukalla Ibn Sina hospital

7.Seiyun General

8. Socotra Hadibo hospital

9.Gunaid Hospital Sana

Working on an ear template for complicated microtia reconstruction


•The costal cartilage is the most commonly used and preferred material because it is durable and 

stable; however it leaves an anterior chest wall deformity


The cartilage framework is harvested from the synchondrosis of the 6th,7th and 8th ribs


The pericondrium is preserved


Silicon and porous polyethylene are not popular anymore because of the high complication rate post 

op (migration, infection,extrusion even after minor trauma)










Trace the normal ear on a piece of x ray film

The template is made several mm smaller to accommodate for the thickness of skin
For symmetry: ear relationship to nose, lateral canthus and position of lobule, superior pole of opposite ear
* The cartilage is stacked in 2-3 layers(fig7);nylon sutures can also be used


2nd stage after 6 months: The ultra thin skin graft for second stage microtia repair
(Chen C OT hands on OT demos CGMH 2006)


suggested reading:

  .   Kotaro Y MD:One stage recon of upper defect of auricle: Aesthetic Plastic 

         Surgery.22:352 355,1998

   .  LF Ou :firm elevation in recon of microtia with a retroauricular fascial wrapping an 
          autogenous cartilage wedge : BJPS 2001,54,573-580

Eli                  Elisabeth KB,MD :Microtia Part 1 :PRS  CME June 2002

          Elisabeth KB,MD :Microtia Part 2: PRS CME July 2002

      . Zung Chen MD :Microtia Recon with adjuvant 3D template model: Annals Plastic Surgery       2004;53:282-287

Tuesday, April 19, 2016

Two shades of the other aesthetic -Smilemaker hybrid 2 on its way soon@design studio



It has been over a year since I designed the first hybrid Smilemaker 1 with an mP3 unit;the product has stood the test of time and the weather test




demo of Smilemaker 1 in Queens NYC in 2015


The second hybrid is coming out sometime this year
It should be an improvement over this first model.Bon chance and happy listening!

rough sketch: the 2 fretboard, 2 machine head on a single body -2 shaded of whatever!


Replicas of my models will start after the initial "guitar stress" tests which generally take about 6 months!







Magic area of your face- keeping it alive

One of the magic areas of your face is your skin.



As one gets older , intrinsic and extrinsic changes occur as a result of the ageing process.Over 80% of extrinsic changes are due to photo damage ,which manifest mostly as wrinkles and pigmented marks. Smoking aggravates these changes and make the skin quality worse.

The Dermnayseum of the skin includes some simple tips:

1. removal of those accumulated dead cells ,also known as exfoliation . I commonly use Lumina Gel 30% which is a great way to exfoliate dead cells through superficial peeling .It also stimulates collagen synthesis and keeps skin plumper and younger via biosynthesis of glycosaminoglycans

2. lightening with the help of tyrosinase inhibitors like kojic acid and bearberry extracts,licorice
(chi 7 gel)


I like to use this regime of skin conditioning for about 6 weeks
This is a great way to keep one's skin clear and healthy
Regular maintenence of the skin  using this strict regime prevents the dreaded complications of PIH(post inflammatory hyperpigmentation) when one uses lasers.IPL or peelings later especially in FP skin types 4 ,5,6.

smilemakernyc.com

Monday, April 18, 2016

A complicated thing called BSSO


A complicated thing called BSSO -several of us attended lectures and hands on sessions  at the famous Chang Gung Craniofacial Centre Taipei in 2006



Very useful,but not for the occasional player. Too complicated and time consuming.


          Oral cavity cleansed with half strength hydrogen peroxide and diluted betadine solution
          1%xylocaine in 1:200,000 epinephrine is injected into the vestibule of the mandible below the ramus on both sides
          A vestibular incision is made below the ramus and carried down to the bone
          With a periosteal elevator,subperiosteal dissection is carried down to the lateral aspect of the mandibular body and the ramus superiorly to the sigmoid notch
          The attachments of the masseter and the periosteum on the posterior aspect of the ramus are stripped off the bone with a stripper
          On the medial side of the ramus,the subperiosteal dissection is carried down to the condylar region connecting the disssection on the lateral side;great care is taken to preserve the infero alveolar nerve
          With both medial and lateral ramus retractors in place,the osteotomy lines of the saggital split osteotomy are marked by a lead pencil

          Anteriorly, the oblique line is about 5mm from the mental nerve
          Make a transverse burr  over the lingula till you see the marrow;check inf al nerve in canal
          then cut across/posteriorly burr down and split with  thin osteomes (after the anterior-burr the impaction points) ;the 2nd osteotomy is made rhrough the lateral cortex in the region of the 2nd molar
          Detach and burr the medial pterygoid insertions to prevent relapse post op: > 10 mm redn possible if combined with muscle stripping
          Set back by removing  a vertical segment of bone from the anterior aspect of the proximal lateral bony segment ;
          The width of the segment to be removed should equal that of the setback to be achieved
          Complete the same on the other side
          Occlusion is obtained with a wafer occlusal splint; the proximal segments are carefully positioned in each glenoid fossa
          burr off excess bone and fix with miniplates or screws after checking for alignment: no need for IMF
          Close angle, muscle –periosteum then the rest-insert drain anteriorly


Difficult lessons in Le Fort 1 osteotomy@ Chang Gung Craniofacial Taipei



          Useful lessons in Le Fort 1 osteotomy



          Incision:7 mm above mucogingival jn
          Undermine mucoperiosteum backward to and around the maxillary tuberosity on both sides:protect the infra orbital nerve
          Elevate mucosa from lateral wall and floor of nasal cavity and lower part of septum; use Rongeurs to trim the vomer

          Straight saw cut from pyriform aperture base laterally to maxillary tuberosity; use flat retractors to protect the mucosa 
          Keep 5mm of bone above the apices of the teeth
 


          Most crucial step is the pterygomaxillary junction didsimpaction



          Use the horizontal saw to make the first cut at the pmj   cut is about 1.5 mm
    in depth which is safe and away from the neurovascular bundle
Disimpact gently with an osteotome
Next the posterior attachments are freed with an osteotome by gentle tapping till a “change in sound”occurs:this is the end point :resect 3-4mm of caudal septum
The entire segment is rocked side to side and gently disimpacted with a Tessier hook/or Rowe disimpaction forceps
advance as required according to the orthodontic chart IMF to check correction/make small adjustments and then remove wires
Miniplate fixation after occlusal dental wafer: before miniplate fixation,the mandible is recessed so as to place the condyles into the glenoid fossa-failure to seat the condyles properly will cause upward and posterior movement of the mandible and malocclusion when the IMF is released
(wafer fixed to teeth with steel wires)
Check alignment: centre of Cupid’s bow to midline of incisors and distances of both commisures to mid pupil level

Drill a small hole in the ANS and fix the depressor nasi to the spine with proline 40
The wound is closed and a drain inserted for 24 hrs
pic: results (journal pic)



Suggested reading:
          Skeletal stability of LF 1 Osteotomy in pts with isolated cleft palate and bilateral cleft lip and palate:AH, R Ranta IJ Oral Maxfacial Surg 2002: 31:358-363
          Intra and peri op complications of LF 1 osteotomy : a prospective evaluation of 1000 pts :J Craniofacial Surgery 15:6 2004 Nov, 971-077

acknowledgement: Chang Gung Craniofacial Taipei 2006





Using the versatile running V-Y plasty to help burns victims


Using a versatile  technique to help burn contracture victims

The running V-Y plasty is a versatile technique where multiple V-Y incisions lengthen the contracted scar and improve  the aesthetic and functional result. The length of the Y limb is approximately one third of the flap

This is a useful technique and corrects most contractures









Some useful tips in osteotomies for aesthetic rhinoplasty

Nasal bone modification using a small 2 mm chisel is often a necessary part of  complicated aesthetic rhinoplasties.

Over the years, I have modifed the techniques,always using a more conservative approach to avoid potential post operative complications.

A good understanding of the nasal bones is useful for accurate adjustments.


Relevant anatomy:

The principal structure base of the nose is the bony vault  composed of the ascending frontal process of the maxilla and the paired nasal bones

The vault is generally pyramidal in shape and comprises 1/3 of the external nose



Anatomic suture lines are located in the thickest areas of the nasal bones and require greater

 osteotomy forces which results in uncontrolled fracture


Useful tips:

n  For optimal results the osteotomy should cut through intermediate zones of bony 

thickness which lie in the ascending frontal process of the maxilla from the pyriform to the 

radix along the lateral nasal wall


n  This region of the nasal wall is less than 2.5 mm thick and can be safely   

osteotomized,promoting predictable fracture patterns


n  Avoid osteotomies in short nasal bones,or in very thin nasal bones and in those with thick 

nasal skin

2 cc of 1% lidocaine with 1:200,000 epinephrine is injected intranasaslly, along the lateral nasal 

sidewalls

Use a 2mm sharp osteotome

Position it on the mid portion of the pyramid

Introduce it in a horizontal plane parallel to the surface of the maxilla ,at the level of the

 inferior orbital rim and nasofacial junction

n  The osteotome is angled in a way that one edge strikes the bone

n  With gentle tapping, a change in sound and feel indicates complete bony 

division at that location

n  Multiple perforated 2mm osteotomies are made in the maxilla at the level of 

the pyriform extending inf,sup and supero oblique

n  Direct the osteotome medially just inferior to the medial canthus

n  Leave 2mm normal bone between the osteotomies




n  While exerting gentle pressure on the nasal bones,the osteotome is swept down the

 lateral nasal wall and laterally along the frontal process until the site of the first 

osteotomy is reached

n  Go  in a subperiosteal plane to displace the the angular artery ,preventing any injury

pic:



pic: result of nasal osteotomy with aesthetic rhinoplasty for the complicated crooked 

nose rhinoplasty 




suggested reading:

n  Rod JR, Achieving consistency in the lateral nasal osteotomy during rhinoplasty:

 PRS 2001,108:21,22

n  Raymond JH, Optimal medial nasal osteotomy: PRS 2001,108:2114

n  Joe MG .Nasal osteotomies, perforating vs continuous : PRS 2004, 113:1445