Monday, December 25, 2017

Getting an ear bitten off in Djibouti

An interesting case of human ear bite
Thankfully,  the defect was corrected with a local flap.

Thursday, November 30, 2017

Je ne c'est quoi ? This Advent –“finite humans in the universe and an Infinite Creator God”

Je ne c'est quoi ? This Advent –“finite humans in the universe and an Infinite Creator God”

What kind of world are we all living in? Today, we are dealing with a total plurality of belief systems. We should not just open the bible and expect people to fall on their knees and believe in Jesus.
Things to consider when we share our precious Christian faith:
1.       Look at the root of man’s problems
2.       Share what the bible has to say
3.       Gently persuade people to accept the truth in Christ Jesus
Our faith is constantly challenged in several ways:
1.       Direct opposition to Christians
2.       Indifference to the Christian truth
We can either get discouraged or defensive and say,” I believe in it anyway; Jesus is in my heart and so do not bother me with arguments”. On the flip side, we ourselves lose hope and begin to doubt in our hearts, and some are even crippled with doubts that build up over years of opposition and indifference by those around.
At times, some of us feel threatened and retreat into our own shells and become unapproachable and confrontational, seeing a “demon behind every bush!” .This leads us to blast the so called “non-believers” or weaker Christians with judgment and condemnation. This unwholesome mindset soon becomes part of our distorted worldview and so we put people we “disapprove of” into our own petty, preconceived “basket of rotten eggs”. Little do we realise that this is not from God but from our own depraved human nature. I love the conversation the Indian humourist, Kushwant Singh had with some friends who were criticising the decadent west, judging their entire race as “filthy, depraved and full of dirty, sinful lifestyles”. Kushwant Singh replied,” Yes, yes. They are doing dirty things and watching all those terrible, dirty things. We are not like them. We do it only in our minds!”
Some Christians prefer to take a very low profile, not sticking their necks out. Others unconsciously compromise and dilute their faith. The bible reminds us again and again that there were many prophets in the Old Testament who were zealous for the Lord and never let untruth go unchallenged.
Someone once said,” the best way for evil people to succeed is for good people to do nothing”.

The Challenges facing us today: What are we facing in society today?
The world has not changed much . We all live in a pluralistic society where there are no absolutes. Everything is relative.
When a pastor shares about the exclusiveness of Jesus in John 14:6,” I am the Way, the Truth and the Life. No one comes to the Father but by me”, what are some of the expected responses from the secular world to such a message?
1.       Immediate confrontation – we are soon labelled as ethnocentric and intolerant for claiming that Jesus is the Only Way, The Truth and the Life. For many, this verse is one of the most confrontational verses in the bible.
2.       Not exposed to the views of others. We are accused of absolutizing our own private experience and not ready to compromise with their version of reality.
3.       Dubbed intolerant and arrogant people, who are self-centred. Christians are often portrayed by the secular world as people who are psychologically imbalanced, with a need to control others and impose only their own views. The biggest challenge then is, “How can you say that only Jesus is the Way, the Truth and the Life?” That is a preposterous claim.

Faced with this mountain of unbelief and indifference before us, how does one reconcile truth with day to day reality? Understanding this challenge from scriptures, the Bible tells us that –
1.       We were made in God’s image Gen 1, 2 “making man in the image of God”. God is a personal, loving Creator who made us, and everything that exists
2.       In Gen 3:5  the serpent said,” You will be like God” and both Adam and Eve believed it.From that moment, they could make up their own minds and do what they thought best, without acknowledging their Creator.  In Isa 14 Satan said,” I will make myself as the most high. Run the whole thing myself”. This was the exact same, false promise offered to Adam and Eve that you can be like God! You do not need God because you can be God. In the moral area,” you can be like God, knowing good and evil”. This is one of the most popular worldviews in our world today because it means we are not accountable to our God. Man has become God over good and evil, becoming like God determining good and evil, being sovereign determiners of the very character of good and evil. As a result, man sets himself up as a rival to God. God no longer has any authority over him.
All of us are living under this influence, trying to live without God and becoming autonomous – no one above me, I will set the rules and laws.
The greatest aim of man is to become a cosmic hero- a self-made project, “self-made leader, pastor, worker...” without any dependence on anyone.

Thought: “if there is no God, what is man? Man without God is the highest thing there is- self-determining, self-judging, self-governing”

But there are limitations to this! Humans find themselves trying to make a better world, playing for change. The buzz word in today’s war troubled world is “change, change we need. Get us out this MESS we have created”.  We are all limited by death, disease, pain- the limitations of the world cutting across our intentions and plans. At the end of the day, all of us are exhausted playing God. It just does not work.

This brings us to a logical conclusion that we are humans in the universe, after all. We are not God and He is not man. We are human beings and He is God! In psalm 9: 20 the psalmist says, “let the nations know that they are but men” The world nations do not realise that they are “but men, made by God in His image ,dependent on Him for their very breath and existence”. They think they are gods somehow, trying to decide what is real and saying that they do now want or need God”. Look at what is happening in nations today where other nations drop bombs to maim and kill people and later desperately plead with the world for “ immediate aid to feed the now famine ravished land”. What a mess. This is the reality of our humans in the world.

Some doctors entice patients with false promises,” we will give you a face, a body that God could not give you!” The psalmist in psalm 49:20 says, “Like beasts that perish”. What an insult to man made in the image of God, distinct from the animals. Now he is like the beasts that perish and left to rot. Such is the state of man, says God. What a fall from the grandeur that he had been in.

Could it be that we need to reconsider our ways and seek God again? We humans in the universe need to be reconciled to our Creator.

What is at the core of “modern thought process”?

A huge content of our modern day talking and thinking is in the denial of sin. There is no such thing as sin. It is all a state of mind. When a person does not believe in sin, the whole relevance of the Christian faith falls to the ground. That is because sin is the diagnosis that needs a solution through Christian thought and action to bring back the alienated human mind back to the Bible. Back to the Creator.

Some self-help schemes:
1.       I am getting better every day-fact is, I am stuck and trying to survive and make sense of this mess called life
2.       I am better than that bloke down the street- I am still a mess anyway
3.       It is not my fault that I am not good-I blame events and circumstances that made me this way!
 Stop, look and listen! For God has spoken in the Bible like he did a long time ago.  God shows us His great love through creation itself. He cares deeply about our lives, about our hurts and pains and about our whole life. Psalm 19 tells us, the heavens declare the glory of God.  The whole of creation speaks of God... all heaven declares... the trees, the mountains... all declare the glory of God!
Except for humans in the universe! Romans 1: 18-21 tells us that the revelation of God is clear, His invisible nature, His eternal power and deity have been clearly perceived in the things that are made. But human beings have grasped the truth in unrighteousness. The unregenerate mind has to grasp the truth of God through nature in unrighteousness and twist it to keep from being challenged by it, to keep from having the message of God challenge his or her autonomy.
In Romans 2, God is showing us what we are like. All of us are guilty, not just before God’s standards but our own standards of other people. We set moral standards for others but fall into potholes ourselves! We are all without excuse.
Here is an analogy about the state we are in. A tape recorder is tied around our necks that clicks on when we make moral judgments and record it. God will use that exact same tape recorder, rewind it and play it back to us and say, “Now where do you stand?”
God reveals us to ourselves when we read His word. He shows us our areas of need. We fall short of our own standards, let alone God’s.
When we have that revelation of ourselves to ourselves, we may be confronting a world where the TRUTH has been twisted. Romans 1: 18...not just non-Christians, but believers as well.
Once God speaks to us about our area of need-the truth is so close that we cannot ignore it. It is wiser to listen and grasp His truth and be free.
For instance, Psalm 19 tells us that creation declares the glory of God. We can hold that in unrighteousness by worshipping created things rather than God the Creator Himself. Or we can argue that we should live moral lives, minus God – we do our duties to the world, to society and fulfil some expectations of society. But then we miss the moral compass totally. We have missed the target God set for us. All of us have to come to this realisation that without Him we are helpless and hopeless-like a ship without a sail. Apart from God’s grace and favours, we are nothing.
But the sad reality is that, all said and done, at the end of the day, folks AVOID this ultimate moral challenge from the Bible.
CS Lewis described it as, “man’s sincere search for God, is like the mouse who searched for the cat”. The mouse wants to know exactly where the cat is, to say,” Well away, well out of reach”.

As we see the principle of self-law,or autonomy at work in our own lives and in the world around us, God continues to remind us that He is God the Creator and He is ready to help us know Him so that we can be free and fulfilled humans of His universe.
“ All heavens declare,the glory of the Risen Christ” amen.

Wednesday, November 22, 2017

Some handcrafted aesthetic skincare items at smilemakernyc

Some of my handcrafted, made to order skincare stuff for friends who use our products -enjoy!

colhibin inhibits metalloproteinases which destroy collagen when you are exposed to the sun; it helps protect your skin;use as a day care lotion,once a day

the ultra pigment lite has several pigment lighteners like licorice root extract, kojic acid,fission white arbutin, oils,allantoin,stearic acid, optiphen plus,willow bark extract,fruit extract
Apply on face and neck, morning and evening. Ensures healthy and clear skin over a few months use.

a limited edition face and hand scrub with aluminium oxide microcrystals, and pigment lighteners kojic,arbutin,licorice,willow bark,optiphen plus,allantoin, honey soap base. Great for your skin. Makes it soft and smooth.  Scrub face and hands for 3-4 minutes and wash off,leaving your skin smooth and clear.

Aloe gel with allantoin,extracts,glycerine,oils - good moisturizer for dry skin conditions,prevents TEWL and keeps skin well hydrated

Pre shampoo for dry hair and dandruff with oils, allantoin, fruit extract;i use a bit of ketaconazole for treating dandruff . Good for healthy hair growth. Suggested for dandruff and dry scalp.

The very gentle 3 minute peel with kojic acid lightener,lactic and salicylic acid,optiphen,fruit extract. Good for antiageing,acne comedones ,pigment and superficial scar reduction

Handcrafted kojic acid soaps for pigment lite

Ramblings of a global surgery outreach enthusiast :tips in thyroid surgery for large goitre

Large multinodular euthyroid goitres are still seen in some developing regions .

Today's OR demo was on hemithyroidectomy for a right sided euthyroid colloid goitre.
Use a sandbag between the scapula and a neck roll to extend the neck and a ring for the head support

Some tips:
1. My incision is a bit higher than usual because of the large size.I find this helps in surgery
2. Finger dissection is also a good idea in
avascular planes
3. Helps to divide strap muscles at least on the affected side: makes your work easier
4. Once you control the superior and inferior pedicles, the rest is straightforward
5. In very large multinodular goitres, the superior pole is shifted more towards the midline, so be aware of this
6. After dividing the middle thyroid vein, the inferior thyroid artery is ligated away from the gland in order to prevent injury to the recurrent laryngeal nerve. For the superior pole, ligated close to the gland to avoid the superior laryngeal nerve
7.  In a very large goitre I sometimes enucleate the gland; this ensures minimal chances of injury to the nerve and parathyroids
8. We always use a closed suction drain for 24-48 hours and close the platysma followed by cosmetic closure of the skin
Make sure you use a very light gauze dressing. Large padded dressings are contraindicated and can easily cause respiratory obstruction if a hematoma is missed.

Hope this is helpful for those in med mission outreach

Tuesday, November 14, 2017

Global surgery outreach missions : abdominal hysterectomy tips

In many mission hospitals, the surgeon is often requested by gynecologist friends to help with abdominal hysterectomy.
The patient in this case was a middle aged multi, with chronic DUB and a posterior adnexal fibroid close to the cervix.

I share some useful tips during mission hospital demo sessions:

1. In this case the preferred incision was vertical
2. I always like to mobilise the uterus by dividing and ligating  the round ligaments first
3. The ureters are identified in the medial leaves of the broad ligaments and displaced laterally with wet gauze
4. The uterus is devascularized from the broad ligaments to isthmus
5. Uterine vessels are divided by using a Heany clamp at right angles to the longitudinal axis of the uterine body; stay close to the uterus.the ureters are behind the vessels at about a cm distance - they are displaced laterally by a wet gauze.
6. Divide and suture the cardinal ligaments,with clamps almost parallel to the body of uterus ,after dividing the uterine arteries
7. The bladder is always dissected away from the uterus in the initial steps.
8. To prevent vault prolapse, the cardinal ligaments are fixed to utero sacral ligaments
9. Hemostatic transfixion sutures like the heany stitch or tailor stitch are reliable and prevent blood loss.

Following these tips make your procedure relatively easier and blood loss will also be negligible.

For our friends and well wishers @ smilemakernyc

Thanks to all our friends and well wishers who use our products.  Here is some good news for you all.
There will be an introductory offer  for the products in north east India, Nagaland by December 2017.

Saturday, November 11, 2017

This seasons aesthetic handcrafted skincare @

This season, we will be launching some new handcrafted aesthetics for our aesthetic collection.

Using a perfect blend of hi end ingredients from FDA lab suppliers in the USA with

exotic organic ingredients from India, we hope our clients will enjoy the great experience.

For the present, the items will be mostly available in  Nagaland, India  for all our friends and well wishers.

This limited edition aesthetic range is for pigment correction, healthy hair growth and  organic facial scrub.

Saturday, November 4, 2017

Medical Missions Revisited: safety issues and checklists

Surgical safety checklists are absolutely necessary in all medical mission endeavours. The risks are greatly minimized by following a few simple rules and doing regular checklists on every procedure.

What you require in a recovery room/ ICU:  Checklist

A. First Line Drugs in a medicine tray -these are what you call the essential and life saving drugs in any emergency
1. Adrenaline ampoules
2. Atropine
3. Lidocaine
4.dexamethasone vials
5.hydrocortisone vials
6.dopamine ampoules
7.Deriphylline ampoules
8.Aminophylline ampoules
9.50 % dextrose vials
10. IV fluids. Dextrose saline, 5 % dextrose, Ringer Lactate
11.sodium bicarbonate vials
12. Calcium gluconate/chloride vials
13. Lasix ampoules
14. Morphine vial
15.Manintol bottle
16.Diazepam ampoules
17 Phenobarbital ampoules

18. Metroprolol injection(2 ampoules)

B.  An Electrocardiogram machine and a defibrillator; multiparameter monitor, a finger pulse Oximeters for the nurse on duty in the room

C. A ventilator, suction unit and at least 2-3 oxygen cylinders with all connector masks, an IV fluid warmer, warm blankets for children,

D. An Ambu bag resuscitation kit for adults and child/ keep a bed pan and also some plastic bins in case patient vomits

E. Plastic disposable airways , laryngeal masks, suction catheters different sizes, Foleys catheters child and adult with urine bags, disposable gowns,masks,and caps, disposable syringes 3cc, 5cc and 10cc,naso gastric tubes different sizes

F. Headlights for emergency (LED - 800-1000 YR only)/ one portable light source

G. Nursing station with table, chair and records for ready reference

H. Laryngoscopes adult and child, Maegel forceps, dressing trays, sterile gauze in a drum, plaster, cutting scissors, rubbish bins 2
This would be enough for a very good recovery and ICU room

Keep one duty nurse there at all times.. Different shifts

In Yemen Arabia our mission team always kept a booklet of safety measures for every surgery to make sure there were no problems during procedures. It worked well , and we were happy that we had a checklist to follow at all times.

Cleft Craft / Basic music theory n guitar as a hobby

Digital downloads are now here on for
1. cleft craft techniques
2. basic guitar techniques,order:ascending,stats:true

Basic theory and method for beginners in guitar
A good way of relaxing in between busy work schedules­čśŐ

Sunday, October 29, 2017

Pigment Lite Ultra for pigment treatment launching this season

This season, we will be launching an improved handcrafted, version of our previous chi7 pigment gel lightener ,which has sold out.

The " Pigment Lite Ultra" will feature newer additions like collagenase inhibitor colhibin, aloe vera and allantoin for extra moisturising,willow bark extract and multi fruit extract.

Thank you all for using our skincare products.

Thursday, October 12, 2017

My new launch -Pigment Lite Ultra for pigment treatment

Our chi 7 pigment corrector gel has sold out. Thanks to all our well wishers.

This season I am working on our new Pigment Lite Ultra which will be mostly for the Asian market.
I have chosen an exotic blend of kojic acid, licorice, fission white, colhibin,fruit extract, willow bark extract n optiphen plus.

This product will be out soon.

Monday, August 21, 2017

OR Lesson from the pioneers: Taking Long Rib Grafts for Facial Reconstruction

Rib grafts: some advantages
They are easily bent and fixed with wires.
• easily implemented and consolidated
to the host bone.

Important: short incision,no subcutaneous dissection,incise upto rib:wound is irrigated and checked for any air leak and bleeding.

***The targeted rib is identified and the deep
thoracic fascia is incised with an electrocautery.
• Subfascial exposure of the rib.
• Longitudinal incision of the periosteum
along its lateral surface.
• Subperiosteal elevation along the edges
of the rib with an angled square elevator
and then on the medial aspect for a few
• Medial dissection is continued posteriorly
by means of a Doyen semicircular
elevator for 5 cm and then anteriorly
up to the costochondral junction.
• Divide the rib close to the costochondral
junction with an angled Liston
• Grasp the rib with an angled flexible
bone holder and then continue the subperiosteal
dissection posteriorly with a
set of Semb elevators; first, along the
lateral aspect, then on the edges, and
finally on the medial aspect in an alternating

***technique: FIG. Stripping periosteum from lateral surface of the rib; (center) passing the Doyen elevator behind the rib; (right)
cutting dissected rib with the costotome.
important: Preserve the integrity of the parietal pleura with proper use of the Semb periosteal

FIG.  Instruments for taking ribs. A and B, Long rib
retractors; C and D, periosteal elevators; E and F, Farabeuf
retractors; G and H, Semb dissectors.

FIG. More instruments for taking ribs. A and B, Long
costotomes; C, strong bone cutter; D, bone-contouring forceps;
E and F, bone-holding forceps; G and H, 10- and 15-mm
straight, sharp osteotomes.

***ref: P. Tessier, M.D., H. Kawamoto, M.D., D. Matthews, M.D., J., Posnick M.D., Y. Raulo, M.D.,
J. F. Tulasne, M.D., and S. A. Wolfe, M.D.
Miami, Fla., Taking long rib grafts for facial reconstruction,Vol. 116, No. 5 October Supplement 2005 / 

The "makhwa " facial branding scars in the Arabian Gulf

In some parts of the Arabian Gulf, the makhwa or red hot iron branding is still used  by some traditional Arabian healers.
This young patient was branded several years ago, leaving two large scars in the nasolabial regions.

Fortunately for her,the scars were in the line of the naso labial folds and so they could be excised in an aesthetic pattern.
When the stitches are removed,the resultant faint scar becomes a part of the naso labial fold and will be aesthetically acceptable.

Direct excision of naso labial scars is an acceptable treatment for bad scars in the region.

Global Plastic Surgery Outreach Missions : some useful workhorse MC Flaps one can use for coverage of defects

Some time tested MC flaps,the workhorses of good reconstructive surgery in different situations.

The techniques can be modified over time , as one gains more experience.
Some of my favorite ones are:
a. PM flap
b. LD flap
c. M Gastrocnemius flap
d. Reverse LD and PM
e.turn over flaps using segmental perforators
f. bilateral LD advancement flaps for large defects of spine
j. trapezius

All these flaps are well supplied with a major vessel and have several mc perforators and branches;therefore,the viability is usually very good.

I have found these flaps to be very useful for reconstruction of major defects.

pic:medial gastrocnemius flap for large anterior tibia defect following trauma

The techniques are best learnt in hands on training sessions in the OR. To know how to execute these flaps,join OR teaching sessions with specialists experienced in the techniques.

MC flaps: illustrations and arc of rotation,coverage of head and neck,chest,limb defects ( ref: Clinical applications for muscle and MC flaps- Mathes.Foad Nahai ,Mosby)

Sunday, August 20, 2017

NLF workhorse: Staged repair of a full thickness traumatic nasal defect

This child presented to our mission clinic years ago, with  a complicated full thickness defect of her nose following trauma and infection

The first stage NLF was used to cover the  turned in flap from the nose and surrounding cheek

The patient did well post operatively and was scheduled for follow up adjustments at a later date.

The naso labial flap is a sort of workhorse for the facial region because it is easy to raise at a subcutaneous plane and is generally viable if done carefully.

Type: arterialised local flap in the head and neck region

Important: " the robust viability of the flap on the basis of a small subcutaneous and subdermal
blood supply " (Barron, J. N., and Emmett, A. J. J. Subcutaneous pedicle
flaps. Br. J. Plast. Surg. 18: 51, 1965)

Axial blood supply:  provided by the  facial artery (inferiorly based) or by
the superficial temporal artery through its transverse
facial branch and the infraorbital artery (superiorly

maximum dimensions of the flap : 7 cm by 1.5 cm.

Important Aesthetic Considerations:

• The preservation of the nasofacial aesthetic
line when possible
• Its optimal use in nonsmokers
• Its best results when used for defects involving
part or all of the alar subunit or the lateral
side wall (2 cm in width)
• The use of a nonanatomic alar contour
graft for lesions within 5 mm of the alar rim
• The precise fit of the donor flap into the
recipient site, as well as adequate debulking
and the obliteration of any dead space with
transfixation sutures (through and through) to
prevent pin-cushioning
• The maintenance of a 2-mm isthmus lateral
to the ala on the cheek for optimal
The plastic and reconstructive surgeon is often
presented with a patient who has multiple
defects secondary to skin cancer. In this article,
we presented a unique application of a nasolabial
flap used for a simultaneous cheek and
nasal defects, with preservation of the nasofacial
aesthetic line. ( ref: page 1729 ;R Rohrich,Dept of Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center, SUPERIORLY BASED NASOLABIAL FLAP) PRS Vol. 108, No. 6  Nov 2001/

reconstruction of the lower eyelid and small defects of
the nose, lips and oral cavity.
 In cancer treatment -for reconstruction of the floor of the
mouth,1–3 palate4 and ala of the nose.5 The recent innovation
of folding the flap has further expanded its role,
as it is now able to provide lining and cover for a fullthickness
commissural defect.

Saturday, August 19, 2017

MCQ Primary Cleft Course for trainees in cleft

MCQ Primary Cleft Course
Smiles 4 All
A charity project of

To understand the concepts of primary cleft aesthetic surgery,please read the pdf study articles on cleft surgery training @

•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. 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
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.
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.
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
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
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
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
13. The muscles of the soft palate include Levator veli palatini ,Tensor veli palatini ,Musculus uvulae ,palatoglossus ,palatopharyngeus.
•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.
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
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
•Levator veli palatini
25.Velopharyngeal closure is primarily due to the the action of the:
•Superior constrictor
•Tensor veli palatini
•Levator veli palatine
26.Normal speech production requires the velopharyngeal port coupling of the nasal and oral cavities.
27.After primary palate repair and muscle repositiong ,all patients have satisfactory speech.
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.
31.The three common speech characteristics secondary to increased transmission through the nasal cavity are hypernasality, nasal emission,reduced aspiration and frication.
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.
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
•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
•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
• 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 abov
42.Topical tetracycline in cleft lip surgery is effective against methicillin resistant staph aureus and also streptococci pneumoniae,e coli and klebsiella pneumoniae
•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
• 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

Plastic Surgery Topic Discussion: Perforator based V-Y advancement flaps for lower limb defects

Perforator based V-Y advancement flaps for lower limb defects 
 How to do it sessions

Fasciocutaneous flaps were first described in 1981 by Ponten,but improvements were made in the 90s by various surgeons ;the V-Y flap was known as early as 1848(Blasius)
The improved flaps are based on perforator and fascial feeder vessels and cutaneous nerves
Main advantage over the traditional skin graft :primary closure of defect with intact sensation,better cosmetic result and early mobilisation of the patient

Anatomical concepts
3 main arteries of the leg,posterior tibial,anterior tibial and peroneal artery give out several perforators which pierce the deep fascia to enter the suprafascial plane
The flaps are based on direct perforators from the main vessels,perforators from the muscle and upon fascial feeder vessels

The V-Y flap

Flap planned around perforator vessels
Perforator vessels identified by a hand –held Doppler probe
Cutaneous nerve supply identified and preserved

Summary of operative technique
1.location of perforators by Doppler
2. explore one margin to locate perforators
3.after locating suitable perforators,free them for some distance from the fascia and muscle to get extra length
4.insert the flap and leave a drain for 24 hrs
Post op bed rest with leg elevation for 48hrs;discharge pt on the 5th day

Suggested reading

1. A Hayashi, Step ladder V-Y advancement flap for postero planter heel ulcer:BJPS,1997,50:657-661
2. V.Venkat,D Mohan Perforator based V-Y adv flaps in the leg: :BJPS,1998,51,431-435
3. NS Niranjan, Price Fascial feeder and perforator based V-Y flaps in lower limb defects: BJPS 2000:53-679-689
4. GA Georgeu,The horn shaped f-c flap in cutaneopus malignancy of the leg:BJPS 2004,57,66-76