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
millimeters.
• 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
bone
cutter.
• 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
manner.







***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
elevators.




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
g.temporalis
h.platysma
i.SM
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
based).

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
cosmesis
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/

Uses:
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 surgery@smilemakernyc.com


MCQ Primary Cleft Course
Smiles 4 All
A charity project of www.smilemakernyc.com

To understand the concepts of primary cleft aesthetic surgery,please read the pdf study articles on cleft surgery training @ https://smiles4allblog.wordpress.com



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 abov
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

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

Introduction
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
Fig:


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

Thursday, August 10, 2017

Palatoplasty: Hands on OR training , not done by reading!

Cleft palate surgery should not be attempted by reading books on the subject. Proper training is necessary before the surgeon attempts such repairs,because there are many finer aspects of the surgery to be learnt in the process.
I have been approached online by some overseas surgeons who wanted to learn this surgery through online consults. It is a very bad idea to try palate surgery through online discussions. 
My advice to trainees has been the same throughout the years. Learn the basic concepts,assist the surgeries and later on, be confident enough to attempt the simpler soft palate repairs and finally,the whole surgery of hard and soft palate with muscle repositioning. That way,one can avoid unnecessary headaches and serious complications.
Mini incision palatoplasty OR demo session
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:100s of cases,no intra/ post op bleeds or hypoxia in any 

Wednesday, August 9, 2017

New Creations @ smilemakernyc.com Aesthetics

Thanks to all for the support. There are over 1.2 millions views now since Sept 2012. Many thanks.



I am coming out with my own new creations for smilemakernyc.com soon ,in honor of my late mother who prayed so many years for us.

It includes a large range of over 100 new aesthetic designs for the skin,hair,hands,body and feet.

Aesthetic Medcare

100 Variations on  smnyc


Name
PIGMENT LITE
In
 EI

1.Fusion Claire
FW
Lavender
2. Fusion Claire
FW
Grape
3.Fusion Claire
FW
Apple
4.Blanc Sauvage L
FW
Lico+ Lavender
5.Blanc Sauvage G
FW
Lico+ grape
6.Blanc Sauvage A
FW
Lico + apple
7.Claire Plus L
FW
KA/Lico + Lavender
8.Claire Plus G
FW
KA/Lico+ Grape
9.Claire Plus A
FW
KA/Lico + apple

DAY CREAM


10. Jour B3 L
B3
B3+L
11. Jour B3 G
B3
B3+G
12. Jour B3 A
B3
B3+ A
13. Peau de soie
B3
Silk AA + L
14. peau de soie
B3
Silk AA+ G
15.peau de soie
B3
Silk AA + A
16.Colhibin UV L
Colhibin
L
17. colhibin UV G
Colhibin
G
18. colhibin UV A
Colhibin
A
19. Jour d’aloe L
Aloe vera
L
20.jour d’aloe G
Aloe vera
G
21.jour d’aloe A
Aloe vera
A
22.vita E
Vit E
L
23.vita E
Vit E
G
24.vita E
Vit E
A
25.visage de chamomile
Chamomile
-
26. wild willow
Willow extract
-
27.green tea moist
Green tea extract
-
28. iris sauvage
Iris extract







PEPTIDE 3


29.Aldenine Tri-P   L
Aldenine
L
30.aldenine Tri-P G
Aldenine
G
31.aldenine Tri-P A
Aldenine
A
32.under eye gel  L
Eyeseryl
L
33.under eye gel G
Eyeseryl
G
34.under eye gel A
Eyeseryl
A


 COLLAGEN GEL


35. Colhibin visage L
Colhibin
FAC ,L
36. colhibin visage G
Colhibin
FAC, G
37.colhibin visage A
Colhibin
FAC, A
38. visage antyox L
Antioxidant
L
39.visage antyox G
Antioxidant
G
40.visage antyox A
Antioxidant
A


Al O scrub FACE


41. smooth operator L
Al 0
L
42.smooth operator G
Al 0
G
43.smooth operator A
Al 0
A
44. Gommage des fruits
FAC
-
45. S-Olive scrub
Al O
Olive


Al 0 hand/foot scrub


46. phi 7 aloe L
Al 0
Aloe vera L
47.phi 7 aloe G
Al 0
Aloe vera G
48.phi 7 aloe A
Al 0
Aloe vera A
49. Smooth Hand L
Al 0
L
50. smooth hand G
Al 0
G
51.smooth hand A
Al 0
A
52. gommage loofa L
Al 0
Loofah L
53.gommage loofa G
Al 0
Loofah G
54.gommage loofa A
Al0
Loofah A





SilkAA hands


55. Silk AA hands
Silk AA
Iris, LA
56. silk AA hands L
Silk AA
LA , L
57. silk AA hands G
Silk AA
LA, G
58. silk AA hands A
Silk AA
LA, A


Acne Care Gel


59. Acne Care SA
Sal A, LA,
-
60. Acne Care L
Sal A,LA
L,
61. acne care G
Sal A, LA
G
62. acne care A
Sal A, LA,
A
63. Acne pigment lite
LA
KA
64. acne pigment lite plus
LA
KA, licorice


65.Smilemakernyc SPF 30
SPF30
-


Dry Skin AA


66.Derma mist
Smnyc 1
Silk AA. Lico, chamomile
67. derma mist L
Smnyc 1
Silk AA, lico, L
68. derma mist G
Smnyc 1
Silk AA,lico, G
69. derma mist A
Smnyc 1
Silk AA,lico,A
70. dry skin cream O
Smnyc
Olive, silk, lico


Colla- genesis X


71. Collagenesis X
Vit C , colhibin
-
72. Vita E C
Colhibin
E, C vit
73. collagenesis L
Vit C , colhibin
L
74. collagenesis G
Vit C, colhibin
G
75. collagenesis A
Vit C,colhibin
A






Back Scrub Silk



76. Back scrub  L
Al0
LA, L,silk AA
77. back scrub G
Al 0
La,silk aa, L
78. back scrub A
Al 0
LA, silk AA, A




SMNYC OEM
FDA labs USA

79. Lumina Gel


80.chi7


81.phi 7


82.herbal astringent


83.24K gold sensation


84.perfect 5th cleanser




Cool Hair Days

Pre shampoo treatment

85. Aloe Hair Treatment
Smnyc + aloe vera
LA
86. Aloe Hair L
Smnyc 1 ,aloe vera
L , LA
87. aloe hair G
Smnyc 1, aloe vera
G, LA
88.aloe hair A
Smnyc 1, aloe vera
A, LA
89. Rice protein treatment
Smnyc 1, rice protein
LA,
90. Rice Protein treatment L
Smnyc 1, rice protein
L- silk AA, LA
91. rice protein treatment G
Smnyc 1,rice protein
G-silk aa, LA
92.rice protein treatment A
Smnyc1,rice protein
A-silk aa,LA










Sensitive Skincare




93. Day n Nite Silk
smnyc 1,silk AA
Antiox E
94. day n nite silk L
Smnyc 1,silk AA
Antiox E, L
95. day n nite  silk G
Smnyc 1, silk aa
Antiox E, G
96. day and nite silk A
Smnyc 1, silk aa
Antiox E, A


Al 0 body scrub silk




97. Silk Derma
Al 0
Silk AA
98. Silk Derma L
Al 0
Silk aa/ L
99. silk derma G
Al 0
Silk aa/ G
100. silk derma A
Al 0
Silk aa A






Thank You God!