Apr 2016 Thrissur/Rotterdam - Lee Seng Khoo (Rio de Janeiro, Brasil)

I completed the 6 months fellowship under the DAFPRS program spending 3 months in Thrissur, India and an additional 3 months in Rotterdam, Netherlands.

In Thrissur, India I worked under the direction of Dr Hirji Adenwalla and Dr PV Narayanan at the Charles Pinto Center of Cleft Lip, Palate & Craniofacial Anomalies based at the Jubilee Mission Hospital in Thrissur, Kerala. The Charles Pinto Cleft Center is a Smile Train partner and Dr Adenwalla has been performing cleft surgeries exclusively for the past 15 years. The center has logged over 16,000 cleft related surgeries being performed over 50 years. Dr Hirji Adenwalla is very much a Renaissance man, performing meticulous surgery (at the age of 86 years old) -explaining the intricacies with much enthusiasm sprinkled with wisdom and surgical tales and history. Even at this age, Dr Adenwalla is not averse to criticism and is open to learn or adapt a new approach. Dr Adenwalla has quite recently adapted the technique taught to him by Dr Philip Kuo Ting Chen from Chang Gung Memorial Hospital named the Furlow-Chen pharyngoplasty for Velopharyngeal Incompetence (VPI), which he found has superseded his previous approaches. His chosen prodigy Dr PV Narayanan is equally proficient with the scalpel and also has an encyclopedic knowledge on cleft/craniofacial disorders and surgical history. Surgeries are performed 3 times a week with 3 days of outpatient clinics. Ward rounds and the outpatient clinics provided excellent teaching sessions by the team led by Dr Hirji Adenwalla. Scrubbing in to participate actively requires temporary registration with the Medical Council of India, which I fortunately managed to obtain in time for the fellowship. (Advise: Do not leave this to the eleventh hour). During my fellowship; I also attended surgeries with maxillofacial surgeon Dr Philip Matthew who performs alveolar bone grafting, transpalatal distraction and orthognathic surgery for cleft disorders. Dr M Pasupathy and Dr Vasant Radhakrishnan who were also cleft surgeons on the team were very hospitable and a pleasure to scrub in with. Dr Pasupathy introduced me to Dr Varghese Mani who is considered the Father of Orthognathic Surgery in India; whereby I managed to attend his surgeries performed at night at a private center. I remember those nights with much gusto whereby Dr Pasupathy will cruise down the roads in Thrissur in his motorcycle with me as the pillion rider; wind blowing down our faces after the end of Dr Mani’s surgeries. With the connections of Dr Adenwalla and Dr Narayanan; I also managed to attend the 2nd Amrita Craniofacial Update Course with hands-on training in management of craniosynostosis deformity / Midface & calvarial distraction osteogenesis on stereolithographic models. I found my time in India very memorable and have learnt many valuable techniques and management pearls in both cleft and craniofacial disorders.

Following my stint in India; I continued the second phase of my fellowship in Rotterdam, The Netherlands. As my major interest was Craniofacial Surgery; I was based primarily at Sophia Children’s Hospital at Erasmus MC. Scrubbing in for various cranial and forehead deformities, craniosynostosis, hypertelorism, ear and nasal reconstruction with Prof Irene Mathijssen and Dr Sarah Versnel were highlights of time spent at Erasmus MC. The craniofacial techniques developed at Erasmus MC were distilled from years of experience and some notable techniques utilized here included the use of spring mediated cranial vault remodeling and the absence of the use of plates/screws in favour of absorbable sutures after cranial bone remodeling for intracranial procedures. Every week the team meets up to discuss the following week’s operative plan and as courtesy to the fellow, these sessions are held in English. Apart from craniofacial surgery at Erasmus MC, I managed to observe/assist some microsurgical cases at the adult hospital Erasmus MC-Daniel den Hoed with Dr Marc Mureau namely DIEP and PAP flaps for breast reconstruction surgery; and facial reanimation with gracilis & cross face nerve grafting. In addition; I completed over 40 hours of lab training in microsurgery on the animal model based on the Acland’s course conducted by Ms Manja Muijtjens and Ms Esther Fijneman at the Erasmus MC SkillsLab.

On other days where no craniofacial surgeries were scheduled; I attended surgeries at the Velthuis Kliniek with Dr Jacques van der Meulen and Dr Heike Klepetko where the entire spectrum of aesthetic plastic surgery was performed. Dr van der Meulen brings his expertise from a background as a craniofacial surgeon performing facial aesthetic surgery at an extremely high level (in particular rhinoplasties). Coming from Brazil with a strong aesthetic component in my residency training and having performed many rhinoplasties myself and assisting many other masters; I still learnt many invaluable tips and tricks in aesthetic and functional rhinoplasty from Dr van der Meulen which I will implement directly after this fellowship. (Interesting note- Dr van der Meulen was once a cleft fellow of Dr Hirji Adenwalla several decades ago of which Dr Adenwalla says fondly, “He came as a student but returned as a teacher.” Dr van der Meulen returned to India and shared his skills in cleft rhinoplasty with his former mentor after completing his training in craniofacial surgery). Dr Heike Klepetko with her longstanding experience as a reconstructive breast microsurgeon, performs excellent breast and body contouring surgery with her meticulous surgical skill. They were both a class act and eager to teach the fellows patiently and conscientiously.

To top it all, I also had a great opportunity to work with Dr Jeroen HP Stevens from the Bergman Clinics in The Hague. Dr Stevens performs all his surgery with an element of sprezzatura . Dr Stevens is a gung ho mentor who will challenge you to rethink what you thought you knew about plastic surgery. I assisted Dr Stevens on various cases and accumulated a wealth of knowledge on “organic surgery”, 1.2.3.D concept for the face, lipofilling, body contouring and rejuvenation with Platelet Rich Plasma (PRP), Stromal Vascular Fractionate(SVF) and stem cell modalities. Apart from surgery; Dr Stevens also teaches fellows on business aspects of running a private practice and the importance of publishing academic work to remain relevant in the industry.

In conclusion; I can highly recommend this fellowship to any plastic surgeons with a particular interest in facial surgery of the face; be it aesthetic or reconstructive. The flexibility of this program allows the fellow to focus on his or her particular areas of interest.

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