Science, Medicine,Nature and Troubleshootings

Asian Rhinoplasty

2022-01-03T00:14:00.005-08:00

Asian rhinoplasty is totally different from Caucasian Rhinoplasty in myriad of ways. Asian nose has small septum, thick skin, wide ala and hypoplastic/small collumela. Goals of the rhinoplasty include but not limited to alarplasty to address alar overhang, tip plasty to address wide and depressed tip, dorsal augmentation with an implant. Shown in the picture below is an example of a patient who underwent Asian Rhinoplasty.

To Book for consultation https://medifi.app.link/MTVaX2Lwv6

How to spot a fake or counterfei 2091 filter?

2020-06-09T06:57:00.001-07:00

How to spot a fake 2091 filter?

It is really hard to differentiate counterfeit filters unless you really pay attention. There are 3Ms 2091 made in the USA, China and Singapore. Those filters made in China and Singapore are marked with CN for distribution in the domestic market of China. Legitimate personal protective equipment should passed the LA mark of certification before distribution in China. This is to distinguished them from the ones made in the US.

At the right lower hand side of the packaging you will find the Lot code for example 20054(1st five numbers) that should be the same or reflected in the filter itself. Most 2091CN filters are made in Singapore with marked LA certification(green color) for distribution in China.

Here are some link for the videos to spot fake 3M 2091 filter https://youtu.be/BPhdshC6Yew

Sample of fake packaging

How to make a Disinfecting Solution?

2020-06-02T08:24:00.001-07:00

How to make a disinfecting solution? You can do it with just Zonrox and mineral water. Please listen to my podcast.

First Aid For Burns

2020-06-02T08:19:00.002-07:00

What to do when you get Burned? Be infomed!

How to Make a Daikins Solution?

2020-06-01T22:36:00.001-07:00

What is a Daikin's solution? It is a disinfecting solution used to clean or disinfect wounds. Today a formulation of this is being use to disinfect shoes, medical equipments and surfaces. So the question how to prepare the solution? Here are the steps

1. Secure a sodium hypochlorite(in the local setting ie Zonrox)

2. Buy 1liter of sterile water it can be plain saline or sterile mineral water (Wilkins, absolute, Summit)

3. Get a measuring cup or syringe. Measure 15cc of sodium hypochlorite.

4. Remove 15cc of sterile water and replace with the 15cc of Zonrox.

5. Youve made a Daikin's solution

Warning: Effectivity of the solution may last up to 24 hours only.

Covid 19 Podcast

2020-06-01T21:13:00.003-07:00

This is my first podcast entitled Covid19 update. Please feel free to listen. This is a test run. Covid19

Online Medical Consult Enabled Thru Medifi

2020-05-25T16:51:00.005-07:00

Good day everyone! Im offering now my medical expertise online. You can reach me via Medifi platform. Just download it at Appstore for IOS or at Playstore on Android. See you there!

https://medifi.app.link/MTVaX2Lwv6

Facial Fractures in Trauma

2020-04-24T18:46:00.002-07:00

Always wear a Helmet. Dont ever think of driving when drunk or when you under the influence of alcohol. Click and watch the link below.

https://youtu.be/KQ91UTgn1is

Philippines Public Hospitals Need Help with Personal Protective Equipments

2020-04-06T06:49:00.001-07:00

We are in dire need of donations for personal protective gear and diagnostic kits in our country.
For donations, you can contact thru this channel.

Covid19 Update in the Philippines

2020-04-06T06:46:00.000-07:00

What are the latest updates for Covid 19?
Ano ang kalagayan ng Covid19 sa Pilipinas?
Launching my youtube Channel. For more updates, please follow me on my youtube channel.

Covid 19 Response in the Philippines

2020-03-19T16:48:00.001-07:00

Since we are in the verge of pandemic the Philippine hospitals is in need of personal protective equipment, 70% alcohol, gloves, N95 mask. For donations in cash or actual materials please feel free to email me. #bayanihanNa

Wound Dressings

2019-06-01T04:52:00.000-07:00

There is no such thing as an ideal dressing.

There has been a lot of interest with the wound dressings. Broadly it is classified as either biologic or synthetic. Biologic dressings would include chorion-amnion from placenta, tilapia skin and pig skin. Synthetic dressings are the the premium dressings today such as the silver based dressings such as hydrofiber silver, nanocrystalline silver, foam dressings, and silver sulfadiazines.

Recently, there has been a lot of interest with this endeavor. Numerous companies are trying to develop dressings which inherently contains antibiotic, atraumatic to wounds, maintains moisture to promote epithelialization and absorb the exudates and requires less frequent changes.

BURN Surgery Notes

2018-12-30T21:38:00.001-08:00

PONS MD Notes

At the ER? What questions will you ask?

Ano po nakasunog sa inyo?

Saan eto nangyari?

How to assess the patient at the ER?

ABCDEF

A-Airway
Inspection: Check if the patient is gasping, abdominal breathing, alar flaring

Can the patient tolerate room air or is the patient intubated

Check if the patient can speak in phrases, full sentences

B- Breathing

Auscultate if the patient has clear breath sounds, check for decreased breath sounds

If yes? Consider pneumothorax. If the patient is normotensive may do CXR , if positive for pneumothorax then do CTT

If patient is hypotensive with decreased breath sounds? May do needling(2^nd -3^rd ICS MCL) if positive proceed with CTT

C- Circulation

what is the most accurate way to check for circulation?

Urine output is the most accurate way to check systemic circulation in burn patients

Other ways to check-BP, CRT, pulses

D- Deficits

Check for GCS(Glasgow coma scale)

Check for neurosensory deficits ( Review neuro PE)

E-Exposure

Open all the wounds

Check for SPTs, DPTs, FTs

Check for circumferential burns

F-Fluids

FORMULAS

Parkland’s Formula- uses a factor 2-6, Fluid of choice Ringers lactate

Uses a factor of 2 for elderlies and those patients with cardiac disorders

3- for children

4-baseline for adults

5-6 adjust the factor use base on urine output

When to use Parklands or when not to use it?

Modified Brooke’s 0.5 D5

Evans uses crystaloids at 1mL/kg/%TBSA plus colloids

Slater uses ffp as a part of resuscitation

Monafo high sodium(250meqs of Na, 150 lactate,100meq Cl) reserved for cardiac patients

Formulas develop for Children

Shriners Cincinnati

Galveston

Choice of Fluids? Why is that so?

Crystalloids- readily available and cheaper than other alternatives

e.g. Ringers lactate,saline,Hartmann solution

High volume of administration produces hyperchloremic acidosis

Increase neutrophil activation

Isomers of lactate increased production of ROS

In vivo dilution of crystalloids causes of hypercoagulable state

Hypertonic solution –lower volume required lead to hypernatremia and renal failure

Colloids- due to leaky status of the capillaries, colloids/plasma proteins leaks outside causing edema formation

What is Fluid Creep?

It is the over resuscitation more than what is predicted by the parklands formula which could lead to abdominal compartment syndrome

Stretegies to avoid it;

1. Avoidance of early overresuscitation

2. Use of colloid as a routine component of resuscitation or for rescue

3. Adherence to protocols

EMERGENCIES OF BURN

1. Electrical Burn with compartment syndrome

2. Burn shock

3. Inhalational Injury

What are the components of burn shock?

1. Distributive

2. Cardiogenic

3. Hypovolemic

Zones in Burn Wound

Zone of coagulation-avascular area, necrotic areas meant for excision/ debridement

Zone of stasis- salvageable area , sweet spot of resuscitation, over and under resuscitation may lead to progression of burn wounds

Zone of hyperemia- areas with erythema

How does and how long does Burn wounds Heal?

First degree burn -7days may apply lotions/moisturizers

2^nd degree burns

SPTs- heal approximately in 2-3 weeks, heal by? Epithelialization

DPTs-heal in 3-5 weeks resulting in hypertrophic scarring and contracture if not yet operated on

FT-heal by granulation

What is the cancer associated with burn?

Marjolins ulcer is an SCCA common sequelae of chronic burns

Dressing FAQs

How many gram of Silver in acticoat flex?

-100ug/mL water due to structure and sustained release, increased surface area

SSD- 3030ug Ag+/ gram

Silver nitrate 3180 Ag+/ mL water

Dressing causing metabolic acidosis due to inhibition of what enzyme? Answer: Mafenide acetate. Adverse effect: Inhibits Carbonic anhydrase leading to metabolic acidosis

For difficult to treat wounds like post irradiated wounds, what are the options?

Topical hemoglobin spray. MOA? Increase the availability of O2 in the vicinity, thus in theory contributes to faster wound healing

What is VAC? Vacuum Assisted Closure or commonly known as Negative pressure wound therapy

Indications:

1. Exposed bone

2. Exposed tendon

3. Highly exudative abdominal wounds

Contraindications:

1. Infected wounds

2. Exposed major vessel

What is the ideal pressure for VAC? -100 to -150

Components of VAC

Sterile foam, ioban, suction catheter

Why is the pressure intermittent? To stimulate further granulation

What is the molecular mechanism behind VAC?

By subjecting the wound under intermittent stress production of growth factors such as VEGF, PDGF, FGF are stimulated.

By subjecting the wound to negative pressure exudates are removed which contains excess inflammatory agents, metalloproteinases and cytotoxic agents.

Other uses of VAC;

In open abdomen that is difficult to close

In grafted wounds in order to keep the graft adherent to the wound

What are stages of graft take?

Imbibition- occurs within the 24-48 hours where the graft obtains its nutrition and oxygen from the wound thru passive diffusion.

Inosculation- occurs after 48 hours characterized by kissing of the newly formed capillary buds

Early revascularization- at 72 hours new vascular connections are made. At this point GSO can be done if we are suspecting infection

What causes graft site loss?

1. Hematoma

2. Seroma

3. Infection- critical count 10⁵ CFU/gram of tissue

4. Shearing- prevented with splinting

5. What are microorganisms are the exception to the rule, even though their amount <1 b="">0⁵ CFU/gram of tissue can lead to graft site loss?

a. MRSA

b. Pseudomonas

c. Group B streptococcus

Whats the difference between primary contraction vs secondary contraction?

Primary contraction- the immediate coiling the graft due to its elastin content

FTSG> STSG

Secondary Contraction- late event which arises due to increased activity of the fibroblast

Mesh STSG> STSG> FTSG

What is the best donor site for the STSG of the face?

Back

What is the best donor in terms of cosmesis and the amount of pilosebaceous unit?

Scalp

What are the components of the pilosebaceous unit?

a. Hair follicle

b. Sebaceous gland

c. Sweat gland

d. Apocrine gland

e. Dermal appendages

In theory, when can you reharvest from a previous donor site(STSG)?

2 weeks

What is a reconstructive ladder?

This is guide use by the plastic surgeons in their reconstruction

From lowest to highest

1. Delayed primary closure

2. Primary closure

3. Skin graft

4. Local flap

5. Regional flap

6. Free flap

What is the thickness of various skin grafts?

Thin STSG 0.15–0.3 mm

Intermediate STSG 0.3–0.45 mm

Thick STSG 0.45–0.6 mm

How to dress skin grafts?

It depends on location

At the chest, trunk or pelvis it is dressed with tie over dressing or bolster dressing

For extremeties it is dressed with circumferential dressings.

Nutrition questions

What is the best protein for burn patients? Whey protein

Differentiate Whey from Casein?

Whey is absorbed fast

Casein is long acting best for atheletes

What is permissive underfeeding?

Study showed that with decreased feeding compared to the standard have less incidence of infection given that the feeding is a high protein diet

BURN Surgery

How to do escharectomy in the hand?

Identify the peak points of the digit. For the thumb incision is at the ulnar side. From index finger to ring finger incision should be done at the radial side

How to do fasciotomy of the upper extremity?

In the thigh and leg? Release at the medial and lateral aspect of the leg.

How many compartments in the leg? 4

Lateral

Deep posterior

Superficial temporal

Landmarks

Tibial spine

Lateral Incision

Lateral 1 fingerbreath in front of the fibula, maintain anterior to the fibula to avoid damaging the superficial peroneal nerve

Medial incision -1 fingerbreath below the palpable medial edge of the tibia

Differentiate escharectomy vs escharotomy

Escharectomy is the process of removing the eschar thru sharp debridement

Escharotomy is incising directly into the eschar to relieve the tourniquet effect of circumferential full thickness burns

Aesthetic unit of the face

SPLINTS

Functional hand splint?

Thumb abducted, Wrist 30 deg extended, MCP 45-50 flexed

Dynamic Hand splint

For rehab excises , practice finger extensions

Sugar thong splint designed for genital surgeries where the goal keep bilateral lower extremity separated

Log leg splint

JAQ favorites?

What causes compartment syndromes in burns?

Circumferential full thickness burns

high voltage electrical burns

trauma

What are the composition of various IV fluids?

Dressings

What are the adjuncts for difficult wounds?

Hemoglobin spray

Can we combine MEBO and Ganulox? NO Mebo an oil based product will decrease the availability of surface oxygen in the wound

Acute Burn Wound versus Chronic Burn Wound

2017-07-24T06:39:00.003-07:00

Key Points

Acute Burn are burns that has a duration of less than 12 weeks or 3 mos from the time of injury. It follows the normal phase of wound healing
Chronic Burn occurs with more than 12 weeks or 3 mos duration. It does not follow the normal phase of wound healing

Modified Radical Mastectomy

2017-05-09T15:57:00.002-07:00

As a surgical resident this operation is one of the most interesting and aesthetically requiring procedure. I am hoping to more mastectomies and breast reconstruction in the future.
.

Split thickness skin grafting

2016-12-02T01:24:00.000-08:00

Figure 1. split thickness skin grafting( with signed consent)

This is my first STSG during my first rotation in Plastic Surgery, PGH.

First Graft site opening done 4 days post surgery. I hope to post the pictures of my patient once
available.

Follows up in our clinic.

By the way what is Split thickness skin grafting?

This is one of the procedure use to cover wounds that cannot be closed primarily or in

other large wounds cause by avulsion and laceration. This procedure is frequently use in

Burn surgery doing tangential excision of burn wounds.

Plastic Surgery study

2016-11-22T02:17:00.001-08:00

It is fun studying plastic surgery. Anatomy at its best..

Plastic surgery rotation

2016-10-19T01:08:00.001-07:00

i rotated in burn and Plastic surgery during the month of May and March 2016. I was able to do multiple split thickness skin grafting,able to assist in free flap and aesthetic surgery. I also learned to apply negative pressure wound therapy and to do escharotomy.

Figure 1. This is a picture post application of negative pressure wound therapy

Subcuticular Running Suture - Suture Techniques

2016-03-07T04:29:00.001-08:00

One of the most informative and easy to learn videos for knot tying

post splenectomy vaccination

2016-02-15T08:52:00.000-08:00

Patient who have undergone splenectomy either due to shattered spleen due to blunt trauma or due to hemolytic problems should be given vaccination to cover for Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis. Patients should be advised prior to discharge on the risk of overwhelming post splenectomy sepsis and their immunocompromised state.

Appendectomy

2016-02-15T08:01:00.000-08:00

Ive found this video interesting online. This a rocky davis incision with noted peritoneum closure.
During my first year in surgery I did 38 appendectomies, 15 during second year another 40 during my third year in general surgery residency.

Passion vs Job

2015-10-24T06:05:00.000-07:00

I want to be a plastic and reconstructive surgeon . This occured to me while waiting for the facial CT scan result of my multiple injured trauma patient.

My Experience As a First Year General Surgery Resident

2015-10-24T05:04:00.001-07:00

the most gruelling test of personality and dedication to achieve a perfect cut of becoming a great surgeon..this is a test of patience and dedication (10/24/2015)

Emergency thoracotomy

2014-12-29T01:33:00.000-08:00

This is an actual performance of emergency thoracotomy. This is just a video I got from youtube. I don't ownership of this clip. Viewer discretion advised. This is just for learning purposes only.

Chest tube insertion

2014-12-29T01:21:00.000-08:00

Ive found this amazing video about chest tube thoracosotomy.

http://youtu.be/EcIDkJHRq8c