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Uh, hi, guys. My name's dashi, and I'm part of the back to the future. Course, I'd like to welcome you all to another session to the back to the future Today. Um, this week we'll be presenting on maxillofacial surgery, and the presentation will be given by Mr Ramachandra Matagorda. Along with this, we'll also be showing a video on about sutras and about interrupted sutures. Today, before we start the webinar session, I'd like to say a big thanks to asset for helping us develop this course. Thank you to medal for providing us a platform to provide feedback forms and giving you the certificates. They will be very useful in your future. And finally a big thanks and big shout out to M D U for sponsoring us. Um, now we'll just move on to the video. The video will be on interrupted sutures and sutures. Yes, suture material can be categorized in a number of ways braided or mono filament, natural or synthetic, absorbable or non absorbable. Along with the speed of degradation. The size and needle shape can also be selected for each purpose. If the future is braided or polyp filament the extra surface area will allow it more grasp on tissues it runs through, however, it induces a greater tissue reaction and so impairs cause mastitis. If sutures absorbable, they will not require the future removed post operatively. However, as the future dissolves, the attention it gives to the wound is reduced. Here we have vicryl repeat quickly absorbable braided PDS polyp, dioxin, absorbable, monofilament vicryl more slowly absorbable braided and proline non absorbable monofilament. The optimum grasp of the needle is approximately two thirds from the point, keeping the needle at the right angle to the instrument. Beyond this, you're gripping part of the Neil, which houses the thread with risk of damaging this connection. When picking up the future, use the driver to take directly from the packet. Avoid touching the needle with gloved hands at all costs. This is a hard habit to break. If you get used to it, the needle should be held close to the tip of the instrument. This is particularly important when working in smaller spaces as it improves the accessibility and ease of suit replacement. Make the sutures safe by directing the point back towards the instrument before handing it to your scrub nest or assistant surgeons should be mindful of the concepts of opposition and skin aversion. Achieving wound opposition and not tension is paramount. If the skin is not averted, wound healing is impaired and this can result in pork osmosis. Enter at right angles and rotate the risks and twist to come out of the wound from the same line. Enter perpendicularly and twist around. Pull the thread through to avoid any unnecessary waste. This is an instrument time to tie surgeons, not place two loops around the instrument with the long end and use the needle holder to grab the short end of the suture. Hold both ends two opposite sides to form a knot over the wound so that both ends lie on opposite sides to where they started. Avoid over tightening the future as this will reduce blood flow to the tissue, leading to poor wound healing. Avoid performing this maneuver in one goal as shown here, this can cause a suture to become too short. Um, okay. When cutting the suture ends, make sure not to cut it too short as sutures may become undone but not too long either. As this can get tangled with neighboring sutures. What about? There's our video on interrupted sutures and sutures. Now, as I've explained before, this week's teaching will be on oral and maxillofacial surgery. And the presentation will be given by Mr Ramachandra Moratti Ghada. He works as a senior registrar here at the Royal Surrey County Hospital With great pleasure. I'd like you to introduce to Mr Ramachandra Maradi Godda. Thank you dot Uh, good evening, everyone. Uh, my name is, uh, Ram. Just call me Ram. I'm gonna have to Can everybody hear me? Can you hear me a dash? Yeah. Okay. All right. Um, the idea today, what I think is, uh I don't think many of you have been through Max facts or maxillofacial surgery rotation either during your medical school or during your foundation, uh, training. So I thought I would use this opportunity to give you, like, an introduction. What? What we do, basically. And if there is anything that you guys want to know a bit more, Uh, please come back to me. I'm happy to guide you. If anybody entrusted in the specialty, uh, or want to have, like, a work experience or a taste of weeks, something like that. come back to me. I'm quite happy to organize that. Okay, So I'm just gonna go to my presentation. Um, Dash, uh, the presentation, uh, is on the screen. Can you see it? Okay, um, as a a max fax as a specialty. So I don't know how many of you know, uh, you need a dual qualification. Uh, you need to be a dentist as well as a medical graduate. Uh um, Then you get into ST three. So before that, you should have the register herbal degree in dentistry with the General Dental Council. Register third degree with GM, see? And then you would have had, uh, MRCs. And then you qualify to apply for F C three. Okay. Uh, for some reason, my presentation is not going, uh, screen. Uh, can you go? It's not working. OK, Dash, can you open my presentation? Uh, computer. Okay, One second. One second. Sorry. Uh, I think mine started. Carry on. Okay, So this is just a slide to, uh what is, uh, Max fact or oral maxillofacial surgery as a specialty. So we do various, um, range of, uh, surgery. Uh, and we can do a bit of a dentist as well. It's a surgical dentistry. A bit of oral medicine, head neck surgery, celebrate gland surgery, uh, facial pain, TMJ surgery, and, uh, facial reconstruction, including the cosmetic surgery. This is just a slide to show how the career pathway, whether you come from a dental background or a medical background. So which way you go to the specialty? Uh, there are training pathways, uh, starting with S t one, uh, and s t three. But there have been, uh, integrating the court surgical training into the, uh, pathway. Okay, so you just have to excuse me. Apologies, guys. I think, um, we just run through, run into some some error. Could just stay with us kindly for a few minutes, I'm sure. OK, Love it. Okay, so so again, s t three application process goes through. Uh, Auriol website. And there are daenerys that deal with that. And in 2020 there were two rounds for S t three, and you can see the numbers there. I just said as a specialty, we do have neck reconstruction. Uh, cancer work, facial deformity, including automatic surgery, uh, dental, your skin, uh, cancer, melanoma, basal cell carcinoma. And if you really want to do? Cleft lip craniofacial? Uh, surgery. Then you would have had, uh, fellowship. And then you'd have taken that pathway. So, yeah, uh, as a specialty, we do trauma. So I'll give you some examples with some, uh, schematic, uh, photographs with what we do. This is just a photograph, uh, picture of the mandible. And, uh, the communist fracture that we deal is a fracture. Mandible. You can see there is a fracture in the left parasymphysis area and right, uh, gondola area. And that's been fixed. So there are various principles how we fix it. It's called, uh, champagne Astro synthesis lines. We use the principle to decide how many places groups we need in each area. Midface fracture. Uh, it's been divided into Lee Fort 123. If anybody's taking MRCS exam, this could be one of the, uh, MCQ the classification of midface fracture into the fort. 123. So one is at this level, uh, just about the teeth. Nasal floor levels and leave for two goes up. It's like a pyramid, including the medial wall of the orbit and the info bickel room and plea for three Includes the cranial base. So the next one is automatic surgery. But you can see how just by moving the jaw, the lower jaw and the upper jaw how that face changes. Okay, so this girl is into class to facial profile. And this boy is class three, where the lower job is, uh, pragmatic. And just by, uh, making certain splits. We call it a bilateral PSA. Gitell split. We split the mandible in the sagittal plane, and then we slide onto the and pasta, and that changes the profile, and we deal with the oral cancer. This is a photograph. The past photograph is showing how, um the oral cancer is looking under the right lateral bar of the tongue and that's been removed and reconstructed with a free flap. And this is a radial, uh, free flap Means we take a skin and a bit of a fact issue along with the radial artery and radial vein, and then we graft it under the tongue to reconstruct the tongue. Uh, it involves a microvascular anastomosis. So this is the radio. This choir patch is where we have taken the radios for, um, skin along with aphasia. And you can see a small photograph here where you can see, uh, the artery and veins. And this is just after the incision is done. So again, we do take free flap graph from other parts of the body. If we have to reconstruct the bony aspect of the head neck area, the majority we do is a reconstruction of the mandible, and that's been done using fibula. Here you can see a schematic diagram where there is a perennial artery coming out from the stipulate artery. We use the bone along with the muscle and the skin on top of it to rise as a free flap. And then we use that to reconstruct the mandible, and we can put the teeth into it by using implants. And that completes the total rehabilitation for the patient. And after taking the fibula, patient's will be perfectly fine. Uh, they would come back to normal. They're working ability. There's no any problem with that. So nowadays we are using a three D guided uh, reconstruction, where you can see the three d aspect of the city of the fibula has been used to reconstruct the mandible here. So the red part in the The picture is where we have done the, um, a reception for the cancer. And then you really guided, uh, measurement and to design the bone only aspect of the big lab. So this is again using hip bone to reconstruct the, uh, mandible. We can use that as well. So you can just see this is just to make you understand what we do. We do skin surgery. You can see a large pigmented, uh, area, uh, the left, uh, post auricular area. So that's been excised. And you can see the skin graft has been taken from the chest wall where we we have plenty of skin, and that's been grafted here. So we put a pressure dressing on top of this skin graph. Leave it for 7 to 10 days, and that's completely taken. So they usually take very well. Uh, this is one of the case that we did for a construction of total rhinectomy where they have a cancer of the nose itself. Then they will lose the total nose. So in that you can see this is the forehead on the top, uh, left hand corner of your screen, Uh, a designed skin flap is in rice and you can see a small, uh, calculate struck been inserted into it. And that's been put back for a few weeks so that the tissues get conditioned. And then the skin forehead has been rice, and that's been turned down to reconstruct the nose. And the, uh, cartilage struck acts, uh, to give a definition to the nasal shape. Otherwise, the skin flap will just collapse, which we don't want. And the donor site. Either you can close it primarily if there is enough, Uh, laxity. If not, we put a, uh, skin graft, and that will feel perfectly fine. So this is a, uh, total, uh, rhinectomy patient. What you see here, the nose that's come from the forehead you can on the left hand side of your screen. You see addressing That's the dressing at the donor side. The skin graft and this skin has come from the forehead, and the shape of the nose is held by the rib graft. Take the cartilage graft taken from the rib. Uh, this is another, uh, similar case in this case. What we have done differently is when we raise the forehead, uh, skin. We put a skin graft underneath, and then we put the skin flap back for a few weeks so that it gets conditioned. And so this is the skin flap, and there's a, uh, skin graft underneath. So when we rotate, it's just like that. But this surfaces are already with the heel with the skin graft, it's not a raw surface. Otherwise, you will have to protect 1 80 degrees again, Another skin, uh, surgery here. So somebody this lady has got a like a basal cell carcinoma and the nose. So once we take it out, we can't just send the patient back home with a big dent, Uh, wound on the face we have to reconstruct. So this is like a sliding mechanism, and we call it as a bilobed lab. So if you see on the left hand side the lower photo there is a, uh, the effect. See the right lower photo and that's been closed, just understanding the geometric movement of the skin. So to use the laxity of the skin in another area and to use that complexity to reconstruct, uh, in a area that we need, uh, that's just a an introduction. Uh, I'm happy to discuss or anything that you want to ask me. Uh, as I said, if you want to have a test a week or if you wanna If you are considering Max Max facts as a career, it's a fantastic career. Uh, you need to If you're a medic, you need to go back to do a dentistry. Uh, there are dental schools who are doing three years, Uh, some four years, but again, you know, you you you will be fine. Dash. Um, you got any anything to discuss, or is there anyone else want to discuss? I just wanted to say so during your so you'll go through into if you for, for example, me. I've done my med school and then once doing a dentistry, you know, 345 years. And do you need to go back into Can you go straight into s one or how does it work? Okay, uh, normally, how it works. You need to have a double qualification. You need to have MRCs. Uh, the basic requirement and the other rest of the things. You know, you need to have application audit. You should show that your, uh you have some experience with specialty. So you've done your medicine. Now you're in a foundation. So hopefully during this time you would have done either passed part of your Marcy s or, you know, whether you want to complete it before you finish your foundation. That's up to your personal preference. But you need to apply for, uh, dentist school. Uh, ideally, it's good to have somebody from Max fax as a referee apply for medical school. For that, you need to get in touch with local, uh, max fax department. Tell them that you're interested. You come into, uh, theaters. Uh, you do a test week, so that will show that you're interested in at the same time. It will reinforce the fact that what you are deciding is what you want. Okay, So while you are doing dentistry, you are You can still keep doing your local work. Uh, you know, weekends, nights and things like that. So that that's financially I don't think you will be penalised. Uh, and it is maxillofacial surgery. Is it equivalent to cosmetics slash plastic surgery? Um, yeah, you can in again in max. Fact, there are subspecialties. You have a head and neck. You deal with the cancer and reconstruction to do orthognathic. Uh, as I said, moving the jaw, uh, facial work. And whichever you do, you can add on to a cosmetic work. Uh, dental villa, Uh, skin, uh, TMJ. Now, TMJ is picking up TMJ reconstruction, Uh, dental implants. So there there is so much of, uh, you know, very 80 of work you do skin, soft tissue, heart issue work, celebrity gland surgery, minimally invasive saliva gland surgery. The endoscopic work for the celebrity doctor system. So there's so much that you can do. You won't be able to do everything you have to specialize, but, yes, you can go into a facial Plastics? Yeah, last year and everything. Uh, another question is, how competitive is maxillofacial surgery. Okay, um, compared to other specialty, it is not that competitive. I shouldn't say that, but you have to. It's like self selecting. You're committing yourself going to, uh, double degree and doing a masius and showing your commitment to the specialty. That itself will prove that Yes, you. This is what you want to do compared to other specialty, like an orthopedic and, uh, plastics and things like that it's not that, uh, competitive because not many people would, uh, going to be smart to do both listen. And dentist? Yeah, someone's mentioned. Is there any competition with other specialties to treat patient's, for example, Plastic, E N T or dermatologists? Uh, that's a very good question. Uh, there is always an overlapping aspect. Okay, I'll tell you about E n T and plastics and dermatology. I'll comment about that as well. Coming to dermatology. Uh, dermatology. They will do medical treatment for any skin disease. And if there is any simple thing a small mall or a small cancerous legion, they will take it out. And if anything that needs primary closure, they will do that. Anything beyond that, especially in the hedonic area, they have to send it to a max fact, OK, coming to, uh, e N t so E n t s. It's all lapping, uh, head neck cancer. It put it in the oral cavity, uh, including the lips on the face. Uh, any other cancer that will come to Max Fact anything in the oropharynx upper uh, disease will go to the ent. Okay. And the celebrity land disease, it's It's wherever whoever gets the, uh, referall, it's It's like a common, uh, and all the other automatic surgery. Uh, celebrity, uh, endoscopic work. Everything. Is Mexico coming to plastics in the UK majority of the max fax units they do their own reconstruction or head neck cancer. I do know that there are very few units where there is There isn't enough manpower from max fax side. So the plastics will come in and do the reconstruction for cancer patient and the cosmetic work. You know, it's it's majority. It's private. Whoever gets it, they will do it. Okay. And, uh, cleft and the beneficial that usually, um, combination of plastics, e n t. And Max facts. So you have to have, uh, fellowship for that. And to get that fellowship, either you can come from all three, uh, specialty plastics E N t or Max facts. It's unusual that ent, uh, will go into craniofacial, uh, cleft. But I do know one e ent person who is doing, uh, it's usually plastics and Max tracks coming together. And as a registrar in Max fact surgery, and even as a consultant, what is your day to day life like, So it's very similar. If I want to put it in a generic terms, you will, uh, do a morning ward round. You'll discuss the patient in patient's and, uh, the patient's will come in when you're on call, uh, and then you go to the ward round, Uh, and then you, uh you if you are in pate, er, then you go and see the patient's pre op. You consent them, you make sure all the scans and all the other investigations are available and everything. And then you go and, um, do that, Tim Brief. And once the patient is ready and then you go and, uh, do whatever you need to do in terms of operation. So if you're doing a head neck operation and if the patient is a reconstruction with the free flap, it's usually anywhere between 8 to 10, 12, 14 hours operation. Uh, if it is after nothing, it's anywhere between 2 to 4 hours. Uh, it is dental Vela. It's, I don't know, 30 minutes, 40 minutes. Celebrity, uh, tumor. Couple of hours like that. So if you're in the clinic on the road to then it's your clinic day, you're going to do the clinic. Uh, if you're on call, if there is a patient, uh, in seaport, then you go on to the trauma, uh, on the seaport. And if you're on call, you go and read whatever comes through A and e whatever being referred to you. So another has asked, Is there a strict criteria for where you can take a skin graft from to be used on the face? Uh, there are many areas that you can take. It depends to where your grafting it's usually taken from the neck because neck, you've got a lot of skin. And, uh, donor site is usually closed primarily because once you take it, you can close it primarily, and you can take it. Preauricular. Uh, it is a couple of centimeter. You can, uh, you can pinch, uh, a bit of a skin. And then again, you can close it primarily, Uh, you can take it from a upper chest again. There is plenty of skin that you can pinch, uh, and it hides under the color, especially men. Uh, you can primarily close if you're doing, uh, split thickness graft because this is usually done a full thickness. If you're doing a split thickness. Depends where you are. Um, if you're you can take it from the tie. You can take it from the the leg, or you can take it from the upper arm. So it depends how how you're working. Um uh, design in data. Because if somebody needs a, uh, free flap, because once we for radial, once we take the radial forearm, there is a district. You need something to close. We take the graph from the abdomen and then grafted here. That's a good thing. So then patient's will be armed out. So one team working on the arm. So that team is closer to the abdomen. So they will take the graft from the abdomen. They close the wound, and then that's done. If you are doing a fibula again, you need that. It's usually, uh, stick thickness, then usually go for an upper. Uh, tied. Um, someone's asked, What would you do differently if you looked back in your career? Uh, in terms of professionally career wise? Nothing. Nothing. All right. That's right. Uh, yeah, I think, uh, anyone else have any other questions that you can put on the chat? Yeah. So I think, um, is there anything else you want to tell us, Mr Ramchandra? Um I mean, uh, as I said, um, I don't think any of you had any max fax rotation in your under graduation. I know that for the fact. Okay, there isn't any a single medical school in the UK where they send you your like. They send you a general surgery rotation after pedicure rotation. Uh, your upper GI rotation, your dermatology. There isn't a single medical school where they send you for out this week. This month, you've got a max for exportation. I didn't want it to go into detail into a case discussion because it would be very unfair for you to understand what's going on here. I just wanted to have an introductory talk for you to understand as a specialty what we do. Okay, if you're interested from now on, as I said, get hold of me. My email addresses are dark. Then my surname, which is mother to go dot NHS dot net. Um email. Email me what your interest is. I'm happy to organize your taste of it. Are you? Is there any day that you're free? You want to be, uh, thinking. You want to get into Tater in the clinic, Feel free to email me. I'm happy to, uh, organize that by you, or even if you want to have a, uh, just a casual chat. Uh, what we do what you're thinking. What about your carrier? I'm happy to. So someone asked what made you get into max packs? Sorry. What made you get into Max Fax? Um, what made me I always wanted to be a surgeon, and, uh, I did dentistry first. So as a dentist, I've always enjoyed the surgical aspect of dentistry. So I explode a bit more, Uh, in that and then that interested me head neck, beautiful anatomy and, uh, long challenging operations where you can rebuild somebody's tongue. Somebody's face change. Somebody's, uh, outlook. Uh, you know, all these challenges. So, yeah. Uh, someone's asked if you had to choose another specialty. What would it be and why, Max Fact only Max fax. I've never thought I've been through medical school. I've been through all the, uh, you know, specialty. I've done plastics core training. I've done the cardiothoracic I've done. I t u. I've been periodic surgery I've done after police. I've done general surgery. Um, yeah. Uh I mean, it's very my choice. I don't expect everyone to be thinking that way. Uh, so I've always start. Yeah. Expect, uh, someone mentioned which subspecialty in maxillofacial surgery has more scope. Okay. In NHS, its head neck. Okay, because head neck surgery, they deal with the cancer as a NHS. Uh, you know, they want you to deal with cancer. That's a priority, isn't it? And the other benign tumor celebrity gland, uh, coming to cosmetic aspect. You know, would you expect people to get the cosmetic work done? Uh, under NHS know. But, you know, if you're trained, if you can do it, you can do it outside as a private. That's what people, uh, look for to do private work. But there are plenty, As as I'm aware, uh, and it just wants more head neck surgeons, and there are plenty of jobs available. Uh, what type? A number of switches are usually used for the face and neck. Okay, that's a good question. So if you need to do a deeper, uh, suture, you do resolvable state, which is usually 403 war 50 y krill. Why current rapid undyed the white thread, which is not a blue thread. Okay, if you use a blue white krill once the wound heals, the stitch will show up on the skin, especially a fair white skin. It may not show up in a skin like mine. Ok, um, for a skin superficial skin closure, uh, it depends where it is, but as a general rule rule anywhere between four and five. War nonvisible resolvable nylon rolling things like that. Okay, uh, if you're using around the eye eyelid again, you know, the skin is very thin. I would go for six hour. Okay. All right. You have all you all done? Uh, basic suturing, uh, skill, uh, courses basic, uh, surgical, Uh, BSS Basic surgical. Uh, yeah. So the BSS course is, uh I think a lot of people who would want to get into surgery would have ended up doing the course themselves. So I myself have done the BSS course myself. Yeah. So, uh, the more you practice, uh, suturing is the scale you need if you want to be a surgeon. Yeah. If you wanna as a junior, if you want to impress your consultant, your registrar to the best suturing How you handle the tissues? How you hold the needle. How you lower the needle, Have you hold the instrument? The need holder? What instrument you pick up when your surgery. What angulation you, uh, insert the needle into the skin or the tissues And how much bite you take And the second bite, How much you're matching to the other side. What angulations you come out and how you throw the Not where you want the not to set everything out. Um, just from from my from my question is, um I think in general surgery, they use a lot of hand tying. Whereas in orthopedics, they use a lot of, um, instrument ties in max back surgery. What do you usually use? Uh, if we are trying vessel and time. Okay. If you are trying after internal jugular vein, facial, rt, superior, parador artery or any vessel. Okay, um, if we are closing a tight, um, wound, then we tend to use, uh, anti. Otherwise, majority. It's, uh, you know, because I think in general surgery, everything goes into the abdomen, so it's easy to you. Use your finger, which is much safer, uh, to push the not down. Yeah. Um, guys, are there any other questions that you have for for Mr Ramachandra? All right. I think I'd like to thank you, Mr Ramachandra, for providing a great insight into maxillofacial surgery. Um, in fact, myself, I thought Max fax was a very competitive, uh, specialty myself. I thought, you know, you have to work through medical studies and then go through dental studies only to be later said, Oh, you won't get into, You know, Max facts, surgery. Um, so that's, you know, the fact that you're saying that there is a job opportunities even after you've done, you know, both degrees, and then you will get a max fax job is something that I would definitely consider myself. Um, like you said, I think I've not had any exposure to Max facts, surgery, even as I'm working as an F two f one f two. Um, So I've thoroughly enjoyed the presentation, and a lot of people have also enjoyed the presentation. Um, so I'd like to give you a big thank you for taking your time out to present today. Um and, um, guys we haven't put the QR code or the link for the feedback forms, but we will send you an email so that you can fill out the feedback forms. Uh, and that way you can get a certificate of saying that you've attended the course today saying that Mr Ramchandra matter to God, A has given the presentation on Max facts. Surgery. Um, if there's any questions, guys, uh, do message now. If not, I think I'd like to give you a big thank you, Mr Ramachandra, for taking a problem. Just the last few words. Uh, all the max facts seemed very, uh, encouraging. Welcoming. And, uh, they would be very happy just to have a chart in the corridor if you see somebody. Oh, hi. I'm so and so, uh, you know, I'm very curious. Uh, what you're doing today, You know, they're very happy to talk to you. Uh uh. I haven't seen any one person who had done for dentistry, medicine and MRCS and, uh, didn't get into Max fax training. Okay, Okay. Unless they chose not to get into Max facts and they're going to something else that's entirely fine. Okay, So if you're thinking about it. I think more about it and come and talk to us. We we will guide you, if not just you. That anyone else in in listening to me. Yeah. I would put your email address on the bottom of the link so that people can get in touch with you. Mr. Uh, I'd like to thank you. All of you for coming today to the back to the future. I know it's lovely weather outside, so, you know, But thank you for turning up turning up with us. Uh, I'd like to thank Mr Ramachandra for giving a huge, amazing presentation on Max back surgery until next time, guys. Next week, the presentation will be on esophagogastric surgery given by Mr Pritam Singh. Uh, so I look forward to seeing you all their, uh, until then, look after yourselves and enjoy the good weather outside. Thank you, guys. Have a good evening. Thank you, Dash. Thank you, Martha.