Noma is a condition that results in severe facial disfigurement.  It is caused by a gum infection that rapidly spreads into the cheeks and lips. It only occurs in malnourished people that have no access to medical care. Today it is only commonly seen in sub Saharan Africa.

Facing Africa organises two missions a year to Ethiopia and undertakes about 100 complex reconstructions a year.

You can find out more about the work of Facing Africa at www.facingafrica.org

As one would expect from such leaders in the field, the results shown were quite spectacular and I really don’t think that in terms of final outcome, that there was much difference between the techniques and treatment philosophies described. One thing did strike me though, and that was that more extensive and complicated the surgical techniques resulted in longer the recovery times and higher adverse event rates. Part of my remit for the day was to review pitfalls and complications in the literature and after a comprehensive review the same message evolved. – Minimally invasive facelifts produce results that are just as good as more complicated techniques and the recovery time for these more modern minimal procedures is much less.

These thoughts have very much reflected my own practice in recent years. It is now very uncommon for me to undertake an extended SMAS lift and my most commonly performed lift is the Lateral SMASectomy with quite minimal undermining of the skin. The procedure can often be performed as a day case procedure and in situations where a dramatic lift isn’t needed, sedation rather than general anaesthetic can be used.

The Royal Society of Medicine day on facial rejuvenation was a great success and it was a real pleasure to be involved in an event dedicated to cosmetic surgery that was truly based on surgical science and audit.

My own private practice has benefitted enormously from having ready access to respected clinicians who have skills that compliment my own plastic surgical experience.

I am very pleased that Professor John Harper, consultant paediatric dermatologist has joined us. I have a close working relationship with him in our NHS practices at Great Ormond Street where we treat children with pigmented skin lesions, vascular anomalies and unusual skin conditions that require a joint dermatological and plastic surgery approach.

We are establishing a joint private paediatric dermatology and plastic surgery clinic at 152 Harley Street to treat difficult conditions or where decision making requires a multidisciplinary approach.

152 Harley Street is one of the very few independent private facilities licensed to treat children. The facilities include a child friendly local anaesthetic theatre. This means that older children willing to undergo minor procedures such as removal of moles under local anaesthesia with the support of their parents and our staff can have treatment without the need for an admission to hospital or general anaesthesia. This form of treatment isn’t suitable for all children, but can be a great benefit in selected cases.

Professor Harper can be contacted on 020 7390 8308  or portjh@tiscali.co.uk

In reality, extraordinary events like this are built on the experience of others and the existence of dedicated teams of clinicians and professionals in the healthcare sector.

Our craniofacial team is situated at Great Ormond Street Hospital for Children, which I think is probably one of the few institutions in the world that is able to support a team able to plan and carry out complex procedures such as these.

The road to separation was long and involved. The first task involved working out how they were joined together which involved some quite complex radiology. By the time the twins had had MRI’s,  CT scans and angiograms the team was able to establish that Rital and Ritag’s brains were separate but that they shared some important veins. The information provided, allowed us to make a detailed plan for a staged separation, which in the end turned out to be based on very accurate information.

Sharing major blood vessels in the head led to many other unexpected consequences. The circulating blood was flowing predominantly through Ritag which meant that her heart and kidneys were overloaded. In effect, she was doing the work needed to survive for both twins. This caused heart failure and renal problems needing expert cardiological and renal intervention. The fact that both twins shared a blood supply caused problems for anaesthesia, because anaesthetic drugs given to one twin would affect the other in unpredictable ways.

Without experts in all of these fields who were used to dealing with unusual situations, it would not have been possible to safely separate the twins.

Another great advantage we had as a team was that a number of us had been involved in a similar separation a few years before. At the time, we had been advised and guided by two New York Surgeons, Jim Goodrich and David Staffenberg who had really established the principle of staged separation.

The separation would not have been possible without charitable funding. Facing the World, a London based charity raised the funds and organised the transfer of the twins to the UK. You can read more about the separation and other cases on their website www.facingtheworld.net

It has been an extraordinary experience leading the team that separated the twins which leaves me very proud to be part of Great Ormond Street Hospital and Facing the World.