Surgery Rona Slator Consultant Plastic Surgeon Clinical Director, West Midlands Cleft Centre

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SurgeryRona SlatorConsultant Plastic
SurgeonClinical Director, West Midlands Cleft
Centre

• CLAPA Annual MeetingSaturday, 11th October, 2008

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The service providedDevelopment of that
serviceProblems/challenges for the future
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Surgery - the serviceto try to restore the
disrupted anatomy
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0-5 years3 months lip repair 6-9
months palate repair closure of
fistula surgery for speech lip/nose
revision
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5-10 years closure of fistula surgery
for speech 8-10 years alveolar bone
graft lip/nose revision
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10-20 years lip/nose revision gt16
years lip/nose revision orthognathic
surgery implants
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(ENT surgery for glue ear)?
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But surgeons also

• Often visit newborn babies and their families
• Counsel parents who have had an antenatal
  diagnosis of their baby having a cleft lip
• Continue support for families as the children
  grow up

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• With geneticist and paediatrician will have a
  role in diagnosing other anomalies and/or
  developmental problems
• Engage and liaise with specialists (both within
  and) outside the cleft team in coordinating care
• May have a major role in looking after babies
  with Pierre Robin Sequence with airway/feeding
  problems

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Teaching/training

• Surgeons
• Other members of the cleft team in training
• Other specialties outside the cleft team but also
  involved in the care of children with cleft lip
  and/or palate
• Being open themselves to learning from other
  specialists in the cleft team

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Development of the surgical service
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Following CSAG and reorganisation

• Reduced numbers of surgeons involved in cleft
  care
• Increased time commitment of surgeons to cleft
  care (particularly for those involved in
  primary surgery)
• All surgeons carrying out primary lip and
  palate repair treating increased numbers of new
  babies (range in 2008, 29-77 per year)

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Developments - Surgical training

• Significantly improved and specific training (1-2
  year Cleft Fellowship) for trainee surgeons
  wishing to become consultant surgeons carrying
  out primary cleft lip and palate repair.
• Currently there are talented young surgeons
  interested in the specialty

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Developments

• Coordination of care improved following
  reorganisation all aspects of cleft care within
  the one team
• Longitudinal care established
• Colleagues with whom to discuss difficult or
  unusual surgical problems
• Other specialist disciplines within the team
  contribute to surgical decisions

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Developments

• Measurement of outcomes
• There is a more open culture about outcomes and
  intercentre audit
• And a desire to improve care by working together
• Continuing effort to move towards the CSAG
  inspired standards of multidisciplinary care
  (ENT, impact of psychology input)

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Challenges for the future
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Challenges

• Developing evidence to support best surgical
  practice

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So, for example, order and timing of repair of
lip and palate

• Unilateral cleft lip and palate
• Lip all of palate
• Lip/(anterior) hard palate rest of palate
• Lip and soft palate rest of palate
• 3 months 6-9 months

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An easier question?

• Which sutures to use?
• Still have at least one problem of outcome measure

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ChallengesOutcome measures

• Speech
• Facial growth
• Appearance/symmetry
• Well being
• burden of care

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plus

• Small numbers
• Workload and infrastructure to collect data
• Having equipoise for different approaches

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ChallengesAnd evidence from

• Developing a better understanding of the
  patients views on surgery, particularly so
  called secondary surgery.

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Challenges

• Development of basic science research that might
  fundamentally change the surgery needed

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Challenges - A very specialist area

• Continue to attract the best young surgeons
  into the field
• And train them so that the learning curve is
  eliminated as far as possible
• Who will have wide knowledge and awareness of
  surgical and technical developments in all areas
  of surgery and elsewhere so that these can be
  introduced into cleft care where appropriate
• Innovation