surgery rona slator consultant plastic surgeon clinical director, west midlands cleft centre clapa...

Surgery

Rona SlatorConsultant Plastic Surgeon

Clinical Director, West Midlands Cleft Centre

CLAPA Annual MeetingSaturday, 11th October, 2008

The service provided…Development of that service…Problems/challenges for the

future…

Surgery - the service

to try to restore the disrupted anatomy

0-5 years

3 months lip repair 6-9 months palate repair

closure of fistulasurgery for speech

lip/nose revision

5-10 years

closure of fistulasurgery for speech

8-10 years alveolar bone graft

lip/nose revision

10-20 years

lip/nose revision

>16 years lip/nose revision orthognathic surgery

implants

(ENT surgery for glue ear)

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

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

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

Development of the surgical service

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)

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

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

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)

Challenges for the future

Challenges

Developing evidence to support best surgical practice

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

Unilateral cleft lip and palate

Lip all of palateLip/(anterior) hard palate rest of palateLip and soft palate rest of palate

3 months 6-9 months

An easier question?

Which sutures to use?

Still have at least one problem of outcome measure

ChallengesOutcome measures

Speech

Facial growth

Appearance/symmetry

Well being

‘burden of care’

plus

• Small numbers

• Workload and infrastructure to collect data

• Having equipoise for different approaches

ChallengesAnd evidence from

Developing a better understanding of the patients’ views on surgery, particularly so called ‘secondary’

surgery.

Challenges

Development of basic science research that might fundamentally

change the surgery needed

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