Cleft Surgery in Rural Bangladesh Reflections and Experiences

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J Oral Maxillofac Surg67:1581-1588, 2009

Cleft Surgery in Rural Bangladesh:Reflections and Experiences

Shahid R. Aziz, DMD, MD,* Samuel T. Rhee, MD,† and

Imre Redai, MD‡

Purpose: The authors review their experiences during multiple cleft surgical missions to rural Bangladeshfrom 2006 to 2008. A significant number of patients who underwent primary palatoplasty or cheiloplastywere of adult age or size. Adult primary cleft lip and palate repair is often more challenging than repair at thestandard age of fewer than 2 years. This patient population is rarely seen in the United States, but may betreated more often by American surgeons during surgical missions to the developing world. This reportdiscusses the experiences of the authors’ treatment of cleft lips and palates in rural Bangladesh.

Patients and Methods: One hundred forty-six cleft-lip and cleft-palate patients were treated during 3missions to rural Bangladesh, from 2006 to 2008. Thirty-three (23%) patients were of adult size, and aged 13to 35 years. One hundred thirteen (77%) patients were aged 12 years or younger. Unilateral cleft lips wererepaired with a Millard advancement-rotation technique. Bilateral cleft lips were repaired via the 1-stageprocedure advocated by Mulliken and Salyer. Cleft palates were repaired using a 2-finger flap method.

Results: Overall, 8 of 146 patients (5.5%) had nonlife-threatening complications (infection or wounddehiscence) requiring subsequent revision surgery. The adult-sized patients had clefts of significantly in-creased size secondary to patient growth, as well as maxillary expansion transversely and anteriorly. Adultcleft-lip repair required significant soft-tissue dissection to close the cleft adequately, and ensure symmetry tothe upper lip and alar bases. However, this procedure sometimes resulted in placement of the lip cicatrix inan anatomically disadvantageous position. In addition, with the increased transverse dimension of the adultcleft palate, tension-free 3-layer closure was difficult. Again, aggressive dissection of the soft tissue wasrequired: the nasal and muscular layers were closed without much tension, but oral closure was often undertension, requiring the assistance of dermal biomaterials to bolster the repair.

Conclusions: Patients in the developing world often have limited access to specialized health care, andmay not realize that cleft lips and palates can be repaired. As a result, there is an increased incidence ofunrepaired clefts in adult-sized individuals in this part of the globe. The American surgeon may encounterthese patients during surgical missions. The surgeon should be prepared to repair adult patients withclefts that are significantly enlarged in all 3 dimensions. Closure will require significant soft-tissuedissection as well as the use of biomaterials as needed to repair wide cleft palates.© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1581-1588, 2009
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Whenever a lip, in particular the uppermost one, is cleft byirth or nature, it is called a harelip, because in hares theppermost lip is quasi-cleft too . . . It causes great ugliness ofhe face but also prevents newborn children from suckingorrectly and afterwards from speaking clearly . . . and if theleft is large, such people cannot help speaking nastilynd unacceptably through their nose for the term of theirife.”

*Associate Professor, Department of Oral and Maxillofacial Surgery,

MDNJ-New Jersey Dental School, and Division of Plastic and Recon-

tructive Surgery, UMDNJ-New Jersey Medical School, Newark, NJ.

†Director, Craniofacial Surgery Program, and Assistant Professor,

ivision of Plastic Surgery, Department of Surgery, Weill Cornell

edical College, New York Presbyterian Hospital, New York, NY.

‡Assistant Professor, Department of Anesthesiology, Columbia

niversity College of Physicians and Surgeons, New York, NY.

1581

Lorenz Heister, 18th Century German Anatomist andurgeon1

pecialized health care in the developing world isften nonexistent for those who are extremely poorr living in rural areas. Bangladesh is no exception. Incountry of 150 million, there are 15 plastic sur-

Address correspondence and reprint requests to Dr Aziz:

epartment of Oral and Maxillofacial Surgery, UMDNJ-New Jersey

ental School, 110 Bergen Street, Room B854, Newark, NJ 07103;

-mail: [email protected]

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6708-0002$36.00/0

oi:10.1016/j.joms.2008.11.021

mailto:[email protected]

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1582 CLEFT SURGERY IN RURAL BANGLADESH

eons.2 In 2000, the International Association of Oralnd Maxillofacial Surgeons (IAOMS) documented 1rained oral and maxillofacial surgeon per 24 millioneople (6 in the nation).3 The current IAOMS direc-ory lists 14 members from Bangladesh, with 12 basedn the capitol, Dhaka.4 As a consequence, an esti-

ated 300,000 Bengalis are suffering with unrepairedleft lips and palates.5

Although numerous techniques and protocols canreat this congenital deformity, the surgical literatures consistent in recommending early repair, typicallyompleting primary repair of the lip and palate by ageyears. A commonly accepted protocol in many sur-

ical textbooks is repair of a cleft lip at 10 to 12 weeksf age, followed by primary palatoplasty at 9 to 12onths of age, before the development of speech.

ome centers delay palatal repair until after 2 years ofge, to allow for maxillary skeletal growth, and toinimize the risks of anesthesia. As such, it is excep-

ionally rare for American surgeons to perform pri-ary repair of a cleft lip or palate in adult-sized indi-

iduals (for the purposes of our review, this would ben individual aged 13 years or older, based on thenesthesia guidelines of the American Association ofral and Maxillofacial Surgeons6). However, in devel-ping nations with limited specialized health care,ntreated cleft lips and palates in adults are foundith increasing frequency. Medical personnel partic-

pating in international surgical missions, particularlyo Africa and the Indian subcontinent, may encounterhis unique category of cleft patient. Although soundnowledge of the fundamentals of cleft surgery willertainly allow any surgeon to repair an adult cleft lipr palate adequately, obtaining the most favorableurgical outcome may require creative modification tohe design of the cleft surgery secondary to variousactors, including the increased size of the adult cleft.

e review the experiences and challenges of multi-

Table 1. CLEFT LIP AND PALATE PATIENTS TREATEDDURING BANGLADESH MISSION OF 2006 TO 2008

Age �1 Year Old 1 to 12 Years Old �13 Years Old

CCL 10 45 13ICL 0 23 13CCL 3 4 2ICL 0 5 1P 2 21 4otal 15 98 33

Abbreviations: UCCL, unilateral complete cleft lip; UICL,nilateral incomplete cleft lip; BCCL, bilateral completeleft lip; BICL, bilateral incomplete cleft lip; CP, cleft palate.

ziz, Rhee, and Redai. Cleft Surgery in Rural Bangladesh. J Oralaxillofac Surg 2009.

le cleft missions to rural Bangladesh.AM

atients and Methods

From 2006 to 2008, the authors traveled annually toangladesh to surgically treat patients with eitherleft lips or cleft palates. The 2006 mission included 3ays of surgery. The 2007 and 2008 missions each

ncluded 6 days of surgery. The surgical teams con-isted of 3 anesthesiologists, 2 attending surgeonsexcept in 2007, when there were 3 surgeons), 2urses, and 1 or 2 surgical residents.In total, 146 cleft-lip and cleft-palate patients were

reated: 129 cases by the authors, and an additional 17ases by a third attending surgeon who participated inhe 2007 mission (Table 1). One hundred thirteenatients (77%) were aged 12 years or younger: 90nderwent primary cheiloplasty, and 23 underwentleft-palate repair. Thirty-three patients (23%) were ofdult height and weight. These patients ranged in agerom 13 to 35 years. Twenty-nine of these patientsad an untreated cleft lip, and underwent primaryleft-lip repair. The remaining 4 patients had a cleftalate only, and underwent primary palatoplasties.All procedures were completed under the auspices

f Impact Foundation Bangladesh, a nonprofit, non-overnmental health care foundation based in Dhaka,angladesh. Seventy-one surgical procedures wereompleted on Impact’s hospital ship, the “Jibon Tari”Bengali for “Boat of Life”) (Fig 1). The remaining 75urgeries were completed on land at Impact’s Ma-udul Haque Memorial Community Health Centre inhuadanga, Bangladesh. The foundation’s local phy-icians prescreened all potential patients for surgery.ecruitment occurred via newspaper, word ofouth, or local fieldworkers traveling to surrounding

illages to identify potential patients. Initial inclusionriteria included any unrepaired cleft lip or cleft pal-te. At the start of each mission, before surgery, pa-ients were evaluated by the team’s attending anes-hesiologists and surgeons. Perioperative risks were

IGURE 1. Impact Foundation Bangladesh’s floating hospital ship,he “Jibon Tari.”


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AZIZ, RHEE, AND REDAI 1583

ssessed based on physical examination, weight (min-mum of 10 pounds), and a complete blood countminimum hemoglobin of 10 g/dl). Only patients whoere good candidates for general anesthesia and

ould obtain an appropriate surgical result werecheduled for surgery.

nesthetic Technique

All patients underwent general endotracheal anes-hesia with locally injected lidocaine or bupivicaineolutions. Dehydration is a concern in a hot climate,nd patients were encouraged to take clear liquids upo 2 hours before surgery. Even with this precaution,everal children needed intravenous hydration preop-ratively. All patients were given a wrist bracelet fordentification purposes.

Anesthesia machines in Bangladesh were simple andeliable (Soft Lander, Sin-ei Industry Co, Ltd, Saitama,apan), and were connected to a circle, Jackson-Reese,r Bain circuit as needed. Intraoperative monitoringomplied with American Society of Anesthesiologiststandards, except for a lack of airway pressure measure-ents.Children underwent inhalational induction. Adults

eceived an intravenous induction of anesthesia. An-sthesia was maintained using halothane, nitrous ox-de, and oxygen. Halothane is a common inhalationgent in the developing world because it is inexpen-ive, but it may cause arrhythmias after an exogenousdministration of catecholamines.7 As such, local an-sthesia with epinephrine was kept to a minimum.uscle relaxants were used sparingly, and in smalloses (rocuronium, 0.3 mg/kg). This allowed forpontaneous ventilation throughout procedures, andvoided any reversal of neuromuscular blockade,nsofar as the administration of parasympatholyticgents is undesirable in children in hot climates. Pa-ients received a slow bolus of dexmedetomidine (0.5g/kg) that reduced the anesthetic and postoperativenalgesic requirements. Preoperative antibiotics weredministered intravenously just before surgery. Post-perative analgesia was provided, using acetamino-hen, ketorolac, and morphine when available.inger’s lactate was used as maintenance fluid, andas continued postoperatively until oral intake was

eestablished.Preformed, age-appropriate Ring-Adair-Elwyn (RAE)

ndotracheal tubes were used for endotracheal intu-ation. Two problems were encountered. Firstly, par-nts were often uncertain about the age of theirhildren; in these cases, we used the little finger as aauge to select the appropriate endotracheal tube.econdly, children in rural Bangladesh were smallernd shorter than their English counterparts, who had
erved as templates for the developers of the RAE i
ube. This resulted in the RAE tube’s tip sliding intohe right mainstem bronchus on a regular basis. Earlyecognition of this is important for intraoperative ox-genation, and to prevent postoperative atelectasis.areful auscultation after endotracheal intubation andurgical positioning was used to confirm the properocation of an endotracheal tube before surgical drap-ng. If needed, a small cushion was shaped from gauzend used as padding between the chin and the curvef the RAE tube. Throat packs were used for mostases, and the anesthesiologist was responsible foreeping track of the packs. All patients recovered at aocation adjacent to the operating rooms. Postopera-ive atelectasis was the main concern, and all patientseceived aggressive, early chest physiotherapy.

ip and Palate Repair

Four types of unrepaired cleft lips were surgicallyreated:

1. Unilateral complete cleft lip;2. Unilateral incomplete cleft lip;3. Bilateral incomplete cleft lip; and4. Bilateral complete cleft lip.

nilateral complete cleft lips were repaired usinglassic Millard rotation-advancement flaps. In caseshere an incomplete unilateral cleft lip had minimal

oft-tissue bridging (such as a Simonart’s band), thetretic soft tissue was completely excised, and theleft lip was subsequently repaired with a rotation-dvancement technique.8

In cases where the incomplete cleft lip had a sig-ificant amount of soft tissue present, the cleft wasepaired with either a Randall-Tennison triangle flapechnique or a modified straight-line repair. Bilateralleft lips were repaired according to the 1-stage pro-edure of Mulliken9 and Salyer.10 All cleft palatesere noted to be complete in nature. All patientsnderwent the 2-finger flap palatoplasty advocated byardach.11 All incisions were closed with resorbableuture.

Postoperatively, all patients were hospitalized be-ween 2 and 7 days. Patients received oral antibiotics,soft diet, and intravenous fluid hydration. Patients

nd families were given a 5-day supply of oral antibi-tics upon discharge, specific local wound-care in-tructions, and strict follow-up appointments with thempact Foundation Bangladesh medical personnel noater than 10 days after discharge.

After the 2006 mission, 1 pediatric patient devel-ped mild infection of a lip repair, resulting in aound dehiscence at the right alar base. Secondary

evision of the alar base was performed after the
nfection had resolved. During the 2007 mission, 6

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ediatric patients (4 patients after cleft-lip repair, andpatients after palatoplasty) developed postoperative

nfections with associated wound dehiscences. All 6atients’ infections resolved with oral antibiotics and

ocal wound care. All patients subsequently under-ent successful secondary repair. During the 2008ission, 1 pediatric patient developed partial necrosis

f the distal portion of the right palatal flap, withevelopment of a small palatal fistula (Table 2).

left Surgical Missions inural Bangladesh

Few 60-minute surgical procedures have as pro-ound an impact on a person’s life as a cleft-lip repair.n the developing world, where specialized surgicalare is often the exception rather than the norm,illions of children and young adults suffer with un-

epaired clefts. In Bangladesh, a nation of 150 millioneople, it is estimated that 300,000 people have un-reated clefts; the majority are impoverished, androm rural areas. Rehabilitation of the cleft patient islso multidisciplinary. Genetic counseling, dental spe-ialty care, speech pathology, audiology, and pediat-ics are all among the typical cleft center specialties,n addition to surgery. Bangladesh lacks the resourceso provide this comprehensive multispecialty care.his means that even those who are able to receiveurgical care often lack the necessary supportive care.s a result, cleft patients in Bangladesh are oftenocially, intellectually, and cognitively impaired de-pite their surgical success, and are not productiveembers of Bengali society.5 Local education in poor

r rural areas also needs to be developed. Many pa-ients were unaware that clefts can be surgically cor-ected, until a field health worker visited the patient’sillage. Moreover, many Bengalis do not realize thatleft lips and palates are a congenital anomaly ofultifactorial etiology. A popular misconceptionolds that children with clefts are born to mothersho cut fish and vegetables on the night of a fulloon while pregnant. As a result, many mothers feel

esponsible for their child’s ailment, and often both

Table 2. COMPLICATIONS IN 8 OF 146(5.5%) PATIENTS

Patient Type 2006 2007 2008 Totals

Cleft lip 1 4 0 5Cleft palate 0 2 1 3Totals 1 6 1 8

OTE. All patients were pediatric, ie, under 13 years of age.


other and child are alienated by their family.5AM

The cleft problem in the developing world is fur-her compounded by a lack of qualified surgeons toerform the work. In Bangladesh, this lack is beingddressed on multiple levels. The most importantnitiative is the introduction of surgical training pro-rams within Bangladesh. In 1990, a joint Australian-angladesh effort led to the development of the onlyral and maxillofacial training program in the country,t Bangabandhu Sheikh Mujib Medical University, inhaka. This program was initiated by Dr Barry Fitz-atrick, an Australian maxillofacial surgeon, and Pro-

essor Motiur Molla, and accepts 4 to 5 surgeons perear in a 5-year training program3 (Fig 2). In 2000,haka Medical College Hospital initiated a postgrad-ate program in plastic surgery. Ten of the 15 plasticurgeons in-country were trained in this program.2

ith this increase in local surgical specialist care,obile cleft camps have been developed, in which

ity-based surgeons travel to rural parts of Bangladeshnd treat patients with clefts. Most of these campsave minimal surgical facilities, and are often limitedo surgery under local anesthesia. As such, only lipsre treated.5

International surgical volunteerism and teachingomprise a third way to increase cleft care in theeveloping world. Many organizations in the Unitedtates, such as Healing the Children Northeast (Newilford, CT; the American sponsor of the authors’issions to Bangladesh), will facilitate overseas travel

f medical professionals to underserved areas. Therere a number of remarkable opportunities to partici-

IGURE 2. From left: S.T.R., Ms Christina Rozario (Impact Foun-ation Bangladesh), Dr Amy Tanchyk (oral and maxillofacial sur-ery resident, UMDNJ), S.R.A., Dr Motiur Molla (Professor andhairman, Department of Oral and Maxillofacial Surgery, Banga-andhu Sheikh Mujib Medical University, Dhaka, Bangladesh),une 2007.


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ate in or develop cleft-surgery teams in regionsorldwide. The authors have participated in a total of

2 volunteer cleft programs, including five developednd led by S.R.A. Based on this experience, someasic guidelines are suggested to facilitate participa-ion in cleft missions to the developing world:

1. For the novice mission participant, travel withan experienced team as an observer or assistant,to learn “the ropes” of medical missions, is ad-visable. After becoming comfortable with thelogistics of cleft missions, the surgeon, on sub-sequent trips, should focus on surgical care. Ofnote, surgeons should be prepared to bring theirown equipment and supplies (including surgicalequipment, sutures, and headlights).

2. These missions are not intended to provide“practice” for the surgeon or surgical resident.Only individuals qualified to repair clefts in theirhome countries should be the primary surgeonson these missions to ensure the highest qualityof repair, especially because operative condi-tions and surgical repairs are often more difficulton missions abroad. The goal of including surgi-cal residents on missions is to expose them tosurgical philanthropy and international volun-teerism.

3. Team anesthesiologists must be experiencedwith both pediatric and adult anesthesia, andthey should be comfortable working in less thanideal facilities. In addition, the mission teamshould bring multiple sets of portable anesthe-sia-monitoring equipment to augment and backup the host facility’s anesthesia equipment.

4. Working with a credible local sponsoring orga-nization or foundation is important. This oftenrequires a scout visit to the organization by teamleaders before the actual mission to evaluatefacilities, organization personnel, and medicalsupport. Local sponsors must be able to recruitand screen appropriate patients, provide facili-ties adequate to ensure patient safety, and havesufficient medical personnel to care for patientsafter the team has left the host country, to con-tinue postoperative patient management.

5. Before surgery, each patient must be thoroughlyevaluated by anesthesiologists to determine peri-operative risks. This includes a proper physicalexamination and appropriate preoperative test-ing. In addition, surgeons must thoroughly eval-uate a patient to ensure that the surgical anat-omy is amenable to an adequate repair. Nosurgery should be performed in which an ac-ceptable outcome is in doubt: “in dubio abstine”
(when in doubt, abstain).
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6. Create a surgical schedule in coordination withthe host organization. Ensure that the scheduleis not too overwhelming for the mission team aswell as the host personnel. Operating while ex-hausted is a method likely to obtain a suboptimalsurgical repair.

7. Arrange to work with local surgical personnel.Training local surgeons, anesthesiologists, andnurses in cleft surgery and patient managementis as important as repairing the cleft itself. Train-ing local personnel empowers these individualsto provide competent care on a local level tothose in need, and is an investment in the evo-lution of adequate cleft management in the de-veloping world (Fig 3).

8. Develop a small team of surgeons, anesthesiolo-gists, and nurses who work well together. Teamsolidarity is key to a successful and rewardingmission experience. Personal conflicts withinthe team can be exacerbated because of theremote locations, resulting in attention divertedfrom medical care.

9. Postoperative care is important. Treatmentshould be identical to that in the United States.Intravenous antibiotics and fluids, local woundcare, oral antibiotics, and analgesia are all part ofthe postoperative management of these pa-tients. Consider keeping postoperative patientslonger than is normally the case in the UnitedStates, if there are concerns about wound care,antibiotic administration, or nutrition after thepatient is discharged.

Cleft lips and cleft palates are congenital anomalieshat have been documented in the medical literature

IGURE 3. S.T.R. and S.R.A. with Bangabandhu Sheikh Mujibedical University oral and maxillofacial surgery residents Drs

ayanta and Haider, January 2008.


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ince the 4th century AD.12 Typical surgical protocolsnclude performing cleft-lip repair at ages 10 to 12

eeks, and primary palatoplasty at ages 9 to 12onths. The early timing of repair was shown to be

dvantageous in repairing cleft lips from an esthetictandpoint, because the cleft is less wide at this point.any American centers advocate repair of cleft pal-

tes by age 1 year to facilitate feeding, and to maxi-ize the development of appropriate speech pat-

erns, although some centers prefer to delay closurentil after 2 years of age. Early repair of cleft lips andleft palates has disadvantages, most notably the re-ultant restriction of maxillary and midfacial growth.

Multiple studies compared unrepaired adult cleft-ip and cleft-palate maxillary morphology to that indults with repaired clefts.13-18 The results are well-ocumented: adults with unrepaired cleft lips or pal-tes have maxillas with a normal to slightly prog-athic cephalometric position anterior-posteriorly,nd a normal to widened maxillary transverse width.ased on these studies, it is evident that the facialharacteristics of an unrepaired adult cleft lip andalate patient are unique: a normal to slightly protru-ive upper jaw, protruded maxillary anterior denti-ion, and a normal or slightly hypoplastic mandibularelationship. In addition, the cleft-lip and cleft-pal-te dimensions are that much greater, because theleft grows proportionately with the surroundingnatomy.

IGURE 4. A, A 28-year-old male with large left unilateral compleymmetry of alar bases, vermilion, and Cupid’s bow; however, th

ziz, Rhee, and Redai. Cleft Surgery in Rural Bangladesh. J Oral Maxil

The authors had a unique opportunity to completerimary palatoplasty and cheiloplasty on adult-sizedleft patients. Based on this experience, the followingbservations were noted. What is initially most strik-

ng about repairing an adult cleft lip is that the ana-omic landmarks are appreciably easier to discernhan in an infant. In addition, there is increased soft-issue bulk that can be readily utilized during adultepair, but that is not present for repairs in an infant.owever, the dimensions of the adult cleft gap can beppreciably larger. As such, aggressive soft-tissue dis-ection may be required as the rotation-advancementaps are raised.When repairing an adult cleft lip (particularly a

nilateral complete cleft lip), the authors found itdvantageous to rework some traditional conventionsf lip repair to achieve improved final results. Inxceptionally wide unilateral complete cleft lips, andequate rotation/advancement of skin flaps was fre-uently best achieved by increasing the dimensions ofhe backcut, allowing for mobilization of the “C” flapcross the cleft. In addition, alar-base dissection onhe cleft side was often beneficial, as was more ex-ensive dissection of the musculature. Such variationsllowed for improved tension-free closure of the uni-ateral cleft lip and good symmetry in the alar-baseeconstruction, but sacrificed esthetic scar placemento an extent (Fig 4). Postoperatively, secondary toggressive muscle dissection, many complete cleft-lip

lip. B, Immediately after repair using Millard technique. Note theon design is not ideally placed. C, Four days after surgery.

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epairs had significant edema that lasted up to 3eeks. For incomplete unilateral cleft lips, a simple

traight-line closure or triangle flap was often ade-uate. Again, the anatomic landmarks were easily

dentified (Fig 5). Maxillary anterior teeth may inter-ere with the closure of the lip. These teeth are oftenrotruded and rotated. This may create tension and aenting effect on the lip repair. Although it is prefer-ble to save the tooth if possible, if a tooth compro-ises adequate repair of the lip or is diseased (either

arious or nonrestorable), it should be extracted (Fig 6).he average Bengali girl is married by age 14, so

FIGURE 5. A, Seventeen-year-old male with right incomp

ziz, Rhee, and Redai. Cleft Surgery in Rural Bangladesh. J Oral

FIGURE 6. Maxillary dentition erupting into cleft.

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rioritizing teenage girls with cleft lips is important tomprove their chances for matrimony.19

Primary palatoplasty in the adult is a significanthallenge, secondary to the increased width of theleft palate that is to be closed. Complete cleft palatesith an associated alveolar cleft were repaired using

he Bardach 2-finger flap technique. Isolated com-lete cleft palates were closed using a V-Y pushbackechnique. The primary problems with palatal closuren the adult cleft stemmed from increased cleft width,

ith vertically displaced palatal segments. This situa-

IGURE 7. Team from 2007 mission, surrounded by children fromvillage in Surajgonj District, Bangladesh (photograph courtesy ofruce Byers).

eft lip. B, Aggressive muscle dissection. C, Final closure.

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ion is thought to be secondary to prolonged tonguenterposition in the cleft.20 In addition, adult cleftalates have increased mucoperiosteal fibrosis, mak-

ng dissection of the palatal flaps difficult. The levatoralatini muscle may have increased contracture in thedult cleft palate, resulting in a more difficult dissec-ion and anatomic repositioning of this muscle. Fi-ally, greater bleeding is often evident in adult palatalissection, secondary to the increased tissue dissec-ion of this surgery. With the increased size of aalatal cleft, the ideal 3-layer, tension-free closure cane challenging. Although the nasal mucosa and mus-le layers were often closed with minimal tension,ral mucosal closures tended to have increased ten-ion. To overcome this, outfracturing of the hamuluss well as careful dissection of the greater palatineeurovascular bundle from its foramen can be per-ormed, to mobilize the palatal finger flaps further. Inddition, the use of biomaterials as an adjunct mayccasionally be helpful. Processed, acellularized, der-al biomaterials such as Alloderm (Life Cell Corp,ranchburg, NJ) or Dermamatrix (Synthes Maxillofa-ial, Paoli, PA) were used judiciously as onlay patcheso support areas of increased tension. The processedermal tissue was sutured on top of the area of ten-ion, providing further support to the repair. It shoulde noted that whereas adult primary palatoplasty doesot improve speech, it does significantly reduce nasalegurgitation and enhances oronasal hygiene.

Cleft missions to the developing world are an im-ortant and rewarding way for the American oral andaxillofacial surgeon to serve the global community.ecause of limited access to specialized surgical care,merican surgeons may find themselves faced with

reating an adult with an unrepaired cleft lip or palate.rimary repairs of adult cleft lips and palates can behallenging, even for experienced cleft surgeons. Thencreased dimensions of the cleft may necessitatextensive soft-tissue dissection. The unrepaired cleftip causes the developing maxilla to take a somewhatrognathic position relative to the mandible, withroclined anterior maxillary teeth. These teeth canreate excessive tension on the lip repair, and mayequire extraction. The primary cleft palate in thedult is typically wide and fibrotic, making surgicallosure more complex. Because speech developmentas already occurred in the adult, primary palato-lasty will not improve speech. However, the repairill minimize oronasal regurgitation. These interna-

ional missions can be among the most rewardingxperiences in a surgeon’s career. Mission successan be optimized if surgeons travel with experiencedeams that work well together and maintain appropri-te safety, surgical, and medical-care standards. Spon-
orship with appropriate host organizations and care-
2

ul surgical case selection will also reduce the risk ofotential complications. Training local surgeons inepair techniques empowers these individuals to con-inue the care of cleft patients in the future (Fig 7).

cknowledgments

The authors thank the Impact Foundation Bangladesh and Heal-ng the Children Northeast for their sponsorship, the Smile Trainor financial support, and KLS Martin, Synthes Maxillofacial, andtryker CMF for their instrumentation support of these missions toangladesh. Special thanks go to Dr Vincent Ziccardi for reviewinghe manuscript.

eferences1. Heister L: A General System of Surgery. London, W. Innys, 17572. Interplast: Dhaka, Bangladesh 2007. Available at: http://

interplast.blogs.com/dhaka_bangladesh_2007. Accessed Jan-uary 9, 2009

3. International Association of Oral and Maxillofacial Surgeons:History of IAOMS: 1992-2001. Available at: http://www.iaoms.org/History_1992_2001.aspx. Accessed January 9, 2009

4. International Association of Oral and Maxillofacial Surgeons:Available at: http://www.iaoms.org/IAOMSDIRECT/images/membership/membership_top.jpg. Accessed January 9, 2009

5. Ghani S, Mannan A, Sen S, et al: The problems of establishingmodern cleft lip and palate services in Bangladesh. J Surg 2:43,2004

6. Commission on Dental Accreditation: Accreditation Standardsfor Advanced Specialty Education Programs in Oral and Maxil-lofacial Surgery. Chicago, IL, American Dental Association,2008, p 26

7. Pham AM, Tollefson T: Cleft deformities in Zimbabwe, Africa.Arch Facial Plast Surg 9:385, 2007

8. Salyer KE, Marchac A, Cheng MS, et al: Unilateral cleft lip/noserepair, in Losee JE, Kirschner RE (eds): Comprehensive CleftCare. New York, McGraw Hill, 2009, pp 299-330

9. Mulliken JB: Principles and techniques of bilateral completecleft lip repair. Plast Reconstr Surg 75:477, 1985

0. Salyer K. Primary bilateral cleft lip/nose repair, in Bardach J, SalyerK (eds): Salyer and Bardach’s Atlas of Craniofacial and Cleft Sur-gery. Volume 2. Philadelphia, PA, Lippincott, 1999, pp 543-607

1. Bardach J: Two flap palatoplasty: Bardach’s technique. Opera-tive Techn Plast Reconstr Surg 2:211, 1995

2. Bill J, Proff P, Bayerlein T, et al: Treatment of patients with cleftlip, alveolus, and palate—A short outline of history and currentinterdisciplinary treatment approaches. J CraniomaxillofacSurg 34:17, 2006 (suppl 2)

3. Will L: Growth and development in patients with untreatedclefts. Cleft Palate Craniofac J 37:523, 2000

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0. Ward C, James I: Surgery of 346 patients with unoperated cleftlip and palate in Sri Lanka. Cleft Palate J 27:11, 1990

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Cleft Surgery in Rural Bangladesh Reflections and Experiences

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