11 Oct 2005 KKU Medical Annual Meeting 1

Excellent Care in Clefts and Craniofacial Anomalies

Bowornsilp Chowchuen, MD, MBAChair of “Tawanchai Project”

and KKU Cleft Center,Division of Plastic Surgery,

Department of Surgery, Faculty of Medicine, Khon Kaen University

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“Tawanchai” Project

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The Cleft Palate Team (CPT):The Cleft Palate Team (CPT):

• consists of – an operating surgeon, orthodontist, speech-language

pathologist, and at least one additional specialist from otolaryngology, audiology, pediatrics, genetics, social work, psychology, and general pediatric or prosthetic dentistry

• meet face-to-face – at least six 6 times per year to evaluate and develop

treatment plans for its patients• evaluates at least 50 patients per year• has at least one surgeon

– who operates on at least 10 primary cleft lips and/or palates per year

• coordinates treatment

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Interdisciplinary Team Management

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FETAL DIAGNOSIS OFCLEFT LIP-PALATE AND

CRANIOFACIAL ANOMALIES

Associate Professor Thawalwong Ratanasiri, MD, RTCOGDivision of Fetal Diagnosis and Therapy

Department of Obstetrics and GynecologyFaculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.

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CoPs: Feeding and Neonatal CareDevelopment of infant feeding practices

• Baby Friendly Hospital policy• As a nurse specialist in multidisciplinary team

• Provision of Lactation-Aid and Lactation supplementation of breast-feeding since the year 2000

Nipple tube feeding & cup feeding

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CoPs: OPDชุมชน, PCU

รพ.ชุมชน

รพ.ศูนย, รพ.จังหวัด รพ.ศรีนครินทร

พยาบาลประสานงาน

นักสังคมสงเคราะห/แพทย

กุมารแพทย

ศัลยแพทยตกแตง

ทันตกรรมเฉพาะทางดานตางๆ

แพทยหุ คอ จมูก, นักโสตสัมผัส

พยาบาลเชี่ยวชาญฌฉพาะทาง

นักอรรถบําบัด

สูตินรีแพทย

Special Cleft ClinicCoordinator Center

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Information needs of parents of children with craniofacial anomalies undergoing operation

Augsornwan D

Diagnosis and Disease:Most of them wanted to know

-Cause of disease -How long to treat?-Why it should happen to them or-Did they do anything wrong in the past?-Is it their sin ?

-If have another baby can it happen again or can it be prevented?

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Information needs of parents of children with craniofacial anomalies undergoing operation

Augsornwan D

Operation: Parents concern about:

-Receiving assurance of their child’s safety during operation

-What’s time of operation and how long?

-Possible complications

-Will their child feel pain?

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Parent-Family Needs & Expectations

• cleft children are looked like normal and able to involve in the society

• training parents & families for more knowledge about the cleft care, including pre- and post- operative care

• continuing follow up and taking care the cleft children

• support the collaborative work of their group and help other families

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Community-based Model & Family Support Program

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Goal of Cleft Lip Goal of Cleft Lip and Cleft Palate and Cleft Palate RehabilitationRehabilitation

• The goal of clef lip and palate care– complete rehabilitation of

cosmetic, functional, and psychosocial aspects.

• Longitudinal integrated outcomes – have to be evaluated at the

end of complete facial development in adolescent

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Clinical Outcome in CLPEvidence –Based and Holistic

Approached

• Aesthetic• Dental, speech and hearing function

• Growth & development• Quality of life and social aspect

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Primary cleft lip repair was performed at appropriate timing according to the

Cleft Center protocol

• 3 Months- Primary cleft lip-nose repair with or without pre-surgical

orthopedics• 10-12 months

- Palatal repair• 4-6 years

- Correction of secondary lip and nose deformities- Correction of velopharyngeal insufficiency

• 7-11 years- Secondary bone grafting

• 16-18 years- Orthognathic surgery and corrective rhinoplasty

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The pre-surgical orthodontic treatment-controversies of long-term outcome -may have benefit to surgical results in moresevere deformities-consultation with orthodontist and parents

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Timing of Minimum Records and Treatment in Dental Aspect

overall assessmentxXXXXX18+ years

prior to orthognatic surgeryXXXXXX> 16 years

prior to orthodontic treatmentXXXXXX12-15 years

prior to maxillary protraction orthopedics

XXXXXX11-12 years

prior to bone graftingXXXX9-11 years

full deciduous dentitionXXX4-5 years

prior to palatoplastyXXX9-12 months

prior to cheiloplastyXX3 months

prior to PSOTXX0-3 month

OH

PaLC

OPGPhotos

SM

TreatmentRecordsAge

*Post treatment follow up 3, 6, and 10 years

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Primary Cleft SurgeryIntegrated Concept

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Rotation advancement incision

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Dissection of abnormal muscular attachment

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Cartilage mobilization, repositioningand transfixing

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The differential muscle repair

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Adjust the position of cupid’s bow and columella base position

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Adjustment of advancement flap

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Reconstruction of Wet-Dry Mucosal Junction ((NoordhoofNoordhoof,, 1984)1984)

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Incomplete Unilateral Cleft Lip

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Incomplete Unilateral Cleft Lip

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Complete Unilateral Cleft Lip

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Complete Unilateral Cleft Lip

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Bilateral Cleft Lip

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Alveolar Bone Grafting

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Orthognathic Surgery & Final Correction of 20 Deformities

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Facial Cleft Facial Cleft No 0/14No 0/14

Holoprosencephaly or Tissue-Deficient Median Facial Cleft

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Holoprosencephaly or Tissue-Deficient Median Facial Cleft

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Holoprosencephaly or Tissue-Deficient Median Facial Cleft

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Tissue Excess-Median Facial Clefts

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Tissue Excess-Median Facial Clefts

Significant of notching of the vermillion border

bifid nose with duplicated columella.

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CT: bone defect at midface, involved frontal,

nasal and maxilla with fronto-ethmiodal defect

and orbital hypertelorism.

MRI: congenital microphthalmia of rt. eye with associated agenesis of corpus

callosum of the brain.

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Fronto-EthmoidalMeningo-

encephalocele

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Facial Cleft No 1/13

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Facial Cleft No. 2/12

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Bone defect extends to midline skull base with

hypertelorism and low lying of frontal lobe of the brain

Hypoplasia of maxillary antrum

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Facial Cleft No. 3/11

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Facial Cleft No. 4/10

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Soft tissue revision with calvarial bone graft

Soft tissue correction with lower eyelid and

upper lip reconstruction

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Facial Cleft No. 5/9

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Facial Cleft No. 6,7,8Treacher Collins Syndrome

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Craniofacial Microsomia

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Craniofacial Microsomia& Soft Tissue Reconstruction

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Craniofacial Microsomia& Distraction Osteogenesis

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Craniofacial Microsomia& Free Tissue Transfer

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Craniosynostosis& Craniofacial Surgery

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Craniosynostosis& Craniofacial Surgery

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Pierre Robin Sequence

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Pierre Robin Sequence& Distraction Osteogenesis

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Principle of Surgical Technique in Craniofacial Clefts

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Factors Affect Outcome

Related to• Severity of primary

defects• Surgical treatment and

protocol • Competency and well-

coordination of interdisciplinary team

• Long term follow up and continuous evaluation at appropriate schedule and age group

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การดแูลผูปวยปากแหวงเพดานโหวแบบองครวม

การดูแลรักษาพยาบาล

การฟนฟูสภาพและการดูแลอยางตอเนื่อง

การปองกัน

ผูปวย

นโยบายดานสาธารณสุขของรฐั

องคกรเ

อกชน องคกรอิสระ

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Optimum Cleft CareOptimum Cleft CareReduce the Health Care BurdenReduce the Health Care Burden

Benchmarking & Knowledge SharingBenchmarking & Knowledge Sharing

1. Balancing the needs & expectation of patients/ family/ stakeholders.

2. Cost effectiveness (cleft care system, record keeping, and protocol evaluation).

3. Reaching the ultimate goal of improved outcome by restore normal anatomy or create “esthetic acceptability” , be able to function normally, and gain psycho-emotional normality.

4. Interdisciplinary cleft team development and conducting innovation and relevant research.

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1. บริบท2. ประเด็นความเสี่ยงที่สําคัญ

3. เครื่องชี้วัดที่สําคัญและการนําไปใชประโยชน(Cosmetic, Function,Psychosocial, Development)

4. กระบวนการเพื่อใหไดคุณภาพ Clinical Outcome

Cleft Birth/Referral

EvaluationCounseling

PlanningTeam

Consultation

Coordinated Interdisciplinary

CareDischarge

HomeHealthCare

Program/Long-termFollow Up

Prevention/Education/Research/ Integrated

Model/

Needs &ExpectationCommunity-Based Network

Innovation & Benchmarking

Record & Data Base

KPI Monitoring

Coordinated Interdisciplinary Team

Holistic & Longitudinal Care

Evaluation & Review

“Desired State” of KM

5. Knowledge Management

Evidence-based practice

6. Excellent Care

Technology, Evidence, Context

Cleft Lip-Palate Excellent Care Model

11 Oct 2005 KKU Medical Annual Meeting 66

Khob Khun KrabThank You for Your

Attentionhttp://web.kku.ac.th/~cleft/E-mail: bowcho@kku.ac.th