A Cleft Team Can Improve Your Child’s Cleft Palate or Cleft Lip TreatmentThe first three months of development are crucial for parents with a child born with cleft palate or cleft lip. The steps taken during this time can significantly impact the success of future…
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June 16, 2020
Kids Health Interviewer: We're here with Dr. Barbu Gociman, a craniofacial surgeon and the Medical Director of the Cleft Center here at the University of Utah. Dr. Gociman, when does a parent usually find out that their child might have a cleft lip or a cleft palate? Dr. Gociman: Here in the United States, most cleft lip patients are diagnosed with their condition during pregnancy. So the parents will know that the baby is going to be born with a cleft. By contrast, when the babies have only a cleft palate, usually the diagnosis is not obvious on ultrasound and is not made prior to birth. So the diagnosis is made in the first day of birth. Interviewer: So what are some of the things that a parent needs to be doing those first few months with their child to make sure that . . . how early are they getting surgeries? What do they need to be doing the first couple months? Dr. Gociman: Considering what the problems are, as we said, the lip, the gum, the hard and soft palate are involved. One of those structures or all of them, you can imagine the baby will have difficulty with feeding, with suckling. If a cleft lip is present, they cannot create a seal around the nipple. If there is a clefting of the palate, the babies will have a very hard time developing suction. Specialized devices are needed to provide adequate caloric intake, meaning adequate amount of milk or formula to keep with the needs of the newborns. Interviewer: When does the first surgery usually take place? Dr. Gociman: For a cleft lip patient, if we assure adequate nutrition, there are no other anomalies associated with the condition, and the baby grows normally, the timing is approximately three months of age. And the reason for that is the baby has grown sufficiently enough to withstand the anesthesia without any additional risk, and all the structures that are involved in the cleft are bigger and stronger, and the operation is performed easier, with less risk of things breaking down or having other complications during the surgical procedure. Interviewer: What happens during those first three months while you're waiting for the child to get stronger? Who should they be visiting? Dr. Gociman: Here at the University of Utah, we have an excellent system in place to assure that all the needs of cleft patients are met. For a cleft lip patient, the diagnosis is most of the time made prenatally, so the parents already had a prenatal visit with the nurse coordinator, with the physician assistant in charge of the cleft team, and with the craniofacial surgeon that will perform the repair. So they already have a good idea of what is coming. Once the baby is born, especially if it's born here, close, at the university hospital, or even at a hospital in close proximity, a cleft surgeon will visit with the family, evaluate the exact anatomy of the cleft, and start with the process of treatment. And this involves two major elements in the first three months of life. One is assuring adequate feeding, and, as I said, there are different modalities through which this is achieved with specialized nipples, specialized bottles, specialized techniques of holding the baby to prevent regurgitation. And the second thing that is as important is what we called molding. We are trying to achieve normal anatomy. Due to the lack of continuity in the muscles of the lip and the palate, the elements that compose those structures can migrate apart, and the anatomy becomes very difficult to recreate. So in those first three months of life, we attempt to bring all those structures together. We try to reshape the nose, the lip, the alveolus, and the palatal shelves. Interviewer: Seems like the treatment of cleft lip and cleft palate has more than just the surgical components and just the restructuring. There's also speech. There's also feeding. There's also socialization. What sort of resources are available to a new parent here with the cleft team? Dr. Gociman: We have a comprehensive cleft team. First, we see the patient right after birth to assure adequate feeding and the molding has been started. And at the same time, we schedule a clinic visit with the cleft team so the family gets a chance to visit with all the members of the team. And each member has an important role in cleft care. So the team is made up of a cleft craniofacial surgeon, an ENT surgeon, pediatric orthodontist, a speech therapist, feeding specialist, and a social worker. So the reason for that is to assure that all the problems encountered in cleft are addressed from the beginning and the family has a complete understanding on all the steps and all the elements that need to be addressed. As such, the cleft surgeon will talk about a cleft repair, the sequence of different operations based on the particular anatomy of the patient. The ENT surgeon will talk about hearing. Most cleft babies have a hard time with draining the ears and have significant infections of the middle ears and require tubes early on. Also, they have to assure later on that the speech is adequate, possibly perform speech correction surgeries down the road. The orthodontist, as I said before, initially will have a very significant role in performing the molding and then, later on, in assuring eruption of the teeth, orthodontic work, and help with any orthodontic operations. The speech therapist will be there, initially, to help with feeding, assure that the method that is most effective is used, and then, later on, as the speech starts developing, address any problems, involve the patient in speech therapy, and so forth. Finally, the social worker is there at all steps of cleft care just to address any social problems that may arise, and we have quite a long number of issues that arise in our cleft patients. So it's a very useful component of the team. Interviewer: So I understand that cleft care can be a long process. It's years and years of treatments and procedures. But it seems like this type of team can really help set a child and their family on the right path and get them started and give them a step up. Dr. Gociman: It has been shown over and over again that having a cleft team and having a professional cleft team makes all the difference. This is a standard across the United States. We are proud to have the largest, oldest, dare I say, the best team in Utah and in surrounding states. So we are getting patients from all the states around us. We pride ourself with our results, with innovation. We publish a lot. We are actively involved in research. And we are always trying to improve our technique and our results. We are very critical with our results, and we are trying to achieve perfect outcomes every time.
The first three months of development are crucial for parents with a child born with cleft palate or cleft lip. The steps taken during this time can significantly impact the success of future corrective procedures. The first few months are critical for your child and how a comprehensive cleft team can set up you and your child for success. |
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New Strategy May Reduce Amount of Lifetime Cleft Palate OperationsFor children with cleft palate, corrective treatment typically requires years of complex surgical operations for most of their childhood. But a relatively new surgical strategy developed at…
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May 27, 2020
Kids Health Interviewer: So what's new in treatment for cleft lip and cleft palate? We'll be covering that today on The Scope. We're here with Dr. Barbu Gociman, a craniofacial surgeon here at the University of Utah and the Medical Director of the Cleft Center. Dr. Gociman, what is the usual treatment plan for a child born with a cleft lip or a cleft palate? Dr. Gociman: We have a unique way of treating cleft children at the University of Utah, and we are very proud of our treatment modality we developed over years. It was a progression. So traditionally, in the United States, the sequence of treatment for a patient with cleft lip and palate is cleft lip repair at around 3 months of age, cleft palate repair at around 10 to 12 of age, alveolar cleft repair at around 6 or 7 years of age with bone grafting of the alveolus, orthodontic work followed by any orthognathic operation usually at facial maturity, which occurs at around 16, cleft rhinoplasty at around 18. That's around five surgeries given that no problems are encountered and no other issues with growth develop during the treatment protocol. Interviewer: So my understanding is with treatment of cleft lip and cleft palate, the definition of success is to minimize the amount of surgeries. And my understanding is that you guys have a new, well, a relatively new procedure that might actually help reduce the amount of surgeries necessary. Do you want to walk me through that? Dr. Gociman: It not necessarily minimizes the core operations, but it minimizes, in our mind and from what we've seen so far, the number of additional operations that usually are not counted as the main operations. So we do the cleft lip repair at around 3 months of age, and at 10 to 12 months of age we repair the palate, but only the soft palate. The reason to repair the soft palate at that age is that's when the speech starts developing and not repairing it could lead to development of abnormal sounds that are very hard to correct later on. At around two years of age, so one year later, we close the hard palate and the alveolus in one operation, and we bone graft both structures. So this is the novelty of our protocol. So we think by achieving that we reestablish a normal anatomy. Normally, the hard palate contains bone grafting, which in a standard treatment modality is repaired only with the soft tissues. And we also achieve bone grafting at a much younger age when the cleft elements, bony elements are much closer to each other. So we think the efficiency and the efficacy of the bone grafting processes is much, much higher. We need much less bone, and, again, the elements are much closer, so the gap that you are trying to graft is smaller. So we think that we have much, much higher success. This has been possible due to the availability of a series of cadaver bone grafts that are sterilized and synthetic bone elements that we all mix together so we do not need to use the traditional hip bone graft that was used in the traditional protocol. And then no operation unless the patient will require orthodontic work and orthognathic surgery. So far we did not need to do those. And finally, the final rhinoplasty will be the same as in the traditional protocol. We have a different philosophy at the university. We perform the rhinoplasty at around 14 years of age. So we want kids that, once they go to high school, to have the shape of the nose fully corrected. We think that even when you do a little bit earlier and the facial growth is not fully completed, it's almost there, and then the psychological benefit that they gain from the earlier operation far outweighs the small risk. Interviewer: So with this new procedure, what can a parent expect for their child's outcome? Dr. Gociman: We hope that less operations, much more stable maxilla that will mean less orthodontic work and less orthognathic procedures and overall a happier child. The hardest timing for cleft kids is when they are older and they have the big orthognathic operations, and it is very hard for them. Imagine you have to wear the halo device for three months walking around. So if you eliminate that operation, it's a huge benefit. So in our mind that is a huge step forward, and we hope that we will be able to demonstrate that most children that go through our protocol do not need that type of operation down the road.
For children with cleft palate, corrective treatment typically requires years of complex surgical operations for most of their childhood. But a relatively new surgical strategy developed at University of Utah Health may reduce the amount of procedures necessary. Dr. Barbu Gociman, a craniofacial surgeon and director of the Cleft Palate Team, explains the new approach that could improve a child’s experience with cleft palate repair. |