ORIGINAL ARTICLE
CIRPLAST: Cleft Lip and Palate Missions in Peru Carlos E. Navarro, MD, FACS Background: The author presents a 20-year experience leading cleft lip and palate surgical volunteer missions in Peru for CIRPLAST, a nonprofit volunteer plastic surgery goodwill program that has provided free surgery for patients with cleft lip and palate deformities in remote areas of Peru. Surgical procedures were performed by the author, together with a group of experienced plastic surgeons, under the auspices of the Peruvian Plastic Surgery Society, and local health authorities. Methods: CIRPLAST missions are scheduled annually in different locations around Peru. Selected patients for surgery after adequate screening are photographed, and their cleft deformity is recorded. Scheduled patients or their parents, when they are minors, sign an informed consent form. Patients operated on in any given day are examined and photographed 1 day after surgery, before discharge. Between 30 and 35 patients are operated on at each mission site. About 2 weeks after the mission, patients are checked and photographed, and the outcome of surgery is recorded. Complications that may occur are recorded and treated by the CIRPLAST team as soon as possible. Almost all operations are performed under general endotracheal anesthesia coupled by local anesthesia containing a vasoconstrictor, to reduce bleeding and facilitate tissue dissection. All wounds of the lip and palate are closed with absorbable sutures, to avoid the need for suture removal. After cleft lip surgery, patients go to the recovery room for monitoring by nurses until they recover completely. Results: A total of 6108 cleft lip and palate repairs, primary and secondary, were performed by CIRPLAST in 141 missions, between May 12, 1994, and October 15, 2014. The medical records of the 5162 patients (84.5%) who returned for follow-up (ranging from 12 days to 9 years) were reviewed retrospectively. Between 45% and 70% of the patients operated on a mission have returned for early follow-up and some the following year. There were 3176 males (51.9%) and 2932 females (48.1%). The incidence of isolated lip clefts was 1546 patients (25.3%); of isolated palate clefts, 2223 patients (36.4%); and combined defects, 2339 patients (38.3%). Of the 5162 patients who returned for follow-up, 377 patients (7.3%) had complications. Lip wound dehiscence was present in 58 patients (15.4). Palate fistula formation in 33 patients (8.8%): 24 (6.4%) after primary palate closure, and 9 (2.4%) after previous fistula closure. Infection occurred in 37 cleft lip patients (9.8%). Hypertrophic lip scars were seen in 56 patients (14.9%). Bleeding occurred in the From the Universidad Peruana Cayetano Heredia and CIRPLAST, Lima, Peru´. Received October 29, 2014. Accepted for publication January 24, 2015. Address correspondence and reprint requests to Carlos E. Navarro, MD, CIRPLAST President, Calle Piura 810, Lima 18, Peru; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001637
The Journal of Craniofacial Surgery
recovery room after palatoplasty in 48 patients (12.7%), and in most cases, it was contained by applying pressure. No blood transfusions were used. Residual deformities of varying degree of the nose and/or lip occurred in 145 patients (38.5%). All required reoperation for correction. There were no intraoperative deaths in this series. Conclusions: During the past 20 years, the CIRPLAST team has offered free surgery with good outcomes and few complications, to more than 6000 cleft lip and/or palate patients in remote areas of Peru. Key Words: Cleft lip and palate surgery, volunteer missions, Peru (J Craniofac Surg 2015;26: 1109–1111)
F
acial deformity associated with clefts of the lip and palate is a very complex health problem that has affected many people since ancient times. This has been well documented by the Moche portrait vessels (Huacos Retratos) in northern Peru dating back to about 1000 years before the Inca Empire. Peru, with more than 31 million inhabitants, is the third largest country in South America (roughly 21/2 times the size of Texas). Despite a recent macroeconomic upsurge, Peru remains a very poor country. Substandard medical and surgical care is usually the rule rather than the exception, especially outside Lima, the capital city of Peru. There is a high incidence of clefts of the lip and palate in Peru, about 1 in 500 births. CIRPLAST carries out about 10 surgical missions each year and provides free surgery for low-income patients affected with clefts of the lip and/or palate, in different parts of the country. Program is organized by the author’s wife, Marı´a Elvira Mula´novich, who is CIRPLAST’S general coordinator. Team goes back to the same places every year, so there is continuity of care in the communities we serve. Missions have been accomplished by coordinating and consolidating efforts with other health institutions in Peru, encompassing regional and local charities, when available. This allows our group to operate on a greater number of cleft patients, especially children, who either never had the opportunity to receive surgical care or had previous inadequate surgical repairs.
MATERIALS AND METHODS Missions are scheduled in advance at the different locations in Peru. Each mission lasts 1 week. During the first and second days, previously registered patients are screened. Selected patients are sent to the laboratory for blood work, electrocardiogram, and a cardiologic examination. Chest x-rays are not routinely done. After the testing, patients who are cleared for surgery are scheduled. Surgery is performed on the following 3 or 4 days, depending on the number of patients. Each selected patient is examined carefully and photographed. Procedure or procedures to be performed are recorded on their medical record. All scheduled patients or their parents, when they are minors, sign an informed consent form. Patients operated on in any given day are examined and photographed on the following day, before discharge. Usually, between 30 and 35 patients are operated on at each mission site. About 2 weeks after the mission, patients are checked and photographed, and the outcome of surgery is recorded.
Volume 26, Number 4, June 2015
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Navarro
If complications occur, they are treated by the CIRPLAST team as soon as possible. We take our own anesthesia machines, suction machines, electrocauteries, surgical instruments, medications, anesthetic agents, sutures, and so on, to each mission site. Proposed surgical procedure, or procedures to be performed, depends on each patient’s individual needs. Almost all operations are performed under general endotracheal anesthesia coupled by local anesthesia containing a vasoconstrictor. This will reduce bleeding and facilitate tissue dissection. All wounds of the lip and palate are closed with absorbable sutures, to avoid the need for suture removal. When the cleft lip is very wide, the patient’s nutrition is not optimal, or the hemoglobin level is at the lower limit of normal, a lip adhesion is performed before a definitive lip repair several months later. Preoperative, active, or passive maxillary orthopedics is not available at any of our mission sites. At the end of surgery, tissues in the operative field are infiltrated with a small amount of local anesthetic containing a vasoconstrictor, for immediate postoperative pain control, and to reduce the possibility of bleeding. After completion of cleft lip surgery, patients go to the recovery room for monitoring by nurses until they recover completely. Once they are fully awake, they are fed by the mother, preferably with breast milk. Patients, who have had surgery of the palate, receive a liquid diet for 3 days. Followed by soft foods for several weeks, until all sutures have fallen out, and the wounds are completely healed.
RESULTS There were a total of 6108 cleft lip and palate repairs, primary and secondary, performed by CIRPLAST in 141 missions, between May 12, 1994, and October 15, 2014. The medical records of the 5162 patients (84.5%) who returned for follow-up (ranging from 12 days to 9 years) were reviewed retrospectively. Usually, between 45% and 70% of the patients operated on a particular mission returned for early follow-up and some the following year. Patients were aged 2 months to 82 years at the time of surgery, with a median of 9 years. There were 3176 males (51.9%) and 2932 females (48.1%). The incidence of isolated lip clefts was 1546 patients (25.3%); isolated palate clefts, 2223 patients (36.4%); and combined defects, 2339 (38.3%) patients. Complications in terms of lip wound dehiscence, palate fistula formation, infection, bleeding, hypertrophic lip scars, and residual deformities of the nose and/or lip were compiled. Of the 5162 patients who returned for follow-up, 377 patients (7.3%) had complications. Lip wound dehiscence occurred in 58 patients (15.4%): 25 unilateral (6.6%) and 33 bilateral (8.8%). Dehiscence was due to closure under tension and, in some cases, trauma in the postoperative period. The use of dissolvable sutures was not the cause. The same sutures were used to treat dehiscence cases, and there were no recurrences, because the predisposing factors had been eliminated. Palate fistula formation occurred in 33 patients (8.8%): 24 (6.4%) after primary palate closure and 9 (2.4%) after previous fistula closure. Most fistulas (67%) were located at the junction of the hard and soft palate. All fistulas were closed in 2 layers. Infection was seen in 37 cleft lip patients (9.8%). All infections responded to antibiotic treatment. Hypertrophic lip scars were seen in 56 patients (14.9%). These scars were treated with intralesional triamcinolone injections. Forty-eight patients (12.7%) developed postoperative bleeding in the recovery room after palatoplasty. The bleeding was contained by applying pressure in most cases. However, 12 patients were taken back to the operating room to control the hemorrhage. No blood transfusions were used. Residual deformities of the nose and/or lip, of varying degree, occurred in 145 patients (38.5%). All required reoperation for correction. There were no intraoperative deaths in this series.
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However, 9 children who had been operated on to close palate clefts died, 3 days or more after surgery, because of pneumonia.
DISCUSSION The author presents a 20-year experience leading cleft lip and palate surgical volunteer missions in Peru for CIRPLAST. The main objective of CIRPLAST, a Peruvian nonprofit volunteer plastic surgery goodwill program, is to provide free surgery for poor patients with cleft lip and palate deformities. We travel to remote areas in Peru, so that the patients we operate on will eventually have access to education and employment, be accepted in society, get married, and raise a family. All of which is usually denied to untreated patients. Surgical procedures are performed by the author, together with a group of experienced plastic surgeons; some of which have been trained by the author at the university and also with the auspices of the Peruvian Plastic Surgery Society and local health authorities. Safe surgery is emphasized, as well as continuity of care. A quality review is conducted after each mission, to ensure accountability of our missions. Our CIRPLAST team is neither politically nor religiously motivated. All cleft patients who will be operated on must be in good health and infection free. Otherwise, they must receive adequate treatment before scheduling surgery. They need good nutrition, favoring breast feeding in infants, and a well-balanced diet, rich in proteins and vitamins, in young children and adults.1 No syndromic patients were operated on. The first operation is the best opportunity for patients to achieve a good outcome. Subsequent operations to correct sequelae or residual deformities from previous surgery, no matter how well they may be performed, will never be optimal. In the majority of cases, the best time for the cheiloplasty is at approximately 3 months of age and after 9 months for palatoplasty. Several surgical techniques for primary cleft lip and palate repair, as well as for the treatment of residual deformities after previous surgery, have been developed by the author. These techniques have been used successfully by the CIRPLAST team to obtain satisfactory outcomes and decrease the chance of complications.2,3 Preoperative active or passive maxillary orthopedics is considered by many surgeons as a good option to facilitate surgical closure of lip and palate clefts.4– 6 However, the use of these techniques is still controversial. Some surgeons prefer to use a surgical lip adhesion instead, whereas others think a lip adhesion is never indicated and opt for static modeling.7 They believe dynamic modeling interferes with normal bone growth. Some favor the presurgical active nasal modeling8 or nasomaxillary molding.9 We prefer surgical lip adhesion.10 Alar base and nasal tip symmetry must be achieved at the time of lip closure. In the past, nasal repair was not performed together with lip closure. It was usually postponed until the patients were 4 or 5 years old, or later, with the notion of avoiding interference with nasal growth. However, currently, in the majority of cases, the nasal repair is carried out at the time of cleft lip closure.2,3,11 Repair of the unilateral cleft lip nasal deformity is accomplished by elevating and repositioning the alar cartilage (lower lateral cartilage) in the nasal tip. This is accomplished through a vestibular rim incision approach to move up and fix the cartilage with sutures so that it slightly overlaps the triangular cartilage (upper lateral cartilage). The same principles apply to the bilateral cleft lip nose deformity. During complete or incomplete unilateral cleft lip closure, it is very important to preserve the upper lip philtrum and at least half of the Cupid bow. Adequate liberation, segmentation and horizontal reorientation of the labial muscles, is indispensable to lengthen the lip on each side of the cleft and to achieve a good anatomical, functional, and #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
aesthetic repair with a straight-line cleft closure, without skin flaps.10 Basically, the same principles apply to closure of bilateral clefts. When closing a palatal cleft, lateral relaxing incisions should be avoided as much as possible or at least minimized. These incisions heal by secondary intention and retract, causing significant transverse maxillary collapse, along with dental and alveolar deformities.2,12 In many cases, palatal cleft closure is accomplished without relaxing incisions by wide dissection through the cleft borders to free the oral mucoperiosteum and the nasal mucosa. However, when the cleft is very wide, an alternative to avoid lateral relaxing incisions is by inserting a periosteal elevator in the lateral part of the hard palate through the dentogingival space, a natural space between the teeth and the gum on the lingual side of the alveolus. This separates the gum from the teeth and facilitates the subperiosteal detachment of the oral mucosa from the hard palate bones, so the separated gum becomes a lateral extension of the oral flap, facilitating the approximation and midline closure of the oral flaps without tension. In very wide clefts, this maneuver is performed on both sides of the cleft. Bifidity or deformity of the uvula is common after palatal cleft closure. However, the problem can be avoided by centralizing 1 of the 2 hemiuvulae of the soft palate cleft and either incorporating the other one transversely into the soft palate for added length or just resecting it, when the soft palate length is adequate.13 Velopharyngeal insufficiencies may be reduced by doing an intravelar veloplasty, as described by Kriens.14 We free the palatine muscles from their abnormal insertion along the cleft borders and into the posterior border of the hard palate, so they can then be moved posteriorly on each side of the cleft and sutured together transversely to form a functional levator sling.13 As we move toward the end of the year, it is time not only to look forward, but also to look back reflecting on the history of CIRPLAST and the events that have helped to shape our institution. Since our launch 20 years ago, there have been some economic events that have shaken up the world in ways no one could have imagined. These occurrences were unexpected. Money is a very important factor. However, it is the way our team members dealt with these dramatic changes on a daily basis that has ultimately been the determining factor for success during those trying times. Basically, it comes down to the way we do things at CIRPLAST. It is the enthusiasm of our team that has gotten us to where we are today. Even from our humble beginnings with just a handful of people, we realized the importance of building a strong culture of cooperation among team members. We formed a solid base on which our nonprofit entity could grow. We remain a small, close-knit team. During our missions, we have lived, worked, and socialized together. It was not difficult to identify for ourselves as members of CIRPLAST. We must point out that we have received support from several sources, including Smile Train. Since we started our partnership with them in the year 2000, their ongoing sponsorship has been of great value to us. We hope to continue working with them for many years to come. By incorporating enthusiastic people who firmly believed in our institutional values and objectives, we have been able to shape our institution from its
#
2015 Mutaz B. Habal, MD
CIRPLAST: Cleft Lip and Palate Missions in Peru
inception. Few groups that treat clefts have the same level of enthusiasm, professionalism, and commitment as that shown by our CIRPLAST team. What we have achieved as a group in the last 20 years—operating on more than 6000 indigent patients in Peru during 141 missions—is nothing short of extraordinary. I am convinced that we could not have done it if we did not have a very strong cooperative culture to begin with.
REFERENCES 1. Meneses de Bardales D, Mula´novich de Navarro E. La preparacio´n y el postoperatorio del paciente fisurado de labio o paladar. Cir Plast Peruana 1977;1:101–103 2. Navarro-Gasparetto CE. Aportaciones personales al tratamiento de fisuras labio palatinas. Mesa redonda: Cirugı´a de labio y paladar. Presented at the XV Congreso de la Federacio´n Ibero Latinoame´rica de Cirugı´a Pla´stica; Sevilla, Spain; May 11, 2004. 3. Navarro CE. Working in Peru—Cleft Missions and Tips on Effective Techniques for Best Outcomes. Presented at the ‘‘Ask the Experts— Mission Trips for Cleft Care’’; American Society of Plastic Surgeons (ASPS); San Diego, CA; 2013. 4. Spira M, Findlay S, Hardy SB, et al. Early maxillary orthopedics in cleft palate patients: a clinical report. Cleft Palate J 1969;6:461–470 5. Santiago P, Garyson B, Cutting C, et al. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperosteosteoplasty. Cleft Palate Craniofac J 1998;35:77–80 6. Millard DR Jr, Latham R, Huifen X, et al. Cleft lip and palate treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA). Compared with previous lip adhesion method: a preliminary study of serial dental casts. Plast Reconstr Surg 1999;103:1630–1644 7. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose repair— long term outcome. Clin Plast Surg 2004;31:191–208 8. Monasterio L. Modelaje Nasal. Presented at the Actualizacio´n en el tratamiento integral de la Fisura labio palatina; Fundacio´n Gantz; Santiago, Chile; November 14–15, 2003. 9. Bennun RD, Perandones C, Sepliarsky VA, et al. Nonsurgical correction of nasal deformity in unilateral complete cleft lip: a 6-year follow-up. Plast Reconstr Surg 1999;104:616–830 10. Navarro-Gasparetto C. Tratamiento quiru´rgio de las fisuras labiales y labiopalatinas unilaterales. In: Coiffman F, ed. Cirugı´a Pla´stica, Reconstructiva y Este´tica; vol 3. Venezuela: Actalidades Me´dico Odontolo´gicas Latinoamericanas, C.A. (AMOLCA); 2007 11. Navarro CE, Bardales A, Sarmiento M. Primary aesthetic repair of unilateral cleft lip and nose in adults [abstract]. Presented at the 12th Congress of the International Confederation for Plastic, Reconstructive and Aesthetic Surgery; San Francisco, CA; June 27–July 2, 1999. 12. Navarro-Gasparetto CE. Aportaciones personales al tratamiento de fisuras labio palatinas. Mesa redonda: Cirugı´a de labio y paladar. Presented at the XV Congreso de la Federacio´n Ibero Latinoame´rica de Cirugı´a Pla´stica. Sevilla, Spain; Mayo 7–11, 2004. Libro de Resu´menes, de Ponencias y Comunicaciones del XV Congreso de la FILACP y XXXIX Congreso de la SECPRE. Sevilla: Sociedad Espan˜ola de Cirugı´a Pla´stica, Reconstructiva y Este´tica; 2004:182 13. Navarro CE, Bardales A, Sarmiento M, et al Double flap palatoplasty without relaxing incisions. Plastic Surgery Forum. Vol XXIII. Presented the 69th Annual Scientific Meeting of the American Society of Plastic Surgeons; Los Angeles, CA; October 15, 2000. 14. Kriens O. An anatomical approach to veloplasty. Plast Reconstr Surg 1969;43:29–41
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CIRPLAST: Cleft Lip and Palate Missions in Peru Carlos E. Navarro, MD, FACS Background: The author presents a 20-year experience leading cleft lip and palate surgical volunteer missions in Peru for CIRPLAST, a nonprofit volunteer plastic surgery goodwill program that has provided free surgery for patients with cleft lip and palate deformities in remote areas of Peru. Surgical procedures were performed by the author, together with a group of experienced plastic surgeons, under the auspices of the Peruvian Plastic Surgery Society, and local health authorities. Methods: CIRPLAST missions are scheduled annually in different locations around Peru. Selected patients for surgery after adequate screening are photographed, and their cleft deformity is recorded. Scheduled patients or their parents, when they are minors, sign an informed consent form. Patients operated on in any given day are examined and photographed 1 day after surgery, before discharge. Between 30 and 35 patients are operated on at each mission site. About 2 weeks after the mission, patients are checked and photographed, and the outcome of surgery is recorded. Complications that may occur are recorded and treated by the CIRPLAST team as soon as possible. Almost all operations are performed under general endotracheal anesthesia coupled by local anesthesia containing a vasoconstrictor, to reduce bleeding and facilitate tissue dissection. All wounds of the lip and palate are closed with absorbable sutures, to avoid the need for suture removal. After cleft lip surgery, patients go to the recovery room for monitoring by nurses until they recover completely. Results: A total of 6108 cleft lip and palate repairs, primary and secondary, were performed by CIRPLAST in 141 missions, between May 12, 1994, and October 15, 2014. The medical records of the 5162 patients (84.5%) who returned for follow-up (ranging from 12 days to 9 years) were reviewed retrospectively. Between 45% and 70% of the patients operated on a mission have returned for early follow-up and some the following year. There were 3176 males (51.9%) and 2932 females (48.1%). The incidence of isolated lip clefts was 1546 patients (25.3%); of isolated palate clefts, 2223 patients (36.4%); and combined defects, 2339 patients (38.3%). Of the 5162 patients who returned for follow-up, 377 patients (7.3%) had complications. Lip wound dehiscence was present in 58 patients (15.4). Palate fistula formation in 33 patients (8.8%): 24 (6.4%) after primary palate closure, and 9 (2.4%) after previous fistula closure. Infection occurred in 37 cleft lip patients (9.8%). Hypertrophic lip scars were seen in 56 patients (14.9%). Bleeding occurred in the From the Universidad Peruana Cayetano Heredia and CIRPLAST, Lima, Peru´. Received October 29, 2014. Accepted for publication January 24, 2015. Address correspondence and reprint requests to Carlos E. Navarro, MD, CIRPLAST President, Calle Piura 810, Lima 18, Peru; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001637
The Journal of Craniofacial Surgery
recovery room after palatoplasty in 48 patients (12.7%), and in most cases, it was contained by applying pressure. No blood transfusions were used. Residual deformities of varying degree of the nose and/or lip occurred in 145 patients (38.5%). All required reoperation for correction. There were no intraoperative deaths in this series. Conclusions: During the past 20 years, the CIRPLAST team has offered free surgery with good outcomes and few complications, to more than 6000 cleft lip and/or palate patients in remote areas of Peru. Key Words: Cleft lip and palate surgery, volunteer missions, Peru (J Craniofac Surg 2015;26: 1109–1111)
F
acial deformity associated with clefts of the lip and palate is a very complex health problem that has affected many people since ancient times. This has been well documented by the Moche portrait vessels (Huacos Retratos) in northern Peru dating back to about 1000 years before the Inca Empire. Peru, with more than 31 million inhabitants, is the third largest country in South America (roughly 21/2 times the size of Texas). Despite a recent macroeconomic upsurge, Peru remains a very poor country. Substandard medical and surgical care is usually the rule rather than the exception, especially outside Lima, the capital city of Peru. There is a high incidence of clefts of the lip and palate in Peru, about 1 in 500 births. CIRPLAST carries out about 10 surgical missions each year and provides free surgery for low-income patients affected with clefts of the lip and/or palate, in different parts of the country. Program is organized by the author’s wife, Marı´a Elvira Mula´novich, who is CIRPLAST’S general coordinator. Team goes back to the same places every year, so there is continuity of care in the communities we serve. Missions have been accomplished by coordinating and consolidating efforts with other health institutions in Peru, encompassing regional and local charities, when available. This allows our group to operate on a greater number of cleft patients, especially children, who either never had the opportunity to receive surgical care or had previous inadequate surgical repairs.
MATERIALS AND METHODS Missions are scheduled in advance at the different locations in Peru. Each mission lasts 1 week. During the first and second days, previously registered patients are screened. Selected patients are sent to the laboratory for blood work, electrocardiogram, and a cardiologic examination. Chest x-rays are not routinely done. After the testing, patients who are cleared for surgery are scheduled. Surgery is performed on the following 3 or 4 days, depending on the number of patients. Each selected patient is examined carefully and photographed. Procedure or procedures to be performed are recorded on their medical record. All scheduled patients or their parents, when they are minors, sign an informed consent form. Patients operated on in any given day are examined and photographed on the following day, before discharge. Usually, between 30 and 35 patients are operated on at each mission site. About 2 weeks after the mission, patients are checked and photographed, and the outcome of surgery is recorded.
Volume 26, Number 4, June 2015
1109
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Navarro
If complications occur, they are treated by the CIRPLAST team as soon as possible. We take our own anesthesia machines, suction machines, electrocauteries, surgical instruments, medications, anesthetic agents, sutures, and so on, to each mission site. Proposed surgical procedure, or procedures to be performed, depends on each patient’s individual needs. Almost all operations are performed under general endotracheal anesthesia coupled by local anesthesia containing a vasoconstrictor. This will reduce bleeding and facilitate tissue dissection. All wounds of the lip and palate are closed with absorbable sutures, to avoid the need for suture removal. When the cleft lip is very wide, the patient’s nutrition is not optimal, or the hemoglobin level is at the lower limit of normal, a lip adhesion is performed before a definitive lip repair several months later. Preoperative, active, or passive maxillary orthopedics is not available at any of our mission sites. At the end of surgery, tissues in the operative field are infiltrated with a small amount of local anesthetic containing a vasoconstrictor, for immediate postoperative pain control, and to reduce the possibility of bleeding. After completion of cleft lip surgery, patients go to the recovery room for monitoring by nurses until they recover completely. Once they are fully awake, they are fed by the mother, preferably with breast milk. Patients, who have had surgery of the palate, receive a liquid diet for 3 days. Followed by soft foods for several weeks, until all sutures have fallen out, and the wounds are completely healed.
RESULTS There were a total of 6108 cleft lip and palate repairs, primary and secondary, performed by CIRPLAST in 141 missions, between May 12, 1994, and October 15, 2014. The medical records of the 5162 patients (84.5%) who returned for follow-up (ranging from 12 days to 9 years) were reviewed retrospectively. Usually, between 45% and 70% of the patients operated on a particular mission returned for early follow-up and some the following year. Patients were aged 2 months to 82 years at the time of surgery, with a median of 9 years. There were 3176 males (51.9%) and 2932 females (48.1%). The incidence of isolated lip clefts was 1546 patients (25.3%); isolated palate clefts, 2223 patients (36.4%); and combined defects, 2339 (38.3%) patients. Complications in terms of lip wound dehiscence, palate fistula formation, infection, bleeding, hypertrophic lip scars, and residual deformities of the nose and/or lip were compiled. Of the 5162 patients who returned for follow-up, 377 patients (7.3%) had complications. Lip wound dehiscence occurred in 58 patients (15.4%): 25 unilateral (6.6%) and 33 bilateral (8.8%). Dehiscence was due to closure under tension and, in some cases, trauma in the postoperative period. The use of dissolvable sutures was not the cause. The same sutures were used to treat dehiscence cases, and there were no recurrences, because the predisposing factors had been eliminated. Palate fistula formation occurred in 33 patients (8.8%): 24 (6.4%) after primary palate closure and 9 (2.4%) after previous fistula closure. Most fistulas (67%) were located at the junction of the hard and soft palate. All fistulas were closed in 2 layers. Infection was seen in 37 cleft lip patients (9.8%). All infections responded to antibiotic treatment. Hypertrophic lip scars were seen in 56 patients (14.9%). These scars were treated with intralesional triamcinolone injections. Forty-eight patients (12.7%) developed postoperative bleeding in the recovery room after palatoplasty. The bleeding was contained by applying pressure in most cases. However, 12 patients were taken back to the operating room to control the hemorrhage. No blood transfusions were used. Residual deformities of the nose and/or lip, of varying degree, occurred in 145 patients (38.5%). All required reoperation for correction. There were no intraoperative deaths in this series.
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Volume 26, Number 4, June 2015
However, 9 children who had been operated on to close palate clefts died, 3 days or more after surgery, because of pneumonia.
DISCUSSION The author presents a 20-year experience leading cleft lip and palate surgical volunteer missions in Peru for CIRPLAST. The main objective of CIRPLAST, a Peruvian nonprofit volunteer plastic surgery goodwill program, is to provide free surgery for poor patients with cleft lip and palate deformities. We travel to remote areas in Peru, so that the patients we operate on will eventually have access to education and employment, be accepted in society, get married, and raise a family. All of which is usually denied to untreated patients. Surgical procedures are performed by the author, together with a group of experienced plastic surgeons; some of which have been trained by the author at the university and also with the auspices of the Peruvian Plastic Surgery Society and local health authorities. Safe surgery is emphasized, as well as continuity of care. A quality review is conducted after each mission, to ensure accountability of our missions. Our CIRPLAST team is neither politically nor religiously motivated. All cleft patients who will be operated on must be in good health and infection free. Otherwise, they must receive adequate treatment before scheduling surgery. They need good nutrition, favoring breast feeding in infants, and a well-balanced diet, rich in proteins and vitamins, in young children and adults.1 No syndromic patients were operated on. The first operation is the best opportunity for patients to achieve a good outcome. Subsequent operations to correct sequelae or residual deformities from previous surgery, no matter how well they may be performed, will never be optimal. In the majority of cases, the best time for the cheiloplasty is at approximately 3 months of age and after 9 months for palatoplasty. Several surgical techniques for primary cleft lip and palate repair, as well as for the treatment of residual deformities after previous surgery, have been developed by the author. These techniques have been used successfully by the CIRPLAST team to obtain satisfactory outcomes and decrease the chance of complications.2,3 Preoperative active or passive maxillary orthopedics is considered by many surgeons as a good option to facilitate surgical closure of lip and palate clefts.4– 6 However, the use of these techniques is still controversial. Some surgeons prefer to use a surgical lip adhesion instead, whereas others think a lip adhesion is never indicated and opt for static modeling.7 They believe dynamic modeling interferes with normal bone growth. Some favor the presurgical active nasal modeling8 or nasomaxillary molding.9 We prefer surgical lip adhesion.10 Alar base and nasal tip symmetry must be achieved at the time of lip closure. In the past, nasal repair was not performed together with lip closure. It was usually postponed until the patients were 4 or 5 years old, or later, with the notion of avoiding interference with nasal growth. However, currently, in the majority of cases, the nasal repair is carried out at the time of cleft lip closure.2,3,11 Repair of the unilateral cleft lip nasal deformity is accomplished by elevating and repositioning the alar cartilage (lower lateral cartilage) in the nasal tip. This is accomplished through a vestibular rim incision approach to move up and fix the cartilage with sutures so that it slightly overlaps the triangular cartilage (upper lateral cartilage). The same principles apply to the bilateral cleft lip nose deformity. During complete or incomplete unilateral cleft lip closure, it is very important to preserve the upper lip philtrum and at least half of the Cupid bow. Adequate liberation, segmentation and horizontal reorientation of the labial muscles, is indispensable to lengthen the lip on each side of the cleft and to achieve a good anatomical, functional, and #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
aesthetic repair with a straight-line cleft closure, without skin flaps.10 Basically, the same principles apply to closure of bilateral clefts. When closing a palatal cleft, lateral relaxing incisions should be avoided as much as possible or at least minimized. These incisions heal by secondary intention and retract, causing significant transverse maxillary collapse, along with dental and alveolar deformities.2,12 In many cases, palatal cleft closure is accomplished without relaxing incisions by wide dissection through the cleft borders to free the oral mucoperiosteum and the nasal mucosa. However, when the cleft is very wide, an alternative to avoid lateral relaxing incisions is by inserting a periosteal elevator in the lateral part of the hard palate through the dentogingival space, a natural space between the teeth and the gum on the lingual side of the alveolus. This separates the gum from the teeth and facilitates the subperiosteal detachment of the oral mucosa from the hard palate bones, so the separated gum becomes a lateral extension of the oral flap, facilitating the approximation and midline closure of the oral flaps without tension. In very wide clefts, this maneuver is performed on both sides of the cleft. Bifidity or deformity of the uvula is common after palatal cleft closure. However, the problem can be avoided by centralizing 1 of the 2 hemiuvulae of the soft palate cleft and either incorporating the other one transversely into the soft palate for added length or just resecting it, when the soft palate length is adequate.13 Velopharyngeal insufficiencies may be reduced by doing an intravelar veloplasty, as described by Kriens.14 We free the palatine muscles from their abnormal insertion along the cleft borders and into the posterior border of the hard palate, so they can then be moved posteriorly on each side of the cleft and sutured together transversely to form a functional levator sling.13 As we move toward the end of the year, it is time not only to look forward, but also to look back reflecting on the history of CIRPLAST and the events that have helped to shape our institution. Since our launch 20 years ago, there have been some economic events that have shaken up the world in ways no one could have imagined. These occurrences were unexpected. Money is a very important factor. However, it is the way our team members dealt with these dramatic changes on a daily basis that has ultimately been the determining factor for success during those trying times. Basically, it comes down to the way we do things at CIRPLAST. It is the enthusiasm of our team that has gotten us to where we are today. Even from our humble beginnings with just a handful of people, we realized the importance of building a strong culture of cooperation among team members. We formed a solid base on which our nonprofit entity could grow. We remain a small, close-knit team. During our missions, we have lived, worked, and socialized together. It was not difficult to identify for ourselves as members of CIRPLAST. We must point out that we have received support from several sources, including Smile Train. Since we started our partnership with them in the year 2000, their ongoing sponsorship has been of great value to us. We hope to continue working with them for many years to come. By incorporating enthusiastic people who firmly believed in our institutional values and objectives, we have been able to shape our institution from its
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2015 Mutaz B. Habal, MD
CIRPLAST: Cleft Lip and Palate Missions in Peru
inception. Few groups that treat clefts have the same level of enthusiasm, professionalism, and commitment as that shown by our CIRPLAST team. What we have achieved as a group in the last 20 years—operating on more than 6000 indigent patients in Peru during 141 missions—is nothing short of extraordinary. I am convinced that we could not have done it if we did not have a very strong cooperative culture to begin with.
REFERENCES 1. Meneses de Bardales D, Mula´novich de Navarro E. La preparacio´n y el postoperatorio del paciente fisurado de labio o paladar. Cir Plast Peruana 1977;1:101–103 2. Navarro-Gasparetto CE. Aportaciones personales al tratamiento de fisuras labio palatinas. Mesa redonda: Cirugı´a de labio y paladar. Presented at the XV Congreso de la Federacio´n Ibero Latinoame´rica de Cirugı´a Pla´stica; Sevilla, Spain; May 11, 2004. 3. Navarro CE. Working in Peru—Cleft Missions and Tips on Effective Techniques for Best Outcomes. Presented at the ‘‘Ask the Experts— Mission Trips for Cleft Care’’; American Society of Plastic Surgeons (ASPS); San Diego, CA; 2013. 4. Spira M, Findlay S, Hardy SB, et al. Early maxillary orthopedics in cleft palate patients: a clinical report. Cleft Palate J 1969;6:461–470 5. Santiago P, Garyson B, Cutting C, et al. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperosteosteoplasty. Cleft Palate Craniofac J 1998;35:77–80 6. Millard DR Jr, Latham R, Huifen X, et al. Cleft lip and palate treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA). Compared with previous lip adhesion method: a preliminary study of serial dental casts. Plast Reconstr Surg 1999;103:1630–1644 7. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose repair— long term outcome. Clin Plast Surg 2004;31:191–208 8. Monasterio L. Modelaje Nasal. Presented at the Actualizacio´n en el tratamiento integral de la Fisura labio palatina; Fundacio´n Gantz; Santiago, Chile; November 14–15, 2003. 9. Bennun RD, Perandones C, Sepliarsky VA, et al. Nonsurgical correction of nasal deformity in unilateral complete cleft lip: a 6-year follow-up. Plast Reconstr Surg 1999;104:616–830 10. Navarro-Gasparetto C. Tratamiento quiru´rgio de las fisuras labiales y labiopalatinas unilaterales. In: Coiffman F, ed. Cirugı´a Pla´stica, Reconstructiva y Este´tica; vol 3. Venezuela: Actalidades Me´dico Odontolo´gicas Latinoamericanas, C.A. (AMOLCA); 2007 11. Navarro CE, Bardales A, Sarmiento M. Primary aesthetic repair of unilateral cleft lip and nose in adults [abstract]. Presented at the 12th Congress of the International Confederation for Plastic, Reconstructive and Aesthetic Surgery; San Francisco, CA; June 27–July 2, 1999. 12. Navarro-Gasparetto CE. Aportaciones personales al tratamiento de fisuras labio palatinas. Mesa redonda: Cirugı´a de labio y paladar. Presented at the XV Congreso de la Federacio´n Ibero Latinoame´rica de Cirugı´a Pla´stica. Sevilla, Spain; Mayo 7–11, 2004. Libro de Resu´menes, de Ponencias y Comunicaciones del XV Congreso de la FILACP y XXXIX Congreso de la SECPRE. Sevilla: Sociedad Espan˜ola de Cirugı´a Pla´stica, Reconstructiva y Este´tica; 2004:182 13. Navarro CE, Bardales A, Sarmiento M, et al Double flap palatoplasty without relaxing incisions. Plastic Surgery Forum. Vol XXIII. Presented the 69th Annual Scientific Meeting of the American Society of Plastic Surgeons; Los Angeles, CA; October 15, 2000. 14. Kriens O. An anatomical approach to veloplasty. Plast Reconstr Surg 1969;43:29–41
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
