Cleft Lip and Palate Treatment

396 Pages·2018·30.13 MB·English

by  Nivaldo Alonso

Nivaldo Alonso
Cassio Eduardo Raposo-Amaral Editors
Cleft Lip and
Palate Treatment
A Comprehensive Guide
123
Cleft Lip and Palate Treatment
Nivaldo Alonso
Cassio Eduardo Raposo-Amaral
Editors
Cleft Lip and Palate
Treatment
A Comprehensive Guide
Editors
Nivaldo Alonso, M.D., Ph.D. Cassio Eduardo Raposo-Amaral, M.D., Ph.D.
University of São Paulo Medical School SOBRAPAR Hospital
São Paulo, SP, Brazil Campinas, SP, Brazil
ISBN 978-3-319-63289-6 ISBN 978-3-319-63290-2 (eBook)
https://doi.org/10.1007/978-3-319-63290-2
Library of Congress Control Number: 2017961998
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In memory of my parents, Nelson and Maria
Apparecida, who dedicated their lives to my
education.
I have had many mentors in my life, and
three of them, Daniel Marchac, William
Magee, and John Persing, guided me toward
craniofacial surgery and the treatment of
patients with cleft lip and palate.
These men showed a passion for plastic
surgery and the treatment of congenital
deformities. Daniel Marchac gave me a
grounding in technical skills and passed on
his knowledge, and William Magee and John
Persing shared with me their great passion
for teaching and for the treatment of cleft lip
and palate.
But none of my work in this field would have
happened had I not had a beautiful and
patient family. So this dedication is made
with all my love to Elci, Catherine, Ligia and
Alexandre; they are the reason for all that I
have accomplished
Nivaldo Alonso
vi Dedication
This book is dedicated to my late father,
Cassio Raposo do Amaral, a pioneer in the
craniofacial field in Brazil, who, together
with my mother, Vera Raposo do Amaral,
established the SOBRAPAR hospital in 1979.
Regrettably, my father did not live long
enough to see our family’s achievements.
When he passed away, I was a senior plastic
surgery resident and my brother Cesar was a
senior resident in general surgery. Currently,
we are both plastic and reconstructive
surgeons working together to offer an oppor-
tunity to the underprivileged population in
Brazil who were born with craniofacial
deformities. SOBRAPAR has been a project
of two generations, and it recruits excellent
professionals for the same cause as that
espoused by its founder. Some of these
professionals are contributors to this book.
I feel fortunate and grateful to have gained
additional experience in craniofacial surgery
and surgery for cleft lip and palate at the
Institute of Reconstructive Plastic Surgery
under the direction of Dr. Joseph McCarthy.
In the same year I also gained additional
experience as an international fellow at
University of California Los Angeles (UCLA)
under the leadership of Dr. Henry
K. Kawamoto. This was a life-changing
experience that helped me to mold some of
the principles I had acquired during my
residency.
Lastly, I thank my wife Tatiana for providing
loving support during the hours of night
work, and I thank our 3-year old son, Marc,
for being our source of joy and happiness.
Cassio Eduardo Raposo-Amaral
Foreword I
Almost to the end of the twentieth century, medical/surgical practice was confined
to individual clinicians functioning in isolated offices. The concept of multidisci-
plinary or team care had not yet evolved. However, with the explosion of diagnostic
and therapeutic advances resulting from biomedical research, it became apparent
that a new model was needed as optimal medical/surgical care was beyond the
expertise of a single practitioner or only one discipline. Moreover, the required tech-
nological support system was available only in a modern hospital setting.
By the early twenty-first century the concept of true multidisciplinary care under
hospital auspices had gained wide acceptance, especially in the treatment of heart
disease and cancer. For example, a patient with coronary artery disease is poten-
tially evaluated or treated by a radiologist skilled in cardiac imaging, an adult cardi-
ologist, an electrophysiologist, or interventional cardiologist or cardiothoracic
surgeon.
It should be noted that the concept of multidisciplinary or team care was pio-
neered by clinicians caring for children with cleft lip/palate. I believe the first such
integrated center was founded in 1938 in Lancaster, Pennsylvania, by a dentist, Dr.
Herbert K. Cooper. He was joined in his early efforts by experts in speech and com-
munication and by Dr. Robert H. Ivy, the first Chief of Plastic Surgery at the
University of Pennsylvania. In organizing their team, they recognized that multidis-
ciplinary care provided the optimal outcomes by addressing all aspects of the medi-
cal problem on behalf of the patient and family, the latter eventually leading decades
later to a new expression in the medical lexicon—holistic medicine. Moreover, it
was efficient, as well as caring. Being evaluated in a single setting during one visit
by all of the requisite specialists obviated the need for multiple visits at different
locations—a scheduling nightmare.
For the team members this model is likewise beneficial. There is direct, face-to-
face communication among the members. A discussion with a member from another
specialty or discipline is invariably a learning experience. Treatment plans are for-
mulated collectively and presented to the patient in a concise and sympathetic man-
ner. Team meetings also promote clinical research projects, the development of
treatment protocols and clinical trials. Moreover, professional meetings are orga-
nized more and more along clinical conditions rather than specialty groups.
This text, authored by Drs. Nivaldo Alonso and Cassio Eduardo Raposo-Amaral,
reflects the historic heritage and modern evolution of the cleft team.
vii
viii Foreword I
Organized in a concise and well-written style, the book defines the full spectrum
of multidisciplinary cleft care:
• The promotion of cleft care as an important component of every integrated
national health care system, as well as the evolving field of international or global
health.
• The genetics of cleft lip and palate—an especially important topic in the era of
genomics research. The latter has to be correlated with a rigorous classification
of cleft phenotypes.
• An overview of clinical protocols and outcome studies—a requisite metric by
government agencies and insurance companies in a time when health care costs
are skyrocketing.
• The details of treatment, including surgical, protocols for patients with unilateral
cleft lip, bilateral cleft lip, and cleft palate.
• Speech therapy and the treatment of velopharyngeal insufficiency.
• Longitudinal orthodontic therapy.
• Closure of alveolar clefts with bone grafts and substitutes.
• The role of orthognathic surgery and cleft rhinoplasty.
• Standardized record keeping with two-dimensional photography and the newer
imaging technique of three-dimensional digital stereophotogrammetry.
This book highlights the role and activities of a well-functioning modern-day
cleft team as it helps the patient and family navigate a complex clinical trial that
often begins before birth with the ultrasonic diagnosis and continues for almost two
decades until the face is fully grown. While the treatments may be many and the
required resources large, the rewards are enormous—a young person facing life
with increased self-confidence and determination to lead a full and productive life.
Joseph G. McCarthy, M.D.
Wyss Department of Plastic Surgery
NYU Langone Medical Center
New York, NY, USA
Foreword II
Cleft lip and palate is the most prevalent congenital anomaly in Brazil that affects 1
per 650 live births, according to our government data.
Cleft Lip and Palate Treatment: A Comprehensive Guide has brought useful
knowledge and information to those involved in the rehabilitation of this expressive
group of patients in our country.
This twenty-three chapter book aims to cover the diagnosis and treatment of the
broad clinical spectrum of cleft, from an incomplete cleft lip to the rarest Tessier
facial clefts.
Twenty-seven coauthors were invited to collaborate with this meticulous work
planned by Nivaldo Alonso and Cassio Eduardo Raposo-Amaral, who always pas-
sionately dedicated themselves to the treatment of these patients, in a feverish search
for something that would seem simple—the normalcy. That is definitely not!
The achievements in various areas of health (medicine, dentistry, nursing, speech
therapy, psychology, etc.) associated with the new technologies have led the
Craniofacial Surgery to become a fascinating specialty. Great refinements in both
aesthetic and functional morphology have been amply demonstrated by the authors
of this work. In spite of the evolution and consolidation of several surgical tech-
niques in the treatment of cleft lip and palate over the years, many basic precepts
regarding the care of this group of patients remain the same. Compassion is undoubt-
edly one of the most important among these precepts.
Indeed, a coordinated effort in the longitudinal care of this cohort is of para-
mount importance aiming to avoid excessive scars in the soft tissue envelope that
may cause impairment of craniofacial growth. All this must be understood by fami-
lies who may be afflicted by the burden of multiple surgeries along the years.
The authors have admirably worked in providing a text that demonstrates the
results that can be obtained with cooperation between numerous experts, with spe-
cial emphasis on the most modern and established surgical techniques to correct
various problems related to cleft.
ix
x Foreword II
I have absolute conviction that this book will represent an excellent source of
information to guide experienced professionals and students and even collaborate
for understanding basic care issues connected with craniofacial anomalies. In this
way, I am pleased to commend the editors and authors for this wonderful effort to
present a succinct and practical text to the readers.
Ricardo Cruz, M.D.
National Institute of Traumatology
and Orthopedics
Rio de Janeiro, Brazil