excellent care in clefts and craniofacial anomalies · 11 oct 2005 kku medical annual meeting 4 the...

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

11 Oct 2005 KKU Medical Annual Meeting 2

“Tawanchai” Project

11 Oct 2005 KKU Medical Annual Meeting 3

11 Oct 2005 KKU Medical Annual Meeting 4

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

11 Oct 2005 KKU Medical Annual Meeting 5

Interdisciplinary Team Management

11 Oct 2005 KKU Medical Annual Meeting 6

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.

11 Oct 2005 KKU Medical Annual Meeting 7

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

11 Oct 2005 KKU Medical Annual Meeting 8

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

11 Oct 2005 KKU Medical Annual Meeting 9

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?

11 Oct 2005 KKU Medical Annual Meeting 10

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?

11 Oct 2005 KKU Medical Annual Meeting 11

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

11 Oct 2005 KKU Medical Annual Meeting 12

Community-based Model & Family Support Program

11 Oct 2005 KKU Medical Annual Meeting 13

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

11 Oct 2005 KKU Medical Annual Meeting 14

Clinical Outcome in CLPEvidence –Based and Holistic

Approached

• Aesthetic• Dental, speech and hearing function

• Growth & development• Quality of life and social aspect

11 Oct 2005 KKU Medical Annual Meeting 15

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

11 Oct 2005 KKU Medical Annual Meeting 16

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

11 Oct 2005 KKU Medical Annual Meeting 17

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

11 Oct 2005 KKU Medical Annual Meeting 18

Primary Cleft SurgeryIntegrated Concept

11 Oct 2005 KKU Medical Annual Meeting 19

Rotation advancement incision

11 Oct 2005 KKU Medical Annual Meeting 20

Dissection of abnormal muscular attachment

11 Oct 2005 KKU Medical Annual Meeting 21

Cartilage mobilization, repositioningand transfixing

11 Oct 2005 KKU Medical Annual Meeting 22

The differential muscle repair

11 Oct 2005 KKU Medical Annual Meeting 23

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

11 Oct 2005 KKU Medical Annual Meeting 24

Adjustment of advancement flap

11 Oct 2005 KKU Medical Annual Meeting 25

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

11 Oct 2005 KKU Medical Annual Meeting 26

11 Oct 2005 KKU Medical Annual Meeting 27

Incomplete Unilateral Cleft Lip

11 Oct 2005 KKU Medical Annual Meeting 28

Incomplete Unilateral Cleft Lip

11 Oct 2005 KKU Medical Annual Meeting 29

Complete Unilateral Cleft Lip

11 Oct 2005 KKU Medical Annual Meeting 30

Complete Unilateral Cleft Lip

11 Oct 2005 KKU Medical Annual Meeting 31

Bilateral Cleft Lip

11 Oct 2005 KKU Medical Annual Meeting 32

Alveolar Bone Grafting

11 Oct 2005 KKU Medical Annual Meeting 33

Orthognathic Surgery & Final Correction of 20 Deformities

11 Oct 2005 KKU Medical Annual Meeting 34

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

Holoprosencephaly or Tissue-Deficient Median Facial Cleft

11 Oct 2005 KKU Medical Annual Meeting 35

Holoprosencephaly or Tissue-Deficient Median Facial Cleft

11 Oct 2005 KKU Medical Annual Meeting 36

Holoprosencephaly or Tissue-Deficient Median Facial Cleft

11 Oct 2005 KKU Medical Annual Meeting 37

Tissue Excess-Median Facial Clefts

11 Oct 2005 KKU Medical Annual Meeting 38

Tissue Excess-Median Facial Clefts

Significant of notching of the vermillion border

bifid nose with duplicated columella.

11 Oct 2005 KKU Medical Annual Meeting 39

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.

11 Oct 2005 KKU Medical Annual Meeting 40

Fronto-EthmoidalMeningo-

encephalocele

11 Oct 2005 KKU Medical Annual Meeting 41

Facial Cleft No 1/13

11 Oct 2005 KKU Medical Annual Meeting 42

11 Oct 2005 KKU Medical Annual Meeting 43

Facial Cleft No. 2/12

11 Oct 2005 KKU Medical Annual Meeting 44

11 Oct 2005 KKU Medical Annual Meeting 45

Bone defect extends to midline skull base with

hypertelorism and low lying of frontal lobe of the brain

Hypoplasia of maxillary antrum

11 Oct 2005 KKU Medical Annual Meeting 46

Facial Cleft No. 3/11

11 Oct 2005 KKU Medical Annual Meeting 47

Facial Cleft No. 4/10

11 Oct 2005 KKU Medical Annual Meeting 48

Soft tissue revision with calvarial bone graft

Soft tissue correction with lower eyelid and

upper lip reconstruction

11 Oct 2005 KKU Medical Annual Meeting 49

11 Oct 2005 KKU Medical Annual Meeting 50

11 Oct 2005 KKU Medical Annual Meeting 51

Facial Cleft No. 5/9

11 Oct 2005 KKU Medical Annual Meeting 52

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

11 Oct 2005 KKU Medical Annual Meeting 53

Craniofacial Microsomia

11 Oct 2005 KKU Medical Annual Meeting 54

Craniofacial Microsomia& Soft Tissue Reconstruction

11 Oct 2005 KKU Medical Annual Meeting 55

Craniofacial Microsomia& Distraction Osteogenesis

11 Oct 2005 KKU Medical Annual Meeting 56

Craniofacial Microsomia& Free Tissue Transfer

11 Oct 2005 KKU Medical Annual Meeting 57

Craniosynostosis& Craniofacial Surgery

11 Oct 2005 KKU Medical Annual Meeting 58

Craniosynostosis& Craniofacial Surgery

11 Oct 2005 KKU Medical Annual Meeting 59

Pierre Robin Sequence

11 Oct 2005 KKU Medical Annual Meeting 60

Pierre Robin Sequence& Distraction Osteogenesis

11 Oct 2005 KKU Medical Annual Meeting 61

Principle of Surgical Technique in Craniofacial Clefts

11 Oct 2005 KKU Medical Annual Meeting 62

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

11 Oct 2005 KKU Medical Annual Meeting 63

การดแูลผูปวยปากแหวงเพดานโหวแบบองครวม

การดูแลรักษาพยาบาล

การฟนฟูสภาพและการดูแลอยางตอเนื่อง

การปองกัน

ผูปวย

นโยบายดานสาธารณสุขของรฐั

องคกรเ

อกชน องคกรอิสระ

11 Oct 2005 KKU Medical Annual Meeting 64

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.

11 Oct 2005 KKU Medical Annual Meeting 65

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