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
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Khob Khun KrabThank You for Your
Attentionhttp://web.kku.ac.th/~cleft/E-mail: [email protected]