Download CIRPLAST: Cleft Lip and Palate Missions in Peru

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,
Perú.
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, Marı́a Elvira Mulánovich, 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.
1110
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
#
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, Mulánovich de Navarro E. La preparación 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: Cirugı́a de labio y paladar.
Presented at the XV Congreso de la Federación Ibero Latinoamérica de
Cirugı́a Plástica; 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 Actualización en el
tratamiento integral de la Fisura labio palatina; Fundación 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 quirúrgio de las fisuras labiales y
labiopalatinas unilaterales. In: Coiffman F, ed. Cirugı́a Plástica,
Reconstructiva y Estética; vol 3. Venezuela: Actalidades Médico
Odontológicas 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: Cirugı́a de labio y paladar.
Presented at the XV Congreso de la Federación Ibero Latinoamérica de
Cirugı́a Plástica. Sevilla, Spain; Mayo 7–11, 2004. Libro de Resúmenes,
de Ponencias y Comunicaciones del XV Congreso de la FILACP y
XXXIX Congreso de la SECPRE. Sevilla: Sociedad Española de Cirugı́a
Plástica, Reconstructiva y Estética; 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
1111
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.