1. Surgery Rona Slator Consultant Plastic Surgeon Clinical Director, West Midlands Cleft Centre CLAPA Annual Meeting Saturday, 11 th October, 2008

2. The service provided… Development of that service… Problems/challenges for the future…

3. Surgery - the service to try to restore the disrupted anatomy

4. 0-5 years 3 monthslip repair 6-9 monthspalate repair closure of fistula surgery for speech lip/nose revision

5. 5-10 years closure of fistula surgery for speech 8-10 yearsalveolar bone graft lip/nose revision

6. 10-20 years lip/nose revision >16 years lip/nose revision orthognathic surgery implants

7. (ENT surgery for glue ear)‏

8. But surgeons also… Often visit newborn babies and their families Counsel parents who have had an antenatal diagnosis of their baby having a cleft lip Continue support for families as the children grow up

9. With geneticist and paediatrician will have a role in diagnosing other anomalies and/or developmental problems Engage and liaise with specialists (both within and) outside the cleft team in coordinating care May have a major role in looking after babies with Pierre Robin Sequence with airway/feeding problems

10. Teaching/training Surgeons Other members of the cleft team in training Other specialties outside the cleft team but also involved in the care of children with cleft lip and/or palate Being open themselves to learning from other specialists in the cleft team

11. Development of the surgical service

12. Following CSAG and reorganisation… Reduced numbers of surgeons involved in cleft care Increased time commitment of surgeons to cleft care (particularly for those involved in ‘primary’ surgery) All surgeons carrying out ‘primary’ lip and palate repair treating increased numbers of new babies (range in 2008, 29-77 per year)

13. Developments - Surgical training Significantly improved and specific training (1-2 year Cleft Fellowship) for trainee surgeons wishing to become consultant surgeons carrying out primary cleft lip and palate repair. Currently there are talented young surgeons interested in the specialty

14. Developments Coordination of care improved following reorganisation – all aspects of cleft care within the one team Longitudinal care established Colleagues with whom to discuss difficult or unusual surgical problems Other specialist disciplines within the team contribute to surgical decisions

15. Developments Measurement of outcomes There is a more open culture about outcomes and intercentre audit And a desire to improve care by working together Continuing effort to move towards the CSAG inspired standards of multidisciplinary care (ENT, impact of psychology input)

16. Challenges for the future

17. Challenges Developing evidence to support best surgical practice

18. So, for example, order and timing of repair of lip and palate Unilateral cleft lip and palate Lipall of palate Lip/(anterior) hard palaterest of palate Lip and soft palaterest of palate 3 months6-9 months

19. An easier question? Which sutures to use? Still have at least one problem of outcome measure

20. Challenges Outcome measures Speech Facial growth Appearance/symmetry Well being ‘burden of care’

21. plus Small numbers Workload and infrastructure to collect data Having equipoise for different approaches

22. Challenges And evidence from Developing a better understanding of the patients’ views on surgery, particularly so called ‘secondary’ surgery.

23. Challenges Development of basic science research that might fundamentally change the surgery needed

24. Challenges - A very specialist area Continue to attract ‘the best’ young surgeons into the field And train them so that the ‘learning curve’ is eliminated as far as possible Who will have wide knowledge and awareness of surgical and technical developments in all areas of surgery and elsewhere so that these can be introduced into cleft care where appropriate Innovation