Childrens Hospital Boston
Good Palate Talking 2012
Brainstorming sessions with JB Mulliken Childrens Hospital Craniofacial Boston
Period: July 30- Office of John B Mulliken July-31 –OT session on palatoplasty
Idea: Try to get it right the first time…
Special thanks to our senior advisor John Mulliken of Childrens hospital for his input in the charity work in Yemen
This was a special visit to discuss some important aspects of cleft palate surgery to help us in the upcoming world conference in Florida /US Task Force discussions on palatoplasty.Special thanks to the American Cleft Palate and Craniofacial Association for inviting me to become one of their members.
Day One: 30th July 2012
Bona: Dear John Mulliken, it is so good to meet you in person, Thanks for having me at your hospital. Let me come straight to the point since we wont have much time. I have a copy of what we are to discuss at your office today-"palatoplasty in the speaking individual with an unrepaired cleft palate". This is what the Palatoplasty Task Force Members of Florida Cleft 2013 are working on. I would also like to mention to you that Brian Sommerlad has suggested that "our report must reflect the fact that late repairs are largely a problem in poorer countries and must address the challenges in those countries".
Some of the trickier questions for you are :
Brian recently mentioned that the evidence against midline flaps is increasing, so I ask," Is it time to abandon ship?"
Mulliken: I couldn't disagree more with Brian so let me explain.
Bona: Okay, let me record this video for our friends so that they can hear it from you.
Let's talk about the muscle now; what are some of your ideas on palatoplasty methods in older patients?
Mulliken: I do have some experience on late repairs , mostly on Chinese children adopted here.
Mulliken: I have a complete cleft palate repair in tomorrow's list-John Meara and I will sneak you in so be here at 7.30am J. Normally it takes almost two weeks to get the paperwork done! Let's go out for a meal now. We could keep on talking for two days! I do believe that the facial growth problem is over emphasized by some of our colleagues , esp. in the dental department. That is another interesting topic.
Bona: Ok, thanks again. Looking forward to it.
31 July OT:
1.Mulliken: We have to wait for some time because I want to make sure the anesthetist has the tube in the right place and that it wont slip out . Ok,that is better(some time to do this with the help of senior anesthetist Kim who was called in to help).
Bona: Wow.. the anesthetist is so important in cleft palate surgery!Numbers are important here).
Mulliken: I usually go for a conventional two flap repair ; I admire what Brian Sommerlad does,but I do not use a microscope. And I do not do a radical muscle repair. I go as far as the hamulus and beyond,fracture it, and reposition the levators about 7-8mm. In addition I also add palatal osteoctomy to get a tension free repair. You will need this in older patients.
Bona: I also do a similar procedure and do not do a radical dissection. Is the junctional fistula your commonest problem? Also,I add saline distension for an easy ,relatively bloodless repair.
Mulliken: Yes,for me it is the junctional fistula. Looks like we got a problem here Bona,at the junction.Doesn't look too good. Ah, a small hole.A bit tight.Brian always makes a small hole to drain the collection. I also fix the flap whenever I can to the stalactite near the vessel-we see it in some patients and it helps the child post op.There is less pain when we fix the flap well. I also use my own modification by stitching this gauze pack (in balm of Peru) for hemostasis of the flaps.
Ok,that's done. Let's meet tomorrow evening for a dinner . I have asked Kelly to give you my papers on lip and palate –that is 15 years of my work. I will give you my book on Vascular Anomalies when it comes out later this year,so come back to Boston and collect it.(writes out a note on journal " Bona,never lose your sense of wonder".)
Bona: Wow! Thanks so much. I will treasure them. And, I liked your style on the 5 string banjo. Hope you will be there at the Flordia conference .
1.Always close the nasal layer well with the knots facing the nasal side- don't try new ideas like keeping a raw nasal surface.It is a crazy idea.
2.Hamulus fracture is done by some,avoided by others.A matter of personal preference
3.Not always necessary to do a radical muscle dissection –debatable.
4.Speech problems may be surgeon induced in some cases where the technique is poor.
5.Is there really a maximum age for palate repair-how old is too old? Don't really know. But would not do it in a very old person.
6.Dead man's skin, augmentation,osmotic expanders – not many takers. Not useful.
7.The advantage of muscle repositioning over Furlows? For one, it is more anatomical and also Furlow's is difficult in wider palates.More chances of a fistula.
8.To avoid junctional fistula- may have to change the incision around this area and make a wider nasal flap . A random thought here.
9.Less is more – stay safe and not be too ambitious. Sometimes the cleft surgeon is baffled by the patient's good speech even after a less than adequate technique.Reasons unknown. After years of experience as a palate surgeon, expect the surgeon to play on a plateau and not climb any higher.
10.Our aim in palatoplasty is to get a fistula rate of less than 1-2 % and also good speech. The bottom line then is " Looking good, speaking good". Acquired nasal resonance and nasal twangs noted in some normal people at the subway from Queens to Times Square and parts of Central London.. Overall VPI rate of 10-12% should be reasonable. Better speech in Veau 1,2 and less in 3,4. Latecomers are sure to have worse speech,over 70 % VPI in some over 2 yrs of age. The challenge remains....
Yes indeed, Mulliken is worth listening to even if some leaders may prefer other treatment options.However when I listen to Mulliken it does seem to make sense to do what he does because he has years of solid evidence to back his methods.
I personally am on the same wavelength as Mulliken when it comes to primary lip and palate methods since we both use very similar techniques which really surprised him! He told his wife and friends," I do not believe it..here is this guy from the Yemen(boondocks!) who knows what i know and does what i do...ha ha ha:-) so he asked me to visit again since he does not think of retiring.
As for muscle retro positioning for both primary and secondary palates, I personally think that this is the way forward.I mentioned earlier to the TF that "what is a good solver is also a good starter" .That is why i use the muscle repositioning methods for the primary and re ops. Some do not agree with us but we think this is the right direction for cleft palate surgery.
In Yemen, i generally prefer a relatively bloodless technique developed here over the years using modified saline hydrodissection. In saline hydrodissection using 1: 500,000 saline adrenaline ( 1 mg adr in 500 ml saline) there is a great advantage because not only is the heart rate ok,but the tumescent method makes dissection a lot easier and bloodless..about 10 ml of less blood loss in soft palates.
This technique was used ealier in 1997 by the Haifa team in Israel,and the results were fairly consistent at 15 month follow up periods.*
*Intra op expansion of the palate by the tumescent technique Issac Peled, PRS vol 100:1 p 100 -102 July 1997
How do we limit palatal fistulae at the junction? One of the ideas is to use dermal cellular matrix - Limiting postoperative fistulae Joseph E Losec,PRS vol122:2 ,p 544 Univ Pittsburgh Aug 2008
one of my suggestions in this discussion is to make a slightly wider nasal incision around this area and a generous lateral release so that there is no tension;an easy technique
Palatoplasties performed by high volume surgeons using proper techniques will result in better outcomes..one of the reasons why Brian and Mulliken have good outcomes after years of using the same standardized and time tested techniques. **
**The Effect of surgeon experience on VP functional outcomes for palatoplasty Peter Dewitt,J Marsh St Louis PRS vol 102:5 ,p 1375-1384 Oct 1998
Why go for levator repositioning as a preferred choice in primary palatoplasty? I personally think this is a more anatomically correct option since the Furlows distorts anatomy;in ST Lee's paper on the Anatomical basis of cleft palate and VP surgery PRS vol 101:3 p 613 March 1998 he mentions " the levator fibres occupy 50% of the velum and act as the prime movers in the components of velar closure". Makes sense to restore this anatomy and not distort the muscle arrangement.Opinions will vary on this and we can discuss it further without any problems.