Guidelines
Guidelines Summary
Treatment for patients who are born with facial clefts is ideally accomplished through an interdisciplinary staff of professionals at a dedicated cleft/craniofacial center. The American Cleft Palate-Craniofacial Association has provided guidelines for such teams to help ensure the coordination and consistent administration of care, with evaluations and treatments properly sequenced in view of a patient’s developmental, medical, and psychological needs. Those guidelines are as follows [25] :
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A designated patient coordinator on the team should facilitate its function and efficiency, as well as the coordination of care and treatment-plan assistance for patients and families/caregivers
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The minimum core of the team must include speech-language pathology, surgery, and orthodontics professionals
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The team must have access to psychology, social work, audiology, genetics, general and pediatric dentistry, otolaryngology, and pediatrics/primary care professionals
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A surgeon trained in transcranial cranio-maxillofacial surgery must be part of the team, which must also have access to a psychologist involved in neurodevelopmental and cognitive assessment; access for referral to a neurosurgeon, an ophthalmologist, a radiologist, and a geneticist is also necessary
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The team must provide the patient and family/caregiver with oral and written information about evaluation and treatment procedures
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The patient and family/caregiver should be encouraged by the team to participate in the treatment process
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Families/caregivers should receive team assistance in locating resources for financial help necessary to meet patient needs
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Team care must be sensitive and flexible with regard to linguistic, cultural, and ethnic diversity among patients and their families/caregivers
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The team must include or have available for referral social workers and psychologists who can see to the psychological and social needs of the patient and family/caregiver
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The team must have a cognitive development evaluation mechanism
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When necessary, cognitive psychometric testing must be administered to patients aged 4 or older whose craniofacial condition requires transcranial surgery
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The team should self-assess its performance and make improvements accordingly
Media Gallery
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Figure illustrates important anatomic landmarks used in all cleft lip repairs. Measurements of various distances are used to guide the surgeon in creating a symmetric lip.
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The Rose-Thompson repair involves curved or angled paring of the cleft margins to lengthen the lip as a straight-line closure.
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Hagedorn-LeMesurier repair. The medial lip element is lengthened by introducing a quadrilateral flap developed from the lateral lip element.
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Tennison-Randall repair. The medial lip element is lengthened by introducing a triangular flap from the inferior portion of the lateral lip element.
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Skoog repair. The medial lip element is lengthened by introducing two small triangular flaps developed from the lateral lip element.
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Millard repair. The medial lip element [R] is rotated inferiorly and the lateral lip element [A] is advanced into the resulting upper lip defect. The columellar flap [C] is then used to create the nasal sill (see text for details).
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Millard repair. Two of the most common variations described with utilization of the C Flap to correct the hemi-columellar deficiency (Millard II] and the nasal sill alar base region [Millard I]
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Millard repair. With maximal rotation of the R flap, any residual lip length discrepancy can be corrected with an inferior Z-plasty or a triangular flap. In a secondary correction, further rotation of the R flap can be considered.
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Millard modification of Kernahan striped-Y classification for cleft lip and palate. The small circle indicates the incisive foramen; the triangles indicate the nasal tip and nasal floor.
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