The importance of an experienced team in the cleft lift/palate treatment

Prof. Dr. Hakan Ağır: The importance of an experienced team in the cleft lift/palate treatment

“If you are not doing these surgeries quite often, you shouldn't be touching the patient”. These are the words of a world-renowned plastic and reconstructive surgeon specialized in cleft surgery, Professor Hakan Ağır, an ACIBADEM expert, also known as the man of impossible medical cases. He has operated and treated hundreds of children with cleft lift/palate, he sees very often babies affected by badly performed surgeries and he knows very well the consequences for these patients. Any parent who faces the challenges of this diagnosis with his child should carefully read the following material.

Professor Ağır, you often say that the parents should chose very cautiously the team and the center when they decide their baby's treatment for cleft lift/palate. Can you define “a skilled trained surgeon” for this precise case?

Prof. Dr. Hakan Ağır: That means that after your plastic surgery training, or oro-maxillofacial training, you should have a post-graduate training of at least one, preferably two years, and when you come back from your training, you must be working in a unit which does these surgeries quite often and observes these kids. Americans say that, as a standard, a cleft surgeon must see 20 cases per year at least. 20 new cases. If you do this surgery once a year or twice a year, don't do that. For example, in the United Kingdom, after many surveys and studies, their national health system, NHS, made a big protocol and examined all the results, and now allows only 11 centers to do this kind of surgeries. No one else can, they don’t have an acreditation for it. Also, in the United States, most of the patients prefer to go to cranio-facial centers or cleft centers. This is how it works. This is a specific area, this is a team work, this is not only a plastic surgeon job, you must have a very good orthodontist, you must have a good speech therapist, a pediatrician, a good pediatric anesthetist, a good hospital, a great genetics department, they all play their roles during the protocol. It's not only about the surgery. Here at ACIBADEM I have a great team and in Turkey there are, I think, 20 or 25 big centers, with skilled surgeons, doing these operations quite often.

What are the risks of being operated, treated, by an unexperienced team? What can go wrong?

Prof. Dr. Hakan Ağır: This surgery, let’s put it very simplistically, has 2 main characters. One of them is the anesthetist. And we need an anesthetist with experience in the pediatric field because if the anesthetist is not good, skilled, then he may kill the child. Then we have the surgeon: if the planning is not good, the performance is not good, the materials and the instruments used are not of the highest standard, if the skills are not high enough to perform this very delicate surgery, the end result will be affected in 2 ways: one is the shape, the form, the cosmetical aspect - the child will have a bad look, bad scars, bad looks of the nose and of the upper lip. This is a stigma, we call it, a bad stigma. And then, the second thing, we may have worse problems – a lifetime affected speech. The speech outcome after a badly performed surgery is very low, the intelligibility of the speech of the kid is significantly low compared to the results obtained by a skilled surgeon. There's a 30-40% difference, it's a huge difference. The cosmetical appearance, in a way, you can correct it, but for the speech… It’s our way of communication, the child will be affected for life.

Can you undo the damage? With a second, third operation…

Prof. Dr. Hakan Ağır: If the surgery is performed in a bad way, to correct it afterwards is very difficult. Because the first surgeon, the first operation, touched the first, original tissues. That was the virgin tissues. And it is the best and the easiest way and the only chance that you get a good result. It's just like, you know, fastening up the first button of your shirt. If it goes wrong, then all the way it goes wrong. And to correct it, you'll need multiple operations, even in good hands of a surgeon. I do this, I try to correct the badly performed operations and I can hardly get the same results they are operated originally because there are scar tissues, fibroses, scatris we call it. For example, if the clef palate is operated in a bad way, there are big holes, there will be falling apart, breaking down of the fistulas, as we call it, fistula, a hole in the palate that will require another operation. And another operation will be difficult and the risk of having another hole after that operation is very high, like 50-60%. You lose your chance, you use the original tissues that you can close the palate with. So, it's very important, there are two operations very very important: the first two surgeries, the ones done in the first year of life. I am very serious when I say this: If you're not familiar with the surgery, if you are not trained and if you are not experienced and if you are not doing these surgeries quite often, you shouldn't be touching the child. It's not one of these things like riding a bicycle, you know, you never forget it, right, after two years you can ride a bicycle again. It's not like that. You must be doing it every week. So, you keep your hands fresh, like a soccer player, all these practice sessions and then the weekend match. You know, these badly performed operations are also an economical burden, besides the psychological, social burden. Because, when the surgery is done by unskilled people, these kids need having 3 or 4 or 5 operations more. This means 5 or 6 or maybe 10 more admissions to hospital, more money spent by the government. So, at the end of the process, basically, when the patient is 20 years old and the surgeries come to an end, the money spent for this child will be double, maybe triple in the bad centers, in the bad hands. This is what they have actually recognized in the national healthcare system in the UK. Not on the behalf of the cleft surgeons, but on the behalf of the government because they lose the money on badly performed surgeries under insurance cover. That's another reason why these operations should be done by skilled surgeons.

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