Gaurav Deshpande

Early complications after cleft palate repair: a multivariate statistical analysis of 709 patients.

Abstract This study presents a large consecutive institutional experience with primary cleft palate repairs. The purpose of this study was to determine the incidence of early complications after cleft palate surgery in a series of nonsyndromic children treated at the authors’ comprehensive cleft center. This retrospective analysis includes 709 consecutive patients with cleft palate treated by 6 different staff surgeons at Guwahati Comprehensive Cleft Care Center between April 2011 and December 2012. Secondary cases were excluded from this study. The patients were initially followed up between 1 week and 1 month after surgery. The overall incidence of early complications was determined, and the effect of the extent of clefting, the type of repair, the age at repair, and the operating surgeon were analyzed. Early complications in this study include dehiscence of the wound, fistula formation, hanging palate, and total or partial flap necrosis. There was a 2.4% rate (17/709) of take-back to the operating room in the immediate postoperative period for control of bleeding, although no blood transfusions were required. The incidence of postoperative fistulas in this series was 3.9% (20/512). There was a statistically significant increase in the incidence of cleft palatal fistula for Veau IV clefts, but there were no significant differences with respect to operating surgeon, patient sex, patient age, and type of palatoplasty. The complication and fistula rate is consistent with other published reports from developed countries and provides evidence for the value of this model for surgical delivery in the developing world.

Scalable, Sustainable Cost-effective Surgical Care: A Model for Safety and Quality in the Developing World, Part Iii

Background The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. Methods The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011–November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. Results During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. Conclusion The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment.

Background With an estimated backlog of 4,000,000 patients worldwide, cleft lip and cleft palate remain a stark example of the global burden of surgical disease. The need for a new paradigm in global surgery has been increasingly recognized by governments, funding agencies, and professionals to exponentially expand care while emphasizing safety and quality. This three-part article examines the evolution of the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) as an innovative model for sustainable cleft care in the developing world. Methods The GCCCC is the result of a unique public-private partnership between government, charity, and private enterprise. In 2009, Operation Smile, the Government of Assam, the National Rural Health Mission, and the Tata Group joined together to work towards the common goal of creating a center of excellence in cleft care for the region. Results This partnership combined expertise in medical care and training, organizational structure and management, local health care infrastructure, and finance. A state-of-the-art surgical facility was constructed in Guwahati, Assam which includes a modern integrated operating suite with an open layout, advanced surgical equipment, sophisticated anesthesia and monitoring capabilities, central medical gases, and sterilization facilities. Conclusion The combination of established leaders and dreamers from different arenas combined to create a synergy of ambitions, resources, and compassion that became the backbone of success in Guwahati.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care.

Background The Guwahati Comprehensive Cleft Care Center (GCCCC) is committed to free medical and surgical care to patients afflicted with facial deformities in Assam, India. A needs-based approach was utilized to assemble numerous teams, processes of care, and systems aimed at providing world-class care to the most needy of patients, and to assist them with breaking through the barriers that prohibit them from obtaining services. Methods A team of international professionals from various disciplines served in Guwahati full time to implement and oversee patient care and training of local counterparts. Recruitment of local professionals in all disciplines began early in the scheme of the program and led to gradual expansion of all medical teams. Emphasis was placed on achieving optimal outcome for each patient treated, as opposed to treating the maximum number of patients. Results The center is open year round to offer full-time services and follow-up care. Along with surgery, GCCCC provides speech therapy, child life counseling, dental care, otolaryngology, orthodontics, and nutrition services for the cleft patients under one roof. Local medical providers participated in a model of graded responsibility commiserate with individualized skill and progress, and gradually assumed all leadership positions and now account for 92% of the workforce. Institutional infrastructure improvements positioned and empowered teams of skilled local providers while implementing systemized perioperative processes. Conclusion This needs-based approach to program development in Guwahati was successful in optimization of quality and safety in all clinical divisions

Surgical education through video broadcasting.

Abstract Surgical training is facing new obstacles. As advancements in medicine are made, surgeons are expected to know more and to be able to perform more procedures. In the western world, increasing restrictions on residency work hours are adding a new hurdle to surgical training. In low-resource settings, a low attending-to-resident ratio results in limited operative experience for residents. Advances in telemedicine may offer new methods for surgical training. In this article, the authors share their unique experience using live video broadcasting of surgery for educational purposes at a comprehensive cleft care center in Guwahati, India.

Longitudinal treatment of cleft lip and palate in developing countries: dentistry as part of a multidisciplinary endeavor.

Abstract Cleft lip and palate affects roughly 1 in 600 children and predisposes patients to a lifetime of functional and esthetic discrepancies. Disparities in access as well as quality of care exist worldwide, with many children in developing countries unable to receive treatment. In the late 20th century, humanitarian medical missions emerged as a means of delivering surgical expertise to patients in resource-limited settings. These early missions took on a patient-centered approach focused solely on cleft repair, with little emphasis on treating the dental abnormalities that arose after the initial surgery. However, modern cleft care is characterized by a multidisciplinary, team-based approach with significant dental involvement. Recent cleft lip and palate endeavors have shifted from a mission-based approach to a developmental approach facilitating growth of an independent care center. This strategy focuses on creating an institution with expanded access to dental services, thus facilitating the long-term treatment inherent in modern cleft care. One clinic in a developing country that has experienced successful transitioning from a mission site to an independent craniofacial clinic is Operation Smiles Cleft Comprehensive Care Clinic in Guwahati, India. This article will summarize the rationale and planning of the clinic, underscore the team-based approach required in longitudinal treatment of cleft lip and palate, and demonstrate how treatment methodology may differ in resource-limited settings by outlining the therapeutic considerations of each provider in the Guwahati Clinic.

The efficacy of vomer flap for closure of hard palate during primary lip repair.

BACKGROUND AND AIM This study presents the institutional experience of the use of vomer flap for early closure of hard palate during unilateral complete cleft-lip repair. The purpose of this study was to determine the survival rate of the vomer flap and to investigate its effect on the subsequent palatoplasty. PATIENTS AND METHODS This retrospective analysis includes 101 non-syndromic patients with complete unilateral cleft lip who received a vomer flap for the closure of the hard palate during cleft-lip repair. Patients were aged 6 months to 28 years (median 1 year). Success rates of the vomer flaps were assessed clinically and through pre-operative photographs taken at the time of subsequent palate repair. Ninety-two patients returned for second-stage palate repair, and 74 patients with adequate post-operative follow-up information were statistically analysed. RESULTS Of the 101 patients who were operated with primary lip repair and simultaneous vomer flap, only 54 (52.4%) vomer flaps healed completely. Out of 92 patients who returned for subsequent palatoplasty, 71 (77.2%) were operated with the two-flap technique, and 19 (20.7%) received von Langenbeck repairs. Seven (9.1%) patients had a surgical complication. The failure of previous vomer repair and von Langenbeck surgical technique were identified as factors associated with post-operative complications. CONCLUSIONS We conclude that failed vomer flaps increased the risks of complications in the subsequent palate repair. Furthermore, efforts to use von Langenbeck technique rather than the two-flap technique also resulted in increased surgical complications. As a result, we have abandoned the use of the vomer flap with primary lip repair.

Gingival enlargement in partial hemifacial hyperplasia

Hemifacial hypertrophy is a rare developmental disorder, characterized by unilateral enlargement of facial tissues. The hemifacial hyperplasia is classified as true hemifacial hypertrophy and partial hemifacial hypertrophy. It is unilateral enlargement of viscerocranial condition in which not all structures are enlarged. We present a rare case of gingival enlargement in partial hemifacial hyperplasia highlighting the clinical and radiological findings with the corrective treatment offered for gingival enlargement.

Improved Early Cleft Lip and Palate Complications at a Surgery Specialty Center in the Developing World

Objective: To evaluate complication rates following cleft lip and cleft palate repairs during the transition from mission-based care to center-based care in a developing region. Patients and Design: We performed a retrospective review of 3419 patients who underwent cleft lip repair and 1728 patients who underwent cleft palate repair in Guwahati, India between December 2010 and February 2014. Of those who underwent cleft lip repair, 654 were treated during a surgical mission and 2765 were treated at a permanent center. Of those who underwent cleft palate repair, 236 were treated during a surgical mission and 1491 were treated at a permanent center. Setting: Two large surgical missions to Guwahati, India, and the Guwahati Comprehensive Cleft Care Center (GCCCC) in Assam, India. Main Outcome Measure: Overall complication rates following cleft lip and cleft palate repair. Results: Overall complication rates following cleft lip repair were 13.2% for the first mission, 6.7% for the second mission, and 4.0% at GCCCC. Overall complication rates following cleft palate repair were 28.0% for the first mission, 30.0% for the second mission, and 15.8% at GCCCC. Complication rates following cleft palate repair by the subset of surgeons permanently based at GCCCC (7.2%) were lower than visiting surgeons (P < .05). Conclusions: Our findings support the notion that transitioning from a mission-based model to a permanent facility-based model of cleft care delivery in the developing world can lead to decreased complication rates.

Management of lateral lip element in rotation advancement technique for cleft lip repair: Tips and tricks

A new era in cleft lip repair began when Dr. Ralph D Millard introduced his technique of rotation and advancement. In 1987, Mohler described a variation of Millards unilateral repair that included a columellar extension. In 2005, Fisher introduced the principle of anatomic subunit closure. These techniques can work very well across the spectrum of unilateral clefts of the lip, though challenges arise with wide clefts and those where there is a large discrepancy between the greater lip height and lesser lip height. In cases when the discrepancy is high, the surgeon often tries to gain the necessary lip height on the cleft side by shifting the Noordhoffs point more laterally, sacrificing excessive tissue. This often results in a lateral lip that is hypoplastic, giving an unnatural look to the repaired upper lip. Focus has traditionally been on getting the necessary lip height, sacrificing fullness of the lateral lip element. This paper describes several strategies to optimally manage the lateral lip element in rotation-advancement technique for unilateral cleft lip repair. The results with this technique are encouraging and can be utilized to offset the drawbacks of rotation-advancement technique in very wide and short cleft lips.