Dr. Susan Downey, plastic surgeon: cleft palate surgery in third world countries

Notes from NSSLHA meeting, 10/6/08

Reconstructive surgery means to restore to the normal form or function (vs. cosmetic surgery). If the lip and/or palate doesn’t fuse, then form and function need to be restored.

Dr. Downey has been on 13 missions to different countries, but most recently she’s been focusing on Ecuador. Organizations she’s been with include Healing the Children, Interplast, and Operation Smile. The ultimate goal is to train people in other nations, and to go as teachers and educators. The type of palate repair surgery developed at CHLA is innovative and is not taught in other parts of the world. The advantage to this is that the muscles are repositioned and the palate is lengthened, which might result in little to no need for speech therapy following surgery.

Cleft lip/plate are among the most common birth defects worldwide, and are increased in areas with poor nutrition- especially folic acid. They affect an estimated 1 in 600 newborns. In some cases, there may be genetic components from smaller mating pools.

The goal is to operate on children or adults at any age. As long as children can eat appropriately, the need is not as urgent as with other surgeries. Palate repair in the US is ideally done at 1 year of age.

The team: nurses, anesthesia, plastic surgeons, medical records/coordinator, dentists, speech therapists, youth from a high school volunteer program, and med students.

Once in-country, Operation Smile does a screening of children. People find out about it through radios, churches, and non-profit organizations in the area. Because there is no back-up if things go wrong, they have to be careful not to operate on people with complicating medical conditions. Then they organize the charts to think about how they’re going to do the schedule of surgery. Because adults wake up slower from anesthesia, they have surgeries first in the day.

The airway is suddenly changed after surgery, so a “tongue stitch” can help bring the tongue forward and children are also placed on their side to help them breathe after surgery.

Operation on a cleft lip may take 45 minutes, whereas palate repair will take about 2 hours.

Some people walk for days and take the bus for hours afterward, in order to come for surgery. Often the father, then, is the one to accompany the child.

In surgery, they work closely with local doctors and anesthesiologists so that they can take over after the team leaves. Unfortunately, they don’t often get long-term follow-up, which is a problem for SLP’s—whose role is most effective when they do education with local professionals.

Operation Smile has training programs in the US also, to bring professionals for training. Occasionally children are also brought to the US for surgery. They often partner a lot with local organizations (e.g., Rotary Clubs, Mormon missionaries) overseas, and people in the community help with translation.

To find out about volunteer opportunities on these trips, consult the Operation Smile website or ask to accompany a speech therapist who has contacts in the community. The best way to get in is to be totally flexible in terms of time and say “call me if you have an opening”. If you speak another language, this increases the likelihood that they will need you. Some countries have stipulations on whether (or how) students can have a role on a team. Most trips last 1-2 weeks, with the first week for screening and the second week for operations.