Melanie Cole (Host): If your child needs surgery to fix a deformity caused by a birth defect, injury, illness or tumor, a pediatric plastic surgeon has the experience and qualifications to treat your child. Cleft lip and palate is a congenital deformity that occurs in nearly one out of 600 births in the United States and causes a multitude of problems and represents a special challenge to the medical community. Here to discuss plastic surgery in children, cleft lip and palate, and what to look for when searching for a pediatric plastic surgeon for your child is Dr. Julia Corcoran. She's a recognized pediatric plastic surgeon with Shriners Hospital for Children-Chicago. Welcome to the show. What kind of training typically do pediatric plastic surgeons here?
Dr. Julia Corcoran, MHPE (Guest): It’s a pretty extensive training. People have at least six years of basic plastic surgery training after medical school and college, and then do further fellowship studies of about one to two years specifically in pediatric plastic surgery. It’s eight years of training or so after medical school.
Melanie: What type of treatments so pediatric plastic surgeons provide? What's the scope of your practice?
Dr. Corcoran: The scope of the practice includes trauma, so patients who've had accidents and patients who have differences from birth, including things like cleft lip and palate, but also birthmarks or vascular tumors or missing parts, deformed parts or extras parts that need revisions. Some of those things might include reshaping ears, reshaping noses, reshaping hands, and then as the children grow, it includes things that are acquired. Sometimes, breast surgeons for overly large breasts in either boys or girls or asymmetric breasts in girls.
Melanie: When a parent is looking for a pediatric plastic surgeon, what should they look for or what questions would you like them to ask?
Dr. Corcoran: I think the first important thing is to make sure that your surgeon is a board-certified surgeon, and that would be the American Board of Plastic Surgery, leading your plastic surgery portion of care, and that the person on an individual basis is someone who can speak to both the parent and to the child since it's important that the child's assent is obtained as well as the parent's consent.
Melanie: Interesting. What a neat way to put. Let's talk about cleft lip and palate. How common is this and can you tell in utero if a fetus will have a cleft palate?
Dr. Corcoran: Cleft lip and palate is a pretty common occurrence as you said somewhere between one in 600 to one in 700 births in the United States. Cleft lip can come by itself or it can come with cleft palate, and also cleft palate can come by itself. If there is a cleft lip involved, often times the mid-second trimester ultrasound done by OBs in their office will detect it. If it's only a cleft of the palate, that usually can't be found until birth.
Melanie: What are complications if it’s left untreated? Is it really difficult for children to eat and drink with a cleft palate?
Dr. Corcoran: The job of the palate has four functions. The first and most obvious is to separate the nose from the mouth, which would essentially keep the boogers in the nose and the food in the mouth. The second part of that is that it allows us to create suctions. Feeding off of a breast or a bottle or a straw is something we do with our palate. Initially, this child will require specialized bottles to learn how to feed and eat, but once that’s done, they learn how to do it and the parents learn how to use them. They should feed and grow like anyone else. The next thing the palate does is it helps us pop our ears so that we don’t get that full ear feeling. The most important thing that our palate does is it helps us speak. All those sounds you can think of making spitting sounds – the pa’s, the ta’s, ca’s and da’s – are made by the palate closing off our throat from our nose. All of the sounds that you can think of as nasal from ma’s and na’s coming through our palate being open and allowing the air to flow through our nose. Somebody who couldn’t close their palate would be able to order lemonade and nachos, but wouldn’t be able to order hot dogs, popcorn, caramel or coca cola if they went to a baseball game.
Melanie: When would be the right time to consider surgery? Is it something that you consider right away after birth or do you wait for some of the facial structures to fully grow? Tell us a little bit about the timing.
Dr. Corcoran: It’s really a journey of facial development. Often times, we start at about three to four months of age, depending on how healthy the child is otherwise, to do the initial repair of the lip and the nose. Somewhere between 9 to 12 months of age, we would repair the actual palate. That allows the palate to be ready for speech, which really starts developing in words at about 12 to 15 months. The gum line gets repaired as the adult teeth start coming in, so somewhere between six to eight years or six to nine years of age. Ultimately, the final facial setting of the nose to whatever face grows happens in the early to mid-teenage years, early for girls than it is for boys. The bottom is that the surgery is done based on the timing of facial development, which is what is unique about pediatric surgery compared to adult surgery; we are operating over time with development.
Melanie: Who’s involved in the surgical process? Since it can take so many years, what type of specialists should be involved in treating a child with cleft lip and palate?
Dr. Corcoran: One of the things about cleft lip and palate is you need more than just a plastic surgeon; you need a whole team of people to support your family, to support the child and to support the plastic surgeon. A good team will include first and foremost a speech pathologist to help work with the feeding and the speech. It’ll include an audiologist to make sure that the hearing is good and adequate for speech development. It’ll include nursing staff to help support the family through times of surgery. It’ll include social workers to help with all of the needs through insurance and for finding care providers in your own community. It'll include a psychologist to help both the family figure out how to support their child and how the child can support themselves as they grow older. As far as physicians go, it'll include an orthodontist who’s a specialized dentist, it'll include a pediatric dentist, it'll include an ear, nose and throat surgeon and it'll include finally the plastic surgeon.
Melanie: With all of these specialists involved, it can be quite traumatic for the child. What is life like for the child during what may be a long series of surgeries? As you mentioned, there are counselors involved and speech therapist and all kinds of things going on for this child, but they're still just a child in school. What is life like and what do you tell parents and children about going through this process?
Dr. Corcoran: I think that's probably the scariest thing for a family to consider a lifetime of serial surgery, but I think the best thing to understand about these particular surgeries while they're important and they're real surgeries, they tend to be episodic care. That is to say, most of them are outpatient surgeries where you might come in for a day or maybe a single night and, because they can be timed around a family schedule, can be set up to be minimally disruptive to school and to growing up. One of the most important things about looking at the development of the child is not just the physical development, but the emotional and social development. The great art of any sort of pediatric care is to time things appropriately.
Melanie: Speaking of that great art, and I would imagine you are an artist, you are redesigning these children’s faces for that self-esteem and also for physiological reasons, what is your optimal result?
Dr. Corcoran: The optimal result is to have a patient who can communicate their thoughts and ideas without somebody looking at them and trying to figure out why they're different. I like to think of cleft lip and palate as a communications disorder, and so the optimal result for the face, lip and nose to have them all fit together so people are looking at the eyes of the person and listening to the words coming out – the words need to be clear and forceful and full of their own thoughts, building up that confidence that they have their message that they can see it the way they want to and their appearance is an appearance that doesn’t create secondary questions.
Melanie: What a beautiful sentiment. We certainly applaud all the great work that you're doing. Is there currently any research being done regarding cleft lip and palate that you can speak of?
Dr. Corcoran: At the Shriners Hospital in Chicago, a great deal of our research is about the bone biology and imaging of craniofacial and cleft defects and finding out what we can do to do better surgeries by planning them with very sophisticated radiographic and computer-aided techniques.
Melanie: Thank you so much. Wrap it up with your best advice what you would like parents and their children to know if they do have to go through this series of procedures, what you want them to know about cleft lip and palate, and Shriners Hospital for Children-Chicago.
Dr. Corcoran: I think that when one finds their home, their cleft palate team home, it’s a group of people that you feel that will support you and communicate with you and provide the best solution to your needs. For the most part, I think that is a feeling of being home, and when one finds that feeling of being in your cleft home in your heart or soul or stomach, wherever you feel it, that’s probably the best place to be.
Melanie: Thank you so much for being with us today. It’s really great information. This is Pediatric Specialty Care Spotlight with Shriners Hospital for Children-Chicago. For more information, please visit shrinerschicago.org. That’s shrinerschicago.org. This is Melanie Cole. Thanks so much for listening.
