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Multidisciplinary Care for Children with Cleft Lips and Palates: The Vermont Approach

“Oh, are you a plastic surgeon?”

I have to admit that I sometimes cringe just a little when I hear this question – because usually that will be followed by a complaint of how the speaker doesn’t like their love-handles, a bump on their nose, or some other body part. What I would like people to know is that plastic surgeons do so much more than the nip or tuck to make people who look normal look better. Plastic surgeons also do facial trauma repair, reconstruction after cancer excision, wound management, and hand surgery. My favorite surgery is cleft lip and palate surgery, because it is a chance to make someone who looks markedly abnormal look normal.

Clefts of lips and palates are common birth defects, affecting about one in 600 infants born in the United States. Our upper lip is formed from three parts that fuse at about eight weeks after conception; that’s why we have two lines in our upper lip (the philtrum), those are the seams where those three parts came together. If one or both fusion doesn’t happen, a cleft lip is the result.

With the right intervention, these children can lead normal lives. Because clefts affect all of the functions of the mouth: social interaction, speech, eating, it takes more than one surgery to fix the problem. A multidisciplinary team is the standard of care recommended by the American Cleft Palate – Craniofacial Association (ACP-CFA): These multidisciplinary clinics follow patients through their childhood.

We have an excellent multidisciplinary team in Vermont, run through the Children with Special Health Needs clinics of the State of Vermont: This clinic is an ACP-CFA affiliated clinic. Clinic members include a plastic surgeon (myself), a geneticist, a speech and language pathologist, an oral surgeon, an orthodontist, a pediatric otolaryngologist, an audiologist, nurses, and social workers.

We are lucky in Vermont, as we have a statute that mandates insurance coverage for children with clefts or craniofacial differences. In other states, much of the clinic team’s activity is supported by fundraising – and that can make it difficult for children who have been denied insurance coverage to get the care they need.

I think that our clinic has a uniquely Vermont feel; we meet as a group, and we include the child and family in our planning discussions. We surveyed our families to find out what they thought about this approach, and an overwhelming majority of families said they preferred the team approach, as well as the opportunity to be a participant in decision-making. They also said that the approach often saved them from time involved in traveling and waiting for multiple evaluations. I have been so impressed with this style of team interaction that I gave a presentation to the ACP-CFA about the Vermont cleft team format.