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Inside Cleft Lip & Palate Repair: A Surgeon’s Post-Op Debrief · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:02
  Today, we're joined by Dr. Richard Thompson, Pediatric Plastic Surgeon at UT Health San Antonio.
• 0:08
  Immediately after, he completed left lip and palate surgery on a baby here at University Hospital.
• 0:15
  We did a debrief. So as a team, where we just like discuss everything that went
• 0:21
  well, everything that went better, just reflect on, you know,
• 0:25
  in the case and could do some safety checks.
• 0:28
  Dr. Thompson, it must be so fulfilling.
• 0:31
  After doing a surgery like this, it changes a baby's life for the better.
• 0:35
  Yeah, 100%. I mean, it's life-changing surgery.
• 0:38
  Very common. So one in 700 babies who are born will have a cleft lip or palate.
• 0:44
  It's such an honor to be here and to give us an inside peek.
• 0:48
  A lot of our listeners, they refer a patient for cleft palate surgery, plastic surgery.
• 0:54
  But here you can walk us through a bit what happens actually.
• 0:59
  For example, just now in this surgery on this baby, can you walk us through?
• 1:04
  Yeah, of course. So babies can be born with either a cleft lip,
• 1:08
  a cleft lip and a cleft palate, or just nice a cleft palate.
• 1:12
  This baby we just operated on was born with a bilateral cleft lip. So that means that.
• 1:20
  The middle part of the lip is not connected to the parts of the lip at the side.
• 1:25
  And that goes all the way through to the roof of the mouth as a cleft palate.
• 1:29
  So it's a staged operation so we do the cleft lip operation first and around three months of age
• 1:36
  and in some cases for a bilateral cleft if it's a particularly wide cleft lip
• 1:40
  we may do an intermittent stage where we get the muscles halfway across but
• 1:46
  not quite meeting it's called a lip adhesion and then come back,
• 1:50
  three months later and do the completion so that's what happens this baby.
• 1:54
  Usually three months after the lip surgery, I try and repair the palate.
• 1:59
  So I try and repair the palate quite early, about six months of age,
• 2:04
  which some people may think, whoa, that's so early to do a palate repair.
• 2:07
  But actually what we're aiming to do is try and get everything repaired before
• 2:12
  the baby starts speaking.
• 2:14
  So we know from evidence in the literature and big kind of nationwide kind of
• 2:20
  cohort studies and things like that, we know that,
• 2:24
  if we can repair the palate before the baby starts speaking,
• 2:28
  that's better in the long term for speech and maybe less need for speech therapy.
• 2:34
  So the palate is very important for speech.
• 2:38
  Sounds like Bs and Ts and Ds all need you to generate pressure within your mouth,
• 2:44
  in order to say those sounds.
• 2:46
  And if you have a cleft palate, the air, instead of the pressure coming out
• 2:50
  of the mouth, the air can escape through the nose.
• 2:53
  And that can make understanding somebody's speech really, really difficult.
• 2:57
  So the idea is to put the palate together and crucially the muscles of the palate
• 3:02
  which lift the soft palate up and down to allow the throat to close to the mouth
• 3:09
  and allow allow that pressure to generate,
• 3:12
  so the idea hopefully after we've repaired this palate is everything heals and
• 3:17
  the baby does well initially feeding,
• 3:20
  you know straight away afterwards and recovering well and then afterwards,
• 3:25
  you know, really allowing him to develop his own speech and then if there's
• 3:29
  any concerns at all, just getting into speech therapy very early. So what.
• 3:35
  With regards to sending to plastic surgery, referring to plastic surgery,
• 3:39
  what advice do you have for our pediatrician listeners? Yeah,
• 3:43
  so the biggest advice I could give is cleft care is done as part of a multidisciplinary team.
• 3:49
  So there's lots of different factors within cleft care, and the surgeons are just one part.
• 3:57
  So the cleft lip and palate taking is the best manager in a multidisciplinary
• 4:01
  team, which we do have here at University Hospital. We've got the full,
• 4:06
  comprehensive cleft care.
• 4:08
  So the surgeons, we've got speech therapy, orthodontists, cleft coordinator,
• 4:14
  cleft nurses, and we've got pediatricians, ENT doctors, oral,
• 4:20
  maxillary, facial surgeons.
• 4:21
  And all of those members of the team will play a very important role at different
• 4:26
  stages of the baby's journey.
• 4:28
  Is the first step as early as possible? send the baby, though,
• 4:32
  to see plastic surgery for a consult?
• 4:34
  Yeah. So I think initially when the, so I guess there's two ways in which a,
• 4:40
  baby's diagnosed with a treflip and or pallet.
• 4:43
  The first would be antinatally. So it's detected on the scan in the, you know, 20-week scan.
• 4:50
  And that means that quite often I'm seeing parents or parents-to-be.
• 4:56
  Before the baby's born so we can go through what to expect and and the main
• 5:01
  emphasis on that is just meeting the parents kind of letting them know that
• 5:05
  there's a full team to support them
• 5:08
  and then initially trying to focus on feeding and ensuring that the baby is
• 5:13
  as well putting on weight nicely and so initially there's you know i try and
• 5:17
  avoid kind of any surgical surgical chat
• 5:20
  initially and just focus on you know just the wonder of having a baby for one
• 5:25
  and then secondly just you know emphasizing the feeding which is the most important
• 5:29
  thing initially for a pallet.
• 5:32
  There's also, you know, psychological support because, you know,
• 5:35
  it can be sometimes a bit of an unexpected diagnosis.
• 5:38
  So, you know, having supporting families with that is also important.
• 5:42
  And that's, you know, part of our role in the multidisciplinary team.
• 5:46
  Cleft lips are more easily identifiable on scans rather than the cleft palate.
• 5:52
  Unless the baby's opening their mouth, just it can be quite difficult to get that view, I think.
• 5:56
  So quite often, if it's a high-stage palate, it can sometimes be diagnosed afterwards.
• 6:01
  And sometimes, you know, for whatever reason, there hasn't been any imaging
• 6:05
  before and it's identified after birth.
• 6:08
  So both ways. Initially, we'll be contacted all pediatricians on the NICU.
• 6:14
  We'll contact the craniofacial team and one of us will come along and just introduce
• 6:18
  ourselves to the mother and just really support. The speech therapist will support
• 6:24
  them in their feeding initially.
• 6:26
  And then usually arrange a follow-up appointment with one of the surgeons in
• 6:32
  about six or eight weeks after birth.
• 6:35
  Richard, let's talk about timing. How do you determine the ideal timing for
• 6:38
  cleft lift and palate repair after the baby is born? Can you tell us a little
• 6:44
  bit more about that? Yeah.
• 6:45
  So this is, again, there's no right answer for this.
• 6:49
  There's lots of different protocols out there so which probably tells you that there's no.
• 6:55
  One right way but my personal view is to repair the cleft lip at about three months of age,
• 7:04
  because that's a stage at which you know that the baby's nice and healthy putting
• 7:08
  on weight doing well from a feeding perspective
• 7:11
  and they're a little bit more resilient than they are when they're first born
• 7:14
  and they're ever so slightly bigger, just makes it technically a little bit more feasible to get,
• 7:20
  good repair of the muscle and make sure that the nose is hopefully nice and lined up.
• 7:26
  So three months for a lip and then the palate, my personal view,
• 7:30
  and at the same time as the lip, I actually repair the very front part of the
• 7:34
  palate, which is called a vomer flap.
• 7:37
  And that's kind of almost in continuity with the floor of the nose.
• 7:40
  So it's kind of a nice kind of continuous closure, the kind of front of the
• 7:46
  mouth and then the floor of the nose, which is part of a cleft lip repair.
• 7:51
  And that means that over time I come to the palate repair three months later,
• 7:55
  that means that hopefully the floor of the, the front of the pallet's already healed.
• 8:00
  So it makes the second operation a little bit easier.
• 8:03
  How many operations typically happen? So there's primary surgery.
• 8:09
  So that's cleft, for a baby who has a cleft lip and pallet. So cleft lip repair,
• 8:15
  about three months. Cleft pallet, I was gonna say that I tend to do it three
• 8:19
  months. I think we talked about the importance of speech and doing it before speech.
• 8:25
  I think the evidence says that as long as you repair it within the first 12
• 8:29
  to 13 months, then that's kind of a good time really to repair your palate.
• 8:34
  And it gives us a lot of leeway, you know, because, you know,
• 8:38
  I would have to postpone surgery if a child had a cough or a cold or if they had a temperature.
• 8:44
  And that means that if I go through six months, it's the earliest opportunity.
• 8:49
  And if I need to postpone it, you know, there's still a lot of time to repair
• 8:54
  the palate without amount affecting speech.
• 8:57
  So for pediatric clinicians, why is repairing a cleft palate about so much more
• 9:02
  than closing and opening in the roof of the mouth?
• 9:05
  Can you tell me a little bit more about speech? Yeah, I mean,
• 9:08
  this is the most human thing, isn't it? It's just to interact with the world,
• 9:12
  you've got to be able to speak with your peers, your family.
• 9:17
  And without repairing the cleft palate, it makes speech very difficult to understand.
• 9:24
  And that automatically can really reduce some of these opportunities for education
• 9:30
  for relationships for for the whole of life you know even just
• 9:34
  picking up the phone ordering a pizza like you need to be able to be understood
• 9:38
  right so the the palette is you know actually.
• 9:43
  You know i hate to say i don't want to compare one to the other but the palette is so important because
• 9:48
  this is how you get speech and if the palette if the palette isn't functioning
• 9:53
  properly you know that can have lifelong implications which is why it's so important to get the
• 9:59
  primary repairs hopefully done as in a,
• 10:03
  proper team proper multidisciplinary team where you have the expertise of the
• 10:08
  speech therapists the expertise of the ent surgeons the audiologists and you
• 10:13
  know having a whole team to look after that because if,
• 10:16
  when you're born with a cleft palate,
• 10:19
  the tubes in the ear that equalize the pressure when you go up in a plane and
• 10:24
  your ears pop, that's the eustachian tube.
• 10:27
  And that doesn't work quite as well in somebody who's got a cleft palate because
• 10:32
  the muscles are slightly inserted into a slightly different orientation.
• 10:37
  So that means that you can have a buildup of the fluid behind the ear,
• 10:41
  something called glue ear, and that can need,
• 10:44
  either drainage through a little tube that goes in, tympanostomy tube,
• 10:49
  or hearing aids, which can also, you know, obviously increase the sound rather than,
• 10:54
  put the tube in.
• 10:56
  My youngest daughter had ear tube surgery twice and it helped a lot.
• 11:00
  ENT surgeries often do it kind of prophylactically at the time of palate surgery,
• 11:04
  just before the palate surgery usually, just in the same anaesthetic.
• 11:08
  And that allows, hopefully, the hearing to develop atypically.
• 11:14
  The one thing I will say is, you know, the children do have ongoing audiology,
• 11:19
  you know, for the first five years or so. Every six months, I think, the ENT doctors do that.
• 11:23
  So that's important because that obviously, if you can't hear what's being said,
• 11:27
  then that also has an implication for your speech.
• 11:30
  So getting all of those things, you know, sorted is important.
• 11:34
  And insurance companies, though, it sometimes could be considered cosmetic.
• 11:38
  I'd argue that it's definitely not a cosmetic procedure. Yeah,
• 11:43
  I'd say this is reconstructive surgery.
• 11:45
  This is restoring the form and function of something which is congenitally acquired.
• 11:52
  So this is a congenital surgery.
• 11:54
  Is it sometimes denied though and not covered by insurance?
• 11:58
  I think primary surgery is always pretty much covered.
• 12:01
  I think sometimes some patients have run into problems with some of the secondary
• 12:06
  surgeries that may come much, much later down the line if they.
• 12:12
  Desire to have a lip revision or a nose that they would like to be maybe a little
• 12:19
  bit more symmetrical or their breathing is sometimes affected,
• 12:23
  you know, the nasal breathing.
• 12:25
  So those can occasionally be denied by insurance companies.
• 12:30
  But, you know, that's usually not the case when you see somebody in a proper
• 12:35
  cleft MDT we can usually get those cases funded. I mean, there's no reason that
• 12:41
  they shouldn't be funded. Yeah.
• 12:43
  And for families without insurance, there's an amazing program called Fresh
• 12:46
  Start. Yes, yes. So Fresh Start is a brilliant organization,
• 12:51
  essentially fills a gap between people who,
• 12:55
  can and can't have insurance so things that may be deemed not covered by insurance
• 13:01
  fresh start can step in and do that funding for things that are deemed cosmetic as you said,
• 13:08
  in my opinion are technically not cosmetic but they we can we can cover those
• 13:12
  in fresh start yeah that's amazing and i know you volunteer your time and some
• 13:17
  other surgeons do here on the weekends when there's an,
• 13:20
  operating room that's available and the program covers travel for families.
• 13:24
  It just sounds incredible. It does. And I think it's a real safety net actually
• 13:28
  for children in Texas and also children internationally. You know,
• 13:33
  there's children who are covered internationally.
• 13:36
  There's programs in Costa Rica, in Mexico that work with Fresh Start.
• 13:41
  And are you still traveling to do clubhouse? I do, yeah. So I work with Austin
• 13:46
  Smiles, which is a brilliant tech charity.
• 13:49
  They also have some domestic role as well.
• 13:51
  They cover, they have support groups, which are very good. And they have early
• 13:55
  born, early starter packs with extra bottles and, you know, some kind of advice
• 14:03
  and information leaflets, things like that, which is excellent.
• 14:06
  But yes, they also, we also support local services. So with Austin Smiles,
• 14:12
  they work with the same teams over and over again. So it's not a fly in,
• 14:17
  fly out organization. It's very much kind of supporting local services.
• 14:21
  There's local orthodontists, for example, local speech therapists,
• 14:25
  and we support when asked, support their services. Yeah. That's awesome.
• 14:31
  Richard, how has cleft palate surgery evolved over the past decade and what
• 14:35
  techniques or technologies have most improved outcomes?
• 14:39
  So I'd say one of the most important factors would be collection of data actually.
• 14:46
  So this is looking at big longitudinal studies and that's, you,
• 14:51
  know, by collecting long-term data, there's some countries that have databases
• 14:55
  where every single child who's born with a cleft is actually followed up and
• 15:00
  that is kind of kept on going
• 15:03
  for their whole for their whole life up until 20 21 um so you get an opportunity
• 15:08
  to look at what what operations and what,
• 15:12
  therapies are most effective because quite often parents will ask me you know what's caused the cleft.
• 15:19
  Often it's a complete interplay between genetic causes so some clefts run in
• 15:25
  families, so genetic factors and also environmental factors.
• 15:30
  And we don't always know what those are, but we know that some things can predispose to cleft.
• 15:37
  So some medicines for epilepsy, anti-convulsant medications,
• 15:42
  and for some lifestyle factors that can also predispose to cleft.
• 15:46
  But often it's an isolated anomaly that there's no, we can't find a cause.
• 15:54
  Certain medications could cause it? So medications, it's mainly the anti-epileptic
• 15:58
  medications that are, phenytoin is classic.
• 16:02
  Also, there are lots of, there are lots of medications that interact, can interact.
• 16:07
  You know, it's too long to list. Yes. What does the journey look like from infancy
• 16:12
  through adolescence? What additional procedures or therapies might some children need?
• 16:16
  So I always think of it in terms of kind of getting onto a school bus, I guess.
• 16:21
  So there's lots of people on the bus and.
• 16:26
  That includes the patient, the baby, and their family.
• 16:30
  And the driver of the bus will change according to the age.
• 16:34
  So to start with, you'll have the speech therapist driving the bus,
• 16:39
  and they'll be doing the feeding and making sure they're putting on weight and all those things.
• 16:45
  And then the surgeon takes over and does the cleft lip and the cleft palate.
• 16:49
  And then they swap over, and then it's the speech therapist.
• 16:53
  So when they start speaking, they will be seeing speech pathologists.
• 16:57
  And then after they kind of get to an age around seven, they'll want to be looking
• 17:04
  at their dentition and doing x-rays to see how their teeth are forming,
• 17:09
  the adult teeth are forming.
• 17:10
  Because often if they've got a cleft in the alveolus in the gum,
• 17:14
  they'll need to have a bone graft put in.
• 17:18
  And that's usually between seven and 10 years old.
• 17:20
  And that's when the orthodontist starts driving the bus and also the surgeon.
• 17:24
  So we take bone from the hip usually and put that into the gap.
• 17:29
  So that can allow the adult teeth, usually the canine teeth,
• 17:35
  to come down and erupt into bone as opposed to just interrupting into thin air.
• 17:41
  And that will also allow, once that's set and it's got a tooth in there.
• 17:45
  That will allow the orthodontist to start moving teeth in order to try and make
• 17:51
  with teeth a bit straighter than they may be in somebody who was born with a
• 17:55
  cleft, lip, and or palate.
• 17:57
  So then after that, they go away. They're in the orthodontic chair for quite a while.
• 18:02
  And then they'll go out. They may see speech therapy still. And then they're
• 18:07
  moving into adulthood, really.
• 18:09
  And then once they're getting up to skeletal maturity, so 17, 18.
• 18:15
  If they need surgery on their jaw, occasionally some children who have a cleft
• 18:21
  lip or palate and or palate will have,
• 18:23
  maybe a slight growth restriction in the middle part of their face,
• 18:28
  which means that their teeth don't always meet in the correct occlusion.
• 18:33
  And occasionally that does need surgery to correct. So that's called orthognathic
• 18:37
  surgery and that's moving the jaws either forward or back.
• 18:40
  And that would be usually around 17, 18, 16, 17, 18 years of age.
• 18:45
  So that's, these kind of surgeries when you get later, they're very much kind of the.
• 18:51
  Child's choice, young adult's choice, whereas the primary surgeries,
• 18:56
  the parents will be making those choices for them.
• 18:58
  And I kind of strongly recommend all of those primary surgeries.
• 19:03
  And then the surgeries when you get a little bit older, tend to be up to the
• 19:09
  young adult, kind of older child, young adult.
• 19:12
  So yeah, then after the orthognathic surgery, if they want,
• 19:17
  a nose maybe that's slightly more symmetrical again you know i tend to not put
• 19:23
  any any kind of pressure on on the child to make that decision because that
• 19:27
  is a very personal choice and if they you know i'll usually,
• 19:31
  say what is available and what you know could could be you know done if,
• 19:37
  if if it was something that they were interested in and that would be a septorhinoplasty
• 19:43
  and that would be moving the nose into a straighter position and usually trying
• 19:48
  to match the two sides of the nose,
• 19:51
  and then after that maybe a lip revision if again,
• 19:56
  if that was something that they were interested in having done.
• 20:00
  Richard what's one misconception you wish every pediatric provider understood
• 20:07
  about cleft lip and palate?
• 20:10
  I'd love people to think of cleft lip and palate as more than a cleft lip repair because.
• 20:19
  A lot of people will be aware of cleft lip surgery, but not so many people will
• 20:24
  be aware of cleft palate surgery and the implications on speech and the implications
• 20:30
  that it may have on hearing.
• 20:32
  So I think that's one of the things that I'm very keen to promote.
• 20:38
  And also the fact that we know from big longitudinal studies that a proportion of children who have,
• 20:47
  their palate will need further surgery for their speech. And we know that,
• 20:51
  you know, even in the best hands, in the best centers anywhere in the world,
• 20:56
  we still know that a proportion of those children,
• 21:00
  do need more surgery for their speech.
• 21:02
  And if we know that, we should detect it really early to try and address anything
• 21:08
  before a child starts school.
• 21:11
  That's the priority. So I'm very keen on if there's any detection of some air
• 21:16
  escaping through the nose, getting them in with the speech pathologist for an
• 21:20
  evaluation, and then they'll be able to expertly say,
• 21:25
  this air escape is due to.
• 21:28
  Venopharyngeal insufficiency, which means the palate isn't quite reaching the back of the throat.
• 21:33
  And if that's the case, we can get the child in, have a look at an x-ray or
• 21:39
  camera through the nose and just see how the palate's moving and see if there's a gap.
• 21:43
  And the idea would be to try and address that before the child starts education
• 21:49
  because we can correct that with surgery.
• 21:51
  Well, in fact, you can't correct that with speech therapy if it's aeroscape
• 21:56
  through the nose because of bilopharyngeal insufficiency.
• 22:00
  We can do things like lengthen the palate, which would be the first line.
• 22:04
  And if that's not effective, we can shorten the back of the throat for a pharyngoplasty. Amazing.
• 22:11
  So in the well-child visits for the pediatrician, do you have any advice on
• 22:14
  how do you tell that that could be happening? Oh, 100%.
• 22:18
  If the school teacher or the pediatrician has concerns with speech and the child
• 22:23
  has a history of a cleft palate, then definitely re-refer back to the clefts,
• 22:30
  craniofacial multidimitim. team.
• 22:32
  And we will see the child, they'll have a speech assessment,
• 22:35
  speech evaluation, and we'll see if there's something that can be corrected
• 22:39
  either with more therapy,
• 22:41
  tailored to specific, you know, speech sounds, or if they would benefit from
• 22:46
  surgery, which may be lengthening the palate, maybe re-repairing the palate.
• 22:51
  It may be repairing a hole. Sometimes there's a little hole that can form. It's called a fistula.
• 22:56
  It's maybe a case of repairing that or a pharyngoplasty. So there's lots of
• 23:00
  options. And a lot of that will depend on how short the palate may be or what
• 23:07
  the movement of the palate looks like.
• 23:10
  So after finishing today's surgery, what gives you the greatest sense of purpose
• 23:14
  in caring for these children and families and that baby? Yeah.
• 23:20
  I mean, when a cleft lip has just been repaired, it's a big transition, actually.
• 23:28
  And sometimes that can be very overwhelming, actually, for the parents.
• 23:35
  They're used to their beautiful baby and the appearance of the baby's changed.
• 23:41
  So that's always quite an emotional time, I think.
• 23:44
  When you've first done the surgery and you go to recovery and then go and speak
• 23:50
  to the parents and bring the parents back to see their baby again,
• 23:54
  and that can be quite an emotional time.
• 23:57
  And, you know, that's obviously, you know, I hope that that's,
• 24:02
  that they're happy with the results, but it is even, even though it may look
• 24:07
  more typical for, for a child without a cleft lip,
• 24:10
  you know, it's still a big change because,
• 24:13
  babies who got a cleft lip have got this huge, beautiful smile, really broad.
• 24:19
  And I was thinking, oh, I'm kind
• 24:20
  of, it's a shame that I have to make the smile a little bit less broad.
• 24:24
  The baby will be hospitalized for how long? Yeah. So I usually,
• 24:28
  for actually both cleft lip and cleft palate, I usually keep the babies overnight.
• 24:33
  And that's just checking that they're feeding well, checking their pain's well-controlled
• 24:37
  and also, you know, checking that there's no complications from surgery.
• 24:41
  So that's, you know, any concern with bleeding or any obstruction of the airway.
• 24:46
  And these are things which are very rare in, you know, in surgery,
• 24:49
  thankfully, but can be very serious. And, you know, we just need to monitor that.
• 24:54
  So appreciative to get kind of an inside peek into what happens here in the
• 24:59
  OR and at University Hospital.
• 25:02
  You know, I feel the responsibility, I really do, you know, especially when
• 25:06
  I meet the parents, you know, sometimes before I sit in a clinic and then,
• 25:11
  you know, they're handing over their three-month baby for me to.
• 25:14
  You know, do surgery on the lip and their nose.
• 25:17
  You know, it's a real privilege to do that surgery, but also a huge responsibility
• 25:24
  that I take very seriously.
• 25:26
  And that's also why, you know, people who are doing cleft lip and palate surgery,
• 25:30
  you know, I did three fellowships in order to be able to do this. And that's because...
• 25:35
  You know, this is something which has lifelong implications.
• 25:38
  And, you know, any team, you'd hope that the people who are doing the surgery
• 25:43
  are fellowship trained and they've, you know, got formal residency training and,
• 25:49
  you know, they're certified to be doing the cases.
• 25:53
  And they're working as part of a team. That's the most important thing.
• 25:57
  But, yeah, I feel that responsibility. And that's, you know,
• 26:00
  that's why, you know, I've done three years extra in training to do it.
• 26:05
  And that's why I, you know, try and maintain a practice where I'm doing this regularly.
• 26:10
  You know, I'm doing this regularly. So for me, it is.
• 26:16
  I don't want to say no cases of routine, and certainly cleft lip and palliative
• 26:20
  is never routine, but it's something that I do as part of my normal work,
• 26:25
  as part of my normal practice. Yes.
• 26:26
  And you see patients in clinic at UH and then sometimes at the mark if Medical
• 26:33
  Arts and Research Center for UT Health, so the patient doesn't have to wait to have surgery.
• 26:37
  Yeah, that's right. So I'll see patients initially maybe in the pediatric plastic
• 26:43
  surgery clinic or the cleft craniofacial clinic because certainly all of the
• 26:48
  patients after the initial surgeries will be followed up in the cleft craniofacial clinic
• 26:52
  where we've got all of the team right there in clinic.
• 26:55
  So we don't have to go to all these different appointments. They can go to one
• 26:58
  place and see the whole team.
• 27:01
  And everybody in that clinic is focused on cleft lip and palate.
• 27:04
  They've got a lot of expertise and they've got a lot of additional training
• 27:09
  to be able to do those roles.
• 27:11
  So it's a really good team here at university. And now we're hoping to grow the service even more.
• 27:16
  We hope it's a growing population in South Texas. And there's a lot of children,
• 27:22
  I'm sure, out there who may be struggling with speech and they're not in the system.
• 27:28
  And maybe we can get them back in the system and see if we can help them.
• 27:32
  Yeah. Is there a time when it's too late? No, I don't think it's ever too late because.
• 27:39
  What happens is if you've had a delayed repair, for example,
• 27:44
  or you've had your cleft repair done many, many years ago, it may take more therapy after surgery.
• 27:52
  That's the main thing. So if you've learned to speak with a difference in your palate and you've,
• 28:00
  compensated for the way that the palate works and maybe you use different parts
• 28:05
  of your mouth to form the sounds you can use your throat to form the sounds
• 28:09
  and all that needs to be unlearned if you've got a new repair,
• 28:14
  do you want to quickly say some of the other plastic surgeries that you do yeah oh so,
• 28:19
  i do mainly pediatrics but also a bit of adult surgery as well so the pediatric
• 28:24
  side of things some congenital hand surgery so these are children who are born
• 28:28
  with differences in their hand extra digits digits that fused together,
• 28:32
  ear differences so children who've got different shapes it shaped to their ears there's,
• 28:38
  lots of other kind of maybe slightly more kind of left field things that you
• 28:43
  see in pediatric plastic surgery maybe different shaped heads or different you know,
• 28:49
  congenital lesions so a little you know large pigmented nevus or a scar that's
• 28:56
  happened maybe after burns after trauma it's.
• 29:00
  Even small things small little lesions that are growing little dermoid cysts
• 29:05
  and things like that as well yeah,
• 29:08
  I like to promote having a life outside of medicine. I know you recently joined us from England.
• 29:13
  Are you enjoying it here in South Texas? I really am. I feel like,
• 29:17
  actually, I went home to the UK recently and I came back and I thought,
• 29:22
  oh, do you know what? I'm really glad to be back.
• 29:24
  Nice. I kind of started to feel a bit more like home, actually.
• 29:27
  I was kind of driving back from the airport thinking, actually, it does feel like home.
• 29:31
  The one thing that's missing is my wife is on fellowship at the moment in Canada.
• 29:35
  So I'm hoping that you know she will at some point be becoming this way she's
• 29:42
  also a plastic surgeon so hopefully soon I remember you mentioning it the last.
• 29:47
  Time yeah two surgeons are you know struggling with,
• 29:50
  kind of two surgical careers it's not not the easiest thing but we're towards
• 29:55
  the end of training for my wife and you know I finished training a little while
• 29:59
  ago but yeah we're we're getting hopefully
• 30:03
  back into the same, we're now the same time zone, which makes a massive difference. Yeah.
• 30:07
  And weekends we can, she's in Winnipeg and we can meet somewhere in the middle
• 30:12
  in Denver or somewhere. Nice. Yeah.
• 30:14
  And what do you like to do to unplug? So I'm a big fan of swimming and actually
• 30:19
  recently taken up yoga, which does help when you're, you spend your whole day
• 30:23
  with your neck flexed, looking down into baby's mouth.
• 30:27
  Yes, I could imagine. Sometimes if I do quite If you have palate surgeries,
• 30:31
  you know, I do feel it in my neck and it's so important to look after your neck.
• 30:35
  So yoga has been a massive help, actually.
• 30:38
  I love swimming, too. And that's a great thing about San Antonio.
• 30:41
  There's some awesome pools.
• 30:44
  Great outdoor swimming. Yeah, I'm a big fan of the outdoor swimming.
• 30:47
  The moving meditation. Oh, 100%.
• 30:50
  Yeah. Well, Dr. Richard Thompson with University Health and UT Health San Antonio
• 30:55
  Plastic Surgery, talking to us here in the surgical unit right outside of the operating room.
• 31:01
  Thank you so much for talking to me today and being here on Pediatrics Now. It's a pleasure.
• 31:08
  Click on the link in this podcast.
• 31:24
  Is that what you're doing right now? Well, we already did this with debrief,
• 31:28
  but now it's just the baby waking up. It's going to go through to recovery.
• 31:33
  And it's crying, so the airway is up to fine, which is really critical for a pallet with air.
• 31:40
  Obviously, that's repairing a baby's pallet, which reduces the size of the airways.
• 31:45
  So it's always a concern of mine, certainly, when you're making the airway actually
• 31:50
  smaller, some operations you're making, when you're getting to a pallet,
• 31:53
  you're actually making it smaller. But this baby is doing very well.
• 31:56
  And so that's a wonderful cry.
• 31:58
  It's a wonderful cry. It's a wonderful cry. It's a wonderful cry.
• 32:01
  Like when the baby points. Yes, exactly.
• 32:03
  Probably really hungry, so they can usually feed straight away.