The future of cleft care

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Future Faces bursary report – Alistair Cobb

A single handclap in the gateway of the Golkonda Fort in Hyderabad city can be heard 450 feet above in the Royal Palace thanks to ingenious acoustic panels cut in the corners of the arches way before their time in the 1500s. But the call of cleft surgery is even more reaching. Two surgeons separated by 4 decades in age who met the day before can spend an extended lunch deep in conversation about the nuances of approaches to the reconstruction of the infant face. Engrossed in the commonality of task and committed to its exploration and improvement, barriers are non-existent and time flies.

I had the career changing opportunity of visiting Dr Hirji Adenwalla in Thrisur and Drs Gosla Reddy and Raj Reddy in Hyderbad. Both visits as awe inspiring in what they offered. This was all through the personal connections and advice of Tony Markus, British Cleft surgeon, and the generosity of the Future Faces charitable trust to whom I am eternally so grateful.

The Charles Pinto unit for cleft lip and palate in Thrisur resides in the Jubilee Mission Hospital. This was a small affair when Dr Adenwalla started his career there: grown out of a dispensary, the hospital had just 20 beds in 1952. The hospital has now grown to approximately 1800 beds. Dr Adenwalla has surely the largest experience of primary cleft repair in the world: over 10,000 primary operations

In my week with him I attended Dr Adenwalla’s clinics and theatres sessions as an observer and surgical assistant. We talked a great deal about the milestones of the development of cleft surgery and the characters of the influential cleft surgeons who built this road. Dr Adenwalla had met many of these people but also has a personal interest in the history of the subject and was a fascinating insight into the process of the progression of the field. These lessons were perhaps most useful in approaching different problems on the operating table and adapting one’s approach to the individual case at hand. Every case is different is the message, but by understanding WHY Millard changed his lip repair and WHY Cutting reversed the backcut one can choose to borrow such manipulations when the case calls for it – if not all the time. Dr Adenwalla’s advice was key: think about which approach is the right one in your mind – find a philosophy. Then practice it and evaluate it. Don’t try to compromise and keep trying several different techniques. Ideally practise it 10,000 times! But adapt it to each case in front of you. It is still the same philosophy. Indeed we talked about classical philosophy, history, surgical development and inter-specialty differences too, over plates of curds, dal (my favourite!) and chapatti, and how the lessons inform one’s time in surgery and life.

Dr Adenwalla’s team includes the marvellous Dr Narayanan who demonstrated his modifications of the techniques and a beautiful cleft rhinoplasty technique. Dr Rhadhakrishnan and Dr Pasupathy have brought new ideas into the camp and have great hands and patience in explaining their surgical actions. Their results are all stunning

I was sad to left Thrisur and wished it had been longer, obviously. Whilst the time went quickly I felt that I had gained the experience of months elsewhere – we covered the workload of a UK unit for a couple of months in that week.

So on to Hyderabad.

 Gosla and Raj have set up an amazing unit in Hyderabad. From bottom up it is a terrific achievement. What is most impressive is the step by step assessment of what they need to do and thorough research, implementation and re-evaluation of their work from the beginning. This is evident in Gosla’s PhD thesis on cleft lip repair – chapter by chapter builds on the findings of the previous, each chapter published separately on the way. Now Raj is doing the same with the repair of cleft palates. The same attention to detail is evident in the running of the unit. It is no surprise that KPMG found little to suggest to improve their efficiency.

I was able to learn the basis of the GSR unit’s lip and palate repairs and discuss this at length with the two surgeons. After this period I was able to take on cases myself using my preferred Fisher technique of lip closure. I was also able to do a few bilateral cleft lip repairs, which was a rare treat.

I have set up a small project with the institute where we will look at the presentation features of bilateral cleft lips. I hope this will be something we can present in the future.

I left India able to start work as a UK cleft surgery consultant in the knowledge that I was competent enough to undertake the work on my own. I am immensely grateful to Future Faces and the surgeons at the two centres.

Alistair R.M.Cobb FDSRCS FRCS

Cleft Fellow, South Thames Cleft Service