It is hard to imagine that cleft lip and palate repair is a traditional and ancient technique, but in China, the level of treatment varies greatly from hospital to hospital. At present, Jiu Hospital has become one of the largest centers for the diagnosis and treatment of cleft lip and palate in China and one of the best centers for the treatment of cleft lip and palate in the world. It is also a training and education base for the “Operation Smile” and the “Smile Train” (both of which are charitable activities that provide free relief and treatment for children with cleft lip and palate and head and facial deformities from poor families), and trains relevant doctors from all over China for free. In the face of these remarkable results, Wang Guomin is not complacent, but repeatedly stressed to the reporter that he has to study the treatment technology, “the operation method must be simpler and simpler, so that the technology can be more popular!”
According to the data, there are about 25,000 newborn children with cleft lip and palate in China every year. Today, how far has the relevant treatment level developed in China? To what extent can mature technology rehabilitate children? How many misconceptions do parents have in seeking medical treatment that may delay it?
Congenital cleft lip and palate is often referred to as “harelip”. According to records, the first doctor to perform cleft lip surgery was probably a famous doctor under Yin Zhongkan, the governor of Jingzhou in the Western Jin Dynasty (316 AD) in China. Cleft palate deformities were found in mummies preserved in the 1st century, and surgical treatment of cleft palate dates back to the 6th century BC.
Reporter: What is the incidence of cleft lip and palate in China?
Doctor: The cause of the onset of cleft lip and palate is still unknown. In recent years, there are about 25,000 newborn children with cleft lip and palate in China every year. There are about 14 million patients worldwide, and every 2.5 minutes there is one new cleft face patient. This is a long-term study by American experts.
Reporter: Are there any memorable cases in 30 years of medical practice?
Doctor: I met a child with a severe bilateral cleft during a charity clinic, and my Italian and British counterparts in the international medical team jumped at the chance to get the child back to China for surgery. A year later, I was approached by Mercy Corps again, saying that the surgery hadn’t been done, and could you do it.
The surgery was very risky, but one image that I still remember is that the child could not eat by himself because of the severe facial cleft, so the mother took a bite for herself and fed the child, just like a big bird feeding a little bird.
At that time, it was not all by myself. Experts from France and the United States discussed treatment plans with me many times, but they were all on paper, they had never done this kind of cases. Later, Kenneth E. Salyer, Chairman of Craniomaxillofacial Surgery in the United States, told me that he had done a similar case, but it was not as serious as this one, and he sent me the treatment plan from that time without reservation. My team and I started to design the surgical plan based on the previous one, during which we discussed with academician Zhang Jiesheng (reporter’s note: one of the founders of plastic surgery in China); Professor Fan Xianqun was invited to do the surgery in the eye area of the child. The surgery was successful and the girl’s cleft lip and palate shape was skillfully repaired and reunited with the human middle. in 2008, we reported this case at an international conference and the whole room was a sensation.
I am saying this to show you that the diagnosis and treatment of cleft lip and palate is multidisciplinary and sometimes it is not goodbye in one operation, and the irregular post-operative follow-up is very important, but it is often neglected by patients in China.
Reporter: It sounds like the level of cleft lip and palate treatment in China is in a relatively leading position in the international arena?
Doctor: A few years ago, the president of a cleft lip and palate treatment society in the United States used two national flags, the five-star red flag of China and the stars and stripes of the United States, on the PPT of the keynote presentation at an international conference. He said he wanted to warn his American counterparts that China’s cleft lip and palate diagnosis and treatment technology is at the forefront of the world, and in some aspects exceeds that of the United States. I was not happy to hear that, and I told this expert that our overall level is very uneven.
Reporter: What are the signs of the “uneven” level of diagnosis and treatment around the country?
Doctors: We often encounter failed cases, having undergone one, two, three, or even five or six surgeries – because the first surgery was not done properly and a remedial surgery had to be done. If you can cook, you know that it’s not difficult to remedy a poorly seasoned first time. So what causes the failure cases? I think it’s mostly a matter of surgeon skill.
Cleft lip and palate repair is not a new technique, it has been around for centuries. The modern clinical treatment of congenital cleft lip and palate deformity mainly goes through 3 stages: the first stage is simply to close the cleft, but the effect is not good and the appearance is not beautiful. The second stage gradually focused on anatomical structure and physiological function restoration. To the third stage now: morphological repair also focuses on natural anatomical form and functional restoration or improvement, for example, we are now able to repair the upper lip leaving the only cut scar similar to the human mid-cut on the healthy side. These improvements are based on the absorption and digestion of international conferences and literature journals. Some doctors in the interior of China do not have access to these latest methods and ideas, and still follow the textbook traditional procedures – they are classics, but if we want to make the treatment better and the patients more satisfied, the classical procedures are not enough and must be innovative.
Reporter: To what extent can our cleft lip and palate treatment technology rehabilitate children at present?
Doctor: We have been able to achieve a child with cleft lip that is close to normal in appearance, which means that the post-operative suture scars are hidden and the anatomical structure of the repaired upper lip is natural. Functionally, with the help of speech correction treatment, the child’s speech level can also be restored to almost the same level as a normal child, but this requires the cooperation of each parent. These are the two main internationally recognized treatment goals. Some of our doctors say that a cleft lip and palate repair can be done as long as it is close to normal in appearance, and that it is natural for a child with cleft lip and palate to have poor pronunciation after surgery, which sends the wrong message.
Reporter: What is the biggest headache for you in the field of cleft lip and palate diagnosis and treatment?
Doctor: I can’t say it’s the biggest headache, I should say it’s anxiety. We have so many patients coming from all over the world. At the most, I saw more than 130 patients in half a day; my special needs clinic should have 15 numbers in half a day, but at the most, I put 40 numbers, but the patients were not finished. Because they were foreign patients, they had to pay for food and accommodation in Shanghai, and we had to arrange for them to be admitted to the ward and operated on as soon as possible.
I can only say that this is an individual case. The only patient complaint I have here is “Why can’t we get in?” Many patients are delayed in staying in the hospital, surgery can not be scheduled …… this point I am also very helpless. This shows what, or the treatment technology is not evenly caused. Over the years, we have insisted on visiting various places every year to give medical advice, to teach local doctors and to do free surgeries. The simpler the technology, the better. We definitely don’t want one person to be able to do it, but try to study the kind of technology that more people can operate.
Reporter: What are some of the misconceptions parents have about visiting the doctor?
Doctor: In our department, we discuss failure cases, what causes failure? We believe that one is the doctor’s technique, and another is the cooperation of the patient and family. For example, if a child has just undergone surgery and the parents drive home, the child’s wound is split open and the secondary surgery is likely to be less effective than the first surgery. This is the problem of family care for the patient.
Other parents just had a baby with cleft lip and palate and were so nervous that they found a doctor who said they could do it and had the surgery due to asymmetric information. In fact, it is well established that the younger the cleft lip and palate is by no means the better to undergo surgery, and that surgery in newborns is not good. Now we say that children can have unilateral cleft lip and palate surgery at 3 months of age and bilateral cleft lip and palate surgery at 6 months and older, but this is not absolute. Treatment options depend on the surgeon, the anesthesiologist, and the child’s individual situation, such as nutritional status. The younger the child is when he or she undergoes surgery, the greater the risk.
In addition, it is also important to re-evaluate after surgical treatment. The outcome of modern cleft lip and palate treatment is never determined by whether the incision is good or bad, but has to be considered in terms of appearance (whether the upper lip and nose shape are symmetrical) and whether the voice is like normal. This is a multidisciplinary treatment plan and the treatment period may extend from childhood to adulthood. Therefore, family members should cooperate with the doctor to come to the follow-up appointment on time after the surgery.
Reporter: What is your focus this year as the chairman of the Oral Craniomaxillofacial Committee of the “Operation Smile” China Foundation China Medical Committee?
Doctor: For the past 12 years, my team and I have followed the Operation Smile charity walk throughout the country, and have also visited East Timor, the Philippines, Vietnam, Guinea and other places to provide free surgeries and share our experiences and lessons learned with local doctors. This is important for the spread of medical technology.
After becoming the director, my focus is to improve the standardized medical program and ensure medical safety and quality as soon as possible, and to select the most suitable and authoritative specialists to provide free medical consultation and treatment to patients. Because I had more contact with charitable organizations, I came into contact with many foreign doctors. There was a doctor from a developed country who was unskilled in cleft lip and palate surgery and went to a certain country for half a month of intensive training and could do it. Patients in that country became his practice subjects. This touched me a lot, and I think that although it is a charity surgery, the quality should be guaranteed even more, because this surgery is very important for these patients who do not have money, and if it is not done well this time, they cannot afford to have a second or third remedial surgery. That’s why I always tell parents not to believe in the so-called “foreign experts” and “the latest technology”.
Reporter: What are the unique innovations in cleft lip and palate treatment in Shanghai?
Doctor: Our team works closely with Dr. Sun Lumin, a fetal medicine specialist at ICH and Dr. Chu B., a pediatric surgeon at Children’s Medical Center, which is a kind of private cooperation, formed entirely due to personal relationships with doctors. Over the years, we have successfully used this cross-hospital collaboration to operate on children with hemophilia, cleft lip and palate, combined with severe pediatric congenital heart disease, and other conditions. There is an EU Cleft Lip and Palate organization in Europe, and their treatment experience has been used in Europe for many years and has had a profound impact. Our model of this private partnership is ahead of theirs, intervening before the child is born, which is a leading position worldwide. We hope to develop a more mature treatment mechanism, or even a “Shanghai model”, with the support of relevant authorities.