Global Cleft Care in Low-Resource Settings

Description

Cleft lip and palate represents the most common congenital facial anomaly. Congenital anomalies are one of the top 10 causes of disability and suffering in many low and middle income countries (LMICs.) Further, an estimated 30% of the global burden of disease is treated primarily through surgery, and among surgical conditions, treating clefts conveys disproportionately large benefit relative to cost because suffering can be halted at a young age and deliver a lifetime of health. Over the last 50 years, cleft care has advanced in low-resource settings through international surgical missions and the efforts of sparse local providers. While exciting anecdotes of impact abound from these efforts, recent studies have identified a complication rate that often exceeds 50% and there is concern about the sustainability of foreign volunteer missions. This book serves as a thorough resource for providing medical and surgical care of cleft lip and palate deformities in low-resource settings, geared to the context of those settings. The content is consensus-based and evidence-based, with emphasis on treatment that is appropriate to a low-resource context and how this differs from that in higher-resource environments. It is authored by recognized cleft experts in close partnership with providers who practice in low-resource settings. It is heavily pictorially based through illustrative figures, photos and diagrams, to be facile for those who speak English as a second language.   Following the introduction, Complete Cleft Care in Low-Resource Settings has six main sections: patient workup, surgical treatment, comprehensive care, educational innovation, care delivery models, and finally a series of illustrative case studies. Uniquely, the book’s breadth encompasses cleft care comprehensively, but does so through a practical “how to” format with many “from the field” examples of what has worked.  Foreword Foreword Preface Acknowledgments Contents Case Studies in Cleft Surgery About the Editors Editor Illustrator Section Editors Contributors Part I: Introduction to Global Cleft Care 1: Introduction: A Paradigm Shift in Global Cleft Care Five Forces Shaping Global Cleft Care Surgery as Public Health Locally Delivered Cleft Care Focus on Achieving Great Patient Outcomes Innovation Borne of Low-Resource Settings The Conundrum of Evidence-Based Medicine References 2: Burden of Cleft Disease and Opportunity for Impact Introduction Defining Cleft Conditions The Burden of Cleft Disease Epidemiology Outcomes for Cleft Patients Economics of Cleft Care Approaches to Cleft Care Defining Adequate Cleft Care Methods of Reaching Untreated or Undertreated Patients The Potential Impact of Cleft Care References 3: Patient Barriers to Care Introduction Availability of Care (Supply) Workforce Infrastructure Affordability and Acceptability of Surgical Care (Demand) Affordability Acceptability Conclusion References 4: Innovations in Reaching Patients Introduction Design Thinking Examples from the Field Cleft Lip and Palate Patient Accompaniment: Partners in Health and Operation Smile Honduras Problem Statement Program Overview Why It Works Enhancing the Patient Experience: Operation Smile, Madagascar Problem Statement Program Overview Why It Works Primary Care Nuka System of Care: Southcentral Foundation, Alaska, United States Problem Statement Program Overview Why It Works Community Health Workers: Last Mile Health, Liberia Problem Statement Program Overview Why it Works Infectious Disease Community-Based Surveillance System: CORE Group Polio Project, South Sudan Problem Statement Program Overview Why It Works Conclusion & Key Takeaways References Part II: Patient and Cleft Assessment 5: Patterns, Anatomy, and Classification of Clefts Introduction Epidemiology Patterns of Cleft Lip and Palate Syndromic Clefts Racial and Ethnic Epidemiologic Variations Embryology The Gene-Environment Interplay Facial Development Clefts as Failure of Fusion Events Cleft-Related Anatomy Nose: Tip, Alae, Columella, Nasal Sill, Paranasal Muscles Palate Classification Severity Classification Patterns Unilateral Cleft Lip and Palate (UCLPA): Main Features Bilateral Cleft Lip and Palate (BCLPA): Main Features Cleft Palate: Main Features References 6: Early Nutrition, Feeding and Management of Infants with an Oral Cleft Introduction Feeding Guidance for Patients with Cleft Lip/Palate Normal Feeding Feeding Duration and Amounts Initial Feeding Assessment Specific Feeding Problems of Infants with CL+/− P Cleft Lip Cleft Palate with or Without Cleft Lip Assisted Breast/Bottle Feeding and Devices Breastfeeding Modified Bottles Oral Plates/Obturators Nasogastric (NG) Feeding Oral Hygiene Positioning and Winding/Burping Sources of Milk and Milk Alternatives Weaning Nutrition and Growth Assessment Growth Measurement Weight Measure Length Measure Head Circumference Measure Mid-Upper Arm Circumference (MUAC) Measure Malnourishment: Diagnosis and Management Perioperative Feeding Considerations Preoperative Nutritional Assessment Postoperative Feeding References 7: Surgical Evaluation, Diagnosis, and Treatment Planning Introduction Surgical Diagnosis and Cleft Care Plan Cleft Diagnosis Surgical Treatment Pathway Surgical Patient Screening and Specific Treatment Plan Prioritizing Patients Structuring Safe Surgery in the Mission/Outreach Setting Surgical Schedule Avoiding Complications Postoperative Care Planning References 8: Pediatric and Anesthesiologic Evaluation Introduction Overall Health and Nutrition Ruling Out Syndromic Conditions and/or Associated Congenital Anomalies Cleft Palate and Pierre Robin Sequence Preoperative Assessment of the CLP Patient Review of Systems: Medical History Review of Systems: Physical Examination Further Workup: Laboratory and Imaging Studies CLP Surgery, Anesthesia, and Comorbidities Ruling Out Concurrent Infections Otitis Media Respiratory Tract Infections (RTIs) RTIs and the CLP Surgical Patient Other Respiratory Comorbidities Asthma Obstructive Sleep Disorders (OSDs) Surgical Timing and Surgical Readiness References Part III: Complete Surgical Treatment 9: Anesthesia for Patients with Cleft Lip and Palate Introduction Anesthesia Challenges Epidemiological Public Health Issues Timing of Surgery and Anesthesia Implications Preoperative Assessment Upper Respiratory Tract Infection (URI) Nutrition and Hydration Associated Conditions and Anesthesia Implications Airway Management: Relevant Facts for Surgeons Antibiotic Prophylaxis Anesthesia Technique Intraoperative and Postoperative Pain Management General Consideration Regional Anesthesia in Cleft Surgery Infraorbital Nerve Block Palatal Nerve Blocks Bilateral Maxillary Nerve Block by Suprazygomatic Approach Particular Considerations CL Repair Primary CP repair Secondary CP Repair Alveolar Bone Graft Surgery Secondary Correction of Nasal Deformities in CLP Patients: Open Rhinoplasty Orthognathic Surgery Conclusion Bibliography 10: Principles of Cleft Lip Repair Introduction Aesthetics and Functional Considerations Timing of Repair, Nasoalveolar Molding, and Lip Adhesion Cleft Lip Adhesion Timing of Definitive Repair Technical Considerations Anatomic Subunits of the Nose and Lip Cleft Severity and Tension of Repair Nasal Floor Repair Rhinoplasty at Primary Lip Repair Revisions Conclusions References 11: Unilateral Cleft Lip repair: Rotation-Advancement Technique Introduction Patient Selection and Clinical Planning Timing of Surgery Operative Planning Relevant Surface Anatomy Key Equipment Anesthesia Procedural Technique Incisions on the Non-cleft Side Mohler’s Incision (Fig. 11.2) Simple Rotation Incision (Fig. 11.3) Adequate Rotation Muscle Dissection on the Rotation Flap C-Flap and Footplate of Medial Crura Nasal Septal Dissection Incisions on the Cleft Side L-Mucosal Flap Inferior Turbinate Flap Incision and Dissection Removal of Fat Pad Under the Vestibulum Elevation of Orbicularis Marginalis Flap Nasal Floor Reconstruction and Alar Base Repositioning Lip Repair with Anterior Palate Repair Lip Repair Without Anterior Palate Repair Sequence of Operation When an Anterior Palate Repair Is Combined with Lip Repair Closure of the Base of Columella Muscle Reconstruction Insertion of the WSR Flap Incisions for Triangular Vermillion Flap Closure of the Free Border of the Lip Closure of the Nasal Floor and the Lip Skin Semi-open Rhinoplasty Incision Release of Fibrofatty Tissue from LLCs Repositioning of LLCs Trimming the Excessive Skin Primary Septal Cartilage Graft Alar Base Position Creation of the Alar-Facial Groove Postoperative Care Wound Care Stitch Removal Aftercare Follow-Up and Complication Management References 12: Unilateral Cleft Lip Repair: Modified Mohler Technique Introduction Anatomy Preoperative Planning Surgical Management Surgical Approach Positioning Markings Surgical Technique Postoperative Care Outcomes Complications References 13: Unilateral Cleft Lip Repair: Anatomic Subunit Approximation Technique Introduction Principles Technique Plan Lip Points Nose Points Medial Markings: Connect the Dots Lateral Lip Vermilion Flap Determining Base Width of Lateral Lip Inferior Triangle Flap Fitting the Lateral Lip Markings to the Available Lateral Lip Height Connecting the Two Sides Surgical Release and Re-measure Component Reconstruction Final Closure Case Examples References 14: Bilateral Cleft Lip Repair Introduction Goals of Surgery Timing and Indications for Surgery Our Technique for Bilateral Complete Cleft Lip Repair Patient Preparation and Setup Markings (Fig. 14.1) We Start by Making the Markings on the Prolabium Markings on the Lateral Lip Elements Surgery: the Execution of Your Plan Creation of the Philtral Tie and Posterior Wall of the Upper Buccal Sulcus Incision of the Lateral Lip Markings Release of the Lateral Lip Elements and Alar Bases Muscle Release Evaluation of Alar Base Position with Muscle Closure Closure of the Lip Mucosa Muscle Repair Anterior Closure of the Lip Skin and Vermillion Primary Nasal Correction Postoperative Care References 15: Secondary Cleft Lip Repair Introduction Patient Selection and Clinical Planning Timing of Surgery Planning Surgery Relevant Anatomy Key Equipment Anesthesia Procedural Technique Unilateral Cleft Lip Deformities Clinical Examples of Unilateral Cleft Lip Deformities Bilateral Cleft Lip Deformities Clinical Examples of Bilateral Cleft Lip Deformities Follow-Up and Complication Management Cleft Lip Revision, Case 1 Case Study: Whistle-Notch Cleft Lip Deformity with Unrepaired Nasal Deformity Case Analysis Treatment Considerations Cleft Lip Revision, Case 2 Case Study: Enlarged Philtrum Case Analysis Treatment Considerations Cleft Lip Revision, Case 3 Case Study: Hypertrophic Cleft Lip Scar Case Analysis Treatment Considerations References 16: Principles of Cleft Palate Repair Introduction Anatomy Classification and Protocols Preoperative Considerations Surgical Techniques for Hard Palate Repair One-Flap Palatoplasty (Figs. 16.5, 16.6, and 16.7) Surgical Technique Surgical Techniques for Soft Palate Repair Unilateral Uvuloplasty (Fig. 16.16 and Video 16.4) Postoperative Care Outcome Assessment Palatal Fistulas Speech Maxillary Growth Author’s Approach and Supporting Evidence Conclusion References 17: Cleft Palate Repair: Early Anterior Palatal Closure and Intravelar Veloplasty Techniques Introduction Timing Preparation Presurgical Orthopaedics/NAM Patient Selection Instruments and Equipment Surgical Techniques First Stage – Lip and Vomerine Closure of the Hard Palate Unilateral Cleft Lip and Palate (UCLP) Bilateral Cleft Lip and Palate (BCLP) Second Stage: Closure of the Remainder of the Palate with Muscle Dissection 3–6 Months Later Unilateral Cleft Lip and Palate (UCLP) Bilateral Cleft Lip and Palate Isolated Cleft Palate (and Unilateral and Bilateral Clefts of Lip and Palate After Vomerine Flap Closure of the Hard Palate at Lip Repair) Illustration Submucous Cleft Palate Postoperative Management Airway Analgesia Antibiotics Feeding Arm Splints Complications and Follow-Up Complications Follow-Up References 18: Cleft Palate repair: Double-Opposing Z-plasty Technique Introduction Patient Selection and Clinical Planning Timing of Surgery Operative Planning Relevant Anatomy Key Equipment (Fig. 18.5) Procedural Technique Follow-Up and Complication Management Challenges to Performing Furlow Palatoplasty in Developing Countries Advantages of the Furlow Palatoplasty References 19: Palatal Fistulas and Repair Introduction Causes and Prevention of Fistulas Fistula Evaluation Symptoms and Examination Indications for and Timing of Fistula Repair Fistula Classification Pakistan Comprehensive Fistula Classification Location (L) Size Velopharyngeal Competence Multiple Fistulae Dehiscence of Palate Management of Palatal Fistula Turnover Flap Mucoperiosteal Flap Ginvigobuccal Sulcus Flap Premaxilla Gingival Flap Tongue Flap FAMM or Buccal Myomucosal Flap Algorithmic Approach to Procedure Selection Midline Fistulae; M1 to M6 Management of M1 M2 or M3 Management of M3 (Fig. 19.51) M4 Management of M5 M6 FAR (Fistula Adjacent Regions) Management of Lateral Fistulae Ra or La, S1 & S2 Ra or La, S3–4 Rb or Lb Rb Rc or Lc Subtotal Fistulae Subtotal Bilateral Fistula Multiple Fistulae A Unique Combination of All Three Types of Fistulae Dehiscence Complicated Dehiscence D3-L D3-R after Unilateral Cleft Palate repair D3-R after Bilateral Cleft Palate repair Important Precaution to Avoid a Disaster Conclusion Cleft Palate Revision, Case 1 Case Study: Soft Palate Reconstruction in a Bilateral Cleft Lip and Palate Patient Case Analysis Treatment Considerations Cleft Palate Principles, Case 2 Case Study: Large Anterior Oronasal Fistula Reconstruction in a Bilateral Cleft Lip and Palate Patient Case Analysis Treatment Considerations References 20: Speech Surgery and Treatment of Velopharyngeal Insufficiency Introduction Patient Selection and Clinical Planning Procedure Selection and Timing of Surgery Relevant Anatomy Key Equipment (Fig. 20.7) Anesthesia Patient Preparation Procedural Techniques Furlow Cleft Palate Re-repair (Fig. 20.9) Surgical Steps Sommerlad Palate Re-repair with Radical Muscle Dissection and Retropositioning Palatal Lengthening with Bilateral Double Opposing Buccal Myomucosal Flaps (Fig. 20.11) Surgical Steps Posterior Pharyngeal Flap (Fig. 20.14) Surgical Steps Sphincter Pharyngoplasty (Fig. 20.16) Surgical Steps Hynes Pharyngoplasty (Fig. 20.18a–c) Surgical Steps Tips Posterior Pharyngeal Wall Augmentation Prosthetic Management Follow-up and Complication Management References 21: Alveolar Bone Graft Introduction Patient Selection and Clinical Planning Timing of Surgery Secondary Bone Grafting Gingivoperiosteoplasty (GPP) Grafting Material and Donor Sites Autologous Bone Graft Donor Site Selection Bone Graft Substitutes Operative Staging of Fistulas and Bilateral Clefts Operative Planning Radiographic Evaluation Orthodontic Expansion Relevant Anatomy Key Equipment (Fig. 21.7) Mouth Field Hip Field Splint Anesthesia Hip Donor Site Transverse Abdominis Plane (TAP) Block Bupivacaine-Soaked Sponge Alveolar Recipient Site Procedural Technique Iliac Crest Graft Harvest Alveolar Cleft Simultaneous Tip Rhinoplasty and Lip Augmentation Follow-Up and Complication Management Alveolar Bone Grafts, Case 1 Case Study: Extruded Premaxilla in an 8-Year-Old Male with Bilateral Cleft Lip/Palate Case Analysis Treatment Considerations Alveolar Bone Grafts, Case 2 Case Study: Extruded Premaxilla in a 4-Year-Old Male with Bilateral Cleft Lip/Palate Case Analysis Treatment Considerations References 22: Cleft Rhinoplasty Introduction Nasal Assessment Timing of Surgery Intermediate Correction Techniques/School-Aged Rhinoplasty Repositioning of the Caudal Septum Leveling of the Alar Base Correction of the Lower Lateral Cartilages Definitive Rhinoplasty Approach Nasal Dorsal Augmentation Septal Reconstruction Internal Nasal Valve Nasal Tip/Alar Appearance Complications Postoperative Care Septorhinoplasty, Case 1 Case Study: Alar Deformity Reconstruction in a Unilateral Cleft Lip and Palate Patient Treatment Considerations Septorhinoplasty, Case 2 Case Study: Secondary Cleft Nasal Repair in a Unilateral Cleft Lip and Palate Patient Treatment Considerations References 23: Orthognathic Surgery Introduction The Cleft Dentofacial Deformity Orthognathic Surgery: Team Approach Intermediate Procedures and Alveolar Bone Grafting Surgical Reposition of the Premaxilla (SRP) for BCLP Patients [5] (Secondary) Alveolar Bone Grafting Prior to Orthognathic Surgery [7, 8] Tertiary Alveolar Bone Grafting Treatment Planning Timing for Definitive Orthognathic Surgery The Pre-orthodontic Stage: Setting the Surgical-Orthodontic Treatment Plan [10] Considering a Bimaxillary Approach Surgical Treatment Plan [12] Preoperative Orthodontic: Surgical Planning Data Collection [13] Surgical Planning Surgical Sequence for Bimaxillary Procedures: Maxilla vs Mandible First Strategies in Major Maxillary Advancements (>12–15 mm) Orthodontic and Oral Surgical Preparation Surgical Techniques Maxillary Advancement Mandibular Repositioning Key Equipment Splint and Bony Fixation Alternatives for Low-Resource Setting Anesthetic Considerations Postoperative Orthodontic: Surgical Care Postoperative Stage [17] Long-Term Stability Postoperative Velopharyngeal Insufficiency [18] Final Considerations for Context References 24: Lateral and Rare Craniofacial Clefts Introduction Facial Clefts Facial Cleft 0 Surgical Considerations Facial Cleft 1 Surgical Considerations Facial Cleft 2 Surgical Considerations Facial Cleft 3 Surgical Considerations Facial Cleft 4 Surgical Considerations Facial Cleft 5 Surgical Considerations Facial Cleft 6 Surgical Considerations Facial Cleft 7 Surgical Considerations Cranial Clefts Facial Cleft 8 Surgical Considerations Facial Cleft 6,7,8 Surgical Considerations Facial Cleft 9 Surgical Considerations Facial Cleft 10 Surgical Considerations Facial Cleft 11 Surgical Considerations Facial Cleft 12 Surgical Considerations Facial Cleft 13 Surgical Considerations Facial Cleft 14 Surgical Considerations Facial Cleft 30 Surgical Considerations Anesthesia Craniofacial Clefts, Case 1 Case Study: Persistent Lip, Nasal, and Eyebrow Deformities from a Tessier 3/11 Facial Cleft Case Analysis Treatment Considerations References 25: Pierre Robin Sequence Introduction Growth and Development Sequential Management of PRS Birth CPAP or NP Airway Tongue-Lip Adhesion (TLA) [9] Mandibular Distraction Osteogenesis (MDO) [10] External Pin Mandibular Distraction [11] Mandibular Internal Distractor [12] Tracheostomy [13] Palatoplasty Follow-up Speech Growth [16] Esthetics Conclusion Bibliography Part IV: Comprehensive Cleft Care 26: Cleft Dental Treatment and Naso-Alveolar Molding Introduction Dental Assessment, Oral Health, and Setting Expectations Prenatal Assessment: Treatment Course, Set Expectations, and Reduce Anxiety – Importance of Oral Health Treatment Course and Timeline (Fig. 26.1a, b) Establishment of Dental Home Common Infant Oral Anomalies Importance of Primary Teeth Prevention and Oral Health Pre-surgical Infant Orthopedics Lip Taping Nasoalveolar Molding (NAM) Technique Functional Maxillary Orthopedics (FMO) Technique Comparing Pre-surgical Orthopedic Techniques Myofunctional Therapy and Functional Maxillary Orthopedics After Cleft Lip Repair Functional Maxillary Orthopedics: 6–24 Months of Age Soft Palatal Musculature Cleft Myofunctional Therapy Conclusion References 27: Cleft Orthodontic Care Introduction Phase I Orthodontics at Mixed Dentition Presurgical Orthodontic and Orthopedic Management for ABG Objectives of Interceptive Orthodontics and Orthopedics Treatment Anatomical Characteristics Maxillary Arch Form and Dimensions Patient Selection and Clinical Planning Timing of Interceptive Orthodontic Treatment Diagnostic Records Procedural Technique Maxillary Expansion Expansion Methods Protraction of the Maxilla Occlusal Plane Alignment Use of Planas Direct Tracks (PDT) on Primary Dentition Alignment and De-rotation of Maxillary Permanent Incisors Follow-Up and Management of Complications Phase 2 Orthodontics at Permanent Dentition Management of Missing Lateral Incisors Presurgical Orthodontics in Preparation for Orthognathic Surgery (OGS) Patient Selection and Treatment Planning Type of Orthodontic Appliances: Bracket Slot Size Anterior Maxillary Segmental Distraction (AMSD) Post-surgical Orthodontic Treatment Retention Conclusion References 28: Speech and Resonance Disorders Secondary to Cleft Lip/Palate (CLP) Introduction Causes of Speech and Resonance Disorders in Children with Cleft Lip/Palate Dental and/or Occlusal Abnormalities Upper Airway Obstruction Velopharyngeal Insufficiency (VPI) Normal Velopharyngeal Function Velopharyngeal Insufficiency (VPI) Effects of Velopharyngeal Insufficiency (VPI) on Speech and Resonance Assessment of Speech and Resonance Disorders Perceptual Assessment Speech Samples What to Assess Intraoral Evaluation Instrumental Assessment Nasometry Videofluoroscopy Nasopharyngoscopy Treatment of Speech and Resonance Disorders Secondary to Cleft Lip/Palate Surgical Intervention for VPI Prosthetic Devices Speech Therapy Speech Therapy with Uncorrected VPI Speech Therapy After Surgery Summary References 29: Audiology, Otology, and Airway Introduction Anatomy Audiologic Testing Management of Hearing Loss Myringotomy With or Without Ear Tube Placement Common Airway Issues References 30: Psychosocial, Educational, and Cultural Aspects of Cleft Care Introduction Family Adjustment to Diagnosis School Functioning Social Functioning Psychosocial Screening Models and Tools for Measuring Psychosocial Functioning Mental Health Screening Across Global Contexts Adaptive Functioning Psychosocial Support Conclusions References 31: Optimizing Postoperative Pediatric and Nursing Care Introduction Ward Assessment and Setup Emergency Preparation Patient Assessment on Admission Evaluation and Examination Fluids Medications and Blocks Nutrition Charting and Rounds Common Complications and Troubleshooting Bleeding Respiration Dehydration and Vomiting Fever and Infection Dehiscence Oronasal Fistula (ONF) Procedure-Specific Care and Instructions Cleft Lip and Rhinoplasty Procedures Cleft Palate Repair Alveolar Bone Grafts and Orthognathic Procedures Conclusion References 32: Operating Room Function and Biomedical Equipment Introduction Operating Room Equipment and Setup The “Common Back Table” Concept Traffic Flow in the Operating Room Essential Surgical Equipment Equipment Arrangement Surgical Table Anesthesia Machinery Other Equipment Support Systems Space Required in the Operating Room Outside the Operating Room Postanesthesia Care Unit (PACU) Intensive Care Unit (ICU) Intraoperative Patient Care and Equipment Use Infrastructure Inspection Electrical Power Supply Electrical Load Voltage Supply Electrical Ground Power Generators Oxygen Supply Oxygen Wall Outlets Central Cryogenic Tank and Manifold Gas Tanks Equipment Maintenance Implementation of a Local Biomed Program Surgical Instrumentation Preventive Maintenance Cleaning Drying Storage Lubrication Conclusion References Part V: Cleft Education, Innovation, and Surgical Outcomes 33: Cleft Lip and Palate Simulators in Surgical Training Introduction Surgical Simulation Cleft Simulators Simulators from the Field Cleft Simulator Validation Assessing Performance in Cleft Surgery International Implementation of Cleft Simulators The Future of Cleft Simulation Conclusions References 34: Cleft Surgeon Training Models Introduction Mission Trips Advantages Disadvantages Long-Term Collaborations Through Partner Hospitals Advantages Disadvantages Self-Contained Hospitals Advantages Disadvantages Future Directions Conclusion References 35: Educator Workshops: Visiting Educators, Curricula, and Digital Education The Need for Global Cleft Surgery Education Visiting Educator Curriculum Development and Implementation Tele-mentoring and the Utilization of Digital Technology in Education Conclusion References 36: Educator Workshops: Skills Training Introduction Traditional Models of Foundation-Based Cleft Surgery Education Visiting Trainees Local Trainees Workshops Simulation-Based Comprehensive Cleft Care Surgical Skills Workshops: A New Model for Foundation-Based Cleft Surgery Education Pillars of a Successful Comprehensive Cleft Care Workshop Future Directions and Conclusion References 37: Outcome Assessment Introduction Surgical Outcomes Evaluation in Resource-Limited Settings Patient-Reported Outcomes in Cleft Care Improving Patient Follow-Up in Resource-Limited Settings Conclusions References Part VI: Optimal Cleft Care Delivery 38: Comprehensive Cleft Care Centers: Scalable, Sustainable, and Cost Effective Surgical Care Introduction Establishing a Comprehensive Cleft Care Center Need Identification and Site Selection Partnerships Financing Facilities Equipment and Supplies Leadership and Team Building Quality Care Delivery Patient Mobilization Patient Care Services Patient Assessment Informed Consent Documentation Surgical Care Nursing Postoperative Care and Patient Education Patient Follow-Up Comprehensive Programs Impact and Sustainability Education and Training Research and Outcomes Regional Referral and Resource Center References 39: Empowering Local Partners Creating a Local Team Origins of Local Cleft Teams Teaching and Learning Cleft Surgery Key Team Roles Practical Solutions for Comprehensive Cleft Care In the Future Local Surgeon Partners: The Smile Train Model Evolution of Charity for Cleft Details of the Programme Why Local Partners Partnering with Local Hospitals Safety and Quality Assurance Expansion of Services Economic Impact Sustainability From a Trans-border Partnership to Engaging a National Cleft Society Roots in Local Cooperation Expansion to an Education- and Care-Focused Coalition Collaboration with the National Cleft Society References 40: Short-Term International Cleft Outreach Introduction Quality Safety and Emergency Preparedness Mindfulness Toward Resources Political and Social Partnerships Patient Identification and Mobilization Fund Raising, Publicity, and Social Media Comprehensive Cleft Care Building Capacity and Sustainability References 41: Creating a Culture of Care and Safety Introduction Team Components and Dynamics Adapting the Multidisciplinary Team Care Concept Anticipating Adversity Partnering with the Community Quality Assurance in Outreach Settings Credentialing Mission Preparation Emergency Response Protocols Preoperative Screening and Case Selection Perioperative Care and Safety Protocols Schedule Surgical Safety Checklists Postoperative Care Outcomes Evaluation, Capacity Building, and Sustainability Conclusion References 42: Strengthening Surgical Systems Through Cleft Care Introduction The Role of Surgery in a Health System Strengthening of Surgical Systems Through Cleft Care Service Delivery Human Resources Infrastructure Information Management Finance Governance Future Directions/Call for Action Overview Quality of Care Access to Care Conclusion References Afterword: The Wonder of the Smile Index