title: Cleft surgery in rural Bangladesh: reflections and experiences.
abstract: OBJECTIVE
  The authors review their experiences during multiple cleft surgical missions to rural Bangladesh from 2006 to 2008. A significant number of patients who underwent primary palatoplasty or cheiloplasty were of adult age or size. Adult primary cleft lip and palate repair is often more challenging than repair at the standard age of fewer than 2 years. This patient population is rarely seen in the United States, but may be treated more often by American surgeons during surgical missions to the developing world. This report discusses the experiences of the authors' treatment of cleft lips and palates in rural Bangladesh.
  
  
  METHODS
  One hundred forty-six cleft-lip and cleft-palate patients were treated during 3 missions to rural Bangladesh, from 2006 to 2008. Thirty-three (23%) patients were of adult size, and aged 13 to 35 years. One hundred thirteen (77%) patients were aged 12 years or younger. Unilateral cleft lips were repaired with a Millard advancement-rotation technique. Bilateral cleft lips were repaired via the 1-stage procedure advocated by Mulliken and Salyer. Cleft palates were repaired using a 2-finger flap method.
  
  
  RESULTS
  Overall, 8 of 146 patients (5.5%) had nonlife-threatening complications (infection or wound dehiscence) requiring subsequent revision surgery. The adult-sized patients had clefts of significantly increased size secondary to patient growth, as well as maxillary expansion transversely and anteriorly. Adult cleft-lip repair required significant soft-tissue dissection to close the cleft adequately, and ensure symmetry to the upper lip and alar bases. However, this procedure sometimes resulted in placement of the lip cicatrix in an anatomically disadvantageous position. In addition, with the increased transverse dimension of the adult cleft palate, tension-free 3-layer closure was difficult. Again, aggressive dissection of the soft tissue was required: the nasal and muscular layers were closed without much tension, but oral closure was often under tension, requiring the assistance of dermal biomaterials to bolster the repair.
  
  
  CONCLUSIONS
  Patients in the developing world often have limited access to specialized health care, and may not realize that cleft lips and palates can be repaired. As a result, there is an increased incidence of unrepaired clefts in adult-sized individuals in this part of the globe. The American surgeon may encounter these patients during surgical missions. The surgeon should be prepared to repair adult patients with clefts that are significantly enlarged in all 3 dimensions. Closure will require significant soft-tissue dissection as well as the use of biomaterials as needed to repair wide cleft palates.
authors.affiliation: Department of Oral and Maxillofacial Surgery, UMDNJ-New Jersey Dental School, Newark, NJ 07103, USA. azizsr@umdnj.edu
authors.forename: Shahid R
authors.initials: SR
authors.lastname: Aziz
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Rhee
authors.forename: Imre
authors.initials: I
authors.lastname: Redai
mesh_terms: D000293:Adolescent; D000328:Adult; D000768:Anesthesia, General; D001459:Bangladesh; D001672:Biocompatible Materials / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D002971:Cleft Lip / Q000601:surgery*; D002972:Cleft Palate / Q000601:surgery*; D003906:Developing Countries; D004210:Dissection / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal; D008493:Medical Missions / Q000458:organization & administration / Q000592:standards; D019651:Plastic Surgery Procedures / Q000379:methods; D012086:Reoperation; D012423:Rural Health; D013524:Surgical Flaps; D013529:Surgical Wound Dehiscence / Q000209:etiology; D013530:Surgical Wound Infection / Q000209:etiology; D013536:Suture Techniques; D055815:Young Adult
chemical_list: D001672:Biocompatible Materials