Dr. Travis Tollefson discusses cleft and craniofacial surgery.
Hi. Good morning and welcome to our Facebook live where u C Davis health experts share with you information that you want to know. I am Pamela Wu. And with me today is Dr Travis Tollefson, professor and director of facial, plastic and Reconstructive Surgery in the Department of Otolaryngology. Today we'll be focusing on cleft and craniofacial surgery. It's a field that gained notice in the best selling novel and hit movie. Wonder. If you have questions, please feel free to post them in the Facebook comments and will answer them toward the end of the discussion. Doctor, tell us, Um, good morning, Good morning. Thanks for being with us. Um, tell us a little bit about the work that you and your team do. I guess we should start with the basics. What is otolaryngology? That's a great question when medical students have decided to go into otolaryngology. The first thing I have to do is to learn how to pronounce it, and so there's all kinds of terrible pronunciations, but it's easy way to think about it is the full names otolaryngology head neck surgery, and so it's divide. It's divided up into six sub specialties. All the way from Pedes, E and T and facial, plastic and reconstructive surgery to head and neck surgery. Sinus and skull base surgery, ear surgery and basically everything from the head and neck for surgical reconstruction. And you can think of it as the specialty for communication because we deal with snow and hearing swallow speech, and we have our ophthalmology colleagues who handle the vision part. But there's a lot of your senses in there. That's right, and e m t stands for Ear, nose, throat. That's right. Yeah. All right. Um, what don't people know about this specialty? Well, I think the biggest surprise for a med student or a rotator that comes through is they don't They had no idea that it wasn't just about coughs and earwax and hearing loss and things. They come in and they say, Wow, we cover the entire gamut of surgery for intercon surgery like thyroid surgery, a child that's born like we're gonna talk about from birth until a 96 year old who has a cancer on their nose and has their nose reconstructed. So that's the best part about head neck surgery is that we get to treat all ages and all kinds of different problem. I don't know if there is a typical day for your team, but what does a typical day or sample day look like? We have such a great team on the reason our team so great is we just have a diverse group, um, of professionals who care so much about each of these kids and the kids air not on an island there with their families and with our psychologist are social workers are speech language. Pathologist also coordinates our team. Um, Dr Sprague Cinder started the team way back over almost 30 years ago, and so we get to work early and we start to review the cases, uh, in a core conference that starts between seven and eight oclock and we'll go through cases that might have fallen through the cracks because of an insurance issue or other problems. And we're the net, the safety net that catches them. And then between the surgeons and the nurses and the rest of the team, we get them back on track to get the best care. Then we start seeing kids on a Wednesday morning around 8 30 we have 12 rooms. And we have, um, dentists, oral surgeons, orthodontists, hearing specialists. Everyone's going through. Then we meet at noon and as a team sitting around a big table, it's kind of like a dream. If you ever had a patient, a family member with illness, wouldn't you want to have 12 professionals all see that your family member, then get together and come up with a plan to get everyone talking about you have a lot of you have a lot of people on your side is a patient s. So what are some of the more complex procedures that you do? I was thinking a little bit about this. Um, you know, it's complex from a surgical standpoint to take a muscle from the leg and a nerve from the leg and give back a baby or a child that's born without the ability to smile. Um, those procedures air stage. They're done over a year, and it's a big, technically difficult procedure. Um, on the other hand, a cleft lip repair or something that could be done under two hours, but technically every millimeter that you operate on has an effect on the child for the rest of life. Life changing? Yeah, And so the complexity for the parents is it doesn't matter how hard it is for the surgeon is that they want the baby to come out and to progress into a normal life, live a really full and productive life. Um, is your patient based, mostly Children? You see adults to, uh, so we have a division of pediatric e and T that sees all pediatrics. Um, there's this group of patients that have a cleft palate or a creamy official disorder. And when they reached 21 California Children's services, other insurance has stopped covering them for what they were born with. And so that whole subset of adults with cleft lip and palate they need care to. They have hearing issues, speech, swallow, smell on DSO. They also come through clinics. So I have about a 50 50 split of adults and Children, and I think it's perfect because there's not a lot of difference between 85 year old on a toddler. When it comes to sitting down and talking, they have a view of life that's different than the rest of us. Fascinating. Um, tell us what For those who don't know. Tell us what cleft palate is. So, uh, it's actually even in the medical profession really hard to get the message across, because as soon as the baby is born, everyone's looking through and trying to make sure everything's OK. How many fingers when a baby opens the mouth and you see a little get a little slit in the mouth from the top of the power right here. Actually, if you take your tongue slip right here, Yep. Push it up to the back of your teeth on slide back. And as you feel that there's a space there and that is the palate goes from the hard palate from the front of the teeth all the way back to your villa. You villa moves back and forth when you're singing and you can see it in the mirror on a cleft palate is simply unzipping that never closed when the baby was in the mums uterus. So, around 30 days of gestation inside the wound that how it starts to close and when it doesn't close about one in 1001 in 1000 live births in the world have a tough path. What an incredibly impactful repair. You said you could do it in under under two hours, but if I'm prepared, it really changes the quality of someone's life. I mean, from from the moment of infant is born right, they probably of nursing issues or we're feeding issues can imagine. Yeah, frustration of a mom who's trying to breastfeed. I work all over the world as well, And so sometimes we have cases where they weren't able to have a repair. And you have a nine year old who was brilliant reading books, doing everything but their speeches so bad because they never had the surgery. And so it's just catch them back up and allow them to have the way to communicate like we're doing right now. Um, moms and parents tryingto breastfeed with a baby with a cleft palate. It's just really not possible to create section, so we have specialized feeding their specialists Bola eyes, ours here with the university and Christine or office or a cleft teams speech language pathologists. The two of them worked together to make sure these moms were supported on using these specialized cleft bottles. It was reading statistics that say that a relatively small number of Children are born with cleft palate in the United States, the numbers air higher outside of the US Why is that so? I think when it comes to measurement in the US we have very accurate numbers because every child that's born has those numbers going to a giant registry. So we see, uh, numbers about one in 600 Glad births have a cleft lip, with or without the cleft palate, while if it's just a cleft palate on the inside is only one in 1000. Uh, I work in Zimbabwe, and there the rates are much more difficult to capture because a lot of the babies were born out in areas where there's no nursing. Sure, and there's no numbers e. I don't think it's accurate to state there's a big difference. The highest numbers from ethnic standpoint are Asian and Latin American communities, and that's whether it's in the U. S. Or in South America or in Southeast Asia. Interesting. So it's that the numbers, the numbers aren't necessarily reliable, they're not measured accurately. Okay, Um, what implications do these, um, statistics, um, have when it comes to the untreated cleft lip and palate. A lot of physicians such as yourself, travel outside the US you know, there's, Ah, drive to help, and in medical students and residents and fellows that are coming to interview all of them want to go and contribute their skill set. And I was thinking about it. You know, there's a fine line between going and visiting someplace on a vacation and doing a little bit of medical help and someone who's dedicating themselves to making a change in a different space. And so that field is called global surgery. A lot of people think of Smile, Train and these other organizations. Um, what I've kind of shifted into is to support surgeons in those countries because there's brilliant surgeons and teams that could do the work, so we support them with education. Um, and from from a standpoint of what global surgery has kind of moved into, it's in a it's in a support structure to help build the capacity. What I mean is that if you're born with a cleft palate in a small rural village in in, uh, in the Andes of Ecuador, you have to get down to a hospital where you can have safe anesthesia where you can have the oxygen and be able to recover safely s so that you can have the procedure done. The surgeries could be done safely, but you might not always have all the things you need to make sure that it's safe. So these are the priorities for us when it comes to working with our colleagues overseas. You know, it's a little bit like when you have a skill set you could build houses, you joined Habitat for Humanity and you go and you give and surgeons and pediatricians, anesthesiologists, we all. We were just filled up with this new knowledge. We haven't want to share it. Yeah, absolutely. I mean, for the benefit of so many patients were discussing cleft and craniofacial surgery. Today. We're talking with Dr Travis Tollefson, professor and director of facial plastic and reconstructive surgery in the Department of otolaryngology. And please feel free Thio. Ask questions in the comments. If you're interested in having Dr Thompson answer one of your questions to get a little personal, what is that like for you to travel and meet these families and patients? What is that experience like? I don't say that my home here in Sacramento and the patients that I take care of here. Some of them come from environments that air clear by the Oregon border on sometimes they struggled themselves to have health insurance and assistance and coverage. So it's not much different for me to be working in an environment where someone comes in for some medical mission type surgery work. Then the work we do here, and another big control component of this for me is I was born in a rural Kansas town, and in this little town we also had doctors that had toe fly in just to see us. So I honestly don't think it's changed. I just was. It's normal for me on DSO. The best part about it is, is that when you make those relationships, it's all about relationships, and for me, it used to be relationships with families. Um, you meet a mom and her baby surgery goes well, and the Ecuadorian surgeon and I walk out, and the mom is so grateful, that's about me. What I'm shifting towards and I'm hoping that the medical Mission community could doom or of is shifting it to building the infrastructure of the surgeons in the countries who work in because we're all equal than and that would be more about us giving to build their strengths. More about that. Yeah. Um, what is the difference in the quality of life of an individual who has cleft lip or palate in the U. S compared to outside the U. S. So you can imagine I have a friend that worked for seeing international, and she did stories in Zimbabwe on our families, and she would follow them back to the villages. And, you know, part of the kids would wear different scarves around the mouth. They would stay indoors and not go to school. They would just be ostracized or shamed. There was all kinds of stories told about why they had this problem and the mothers would feel guilty. And I mean, that's not in the past. That's riel. And one thing we have here is that CCS sponsors takes care of these kids so that when they come in, we're able to make sure that a cleft lip repair can be done between two months and five months of age. Cleft palate repair could be done by a year of age, and we don't have kids that fall through the cracks. Yeah. Um, for me, the priority is to be ableto tryto have I talk to moms and dads about I want your kid when they go to prom to stand with pride and do you have confidence? And that's all The work we're gonna do between now and then is to get to that moment and then for them to pass on that in the futures. That's wonderful. Um, we've been talking a lot about cleft lip and palate, but what other types of surgeries do you perform? I really, honestly have the greatest life. The greatest practice you could imagine my department chair, Greg Farwell, has before him. Hill Brody has supported, uh, building the full range of facial, plastic and reconstructive surgery. So, like I said, walk into clinic and have a newborn. They're with a mom and a scared dad with a baby with a cleft lip. And then I'll go to the next room and have an adult who's had a skin cancer in his last facial movement. And so we're working to rebuild the movement of the face way. Take care of the car accidents and, um, the nasal obstruction patients that have problems after breaking their nose in sports. My patients range in all ages and all kinds of complaints. Bond. The best part about my job is I collaborate. So we have different departments that we work together with within my own group. We do micro vascular tissue transfers, like taking parts of the leg or arm and helping to rebuild the nose or a jaw. We work with our three D printing lab and our colleagues at U. C Davis undergrad to kind of take technology to its next level and be able to plan everything we dio and it's the art and the science really come together. I saw the story about a patient that you helped to treat named Fernando, and there is a picture of him on our Facebook page, and he has Treacher Collins syndrome, which is the condition that was highlighted in the book and movie Wonder. And your team has been really instrumental in helping Fernando. Can you tell us a little bit about how you first started to work with him and what you've been able to provide him with these past few years. Yeah, I think it's probably worthwhile to say, uh, Fernando's story is one that I didn't expect to go this Well, it was around two in the morning when I got a page. There was his birth near Woodland, and he was life flighted here. And during the time, the courageous nurses had been, uh, using different techniques to keep him breathing. When I walked into the operating room to Fernando was able to fit in barely two hands, and we were all very worried that he wasn't gonna be able to make it. And in a split second decision, a few of us came together and place toe tracheotomy on and opened his airway so he could breathe. And then we just watched him grow since then, and his mom was having difficulties after her after the birth. And so when she finally got over here and the family was put back together, we got to see this personality and Fernando and our team has been taking care of him from a hearing standpoint because many kids with Treacher Collins will have, uh, not only the appearance of the ears will be low set and a little different looking. But also hearing loss is really common, and so are audiology. Team is top notch. They provide these bone anchored hearing aids. They go on like a strap like a Adidas headband but watching a soccer game. But the hearing aids are stuck on there. And so Fernando wears those. If you see him in his pictures, his tracheostomy site has to have care. Um, with our trick team way, Look at his airway through our pediatric anti group. And then we've been working on getting towards building his jaw so it could be stronger and he could start using it better and opening it more so we could get to his cleft palate and the other issues. And he's about preschool age show. Yeah, you know, there are charming Children and they'll just capture your heart. It's sometimes the kids that are really sitting back and scared that you once they feel trust. Then you walk in the room, and then you could barely keep him under control. And Fernando is one of those, uh, once you gain his trust, Uh, and just to watch how his family cares, loves and interacts with him, and so our team is really we feel blessed to be able to take care of him. And that's why you see so much when we take pictures with him and spend time with him because we're so inspired by him and his family, the story is completely inspiring. You said that he was helicoptered here from Woodland. I believe so. And so it's thanks to these partnerships that we have with area hospitals that were able to treat patients like Fernando. Do you receive a lot of patients via referral from our partner institutions? We do. This is absolutely a priority. I would say it's really hard as a physician to see the patients and try to communicate back to those referring in. But we realize we're a network. U. C Davis is not in Sacramento way. Reach out and we have our arms open to be ableto have referrals come in from from Reno and from the the North. Clear put the Oregon border from renowned. The best part about our referral system is that we put in a lot of time to try to get them in and to get their authorization. What we really need to do is to make sure we can provide feedback back to the doctors that are referring in, and that's our goal. And we've been sending out, you know, programmed letters to make sure that all these refers know how much we appreciate the referrals. But secondarily how those patients are doing yeah, wonderful to follow up with them. Um, my final question is whether there is any way to prevent some of these conditions that you treat, whether it be Treacher Collins or cleft lip and palate. So this is the most common question on if you're a parent and your child has a cleft palate or other Korean official issue, you want to know whether there's something that you did or something you could do in the future to protect from having this problem. Um, and there there's a lot of work going to try to find that there are genetic causes, Uh, for Treacher Collins. It's a few genes that have been identified. A T East. 80% of those cases that have the gene problem will have an autism of dominant inheritance, so that means that if they could pass along the gene in the family on the other hand, cleft lip and palate, which is the most common thing that you would see. Um, those are not typically related. In fact, most of the numbers, Aaron, the percentages like, 3% chance that you might be able to pass it along to your child. Um, when it comes to prevention, we just highly recommend the nutrition avoidance of alcohol and tobacco. There are some seizure medicines that have been shown to increase the risk of cleft palate, folic acid and multivitamins. So it's prenatal care s. So it's a good prenatal care. Exactly. And there is otherwise no proven risk factors that we could advise parents to avoid, or also to medications or other supplements they could take to prevent it. Okay, um, this is Dr Travis Tollefson, professor and director of facial plastic and reconstructive surgery in our Department of otolaryngology here at U. C. Davis Health. Thank you, Dr Thompson, for being with us today. Great conversation. Thank you for joining us for this u C. Davis health. Facebook live. If you have questions, you can continue to leave them in the comments and also feel free to share this post. If you have family or friends who would be interested in learning more and for more information, you are always welcome to visit our website at health dot u c Davis dot e d u. Thanks again for joining us.