This one is about: Q&A Chat with Dr. Canady, January 30, 1998

(c) 1998 Wide Smiles
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Disclaimer: The opinions expressed here represent an academic opinion about the general care and treatment of patients with craniofacial disorders. No attempt was made to practice medicine in any form, nor was there an attempt to treat individual patients. Any opinions or views expressed were general in nature and not specifically addressed at any particular person. If you desire an individual opinion a physical exam will be necessary to render that opinion. If you cannot get adequate help in your location, you may call 319-356-2168 and ask Karen to make an 
appointment for you.

Note: Joanne Green is moderating the chat.

Joanne: I think we can get started now, Dr. Canady -- thank you for being here tonight. Are you ready to start? Kristi has our first question tonight.

Kristi: My question has to do with columella reconstruction. My PS is planning on doing a columella reconstruction with cartilage from left ear sometime this year. Before he does, he wants me weaned off the nasal tubes.

Dr. Canady: What nasal tubes are you using?

Kristi: Experience in the past has told me I can't do a total wean and we tried it right after my surgery in Sept.

Joanne: Kristi - maybe some background would be important here, since your case is so unique.

Kristi: I am using 12 FR and 14 Fr right now.

Dr. Canady: ok

Kristi: I have had total nasal reconstruction and in the past have had two columella detachments. I've been using nasal tubes for most of the last 19 yrs. PS wants me weaned off of them before surgery. Because he doesn't want the pressure of the tubes on them on the columella

Dr. Canady: I understand that.

Kristi: My question is - would it really matter when it is done?? Because I am going to more than likely have to use something to keep the nostrils opened afterwards.

Dr. Canady: Generally, grafts fail because of three main reasons -- inadequate blood supply, shear (mechanical trauma) or infection (goes along with low blood supply usually). Without knowing the entire story of your case, I would suspect that the surgeon is trying to maximize his chances of success by minimizing the potential trauma to the graft as you stated. As long as you are weaned as much as you can be before surgery, that is probably all you can do.

Material on the stents to hold them apart and away from the columella...an anaplastologist or maxilofacial prosthedontist could probably help. I use them occasionally and they have some great tricks. Is that kind of what you were looking for?

Kristi: I go to see him next week for follow up. Looks like we will be having a talk about this. Thanks :-)

Dr. Canady: No problem.

Kristi: Jen you are next :-)

Dr. Canady: Hi Jen

Jen: Hi, Dr. Canady! My daughter will be 17 1/2 months when we do palate repair in March and her PS would like to do outpatient surgery, this makes me a little nervous. Do you have any ideas on this? Is it a common practice now or should I be concerned?

Dr. Canady: I know that in CA there has been a movement toward doing more and more primary repairs as outpatient surgery. A lot of times this is actually "23 1/2 hour stay" surgery which means you get to stay overnight and go home in the morning. I have not had that kind of pressure from the insurance companies.

Jen: Her Ps says that we will go in early morning and should be out by late afternoon.

Dr. Canady: I work with yet and I still admit palate repairs at least overnight for airway observation and to watch for bleeding. I do not think that your surgeon is wrong, and he may be doing that based on his/her experience. I don't have that many kids who would meet maintenance po [Note: Passed Orally] requirements that quickly after palate repair.

Jen: O.K, so maybe I should plan on overnight anyway maybe?

Dr. Canady: I would guess that you guys have talked about what will happen if your daughter is not drinking enough to go home.

Jen: We have not yet had our Pre Op appointment.

Dr. Canady: I am a big believer in a plan B and I would just ask what will happen if your daughter doesn't meet discharge requirements...

Jen: Thank You! I have one more quick one.

Dr. Canady: Sure

Jen: As everyone here knows!! Sarah does not yet have any teeth. I am pretty obsessed by it and was wondering when and if I should really get worried?

Dr. Canady: It is really common for kids who are born with clefts to have a delay in dental development to one degree or another. Some delay is present in almost 100% of my practice. It is hard not to get worried and if your dentist is concerned they can get some X-rays to see what is up there. The down side is that there is some radiation dose from that and even if tooth buds are seen on X-ray, it is difficult to predict if they will be healthy teeth when they are fully formed. In our clinic, we have, on occasion, taken films just to prove that there is something up there, so that discussion with your dentist would probably not be the first time he has had to talk about it in that setting...ok?

Jen: Thank you very much!!

Dr. Canady: Absolutely!!!!!!

Dr. Canady: ok, Joanne.

Joanne: My son Joey (age 10) is having bone graft on Feb 25 -- it's the first time we have had surgery during school -- I was wondering how much school he can expect to miss, and what sorts of restrictions we will need when he goes back (I am looking for optimal probability of success here and am willing to be more restrictive than my PS requires).

Dr. Canady: As you know, the bone graft goes through a remodeling stage that takes longer to complete than the initial phases of soft tissue healing. In my practice, I usually keep the kids out of school until I see them back for the first check (about a week) and then I kind of let the parents dictate the return because I feel that they know the situation at school for their kiddo better than I do. I personally believe that hard blows to the site of the bone graft in the first 2 to 3 months after the graft can cause some resorption, but in this age group, I don't have a foolproof plan to prevent that. I wish that overall bone grafts were a more reliable operation. We've looked at adding growth factors (transforming growth factor beta 3 to be exact) in an animal model and that seems to help, but I don't know that it will be ready for trials in humans anytime soon. Done.

Joanne: Ok - so am I looking at no recess or limited PE for a period of a few months? Joey is very athletic and active and I want to protect that bone.

Dr. Canady: Some of my parents have their kids wear face masks (like hockey or football helmets and face guards) when they play and that is ok with me. Your surgeon may have a different protocol than mine, but that is what I have done for a number of years with the kids I care for.

Joanne: Ok, thanks - - maybe I can just give Joey a choice. Thanks so much. Cindy has a question for you now.

Dr. Canady: Hi Cindy.

Cindy: My first question has to do with Branden - 5 months old with a bilateral cleft lip and palate. His lip repair scheduled for Feb.24. Our PS wants to start lengthening the columella then. Have you heard of this being done at this early stage? Also, will there be any long term problems caused from this? Meaning will there still be enough tissue left to lengthen the columella when he gets older?

Dr. Canady: There are a number of described techniques to repair a bilateral lip. Court Cutting at NYU has described a technique in the last couple of years that some people use to gain some length early on - so what you are talking about is done by some folks.

Cindy: ok

Dr. Canady: As to whether there will be enough tissue left, that really depends on the individual case and I would have to see your kiddo to make that call.

Cindy: You mean see him in person? He is in the gallery!

Dr. Canady: I meant in person because I really like to push and pull on the tissue a little when I am making that judgement - different patients have different laxity of their tissues and I think that can be important when deciding what to do. Sorry I can't do better than that right now.

Cindy: I thought that was what you meant, but you can't blame me for trying, right?

Dr. Canady: Not at all, you're just a good concerned mom looking out for her kid and I like that...

Cindy: Ok - Thank you, Dr. Canady.

Joanne: Thank you, Dr. Canady -- Melissa has a question for you now.

Dr. Canady: Hi Melissa

Melissa: I have a 2 y.o. w/ Sticklers and 2 unsuccessful soft palate cleft repairs. The 2 repairs dehiscensed about a week following each repair, most likely due to the amount of tension on the repaired palate. The cleft is about 1" in length and 1/2" in width beside her uvula. Speech is hypernasal (no plosives). We went for a second opinion today with a different plastic surgeon. I was very interested in a "Furlow" technique. He said that the Furlow would create a lot of tension and given that she has A LOT of scar tissue already. He is suggesting another technique very similar to what has failed twice before. (Done more carefully, now and with some revisions). I am skeptical. Do you find that the Furlow does create a lot of tension in a small palate? Basically, he said the Furlow will put a lot of tension on the palate and obviously, Hannah doesn't heal well with a lot of tension.

Dr. Canady: First of all, we all have our cases of "delayed healing" (I am ever the optimist...). With revisional palate surgery, scarring does come into play as you have mentioned. Any of the described techniques can have some tension and there are some reports in the literature that describe a slightly higher fistula rate with the Furlow technique. The main advantage of the Furlow is the reorientation of the levator....and exactly what this advantage is is still of some debate. The levator can be reoriented and pushed back with other techniques besides the Furlow and I don't believe that anyone knows which is better at this time.

Melissa: Ok, thank you. We are seeing yet another PS, I will be back to ask more after that visit, too. Thanks very much.

Dr. Canady: There are a number of techniques that can be done to reduce tension at the time of repair and you should discuss how your surgeon is going to approach the revision. If you are unable to get the palate repaired soon, you should have some plan for an obturator or other prosthesis to aid in speech production even if only for the short term so you child can begin to make more normal speech sounds.

Melissa: He said that he would do several things differently than the first 2 surgeries were done. He explained them and how they differed from the other 2. He would be able to do the surgery this summer. He would basically do a total revision of cleft repair, but doing some things differently to reduce tension. Nothing was mentioned about appliances, he said that waiting for 4 more months wouldn't make a difference in speech. What do you think?

Dr. Canady: Again, in a 2 year old who is having a hard time getting the palate to heal, I would think about some use of a prosthesis before that child gets too much older to try to reduce the development of compensatory speech patterns. I am not a speech pathologist and I have not heard her speech sample so I would have to defer to those who have.

Melissa: Sorry this is long. He also said that regardless of technique he believes that we only have a 50/50 chance of adequate speech due to the scar tissue.

Dr. Canady: I do believe in waiting approximately 6 months between attempts, though, to let things soften up a bit before a revision is done.

Melissa: (until she is of an age to get a pharyngeal flap if needed.) It has already been 13 months since the last attempt.

Dr. Canady: I would agree that there are some critical times for speech acquisition. Sorry I can't be of more help.

Melissa: I appreciate your suggestions and it gives me questions to ask the PS's that we see. Thanks very much.

Joanne: Thank you, Dr. Canady -- Marti has a question for you now.

Marti: I have some speech-related questions. I am a 43-year-old woman who was born with a unilateral cleft lip and palate. I have no insurance right now, so I am unable to be evaluated for velopharyngeal insufficiency and/or fistulas, but I am concerned about what I think is probably hypernasality. I'm also concerned with some articulation problems. My t-sound is more like a tch-sound. Also, sometimes I hear what sounds like air escaping when I speak. As I really like to have some exercises I can do on my own to improve both tonal quality and articulation. Also, I would like your opinion on what you think the probability of success would be of surgery to correct these problems at this late date, and what type of surgery would likely be best.

Dr. Canady: It is difficult to recommend specific exercises without hearing you and I know that doesn't help much. In order to judge whether surgery would help you probably need to have at least 2 things done -- a subjective evaluation by a speech therapist and a videonasendoscopy to look at your palatal function. For the speech eval you might want to check at local colleges and universities for speech programs and at least get an evaluation there. Sometimes people with a history of clefting and you could work out some kind of deal with them. It is true that correction of VPI is not as successful in more mature patients, but this is not absolute.

Marti: The nearest university with a speech and language department said the only way they could do a speech eval. on me was for me to get the videonasendoscopy done first, which I can't afford right now on the pay of a substitute teacher. I guess I was just hoping there was something I could do in the meantime. Thanks!

Dr. Canady: I would make a few other calls -- it is not unreasonable to have someone listen to a patient before videonasendoscopy is done. You may have a phone me specific problem that would be helped with therapy. Don't give up just yet. Good luck.

Marti: Ok. I'll try some more calls. Thank you.

Joanne: Thank you, Doctor -- Cindy has another question for you now.

Dr. Canady: Hi again Cindy

Cindy: Ok 2nd question also about Branden (5 months) bilateral cleft lip and palate. Our pediatrician thinks there is thrush under his latham pin device. There is only one medication that would get rid of it there and it would make him vomit. He also has reflux so she does not want to use this drug. I talked to PS about it and he thinks the device should be removed 1 week prior to lip repair. I don't want him to go under two times in a week. If the pin device for 4 months and it will be 5 when the repair is done, also it has been suspected that the thrush has been there almost since the device was done.

Dr. Canady: Sorry, I think I missed the question.

Cindy: If there is thrush will there be a problem with the repair - will the thrush cause problems? If there is thrush could there be tissue damage in the palate?

Dr. Canady: One of the causes for any problem in wound healing is infection...bacterial or fungal. It depends a lot on the severity of the infection, but I have cancelled kids for both bacterial infections and for thrush. As you probably know, the Latham device has both its fervent supporters and its vocal detractors. The orthodontist on our team is not in love with active orthopedics and we don't do much of it so I don't claim to be an expert on the Latham

Dr. Canady: Surgeon take a look at the status of the palate and the thrush a few days prior to surgery if you are concerned (and it sounds like you are....)

Cindy: The PS said that the thrush could be treated for a week prior. I am just concerned about him going under twice in a week.

Dr. Canady: Thrush is usually pretty responsive to treatment, I would agree with that. Sure -- I am on your side about minimizing anesthetics, but you have to just take each case on its own.

Joanne: Thank you for your response. Sharon has a question for you now, Dr. Canady.

Sharon: Hi Dr. Canady :-) My name is Sharon, I am 29, and I was born with a bilateral cleft lip and palate (hard palate involvement only). I am currently in nursing school, graduating in 16 weeks. (YIPEE!). My question is - How much luck would it take for a recently graduated nursing student to get in on one of the teams for either Operation Smiles or Interplast. I am very interested in "giving back" by donating my time to...

Dr. Canady: That's a great question and a great idea. I am leaving for the Philippines in a couple of weeks and I really enjoy my yearly trips. I have gone with Op Smile

Sharon: Looking for a willing accomplice????????? :-))

Dr. Canady: For the last 5 years, and they require that you have a nursing license to go in the capacity of a nurse. If you call Karen in my office at 319-356-2168 on Monday, she can give you the number of the OpSmile office in Norfolk and if you need a letter of recommendation, send me your CV when you have finished school and I'll write one for you. You're welcome to go with us anytime.

Sharon: Thank you so much Dr. Canady!!!! I have been looking forward to doing something like this for years!!!

Dr. Canady: I just ran into a woman who had "graduated" out of our team about a year ago and she was interviewing at University Hospitals for a job, having finished her RN.

Sharon: Another CA adult?

Dr. Canady: Yes. She had been treated by our team for 18 years (bilateral lip and palate)

Sharon: Oh my goodness...It seems like we clefties are drawn to this type of work...Thank you so much again!!

Joanne: Thanks, Dr Canady -- and Good luck, Sharon -- it's something I've dreamed of doing, myself. Shannen has a question for you now.

Dr. Canady: Hi Shannen

Shannen: Hello Dr. Canady My husband and I are in the middle of adopting a 9 month old with a cleft lip and hard and soft palate my question is: Is there a bigger chance of the soft palate coming undone than the hard palate? He had the hard palate closed but the PS couldn't close the soft palate at the same time and some of the hard palate came undone.

Dr. Canady: The usual sites of fistula formation in cleft palate repairs are at the area of the alveolus and at the hard/soft junction. At the alveolus, there may not be enough tissue to get a multi-layer closure and tension is the usual culprit at the hard/soft junction.

Shannen: So when the soft palate is closed it is possible for it to open at this junction?

Dr. Canady: Usually it works the other way, ie., there are techniques where the soft palate is closed first and then later the hard palate is closed -- closing the soft palate first can draw the edges of the hard palate closer together. That answer goes with your first statement. And, yes, the hard/soft junction can open after soft palate closure.

Shannen: So is he more likely to have this happen due to the fact that the hard palate was closed first?

Dr. Canady: Again, it is a little hard to say without actually seeing him. I wouldn't be able to say for certain that it was more or less likely.

Shannen: ok Thank you Dr. Canady :)

Joanne: Thanks, Dr. Canady -- Brian has a question for you now.

Brian: I am 35, I have a bilateral cleft lip and palate, most of it has been repaired

Dr. Canady: ok

Brian: I saw a Plastic Surgeon a couple of months ago because I was concerned about my speech. He recommended a pharyngeal flap. I am a little bit leery about that because I afraid of some of the complications. I know that there are other options available, what would you recommend?

Dr. Canady: The management of secondary speech problems is a complex topic and the approach our team uses tries to sort out who would benefit the most from the available options. It seems to be the current thinking that not everyone needs a pharyngeal flap and that some people will benefit from a Z plasty in the palate or a sphincter type procedure. We use a combination of subjective speech eval (by a speech therapist), nasometry, and videonasendscopy (reviewed by me and the speech therapist together) to make a recommendation. I couldn't in good faith say what was the best option for you without seeing you and the results of those tests.

Brian: I understand.

Dr. Canady: The comments I made earlier about managing speech in patients past their early years makes cases like yours all the more complex. (probably not what you wanted to hear, but true, at least in my opinion (for what
that's worth!!!)

Brian: I agree. I wish I had this taken care of when I was young.

Joanne: Thanks, Dr. Canady -- Cindy has another question for you now.

Dr. Canady: ok Cindy

Cindy: Hi again Dr. Canady. My next question has to do with Sarah - 8 years old with unilateral cleft lip and palate. She will be having a sleep study soon. The PS said if it is Sleep Apnea he will detach the pharyngeal flap, but also leave it there. I assume this means connected to the soft palate. Is this procedure successful in preventing sleep apnea and also will the flap still have the same results that she is having from it now?

Dr. Canady: Good question... Secondary management of flaps is very interesting. When we are faced with this problem, we usually do videonasendoscopy to look at the port size from above. Then, depending on the severity of the sleep study, we will either recommend taking the flap down or enlarging one or both ports. This definitely can compromise speech, but some kids just don't seem to tolerate the amount of obstruction necessary to improve the nasal emission. I recently saw one who had significant sleep apnea after a flap done elsewhere and he was mad at his surgeon, but you really couldn't say his flap was too tight because he still had hypernasal speech. I assume that you are far enough out from the surgery to make the sleep study valid.

Cindy: 2 and a half years - is that long enough?

Dr. Canady: There was a report from Oklahoma a few years back that showed that a lot of people with flaps get transient sleep apnea right after the surgery but that it clears up in almost all cases.

Dr. Canady: Yes, that's long enough.

Cindy: It is getting worse the older she gets.

Dr. Canady: I have a low threshold to get sleep studies so I agree with the workup.

Cindy: OK Thank you Dr. Canady.

Dr. Canady: You're welcome

Joanne: Thank you, Dr. Canady - we have another question from Jenny again.

Jen: We just moved to Texas from way up by you, and we have always been told that (our :)) Sarahs cleft extended into her hard palate. Our PS here has told us that it is really just a "tiny notch". If it is truly just a "tiny notch" how would repair be done?

Dr. Canady: Are you describing a submucous cleft of the palate?

Jen: No, I don't think so.

Dr. Canady: Is there a visible opening in the palate?

Jen: She has complete cleft of the soft with this "tiny notch" thing. OH YEAH!!! Very visable!

Dr. Canady: Any one of a number of techniques can be used to close incomplete clefts of the palate. It really depends on the tissue available. The amount of involvement of the hard palate can sway the approach in some 
cases, but there is no one "right" technique for all incomplete (doesn't go all the way to the alveolus) cleft palates.

Jen: Is it likely to be done at the time of soft closure? (as far as you can tell from way up there?)

Dr. Canady: Most of the time incomplete cleft palates are closed in one stage.

Joanne: Thank you -- and now, John has a final question for you, Doctor.

John: Dr. Canady: Thank you for taking the time for this chat. I was operated on in 1958 or 59 for a cleft palate. I finally gave into a long time urge to dig up my early medical history. My parents told me I was used by a surgeon from Germany to demonstrate new closure techniques. Can you give me any suggestions as to where I could find any information about this?

Dr. Canady: You have a legal right to request a copy of all of your medical records. You will need to fill out a release of information form at the hospital where your surgery was done, but (I'm not a lawyer either) it is my understanding that as a matter of law they have to give you the records if you pay for the copying.

John: And if the hospital is closed?

Dr. Canady: Generally the records have been transferred somewhere in the same city.

John: It was part of the SIU school of medicine. Would they still have records?

Dr. Canady: Southern Illinois?

John: Yes.

Dr. Canady: I would contact the social workers there and they may be able to point you in the right direction. If the hospital was university affiliated, I would be surprised if the records are gone -- they might be on microfilm, though, given the amount of time that has elapsed since your surgery. I will ask our hospital attorneys that question.

John: Thank you Dr. Canady.

Joanne: I want to thank you, Dr. Canady, for being with us tonight. You were, Once again - MOST informative.

Dr. Canady: My pleasure. This is fun.

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