Management of Rare Craniofacial Anomalies in Charity Missions: Community-Based Solutions

摘要

In poor communities, patients may suffer from health conditions requiring special management that are not available locally. Missionary visiting teams have attempted to address these issues in collaboration with local healthcare authorities. Children with craniofacial anomalies represent one of these challenging issues. Here we present the senior author’s experience in management of rare craniofacial anomalies during missionary visits to Yemen highlighting outcomes of management of rare and challenging craniofacial anomalies using simple techniques of soft tissue repair adhering to the community limitations and lack of facilities. Introduction Patients suffering from conditions requiring specialist intervention cannot obtain treatment when facilities do not exist locally. Specialist visiting teams in a number of surgical disciplines have attempted to address these issues in collaboration with local clinicians. These interventions require careful planning and communication to achieve optimum results (1). Children with craniofacial anomalies comprise a diverse group of patients, with problems involving many organ systems. In the past, no satisfactory treatment was available for many of these problems. Though the contributions of Tessier and many other innovators together with multidisciplinary team approach are now offering substantial improvement in the management of those patients. The best reconstruction for any given patient can be determined only after a careful analysis of the patient's problems and the patient's and family's wishes (2, 3, 5). Unfortunately, management of these anomalies in underprivileged communities may be a real challenge because of the rarity of the qualified craniofacial surgeons, lack of multidisciplinary team approach and deficiency of facilities needed for adequate diagnosis and treatment. Yemen is a country with rich history and culture but political conflicts during the last four decades have caused severe economic downturn that negatively affected healthcare level. This article describes the experience of two Saudi volunteering plastic surgeons with the rare forms of craniofacial anomalies that had to be treated according to the very limited local resources. It discusses the possible approaches to these malformations based on local resources in these underprivileged areas of the world. Patients and Methods: This article represents the senior author’s experience (Dr. Fadaak) in treating rare craniofacial anomalies in different Yemeni cities in 35 charity missions over a period of 15 years from 1997 to 2011. A total of 5100 plastic surgical procedures were done during this period, the majority of the cases were cleft lip and/or palate and post-burn contractures. Rare craniofacial clefts were met occasionally and a total number of 33 cases were seen during these visits with age range from 9 months to 29 years. Surgeries were done for 14 cases only. All diagnoses were based only on clinical examination and intraoperative findings. No imaging techniques were available before surgery. The spectrum of cases included syndromic craniosynostosis (Apert syndrome=3, Crouzon syndrome=2), proboscis lateralis (n=1), double upper lip deformity (n=1), holoprosencephaly (n=1), and a variety of rare Tessier clefts both isolated and mixed (n=25). Because of the conditions of charity missions, surgical treatment was always tried to be performed as a one-step procedure. Additional surgeries were discussed with the patients and families but none of the patients could be seen again except for one patient who had a second surgery during the same mission two weeks after the first surgery.The cases operated upon were registered by the local doctors before being evaluated by the visiting plastic surgeons. Lacking the experience in this field - as none of the visiting team was a craniofacial surgeon - and limited resources decreased the chance that patients would get the optimum management. The question at that time was eit