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Ryan Hospital Philadelphia, PA

A Tale of Two Palates

By: John Donges Date: Sep 9, 2015

Ruby, a special-needs rescue dogWhen Jenn Clayton met Ruby Sue, a special-needs rescue dog, she had no idea she would be starting a long-term relationship with Penn Vet that would span 18 months and almost 9,000 miles.

Clayton lives in Salt Lake City, UT, and has spent the last 18 years working in animal rescue. She co-founded the Utah Animal Advocacy Foundation (UAAF) in 2002, with her friend and colleague Maryjo Korb. UAAF is a non-profit organization dedicated to the rescue, rehabilitation, and placement of homeless animals.

Clayton and Korb felt there was a need for a rescue organization focused on animals that traditional rescue programs considered “unadoptable.” As a result, UAAF specializes in “special needs” animals, including orphaned newborns, senior animals, animals with behavioral issues, injured animals, and animals with chronic health problems. Clayton is an active foster who has welcomed hundreds of animals into her home.

Ruby’s Story

Ruby was born on December 5, 2013, with a significant cleft lip as well as severe clefts in both her hard and soft palates. For animals with cleft palates, food, fluid, and debris are displaced into the nose, causing infection and inflammation of the nasal passages. When debris ends up in an animal’s lungs, it can result in life-threatening aspiration pneumonia.

Ruby’s breeder found UAAF online and reached out less than 24 hours after Ruby was born.

Ruby, at five days old, and needing special care“With my full-time job, I knew I wasn't in a position to commit to a critically ill puppy needing round-the-clock tube feeding. But I agreed to take her anyway,” said Clayton. “When I saw Ruby for the first time, I felt drawn to that tiny pup in a way that I can't explain. She has completely turned my world upside-down in all the best possible ways.”

Animals with cleft palates cannot eat normally and must be tube-fed, which is how Clayton fed Ruby, starting when she was only five days old. Ruby began to grow and thrive under Clayton’s care. But the tiny puppy would need surgery to repair her cleft palate in order for her to eat and drink normally. Pets with successfully repaired cleft palates can live completely normal lives.

Clayton consulted with local surgeons and was given a grim prognosis for surgical repair. After extensive online research, she contacted several veterinary schools. Some of the oral surgeons she contacted felt that Ruby’s case would be difficult and likely require multiple surgeries. “It wasn’t until I spoke with Dr. Reiter that I really started to feel hopeful,” said Clayton.

In January 2014, Ruby’s veterinarians at Mountain View Animal Hospital consulted with Dr. Alexander Reiter, Associate Professor and Service Head of Dentistry and Oral Surgery at Penn Vet’s Ryan Hospital.

Ruby is fast asleep after drinking a lot of milkPenn Vet is world-renowned for cleft palate surgery, with a proven record of successful operations and other reconstructive procedures.

Reiter felt Ruby's chances for a successful outcome were very good. It is recommended that pets be three to four months old for surgery so they can handle the anesthesia and their delicate palatal tissues can withstand surgery. With that in mind, Ruby’s surgery was scheduled for the end of March 2014, when she was 15 weeks old.

Once the date was set, Clayton started a Facebook page, For the Love of Ruby, to document Ruby’s journey and raise awareness of cleft palate issues. Generous donations ensured that Ruby would be able to make the trip to Philadelphia and receive the surgery she needed. The page is nearing 47,000 followers, and Clayton regularly updates the page to document the journeys of the pets she fosters.

As the surgery date approached, Ruby visited her vet, Dr. Kanda Hazelwood, at Mountain View for preoperative blood work and chest X-rays. Ruby was cleared for surgery, so she and Clayton flew out on March 20 for their biggest adventure yet.

Ruby's surgery was scheduled for the morning of the 25th. The complex surgery took between three to four hours to complete. Clayton was “a bundle of nerves, but simply couldn't feel any better about the team of doctors and students caring for Ruby.” She received regular updates from the team, which helped to ease her mind.

This diagram illustrates the technique for closing the soft palate cleft.

On examination, a 10 mm wide and 9 cm long defect was observed in the hard and soft palate. At the front end, the cleft split into two separate defects like the arms of a Y.

Once in surgery, Reiter used an overlapping flap procedure to close the palate defect. This involved creating a flap from one side of the hard palate that is hinged and sutured underneath a flap on the other side of the palate. The soft palate was then closed by creating fresh edges and suturing them together in two separate layers. The edges of the arms of the Y in the front were cut and sutured together as well.

This diagram illustrates the technique for closing the hard palate cleft.

“One major principle of cleft palate surgery is that the best chance of repair is with the very first procedure,” said Reiter. “If it fails, scar tissue will develop around the defect. Any future attempts at repair then become more challenging because scar tissue is poorly vascularized and unsuitable for making viable tissue flaps.”

Fortunately for Ruby, her cleft palate repair surgery was successful, and there was enough tissue to close the cleft.

It was decided that surgery would not be done to repair Ruby’s cleft lip. Most cleft lips do not result in problems beyond some mild irritation of the nose, and Ruby’s did not cause any significant problems with breathing or eating. “She will always have her unique smile,” said Clayton.

Ruby, post-surgery, wearing her protective coneThe next day, Clayton received frequent status reports on Ruby’s progress. She recovered well overnight in the ICU and had a voracious appetite. She was gobbling up food so quickly that her doctors had to take it away and hand feed her. Ruby’s pain was well-controlled and she was able to leave the hospital that day.

Ruby required close monitoring for the next three weeks. It was critical that she not pick up anything with her mouth, play with toys, or chew on anything. This would give the extensive repair in her mouth a chance to heal as well as possible. Ruby was also put on a strict diet of soft dog food.

“Thanks to the expertise of Dr. Reiter and the rest of the team at Penn Vet, the surgery was a complete success and Ruby has been able to eat and drink normally ever since,” said Clayton.

Pippa’s Story

Fast-forward to February 2015.

Pippa Marie, another special-needs rescue dog, was 10 days old when she entered Clayton’s care. She was in such bad shape that Clayton drove her straight to the ER. Pippa was covered in sores. Her body temperature was a very low 92 degrees, and she only weighed 8.5 ounces, less than she did at birth.

Ruby, with a newborn Pippa

Clayton was certain Pippa was dying, but once she received the care she needed, she bounced back quickly. In addition to these challenges, Pippa also had a cleft palate, running down the middle of the roof of her mouth, which would necessitate tube feeding from Clayton. During her first few days, Pippa was very weak, but she slowly put on weight. From that point on, Pippa continued to thrive.

The cleft in Pippa's hard palate is clearly visible, with some signs of the cleft narrowing.As Pippa grew older, the two sides of her hard palate narrowed to touch in the middle. There was no way of knowing if it would continue to narrow or if it would start to widen again as she grew. In addition, her soft palate also had a significant cleft. After a worrying episode at Mountain View, during which Pippa needed to have her cleft palate cleaned due to persistent debris, Clayton started seriously considering corrective surgery.

She scheduled Pippa’s surgery for July 22, 2015, once again at Penn Vet. She updated her devoted Facebook fans with the following post: “Most of you will recall that this is the amazing place where Ruby had her successful cleft palate surgery last year. We are hoping that Pippa will have an equally good outcome, and be able to eat and drink normally after surgery!”

Within 24 hours of the Facebook announcement, Pippa’s followers generously donated the funds to cover travel and medical expenses for the trip to Philadelphia. Clayton was stunned by the outpouring of support. “I have been sitting at my computer for hours, trying to figure out the right words to thank all of you for the generosity you've shown us. But truth be told, there are no words,” she posted.

After a three-day drive, Clayton and Pippa arrived in Philadelphia. They met with Reiter, who examined Pippa while discussing the surgery. Leaving Pippa was difficult for Clayton. “I was a bit stressed,” she admits. “But Dr. Reiter and the folks at Penn Vet were all as wonderful as I remembered from our first trip for Ruby's surgery last year. I was confident that Pippa was in the very best hands possible.”

Dr. Alexander Reiter examines Pippa's mouth before surgery.Pippa’s surgery went smoothly. There was enough tissue present to completely close the cleft. Reiter again used the overlapping flap technique, but he slightly modified the flap on the other side of her palate to accommodate good apposition of the tissues. Additionally, the left and right maxillary third incisors were removed to prevent any trauma from maloccluding teeth and to provide extra space for proper growth of the opposing lower teeth.

Pippa did well overnight and ate her first meal of canned puppy food in the morning. Her clinical team decided that she should stay at Ryan Hospital for one more day so they could manage her pain and provide another 24 hours of rest before her long drive home.

Dr. Alexander Reiter performs cleft palate surgery on Pippa.

As with Ruby, Pippa could only eat soft food for three weeks and was not allowed to chew on any hard objects while her mouth healed. By the end of July, Pippa was healing “like a champ,” according to Clayton, and has since made a full recovery.

A Special Bond

With many cleft palate cases, Reiter will first hear from owners when their pet is an infant, far too young for surgery. He’ll have long conversations with them even before an appointment is made, and will stay in touch over two, three, and four months, getting updates on the pet’s progress and health.

“A bond forms over time, and then eventually they’re here at the hospital and you finally meet them,” said Reiter. “In some ways, you’re treating not only the pet, but also the owner or family. The best feeling is when everything goes really well and you can make the family happy because the pet has a good chance for a full recovery. We are extremely thankful that Ruby and Pippa found an organization that is able to take such great care of their special needs.”

Ruby and Pippa also found happy endings to their stories. Clayton officially adopted Ruby in June 2014, and is looking forward to their new adventures. Pippa was recently adopted into her forever home in August 2015. There was an instant connection between Pippa and her new owner. Her furry sisters, on the other hand, needed a little convincing, but she managed to charm them both. Pippa will eventually be trained as a therapy dog. The public can follow her adventures on her Facebook page, Peace, Love & Pippa Marie.

“It's bittersweet when these foster babies no longer need our help, and are ready to move on to the next phase of their lives,” says Clayton. “But as I reflect on how far each has come, I can't help but smile.”

Ruby and Pippa