A New Chapter, a Brighter Smile: Violet's Journey Through Cleft Lip Recovery

By Bernard S. Little Walter Reed National Military Medical Center, Hospital Communications

Healthcare providers at Walter Reed National Military Medical Center (WRNMMC) bring smiles to the faces of families receiving care every day at the flagship of military medicine. On some occasions, these smiles are extra special, especially when they come from the hospital’s youngest warriors.

Nine-month-old Violet Ringer is one of those young warriors. Her resiliency amazes even the medical center’s staff, and it’s comparable to that of service members the hospital has the honor to treat every day.

Violet was born with a severe cleft lip and palate in January in South Korea, where her father, Chief Warrant Officer 4 Nathaniel Ringer, an Army Black Hawk helicopter pilot, was stationed.

For more advanced care, providers at Walter Reed worked with their Military Health System (MHS) colleagues and the Ringer family to arrange for them to come to the flagship of military medicine, Walter Reed, for Violet's care.

“Her primary care provider at Camp Humphreys Army Health Clinic in South Korea made some phone calls and eventually connected us with Dr. Perkins,” said Rachel.

U.S. Army Maj. (Dr.) Jonathan Perkins is the associate program director for the National Capital Consortium (NCC) Otolaryngology Residency at Walter Reed. He is a complex pediatric otolaryngologist who co-directs of American Cleft Palate Association (ACPA)-accredited Craniofacial Team at Walter Reed. The team cares for patients from birth to adulthood, and team members include specialists in speech therapy, audiology, behavioral health, child psychology, social work, dental, orthodontics, maxillofacial prosthetics, genetics, craniofacial plastic surgery, and pediatric otolaryngology.

“Dr. Perkins video-conferenced us to take a look at Violet and said, ‘Yep, we can do this,’” explained Rachel. “We talked to him that Thursday; I got my plane ticket Friday; Monday, Violet and I were stateside; and Tuesday, we were in clinic for Violet’s molding.”

Perkins explained that when a baby has a split cleft lip and palate, ideally the surgery to repair cleft lip is done when the infant is 3 to 6 months of age, and the palate procedure is done when the child is around 1 year old. “Babies can be born with the cleft lip with or without cleft palate [roof of the mouth], or with an isolated cleft palate.”

Clefts are congenital disorders that can cause problems with eating, drinking and speech, if not repaired, Perkins added.

U.S. Navy Capt. (Dr.) Michael R. Andersen joined Violet’s medical team to do her nasoalveolar molding (NAM), a nonsurgical treatment used to reshape an infant's gums, lip, and nose before the surgery. The program chair for the Maxillofacial Prosthetics Department at the Naval Postgraduate Dental School (NPDS) at Walter Reed, Andersen is also program director for NPDS’s Maxillofacial Prosthetics Fellowship and an assistant professor at the Uniformed Services University of the Health Sciences (USU).

Dr. Craig Vander Kolk, co-director of Walter Reed’s Craniofacial Team and a specialist in craniofacial plastic and reconstructive surgery and cosmetic medicine, is also a member of Violet’s healthcare team.

“[Dr. Vander Kolk] has been coming to Walter Reed for more than 30 years, including at the former Walter Reed Army Medical Center that was in Washington, D.C. He’s very good at craniofacial care and has institutional awareness and knowledge from his years of experience,” Perkins said.

Violet’s team also includes Navy Lt. Cmdr. (Dr.) Julia Collazo, who recently earned her certificate in prosthodontics residency from the NPDS at Walter Reed and is the current fellow in the Maxillofacial Prosthetics fellowship.

Violet and Rachel stayed at one of the Fisher Houses on Naval Support Activity Bethesda (NSAB), home to Walter Reed and NPDS, during her workup and surgery at the medical center. Chief Warrant Officer Ringer was reassigned to the National Capital Region in time for Violet’s surgery and now serves as the airfield safety manager, aviation safety officer and aviation mission survivability officer for the Pentagon Army Heliport. The family, including the Ringers’ other two children, 8-year-old Savine and 5-year-old Ryland, now live in Virginia.

A recent study by the Clearinghouse for Military Family Readiness at Pennsylvania State University examined the connection between military-family well-being and mission and military readiness, stating, “Access to reliable healthcare for military families directly shapes a service member's ability to focus on missions and remain ready to deploy.”

Violet’s doctors agreed that the sooner they can get to a baby with cleft lip and palate, the better. Andersen explained that cleft lip and cleft palate are common congenital birth anomalies that happen when a baby's facial structures do not fuse completely during pregnancy. He added that they are among the most common structural birth defects, affecting roughly 1 in 700 to 1,000 live births.

Surgeons want to evaluate babies born with a cleft lip and/or palate at birth or within the first days of birth, although surgery would not be until later. This is so they can plan for closing of the cleft, feeding support, non-surgical molding, and to coordinate a long-term care team. Cleft palate initial repair surgery is a permanent structural closure, but a child often needs additional procedures as they grow.

Andersen said the maxillofacial prosthetics team used a 3D scanner to make a 3D printed “baby denture” to cover the opening and the roof of Violet’s mouth to align her gum tissue before surgery.

Andersen explained that the “baby denture” served a few purposes prior to the surgery, primarily to help decrease the size of the palatal cleft using slow, continuous forces similar to how clear aligner braces work. “An additional benefit of this baby denture included blocking the gap between the oral and nasal cavities and stopping milk and food from going up into Violet’s nose to help create suction while feeding to swallow safely and gain weight.”

Throughout the NAM (molding), Andersen and Collazo simultaneously used rigid nasal splints to optimize the shape of her nasal cartilage prior to surgery.

Andersen added Violet’s parents have played an essential role in her ongoing care, ensuring the devices remained in place with tapes and rubber bands provided to the maxillofacial prosthetics to help decrease the palatal cleft and help with her feedings.

Perkins also noted the impact of maxillofacial prosthetics in Violet’s care, explaining that by shrinking the size of the cleft and aligning the tissue ahead of time, the primary repair surgery was a little less complex and more predictable. “The molding is very helpful. It helps to align the borders of the cleft.”

“The [cleft lip] surgery took about two-hour surgery,” Perkins added. “The sutures were dissolvable, and we monitored her feedings post op. She was discharged the first day after surgery and I saw her back in mid-June and again this month. We’re going to continue to follow her. She’s 9 months, and when she’s 1 year old, [the cleft] palate surgery will happen to help with her feeding and speech. It’s important to wait that long, approximately one year, because if you do it too early then there is less tissue there.”

Coordinated Care, Encouraging Results

Andersen and Perkins celebrated the team’s effort to get Violet care at Walter Reed.

“We were able to connect with the family through virtual health from across the globe, and bring them to Walter Reed for care, which is incredible to me,” Perkins said.

“I’m really happy with the results,” Andersen added. “It’s a team effort with Mom, us, Dr. Perkins’ and Dr. Vander Kolk’s team. Success has a lot to do with the parents in compliance, which is why Violet has had such a good outcome.”

Rachel said that seeing her daughter thrive has been most rewarding for her and her family. “Also, knowing that I have a team behind us that will support us and answer any question we may have any time of day [is rewarding],” she said.

“Walter Reed has been nothing but phenomenal for our family,” Rachel added. “They have been very accommodating in helping us to get Violet the care she needs and truthfully, she deserves. It’s just so reassuring. This is like a one-stop shop where all of Violet’s care is centered and specifically tailored for her. I love how the team gets together at the end of her clinic to discuss her progress.”

She explained that Violet’s team includes nine different specialties, and that “when the team gets together following Violet’s clinics, the focus is just on her care.

“It’s been a blessing and Violet’s living her best life,” Rachel said.

In addition to the NAM, Andersen’s team works with other patients who have deformities resulting from trauma, cancer, congenital and developmental conditions, and other causes. This includes patients who may be missing parts of their jaws, nose, eyes, ears, and face. Their focus is on extraoral prosthetics to restore facial appearance and function, intraoral prosthetics to restore oral function, advanced surgical and implant solutions, and supportive and comprehensive care.

“We work with otolaryngology, plastic surgery, radiation oncology, ophthalmology, speech pathology, anaplastology, and other teams at Walter Reed to get patients back to a better quality of life,” Andersen said.

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