Is cleft lip repair in older children associated with higher complication rates? A postpandemic review

BACKGROUND: In a complete cleft lip and palate, a defect exists in the alveolar segment of the maxilla. In order to achieve successful restoration of the maxillary arch, several techniques have been employed with the ultimate goal of achieving continuity and adequate bone stock across the alveolus. Passive orthodontic appliances (POA) and gingivoperiosteoplasty (GPP) are adjuncts utilized by some surgeons with primary cleft lip repair. POA aligns the alveolar segments prior to cleft lip repair, and GPP is utilized to achieve bony union across the cleft at the time of primary lip repair. The use of these treatments remains controversial. Along with the surgical technique of the cleft lip and palate repair, they have the possibility of impacting midface growth. Here, we present our protocol for cleft lip and palate repair utilizing GPP and POA for complete unilateral and bilateral cleft lip and palate patients. We also report preliminary treatment results in complete unilateral and bilateral cleft patients, evaluating midface growth at mixed dentition. METHODS: Ten consecutive complete unilateral and 10 consecutive complete bilateral cleft lip and palate patients were recruited. All presurgical molding was performed by a single individual, and all surgical treatments were performed by the senior author. Patients underwent POA treatment (initiated at 7 days) for 35 weeks. The nasal component was incorporated after 6 weeks. GPP was performed by elevating flaps in the subperiosteal or supraperiosteal plane and closing the alveolar defect. Unilateral cleft patients underwent rotation advancement repair at approximately 6 months, whereas bilateral cleft patients underwent staged repair with a similar technique at approximately 6 and 9 months of age. Cephalometric analysis of lateral radiographs of patients at mixed dentition was performed to evaluate maxillary and mandibular growth (SNA, SNB, ANB) and facial growth relative to the facial axis (facial axis angle). RESULTS: Twenty patients underwent POA, cleft lip closure with GPP and cephalometric analysis. Mean age at time of surgery for all patients was 6.8 months ± 2.6 months of GE with a range of 5–14 months of age. Mean cephalometric values were within age-specific normal values for SNA (80° ± 3.7°), SNB (74° ± 3.4°), ANB (4° ± 1.4°), and the facial axis angle (90° ± 3.5°). One unilateral patient and zero bilateral patients exhibited skeletal Class III malocclusion. CONCLUSION: Although controversy exists regarding the impact of GPP and POA on midface growth in cleft patients, our results demonstrate that GPP and POA do not interfere with maxillary grow or cause a Class III malocclusion at mixed dentition in most patients. POA, combined with GPP at the time of cleft lip repair, leads to normal maxillary development in unilateral and bilateral cleft lip and palate patients at mixed dentition. We feel that the normal maxillary growth justifies continuing the use of GPP and POA, especially when considering the potential advantageous that they can afford at the time of primary cleft lip repair, such as allowing for closure of the alveolus and anterior palate and achieving bony union across the cleft.

Anaesthesia for cleft lip and palate surgery

REVIEW QUESTION / OBJECTIVE The objective of this systematic review is to examine the impact of breastfeeding or bottle-feeding on surgical wound dehiscence after cleft lip repair in infants. INCLUSION CRITERIA Types of participants This review will consider studies that include infants who have undergone cleft lip repair. The review will exclude studies that include patients who have undergone cleft lip or palate repair over the age of one year. Types of intervention(s) This review will consider studies that evaluate the impact of breastfeeding or bottle-feeding on surgical wound dehiscence after cleft lip repair in infants. Particular focus will be given to studies in which the same feeding method (breastfeeding or bottle-feeding) as that used preoperatively is compared with alternative feeding methods (spoon-, cup-, or syringe-feeding). Types of outcomes This review will consider studies that include the following outcome measure: incidence of surgical wound dehiscence as ascertained by health professionals. Secondary outcomes include weight gain, length of postoperative stay and hospital discharge, if enough data is available.

To determine the degree of weight loss, time to regain lost weight, and impact on postoperative outcomes after primary cleft lip (CL) and cleft palate (CP) repair. Single institution retrospective. Two hundred seven patients who underwent primary CL and/or CP repair procedures. One hundred thirty primary CL repairs (isolated CL = 59; cleft lip and palate [CLP] = 71) and 140 primary CP repairs (isolated CP = 72; CLP = 69): At the first postoperative visit, 21.54% of CL and 57.14% of CP repair patients had not returned to their immediate preoperative weights ( P < .0001). Maximum weight loss after CL repair was 0.44 kg (mean = 0.15 kg; standard deviation [SD]: 0.11) and for CP repair was 0.85 kg (mean = 0.31 kg; SD: 0.21; P = .002). Maximum percentage body weight loss was 6.11% after CL repair (mean = 2.08%; SD: 1.56) and 9.2% after CP repair (mean = 3.10%; SD: 2.13; P = .02). If not returned to preoperative weight by first postoperative visit, CP repair took significantly longer. Median time to return to preoperative weight was CL = 14.08 days (interquartile range [IQR]: 7.26) and CP = 25.37 days (IQR: 21.07; P < .0001). Patients undergoing CP repair with slowed weight recovery had a 22.5% rate of unintentional fistula/partial dehiscence compared to 10.0% of those who recovered quickly ( P = .052). Primary CP repair involves significantly higher risk and degree of postoperative weight loss and slower rates of weight recovery when compared with primary CL repair. Postoperative weight loss is associated with increased risk of complications with palatal healing. Cleft palate repair patients should be monitored closely for weight recovery and considered for nutritional interventions to support improved postoperative outcomes.

Measurement of treatment outcome is important in estimating the success of cleft management. The aim of this study was to assess the surgical outcome of cleft lip and palate surgery. The surgical outcome of 131 consecutive patients with cleft lip and palate surgeries between October 2008 and December 2010 were prospectively evaluated at least 4 weeks postoperatively. Data collected included information about the age, sex, type of cleft defects, and type of surgery performed as well as postoperative complications. For cleft lip repair, the Pennsylvania lip and nose (PLAN) score was used to assess the surgical outcome, while the integrity of the closure was used for cleft palate repair. A total of 92 patients had cleft lip repair and 64 had palate repair. Overall, 68.8% cases of cleft lip and palate repair had good outcomes; 67.9% of lip repairs had good lip and nose scores, while 70.2% of palatal repair had a good surgical outcome. Oro-fistula was observed in 29.8% of cleft palate repairs Inter-rater reliability coefficient was substantially significant. The fact that 25.7% of those treated were aged >1 year suggests a continued need to enlighten the public on the availability of cleft lip and palate expertise and treatment. Although an overall good treatment outcome was demonstrated in this study, the nasal score was poorer than the lip score. Complication rate of about 14% following surgical repair is consistent with previous reports in the literature.

Passive orthodontic appliances and gingivosupraperiosteoplasty are adjuncts that can be used by surgeons at the time of primary cleft lip repair. These treatments, along with the surgical technique of cleft lip and palate repair, may impact midface growth. The objective of this study was to describe the authors' protocol for unilateral and bilateral cleft lip repair and to evaluate midfacial growth in a cohort of patients at mixed dentition who had undergone presurgical passive orthodontic appliance therapy and gingivosupraperiosteoplasty at the time of unilateral and bilateral cleft lip repair. Fifteen complete unilateral and 15 complete bilateral cleft lip and palate patients underwent passive orthodontic appliance treatment and primary lip repair with gingivosupraperiosteoplasty. Lateral cephalograms were analyzed by three blinded reviewers. Mean cephalometric measurements at mixed dentition were compared to cephalometric values for noncleft patients, unilateral cleft lip and palate patients who did not undergo gingivoperiosteoplasty or presurgical treatment, and unilateral cleft lip and palate patients who underwent gingivoperiosteoplasty/nasoalveolar molding with independent samples t tests. Mean cephalometric values were within age-specific normal values for sella-nasion-A point, sella-nasion-B point, A point-nasion-B point, and facial axis. Eighty-seven (13/15) percent of unilateral cleft lip and palate patients and 93 percent (14/15) of bilateral cleft lip and palate patients did not exhibit skeletal class III malocclusion. There was no significant difference between cephalometric values for our patients and patients who did not receive gingivosupraperiosteoplasty or presurgical treatment or who underwent the gingivoperiosteoplasty/nasoalveolar molding protocol. Presurgical passive orthodontic appliances, combined with gingivosupraperiosteoplasty at the time of lip repair, leads to normal maxillary development in most patients at mixed dentition. Assessment of midface growth at skeletal maturity is required. Therapeutic, IV.

To describe the range of surgery used to repair the lip and palate in the UK with specific interest in the sequence/timing used in complete unilateral cleft lip and palate (cUCLP). The Cleft Care UK study, a cross-sectional study of 268 5-year-olds, born from 2005 to 2007, with complete unilateral cleft lip and palate. Information on surgery was extracted from medical notes by surgeons during research clinics and transcribed onto a standardized questionnaire. Surgical data were available for 251 (94%) children from all cleft centres in the UK (n=18). Over a two-year period, 32 surgeons used 10 different surgical sequences in primary repair of the cleft lip and palate. The most frequently used sequence was repair of cleft lip and anterior hard palate followed by repair of posterior hard palate and soft palate (70%). Four surgical sequences were used only once. Most surgeons had a preferred sequence, but 38% (11/29) used more than one sequence during the study period. The timing of repair of the lip, the hard palate and the soft palate varied with surgical sequence, and also between surgeons, even adjusting for the different sequences used. Despite centralization of cleft services in the UK, there remains considerable variation in both the sequence and timing of surgical repair of cleft lip and palate in infancy. Further work is required to understand whether these factors are associated with differences in outcome.

In search of the optimal pain management strategy for children undergoing cleft lip and palate repair: A systematic review and meta-analysis

To examine the impact of race/ethnicity on timing and postoperative outcomes of primary cleft lip (CL) and cleft palate (CP) repair. Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database from 2013 to 2018. Patients under 2 years of age who underwent primary CL or CP repair were identified in the NSQIP-P. Outcomes were the timing of surgery and 30-day readmission and reoperation rates stratified by race and ethnicity. In total, 6021 children underwent CL and 6938 underwent CP repair. Adjusted rates of CL repair over time were 10% lower in Hispanic children (95%CI: 0.84-0.96) and 38% lower for Asian children (95%CI: 0.55-0.70) compared with White infants. CP repair rates over time were 13% lower in Black (95%CI: 0.79-0.95), 17% lower in Hispanic (95%CI: 0.77-0.89), and 53% lower in Asian children (95%CI: 0.43-0.53) than in White infants. Asian patients had the highest rates of delayed surgical repair, with 19.3% not meeting American Cleft Palate-Craniofacial Association (ACPA) guidelines for CL (P < .001) and 28.2% for CP repair (P< .001). Black and Hispanic children had 80% higher odds of readmission following primary CL repair (95%CI: 1.16-2.83 and 95%CI: 1.27-2.61, respectively). This study of a national database identified several racial/ethnic disparities in primary CL and CP, with reduced receipt of cleft repair over time for non-White children. Asian patients were significantly more likely to have delayed cleft repair per ACPA guidelines. These findings underscore the need to better understand disparities in cleft repair timing and postoperative outcomes.

As healthcare spending within the United States grows, payers have attempted to curb spending through higher cost sharing for patients. For families attempting to balance financial obligations with their children's surgical needs, high cost sharing could place families in difficult situations, deciding between life-altering surgery and bankruptcy. We aim to investigate trends in patient cost sharing and provider payments for cleft lip and palate repair. The IBM® MarketScan® Commercial Database was queried to extract patients younger than 18 years who underwent primary or secondary cleft lip and/or palate repair from 2007 to 2016. Financial variables included gross payments to the provider (facility and/or physician), net payment as reported by the carrier, coordination of benefits and other savings, and the beneficiary contribution, which consisted of patients' coinsurance, copay, and deductible payments. Linear regression was used to evaluate trends in payments over time. Poisson regression was used to trend the proportion of patients with a nonzero beneficiary contribution. All financial values were adjusted to 2016 dollars per the consumer price index to account for inflation. The sample included 6268 cleft lip and 9118 cleft palate repair episodes. Total provider payments increased significantly from 2007 to 2016 for patients undergoing cleft lip (median, $2527.33 vs $5116.30, P 0.008) and palate ($1766.13 vs $3511.70, P < 0.001) repair. Beneficiary contribution also increased significantly for both cleft lip ($155.75 vs $193.31, P < 0.001) and palate ($124.37 vs $183.22, P < 0.001) repair, driven by an increase in deductibles ( P < 0.002). The proportion of cleft palate patients with a nonzero beneficiary contribution increased yearly by 1.6% ( P = 0.002). Higher provider payments and beneficiary contributions were found in the Northeast ( P < 0.001) and South ( P < 0.011), respectively, for both cleft lip and palate repair. The US national data demonstrate that for commercially insured patients with cleft lip and/or palate, there has been a trend toward higher patient cost sharing, most pronounced in the South. This suggests that patients are bearing an increased cost burden while provider payments are simultaneously accelerating. Additional studies are needed to understand the impact of increased cost sharing on parents' decision to pursue cleft lip and/or palate repair for their children.

Sir: We read with great interest the article by Dr. Greives et al.1 entitled “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” We would like to acknowledge the authors for sharing with us this very comprehensive analysis, performed to provide us with a practice-based assessment of preoperative evaluation, anesthesia, surgical treatment plan, perioperative management, and outcomes. Moreover, the different techniques used for cheiloplasty and nasal repair are critically discussed, giving us a complete overview and providing us with exceptional consultation material for decision-making. However, Dr. Greives et al. did not mention in their review the use of autologous fat grafting in primary cleft lip repair, which has been recently described as a further, new and emerging technique.2 We believe that this technique needs to be considered as an option for this operation. Indeed, fat tissue transfer can be considered as an excellent tool with which to solve the lack of tissue in the nasolabial complex, which is typical for this deformity. So doing can avoid one of the detailed stigmatizing signs, which is that resulting from the low projection of the upper lip, usually found together with a similarly affected nasal columella. These two deformities are, together, responsible for an unsuitable nasolabial angle.3 Fat transfer techniques have gained worldwide acceptance for the correction of a host of deformities through soft-tissue augmentation.4 Their efficacy in providing wound healing and regeneration has been related to the evidence that fat grafts harbor stem cells, termed adipose-derived stem cells, pluripotent cells producing beneficial factors. This autologous tissue may also improve scar caliber and minimize scar burden. Most importantly, for primary treatment of cleft lip and nose, research from Wu et al.5 has revealed that infant-derived adipose-derived stem cells are more biologically robust than those obtained from adult tissue. Therefore, in our opinion, the section of the article by Dr. Greives et al. regarding the surgical techniques can be enriched by considering the recent article of Dr. Balkin et al.,2 that described their experience with autologous fat tissue transplantation for primary cleft lip and nose repair. In their retrospective analysis, Dr. Balkin et al.2 performed fat grafting to various elements of the lip and nose in a series of consecutive infants who underwent primary cleft lip and nose repair with immediate fat grafting. The results, judged with clinical examination, were reported as excellent, without complications or delays in recovery. According to these results and to the well-accepted background regarding the biophysical and biochemical properties of adipose tissue, we strongly believe that adipose tissue fat grafting for the correction of primary cleft lip and nose should be taken into consideration. Thus, prospective investigations, with long follow-up, are needed to corroborate these findings. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No external funding was received. Andrea Sisti, M.D. General and Specialist Surgery Department Plastic Surgery Division University of Siena Siena, Italy Carlo M. Oranges, M.D. Plastic, Reconstructive, and Aesthetic Surgery School Marche Polytechnic University Ancona, Italy

Purpose: Over the last three years a shift at our institution has taken place in which patients originally designated for nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. After implementing the ECLR program at CHLA, only a small subset of patients still undergo NAM with the standard surgical timing of repair. The financial and social impact of this potential paradigm shift has not been studied. We sought to examine the financial and cost-effectiveness of the ECLR protocol. Methods: We reviewed records for all patients who underwent NAM as an adjunct to cleft lip repair from November 2011 to June 2018. From November 2011 to February 2014, NAM with standard timing of lip repair was the only intervention offered to patients with wide cleft lip defects. From February 2014 to June 2018, ECLR without adjunctive NAM was offered as an alternative. Retrospective chart review of the two groups was conducted with emphasis on the following variables: NAM and ECLR cleft classifications, NAM dental visits, ECLR length of hospital stay, ECLR patients’ cleft width ratio (CWR), and operative dates. ECLR patients who had a Cleft Width Ratio (CWR), defined as the cleft width/commissure width, of > 0.5 and unilateral complete cleft lip (UCL) were identified as patients who would have originally been offered NAM as an adjunct to their cleft lip repair. Results: NAM patients required an average of 11 preoperative dental visits, accounting for $2,132 in lost income per family. The average direct costs of NAM totaled $12,290 for the hospital, physician, and device costs. The cumulative direct cost of NAM over the entire study period was $970,910. ECLR patients underwent lip repair significantly earlier than NAM patients (33 ± 14 days vs. 112.9 ± 28 days, p< 0.001). Following the introduction of ECLR, NAM usage decreased by 48% (52 to 27 patients) and unilateral cleft lip patients undergoing NAM decreased by 86% (35 to 5 patients). 26 patients were diverted from NAM to ECLR resulting in a healthcare cost burden of $319,540 less ($96,830 per year). Conclusion: ECLR without NAM is more cost-effective and results in excellent surgical and aesthetic outcomes. NAM as an adjunct to wide cleft lip and nasal repair is no longer the most cost-effective option at our institution. We believe that ECLR has the potential to decrease the burden of health care costs in the United States.

Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country. Prospective outcomes study. Comprehensive Cleft Care Center. Candidate patients presenting for cleft lip or palate repair or revision. Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals. Complication was defined as fistula, dehiscence and/or infection. Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery. Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.

ObjectiveTo quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31...

Botulinum toxin is a neurotoxin that has been utilized to induce chemo-denervation of muscles. Cutaneous wounds represent a special situation in which the tensile forces applied by these muscles on wound edges might have deleterious effects on the healing process. The aim of this review was to investigate such an effect and to review other mechanisms this toxin might have on the healing process. We also reviewed the role of botulinum toxin in the management of hypertrophic scars and cleft lip repair.