Timing Is Everything: Measuring Outcomes in Primary Cleft Rhinoplasty

Abstract

<h3>Purpose</h3> The timing of ideal repair of the cleft nasal deformity has been a contentious topic among craniomaxillofacial surgeons over the last several decades. Several tissues are adversely affected, from bone through the vestibule, cartilage, and external skin. While surgical techniques, paradigms and philosophies have evolved, several important considerations are factored into the clinical decision making to perform a rhinoplasty at the time of cleft repair, such as growth interruption and several craniofacial growth centers, scarring, and the predicted aesthetic result at growth maturity. To this end, we investigated the safety profile, hospitalization characteristics and costs of primary cleft lip repair with and without rhinoplasty. <h3>Methods</h3> A retrospective cohort was designed using the Kids Inpatient Database (KID), which is comprised of databases organized by the Healthcare Cost and Utilization Project. Data were collected from January 2000 to December 2011 and included infants 12 months and younger who underwent complete and incomplete cleft lip repair. Data were excluded if records did not include age at time of cleft lip repair. Predictor variables included extent of the initial cleft surgery, with or without rhinoplasty. Outcome variables included length of stay, total charges, and overall complications. Demographic characteristics included age, gender, race, insurance status, and median household income. Independent <i>t</i>-tests and chi-square tests were performed. Multiple linear regression models were used to analyze continuous variables, and a <i>P</i> value of .05 was considered statistically significant. <h3>Results</h3> The study sample included 4559 infants, of whom 1422 (31.2%) underwent primary cleft rhinoplasty. Primary cleft rhinoplasty patients had a significantly shorter length of stay (1.6 vs 2.8 days, <i>P</i> < .01) compared to the nonrhinoplasty cohort. However, the hospital charges between both groups were not significantly different, suggesting that the cost of additional rhinoplasty offset the cost savings of the shorter length of stay. There was a significant increase in the inclusion of rhinoplasty with cleft lip repair over time (<i>P</i> < .01). A greater proportion of patients with unilateral cleft lip received a rhinoplasty (33.8% vs 26.0%, <i>P</i> < .01). Likewise, patients without cardiovascular anomalies (31.6% vs 24.4%, <i>P</i> = .02), patients with a cleft palate (33.1% vs 28.6%, <i>P</i> < .01), and patients treated in urban settings (72.9% vs 69.1%, <i>P</i> < .01) were more likely to undergo primary cleft rhinoplasty. The proportion of African Americans undergoing primary cleft rhinoplasty was less than that of the other cohort (4.6% vs 7.3%, <i>P</i> < .01). Similarly, the proportion of patients from the lower income quartile was less in the rhinoplasty cohort compared to that of the nonrhinoplasty cohort (23.3% vs 28.1%, <i>P</i> < .01). Patients treated with rhinoplasty were slightly older at the time of admission (4.2 vs 4.0 months, <i>P</i> = .03). <h3>Conclusion</h3> Performing primary cleft rhinoplasty is becoming more commonplace among pediatric craniomaxillofacial surgeons. Although concomitant rhinoplasty at the time of primary cleft lip repair is more costly, the length of stay in the hospital setting was shown to be shorter. Future studies should further investigate the safety profile and risk of postoperative complications in the rhinoplasty vs non-rhinoplasty cohort in primary cleft lip repair patients.