Early Cleft Lip Repair Research Articles

Lessons Learned from a Single Institution's Eight Years of Experience with Early Cleft Lip Repair.

Background and Objectives: The traditional approach in managing wide cleft lip deformities involves presurgical nasoalveolar molding (NAM) therapy followed by surgical cleft lip repair between three and six months of age. This institution has implemented an early cleft lip repair (ECLR) protocol where infants undergo primary cleft lip repair between two and five weeks of age without NAM. This study aims to present this institution's ECLR repair protocol over the past eight years from 188 consecutive patients with unilateral or bilateral CL/P deformity. Materials and Methods: Retrospective review was conducted at Children's Hospital Los Angeles evaluating patients who underwent ECLR before three months of age and were classified as American Society of Anesthesiologists (ASA) class I or II from 2015-2022. Anthropometric analysis was performed, and pre- and postoperative photographs were evaluated to assess nasal and lip symmetry. Results: The average age at cleft lip repair after correcting for gestational age was 1.0 ± 0.5 months. Mean operative and anesthetic times were 120.3 ± 33.0 min and 189.4 ± 35.4, respectively. Only 2.1% (4/188) of patients had postoperative complications. Lip revision rates were 11.4% (20/175) and 15.4% (2/13) for unilateral and bilateral repairs, respectively, most of which were minor in severity (16/22, 72.7%). Postoperative anthropometric measurements demonstrated significant improvements in nasal and lip symmetry (p < 0.001). Conclusions: This analysis demonstrates the safety and efficacy of ECLR in correcting all unilateral cleft lip and nasal deformities of patients who were ASA classes I or II. At this institution, ECLR has minimized the need for NAM, which is now reserved for patients with bilateral cleft lip, late presentation, or comorbidities that preclude them from early repair. ECLR serves as a valuable option for patients with a wide range of cleft severity while reducing the burden of care.

Does Early Referral Lead to Early Repair? Quality Improvement in Cleft Care.

Cleft lip and palate is the most common congenital defect of the head and neck, occurring in 1 of 700 live births. Diagnosis often occurs in utero by conventional or 3-dimensional ultrasound. Early cleft lip repair (ECLR) (<3 months of life) for unilateral cleft lip (UCL), regardless of cleft width, has been the mainstay of lip reconstruction at Children's Hospital Los Angeles since 2015. Historically, traditional lip repair (TLR) was performed at 3 to 6 months of life ± preoperative nasoalveolar molding (NAM). Previous publications highlight the benefits of ECLR, such as enhanced aesthetic outcomes, decreased revision rate, better weight gain, increased alveolar cleft approximation, cost savings of NAM, and improved parent satisfaction. Occasionally, parents are referred for prenatal consultations to discuss ECLR. This study evaluates timing of cleft diagnosis, preoperative surgical consultation, and referral patterns to validate whether prenatal diagnosis and prenatal consultation lead to ECLR. Retrospective review evaluated patients who underwent ECLR versus TLR ± NAM from 2009 to 2020. Timing of repair, cleft diagnosis, and surgical consultation, as well as referral patterns, were abstracted. Inclusion criteria dictated: age < 3 months for ECLR or 3 to 6 months for TLR, no major comorbidities, and diagnosis of UCL without palatal involvement. Patients with bilateral cleft lip or craniofacial syndromes were excluded. Of 107 patients, 51 (47.7%) underwent ECLR whereas 56 underwent TLR (52.3%). Average age at surgery was 31.8 days of life for the ECLR cohort and 112 days of life for the TLR cohort. Furthermore, 70.1% of patients were diagnosed prenatally, yet only 5.6% of families had prenatal consults for lip repair, 100% of which underwent ECLR. Most patients were referred by pediatricians (72.9%). Significance was identified between incidence of prenatal consults and ECLR (P = 0.008). In addition, prenatal diagnosis was significantly correlated with incidence of ECLR (P = 0.027). Our data demonstrate significance between prenatal diagnosis of UCL and prenatal surgical consultation with incidence of ECLR. Accordingly, we advocate for education to referring providers about ECLR and the potential for prenatal surgical consultation in the hopes that families may enjoy the myriad benefits of ECLR.

Discussion: Early Cleft Lip Repair: Demonstrating Efficacy in the First 100 Patients.

Philadelphia, Pa. From the Division of Plastic and Reconstructive Surgery, Children’s Hospital of Philadelphia. Received for publication April 2, 2021; accepted January 18, 2022. Disclosure:Dr. Taylor is co-founder and chief medical officer of Ostiio, LLC. The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article. Jesse A. Taylor, M.D., Division of Plastic and Reconstructive Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pa. 19104, [email protected]

Does Early Referral Lead to Early Repair? Quality Improvement in Cleft Care

BACKGROUND/PURPOSE: Cleft lip and palate (CLP) is the most common congenital birth defect of the head and neck, occurring in approximately 1 in 700 live births. This diagnosis can often be made prenatally by conventional or 3-dimensional ultrasound. Early cleft lip repair (ECLR) (<3 months of age) for unilateral cleft lip, regardless of cleft width, has been the mainstay of cleft lip reconstruction at our institution for the past 6 years. Prior to this novel protocol, traditional lip repair (TLR) was performed at 3-6 months of age ± preoperative nasoalveolar molding (NAM). Previous publications from this institution report on the benefits of ECLR, such as enhanced aesthetic outcomes, decreased revision rate, better weight gain, increased alveolar cleft approximation, cost savings of NAM, and improved parent satisfaction. Occasionally, parents are referred to our institution for prenatal consultations to discuss ECLR. The purpose of this study was to evaluate the timing of both prenatal cleft diagnosis and preoperative surgical consultation as well as referral patterns to validate whether prenatal diagnosis and prenatal consultation lead to ECLR. METHODS: A retrospective chart review evaluated patients who underwent ECLR or TLR±NAM from November 2009-January 2020. Timing of repair, cleft diagnosis, and surgical consultation, as well as referral pattern, were abstracted upon review. Inclusion criteria dictated: age <3 months (ECLR group) or 3-6 months (TLR); no major comorbidities (ASA class I/II); and diagnosis of non-syndromic unilateral cleft lip without palatal involvement. Patients >6 months, or with bilateral cleft lip, cleft palate, clefts associated with craniofacial syndromes, or significant systemic comorbidities were excluded. RESULTS: Upon review, 51 patients (47.7%) received ECLR while 56 patients received TLR (52.3%). The average age at surgery was 31.8 days for the ECLR cohort and 112 days for the TLR cohort. Of these 107 patients, 75 patients (70.1%) were diagnosed prenatally with unilateral cleft lip while only 5.6% of families (6/107) had a prenatal consult for cleft lip repair, all of which underwent ECLR (11.8% of ECLR cohort). The majority of patients who received ECLR were referred by a pediatrician (n=39, 76.5%). A statistically significant association was found between the incidence of prenatal consults and ECLR (p=0.008). Additionally, prenatal diagnosis of unilateral cleft lip was significantly correlated with the incidence of ECLR (p=0.027). CONCLUSION: Our data demonstrates significance between prenatal diagnosis of cleft lip and prenatal surgical consultation with the incidence of ECLR; accordingly, we advocate for education to the referring providers as well as those in the surrounding community about the benefits of ECLR and the potential for prenatal surgical consultation. Efforts will be expanded to Obstetrician/ Gynecologists and Maternal-Fetal Medicine providers in the hopes that patients and families alike may enjoy the myriad benefits of ECLR. Further research should investigate the correlation of socioeconomic status with prenatal consultation for ECLR.

Does Early Referral Lead to Early Repair? Quality Improvement in Cleft Care

INTRODUCTION: Early cleft lip repair (ECLR; less than 3 months of age) for unilateral cleft lip has been the mainstay of cleft lip reconstruction at our institution since 2015. Before this protocol, traditional lip repair (TLR) was performed at 3–6 months of age. The purpose of this study was to evaluate timing of prenatal cleft diagnosis and preoperative surgical consultation as well as referral pattern to validate whether prenatal diagnosis and prenatal consultation lead to ECLR. METHODS: A retrospective chart review evaluated patients who underwent ECLR or TLR from November 2009 through January 2020. Timing of repair, cleft diagnosis, and surgical consultation, as well as referral pattern, were abstracted on review. RESULTS: On review, 51 patients received ECLR whereas 56 patients received TLR. Of these 107 patients, 70.1% were diagnosed prenatally with unilateral cleft lip whereas only 5.6% of families had a prenatal consult for cleft lip repair, all of which underwent ECLR. The majority of patients who received ECLR were referred by a pediatrician (76.5%). A statistically significant association was found between incidence of prenatal consults and ECLR (p = 0.008). Additionally, prenatal diagnosis of unilateral cleft lip was significantly correlated with incidence of ECLR (p = 0.027). CONCLUSION: Our data demonstrate significance between prenatal diagnosis of cleft lip and prenatal surgical consultation with incidence of ECLR; accordingly, we advocate for education to the referring providers about the benefits of ECLR and the potential for prenatal surgical consultation. Further research should investigate the correlation of socioeconomic status with prenatal consultation for ECLR.

Early Cleft Lip Repair: Demonstrating Efficacy in the First 100 Patients.

Cleft lip and/or palate affects approximately one in 700 live births. Optimal timing for repair of cleft lip has yet to be objectively validated. Earlier repair takes advantage of a high degree of plasticity within the nasal cartilage and maxilla. The authors present patients enrolled in an early cleft lip repair protocol facilitating effective repair of the cleft lip and nostril. American Society of Anesthesiologists class I to II patients with unilateral cleft lip and/or palate undergoing repair before 3 months of age were enrolled over 5 years. Perioperative data, surgical and anesthetic complications, preoperative and postoperative nostril breadth, nostril width, nasal angle, lip length, frontal nasal breadth, and commissure length measured as ratios between the cleft and noncleft sides were abstracted. Early cleft lip repair and nasoalveolar molding patients were matched for cleft lip severity using the cleft width ratios and compared. The surgical and anesthetic complication rate for 100 early cleft lip repair patients was 2 percent. Operative and anesthetic times were 123 ± 37 minutes and 177 ± 34 minutes, respectively. Hospital length of stay was 1 ± 0 day. Age at repair between early cleft lip repair and nasoalveolar molding was 33 ± 15 days and 118 ± 33 days, respectively. After early cleft lip repair, preoperative to postoperative distance from symmetry for all anthropomorphic measurements improved ( p < 0.001). Comparing severity-matched early cleft lip repair to nasoalveolar molding patients, similar improvements were observed, suggesting equivalent results ( p > 0.05). Early cleft lip repair provides an efficacious method for correcting the cleft lip and nasal deformity that simulates nasoalveolar molding. Therapeutic, III.

25. Rethinking The Rule of 10s: Early Cleft Lip Repair Improves Weight Gain

Purpose: This study compares patients undergoing early cleft lip repair (ECLR) and traditional lip repair (TLR) with or without nasoalveolar molding (NAM) to evaluate the effects of surgical timing on weight gain in hopes of guiding future treatment paradigms. Methods: A retrospective chart review evaluated patients who underwent ECLR or TLR±NAM from November 2009 through January 2020. Patient demographics, birth and medical history, perioperative variables and complications were collected. Infant weights, using age-based percentiles, were recorded at the time of operation, 8-weeks, 6-months, 12-months, and 24-months postoperatively. The main outcome measure was weight percentile amongst ECLR and TLR±NAM groups. Results: 107 patients met inclusion criteria: ECLR, n=51 (47.6%); TLR+NAM, n=35 (32.7%); and TLR-NAM, n=21 (19.6%). There were no major adverse events recorded with the ECLR operations. A novel dexmedetomidine-based neonatal anesthetic protocol (DBNAP), with perioperative equivalence to traditional volatile agents, was developed for patients undergoing ECLR; there were no major complications reported with the regimen. Age-matched weights in the ECLR group were significantly greater than the TLR+NAM group at time of surgery and 24-months postoperatively and greater than the TLR-NAM groups at time of surgery, 6-, 12-, and 24- months postoperatively (p<0.05). Significant associations between variables were calculated with independent Student’s t-tests. Descriptive statistics and significance testing were performed on SPSS Advanced Statistics version 17.0 (SPSS Inc, Chicago, Illinois). Conclusion: The results of this study suggest that performing cleft lip repair on patients as young as 13 days old is safe and improves weight gain during infancy. No patients in this study suffered major complications, so a weight-based threshold to guide ECLR eligibility was unable to be established. ECLR significantly increased patient weights 24-months postoperatively when compared to TLR±NAM. Specifically compared to TLR-NAM, ECLR weights were significantly greater at all time points past 6-months postoperatively. The results of this study demonstrate that ECLR can mitigate feeding difficulties and malnutritioz traditionally seen in patients with cleft lip.

127. Reducing the Burden of Care of Cleft Lip Nasal Deformities Using Early Cleft Lip Repair

127. Reducing the Burden of Care of Cleft Lip Nasal Deformities Using Early Cleft Lip Repair

Rethinking the Rule of 10s: Early Cleft Lip Repair Improves Weight Gain.

This study compares patients undergoing early cleft lip repair (ECLR) (<3-months) and traditional lip repair (TLR) (3-6 months) with/without nasoalveolar molding (NAM) to evaluate the effects of surgical timing on weight gain in hopes of guiding future treatment paradigms. Retrospective review. Children's Hospital of Los Angeles, California. A retrospective chart review evaluated patients who underwent ECLR or TLR ± NAM from November 2009 through January 2020. No intervention was performed. Patient demographics, birth and medical history, perioperative variables, and complications were collected. Infant weights and age-based percentiles were recorded at birth, surgery, 8-weeks, 6-months, 12-months, and 24-months postoperatively. The main outcomes were weight change and weight percentile amongst ECLR and TLR ± NAM groups. 107 patients met inclusion criteria: ECLR, n = 51 (47.6%); TLR + NAM, n = 35 (32.7%); and TLR-NAM, n = 21 (19.6%). ECLR patients had significantly greater changes in weight from surgery to 8-weeks and from surgery to 24-months postoperatively compared with both TLR ± NAM (P < .05). Age-matched weights in the ECLR group were significantly greater than TLR ± NAM at multiple time points postoperatively (P < .05). ECLR significantly increased patient weights 24-months postoperatively when compared to TLR ± NAM. Specifically compared to TLR-NAM, ECLR weights were significantly greater at all time points past 6-months postoperatively. The results of this study demonstrate that ECLR can mitigate feeding difficulties and malnutrition traditionally seen in patients with cleft lip.

The Effect of Early Cleft Lip Repair on Infant Weight Gain

The Effect of Early Cleft Lip Repair on Infant Weight Gain

Assessing the Safety of a Novel Neonatal Anesthesia Protocol: A Review of 101 Patients With Early Cleft Lip Repair.

Our study introduces a novel anesthetic protocol for neonates without using volatile agents with the goal to minimize potentially neurotoxic and pro-apoptotic agents. The authors evaluated the short-term safety and efficacy of our anesthetic protocol in patients undergoing early cleft lip repair (ECLR). A retrospective review of ECLR patients who underwent repair before 2.5 months of age within the last 4.3 years was performed. This sample was comprised of 2 groups, those who received either a standard volatile gas-based regimen or a dexmedetomidine-based neonatal anesthetic protocol (DBNAP). Patient demographics, medication dosing, anesthetic time (induction to extubation), major and minor complications, and medication side effects were compared between the 2 cohorts. A total of 101 patients underwent ECLR. All patients were American Society of Anesthesiologists class 1 or 2. Mean age at surgery was 31 ± 13 days and mean anesthetic time was 179 ± 36 minutes. DBNAP was used in 65 patients while the standard anesthetic protocol was used in 36 patients. Patient weight was significantly lower in the DBNAP group (4.01 ± 0.61 versus 4.38 ± 0.72 kg, P = 0.007). There were no significant differences between the 2 cohorts when comparing anesthetic time, emergence time, complication rate, or medication side effects. For patients undergoing ECLR, DBNAP is perioperatively equivalent to the anesthetic standard of care, demonstrating no major complications and acceptable rates of minor complications and medication side effects.

Nasoalveolar Molding: Assessing the Burden of Care.

Over the last 3 years a shift at our institution has taken place in which patients who would have been offered 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. This study sought to examine the financial and social impact of the transition away from NAM to ECLR. The efficacy of NAM is limited by patient compliance to a rigorous treatment schedule requiring weekly visits for appliance adjustments. Nasoalveolar molding patients required an average of 11 dental visits, accounting for $2132 in indirect lost income per family. Average direct charges for NAM totaled $12,290 for the hospital, physician, and appliance costs. Over the entire study period, the cumulative direct cost of NAM separate from the surgical repair of the lip was $970,910. Following the introduction of ECLR as an alternative to NAM with standard lip repair, NAM usage decreased by 48% and unilateral cleft lip patients undergoing NAM decreased by 86%. Those diverted from NAM to ECLR resulted in a decreased healthcare cost burden of $368,700 ($111,727 per year). In addition to the time burden, the financial burden of NAM is significant. Early cleft lip repair without NAM is more cost effective. Nasoalveolar molding has significantly decreased utilization since the implementation of ECLR. We believe that ECLR, with increased experience, long-term data, and increased awareness, has the potential to decrease the burden of health care costs in the United States.

A Novel Protocol in Early Cleft Lip Repair: Demonstrating Efficacy and Safety in the First 100 Patients

A Novel Protocol in Early Cleft Lip Repair: Demonstrating Efficacy and Safety in the First 100 Patients

Early Cleft Lip Repair and Its Effect on Infant Weight Gain

Cleft lip and palate (CLP) is the most common congenital birth defect of the head and neck. Infants with CLP experience difficulties with feeding, leading to low weight gain and failure to thrive.1 At our institution, a paradigm shift has occurred where children with unilateral cleft lip defects are repaired in the late neonatal to early infantile period.2 Before the introduction of early cleft lip repair (ECLR), wide complete cleft lip defects were treated with adjuvant nasoalveolar molding (NAM) and repaired at the age of 3-6 months. The advantage of ECLR lies in the avoidance of the cumbersome and irritating NAM process that requires frequent biweekly dental clinic visits and parental adherence to an appliance protocol. Because little is known about the effects of ECLR on infantile feeding and weight gain, the purpose of this study is to compare the effect of ECLR on weight gain in contrast to NAM and standard timing of cleft repair.

A Neuroprotective Protocol in Neonatal Anesthesia: A Review of 101 Early Cleft Lip Repairs

Dogma established by Millard in 1976 regarding the ideal timing of elective surgery in infants has long centered on the “Rule of 10s” (> 10 weeks of age, > 10 pounds and has > 10g hemoglobin and < 10 white cell count) (Wilhelmsen et al. 1966). These guidelines were built upon archaic anesthetic protocols and do not accurately represent the safety profile of modern-day agents. Opposition to neonatal anesthesia cite concerns regarding GABA-agonists and NMDA-receptor antagonists being associated with a degree of neural apoptosis. Opioids and low-dose dexmedetomidine, a highly selective alpha-2 agonist, remain among the few agents used for anesthesia that have not shown pro-apoptotic activity (Sanders et al. 2010). As such, the divisions of plastics and craniofacial surgery and anesthesiology at Children’s Hospital of Los Angeles created a neonatal neuroprotective anesthetic protocol (NPP) designed with dexmedetomidine as the dominant agent in early cleft lip repair (ECLR).

A Novel Protocol in Early Cleft Lip Repair: Demonstrating Efficacy and Safety in the First 104 Patients

A Novel Protocol in Early Cleft Lip Repair: Demonstrating Efficacy and Safety in the First 104 Patients

Duration of Surgery, Ventilation, and Length of Hospital Stay Do Not Affect Breastfeeding in Newborns After Early Cleft Lip Repair.

There are minimal data available on nutrition after early repair of cleft lip and the factors influencing initiation of breastfeeding. This study assessed the impact of the length of surgery, length of ventilation support, and duration of hospital stay on breastfeeding rates after early cleft lip surgery. This is a prospective observational cohort study comparing 2 hospitals providing early surgical repair of facial clefts from January 2014 to December 2016. Both hospitals are designated as Baby-Friendly Hospitals. Demographic and anthropometric data from mothers and newborns were recorded. Tertiary neonatal and pediatric surgery center. Hospital A: 61 newborns, Hospital B: 157 newborns. Early (day 5 to 14) cheiloplasty in newborns with cleft lip or cleft lip and palate. Influence of duration of hospital stay, length of operation, and artificial ventilation on the rate of breastfeeding. Significantly, more newborns were breastfed following early surgical repair of an isolated cleft lip compared to those with both cleft lip and palate, in both hospitals (hospital A 82% vs 0%, P = .0001, hospital B 66% vs 5%, P = .0001). Duration of hospital stay, length of operation, and duration of artificial ventilation did not significantly affect the rate of breastfeeding. The factors associated with early cleft lip repair (length of operation, length of ventilation support, and duration of hospital stay) do not affect breastfeeding rate.

Abstract QS11: The Burden Of Nasoalveolar Molding: Is It The Most Cost-effective Approach To Facilitate Wide Cleft Lip And Nasal Repair?

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.

Early Cleft Repair Versus Nasoalveolar Molding: Comparing Preoperative Severity and Postoperative Results Utilizing a Computer Engineered AI System

BACKGROUND: Early cleft lip repair (ECLR) can be performed safely and effectively. One persistent question is whether ECLR may be offered to wide unilateral complete clefts who historically would have received nasoalveolar molding (NAM). This study aims to compare the preoperative cleft severity of ECLR patients to those who underwent NAM pretreatment and compare postoperative outcomes. METHODS: Unilateral CL patients (January 1, 2005, to September 11, 2018) were retrospectively reviewed and divided into 2 groups: ECLR (age <3 months) and presurgical NAM with CL repair (age 3–6 months). Pretreatment CL severity was assessed using an AI computer engineered system that calculated cleft width ratios (CWRs, pretreatment cleft width divided by commissure width). For further analysis, a second subset of wide complete cleft lip patients undergoing ECLR (excluding incomplete clefts) was created to compare to the NAM group. RESULTS: Seventy-four ECLR patients and 25 NAM patients (average age at repair 32.24 and 117.56 days, respectively) met inclusion criteria. Mean CWR was 0.456 for ECLR patients and 0.501 for NAM patients (P = 0.165). The ECLR subgroup considering only patients with complete cleft lips had a mean CWR of 0.520, suggesting that this group had more severe clefts. The ECLR subgroup’s average lip length, frontal nasal breadth, commissure length, nostril breadth, nostril width, and nasal angle symmetry ratios were compared to the NAM group’s postoperatively. The average lip length, frontal nasal breadth, and commissure length symmetry ratios for the ECLR subgroup of 27 complete clefts were 0.88, 1.05, and 0.92, respectively, compared to 0.93, 1.08, and 0.89 for the NAM group (P = 0.181, P = 0.526, P = 0.378). The average nostril breadth, nostril width, and nasal angle ratios among the ECLR subgroup were 1.09, 1.17, and 1.12, respectively, compared to 1.12, 1.19, and 1.14 in the NAM group (P = 0.480, P = 0.613, P = 0.640). CONCLUSION: ECLR provides patients with severe cleft lips an alternative option to NAM with at least equivalent results. With increased experience, long-term data, and increased awareness, we feel that ECLR has the potential to be a paradigm shift in the treatment of the cleft lip/nasal deformity.

Early Cleft Lip Repair Revisited: A Safe and Effective Approach Utilizing a Multidisciplinary Protocol.

Background:The optimal timing for cleft lip repair has yet to be established. Advances in neonatal anesthesia, along with a growing body of literature, suggesting benefits of earlier cleft lip and nasal repair, have set the stage for a reexamination of current practices.Methods:In this prospective study, cleft lip and nasal repair occurred on average at 34.8 days (13–69 days). Nasal correction was achieved primarily through molding the nasal cartilage without the placement of nasal sutures at the time of repair. A standardized anesthetic protocol aimed at limiting neurotoxicity was utilized in all cases. Anesthetic and postoperative complications were assessed. A 3-dimensional nasal analysis compared pre- and postoperative nasal symmetry for unilateral clefts. Surveys assessed familial response to repair.Results:Thirty-two patients were included (27 unilateral and 5 bilateral clefts). In this study, the overall complication rate was 3.1%. Anthropometric measurements taken from 3-dimensional-image models showed statistically significant improvement in ratios of nostril height (preoperative mean, 0.59; postoperative mean, 0.80), nasal base width (preoperative mean, 1.96; postoperative mean, 1.12), columella length (preoperative mean, 0.62; postoperative mean, 0.89; and columella angle (preoperative mean, 30.73; postoperative mean, 9.1). Survey data indicated that families uniformly preferred earlier repair.Conclusions:We present evidence that early cleft lip and nasal repair can be performed safely and is effective at improving nasal symmetry without the placement of any nasal sutures. Utilization of this protocol has the potential to be a paradigm shift in the treatment of cleft lip and nasal deformity.