Primary Cleft Lip Surgery Research Articles

Regional anesthesia in neonates with cleft lip and palate: Retrospective study

BackgroundOrofacial clefts are the most common congenital abnormalities. Cleft lip reconstruction is performed mostly in 3 months of life including the neonatal period. The consumption of opioids during anesthesia is one of the monitored parameters of anesthesia safety. We investigated the effect of using an infraorbital nerve block for reducing opioid consumption during cleft lip surgery in neonates. Patients/methodsOverall, 100 patients who underwent primary cleft lip surgery in neonatal age between 2018 and 2021 were included in the study. The primary outcome was to compare opioid requirements during cleft lip surgery with and without using regional anesthesia. Secondary outcomes included a first oral intake from surgery between neonates with and without regional anesthesia and complications rate of infraorbital nerve block. ResultsData from 100 patients (46 patients with and 64 without regional anesthesia) were retrospectively analyzed and classified into two groups according to whether regional anesthesia during neonatal cleft lip surgery had been performed or not. The use of infraorbital block was found to be positively correlated with lower doses of opioids used during the general anesthesia for the surgery (mean 0.48 μg/kg vs 0.29 μg/kg, p < 0.05). The postoperative course was evaluated based on the interval from surgery to first oral intake which was statistically insignificant shorter (p = 0.16) in the group of patients using regional anesthesia. No complications were recorded in the group of patients with regional anesthesia. ConclusionsRegional anesthesia is associated with reduced opioid consumption during anesthesia thereby increasing the safety of anesthesia in neonates. Clinicaltrials.gov identifierNCT06067854https://clinicaltrials.gov/study/NCT06067854?cond=NCT06067854&rank=1.

Is There Utility in Preoperative Testing of Hemoglobin Before Primary Cheiloplasty?

To examine whether a preoperative hemoglobin of less than 10 g/dL is associated with a higher rate of perioperative complications. Retrospective review. Tertiary academic hospital at Arkansas Children's Hospital of Little Rock, Arkansas. A retrospective chart review evaluated patients undergoing primary cleft lip surgery from 2012 to 2017. No prospective intervention was performed for this study care. Age, sex, medical history, weight, and perioperative complications. Hemoglobin level was collected in the preoperative area. The primary outcome was rate of perioperative complications including infection, dehiscence, return to the operating room, unplanned admission, and emergency department visit within two weeks postoperatively. 105 patients undergoing primary cheiloplasty met inclusion criteria. Hemoglobin levels were obtained on all patients. 93.3% (n = 98) of patients had a hemoglobin of >10 g/dL before surgery, and 6.6% (n = 7) had levels <10 g/dL. 1 of 7 patients with a hemoglobin of <10 g/dL experienced a postoperative complication (Tet spell) and one patient with a hemoglobin of >10 g/dL experienced a postoperative complication (unplanned intensive care admission for respiratory distress). Post-operative complications are rare after primary cheiloplasty in patients with low or normal hemoglobin levels. The results of this study show that a preoperative hemoglobin of <10 g/dL does not predict perioperative complications in patients undergoing primary cheiloplasty.

Parents satisfaction with primary cleft lip surgery

The purpose of this study was to investigate parents satisfaction with the result of primary cleft lip surgery. Moreover this study will investigate the influence of educational factors, the severity of clefts, the number of children, on the level of satisfaction with primary surgery results cleft lip palate.One hundred and ninety children were included in this study. Cleft evaluation profile was used to measure parents satisfaction, both mother and father were included in this study. Overall it can be concluded that the level of satisfaction of parents both father and mother, towards primary lip repair surgery are considerably high. Mothers were the least satisfied with nose appearance of the patient (4.2 %). The gender of the child (P = 0.03) and the type of lip abnormality (P = 0.001) were factors that had a significant effect on the level of mother's satisfaction with the results primary cleft lip surgery. Female patient gender and bilateral cleft lip abnormalities were factors that affect the level of parents satisfaction with the outcome of the operation.The factor of parent education level had no significant effect on the level of parents’ satisfaction with the results of primary cleft lip surgery.

Trends of cleft surgeries and predictors of late primary surgery among children with cleft lip and palate at the University College Hospital, Nigeria: A retrospective cohort study.

Cleft of the lip and palate is the most common craniofacial birth defect with a worldwide incidence of one in 700 live births. Early surgical repairs are aimed at improving appearance, speech, hearing, psychosocial development and avoiding impediments to social integration. Many interventions including the Smile Train partner model have been introduced to identify and perform prompt surgical procedures for the affected babies. However, little is known about the trends of the incidence and surgical procedures performed at our hospital. Nothing is also known about the relationship between the clinical characteristics of the patients and the timing of primary repairs. To determine the trends in cleft surgeries, patterns of cleft surgeries and identify factors related to late primary repair at the University College Hospital, UCH, Ibadan, Nigeria. A retrospective cohort study and trends analysis of babies managed for cleft lip and palate from January 2007 to January 2019 at the UCH, Ibadan was conducted. The demographic and clinical characteristics were extracted from the Smile Train enabled cleft database of the hospital. The annual trends in rate of cleft surgeries (number of cleft surgeries per 100,000 live births) was represented graphically. Chi square test, Student's t-test and Mann Whitney U were utilised to assess the association between categorical and continuous variables and delay in cleft surgery (≥12 months for lip repair, ≥18months for palatal repair). Kaplan-Meier graphs with log-rank test was used to examine the association between sociodemographic variables and the outcome (late surgery). Univariable and multivariable Cox proportional hazard regression was conducted to obtain the hazard or predictors of delayed cleft lip surgery. Stata version 17 (Statacorp, USA) statistical software was utilised for analysis. There were 314 cleft surgeries performed over the thirteen-year period of study. The male to female ratio was 1.2:1. The mean age of the patients was 58.08 ± 99.65 months. The median age and weight of the patients were 11 (IQR:5-65) months and 8 (IQR: 5.5-16) kg respectively. Over half (n = 184, 58.6%) of the cleft surgeries were for primary repairs of the lip and a third (n = 94, 29.9%) were surgeries for primary repairs of the palate. Millard's rotation advancement flap was the commonest lip repair technique with Fishers repair introduced within two years into the end of the study. Bardachs two flap palatoplasty has replaced Von Langenbeck palatoplasty as the commonest method of palatal repair. The prevalence of late primary cleft lip repair was about a third of the patients having primary cleft lip surgery while the prevalence of late palatal repair was more than two thirds of those who received primary palatoplasty. Compared with children who had bilateral cleft lip, children with unilateral cleft lip had a significantly increased risk of late primary repair (Adj HR: 22.4, 955 CI: 2.59-193.70, P-value = 0.005). There has been a change from Von Langenbeck palatoplasty to Bardachs two-flap palatoplasty. Intra-velar veloplasty and Fisher's method of lip repair were introduced in later years. There was a higher risk of late primary repair in children with unilateral cleft lip.

Closure of cleft lips with Pfeifer's wave line technique does not inhibit upper lip growth: A retrospective study

The aim of this study is to describe the growth of the upper lip after reconstruction with a Pfeifer wave-line incision in patients with unilateral and bilateral cleft lip and palate (CL/P) in the long term.This was a longitudinal, monocentric, retrospective study. Metric standardized lip length measurements were taken annually from the age of 6 months to the age of 16 years. Defined anatomical points were determined which describe the lip length from the nasal entrance to the highest point of the Cupid's bow. The lip length of the unaffected side in unilateral cleft patients was taken as control.A total of 234 patients with cleft lip with/without cleft palate (CL/P) were included in the study. At the time of the primary surgery, the medial sides in unilateral clefts were 2–4 mm and the lateral sides 1.5–2 mm shorter than the normal unaffected side (p≤0.001). Two main periods of growth, one during childhood (first to sixth years) and one during adolescence (12th–16th years) were seen. At the age of 16 years, the end of the observation period, the lip length in unilateral clefts resulted in a clinically not noticeable shortening of the cleft side (0.37±0.26 mm). There was no correlation between lip length development and primary cleft width at the time of primary cleft lip surgery at 6 months. The upper lip in patients with bilateral clefts developed symmetrically without any obvious asymmetry. Both sides showed a lip length difference of 0.1±0.05 mm at the age of 16 years (p=0.1). Compared to the upper lip length of the control group, bilateral clefts showed a slight tendency toward a longer upper lip (p=0.52).Within the limitations of the study it seems that when lip length development is a priority in cleft lip surgery, Pfeifer wave-line procedure is good option to achieve symmetric results in unilateral and bilateral cleft lip surgery and, therefore, is a relevant option among a variety of other techniques.

The Nasal Lift Technique in Primary Cleft Lip Surgery.

Whether it is a unilateral or bilateral cleft lip, the nose tends to act as a collapsing pyramid with a tilt in case of the former. This gives the nose a tethered and flattened look with varying degrees of asymmetries. No matter how aggressive soft tissue manipulations are made to the tip and columella, we believe unless the nose is lifted and secured to a stable structure, the correction is inadequate. Here, we are describing our approach. Initially closed nasal correction is considered utilizing method described by Mulliken. This is followed by lifting the entire cartilaginous framework with a suture being looped around tip cartilages and secured into the periosteum of the nasal bones in a "Cantilever" fashion.

The nasal cantilever technique in children undergoing primary cleft lip surgery: novel concepts and review

BackgroundNasal deformity associated with cleft lip deformity is a challenging issue, encompassing controversies, theories, and a diversity of techniques. Historically, esthetic outcomes have ranged from being below expectations to barely acceptable.MethodBased on the concept that the nasal cartilaginous framework in clefts is similar to that of a collapsing pyramid, a novel suspension technique has been described. The entire cartilaginous structure is lifted from the infratip segment with a loop suture and is secured in a cantilever fashion onto the periosteum overlying the nasal bone. This part of the operation is performed in a semiclosed manner. The technique is applied during primary surgery in bilateral and unilateral nasal cleft lip deformities, with changes in the orientation of the cantilever loop suture. Studies conducted by Masters S. Tajima, H. McComb, H. Thomson, D. Fisher, and J. Mulliken, which are most relevant to this article, have been reviewed and discussed throughout.ResultsThe technique was first applied over 10 years ago. A case series of nine children whose parents consented to the developing technique is presented with follow-up ranging from months to years, along with technical descriptions and illustrative drawings. None of these cases had preoperative orthopedic correction, molding, or postoperative nostril splints. The esthetic outcome was optimal enough; none of the cases requested a secondary correction.ConclusionThe nasal cantilever technique is a novel concept in cleft nasal deformity, which can be used in conjunction with an appropriate lip technique, per the surgeon’s discretion. Other than a learning curve, we believe that it provides a solid correction by securing the cartilaginous structures after they have been mobilized to a stable base, the nasion.

Prioritizing Cleft/Craniofacial Surgical Care after the COVID-19 Pandemic.

It is anticipated that in due course the burden of emergency care due to COVID-19 infected patients will reduce sufficiently to permit elective surgical procedures to recommence. Prioritizing cleft/craniofacial surgery in the already overloaded medical system will then become an issue. The European Cleft Palate Craniofacial Association, together with the European Cleft and Craniofacial Initiative for Equality in Care, performed a brief survey to capture a current snapshot during a rapidly evolving pandemic. A questionnaire was sent to the 2242 participants who attended 1 of 3 recent international cleft/craniofacial meetings. The respondents indicated that children with Robin sequence who were not responding to nonsurgical options should be treated as emergency cases. Over 70% of the respondents indicated that palate repair should be performed before the age of 15 months, an additional 22% stating the same be performed by 18 months. Placement of middle ear tubes, primary cleft lip surgery, alveolar bone grafting, and velopharyngeal insufficiency surgery also need prioritization. Children with craniofacial conditions such as craniosynostosis and increased intracranial pressure need immediate care, whilst children with craniosynostosis and associated obstructive sleep apnea syndrome or proptosis need surgical care within 3 months of the typical timing. Craniosynostosis without signs of increased intracranial pressure needs correction before the age of 18 months. This survey indicates several areas of cleft and craniofacial conditions that need prioritization, but also certain areas where intervention is less urgent. We acknowledge that there will be differences in the post COVID-19 response according to circumstances and policies in individual countries.

The Trend of Cleft Care at a Children's Referral Center in Thailand.

To investigate the trend in cleft care at a major children's referral center in Bangkok, Thailand. Retrospective chart review. A review of 129 patients under 18 years of age who had underwent care by the senior author for cleft treatment between January 2015 and October 2017 was done. The impact of varying factors on patient care was analyzed. We compare our demographics and treatment timeline to that of previously published literature in more developed countries. Tertiary care medical center. One hundred and two patient charts were reviewed with 53% male patients. Most patients had both cleft lip and cleft palate, 44%. Cleft lips most commonly were complete and occurred on the left side. In all, 77.4% of clefts were nonsyndromic. On average, primary cleft lip surgery was delayed being performed about 11 months of age. Sixteen percent of patients were treated with an obturator, while 11 patients had nasoalveolar molding use. Hearing screenings occurred on average at around 6 months of age. Abnormal tympanograms were evident in 32% of individuals. There was a significant difference in timing of surgery for patients who lived a distance greater than 30 kilometers from the hospital versus those from the Bangkok metropolis (P < .05). Reviewing data from a high-volume referral center in Thailand reveals mild variance with regard to cleft care timing compared to published literature from the developed world. Distance traveled was found to impact timing of surgery.

Use of cost-effective prophylactic ′Rocket′ in infants undergoing primary cleft lip surgery: A retrospective cohort analysis

Background and Objectives: Adverse postoperative airway events are a significant problem in infants following primary cheiloplasty. This study aims to describe a simple inexpensive tool which, used prophylactically, can minimize postoperative airway obstruction (POAO). A retrospective cohort analysis was conducted among 314 infants who underwent primary cheiloplasty under general anesthesia at a hospital in Kanyakumari District in Tamil Nadu, India. Materials and Methods: The infants were divided into two cohorts, the first prior to introduction of the modified nasal airway (termed locally as due to its appearance once fixed in position), and the second after its use began in July 2007. The Rocket, consisting of an uncuffed endotracheal tube, 0.5 mm smaller in diameter than that used for intubation, was placed prophylactically prior to extubation in the nasal space of infants considered at risk. The incidence of POAO was compared between the two cohorts. Results: The incidence of POAO in cohort I ( N = 86) was 8.1%, which reduced significantly to 0.44% in cohort II ( N = 228) where the Rocket was used prophylactically prior to extubation. Interpretations and Conclusions: The prophylactic use of the Rocket minimized the occurrence of POAO following primary cheiloplasty in infants with cleft lip ± cleft palate ± cleft alveolus. The Rocket may be a costeffective solution to prevent POAO in infants undergoing these procedures, particularly in challenging and rural circumstances, where access to short-acting agents and customized airways may be limited.

Reduced nasal growth after primary nasal repair combined with cleft lip surgery

Nasal growth after cleft lip surgery with or without primary nasal repair was evaluated using lateral cephalograms. In 14 patients who underwent simultaneous nasal repair with primary cleft lip repair and 12 patients without simultaneous nasal repair, lateral cephalograms were obtained at 5 and 10 years of age. Lateral cephalograms of normal Japanese children were used as a control. At 5 years of age, there were significant differences in the nasal height and columellar angle among the three groups. Children without simultaneous nasal repair had shorter noses with more upward tilt of the columella compared with the controls, while children with simultaneous nasal repair had much shorter noses and more upward tilt than those without repair. At 10 years of age, the children without simultaneous nasal repair showed no differences from the control group, while those with simultaneous repair still had shorter noses and more upward tilt of the columella. These findings suggest that performing nasal repair at the same time as primary cleft lip surgery has an adverse influence on the subsequent growth of the nose.

A systematic review of skin closure techniques in primary cleft lip surgery

AbstractAimTo carry out a systematic review of the published evidence for skin closure techniques in primary cleft lip surgery.MethodsFive electronic databases were searched from their inception to February 2013 to identify all relevant studies of wound closure techniques in primary cleft lip surgery. Two reviewers independently determined eligibility of studies, assessed the methodological quality of the included studies and extracted data.ResultsSix eligible studies were included. Five were observational studies so were prone to bias. One was a randomised controlled study. Four compared adhesive with sutures, one compared adhesives with steri‐strips and one compared absorbable and non‐absorbable sutures. No cases of dehiscence (primary outcome measure) were reported. The methodological quality of all the included studies was poor.ConclusionsThere is currently insufficient evidence to guide clinical practice for incision closure in primary cleft lip surgery. Adequately powered randomised controlled trials are required to address this issue.

How antenatal diagnosis changed our timing for primary cleft lip surgery

How antenatal diagnosis changed our timing for primary cleft lip surgery

The timing of primary cleft lip and palate surgery – the experience of a craniofacial centre in South India

Introduction: The goal of an optimally timed primary surgery of a cleft deformity is to achieve anatomic reconstruction and functional rehabilitation. The optimal timing of primary cleft surgery has been controversial and the subject of intense debate from historical times. American cleft palate craniofacial association (ACPCA) recommends that primary cleft lip surgery should ideally be performed by 6–12 months of age and for the cleft palate by 18 months. Various factors influence the timing of cleft surgeries in a developing country like India.

Cosmetic Surgery in Children with Cognitive Disabilities: Who Benefits? Who Decides?

Cosmetic Surgery in Children with Cognitive Disabilities:Who Benefits? Who Decides? Douglas J. Opel (bio) and Benjamin S. Wilfond (bio) Recently, as part of a clinical ethics consult, a clinician told the story of a mother and her teenage son. A couple of years ago, the boy had a skateboarding accident and injured his brain and spine, leaving him quadriplegic, unable to communicate, and in need of mechanical ventilation. At the time of the ethics consult, the boy was back in the hospital because the bone graft—bone taken from another part of his body to fill two large sections of his skull removed after the initial injury—had now failed, leaving only a layer of skin to protect his brain. To safeguard his brain from further injury, surgery was planned to cover this fragile area of his head with plastic prosthetic plates. The parents had requested the surgery and the surgeon agreed, but some of the other clinicians caring for the boy had a problem with it. Although the prosthetic plates were reconstructive, the surgery involved serious risks with questionable benefits. The boy's risks of falling and hitting his head were nearly zero since he remained in bed unless placed in a wheelchair. When one of the doctors asked the mother why she wanted this cosmetic surgery for her son, she responded angrily, "How dare you call it cosmetic!" It is not difficult to understand the mother's reaction given the negative connotations often associated with "cosmetic surgery." The prevalence of nose jobs, face lifts, and breast augmentation has not helped, leading to the label "psychiatry with a scalpel."1 In response to critiques of cosmetic surgery, many people make distinctions that are meant to be morally meaningful. For instance, there is the distinction between enhancements and restorative procedures: breast augmentation is considered an enhancement and, therefore, morally quite different from a similar restorative procedure following a mastectomy for breast cancer. There is also the distinction between enhancements and interventions that are normalizing: surgery to remove the fifth toe to better fit into fashionable pointed shoes can be morally distinguished from surgery to remove an extra toe to fit into standard shoes. Although these distinctions may offer some insight into the mother's irritation with the label "cosmetic," they may fail to fully capture the underlying moral concerns and so may not be useful in addressing what should be done. The challenge of balancing risks and benefits in this case raises difficult questions about cosmetic surgery in children: Should different ethical standards be used when considering such surgery in children with developmental disabilities than are used when considering it in children without disability? Should cosmetic surgery in children with severe cognitive disability even be allowed? And should parents be permitted to make this decision? Quality of Life: The Child's or the Parents'? Cosmetic surgery for children primarily entails quality-of-life considerations. These decisions are not life-or-death matters, and they very rarely have the potential to alleviate physical pain.2 The impact of the surgery on the child's quality of life must be balanced with the risks of the proposed procedure. The standard approach to decision-making about cosmetic surgery in children is interdisciplinary. Pediatricians, surgeons, social workers, nurses, psychiatrists, dentists, physical therapists, and others contribute their specific expertise for the most accurate picture of the risks and benefits. How to weigh each burden and benefit, however, ultimately rests with the parents. While clinicians generally give parents great latitude in medical decision-making on behalf of their children, cosmetic surgery may introduce some unique constraints. Participants in the recent Hastings Center research project, Surgically Shaping Children, for instance, largely agreed that parents could pursue primary cleft lip surgery where the risk was small and the psychosocial benefit enduring. However, the group unanimously advocated for postponing "risky and painful surgeries that might fail to reliably retain function and produce more normal appearance" until the child was old enough to participate in the decision-making process.3 That is, when the ratio of risks to benefits is less clear, cosmetic surgery decisions should be deferred. However, this approach does not address cases in which the child...

Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps from the unaffected side

We used three types of subcutaneous pedicle flaps harvested from the unaffected side of the nostril to repair postoperative nose deformity caused by primary cleft lip surgery. By moving the subcutaneous pedicle flap from a nearby tissue-rich area, it was possible to achieve a favourable symmetrical nasal contour for the narrowing of the nostril cavity, depression of the nostril floor and the columella deviation of the affected side. The method, we used here is technically simple. We believe this procedure is a method of choice for repairing small deformities of the nose occurring after primary or secondary cleft lip surgery.

Muscle reconstruction in primary cleft lip surgery

Skeletal maldevelopment in the mid-face in the case of cleft lip and palate is caused by an inadequate surgical reconstruction of the paranasal muscles. This results in deficient functional stimulus to the desmal osteogenesis at the mid-face sutures. Early reconstruction of these muscles can prevent secondary skeletal maldevelopment.