Cleft Lip Repair Research Articles

Three-Dimensional Evaluation of Deformed Noses in Patients With Unilateral Cleft Lip and Palate: A Meta-Analysis.

Multiple surgeries for patients with cleft lip and palate may be required to repair secondary deformities after the completion of cleft repair. This meta-analysis aimed to evaluate the three-dimensional nasal morphology in patients with unilateral cleft palate who underwent cleft lip and palate repair but did not undergo terminal nasal repair. PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and SINOMED databases were searched from inception until December 2020. Studies involving patients ages ≥6 years with cleft lip and palate who did not undergo terminal nasal repair were included. Quantitative data were obtained through three-dimensional evaluation. Mean weighted effect sizes with 95% confidence intervals, heterogeneities, and publication biases were assessed using raw data obtained from 13 studies. In general, patients with unilateral cleft lip and palate had a significantly wider nose; shorter bridge length and nasal height; larger forehead-nose angle, nasal tip angle, and alar slope angle; and smaller nasolabial angle. The number of studies that included patients with unilateral cleft lip, unilateral cleft lip and alveolus, and unclassified deformities was limited, and their results were similar to those involving patients with unilateral cleft lip and palate. Patients with unilateral cleft tend to have short, flat, and wide noses. Nasal tip elevation and alar base adduction should be prioritized during terminal nasal repair to achieve more normalized cleft-side nostrils.

The Implications of Same-day Discharge after Primary Unilateral Cleft Lip Repair: An NSQIP-based Study

The Implications of Same-day Discharge after Primary Unilateral Cleft Lip Repair: An NSQIP-based Study

The Effect of Early Cleft Lip Repair on Infant Weight Gain

The Effect of Early Cleft Lip Repair on Infant Weight Gain

Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua.

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.

Racial Disparities in Cleft Lip Repair: A National Assessment

Background/purposeRacial disparities in surgical care in the United States have been previously demonstrated. In cleft lip repair, however, an association between race and outcomes has not been established. This study aimed to identify the impact of race on timing, costs, and complications following cleft lip repair using the Kids’ Inpatient Database (KID). MethodsPatients who underwent cleft lip repair were identified in the KID database from 2006 to 2012. Demographic data collected included race, diagnosis, insurance status, the mean income of patient Zip Code (as proxy for socioeconomic status), hospital costs, and comorbidities. ANOVA and Chi-squared analyses were used to assess differences in demographic variables across races. Bivariable linear and logistic regression models were used to identify gross differences in timing of surgery, cost of surgery, and hospital length of stay (LOS) for each race in comparison to white patients. Multivariable models were performed across the same parameters to adjust for other contributing variables. ResultsIn total, 5927 patients were identified with cleft lip: 3724 white, 279 black, 1316 Hispanic, 277 Asian/Pacific-Islander, and 331 other races. Cleft diagnoses differed by race (P < .001); bilateral clefts were most frequent among Hispanic patients (29.7%), and white patients were most likely to have concurrent diagnosis of cleft palate (70.4%). There were significant differences in insurance and income status by race (P < .001), with black patients most likely to utilize Medicaid (69.8%) and live in lowest-income quartile areas (45.9%). Overall, white patients received cleft lip repair earlier (3.8 months) than all other patients (P < .001). Hospital charges were also lower among white patients than all other groups (P < .001), with non-white patients costing an additional $10,910.25 per stay. Race-based differences in both timing and costs persisted (P < .05), even when controlling for other factors, with greatest delays (+4.0 months) and highest costs (+$5385.67) among Asian patients. Significant differences (P < .001) were also seen in LOS for each race when compared to whites (1.34 days) with highest LOS seen in black patients (1.99 days). However, race-based differences in LOS were not significant in multivariable regression, which showed a mediating effect by low-income status (P = .017) and comorbidities (P < .001). Similarly, while a minimal increase in complications was seen among Asian patients (OR 1.01, P = .001), these differences were largely mediated by the severity of patient comorbidities (P < .001). ConclusionRace was associated with significant differences in admission characteristics and outcomes in cleft lip repair. White patients generally underwent surgical repair earlier, incurred fewer hospital charges, and experienced shorter lengths of stay and fewer complications than their non-white counterparts. Disparities appear to be partially mediated by differences in socioeconomic status and underlying patient health, among other factors. Future efforts should aim to identify barriers to cleft care and minimize disparities for minority patients.

Sagittal Growth Restriction of the Midface following Cleft Lip Repair: A Systematic Review and Meta-analysis

IntroductionOrofacial clefts are 1 of the most common congenital anomalies worldwide. Cleft lip repair has esthetic and functional benefits, but long-term, devastating sequelae such as midface hypoplasia (MFH) are poorly understood. Historically, experts believe cleft palate repair is the primary cause of MFH.1,2 This study examines whether surgical cleft lip repair contributes to MFH. MethodsA systematic literature review of 3780 articles was done in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria included English-language articles examining operated or unoperated cleft lip patients. Twenty-seven met inclusion criteria, and 13 reported cephalometric measurements amenable to meta-analysis (sella-nasion-A point, SNA and A point, nasion, B point, ANB). Controls were participants with normal craniofacial morphology. ResultsThe 13 studies with patient-level cephalometric data had 224 males (68.7%) and 102 females (32.3%). Mean age for cases versus controls was 14 and 23.3 years, respectively (weighted average). Patients with cleft lip and palate who had cleft lip repair had significantly lower SNA than controls (mean 75.6o + 3.9 vs. 82.0 o +-3.2, P < .001). SNA in patients with cleft lip only (CL) who underwent lip repair was not significantly different than controls (P =.27). ConclusionPatients with cleft lip and palate who undergo surgical repair of the cleft lip only experience sagittal midface growth restriction. Patients with isolated cleft lip deformities who had cleft lip repair did not have sagittal midface growth restriction. Scarring and growth restriction after lip repair is an unlikely source of midface hypoplasia. These data suggest that cleft palate, even without palatoplasty, is a possible source of restricted midface growth. Further prospective studies are necessary to understand the role of cleft physiology and surgery on MFH.

A Prospective comparative Study of Vermilion repair by Modified Vadvancement Vermilion Flap in Unilateral Cleft Lip Patients

Abstract Background Oro-facial clefts include a range of congenital deformities most commonly presenting as cleft lip with or without cleft palate (CLP) or isolated cleft palate (CP). CLP is the second most common congenital birth defect in the U.S. Aim of the Work to assess modified v-advancement vermilion flap combined with Tennison technique for vermilion repair in unilateral cleft lip regarding aesthetic outcome in comparison with repair of cleft lip by Tennison technique. Patients and methods This study was conducted in plastic, maxillofacial and reconstructive surgery department in Ain Shams University between September 2019 to February 2020. It included 20 patients divided into two group; the first group consisted of 10 patients who underwent repair of cleft lip by Tennison technique and the second group consisted of 10 patients who underwent repair by Tennison technique combined with v- advancement vermilion flap. Both groups were assessed postoperatively by Asher-McDade et. al. scoring system. Result The study showed statistically significant difference between the two groups as regard the white lip length which was more symmetrical in cases repaired by Tennison technique combined with modified v-advancement vermillion flap (P = 0.01). The bulge and the deficiency in the lateral vermilion were decreased in the group treated by Tennison technique with modified v-advancement vermilion flap. However the difference was statistically insignificant (P = 0.66). Conclusion The choice of a technique for surgical correction of UCL should be based on an evidence that this technique has the best functional and aesthetic outcomes. The findings of this study support the view that these two methods of cleft lip repair have their own advantages and disadvantages. Tennison technique combined with vadvancement vermilion flap achieved less bulge in the vermilion with no statistically significant difference.

Short-term nasal symmetry repaired by force-balanced muscular reconstruction technique.

This study aimed to compare the postoperative outcome of the new and classical muscular reconstruction technique combined with nasal internal-fixation method for secondary deformity post unilateral cleft lip repair. A rationale is provided for the further surgical improvement of secondary deformities. Sixty patients aged 4-18 years with secondary unilateral cleft lip-nose deformity were involved in this research. The deformities of 28 patients were repaired using the muscular force balance technique through nasal internal fixation method, and 32 were repaired using classical muscular reconstruction technique. Two-dimensional analysis was used to evaluate the nose-lip morphology of pre- and post-operative patients through standardized photographs seven days after surgery. Compared with preoperative nasal morphology in the muscular force balance technique group, the 7-days postoperative results of this group showed the significantly improved short-term outcomes in the correction of columellar deflection, alar rim angle, nasal shape, and the symmetry of alar base width, nostril width, nostril height, alar rim angle (P<0.05). The new muscular reconstruction technique with nasal internal-fixation method has a significant effect on nasal repair.

Comprehensive Nursing Intervention Can Reduce Postoperative Complications and Shorten Hospital Stay of Children with Cleft Lip and Palate Repair Surgery

This research aims to probe into the impact of people-oriented comprehensive nursing intervention on children with cleft lip and palate repair surgery. Totally 112 lip cleft children who underwent surgical treatment in our hospital from June 2017 to March 2019 were randomized into routine and intervention groups. Among them, 55 in the former underwent routine nursing intervention, and 57 in the latter obtained comprehensive nursing intervention additionally. The hospital stay and complications of the two groups were observed. The hospital stay and complications in the latter were less than those in the former. Comprehensive nursing intervention can reduce postoperative complications and shorten hospital stay in children with cleft lip and palate repair surgery.

On randomised trials of surgical timings for cleft palate repair

Background: In this article we review randomised controlled trials (RCTs) comparing palatal surgery at different ages to examine their design features and quantify their conclusions. Method: A literature search of RCTs comparing surgical timings for cleft palate and/or lip repair from 1 January 2004 to 31 December 2013 was undertaken. This supplements an earlier systematic review of 62 RCTs in cleft lip and palate from 1 January 2004 to 31 December 2013 in English using the Cochrane Central Register of Controlled Trials, MEDLINE® and EMBASE with key words ‘cleft lip’ or ‘cleft palate’. Results: Four RCTs were identified, each comparing palate surgery at different lower (six, nine and 12 months) and upper (12, 18 and 36 months) ages with velopharyngeal competence (VPC) also at different ages (three, four, more than four or five years). These surgical and assessment age differences prevent a synthesis using meta-analysis techniques. Nevertheless, three RCTs indicate that VP function is more impaired with later surgery. Two ask questions about the type of surgery; one suggests that VPC is greater with Furlow palatoplasty than von Langenbeck surgery and the other that one technique appears to have better VPC at six months and the other at 12 months. Conclusion: The role of the timing of palatal surgery with respect to VPC remains unclear. We propose an international strategy that is designed to establish the optimal age for palatal surgery in infants requiring palate and/or lip repair.

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty.

Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty. A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models. The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone. Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

Early Postoperative Complications in Primary Cleft Lip and Palate Repair: A Retrospective Analysis of 328 Cases

Aim&#x0D; Primary cleft lip and palate (CLP) repair is the most critical stage throughout lifetime. CLP surgery involves risks of surgery and anaesthesia related complications. In this study, it was aimed to evaluate complications occurred in early period after primary CLP surgery and to determine early factors that trigger these conditions.&#x0D; Materials and Methods&#x0D; In this study 328 surgeries of 271 CLP patients were included. Complications were classified as minor complications such as fever occurring within first 3 days. Complications that cannot be treated with palliative care or required transfer to intensive care were considered as major complications. Epidemiology and causal link of early complications were statistically evaluated.&#x0D; Results&#x0D; Early complications were seen in 19% (n: 63) of all cases that operated for cleft lip and palate. Among them rate of minor complications were 9% (n: 25). It was determined that prolongation of anaesthesia lead to rising of minor complications such as deficiency in oral feeding. Major complications were observed in 11% (n: 38). These major complications were more common in bilateral cleft lip, syndromic, palate and male patients. Mean hospitalisation of complicated cases were 3.35 days. When compairing to noncomplicated cases there was increasing in hospitalisation time (p

Sella Turcica Bridging and its Association with Dental Anomalies

Aim: This study aimed to study the overall incidence of DA and its association with Sella Turcica bridging (STB). Background: Dental anomalies (DA) are associated with morphological changes in the Sella Turcica (ST). Materials and Methods: We retrieved the pretreatment patient records from March 2018 - March 2020 from the archives of the Orthodontics Department (n=806). We excluded the records with missing radiographs, concomitant cleft lip/ palate, history of surgical repair of cleft lip/ palate or any other craniofacial anomaly, history of trauma, and prior orthodontic treatment. A total of 676 patient records were included for initial screening, out of which 103 patients had DA (study group). A similar number of records (n=103) without any DA were randomly selected to constitute a control group. Determination of the extent of STB was done by calibrated and trained examiner. Age and sex were also recorded. Results: The incidence of DA was 15.24%. The most common anomalies recorded were impacted canines (6.8%) and hyperdontia (3.7%), followed by agenesis (2.1%) and others. Type III bridging in patients with DA was 22.3%, while being 9.7% in the control group. Type II bridging was observed in 36.8% of patients with DA as compared to 29.1% in the control group. The presence of partial and complete STB in patients with dental anomalies was significantly higher than in the control group (P=0.006). The study group showed significant association with STB (OR: 2.33; P=0.003; 95%CI: 1.33-4.11) after adjusting for sex. Conclusion: The results of our study revealed a significant association between STB and DA.

Single Stage Cleft Lip and Palate Repair In Toddlers: Retrospective Review of Feasibility and Operative Experience

In children with cleft lip and palate (CLP), we aimed to compare a single-stage surgery group or all in one (AIO) approach with a 2-stage surgery group (2-SSG) of 18 and 12 toddlers, respectively. A retrospective review of 30 patients with CLP was conducted between 2007 and 2019. All in one procedure was performed at 12 to 24 months and 2-SSG patients had lip and primary nasal correction at 3 to 9 months, followed by palatoplasty and myringotomies at 12 to 16 months. In the AIO group, 13 (72.2%) patients had unilateral CLP, while 5 (27.8%) had bilateral CLP, which is comparable to the 2-SSG who had 8 (66.7%) unilateral CLP, 3 (25%) bilateral CLP, and 1 (8.3%) incomplete CL with submucous CP. The 2-SSG had a 30 minutes longer cumulative operative time and increased blood loss that was not statistically significant (P = 0.149 and 0.219, respectively). The AIO group had a slightly longer intubation (0.67 versus 0.33 day) and pediatric intensive care unit admission duration of 1.72 versus 1.67 days, (P = 0.427, 0.927), respectively. Total hospitalization time was significantly shorter with the AIO (8 versus 10.67 days, P = 0.016). The duration of postoperative pediatric intensive care unit and need for supplemental oxygen were higher in the AIO (38.9% versus 8.3%, P = 0.064). The “AIO” approach of lip, nasal, and palate surgery from 12 to 24 months completes early surgical care in a single operation. However, based on our review, this protocol must be selective; children with comorbidities or syndromes are advised to be exempted and operated in stages.

Modified Rotational Advancement Technique for Primary Unilateral Complete Cleft Lip Repair.

Importance: Leveling Cupid's bow while maintaining lip height and width in unilateral complete cleft lip patients with improved nose outcomes is a significant challenge for surgeons. Objective: This study aimed to measure the symmetry of the nasal and labial anthropometric points after using this modified cleft lip repair technique. Design, Setting, and Participants: In this retrospective study, 72 consecutive nonsyndromic unilateral complete cleft lip patients underwent a modified rotational advancement technique. Photos of at least 1 year follow-up period were collected. Main Outcomes and Measures: The nose measurements included columella length, nostril height and width, ala width, nostril inclination, columella angle, and ala bases angle. The lip measurements included lip height and width, vermillion height; midline-philtrum angle, and angles of Cupid's bow peaks. Descriptive quantitative analysis of the lip and nose measurements, intraclass correlation coefficient, and ANOVA tests were conducted. Results: Well-aligned Cupid's bows with symmetrical lip height and width were obtained with satisfactory aesthetic nasal outcomes. Conclusions: The present technique had leveled the Cupid's bow while preserving the lip height and width, with resultant satisfactory nasal outcomes.

Significance of the Nasal Lift Concept in Primary Cleft Lip Repair.

Significance of the Nasal Lift Concept in Primary Cleft Lip Repair.

A Normative Observational Study of the Relationship of the Philtral Ridges to the Columellar Base in South-Indian Population and its Significance on Cleft Lip Repair.

Introduction The philtral ridges form a prominent visual landmark in the upper lip. An aesthetically pleasing cleft lip repair should restore this preferably without any scars cutting across it. Although there are several scientific publications on morphology of this structure and its variations, very few studies on the Indian population have been published. Aim To study the morphology of the philtral ridges and their relationship to the columellar base in normal Indian children and its significance in cleft lip repair. Methods 115 normal healthy children from southern India aged between one and 12 years were studied based on direct observation of the relationship of the superior end of the philtral ridge to the columellar base and nasal sill. In type A, the philtral ridge terminates at the nasal sill just lateral to the columellar base, and in type B, it either reaches or fades before reaching the columellar base. All observations were performed by the first author by examining standardized two-dimensional (2D) photographs of the upper lip-nose complex. Results In this study, 74% of the subjects had the philtral column extending lateral to the columellar base. Conclusion These finding assume a significance since, in a substantial proportion of the studied population, techniques of cleft lip repair such as the rotation advancement method, place a scar that crosses the upper third of the philtral ridge which may be undesirable.

Quality of Life in Patients With Velopharyngeal Insufficiency in West China.

This study aimed to investigate the quality of life (QOL) of patients with cleft lip and palate and velopharyngeal insufficiency (VPI) in relation to sex, age, age at initial cleft lip surgery, and age at initial cleft palate surgery. This is a cross-sectional study. The study was conducted in a tertiary medical center. The participants were caregivers of 72 patients with cleft lip and palate and VPI aged 4 to 20 years. Participants completed the Chinese version of the caregiver report of the VPI Effects on Life Outcomes (VELO) questionnaire. The Mann-Whitney U test was used to evaluate the patients' sex, age, age at initial cleft lip repair, and age at initial cleft palate repair in relation to VELO total score and domains. Spearman correlation analysis was completed including all study variables. Associations between the study variables and the VELO total score were tested using a generalized linear mixed model. In the univariate analysis, patients' age and age at initial cleft palate surgery influenced the QOL of patients with VPI. There were no differences in the VELO total score or domains based on sex or age at first cleft lip surgery. In the generalized linear mixed model, patients older than 8 years had higher VELO total scores. By caregiver report, the QOL of patients under age 8 years with VPI was lower than older patients. In addition, the caregiver impact domain was higher for parents of children who had their initial cleft palate surgery at age 2 years or younger.

Evaluation of Meshra’s Technique in Unilateral Cleft Lip Deformity

Background: White roll vermillion turn down flap is a modification on Millard’s technique of rotation –advancement repair for unilateral primary cleft lip deformity.Aim of Study: This research to evaluate a new modification on Millard’s technique of primary unilateralchieloplasty.Patients and Methods: A prospective study was done and involved 20 patients were surgically treated byMeshra’s technique of white roll vermillion turn down flap at Al-Shaheed Ghazii Alharriri and Al-Wastyhospital between April 2015 to April 2017. 12 male versus 8 female presented to us with unilateral cleftlip there ages were ranging between 3 months to 30 months, these patients surgically treated by white rollvermillion turn down flap.Results: A prospective study was involved of 20 cases of primary cleft lip repair with this technique, wehave achieved 17 cases with a good symmetry and peaking of cupids bow with no vermillion notching ofthe lips and without major complications.Conclusion: White roll vermillion turn down flap gave us a good look of the cleft patient and satisfactoryfor his family. It’s applicable and takes same time for Millard’s technique.

The Implications of Same-Day Discharge After Primary Unilateral Cleft Lip Repair: A National Surgical Quality Improvement Program-Based Study.

Orofacial clefts are the most common craniofacial anomaly observed in the United States. Permitted by recent advancements in anesthesia and multimodal pain management, there has been a trend toward outpatient cleft lip repair to alleviate hospital burden and minimize healthcare costs. The purpose of this study was to compare complication rates between outpatient and inpatient cleft lip repair from large national samples as well as identify preoperative factors that predicted discharge status. The National Surgical Quality Improvement Program database for pediatrics was used to analyze 30-day outcomes for all patients undergoing cleft lip repair (CPT (current procedural terminology) code 40700) from 2012 to 2019. Complication rates were compared across 3 groups: same day discharge, next day discharge, and later discharge. Preoperative factors, including comorbidities and demographics, were analyzed to determine the impact of discharge date on complications as well as identify independent predictors of discharge timing and perioperative complications. A total of 6689 patients underwent primary cleft lip repair, with 16.8% discharging on day of surgery, and 72.4% discharging 1 day after surgery. Complication rates were statistically equivalent between same day and next day discharge. Preoperative factors predicting complication and postoperative admission included age <6 months and weight less than ten pounds at the time of surgery. Patients discharged after more than 1 day in the hospital had higher rates of complications as well as more preoperative comorbidities. Complication rates between same day and next day discharge are equivalent, suggesting that same day discharge is a safe option in select patients. Clinical judgment is critical in making these decisions.