Neonatal cleft lip repair in Ayrshire; a contribution to the debate

The Burden of Care for Children with Unilateral Cleft Lip: A Systematic Review of Revision Surgery

Objective

To identify the average rate of revision surgery following cleft lip repair.

Design

PubMed, CINAHL, and SCOPUS were searched from database inception through March 2013 using the search terms cleft lip and surgery. Two investigators independently screened all abstracts and determined eligibility from review of full manuscripts using prespecified inclusion and exclusion criteria. Strengths and limitation of the studies were assessed, followed by qualitative synthesis. The I2 test of homogeneity was performed to determine if meta-analysis was appropriate.

Results

The search identified 3034 articles. Of those, 45 met the inclusion criteria. Studies were primarily case series and retrospective cohort studies, with only one randomized controlled trial. One-third of studies (n = 15) did not describe how the study sample was selected. Follow-up duration was not reported in one-fourth of studies (n = 11). Nasolabial aesthetics were reported in 44% of studies (n = 20). The incidence of revision surgery ranged from 0% to 100%. Meta-analysis was precluded because of study heterogeneity (I2 = 97%).

Conclusions

The average incidence of cleft lip revision surgery cannot be estimated from the published literature, due to significant heterogeneity among existing reports and limited study quality. To provide valid information about the burden of care for unilateral cleft lip, a population-based or multicenter longitudinal cohort study is necessary; this study should measure the number of surgical procedures and the patient's aesthetic outcomes.

Safety of neonatal cleft lip repair

The timing of repair of a cleft lip continues to be debated. One of the reasons for delaying operation has been the belief that there is an increased risk of anaesthesia during the neonatal period. As a contribution to this debate we have analysed the anaesthetic and surgical complications of neonatal cleft lip repair undertaken at a single centre. We made a retrospective study of 99 babies consecutively referred for repair of cleft lip over a five-year period (January 1995-December 1999). In contrast to other series, all babies were considered for neonatal surgery and no exclusion criteria were set. All repairs were undertaken within 28 days of birth (median 4); the median gestational age was 40 weeks (range 34-42) and median birth weight of 3300 g (range 1500-4600 g). Perianaesthetic complications included one case of hypoxia presumably as a result of transitional circulation, one reintubation for poor respiratory effort in a premature baby, and five cases of nasal obstruction, three of which required a nasal stent. All recovered without long-term effects. There were significantly more surgical complications with bilateral repairs than with unilateral (p < 0.03). Breast feeding was achieved in 54 babies by the time of discharge. We found no evidence that neonatal repair of cleft lip is unsafe. Paediatric anaesthetic and intensive care support within a specialised centre are necessary, and close postoperative monitoring is required, with attention to the nasal airway.

A modified surgical schedule for primary management of cleft lip and palate in developing countries

INTRODUCTION

In developing countries cleft lip and palate (CLP) patients arrive late, and there is a risk of drop out for functionally important palatoplasty after lip repair. Patients may be underweight, anemic, and prone to recurrent infections.

OBJECTIVE

To repair cleft palate at an appropriate time and secondly to avoid the drop out after the first surgery.

PROTOCOL

A new surgical protocol has been designed for patients with CLP in whom the cleft palate is first repaired at 6 to 9 months of age or whenever the patient presents at the clinic. The cleft lip is repaired 3 to 6 months after the first surgery.

PATIENTS AND RESULTS

When cleft lip repair was performed before palate repair (conventional protocol group) in 89 patients with CLP, the median interval between first and second surgery was 290 days. However, when the modified protocol was followed in 330 patients over 13 years, the median interval was 193 days (p < .0002). The reduction in the interval is statistically significant. In eight patients cleft palate fistula encountered after palatoplasty was repaired during cleft lip repair thus avoiding a third surgery.

CONCLUSIONS

The compliance for two surgeries in CLP has improved. Apart from achieving the main aim of the new protocol, a number of advantages were noticed. The palate repair was easier in the presence of an unrepaired cleft lip. The anterior palate repair was more dependable with reduced incidence of anterior palatal or alveolar fistula.

Anthropometric study of the upper lip of 1500 healthy children in Chengdu, Western China

The aim of this study was to measure and analyse morphological data about the upper lips of healthy children in Chengdu, Western China. The characteristics and patterns of growth and development of the upper lip may be helpful in guiding the treatment of cleft lip. A total of 1500 healthy children aged between 2 and 12 were divided into 11 groups according to their age. Seven points on the upper lip were measured directly: the length from the alar base to the commissure, the length of the philtrum, the length from the tip of the Cupid's bow to the commissure, the width of one limb of the Cupid's bow, the length from the alar base to the central columella, the area of the unilateral upper lip, and the angle of the line of the alar base to the commissure and the line of the tip of the Cupid's bow to the commissure. Five aspects were significantly different among the groups: the length from the alar base to the commissure (p=0.04), the length from the tip of the Cupid's bow to the commissure (p=0.02), the width of the upper lip (p=0.02), the area adjacent to the lip (p=0.03), and the area of the unilateral upper lip (p=0.04). These data may be useful for reference to cleft lip repair.

Early repair for infants with cleft lip and nose

OBJECTIVE

To study the results 10 years after early surgical cleft lip and nose repair.

PATIENTS AND METHODS

We present the outcome of 123 early cleft lip repairs whose condition was managed in a multidisciplinary team according to a strict protocol. We give the observation results of operations of a single surgeon's neonatal surgery over a 10-year period in term of aesthetic assessments and dental arch relationships. One hundred and twenty-three patients were operated on during the first 4 weeks of life; a subgroup of 40 child had been operated on at a week or less of age.

RESULTS

The results show good aesthetic assessments and dental relationships, with facial growth appropriate for the age.

CONCLUSIONS

We are currently encouraging early cleft lip and nose repair in the full-term baby as the good method of management of newborns with cleft.

Réparation chirurgicale néonatale des fentes labiales : impact psychologique chez les mères

AIM

To investigate the psychological impact on mothers of an early neonatal cleft lip repair.

METHODS

Between January and December 2004 mothers of 24 infants born with a cleft lip completed psychological interviews and questionnaires 1 month after neonatal repair. We evaluated the psychological impact on mothers of antenatal and postnatal diagnosis. We noted the parental preferences for the timing of cleft repair and their satisfaction after neonatal repair.

RESULTS

Stress, incomprehension and anxiety were often noted. Most mothers preferred their infant to receive neonatal repair. We noted a great satisfaction after neonatal cleft lip repair.

DISCUSSION

We are currently encouraging early repair in the full-term baby as the optimum, reliable and safe method of management of newborns with cleft lip. Mothers expressed a preference for and greater satisfaction with neonatal repair. Parental preferences should routinely be considered in deciding the timing of this procedure.

[Anesthetic management of pediatric cleft lip and cleft palate repair]

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.

Does repairing a cleft lip neonatally have any effect on the longer-term attractiveness of the repair?

OBJECTIVE

To determine whether attractiveness and success of surgical outcome differ according to the timing of cleft lip repair.

DESIGN

Three experiments were conducted: (1) surgeons rated postoperative medical photographs of infants having either neonatal or 3-month lip repair; (2) lay panelists rated the same photographs; (3) lay panelists rated dynamic video displays of the infants made at 12 months. Normal comparison infants were also rated. The order of stimuli was randomized, and panelists were blind to timing of lip repair and the purposes of the study.

SETTING

Four U.K. regional centers for cleft lip and palate.

PARTICIPANTS

Infants with isolated clefts of the lip, with and without palate.

INTERVENTION

Early lip repair was conducted at median age 4 days (interquartile range [IQR] = 4), and late repair at 104 days (IQR = 57).

MAIN OUTCOME MEASURES

Ratings of surgical outcome (Experiment 1 only) and attractiveness (all experiments) on 5-point Likert scales.

RESULTS

In Experiment 1 success of surgical outcome was comparable for early and late repair groups (difference = -0.08; 95% confidence interval [CI] = -0.43 to 0.28; p = .66). In all three experiments, attractiveness ratings were comparable for the two groups. Differences were, respectively, 0.10 (95% CI = -2.3 to 0.44, p = .54); -0.11 (95% CI = -0.42 to -0.19, p = .54); and 0.08 (95% CI = -0.11 to 0.28, p = .41). Normal infants were rated more attractive than index infants (difference = 0.38; 95% CI = 0.24 to 0.52; p < .001).

CONCLUSION

Neonatal repair for cleft of the lip confers no advantage over repair at 3 months in terms of perceived infant attractiveness or success of surgical outcome.

[Early repair for infants with cleft lip. Retrospective study of 263 cleft lip repairs]

This study attempts to define the effect of early repair on the surgical procedure and immediate outcome of cleft lip surgery. The first part deals with 263 consecutive cleft lip repairs (218 infants) categorized retrospectively by age at operation. 123 patients (150 cleft lips) were operated on during the first 4 weeks of life; a subgroup of 40 infants was operated on at a week or less of age; 95 patients (113 cleft lips) were operated at an older age (1 to 12 months). There were no significant difference in immediate surgical result between the groups and there was no apparent difference in the operative results as defined by whether or not the child needed subsequent revision. We are currently encouraging early repair in the full-term baby as the optimum method of management of newborns with cleft lip.

Topics in pediatric plastic surgery

This article discusses pediatric, plastic surgical problems often encountered by primary care pediatricians as unfavorable scars, tattoos, torn earlobes, and secondary burn deformities. Cleft lip and palate surgery as well as plastic surgery of the adolescent breast will also be summarized. Emphasis is placed on diagnosis, evaluation, appropriate referral, and the expected surgical outcomes as well as the philosophical approach to the child and family.

Cleft palate closure in the neonate: preliminary report

Our recent experience with cleft palate closure in the neonatal period (within 28 days of birth) is reviewed in this study. The research involved a series of 21 neonates who presented with untreated cleft palates and underwent a modified Veau-Wardill-Kilner palate closure by a single surgeon between 1991 and 1994. The postoperative clinical follow-up ranged from 8 to 37 months (mean 18 months). All complications discussed do not seem to occur more frequently when surgery is done at this age than at an older age. Our findings demonstrate that cleft palate closure can be safely performed in the neonatal period; we do not, however, recommend that the standard approach should be changed based on this preliminary report.

Relationships between cleft severity and attractiveness of newborns with unrepaired clefts

Perceptions of attractiveness of newborns with unrepaired clefts were investigated by using a range of photographs with clefts of differing severity as ordered by a rule of thumb system commonly adopted by surgeons. The investigation involved a combination of factors such as completeness, unilaterality or bilaterality, and palate involvement. Orderings of attractiveness by surgeons, nursing staff, and adult groups unfamiliar with clefts were remarkably consistent. In addition, the responses reflected the rule of thumb system with ranked preferences of the raters being significantly related to the severity of cleft impairment. The scale devised could be used for comparative treatment outcome studies requiring assessments of initial infant attractiveness.

Neonatal cleft lip repair: the anesthesiologist's point of view

Neonatal cleft lip repair is no longer an unusual procedure and several series have been published to date. We present our 3-year experience from the anesthesiologist's point of view. Preoperative evaluation, perioperative management, and postoperative problems are described. A thorough preoperative evaluation in order to exclude associated malformations (especially cardiac) and experience in neonatal anesthesia are essential for the sake of safety.