The Americleft Project: Burden of Care from Secondary Surgery

A Longitudinal Investigation of Nasolabial Changes With and Without Revision Surgery in Patients with Non-Syndromic Unilateral Cleft Lip and Palate

OBJECTIVE

To determine a baseline of anticipated change in nasolabial appearance following primary repair of unilateral cleft lip/palate and evaluate the degree to which revision surgery improves nasolabial appearance.

DESIGN

Retrospective chart review.

SETTING

Patients treated at the Lancaster Cleft Palate Clinic interdisciplinary clinic.

PATIENTS

Twenty-three patients with complete unilateral cleft lip and palate who underwent primary surgical repair and 19 additional patients who underwent subsequent revision surgery were included.

INTERVENTIONS

Patients in the non-revision group underwent a Tennison-Randall triangular flap lip repair at 3mo. Patients in the revision group underwent a modification of the Nakajima straight-line repair after primary Tennison-Randall triangular flap lip repair at an average age of 141mo.

MAIN OUTCOME MEASURES

A modification of the Asher-McDade Aesthetic Index was utilized to evaluate Nasolabial Frontal (NLF), Nasolabial Profile (NLP), Vermillion Border (VB), and total change in appearance. Scores for patients in the revision group were evaluated before and after revision while appearance for patients without revision was evaluated at 3 distinct ages. Scores were averaged across time-points and inter-rater reliability was assessed.

RESULTS

Nasolabial appearance in the non-revision sample did not change significantly over time, except for nasal profile. Scores improved after revision surgery - NLP: 3.48 to 2.97, (p = 0.001); NLF: 3.50 to 2.95 (p = 0.001); and Total Nasolabial Score: 3.29 to 3.01 (p = 0.004), with no significant change in VB.

CONCLUSION

Decisions regarding need for nasolabial revision surgery may be made as early as 5yo with successful outcomes following secondary surgery improving appearance except for vermillion border appearance.

Three-Dimensional Comparative Changes in the Pharyngeal Airway of Patients with Cleft after Two-Jaw Orthognathic Surgery

BACKGROUND

The present study evaluated the three-dimensional changes of the pharyngeal airway after orthognathic surgery (OGS) in patients with unilateral and bilateral clefts, and in unilateral cleft patients with and without pharyngeal flap (PF).

METHODS

Forty-five patients with unilateral or bilateral clefts undergoing OGS were enrolled. Cone-beam computed tomographic images were obtained before and after OGS. We measured the pharyngeal airway volumes, minimal cross-sectional area, and the horizontal displacement of facial landmarks.

RESULTS

The patients with bilateral cleft exhibited smaller initial velopharyngeal volume (unilateral, 8623 mm 3 ; bilateral, 7781 mm 3 ; P = 0.211), whereas the velopharyngeal volume increased significantly with a median of 744 mm 3 after OGS ( P = 0.031). The median horizontal displacement of A point was 2.9 and 2.6 mm among the patients with unilateral and bilateral clefts, respectively ( P = 0.276), and the median horizontal displacement of B point was -2.9 and -3.3 mm among patients with unilateral and bilateral clefts, respectively ( P = 0.618). The unilateral cleft patients with PF exhibited lower initial velopharyngeal volume (patients with a history of PF surgery, 7582 mm 3 ; patients without a history of PF surgery, 8756 mm 3 ; P = 0.129) and a lower increase in velopharyngeal volume (patients with a history of PF surgery, 437 mm 3 ; patients without a history of PF surgery, 627 mm 3 ; P = 0.739) after OGS.

CONCLUSIONS

Midface hypoplasia and the decrease in the velopharyngeal volume were more prominent among the bilateral cleft patients and the unilateral cleft patients with PF. After OGS, the velopharyngeal volume increased considerably among the bilateral cleft patients, but no considerable differences were noted among the unilateral cleft patients with PF.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Comparative study on cleft palate morphology after passive presurgical plate therapy in unilateral cleft lip and palate

BACKGROUND

Presurgical plate therapy has been widely accepted as a treatment prior to palatal cleft closure. The effects of passive presurgical plate therapy on cleft morphology prior to single-stage unilateral cleft lip and palate (UCLP) repair were quantified.

PATIENTS AND METHODS

We compared the dimensions of cleft width and cleft area (true cleft and palatal cleft) measured preoperatively at 2 European cleft centers. Center A performed single-stage UCLP repair in 8-month-old infants without any presurgical orthopedic treatment. Center B initiated passive presurgical plate therapy immediately after the birth of the neonates, followed by single-stage UCLP repair at 8 months of age.

RESULTS

We included 28 patients with complete UCLP from Center A and 12 patients from Center B. The average anterior width of the true cleft before surgery was significantly smaller in infants at Center B than that in Center A (p = 0.001) with 95% confidence interval of (1.8, 5.7) mm, but the average posterior width was similar in the 2 groups. The mean presurgical true cleft area amounted to 106.8 mm2 (SD = 42.4 mm2) at Center A and 71.9 mm2 (SD = 32.2 mm2) at Center B, with a confidence interval for the difference being (9.8, 60.1) mm2. This corresponded to a 32.7% reduction of the true cleft area when passive presurgical plate therapy was used for the first 8 months of the infants' life.

CONCLUSION

Passive presurgical plate therapy in UCLP significantly reduced the cleft area. Implications for the subsequent surgical outcome might depend on the surgical technique used.

Systematic Review and Critical Appraisal of the Evidence Base for Nasoalveolar Molding (NAM)

OBJECTIVE

To critically appraise the body of scientific literature supporting the risks and efficacy of nasoalveolar molding (NAM), specifically in contrast to alternative methods of presurgical infant orthopedics (PSIO) or to treatment without PSIO.

MAIN OUTCOME MEASURES

Five outcome domains were considered: nasolabial aesthetics; dentoalveolar relationship; midfacial growth; cost and burden of care; and number of anesthetic events.

DESIGN

MEDLINE, Embase, and Scopus were queried for articles from the first description of the Grayson-Santiago NAM technique (1993) through December 13, 2021. After the application of inclusionary and exclusionary criteria, selected articles were critically appraised using a systematic framework that included risk of bias assessment using the Cochrane RoB 2.0 and ROBINS-I tools.

RESULTS

A total of 88 studies were included. Level-I and -II evidence showed on par or better approximation and alveolar alignment achieved by NAM compared to other PSIO. Level-II and -III evidence showed improved nasolabial aesthetics compared to other PSIOs. Level-II and -III evidence supported no harm to maxillofacial skeletal growth through age 12. Sparse level-III evidence supported a reduced number of labial or nasal revisions following NAM. Level-II and -III evidence showed NAM requiring upfront cost and frequent appointments but reducing caregiver psychosocial burden and reducing long-term costs compared to select alternatives. Many studies carried a high risk of bias.

CONCLUSIONS

Current evidence supports the overall efficacy of NAM regarding short/mid-term outcomes, with a low risk of negative effects on midfacial growth or dental development. The high risk of bias discovered in many papers underscores the need for robust study design in future research.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network

OBJECTIVE

To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings.

DESIGN

Cross-sectional analysis of prospectively collected data from 2019-2022.

SETTING

Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol.

PARTICIPANTS

714 English-speaking children and adolescents with non-syndromic cleft lip/palate.

INTERVENTION

Routine multidisciplinary care and systematic outcomes measurement by cleft teams.

OUTCOME MEASURES

Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress.

RESULTS

12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes.

CONCLUSIONS

This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Aesthetic evaluation of nasolabial reconstruction using abbe flap in bilateral cleft lip patients with secondary deformities

BACKGROUND

The Abbe flap is a common technique frequently utilized in secondary surgery for bilateral cleft lip deformities, but objective indications for the Abbe flap remain unclear, and postoperative aesthetic evaluations are limited.

METHODS

The study group consisted of 92 bilateral cleft lip patients with secondary deformities aged 7-39 years, and the control group consisted of 33 people aged 19-35 years. Thirteen objective nasolabial aesthetic parameters were selected to evaluate patients' nasolabial aesthetics.

RESULTS

Minor secondary deformities were characterized by a smaller lip height index than severe deformities, as well as a smaller columellar angle compared with moderate and severe deformities (P < 0.05). For all patients, significant differences were found between preoperative and postoperative values of intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, lip vermilion height index, lip protrusion angle, columellar-labial angle, and nasal tip angle (P < 0.05). For patients with minor deformity, intercanthal distance/philtrum width ratio and intercanthal distance/medial cutaneous upper lip height ratio showed no significant change postoperatively (P > 0.05), and labial protrusion angle was smaller than the control group (P < 0.05).

CONCLUSIONS

Patients undergoing secondary surgery using an Abbe flap achieved good nasolabial aesthetics. Intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, columellar-labial angle, nasolabial angle, nasal tip angle, and columellar angle are the objective aesthetic indicators for Abbe flap selection. Intercanthal distance/philtrum width ratio, intercanthal distance/medial cutaneous upper lip height ratio, and labial protrusion angle are reference parameters for choosing an Abbe flap for secondary bilateral cleft lip revision.

Epidemiological and clinical evaluation of patients with a cleft in lower saxony Germany: a mono-center analysis

OBJECTIVE

The aim was to provide epidemiological and clinical data on patients with orofacial clefts in Lower Saxony in Germany.

MATERIALS AND METHODS

The records of 404 patients with orofacial clefts treated surgically at the University Medical Center Goettingen from 2001 to 2019 were analyzed in this retrospective study. Prevalence of orofacial clefts in general, orofacial clefts as manifestation of a syndrome, sex distribution, and prevalence of different cleft types was evaluated and associated with the need for corrective surgery, family history, pregnancy complications, and comorbidities.

RESULTS

The prevalence of orofacial clefts for Goettingen in Lower Saxony was 1:890. 231 patients were male and 173 were female. CLP was most common (39.1%) followed by CP (34.7%), CL (14.4%), CLA (9.9%), and facial clefts (2%). The left side was more frequently affected and unilateral cleft forms occurred more often than bilateral ones. Almost 10% of the population displayed syndromic CL/P. 10.9% of all patients had a positive family history regarding CL/P, predominantly from the maternal side. Pregnancy abnormalities were found in 11.4%, most often in the form of preterm birth. Comorbidities, especially of the cardiovascular system, were found in 30.2% of the sample. 2.2% of patients treated according to the University Medical Center Goettingen protocol corrective surgery was performed in form of a velopharyngoplasty or residual hole closure.

CONCLUSIONS

The epidemiological and clinical profile of the study population resembled the expected distributions in Western populations. The large number of syndromic CL/P and associated comorbidities supports the need for specialized cleft centers and interdisciplinary cleft care.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort.

The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery.

There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal.

CONCLUSIONS

Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery

OBJECTIVE

To identify child-, surgeon-, and hospital-specific factors at the time of primary cleft lip repair that are associated with the use of secondary cleft lip surgery.

DESIGN

Retrospective cohort study.

SETTING

Forty-nine pediatric hospitals.

PARTICIPANTS

Children who underwent cleft lip repair between 1999 and 2015.

MAIN OUTCOME MEASURE

Time from primary cleft lip repair to secondary lip surgery.

RESULTS

By 5 years after primary lip repair, 24.0% of children had undergone a secondary lip surgery. In multivariable analysis, primary lip repair before 3 months had a 1.22-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.02-1.46) compared to repair at 7 to 12 months of age, and children with multiple congenital anomalies had a 0.77-fold decreased hazard of secondary surgery (95% CI: 0.68-0.87). After adjusting for cleft type, age at repair, presence of multiple congenital anomalies, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals (P < .01). For children with unilateral cleft lip repaired at 3 to 6 months of age, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 4.9% to 21.8% across surgeons and from 4.5% to 24.7% across hospitals.

CONCLUSIONS

There are substantial differences among surgeons and hospitals in the rates of secondary lip surgery. Further work is needed to identify causes for this variation among providers.

Burden of Care: Management of Cleft Lip and Palate

Burden of care has become a commonly used terminology in healthcare in the recent years. Burden of care is the balance how much patients and families commit to their time, compromise quality of life, undergo multiple interventions, and take risks weighing against the benefits the patients and families receive. Cleft lip and palate, congenital anomaly, demands a long-term and interdisciplinary care. These children are at high risk of various treatment/intervention episodes increasing the burden of care. This subject has been widely discussed with many other diseases and health conditions at national, international meetings, and World Health Organization as well. We bring out some facts and practices affecting the burden of care in cleft lip and palate.

The Spectrum of Scarring in Craniofacial Wound Repair

Fibrosis is intimately linked to wound healing and is one of the largest causes of wound-related morbidity. While scar formation is the normal and inevitable outcome of adult mammalian cutaneous wound healing, scarring varies widely between different anatomical sites. The spectrum of craniofacial wound healing spans a particularly diverse range of outcomes. While most craniofacial wounds heal by scarring, which can be functionally and aesthetically devastating, healing of the oral mucosa represents a rare example of nearly scarless postnatal healing in humans. In this review, we describe the typical wound healing process in both skin and the oral cavity. We present clinical correlates and current therapies and discuss the current state of research into mechanisms of scarless healing, toward the ultimate goal of achieving scarless adult skin healing.

Eighteen-Year Follow-Up of 160 Consecutive Individuals Born With Unilateral Cleft Lip or Cleft Lip and Alveolus Treated by the Oslo Cleft Lip and Palate Team

OBJECTIVE

Describe patients born with unilateral cleft lip with or without cleft alveolus (CL±A) in relation to cleft severity and laterality, gender, associated anomalies and syndromes, number and type of lip- and nose operations, and time of alveolar bone graft (ABG) treatment in relation to dental status in cleft area.

MATERIALS AND METHODS

Patients included 220 children born with unilateral CL±A, born between 1988 and 1997 referred to the Oslo Cleft Lip and Palate Team. The data were collected retrospectively. All patients were followed up until 18 years of age.

RESULTS

Among all CL±A, 3.6% had recognized syndromes, 6.8% had associated anomalies, and in 89.6% CL±A was the only malformation. CL±A was more common, but not more severe, on the left side. Among the 160 individuals with CL±A without syndromes and associated anomalies, 66.9% had an isolated soft tissue CL, and 33.1% were diagnosed with a CL alveolus (CL+A). Male predominance was observed. Children with CL+A had more severe soft tissue clefts of the lip and underwent more lip and nose surgeries than children born with CL. The time of ABG was found to be at a younger age when the patient had a lateral incisor in the cleft area than when this tooth was missing.

CONCLUSION

Findings provide a reference for morphologic variations in CL±A, and insight into the surgical burden of care until the age of 18 years.

Patient-Perceived Barriers to Accessing Cleft Care at a Tertiary Referral Center in São Paulo, Brazil

Background:

In low- and middle-income countries, poor access to care can result in delayed surgical repair of orofacial clefts leading to poor functional outcomes. Even in Brazil, an upper middle-income country with free comprehensive cleft care, delayed repair of orofacial clefts commonly occurs. This study aims to assess patient-perceived barriers to cleft care at a referral center in São Paulo.

Methods:

A 29-item questionnaire assessing the barriers to care was administered to 101 consecutive patients (or their guardians) undergoing orofacial cleft surgery in the Plastic Surgery Department in Hospital das Clínicas, in São Paulo, Brazil, between February 2016 and January 2017.

Results:

A total of 54.4% of patients had their first surgery beyond the recommended time frame of 6 months for a cleft lip or cleft lip and palate and 18 months for a cleft palate. There was a greater proportion of isolated cleft palates in the delayed group (66.7% vs 33.3%). Almost all patients had a timely diagnosis, but delays occurred from diagnosis to repair. The mean number of barriers reported for each patient was 3.8. The most frequently cited barriers related to lack of access to care include (1) lack of hospitals available to perform the surgery (54%) and (2) lack of availability of doctors (51%).

Conclusion:

Delays from diagnosis to treatment result in patients receiving delayed primary repairs. The commonest patient-perceived barriers are related to a lack of access to cleft care, which may represent a lack of awareness of available services.

Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study

OBJECTIVES

To test whether cleft centres vary in their use of secondary cleft palate surgery, also known as revision palate surgery, and if so to identify modifiable hospital- and surgeon-factors that are associated with use of secondary surgery.

DESIGN

Retrospective cohort study.

SETTING

Forty-three paediatric hospitals across the United States.

PATIENTS

Children with cleft lip and palate who underwent primary cleft palate repair from 1999 to 2013.

MAIN OUTCOME MEASURES

Time from primary cleft palate repair to secondary palate surgery.

RESULTS

We identified 4,939 children who underwent primary cleft palate repair. At ten years after primary palate repair, 44% of children had undergone secondary palate surgery. Significant variation existed among hospitals (p<0.001); the proportion of children undergoing secondary surgery by 10 years ranged from 9% to 77% across hospitals. After adjusting for patient demographics, primary palate repair before nine months of age was associated with an increased hazard of secondary palate surgery (initial hazard ratio 6.74, 95% CI 5.30-8.73). Postoperative antibiotics, surgeon procedure volume, and hospital procedure volume were not associated with time to secondary surgery (p>0.05). Of the outcome variation attributable to hospitals and surgeons, between-hospital differences accounted for 59% (p<0.001), while between-surgeon differences accounted for 41% (p<0.001).

CONCLUSIONS

Substantial variation in the hazard of secondary palate surgery exists depending on a child's age at primary palate repair and the hospital and surgeon performing their repair. Performing primary palate repair before nine months of age substantially increases the hazard of secondary surgery. Further research is needed to identify other factors contributing to variation in palate surgery outcomes among hospitals and surgeons.