Evaluating the Rule of 10s in Cleft Lip Repair: Do Data Support Dogma?

Challenging Dogmas in Plastic Surgery

In medicine, dogmas are subject to evolution and refinement as new research and technologies emerge. The aim of this study was to search for dogmas which were challenged and potentially revised in the plastic surgery field. A search on PubMed for "dogma and plastic surgery" yielded 80 papers. The queries "surgical dogma and craniofacial surgery" and "surgical dogma and flap" returned 9 and 21 papers, respectively. "Surgical dogma and hand" and "surgical dogma and wound healing" produced 41 and 25 papers, respectively. Removing 35 duplicate papers, 141 abstracts were reviewed. Of these, 78 were excluded, leaving 63 papers for analysis. The dogmas being challenged within the field of plastic surgery were classified into various categories. The distribution of these challenged dogmas was as follows: wound healing: 14.29%, epinephrine use: 9.52%, flap surgery: 7.94%, breast reconstruction: 6.35%, rhinoplasty: 7.94%, hand surgery: 4.76%, pressure sores: 4.76%, chemical peel: 4.76%, and hand injuries: 3.17%. The widespread focus on improving wound healing techniques indicates a need for more effective treatments and faster recovery times. Significant attention has been directed toward the use of epinephrine, particularly in fingers, which may reflect ongoing debates about its safety. Innovations and improvements in flap surgery could lead to better reconstructive outcomes. Challenging existing dogma is a vital process and a driving force in the advancement of clinical science. These challenges and potential revisions reflect the dynamic nature of plastic surgery, where ongoing research, patient outcomes, and evolving societal norms drive continuous improvement and adaptation in practices and principles.

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

OBJECTIVE

To examine whether a preoperative hemoglobin of less than 10 g/dL is associated with a higher rate of perioperative complications.

DESIGN

Retrospective review.

SETTING

Tertiary academic hospital at Arkansas Children's Hospital of Little Rock, Arkansas.

PATIENTS

A retrospective chart review evaluated patients undergoing primary cleft lip surgery from 2012 to 2017.

INTERVENTIONS

No prospective intervention was performed for this study care.

MAIN OUTCOME MEASURES

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.

RESULTS

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).

CONCLUSIONS

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.

Analysis of Different Facets of the Rule of 10 for Cleft Lip Repair for Their Application in the Current Era

OBJECTIVE

To evaluate the relevance of the "rule of 10" as a deciding factor preoperatively for patients undergoing cleft lip repair in the Indian sub-continent.

DESIGN

A questionnaire survey was conducted.

SETTING

All tertiary cleft care centers in the Indian subcontinent participated in an online questionnaire survey with anesthetic and surgical professionals.

MAIN OUTCOME

The primary goal of this survey was to determine the relevance and applicability of various aspects of the rule of 10 as a preoperative guideline for determining the timing of cleft lip repair in ASA I infants. The survey also aids in understanding the systemic factors that need to be prioritized and factors that are no longer of primary relevance in defining the timeline to undertake cleft lip repair in infants in the current era.

RESULTS

Surgeons and anesthetists from 31 tertiary cleft centers in India responded to the questionnaire. Specifically, 64.5% do not apply the "rule of 10" for deciding the timing of cleft lip repair, and 77% of the centers reported that cleft lip repair can be taken up in infants with hemoglobin levels in the range of 9-10 g/dL and an average weight of 4.5 kg. The average blood loss in unilateral lip repair ranged between 5 and 10 mL and 10 and 40 mL in children with bilateral lip repair. Three to six months was the average age at which cleft lip repair was undertaken at most of the centers in India.

CONCLUSION

The rule of 10 is not considered a gold standard by most of the centers in India, and the decision-making was based on the overall physiological status of the patients, the experience of the surgeon, and the anesthetic and post-operative care facilities available at the center.

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

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

Prenatal Consultation Outcomes for Infants With Cleft Lip With and Without Cleft Palate

To assess the clinical impacts of prenatal consultation with a multidisciplinary cleft team on infants with cleft lip with or without cleft palate (CL ± P).

Retrospective cases series.

Tertiary pediatric hospital.

Infants with CL ± P whose mothers received prenatal consultation with a pediatric otolaryngology team from June 2005 to December 2019 were identified. A random sample of infants with CL ± P without prenatal consultation from June 2005 to December 2019 was also identified.

The primary outcomes were the length of hospitalization during the first 12 weeks of life, timing of surgical repair, length of postsurgical hospitalization, and number of unplanned clinic visits and phone calls for feeding evaluation.

Time to cleft lip repair differed significantly between the 2 groups with repair performed at 13.4 (±0.9) weeks for the prenatal consultation group (n = 73) and 15.3 (±2.1) weeks for the control group (n = 80), (P < .05). If hospitalization was required for feeding difficulties during the first 12 weeks of life, length of stay was 4.9 (± 1.7) days for infants with prenatal consultation and 11.5 (± 7.2) days for control infants (P < .05). Unplanned clinic visits with a speech-language pathologist (SLP) for feeding difficulties were needed for 2.7% of prenatal consultation infants and 11.3% of control infants (P < .05).

Prenatal consultation regarding CL ± P resulted in infants with decreased duration of early hospitalizations, earlier cleft lip repair, and decreased engagement with the SLP feeding clinic for feeding difficulties when compared with infants without prenatal consultation.

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

BACKGROUND

Cleft lip and palate is the most common congenital defect of the head and neck, occurring in 1 of 700 live births. Diagnosis often occurs in utero by conventional or 3-dimensional ultrasound. Early cleft lip repair (ECLR) (<3 months of life) for unilateral cleft lip (UCL), regardless of cleft width, has been the mainstay of lip reconstruction at Children's Hospital Los Angeles since 2015. Historically, traditional lip repair (TLR) was performed at 3 to 6 months of life ± preoperative nasoalveolar molding (NAM). Previous publications highlight the benefits of ECLR, such as enhanced aesthetic outcomes, decreased revision rate, better weight gain, increased alveolar cleft approximation, cost savings of NAM, and improved parent satisfaction. Occasionally, parents are referred for prenatal consultations to discuss ECLR. This study evaluates timing of cleft diagnosis, preoperative surgical consultation, and referral patterns to validate whether prenatal diagnosis and prenatal consultation lead to ECLR.

METHODS

Retrospective review evaluated patients who underwent ECLR versus TLR ± NAM from 2009 to 2020. Timing of repair, cleft diagnosis, and surgical consultation, as well as referral patterns, were abstracted. Inclusion criteria dictated: age < 3 months for ECLR or 3 to 6 months for TLR, no major comorbidities, and diagnosis of UCL without palatal involvement. Patients with bilateral cleft lip or craniofacial syndromes were excluded.

RESULTS

Of 107 patients, 51 (47.7%) underwent ECLR whereas 56 underwent TLR (52.3%). Average age at surgery was 31.8 days of life for the ECLR cohort and 112 days of life for the TLR cohort. Furthermore, 70.1% of patients were diagnosed prenatally, yet only 5.6% of families had prenatal consults for lip repair, 100% of which underwent ECLR. Most patients were referred by pediatricians (72.9%). Significance was identified between incidence of prenatal consults and ECLR (P = 0.008). In addition, prenatal diagnosis was significantly correlated with incidence of ECLR (P = 0.027).

CONCLUSIONS

Our data demonstrate significance between prenatal diagnosis of UCL and prenatal surgical consultation with incidence of ECLR. Accordingly, we advocate for education to referring providers about ECLR and the potential for prenatal surgical consultation in the hopes that families may enjoy the myriad benefits of ECLR.

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

OBJECTIVE

This study compares patients undergoing early cleft lip repair (ECLR) (<3-months) and traditional lip repair (TLR) (3-6 months) with/without nasoalveolar molding (NAM) to evaluate the effects of surgical timing on weight gain in hopes of guiding future treatment paradigms.

DESIGN

Retrospective review.

SETTING

Children's Hospital of Los Angeles, California.

PATIENT, PARTICIPANTS

A retrospective chart review evaluated patients who underwent ECLR or TLR ± NAM from November 2009 through January 2020.

INTERVENTIONS

No intervention was performed.

MAIN OUTCOME MEASURE(S)

Patient demographics, birth and medical history, perioperative variables, and complications were collected. Infant weights and age-based percentiles were recorded at birth, surgery, 8-weeks, 6-months, 12-months, and 24-months postoperatively. The main outcomes were weight change and weight percentile amongst ECLR and TLR ± NAM groups.

RESULTS

107 patients met inclusion criteria: ECLR, n = 51 (47.6%); TLR + NAM, n = 35 (32.7%); and TLR-NAM, n = 21 (19.6%). ECLR patients had significantly greater changes in weight from surgery to 8-weeks and from surgery to 24-months postoperatively compared with both TLR ± NAM (P < .05). Age-matched weights in the ECLR group were significantly greater than TLR ± NAM at multiple time points postoperatively (P < .05).

CONCLUSIONS

ECLR significantly increased patient weights 24-months postoperatively when compared to TLR ± NAM. Specifically compared to TLR-NAM, ECLR weights were significantly greater at all time points past 6-months postoperatively. The results of this study demonstrate that ECLR can mitigate feeding difficulties and malnutrition traditionally seen in patients with cleft lip.

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

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Protocols in the management of Cleft Lip and Palate: A Systematic Review

AIM

To identify clinical decisions on surgical as well as non-surgical modalities for the treatment of CLP patients based on randomized controlled trials (RCTs).

MATERIALS AND METHODS

PubMed, Ebscohost, and Cochrane Library were searched and 20 articles based on RCTs conducted on cleft patient management were identified.

RESULTS

The topics explored were infant orthopedics, lip and palate repair, alveolar bone grafting, and management of cleft maxillary hypoplasia. Nasoalveolar molding (NAM) was found to have great benefits when carried out within one month of birth. Fisher and Mohler's lip repair technique and use of recombinant human bone morphogenetic protein-2 (rh-BMP2) for alveolar bone grafting showed promising results. rh-BMP2 for alveolar bone grafting appears to be a promising alternative to autografts.

CONCLUSION

Early commencement of NAM in neonatal life is of great benefit to cleft patients. There is a need for more multicentre collaborations, mainly to identify the ideal surgical technique to reduce the variability in treatment and to ensure that the patient receives appropriate evidence-based treatment.

The Rule of 10s for Cleft Repair: A Historical Review of the Literature

BACKGROUND

Cleft lip is a ubiquitous maxillofacial birth defect encountered globally. Repair of this anomaly has been well established in the literature. Historically, studies have recommended initiating surgical repair by the "Rule of 10s." This states that a baby should be at least 10 weeks of age or older, achieve a weight of 10 pounds, have a hemoglobin exceeding 10 g/dL, and have a white blood cell count <10,000/mm3 before undergoing surgery. However, with advances in both pediatric anesthesia and surgical technique, the concept of prioritizing earlier surgery requires a closer examination of this widespread concept.

OBJECTIVE

The aim of this study was to assess the validity of the Rule of 10s for cleft lip repair and to determine whether plastic surgeons should continue to follow this as a strict rule or employ it as a guideline.

METHODS

A literature search was conducted by G.S., and reviewed by J.L. and M.K. All studies that addressed the "Rule of 10s" for cleft lip patients were considered. Articles were chosen from a comprehensive set of databases, including EMBASE, MEDLINE, and Cochrane Central Register of Controlled Trials databases in March 2022. A literature search was conducted using the following keywords: rule of 10s, Millard criteria, cleft lip/palate, cleft lip/palate repair, and cleft lip/palate complications. Reference lists of selected studies were reviewed for other appropriate publications. Meta-analyses, prospective, randomized clinical trials, retrospective reviews, letters, and literature reviews were included. Single case reports, non-English publications, animal studies, and comments were excluded.

RESULTS

Among the studies included in this review, the authors found that the Rule of 10s has undergone a limited evaluation within the context of today's advances in surgical technique and anesthesia. The current articles generally conclude surgeons may proceed with earlier cleft repair on otherwise healthy infants who do not meet all criteria of the Rule of 10s.

CONCLUSIONS

When taking into consideration the current advances in surgical technique and diminished risks of anesthesia, the Rule of 10s should be applied only as a guideline instead of a rule in plastic surgery. Surgeons should address each patient individually and adhere more rigidly to the Rule of 10s when the infant does not have characteristics warranting expedited repair.

Enhanced Recovery After Cleft Lip Repair: Protocol Development and Implementation in Outreach Settings

Introduction

Clefts of the lip are of the most common congenital craniofacial anomalies. The development and implementation of an enhanced recovery after surgery (ERAS) protocol among patients undergoing cleft lip repair may decrease postoperative complications, accelerate recovery, and result in earlier postoperative discharge.

Methods

A modified ERAS program was developed and applied through Global Smile Foundation outreach craniofacial programs. The main components of this protocol include: (1) preoperative patient education, (2) nutrition screening, (3) smoking cessation when applicable, (4) use of topical anesthetic adjuncts, (5) facial nerve blocks, (6) postoperative analgesia, (7) preferential use of short-acting narcotics, (8) antibiotic administration, (9) use of elbow restraints, (10) early postoperative oral feeding and hydration, and (11) discharge planning.

Results

Between April 2019 and March 2020, GSF operated on 126 patients with cleft lip from different age groups and 58.8% of them were less than 1 year of age. Three patients (2.4%) had delayed wound healing and one (0.8%) had postoperative bleeding. There were no cases of mortality, length of hospital stay did not exceed 1 postoperative day, and patients were able to tolerate fluids intake at discharge.

Conclusion

The implementation of an ERAS protocol among patients undergoing cleft lip repair has shown to be highly effective in minimizing postoperative discomfort while reducing opioids use, decreasing the length of stay in hospital, and leading to early oral feeding resumption. The ERAS principles described carry increased relevance in the context of the ongoing COVID-19 pandemic and opioid crisis and can be safely applied in resource-constrained settings.

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.

The Current State of Cleft Care in Sub-Saharan Africa: A Narrative Review

OBJECTIVE

To identify practices and limitations of cleft care in sub-Saharan Africa (SSA).

DESIGN

A retrospective narrative nonsystematic literature review was performed.

SETTING

Literature exploring the management practices of cleft lip and/or palate across regions in SSA was included.

PARTICIPANTS

Full text case reports, retrospective studies, prospective studies, clinical trials, and review articles written and published in English between 1966 and February 1, 2021, were included in this analysis utilizing PubMed, MEDLINE, EMBASE, and Google scholar databases.

MAIN OUTCOME MEASURES

Qualitative themes identified in analysis were clinical practice patterns, current infrastructure and limitations of cleft repair, training and interdisciplinary teams, economic analyses, and international partnerships.

RESULTS

Significant barriers to care identified in SSA include lack of hospital resources, craniofacial training, access to multidisciplinary specialists, and public awareness. These problems make the entire care journey difficult for patients. Increasing public education has the power to diminish late presentations to hospitals. Providing adequate hospital resources and craniofacial training through international and organizational partnerships can ensure that more patients will receive care. Increasing the availability and number of multidisciplinary specialists is crucial to follow up care which aims at improving functional outcomes.

CONCLUSION

This narrative review highlights current practices and limitations in cleft care, emphasizing the importance of effective and timely repair of clefts in SSA. Targeted efforts aimed at establishing sustainable infrastructure for cleft care in SSA can have significant individual and community health and economic benefits.

Nasoalveolar Molding: Assessing the Burden of Care

ABSTRACT

Over the last 3 years a shift at our institution has taken place in which patients who would have been offered nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. This study sought to examine the financial and social impact of the transition away from NAM to ECLR. The efficacy of NAM is limited by patient compliance to a rigorous treatment schedule requiring weekly visits for appliance adjustments. Nasoalveolar molding patients required an average of 11 dental visits, accounting for $2132 in indirect lost income per family. Average direct charges for NAM totaled $12,290 for the hospital, physician, and appliance costs. Over the entire study period, the cumulative direct cost of NAM separate from the surgical repair of the lip was $970,910. Following the introduction of ECLR as an alternative to NAM with standard lip repair, NAM usage decreased by 48% and unilateral cleft lip patients undergoing NAM decreased by 86%. Those diverted from NAM to ECLR resulted in a decreased healthcare cost burden of $368,700 ($111,727 per year). In addition to the time burden, the financial burden of NAM is significant. Early cleft lip repair without NAM is more cost effective. Nasoalveolar molding has significantly decreased utilization since the implementation of ECLR. We believe that ECLR, with increased experience, long-term data, and increased awareness, has the potential to decrease the burden of health care costs in the United States.

A Closer Look at Delayed Primary Cleft Surgery and Unrepaired Cleft Lip and/or Palate in 5 UK Cleft Centers

BACKGROUND

There may be many reasons for delays to primary cleft surgery. Our aim was to investigate the age of children undergoing primary cleft lip or primary cleft palate repair in 5 cleft centers within the United Kingdom. Identify the reasons for delayed primary cleft lip repair (beyond 6 months) and delayed primary palate repair (beyond 13 months). Identify children who had a cleft lip and/or palate (CL±P) that was intentionally unrepaired and the reasons for this.

METHODS

A retrospective, multicenter review of patients born with a CL±P between December 1, 2012, and December 31, 2016. Three regional cleft centers, comprising of 5 cleft administrative units in the United Kingdom participated.

RESULTS

In all, 1826 patients with CL±P were identified. Of them, 120 patients had delayed lip repair, outside the expected standard of 183 days. And, 178 patients in total had delayed palate repair, outside the expected standard of 396 days. Twenty (1%) patients had an unrepaired cleft palate.

CONCLUSIONS

This large retrospective review highlights variations between centers regarding the timing of lip and palate surgery and details the reasons stated for delayed primary surgery. A small number of patients with an unrepaired cleft palate were identified. All had complex medical problems or comorbidities listed as a reason for the decision not to operate and 50% had a syndromic diagnosis. The number of patients receiving delayed surgery due to comorbidities, being underweight or prematurity, highlights the importance of the cleft specialist nurse and pediatrician within the cleft multidisciplinary team.

What is the Impact of Prenatal Counseling on Postnatal Cleft Treatment? Multidisciplinary Pathway for Prenatal Orofacial Cleft Care

ABSTRACT

In the pediatric general surgery literature, it has been shown that prenatal diagnosis of a congenital anomaly is an independent predictor of parental psychological distress. Surgical prenatal counseling can decrease parental anxiety by helping families understand the surgical needs and potential outcomes of their infant. In this retrospective analysis (n = 440), the authors sought to present our care pathway for prenatally diagnosed cleft lip and palate (CL/P) and explore the impact of cleft lip and palate-specific prenatal counseling on patient care by comparing the timing of clinical and surgical care between a cohort of patients who received prenatal CL/P consultation and a cohort of patients only seen postnatally. The authors hypothesize that our multidisciplinary prenatal care intervention is associated with earlier postnatal clinic visits and surgical repair. The care of all patients whose mother's presented for prenatal CL/P consultation (prenatal cohort, n = 118) was compared to all new CL/P patients without prenatal consultation at our institution (postnatal cohort, n = 322) from January 2015 through August 2019. 81.4% (n = 96) of the prenatal cohort returned for care postnatally while 2 pregnancies were interrupted, four neonates died, and 15 patients did not return for care. Prenatal consultation was associated with earlier postnatal clinic appointments (P < 0.001) as well as a shorter time to CL repair in patients with CL only (P = 0.002) and CLP (P = 0.047). Our described pre- and postnatal CL/P pathway is a multidisciplinary model associated with high retention rates from the prenatal period through complete surgical repair.

Perioperative Management of Cleft Lip Repair: A Meta-Analysis and Clinical Practice Guideline

OBJECTIVE

Few studies have focused on perioperative management of cleft lip repair. We sought to evaluate the available data on this topic to create evidence-based clinical guidelines.

DESIGN

Systematic review, meta-analysis.

METHODS

A PubMed search was performed focusing on perioperative management of cleft lip repair. Studies were included if they included comparative data. A systematic review and meta-analysis was performed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

MAIN OUTCOME MEASURES

Systematic review of literature regarding wound closure, postoperative arm restraints, perioperative antibiotics, outpatient or ambulatory surgery, or feeding restrictions postoperatively.

RESULTS

Twenty-three articles met inclusion criteria after initial screening of 3103 articles. This included 8 articles on wound closure, 2 on postoperative restraints, one on perioperative antibiotics, 6 on outpatient surgery, and 6 on postoperative feeding. Meta-analysis could be performed on dehiscence rates with postoperative feeding regimen and readmission rates after outpatient versus inpatient lip repair. There were few studies with low risk of bias. Outpatient cleft lip repair does not increase readmission (odds ratio [OR]: 0.92, 95% CI: 0.28-3.07). Allowing postoperative breastfeeding or bottle-feeding does not increase dehiscence (OR: 0.61, 95% CI: 0.19-1.95). There was no evidence of publication bias.

CONCLUSION

Within the limitations of available data, there is no evidence of a clearly superior closure material. The evidence does not support use of postoperative arm restraints. The evidence does not support the use of preoperative nasal swabs for antibiotic guidance. With careful patient selection, outpatient cleft lip repair appears safe. The evidence supports immediate breastfeeding or bottle-feeding after cleft lip repair.

Global Anesthesia in Oral and Maxillofacial Surgery

Anesthesia for oral and maxillofacial procedures during volunteer surgical missions requires careful planning of personnel, equipment, supplies, and coordination with the host medical institution. Cleft lip and palate repair are the most common oral and maxillofacial surgeries performed, and can be performed safely in low-resource environments when proper care and planning is taken.

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

OBJECTIVE

To investigate the trend in cleft care at a major children's referral center in Bangkok, Thailand.

STUDY DESIGN

Retrospective chart review.

PATIENTS AND METHODS

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.

SETTING

Tertiary care medical center.

RESULTS

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).

CONCLUSION

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.

Congenital nasal pyriform aperture stenosis: Diagnosis, management and technical considerations

BACKGROUND

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal obstruction in neonates with respiratory distress manifestations. Diagnosis is made with craniofacial computed tomography, prompt and precise treatment creates good outcomes in these patients.

AIM

To present our experience in diagnosis and management considerations with this rare pathology and a case series of our surgically managed patients.

METHODS

A retrospective, analytical study of CNPAS patients surgically managed over a period of seven years. Evaluation and follow up was reviewed.

RESULTS

Thirteen patients were evaluated; pyriform aperture mean width was 5.5mm. Of these patients, 31% also had Congenital Midnasal Stenosis. Medical treatment failed for all the patients and they required surgical enlargement of the pyriform aperture. No complications were seen and all patients improved in symptoms and development.

CONCLUSIONS

Congenital nasal obstruction can be fatal in new-borns, CNPAS is a rare differential diagnosis that must be completely evaluated, properly treated with conservative management and if it fails, with well-planned and executed surgery. Follow-up shows high rates of success.

Variation in hemoglobin across the life cycle and between males and females

WHO recommendations for hemoglobin (Hb) cutoffs to define anemia are based on a handful of studies conducted in the 1960s that did not include participants from all life stages. To evaluate whether there is a need to update Hb cutoffs, we conducted a narrative review of the literature to identify more recent studies that have reported Hb cutoffs in males and females in various life stages. We compiled information from 60 studies conducted around the globe between 1975 and 2018. Many studies reported cutoffs that were similar to WHO recommendations, but cutoffs identified in studies of infants, young children, premenopausal women, and the elderly tended to be lower than WHO recommendations, while cutoffs identified in studies of men tended to be higher than WHO cutoffs. Few studies excluded individuals with iron deficiency or inflammation, which limits the conclusions that can be drawn regarding normal reference ranges. Further research using more stringent exclusion criteria is needed to develop revised recommendations for Hb cutoffs to define anemia.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

Background

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

Methods

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

Results

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

Conclusion

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Cleft Lip and Palate

Orofacial clefts are common congenital malformations with genetic and environmental risk factors. In the perinatal period, feeding and nutrition can be a challenge and the need for specialized feeders is common. Lip taping and nasoalveolar molding are early interventions that can be used to preoperatively modify cleft defects to enhance surgical outcomes. Multiple techniques are available for repair of orofacial clefts and choice of technique depends on cleft extent and surgeon preference. After definitive repair, children remain at increased risk for middle ear disease, velopharyngeal dysfunction, and malocclusion and require ongoing follow-up with a multidisciplinary team.

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

Background:

The optimal timing for cleft lip repair has yet to be established. Advances in neonatal anesthesia, along with a growing body of literature, suggesting benefits of earlier cleft lip and nasal repair, have set the stage for a reexamination of current practices.

Methods:

In this prospective study, cleft lip and nasal repair occurred on average at 34.8 days (13–69 days). Nasal correction was achieved primarily through molding the nasal cartilage without the placement of nasal sutures at the time of repair. A standardized anesthetic protocol aimed at limiting neurotoxicity was utilized in all cases. Anesthetic and postoperative complications were assessed. A 3-dimensional nasal analysis compared pre- and postoperative nasal symmetry for unilateral clefts. Surveys assessed familial response to repair.

Results:

Thirty-two patients were included (27 unilateral and 5 bilateral clefts). In this study, the overall complication rate was 3.1%. Anthropometric measurements taken from 3-dimensional-image models showed statistically significant improvement in ratios of nostril height (preoperative mean, 0.59; postoperative mean, 0.80), nasal base width (preoperative mean, 1.96; postoperative mean, 1.12), columella length (preoperative mean, 0.62; postoperative mean, 0.89; and columella angle (preoperative mean, 30.73; postoperative mean, 9.1). Survey data indicated that families uniformly preferred earlier repair.

Conclusions:

We present evidence that early cleft lip and nasal repair can be performed safely and is effective at improving nasal symmetry without the placement of any nasal sutures. Utilization of this protocol has the potential to be a paradigm shift in the treatment of cleft lip and nasal deformity.