Perioperative Management in Patients With Cleft Lip and Palate

Comparison of the Effects of Postoperative Arm Restraints and Mittens on Cleft Lip Scar Quality after Primary Repair

Introduction: Postoperative management following primary cleft lip repair varies across institutions, cleft care teams, and individual surgeons. Postoperative precautions employed after cleft lip repair include dietary restrictions, pacifier limitations, and immobilization, with arm restraints long being used. Yet, restraint distress has led to the exploration of other forms of immobilization. Thus, this study aims to assess cleft lip scar quality and complication rates after postoperative immobilization with arm restraints versus hand mittens. Methods: A retrospective review of patients with unilateral cleft who underwent primary repair with the senior surgeon was done. Data on demographics, surgical characteristics, and immobilization utilized were gathered. A survey with pictures of postoperative scars were sent to laypeople who assessed scar quality with Modified Scar-Rating Scale scores for surface appearance, height, and color of the scar tissue. Statistical analysis was carried out for significance. Results: Twenty-eight patients with a unilateral cleft underwent arm restraints after primary lip repair, and twenty-seven utilized mittens. In total, 42 medical students completed the scar assessment. Photographs were taken an average of 23.9 (±5.8) and 28.2 (±11.9) months postoperatively in the restraint and mitten groups, respectively (p = 0.239). There were no statistically significant differences in scores between scar surface, height, color, or overall scar appearance. Complication rates were also similar between groups. Conclusions: Arm restraints appear to have no additional benefit relative to scar quality, as compared to mittens. Considering the arm restraints' burden of care, mittens should be considered as a measure to protect the lip after primary repair.

Cleft Palate Repair Postoperative Management: Current Practices in the United States

OBJECTIVE

To describe current postoperative management practices following cleft palate repair.

DESIGN

A survey was administered to cleft surgeons to collect information on their demographic characteristics, surgical training, surgical practice, and postoperative management preferences.

SETTING

Eighteen tertiary referral hospitals across the United States.Participants: Surgeons (n = 67) performing primary cleft palate repair.

RESULTS

Postoperative diet restrictions were imposed by 92% of surgeons; pureed foods were allowed at one week after surgery by 90% of surgeons; a regular diet was allowed at one month by 80% of surgeons. Elbow immobilizers and/or mittens were used by 85% of surgeons, for a median duration of two weeks. There was significant disagreement about postoperative use of bottles (61% allow), sippy cups (68% allow), pacifiers (29% allow), and antibiotics (45% prescribe). Surgeon specialty was not associated with any aspect of postoperative management (p > 0.05 for all comparisons). Surgeon years in practice, a measure of surgeon experience, was associated only with sippy cup use (p < 0.01). The hospital at which the surgeon practiced was associated with diet restrictions (p < 0.01), bottle use (p < 0.01), and use of elbow immobilizers or mittens (p < 0.01); however, many hospitals still had disagreement among their surgeons.

CONCLUSIONS

Surgeons broadly agree on diet restrictions and the use of elbow immobilizers or mittens following palate repair. Almost all other aspects of postoperative management, including the type and duration of diet restriction as well as the duration of immobilizer use, are highly individualized.

Availability and Readability Level of Online Patient Education Materials Provided by Cleft Lip and Palate Teams

OBJECTIVES

Evaluate the readability of online English and Spanish cleft lip and palate patient education materials.

DESIGN

Review of free online materials.

SETTING

English and Spanish language online patient education materials on cleft lip and palate were collected from American Cleft Palate-Craniofacial Association (ACPA) approved teams.

PARTICIPANTS

American Cleft Palate-Craniofacial Association (ACPA) approved teams.

INTERVENTIONS

English materials were analyzed using the Flesch-Kincaid, SMOG, and Coleman-Liau readability calculators. Spanish materials were analyzed using the Fry Graph, Fernandez Huerta, and INFLESZ calculators. A one-way analysis of variance (ANOVA) was used to test for variability between the readability tools.

OUTCOMES

Readability levels were examined for both sets of materials.

RESULTS

171 (90.5%) teams provided English language materials online, with an average readability score calculated as 10.5 ± 2.9 (10th-11th grade). A total of 44 (23.2%) teams listed Spanish language materials online, with average readability score of 7.9 ± 1.2 (8th grade). ANOVA demonstrated statistically significant variability between the readability assessment tools (P < .01).

CONCLUSION

Online cleft lip and palate patient education material provided by ACPA craniofacial teams were more available in English than in Spanish. Both sets of materials demonstrated readability levels above the recommended 6th-7th grade. Refining readability is associated with lowered healthcare costs and increased patient satisfaction.

Implementation of an Ambulatory Cleft Lip Repair Protocol: Surgical Outcomes

OBJECTIVES

Cleft lip repair has traditionally been performed as an inpatient procedure. There has been an interest toward outpatient cleft lip repair to reduce healthcare costs and avoid unnecessary hospital stay. We report surgical outcomes following implementation of an ambulatory cleft lip repair protocol and hypothesize that an ambulatory repair results in comparable safety outcomes to inpatient repair.

DESIGN/SETTING

This is a single-institution, retrospective study.

PATIENTS/PARTICIPANTS

Patients undergoing primary unilateral (UCL) and bilateral (BCL) cleft lip repair from 2012 to 2021 with a minimum 30-day follow-up. A total of 226 patients with UCL and 58 patients with BCL were included.

INTERVENTION

Ambulatory surgery protocol in 2016.

OUTCOME MEASURES

Variables include demographics and surgical data including 30-day readmission, 30-day reoperation, and postoperative complications.

RESULTS

There were no differences in rates of 30-day readmission, reoperation, wound complications, or postoperative complications between the pre- and post-protocol groups. Following ambulatory protocol implementation, 80% of the UCL group and 56% of the BCL group received ambulatory surgery. Average length of stay dropped from 24 h pre-protocol to 8 h post-protocol. The 20% of the UCL group and 44% of the BCL group chosen for overnight stay had a significantly higher proportion of congenital abnormalities and higher American Society of Anesthesiology (ASA) class. Reasons for overnight stay included cardiac/airway monitoring, prematurity, and monitoring of comorbidities. There were no differences in surgical outcomes between the ambulatory and overnight stay groups.

CONCLUSIONS

An ambulatory cleft lip repair protocol can significantly reduce average length of stay without adversely affecting surgical outcomes.

Evaluating the efficacy of single-shot versus prolonged antibiotic prophylaxis in alveolar cleft osteoplasty - A retrospective cohort study

This retrospective cohort study aimed to compare the outcomes of alveolar cleft osteoplasty using single-shot antibiotic prophylaxis versus a prolonged antibiotic regimen. The primary endpoints assessed were the incidence of infection, failure of surgical correction, and antibiotic-related side effects. Patients with orofacial clefts affecting the alveolar ridge who underwent alveolar cleft osteoplasty at a tertiary care center between 2015 and 2021 were included. The prolonged antibiotic group received extended antibiotic treatment, while the single-shot group received preoperative antibiotics only. Among 83 patients (mean age 12.8 years), 51 interventions were performed under prolonged antibiotic prophylaxis (mean duration 5.82 days) whereas in 40 interventions only single-shot prophylaxis was administered. There were no significant differences in infection frequency, surgical correction failure, implant loss, or adverse events between the groups. However, after single-shot antibiotic regimen, patients had significantly shorter hospital stays, being discharged on average one day earlier. The study suggests that single-shot antibiotic prophylaxis does not have drawbacks compared to prolonged antibiotic treatment in alveolar cleft osteoplasty. Considering increasing antibiotic resistance and potential side effects, omitting prolonged antibiotic prophylaxis is recommended for patients undergoing alveolar cleft osteoplasty.

Orthognathic Surgery and Relapse: A Systematic Review

BACKGROUND

This review aimed to analyze the relapse in orthognathic surgery.

METHODS

PubMed, Scopus, and Web of Science databases were used to find papers that matched our topic dating from 1 January 2012 up to November 2022. Inclusion criteria were (1) human studies, (2) open access studies, (3) studies concerning the correlation between orthognathic surgery and relapse. Exclusion criteria were: (1) in vitro or animal studies, (2) off-topic studies, (3) reviews, (4) other languages than English.

RESULTS

A total of 482 results were obtained resulting in 323 publications after duplicate removal (158). After screening and eligibility phases 247 records were excluded: 47 reviews, 5 in animals, 35 in vitro, 180 off-topic. The authors successfully retrieved the remaining 78 papers and evaluated their eligibility. A total of 14 studies from these were ultimately included in the review.

CONCLUSION

Using cephalometric examinations and digital study models, these studies reveal that the relapse after orthognathic surgery is an event that occurs in most of the cases. The limitation of our research is that most of the studies are retrospective and use small sample sizes. A future research goal should be to conduct long-term clinical trials with larger numbers of samples.

Prophylactic Antibiotics After Cleft Lip and Palate Reconstruction: A Review From a Global Health Perspective

Orofacial clefts are common congenital deformities. Global initiatives have increased access to cleft care and reconstruction surgeries for cleft lip with or without cleft palate (CL/P), but there is no consensus on the use of postoperative prophylactic antibiotics. We conducted a narrative review using PubMed on the use of postoperative prophylactic antibiotics in CL/P surgery. A search of PubMed identified 30 potentially relevant articles, of which 15 were reviewed. There was no consensus among surgeons on prescribing patterns, but there was limited evidence that postoperative antibiotics reduce palatal fistulas. Notably, microbiological screening is not used to guide the choice of antimicrobial or to predict postoperative complications. Based on limited available data, we cannot make any strong evidence-based recommendations on prescribing postoperative antibiotics; however, we recommend that each cleft surgeon performing these procedures in lower-income countries without access to tertiary care centers consider the cost-benefit analysis of prescribing antimicrobials postoperatively, without antimicrobial screening, which showed no benefit.

Six-year Burden of Care for Nonsyndromic Unilateral Cleft Lip and Palate Patients: A Comparison Between Cleft Centers and Noncleft Centers

OBJECTIVE

To determine differences in burden of care between nonsyndromic patients with unilateral cleft lip and palate undergoing treatment at American Cleft Palate-Craniofacial Association (ACPA)-accredited centers and nonaccredited centers in New York State.

DESIGN

A retrospective review of the New York Statewide Planning and Research Cooperative System database from January 2001 to December 2014 was performed using ICD-9 and CPT coding.

PATIENTS, PARTICIPANTS

This study included patients with unilateral cleft lip and palate who underwent both lip and palate repairs during their first  6 years of life. Exclusion criteria included orofacial cleft syndromes, follow-up under  6 years, and one-stage combined cleft lip and palate repairs.

RESULTS

Eighty-eight patients were treated at cleft centers, and 29 patients at nonaccredited centers (  n = 117). Age at primary palatoplasty (13.0 months vs 18.1 months;   p = .019), total number of cleft operations (2.3 vs 2.7;   p = .012), and total number of primary cleft-specific procedures (2.2 vs 2.5;   p = .0049) were significantly lower for patients treated in cleft centers. Age at primary cheiloplasty (4.8 months vs 4.6 months;   p = .865), post-cheiloplasty length of stay (1.2 days vs 1.2 days;   p = .673), post-palatoplasty length of stay (1.5 days vs 1.9 days;   p = .211), average hospital admissions (2.2 vs 2.3; p = 0.161), and total complication rates (34.1% vs 21.1%; p = 0.517) did not differ significantly between cleft centers and noncenters.

CONCLUSIONS

This data demonstrates some significant differences in overall 6 year burden of care for nonsyndromic patients with unilateral cleft lip and palate treated at ACPA-accredited cleft centers versus nonaccredited centers.

Enhanced recovery after cleft palate repair: A quality improvement project

BACKGROUND

Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery.

AIMS

The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery.

METHODS

A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts.

RESULTS

Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes.

CONCLUSION

Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.

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.

Dental caries and periodontitis risk factors in cleft lip and palate patients

Cleft lip and palate (CLP) is the most common congenital facial malformation and has a significant developmental, physical, and psychological impact on those with the deformity and their families. Risk factors contributing to CLP may conclude as genetic factors and environmental factors. The anatomical and morphological abnormalities related to CLP are favorable for dental plaque accumulation on the tooth surface. Therefore, patients with CLP undergo poorer oral hygiene and higher susceptibility to dental caries and periodontitis. In this review, we aim to conclude and update probable causes underlying the association between CLP and poor oral health and provide novel ideas of targeted early prevention for such oral diseases.

High quality nursing based on childlike interest in children with cleft lip and palate: application assessment after operation

Purpose

The aim of this study was to assess the effect of high-quality nursing based on the concept of childlike interest in children with cleft lip and palate following operation on healing time, degree of pain, psychological state, quality of life, and the occurrence of complications.

Methods

A series of 62 children with cleft lip and palate was treated in our hospital from January 2019 to March 2021. The patients were randomly divided into observation group (31 cases, given high-quality nursing based on childlike interest) and control group (31 cases, given routine nursing intervention). The healing time and hospital stay of the two groups were recorded. The degree of pain, psychological state and quality of life of the two groups before and after intervention were compared, and the occurrence of complications was closely monitored.

Results

Compared with the control group, the healing time and hospital stay of the study group were significantly shorter after the intervention (P < 0.05). Before the intervention, no significant difference was identified in pain score between the two groups (P < 0.05), after the intervention, however, the pain score of the study group was significantly lower compared with the control group (P < 0.05). Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) scores of the two groups were comparable before intervention (P > 0.05), while after intervention the SDS and SAS scores of the two groups were lower than those before treatment. Compared with the control group, the SDS and SAS scores of the study group were remarkably lower (P < 0.05). Before the intervention, the quality of life scores of the two groups were comparable (P > 0.05), while after the intervention, the scores of quality of life in the two groups were associated with lower outcomes. Compared with the control group, the scores of quality of life in the study group were significant lower (P < 0.05). After the intervention, there were evident fewer incidence of complications in the study group compared to the control group (P < 0.05).

Conclusions

High quality nursing based on childlike interest exerted beneficial outcomes in terms of shortening the healing time and hospital stay, reducing the degree of pain and complications, as well as improving the psychological state and quality of life of children harboring cleft lip and palate. Additionally, its high safety feature contributes to the wide application for clinical practice.

Analysis of Clinical Pathway for Patients With Cleft Lip and Palate

AIM

To evaluate the implementation of a clinical pathway (CP) and identify clinical factors affecting the CP for cleft lip and palate (CLP) patients.

METHODS

A specific CP for CLP patients was developed at CLP Medical Center of Stomatological Hospital affiliated to Nanjing Medical University in 2008. The authors reviewed the collected data of 1810 consecutive patients using the CP for repairing cleft lip, cleft palatal, and alveolar cleft. The patients were treated between January 2008 and December 2019. The rate of completion and risk factors affecting dropout from the CP were analyzed.

RESULTS

The completion rates of the CP in cleft lip, cleft palate and alveolar cleft patients were 68.3% (n = 345), 82.4% (n = 785) and 76.1% (n = 268), respectively. The overall completion rate was 77.2% (n = 1398). The main reasons for dropping out were pre-operation events (n = 212, 11.7%) and post-operation events (n = 188, 10.4%). Among the factors of dropout of CP, laboratory test abnormalities accounted for the majority of pre- and post-operation events (n = 179, 9.9%). In statistical analysis, the combined abnormities and events associated with operations were significant risk factors affecting the dropout rate from CP.

CONCLUSION

The use of CP for CLP patients was reliable but the completion rate was relatively low because of perioperative events. These results provided some evidence of risk factors which should be considered when modifying the protocol of CP for CLP patients in order to achieve higher completion rate.

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.

Oral Flora and Perioperative Antimicrobial Interventions in Cleft Palate Surgery: A Review of the Literature

BACKGROUND

The role of perioperative antibiotics in cleft palate remains a topic of debate. Advocates stress their importance in preventing local and systemic infections and decreasing the incidence of oronasal fistula formation. However, few studies to date have directly evaluated the role of antibiotics and other antimicrobial measures in cleft palate surgery.

OBJECTIVE

The aim of this review is to evaluate the evidence surrounding the use of perioperative antibiotics and other antimicrobial interventions in cleft palate surgery. Additionally, we review the literature on the oral flora unique to the cleft palate patient population.

METHODS

This was accomplished utilizing PubMed, Medline, and the Cochrane Library with MeSH and generic terms. Articles were selected based on predefined inclusion and exclusion criteria.

RESULTS

This review highlights the lack of higher level evidence on perioperative antibiotic use and other antimicrobial interventions in cleft palatoplasty and calls for further research on the matter.

CONCLUSIONS

The literature appears to support the use of preoperative antibiotics for cleft palatoplasty, but the benefits of prolonged postoperative antibiotic use remain questionable.