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Dabbagh W, Groff D, Stauffer L, Newland M, Lo A, Hiller A, Long RE. A Longitudinal Investigation of Nasolabial Changes With and Without Revision Surgery in Patients with Non-Syndromic Unilateral Cleft Lip and Palate. Cleft Palate Craniofac J 2024:10556656241256706. [PMID: 38813767 DOI: 10.1177/10556656241256706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
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.
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Affiliation(s)
| | - Destin Groff
- Pennsylvania State University College of Medicine, Hershey, PA, USA
| | | | - Mary Newland
- Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Alexis Lo
- Division of Plastics and Reconstructive Surgery, Pennsylvania State Hershey Medical Center, Hershey, PA, USA
| | - Andrea Hiller
- Division of Plastics and Reconstructive Surgery, Pennsylvania State Hershey Medical Center, Hershey, PA, USA
| | - Ross E Long
- Lancaster Cleft Palate Clinic, Hershey, PA, USA
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Wagner CS, Barnett SL, Romeo D, Morales CZ, Salinero LK, Barrero CE, Pontell ME, McKenna RA, Folsom N, Taylor JA, Swanson JW. Sociodemographic Factors Predict Long-Term Attrition from Multidisciplinary Cleft Clinic. Cleft Palate Craniofac J 2024:10556656241234804. [PMID: 38425129 DOI: 10.1177/10556656241234804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE Identify and describe factors associated with retention and attrition of patients during longitudinal follow-up at multidisciplinary cleft clinic. DESIGN Retrospective cohort study. SETTING Single, tertiary care center. PATIENTS, PARTICIPANTS Patients born between 1995 and 2007 with a diagnosis of cleft palate with or without cleft lip attending multidisciplinary cleft clinic. INTERVENTIONS None tested, observational study. MAIN OUTCOME MEASURE(S) Age at last clinical appointment with a multidisciplinary cleft team provider. Attrition was defined as absence of an outpatient appointment following 15 years of age. RESULTS Six hundred seventy-eight patients were included. The average age at last appointment across the entire cohort was 13.1 years (IQR 6.6-17.2). Patients who were Black (HR 1.60, 95% CI 1.10-2.32, p = 0.014) and other races (HR 1.90, 95% CI 1.22-2.98, p = 0.004) were more likely to be lost to follow-up compared to white patients. Publicly insured patients were more likely to experience attrition than those who were privately insured (HR 1.30, 95% CI 1.03-1.65, p = 0.030). Estimated income was not significantly associated with length of follow-up (p = 0.259). Those whose residence was in the fourth quartile of driving distance from our center experienced loss to follow-up significantly more than those who lived the closest (HR 2.04, 95% CI 1.50-2.78, p < 0.001). CONCLUSIONS There is a high degree of follow-up attrition among patients with cleft lip and palate. Race, insurance status, and driving distance to our center were associated with attrition in a large, retrospective cohort of patients who have reached the age of cleft clinic graduation.
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Affiliation(s)
- Connor S Wagner
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Sarah L Barnett
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Dominic Romeo
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Carrie Z Morales
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Lauren K Salinero
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Carlos E Barrero
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Matthew E Pontell
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Rachel A McKenna
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Nancy Folsom
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Jesse A Taylor
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Jordan W Swanson
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
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Saito T, Tu JCY, Chou PY, Lo LJ. Primary rhinoplasty in patients with bilateral cleft lip: Longitudinal results and comparison between closed and semi-open approaches. J Plast Reconstr Aesthet Surg 2024; 89:117-124. [PMID: 38176136 DOI: 10.1016/j.bjps.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty. METHODS Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed. RESULTS In the comparative analysis at preschool age, semi-open rhinoplasty significantly improved the typical nasal deformities, including transversely oriented wide nostrils, short columella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age. CONCLUSION This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.
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Affiliation(s)
- Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Junior Chun-Yu Tu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
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Roohani I, Trotter C, Shakoori P, Moshal TA, Lasky S, Manasyan A, Wolfe EM, Magee WP, Hammoudeh JA. Lessons Learned from a Single Institution's Eight Years of Experience with Early Cleft Lip Repair. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1741. [PMID: 37893459 PMCID: PMC10608426 DOI: 10.3390/medicina59101741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023]
Abstract
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.
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Affiliation(s)
- Idean Roohani
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (I.R.); (T.A.M.); (S.L.); (W.P.M.III)
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA;
| | - Collean Trotter
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (I.R.); (T.A.M.); (S.L.); (W.P.M.III)
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA;
| | - Pasha Shakoori
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA; (P.S.); (E.M.W.)
| | - Tayla A. Moshal
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (I.R.); (T.A.M.); (S.L.); (W.P.M.III)
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA;
| | - Sasha Lasky
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (I.R.); (T.A.M.); (S.L.); (W.P.M.III)
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA;
| | - Artur Manasyan
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA;
| | - Erin M. Wolfe
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA; (P.S.); (E.M.W.)
| | - William P. Magee
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (I.R.); (T.A.M.); (S.L.); (W.P.M.III)
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA; (P.S.); (E.M.W.)
| | - Jeffrey A. Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (I.R.); (T.A.M.); (S.L.); (W.P.M.III)
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA; (P.S.); (E.M.W.)
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Hattori Y, Pai BCJ, Saito T, Chou PY, Lu TC, Chang CS, Chen YR, Lo LJ. Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study. Int J Surg 2023; 109:1656-1667. [PMID: 37073546 PMCID: PMC10389451 DOI: 10.1097/js9.0000000000000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature. PATIENTS AND METHODS A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis. RESULTS A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient. CONCLUSION Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.
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Affiliation(s)
- Yoshitsugu Hattori
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Betty C.-J. Pai
- Department of Craniofacial Orthodontics and Craniofacial Research Center, Chang Gung Memorial Hospital, Kwei Shan, Taoyuan, Taiwan
| | - Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Ting-Chen Lu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Yu-Ray Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
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Kondra K, Stanton E, Jimenez C, Chen K, Hammoudeh JA. Does Early Referral Lead to Early Repair? Quality Improvement in Cleft Care. Ann Plast Surg 2023; 90:S312-S314. [PMID: 37227409 DOI: 10.1097/sap.0000000000003399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Kevin Chen
- From the Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA
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Ullrich PJ, Ramsey MD. Global Plastic Surgery: A Review of the Field and a Call for Virtual Training in Low- and Middle-Income Countries. Plast Surg (Oakv) 2023; 31:118-125. [PMID: 37188140 PMCID: PMC10170637 DOI: 10.1177/22925503211034833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/22/2021] [Indexed: 11/16/2022] Open
Abstract
Lack of surgical access severely harms countless populations in many low- and middle-income countries (LMICs). Many types of surgery could be fulfilled by the plastic surgeon, as populations in these areas often experience trauma, burns, cleft lip and palate, and other relevant medical issues. Plastic surgeons continue to contribute significant time and energy to global health, primarily by participating in short mission trips intended to provide many surgeries in a short time frame. These trips, while cost-effective for lack of long-term commitments, are not sustainable as they require high initial costs, often neglect to educate local physicians, and can interfere with regional systems. Education of local plastic surgeons is a key step toward creating sustainable plastic surgery interventions worldwide. Virtual platforms have grown popular and effective-particularly due to the coronavirus disease 2019 pandemic-and have shown to be beneficial in the field of plastic surgery for both diagnosis and teaching. However, there remains a large potential to create more extensive and effective virtual platforms in high-income nations geared to educate plastic surgeons in LMICs to lower costs and more sustainably provide capacity to physicians in low access areas of the world.
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Affiliation(s)
- Peter J. Ullrich
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew D. Ramsey
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Assessing the Impact of Transcutaneous Maxillary Distraction Osteogenesis on Pharyngeal Airway Volume in Children with Cleft Lip and Palate: A 3D Evaluation Study. J Pers Med 2023; 13:jpm13030543. [PMID: 36983724 PMCID: PMC10056267 DOI: 10.3390/jpm13030543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/22/2023] Open
Abstract
Cleft lip and cleft palate (CLCP) patients often have a retrusive maxilla and a severe skeletal Class III malocclusion, which can result in velopharyngeal insufficiency (VPI). The aim of this study was to evaluate the changes in the volume of the 3D airway in CLCP children after maxilla distraction using the transcutaneous maxillary distraction osteogenesis (TMDO) method. 15 children with bilateral or unilateral CLCP were included in the study. 3D CBCT images were taken before and after distraction and were segmented and reconstructed to create a 3D airway model. The airway was divided into three regions: the upper, oropharyngeal, and hypopharyngeal airway. Pearson correlation tests were used to assess correlations between volume changes and corresponding skeletal and dental landmark movements (Point N, ANS, A, B, Pog, U1, and L1). The results showed that the ANS point advanced 9.85 ± 3.60 mm, and the A point advanced 14.22 ± 4.57 mm. The total airway volume change increased by 2535.06 ± 2791.80 mm3. However, there was no significant correlation between the A/ANS/U1 and the three different airway regions. Only B/Pog/L1 showed a positive correlation with these airway regions, with a high correlation between B/Pog/L1 and the hypopharyngeal airway region. TMDO can result in greater anterior advancement of the maxilla and an increase in airway volume, but the changes in bony landmarks did not show a strong positive correlation with the increase in airway volume as expected. Further investigation is needed to analyze the influence of surrounding soft tissue on the changes in airway volume.
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Cleft Lip and Palate Research in Low- and Middle-income Countries: A Scientometric Analysis. Plast Reconstr Surg Glob Open 2022; 10:e4122. [PMID: 35186648 PMCID: PMC8846345 DOI: 10.1097/gox.0000000000004122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
Cleft lip and palate (CLP) comprise over 90% of the world’s congenital anomalies and cause significant disability worldwide, while disproportionally burdening low- and middle-income countries (LMICs). Research can help inform strategies that reduce disparities in accessing CLP care. We performed a scientometric analysis of CLP research in LMICs to identify influential contributors and themes.
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Lim J, Tanikawa C, Kogo M, Yamashiro T. Determination of prognostic factors for orthognathic surgery in children with cleft lip and/or palate. Orthod Craniofac Res 2021; 24 Suppl 2:153-162. [PMID: 33599070 DOI: 10.1111/ocr.12477] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the prognostic factors for orthognathic surgery (OGS) in children with cleft lip and/or palate (CL/P) using artificial intelligence (AI) systems. DESIGN Retrospective cohort study. SETTING An orthodontic department at a university dental hospital. PARTICIPANTS This study included 126 patients with bilateral and unilateral CL/P for whom lateral cephalograms were obtained at three time points: 7 (T1), 10 (T2) and 15 (T3) years of age. MAIN OUTCOME MEASURES Cleft type, severity of lip separation at birth, number of missing teeth, sex, palatal repair methods and surgeons, cephalometric variables at T1 and T2, and the total duration of orthodontic treatment were examined as predictors. The need for OGS and skeletal and dental discrepancies at T3 was examined as outcomes. RESULTS A total of six models were developed, with a mean area under the receiver operating characteristic curve of 0.93. Multiple prognostic factors for OGS were identified. In particular, the number of clefts in the lip and alveolus showed relatively high odds ratios, as did anterior crossbite at T3. Achieving palatal closure with the push-back method, rather than Furlow's method, was also found to be a predictive factor for anterior crossbite at T3, with high odds ratios. CONCLUSIONS The prognostic factors for OGS determined by the AI systems were the number of clefts in the lip and alveolus, the palatal repair method, male sex, several cephalometric variables for the sagittal and vertical dimensions, growth patterns and the number of missing teeth.
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Affiliation(s)
- Jaeyeon Lim
- Graduate School of Dentistry, Osaka University, Suita, Japan
| | - Chihiro Tanikawa
- Graduate School of Dentistry, Osaka University, Suita, Japan.,Center for Advanced Medical Engineering and Informatics, Osaka University, Suita, Japan
| | - Mikihiko Kogo
- Graduate School of Dentistry, Osaka University, Suita, Japan
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Tan RA, Mulder FJ, Schwirtz RMF, Mosmuller DGM, De Vet HCW, Griot JPWD. Atypical Outcomes of Nasal and Lip Appearance After Unilateral Cleft Lip Repair: Judgment by Professionals, Patients, and Laypeople. Cleft Palate Craniofac J 2021; 58:1226-1235. [PMID: 33461321 PMCID: PMC8494007 DOI: 10.1177/1055665620982801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: To gain more insight into the assessment of “atypical” nasal and lip appearance outcomes compared to “typical” appearance outcomes after unilateral cleft lip and palate (UCLP) repair, when judged by professionals, patients with repaired UCLP, and laypeople. Design: An online survey containing 3 series of photographs with various degrees of “typical” and “atypical” nasal and lip appearance outcomes after UCLP repair was sent to 30 professionals, 30 patients with repaired UCLP, and 50 laypeople in 2 countries. Participants were instructed to rank the photographs from excellent to poor based on overall appearance. Mean rank positions of photographs were analyzed and differences in mean rank score between “typical” and “atypical” results were assessed using a T-test. Agreement of ranking between the 3 groups was assessed with an analysis of variance analysis. Setting: Amsterdam UMC, location VUmc, Netherlands and Boston Children’s Hospital, Boston, USA. Patients: Photographs of 6- to 18-year-old patients with repaired UCLP. Results: “Atypical” appearance outcomes were ranked significantly less favorably (small nostril: P = 0.00; low vermillion border: P = 0.02; whistling deformity: P = 0.00) compared to “typical” outcomes. Difference between professionals, patients and laypeople in rank positioning the photographs was not statistically significant (P = 0.89). Conclusions: Noses with a smaller nostril and lips containing a whistling deformity were perceived as poorer outcome compared to the “typical” results. Professionals, patients, and laypeople are in agreement when assessing these outcomes.
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Affiliation(s)
- Robin A Tan
- Department of Plastic, Reconstructive and Hand Surgery, 1209Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Frans J Mulder
- Department of Plastic, Reconstructive and Hand Surgery, 1209Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Roderic M F Schwirtz
- Department of Plastic, Reconstructive and Hand Surgery, 1209Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - David G M Mosmuller
- Department of Plastic, Reconstructive and Hand Surgery, 1209Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Henrica C W De Vet
- Department of Epidemiology and Data Science and the Amsterdam Public Health, Research Institute, 1209Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - J Peter W Don Griot
- Department of Plastic, Reconstructive and Hand Surgery, 1209Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
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Fritz A, Jodeh DS, Qamar F, Cray JJ, Rottgers SA. Patients With a History of Oronasal Fistula Repair Exhibit Lower Oral Health Measured With Patient-Centric Outcomes Measures. Cleft Palate Craniofac J 2020; 58:1142-1149. [PMID: 33353404 DOI: 10.1177/1055665620981331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Oronasal fistulae following palatoplasty may affect patients' quality of life by impacting their ability to eat, speak, and maintain oral hygiene. We aimed to quantify the impact of previous oronasal fistula repair on patients' quality of life using patient-reported outcome psychometric tools. METHODS A cross-sectional study of 8- to 9-year-old patients with cleft palate and/or lip was completed. Patients who had a cleft team clinic between September 2018 and August 2019 were recruited. Participants were divided into 2 groups (no fistula, prior fistula repair). Differences in the individual CLEFT-Q and Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) Oral Health scores between the 2 groups were evaluated using a multivariate analysis controlling for Veau classification and syndromic diagnosis. RESULTS Sixty patients with a history of cleft palate were included. Forty-two (70%) patients had an associated cleft lip. Thirty-two (53.3%) patients had no history of fistula and 28 (46.7%) patients had undergone a fistula repair. CLEFT-Q Dental, Jaw, and Speech Function were all higher in patients without a history of a fistula repair; however, none of these differences were statistically significant. The COHIP-SF 19 Oral Health score demonstrated a significantly lower score in the fistula group, indicating poorer oral health (P = .05). CONCLUSIONS One would expect that successful repair of a fistula would result in improved function and patient satisfaction, but the consistent trend toward lower CLEFT-Q scores and significantly increased COHIP-SF 19 Oral Health scores in our study group suggests that residual effects linger and that the morbidity of a fistula may not be completely treated with a secondary correction.
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Affiliation(s)
- Alyssa Fritz
- Child Development and Rehabilitation Center, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Diana S Jodeh
- Department of General Surgery, University of Pittsburg Medical Center Pinnacle, Harrisburg, PA, USA
| | - Fatima Qamar
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - James J Cray
- Department of Biomedical Education & Anatomy, The Ohio State University College of Medicine, Columbus, OH, USA
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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13
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Le E, Shrader P, Bosworth H, Hurst J, Goldstein B, Drake A, Wood J, David LR, Runyan CM, Vissoci JRN, Harker M, Allori AC. Provision and Utilization of Team- and Community-Based Operative Care for Patients With Cleft Lip/Palate in North Carolina. Cleft Palate Craniofac J 2020; 57:1298-1307. [PMID: 32844676 DOI: 10.1177/1055665620946565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To characterize operative care for cleft lip and/or palate (CL/P) based on location (ie, from American Cleft Palate Craniofacial Association [ACPA]-approved multidisciplinary teams or from community providers). DESIGN Cross-sectional analysis of Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery & Services Database databases for North Carolina from 2012 to 2015. SETTING/PATIENTS AND MAIN OUTCOME MEASURES Clinical encounters for children with CL/P undergoing operative procedures were identified, classified by location as "Team" versus "Community," and characterized by demographic, geographic, clinical, and procedural factors. A secondary evaluation reviewed concordance of team and community practices with an ACPA guideline related to coordination of care. RESULTS Three teams and 39 community providers performed a total of 3010 cleft-related procedures across 2070 encounters. Teams performed 69.7% of total volume and performed the majority of cleft procedures, including cleft lip repair, palate repair, alveolar bone grafting, and correction of velopharyngeal insufficiency. Community locations principally offered myringotomy and rhinoplasty. Team care was associated with higher guideline concordance. CONCLUSIONS American Cleft Palate Craniofacial Association -approved team-based care accounts for the majority of cleft-related care in North Carolina; however, a substantial volume of cleft-related procedures was provided by community providers, with 3 providers accounting for the vast majority of community cases.
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Affiliation(s)
- Elliot Le
- 12277Duke University School of Medicine, Durham, NC, USA
| | - Peter Shrader
- 169142Duke Clinical Research Institute (DCRI), Durham, NC, USA
| | - Hayden Bosworth
- Departments of Population Health Sciences, Medicine, Psychiatry, School of Nursing, Duke University; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Jillian Hurst
- Children's Health & Discovery Initiative (CHDI), 12277Duke University School of Medicine, Durham, NC, USA
| | - Benjamin Goldstein
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA.,Children's Health & Discovery Initiative (CHDI), Department of Pediatrics; 12277Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute (DCRI), Duke University, Durham, NC, USA.,Department of Population Health, Duke University, Durham, NC, USA
| | - Amelia Drake
- Department of Otolaryngology, University of North Carolina-Chapel Hill Medical Center, NC, USA
| | - Jeyhan Wood
- Division of Plastic Surgery, University of North Carolina-Chapel Hill Medical Center, NC, USA
| | - Lisa R David
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Christopher M Runyan
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | | | | | - Alexander C Allori
- Children's Health & Discovery Initiative (CHDI), Department of Pediatrics; 12277Duke University School of Medicine, Durham, NC, USA.,Department of Population Health, Duke University, Durham, NC, USA.,Division of Plastic, Maxillofacial & Oral Surgery, Duke University Medical Center, Durham, NC, USA
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14
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Martin S, McBride M, McGarry K, Hill C. Burden of cleft surgery—a 21-year follow-up of patients with cleft lip and palate. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01633-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Alfonso AR, Ramly EP, Kantar RS, Wang MM, Eisemann BS, Staffenberg DA, Shetye PR, Flores RL. What Is the Burden of Care of Nasoalveolar Molding? Cleft Palate Craniofac J 2020; 57:1078-1092. [PMID: 32500737 DOI: 10.1177/1055665620929224] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This systematic review aims to evaluate nasoalveolar molding (NAM) in the context of burden of care defined as physical, psychosocial, or financial burden on caregivers. SEARCH METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 5 databases were searched from inception through December 24, 2019, for keywords and subject headings pertaining to cleft lip and/or palate and NAM. ELIGIBILITY CRITERIA Clinical studies on NAM with reference to physical (access to care, number of visits, distance traveled), psychosocial (caregiver perceptions, family interactions, breast milk feeding), and financial (direct and indirect costs) burden were included. DATA COLLECTION AND ANALYSIS Study selection was performed by 2 independent reviewers. RESULTS The search identified 1107 articles and 114 articles remained for qualitative synthesis. Burden of care domains were discussed but not measured in 43% of articles and only 25% assessed burden of care through a primary outcome. Of these, 20 articles reported on physical, 8 articles on psychosocial, and 12 articles on financial burden. Quality of evidence is limited by study design and risk of bias. CONCLUSION Nasoalveolar molding has been indiscriminately associated with burden of care in the literature. Although NAM may not be the ideal treatment option for all patients and families, the physical considerations are limited when accounting for the observed psychosocial advantages. Financial burden appears to be offset, but further research is required. Teams should directly assess the impact of this early intervention on the well-being of caregivers and advance strategies that improve access to care.
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Affiliation(s)
- Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Maxime M Wang
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Bradley S Eisemann
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - David A Staffenberg
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Pradip R Shetye
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
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16
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Seo HJ, Denadai R, Vamvanij N, Chinpaisarn C, Lo LJ. Primary Rhinoplasty Does Not Interfere with Nasal Growth: A Long-Term Three-Dimensional Morphometric Outcome Study in Patients with Unilateral Cleft. Plast Reconstr Surg 2020; 145:1223-1236. [PMID: 32332542 DOI: 10.1097/prs.0000000000006744] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary rhinoplasty has not been universally adopted because the potential for nasal growth impairment remains an unsolved issue in cleft care. This study's purpose was to assess the long-term effects of primary rhinoplasty performed by a single surgeon in a cohort of patients with a unilateral cleft lip nose deformity. METHODS Three-dimensional nasal morphometric measurements (linear, angular, proportional, surface area, and volume) were collected from consecutive patients (cleft group, n = 52; mean age, 19 ± 1 year) who had undergone primary rhinoplasty with the use of the Noordhoff approach between 1995 and 2002 and reached skeletal maturity. Normal age-, sex-, and ethnicity-matched subjects (control group, n = 52) were identified for comparative analyses. RESULTS No significant differences (all p > 0.05) were observed for most measures, including nasal height, alar width, nasal dorsum angle, columellar angle, columellar-labial angle, nasal tip/height ratio, nasal index, alar width/intercanthal distance ratio, nasal surface area, and nasal volume. The cleft group displayed significantly (all p < 0.05) lower nasal bridge length and nasal tip projection, and greater nasal protrusion, tip/midline deviation, nasal tip angle, nasal tip protrusion width index, and alar width/mouth ratio values than the control group. CONCLUSIONS Primary rhinoplasty does not interfere with nasal growth as measured by three-dimensional photogrammetric analysis. Further imaging studies are required for the assessment of development in other anatomical nasal structures. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Hyung Joon Seo
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University
| | - Rafael Denadai
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University
| | - Natthacha Vamvanij
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University
| | - Chatchawarn Chinpaisarn
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University
| | - Lun-Jou Lo
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University
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17
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Change in Incisional Design in Primary Unilateral Cleft Lip Repair Under General Anesthesia. J Craniofac Surg 2020; 31:e401-e405. [PMID: 32209931 DOI: 10.1097/scs.0000000000006399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Nasolabial features of infants with unilateral cleft lip (UCL) are different when they are under general anesthesia for lip repair compared to when they are awake. This study aimed to investigate changes in the incisional design of cheiloplasty according to patient position and anesthesia: upright and awake versus supine and under general anesthesia. Three-dimensional images of 20 infants with UCL were randomly selected. Two different incisional designs were drawn on the images captured while the infants were awake. Those incisional designs were anthropometrically compared to the designs drawn on the images captured while the infants were under general anesthesia. Under general anesthesia, vermillion height of both the medial and lateral sides of the cleft became significantly greater. In the rotation-advancement design, the incisional line of the rotation flap on the medial lip element became significantly shorter under general anesthesia, whereas the advancement flap on the lateral lip element was not significantly altered. In an anatomical subunit approximation, both lengths of the philtral ridge on the noncleft side and incisional line along the philtral ridge on the cleft side became significantly shorter under general anesthesia, but these alterations did not affect the calculation of the width of the small triangular flap on the lateral lip element. These changes in nasolabial features after general anesthesia may cause surgical error, which result in secondary cleft lip deformities. However, because these changes varied among infants, preoperative planning using three-dimensional facial images of infants who are awake may be able to avoid surgical error.
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18
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Three-Dimensional Measurement of the Lateral Lip Element Sacrificed in Primary Repair of a Unilateral Cleft Lip. Ann Plast Surg 2020; 85:180-184. [PMID: 32187070 DOI: 10.1097/sap.0000000000002358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In most children with a unilateral cleft lip (UCL), because lateral lip tissue on the cleft side is congenitally short, the lateral lip element should be appropriately excised during primary cheiloplasty so that symmetric nasolabial features are obtained after surgery. The purpose of this study was to measure how much of the lateral lip element is removed during primary cheiloplasty and compare the amount of sacrifice between different incision designs. METHODS Preoperative 3-dimensional images of 50 infants with UCL were randomly selected. The incision designs of 3 representative techniques (Millard, Onizuka, and Fisher) were drawn on the images that were obtained before the primary repair. The lateral lip tissue excised by each technique was estimated as a percentage of the surface area of the sacrificed lateral lip to the entire lateral lip of the cleft side. RESULTS In the case of incomplete UCL, the median values (range) were 3.2% (1.1%-5.9%), 11.6% (8.3%-20.1%), and 27.2% (15.1%-42.3%) for the Millard, Onizuka, and Fisher repairs, respectively. In cases of complete UCL, no sacrifice was needed for the Millard repair, whereas the median values (range) were 10.6% (5.2%-28.9%) and 22.5% (11.5%-48.6%) for the Onizuka and Fisher repairs, respectively. In Millard repair, the median values (range) of the lateral lip element that was resected before skin closure according to the "cut-as-you-go" policy were 5.8% (2.2%-11.8%) in cases with an incomplete UCL and 4.9% (2.7%-9.1%) in cases with a complete UCL. CONCLUSIONS Our study demonstrated that sacrifice of the lateral lip element was minimal in the Millard repair, whereas it could exceed 20% in the Fisher repair. However, additional sacrifice of the advancement flap was needed in the Millard-type repair. The ratio of the lateral lip sacrifice varied between patients. Although UCL repair techniques should not be evaluated with the sacrifice ratio, excessive sacrifice of the lateral lip tissue can complicate the secondary lip correction. We recommend that surgeons estimate preoperatively how much lateral lip element will be sacrificed with each incision design using a 3-dimensional image for each child with a UCL.
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19
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Acum M, Mastroyannopoulou K, O'Curry S, Young J. The Psychosocial Patient-Reported Outcomes of End of Pathway Cleft Surgery: A Systematic Review. Cleft Palate Craniofac J 2020; 57:990-1007. [PMID: 32174163 DOI: 10.1177/1055665620911328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To identify and review the literature on the psychosocial patient-reported outcomes (PROs) of surgery at the end of the cleft treatment pathway. DESIGN A systematic literature search was performed using electronic databases (Medline, PubMed, EMBASE, PsycInfo, Web of Science, and Science Direct) from database inception to September 2017, to identify studies measuring and reporting the psychosocial PROs of end of pathway cleft surgery. RESULTS Of 263 identified papers, 22 studies were eligible for inclusion. Apart from one randomized controlled study, studies were largely observational and adopted a cross-sectional or retrospective design. The majority (n = 16) were small-scale studies. The methodological quality was variable in terms of what, how, and when psychosocial outcomes were measured and reported. None of the studies utilized a psychosocial PRO measure validated in the cleft population, and few studies measured outcomes prospectively. A high proportion of studies utilized bespoke measures of patient satisfaction. Taken together, findings from the included studies are tentative but seem to suggest patients derive some benefit from undergoing end of pathway cleft surgery, in terms of increased satisfaction, quality of life, social interactions, and decreased appearance-related distress. CONCLUSIONS Due to methodological challenges and the heterogeneity of what, how, and when outcomes are measured and currently reported, it is difficult to determine the psychosocial PROs of end of pathway cleft surgeries. Consequently, this review advocates the conduct of well-designed, longitudinal studies using cleft-sensitive tool/s to capture the psychosocial PROs of end of pathway cleft surgery at various time points.
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Affiliation(s)
- Michelle Acum
- Cambridgeshire and Peterborough NHS Foundation Trust, Elizabeth House, Fulbourn Hospital, Cambridge, United Kingdom.,University of East Anglia, Norwich, United Kingdom
| | - Kiki Mastroyannopoulou
- Norfolk and Norwich University Hospital, University of East Anglia, Norwich, United Kingdom
| | - Sara O'Curry
- Psychological Medicine for Children, Young People and their Families, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Judith Young
- University of East Anglia, Addenbrooke's Cambridge University Hospital Trust, Cambridge, United Kingdom
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20
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Sitzman TJ, Carle AC, Lundberg JN, Heaton PC, Helmrath MA, Trotman CA, Britto MT. Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery. Cleft Palate Craniofac J 2020; 57:198-207. [PMID: 31597471 PMCID: PMC6957675 DOI: 10.1177/1055665619880056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas J. Sitzman
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, AZ, USA
- Department of Surgery, Mayo Clinic College of Medicine, Scottsdale, AZ, USA
| | - Adam C. Carle
- Department of Pediatrics, College of Medicine, University of Cincinnati, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, OH, USA
| | | | - Pamela C. Heaton
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Michael A. Helmrath
- Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Carroll-Ann Trotman
- Department of Orthodontics, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Maria T. Britto
- Department of Pediatrics, College of Medicine, University of Cincinnati, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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21
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Padovano WM, Snyder-Warwick AK, Skolnick GB, Pfeifauf KD, Menezes MD, Grames LM, Cheung S, Kim AM, Cradock MM, Naidoo SD, Patel KB. Evaluation of Multidisciplinary Team Clinic for Patients With Isolated Cleft Lip. Cleft Palate Craniofac J 2020; 57:900-908. [PMID: 31961207 DOI: 10.1177/1055665619900625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To report the incidences of secondary lip and nose operations, otolaryngology procedures, speech-language therapy, neurodevelopmental concerns, and dental and orthodontic issues in children with isolated cleft lip to inform multidisciplinary cleft team protocols. SETTING An American Cleft Palate-Craniofacial Association-approved team at a tertiary academic children's hospital. DESIGN Retrospective cohort study of patients evaluated through longitudinal clinic visits by a multidisciplinary cleft palate and craniofacial team between January 2000 and June 2018. PATIENTS, PARTICIPANTS Children with nonsyndromic cleft lip with or without cleft alveolus (n = 92). RESULTS Median age at final team visit was 4.9 years (interquartile range: 2.4-8.2 years). Secondary plastic surgery procedures were most common between ages 3 and 5 (135 per 1000 person-years), and the majority of these procedures were minor lip revisions. The rate of tympanostomy tube insertion was highest before age 3 (122 per 1000 person-years). By their final team visit, 88% of patients had normal hearing and 11% had only slight to mild conductive hearing loss. No patients had speech errors attributable to lip abnormalities. Psychological interventions, learning disabilities, and dental or orthodontic concerns were uncommon. CONCLUSIONS Most patients with isolated cleft lip may not require long-term, longitudinal evaluation by cleft team specialists. Cleft teams should develop limited follow-up protocols for these children to improve resource allocation and promote value-based care in this patient population.
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Affiliation(s)
- William M Padovano
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Kristin D Pfeifauf
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Maithilee D Menezes
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, MO, USA
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Abstract
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.
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Affiliation(s)
- Jyotsna Murthy
- Department of Plastic Surgery, Cleft and Craniofacial Center, Sri Ramachandra University, Chennai, India
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23
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Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons. Plast Reconstr Surg 2019; 144:171-178. [PMID: 31246825 DOI: 10.1097/prs.0000000000005722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision. METHODS Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05. RESULTS The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44). CONCLUSIONS All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.
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Incidence of Secondary Lip Correction for Children With Unilateral Cleft Lip: A Single-Center Retrospective Study. Ann Plast Surg 2019; 83:424-428. [PMID: 31524736 DOI: 10.1097/sap.0000000000001935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous reports have described the incidence of secondary lip correction for patients with cleft lip (CL), and this incidence broadly varies among centers. The purpose of this study was to determine this revision rate for a reasonably large number of patients in our center and identify the clinical factors that contribute to the revision rate. METHODS A retrospective chart review was conducted for all infants with unilateral CL with or without cleft palate who underwent primary cheiloplasty at our cleft center from 2006 to 2012. Four surgeons were in charge of almost all operations. We investigated how many children underwent lip revisions by the end of 2017. RESULTS In total, 490 infants underwent primary lip repair, and 47 underwent revision surgery by the age of 8 years. Half of them (24 children) underwent revisions at the age of 5 or 6 years. There was no significant difference in the revision rate by sex or cleft side. The revision rate in children with CL only tended to be lower than that in children with alveolar cleft or cleft palate, but it was not significantly associated with the cleft type. The revision rate ranged from 2.8% to 15.2% among surgeons. CONCLUSIONS The overall revision rate was 9.6%, which is relatively lower than that in other cleft centers. However, the repair technique and cleft care program should not be evaluated using the revision rate only. Various factors, including surgeons' preference, contribute to the indications for revision, and these factors can change with age. We plan to follow up the patients until our completion of the cleft care program and report the final revision rate.
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25
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Wei Y, Zhong T, Yin X, Shi B, Zheng Q, Li J. Dynamic Nasolabial Growth After Primary Surgery for Patients With Bilateral Cleft Lip: A Five-Year Follow-Up Study. J Oral Maxillofac Surg 2019; 77:2125.e1-2125.e10. [PMID: 31238020 DOI: 10.1016/j.joms.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Bilateral complete cleft lip (BCCL) causes severe tissue deficit and usually requires multiple revisions after primary repair. In the present study, we aimed to illustrate the nasolabial changes after primary BCCL correction. PATIENTS AND METHODS The present retrospective cohort study compared patients who had undergone BCCL and palate (BCCLP) and cleft palate only (CPO). All included patients had undergone surgery at the same treatment center (West China Hospital of Stomatology) from 2007 to 2012. The patients returned for follow-up surgery at 6 months and 5 years after their primary repair surgery. We retrieved the facial plaster casts of the enrolled patients and recorded the key nasolabial measurements. The outcome variables included the prolabial length (PL), peak distance, nasal width, and columellar length (CL). The data were analyzed using a general linear model for repeated measures, and the linear association was tested using SPSS. The level of testing efficiency (P value) was set at .05. RESULTS A total of 160 patients, 80 who had undergone BCCLP and 80 CPO controls, were included. All nasolabial measurements in the BCCLP group had increased during the 5-year follow-up period. The PL of the BCCLP group had increased more quickly than the PL of the CPO group (P = .000 < .05), but the CL had increased nearly as much (P = .270). CONCLUSIONS For the primary correction of bilateral cleft lip nose deformity, dissection and repositioning of the cleft lip and nose did not significantly inhibit the growth of the nasolabial region in the first 5 years after surgery. Nose deformities should not remain uncorrected after primary surgical repair. In contrast, cleft surgeons should focus on the finer adjustment of columella with less doubt regarding adverse effects.
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Affiliation(s)
- Yuhao Wei
- Resident, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Tianhang Zhong
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xing Yin
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China; and Research Fellow, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China; and Professor and Department Head, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qian Zheng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China; and Professor, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China; and Associate Professor, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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26
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Morzycki A, Wong A, Hong P, Bezuhly M. Assessing Attentional Bias in Secondary Cleft Lip Deformities: An Eye-Tracking Study. Cleft Palate Craniofac J 2018; 56:257-264. [PMID: 29742362 DOI: 10.1177/1055665618775728] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Using a well-established measure of attention, we aimed to objectively identify differences in severity between types of simulated secondary cleft lip deformities. DESIGN Volunteer participants viewed a series of images of a child digitally modified to simulate different secondary unilateral cleft lip deformities (long lip, short lip, white roll/vermilion disjunction, and vermilion excess), a lip scar with no secondary deformity, or a normal lip. Eye movements were recorded using a table-mounted eye-tracking device. Dwell times for 7 facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face) were compared. PARTICIPANTS Forty-six naive adults (25 male; mean age 25.5 years) were recruited from our local university community. MAIN OUTCOME The primary outcome of the study was cumulative dwell time between facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face). RESULTS Participants spent significantly more time focused on the upper lip regions in patients with simulated secondary deformities relative to those who did not ( P < .01). Severe short lip deformities resulted in longer fixation times than severe long lips ( P < .05). Participants spent less time focused on the eye region in the presence of a secondary lip deformity ( P < .05). When total facial fixation time was assessed, short lip deformities resulted in the greatest duration dwell time ( P < .001). CONCLUSIONS This study presents objective data to support the concept that observers show varying degrees of attentional bias to the lip region depending on the type and severity of the simulated secondary cleft lip deformity.
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Affiliation(s)
- Alexander Morzycki
- 1 Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alison Wong
- 2 Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Hong
- 3 Division of Otolaryngology, Dalhousie University, Halifax, Nova Scotia, Canada.,4 Department of Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Michael Bezuhly
- 2 Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,4 Department of Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
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27
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Ruff RR, Crerand CE, Sischo L, Peshansky A, Sarwer DB, Kirschner RE, Broder HL. Surgical Care for School-Aged Youth With Cleft: Results From a Multicenter, Prospective Observational Study. Cleft Palate Craniofac J 2018; 55:1055665618765776. [PMID: 29554461 DOI: 10.1177/1055665618765776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE To explore factors related to completion of surgery recommendations among children with cleft lip and palate (CLP) or cleft palate only (CPO). DESIGN Multicenter prospective longitudinal cohort study (2009-2015). SETTING Six cleft centers in the United States. PATIENTS/PARTICIPANTS A diverse sample of 1186 youth aged 7.5 to 18.5 years with CLP or CPO and a caregiver. RESULTS Data were collected from child-caregiver dyads at baseline and up to 3 follow-up visits. Of the 765 surgeries recommended during the study period, 83 were postponed and 597 were completed; this represents a completion rate of 78%. There were multiple reasons identified by patients for why the remaining 85 recommended surgeries were not completed. Children with nonprivate insurance were more likely to postpone recommended surgeries. Hispanic/Latino and Asian children had fewer surgeries compared to whites/Caucasians. Greater severity in rated speech differences was associated with more surgeries. Among participants who had completed all recommended surgeries, providers rated over 86% as having normal or mildly different facial appearance and 83% as having a normal or mild speech intelligibility rating. Similarly, caregivers rated 80% of facial appearance and 78% of speech positively. Approximately 25% of children had an additional surgical recommendation at the end of the study. CONCLUSIONS The majority of surgical recommendations were completed with positive outcomes in facial appearance and speech intelligibility by provider and caregiver ratings. Several factors contributed to surgical recommendations not being completed and the results underscore the importance of examining socioeconomic and demographic disparities in surgical care.
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Affiliation(s)
- Ryan Richard Ruff
- 1 Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY, USA
- 2 College of Global Public Health, New York University, New York, NY, USA
| | | | - Lacey Sischo
- 4 Department of Cariology and Comprehensive Care, New York University College of Dentistry, New York, NY, USA
| | - Alexandre Peshansky
- 5 Research Informatics Core, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David B Sarwer
- 6 Temple University College of Public Health, Philadelphia, PA, USA
| | | | - Hillary L Broder
- 4 Department of Cariology and Comprehensive Care, New York University College of Dentistry, New York, NY, USA
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28
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Papathanasiou E, Trotman CA, Scott AR, Van Dyke TE. Current and Emerging Treatments for Postsurgical Cleft Lip Scarring: Effectiveness and Mechanisms. J Dent Res 2017. [PMID: 28650705 DOI: 10.1177/0022034517717261] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Cleft lip with or without cleft palate is the most common congenital malformation of the head and the third-most common birth defect. Surgical repair of the lip is the only treatment and is usually performed during the first year of life. Hypertrophic scar (HTS) formation is a frequent postoperative complication that impairs soft tissue form, function, or movement. Multiple lip revision operations are often required throughout childhood, attempting to optimize aesthetics and function. The mechanisms guiding HTS formation are multifactorial and complex. HTS is the result of dysregulated wound healing, where excessive collagen and extracellular matrix proteins are deposited within the wound area, resulting in persistent inflammation and resultant fibrosis. Many studies support the contribution of dysregulated, exaggerated inflammation in scar formation. Fibrosis and scarring result from chronic inflammation that interrupts tissue remodeling in normal wound healing. Failure of active resolution of inflammation pathways has been implicated. The management of HTS has been challenging for clinicians, since current therapies are minimally effective. Emerging evidence that specialized proresolving mediators of inflammation accelerate wound healing by preventing chronic inflammation and allowing natural uninterrupted tissue remodeling suggests new therapeutic opportunities in the prevention and management of HTS.
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Affiliation(s)
- E Papathanasiou
- 1 Center for Clinical and Translational Research, Forsyth Institute, Cambridge, MA, USA.,2 Department of Periodontology, Tufts University School of Dental Medicine, Boston, MA, USA
| | - C A Trotman
- 3 Department of Orthodontics, Tufts University School of Dental Medicine, Boston, MA, USA
| | - A R Scott
- 4 Department of Otolaryngology and Pediatrics, Tufts University School of Medicine, Boston, MA, USA
| | - T E Van Dyke
- 1 Center for Clinical and Translational Research, Forsyth Institute, Cambridge, MA, USA
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