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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 99-103

Early cleft lip and palate repair: Experience of the National Orthopedic Hospital Enugu, Southeast Nigeria


Department of Burns and Plastic, National Orthopaedic Hospital, Enugu, Nigeria

Date of Web Publication7-Aug-2019

Correspondence Address:
Dr. Chuwuemeka Patrick Okoye
Department of Burns and Plastic, National Orthopaedic Hospital, PMB 01294, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_26_18

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  Abstract 

Background: Surgical treatment of clefts during infancy poses a challenge for the plastic surgeon and anesthetists. The timing of the procedures has been fraught with controversies with no consensus. Due to the many different treatment philosophies, the timing of treatment varies among cleft centers. Historically, anesthetic risk-related data suggest that the safe time period for surgery in this population of infants could be outlined by the rule of 10's. However, more sophisticated pediatric techniques and advances in intraoperative monitoring and pediatric anesthesia have resulted in the provision of safe general anesthesia for younger infants. This article attempts to provide an audit of the outcome and complications of cleft lip/palate repair performed earlier than the hitherto defined period. Aims/Objectives: The aims of the study were to evaluate the perioperative safety profile of early cleft lip and palate repairs and to evaluate early postoperative surgical complications. Materials and Methods: A retrospective audit of all patients that had early cleft lip and palate repair at the National Orthopedic Hospital Enugu, Nigeria, between May 2006 and May 2014. Early cleft lip and palate repairs were defined as repair done before 10 weeks and 9 months, respectively. Information was obtained from the folders of the patients and the smile train express database. The anesthetic technique was general anesthesia with endotracheal intubation and halothane as the inhalational agent. Armored tubes were used for palatal repairs. The Mohler's technique and Mulliken's technique were used for unilateral and bilateral lip repair, respectively. Intravelar veloplasty ± relaxing incisions/Bardach two-flap palatoplasty were used for palate repairs. All the procedures were carried out by one consultant plastic surgeon. Results: Four hundred and ninety-three cleft-related surgeries were performed in the period. Forty-one were early cleft lip/palate repairs. Thirty-one of these early procedures were done on the lip, whereas ten procedures were on the palate. There were no mortalities. One patient (2.4%) developed anesthetic complication (prolonged recovery time). There was neither need for intra- nor postoperative transfusion. One patient had a need for supplemental oxygen therapy beyond 1 h. There was no need to take any patient back to theater. The most common early complications following lip and palate repairs were wound dehiscence and palatal fistulae, respectively. Conclusion/Recommendation: These procedures can be safely carried out when performed early. The surgical complication rates appear to be few following early procedures. Further study on long-term cleft repair on facial growth and speech needed.

Keywords: Cleft lip, cleft palate, early repair, Enugu


How to cite this article:
Onah II, Okoye CP, Bala E. Early cleft lip and palate repair: Experience of the National Orthopedic Hospital Enugu, Southeast Nigeria. J Cleft Lip Palate Craniofac Anomal 2019;6:99-103

How to cite this URL:
Onah II, Okoye CP, Bala E. Early cleft lip and palate repair: Experience of the National Orthopedic Hospital Enugu, Southeast Nigeria. J Cleft Lip Palate Craniofac Anomal [serial online] 2019 [cited 2019 Oct 22];6:99-103. Available from: http://www.jclpca.org/text.asp?2019/6/2/99/264095


  Introduction Top


Cleft lip and palate anomalies are among the most common congenital anomalies in the craniofacial region.[1] These set of anomalies pose significant challenges to parents of such children, the plastic surgeon, and the anesthetist.[2],[3] The psychological trauma associated with congenital anomalies to the face cannot be overemphasized as the face is a defining feature of the human body and plays significant roles in aesthesis and function[4] as well as a means of identification. Therefore, it is very understandable that parents of such children desire a quick resolution to the problem so the child can carry on as normal as possible and improve body image.[5] In Nigeria, this is more so as such gross facial or mouth anomalies have been attributed to various forms of traditional interpretations with consequent stigmatization.[6] This scenario is even made worse by high levels of ignorance and poverty.

However, the risk of anesthesia has, for many years, precluded reconstruction of these set of anomalies timely as surgeons were adherent to what is called the rule of 10s for cleft lip repair (10 g of hemoglobin, 10 weeks of age, 10 pounds of weight, and white blood cell count of <10,000) as recommended by Wilhelmsen and Musgrave[7] and emphasized by Millard.[8] Different philosophies and controversies also trailed the optimal timing of cleft palate anomalies,[9],[10],[11] with most centers performing them between 10 and 18 months. These set of rules and criteria were predicated on the relative perioperative and surgical risk of performing these repairs in such young children.[5]

These set of rules/criteria eliminated the possibilities of early surgery for these infants and worsened the psychological trauma to the parents leading to impediments in infant–parent bonding.[12] In fact, a preliminary report from our hospital by the lead author (yet to be published) suggests that children with cleft lip and palate anomalies had more challenges with weight gain as compared to those with isolated cleft palate anomaly. This was attributed to poor mother–infant bonding with limited motivation on the part of the mothers to feed the children due to the abnormal facies. Infants with cleft palate anomaly alone had “hidden” defects and were not a constant reminder to the parents that an anomaly existed.

Recently, there have been published reports that have shown successful repairs of the cleft lip much earlier than had been recommended[13] and even in neonates 1–8 day's old.[14] The proponents of this treatment philosophy believe that while the risk of anesthesia was significant for children under 12 months of age, there was little evidence to show that the risk was more below 3 months of age.[14] Refinements in pediatric anesthesia over the years has also allowed such procedures performed earlier[15],[16] Opponents of this philosophy of early repairs believe that there was no effect on long-term attractiveness of the repairs.[17] Similar controversies also trail the timing of palate repairs with proponents of early citing better speech outcomes[18] with opponents citing the risk of perioperative anesthetic complications, effects on maxillary growth among other reasons.[9]

Therefore, we set out to audit the outcomes and complications of the early cleft lip/palate repairs performed outside the prescribed timely period at our hospital, with the aims of evaluating the perioperative safety profile of the procedures as well as to evaluate early postoperative surgical complications.


  Materials and Methods Top


The study design was retrospective in nature to audit the outcome of early cleft lip/palate repair at the National Orthopedic Hospital, Enugu, a regional hospital in Southeast Nigeria, between May 2006 and May 2014.

All the records of all patients who had early cleft lip/palate repairs were obtained from the medical records department and operating theater and were subsequently analyzed.

Early cleft lip and palate repairs were defined as follows.

  1. Early cleft lip repair – repairs done before 10 weeks of age
  2. Early cleft palate repair – repairs done before 9 months of age.


The anesthetic technique was general anesthesia with endotracheal intubation and halothane as inhalation agent. Armored endotracheal tubes were used for palatal repairs. All the procedures were performed by the lead author. None of the patients had presurgical orthopedic treatments or nasoalveolar molding procedures. Routine perioperative antibiotics were given and all patients had the surgical site infiltrated with adrenaline solution. The anesthesia was conducted by a consultant anesthetist for the patients. The Mohler's technique [Figure 1] and Mulliken's technique were used for unilateral and bilateral lip repair, respectively. Intravelar veloplasty ± relaxing incisions/Bardach two-flap palatoplasty [Figure 2] were used for palate repairs. Postoperatively, patients treated for cleft palate received supplemental oxygen for periods not exceeding 1 h except for one who had combined early lip and palate repair. The patients were followed up for between 2 weeks and 4 months. Subsequently, they defaulted on appointments.
Figure 1: (a) Early cleft before surgery. (b) Early lip repair after surgery

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Figure 2: (a) Early cleft palate before repair. (b) Early cleft palate repair after

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Exclusion criteria were:

  1. Infants with other congenital anomalies that may interfere with anesthesia-cardiovascular anomalies, craniofacial (Pierre Robin sequence), etc.,
  2. Infants with body weight not appropriate for age as determined by the nomogram.


Inclusion criteria

All patients with normal routine perioperative investigations were included in the study, this consisted of a complete blood count.

Limitations

There were some records that could not be retrieved as record keeping was still been done manually by the records department. Only patients with complete records were analyzed. Late outcome measures related to cleft lip and palate repairs, for example, speech quality, midfacial skeletal problems, and abnormal scaring were not investigated.


  Results Top


Four hundred and ninety-three cleft-related surgeries were performed during the period with 41 of the patients undergoing early cleft repair giving a percentage of 8.31% of the total procedures. Thirty-one of the procedures were on the lip and 10 on the palate. Analysis of the demography of the patients revealed that there were 24 male and 17 female. In the cleft lip repair group, there were 18 males and 13 females, whereas the cleft palate had 6 males and 4 female patients [Table 1].
Table 1: Sex distribution of subjects and procedure performed

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The age range of the patients who had early repair was 4.71–8.85 weeks with a mean age of 6.01 weeks. For the cleft palate group, the age range was 6.25–8.5 months with a mean age of 7.17 months.

About 67.8% (21) of the cleft lip repairs were for unilateral clefts, whereas 32.8% (10) were bilateral clefts of the lip. Almost, 60% of the palatal procedures were for unilateral cleft palate. A stringent perioperative evaluation was employed to select the patients for early cleft palate repair. Intraoperative monitoring of oxygen saturation was done religiously and any drop in saturation lead to a search and correction of the problem. The elevation of the palatal shelves is easier technically at an earlier age. As the child grows, repeated upper airway infection and subsequent tendency to fibrosis make elevation more difficult.

The early outcome measures assessed were perioperative anesthetic risks/complications-failed/difficult intubation, perioperative hypoxia/hypoxemia, need for intra- or postoperative blood transfusion, laryngospasm, need for supplemental oxygen therapy beyond 1 h, mortality, and other near-miss events related to anaesthesia [Table 2]. Surgical/procedure-related complications assessed included wound infections, total/partial flap necrosis, wound dehiscence, palatal fistula rate, and lip notching among other complications. There were three incidences of wound dehiscence in the cleft lip repair group [Table 3] and [Table 4].
Table 2: Anaesthetic complications

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Table 3: Surgical complications of cleft lip repair

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Table 4: Complications of cleft palate repair

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The cleft lip repairs were generally acceptable to the parents and follow-up visits revealed an improved mother–child bonding after the repairs.


  Discussion Top


This retrospective audit aimed at evaluating the early perioperative and surgical outcomes or complications associated with early repair of cleft lip and palate. The number of patients who participated was 41 because it was very necessary for the weight of the patients to be appropriate for age before surgery. Thomas et al.[19] has demonstrated that the perioperative risks correlated directly with weight at the time of surgery. The chronological age is therefore not as important as appropriate weight for age in determining the perioperative anesthetic outcome in infants. Similar excellent perioperative outcome following early repair has also been reported.[12],[14]

Even though all the patients received routine perioperative antibiotics, it might be difficult to conclude that the low infection rates were as a result of the antibiotic use, there appears to be no consensus on the efficacy of routine perioperative antibiotic use on surgery for primary cleft repair.[20] The improved mother–child bonding noted after the repairs is understandable as some of these cleft lip anomalies present grotesque appearances. Similar reports of improved mother–child bonding after early cleft lip repairs have been documented.[6],[21],[22]

The incidence of dehiscence we report is slightly higher than reports from other studies that performed early lip repairs.[10],[11] The nonuse of preoperative nasoalveolar molding may account for this. Such molding devices are largely nonexistent in our locality.

Perioperative airway problems are common with cleft palate repairs.[23],[24] This is related to the anatomy of the pathology, the relative size of the airways, and associated syndromes among others. In our small series, such adverse events were largely not reported. Palatal fistula formation is a common surgical complication with cleft palate repairs,[25],[26] with a reported incidence of 5%–29%.[27] Our series recorded a fistula rate of 30%. This is slightly higher than the documented incidence rate. This is fairly acceptable as the sheer size of the tissues at this early age and difficulties with exposure are clear challenges that may affect fistula formation.


  Conclusion/recommendation Top


Early repairs of cleft lip and palate can safely be carried out outside the prescribed time period. The perioperative safety profile is good and surgical complication rates comparable to later repairs. Strict patient selection, adequacy of weight for age of these patients, and exclusion of perioperative cardiorespiratory risk factors and competent anesthesia are critical. Further studies to evaluate the effects of these early repairs on maxillary growth and speech are recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

Emmanuel Onyenzoputa has continued to be an inspiration and encouragement. Chukwunonso JacOkereke helped correct the manuscript and added references.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Grollemund B, Galliani E, Soupre V, Vazquez MP, Guedeney A, Danion A, et al. The impact of cleft lip and palate on the parent-child relationships. Arch Pediatr 2010;17:1380-5.  Back to cited text no. 1
    
2.
Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourc'h G. Complications related to anaesthesia in infants and children. A prospective survey of 40240 anaesthetics. Br J Anaesth 1988;61:263-9.  Back to cited text no. 2
    
3.
Ward CF. Paediatric head and neck syndromes. In: Anaesthesia and Uncommon Paediatric Disease. Philadelphia: WB Sanders; 1987. p. 238-71.  Back to cited text no. 3
    
4.
Borah GL, Rankin MK. Appearance is a function of the face. Plast Reconstr Surg 2010;125:873-8.  Back to cited text no. 4
    
5.
Murray L, Hentges F, Hill J, Karpf J, Mistry B, Kreutz M, et al. The effect of cleft lip and palate, and the timing of lip repair on mother-infant interactions and infant development. J Child Psychol Psychiatry 2008;49:115-23.  Back to cited text no. 5
    
6.
John L, Micol A. Cross-cultural attitudes and perceptions towards cleft lip and palate deformities. World Cult Psychiatry Rev 2011;6:127-34.  Back to cited text no. 6
    
7.
Wilhelmsen HR, Musgrave RH. Complications of cleft lip surgery. Cleft Palate J 1966;3:223-31.  Back to cited text no. 7
    
8.
Millard DR. A primary camouflage of unilateral harelook. In Skoog T, Ivy RH, editors. Transactions of the International Society of Plastic Surgeons. Baltimore: William and Wilkins; 1957. p. 163-5.  Back to cited text no. 8
    
9.
Rohrich RJ, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, et al. Timing of hard palatal closure: A critical long-term analysis. Plast Reconstr Surg 1996;98:236-46.  Back to cited text no. 9
    
10.
Kobus K, Kobus-Zaleśna K. Timing of cleft lip and palate repair. Dev Period Med 2014;18:79-83.  Back to cited text no. 10
    
11.
Chow I, Purnell CA, Hanwright PJ, Gosain AK. Evaluating the rule of 10s in cleft lip repair: Do data support dogma? Plast Reconstr Surg 2016;138:670-9.  Back to cited text no. 11
    
12.
Emad HE, Ayman E, Barat A. Early cleft lip repair. AAMJ 2012;10:317-21.  Back to cited text no. 12
    
13.
Hodges AM. Combined early cleft lip and palate repair in children under 10 months – A series of 106 patients. J Plast Reconstr Aesthet Surg 2010;63:1813-9.  Back to cited text no. 13
    
14.
Jiri B, Jana V, Michal J, Jiri K, Dana H, Miroslav T, et al. Successful early neonatal repair of cleft lip within first 8 days of life. Int J Pediatr Otorhinolaryngol 2012;76:1616-26.  Back to cited text no. 14
    
15.
Galinier P, Salazard B, Deberail A, Vitkovitch F, Caovan C, Chausseray G, et al. Neonatal repair of cleft lip: A decision-making protocol. J Pediatr Surg 2008;43:662-7.  Back to cited text no. 15
    
16.
Harris PA, Oliver NK, Slater P, Murdoch L, Moss AL. Safety of neonatal cleft lip repair. J Plast Surg Hand Surg 2010;44:231-6.  Back to cited text no. 16
    
17.
Goodacre TE, Hentges F, Moss TL, Short V, Murray L. Does repairing a cleft lip neonatally have any effect on the longer-term attractiveness of the repair? Cleft Palate Craniofac J 2004;41:603-8.  Back to cited text no. 17
    
18.
Evans D, Renfrew C. The timing of primary cleft palate repair. Scand J Plast Reconstr Surg 1974;8:153-5.  Back to cited text no. 18
    
19.
Thomas F, Christoph H, Ulrich J, Richard W. Perioperative complications in infant cleft repair. Head Face Med 2007;(3):19.  Back to cited text no. 19
    
20.
Smyth AG, Knepil GJ. Prophylactic antibiotics and surgery for primary clefts. Br J Oral Maxillofac Surg 2008;46:107-9.  Back to cited text no. 20
    
21.
McHeik JN, Sfalli P, Bondonny JM, Levard G. Early repair for infants with cleft lip and nose. Int J Pediatr Otorhinolaryngol 2006;70:1785-90.  Back to cited text no. 21
    
22.
Borský J, Tvrdek M, Kozák J, Cerný M, Zach J. Our first experience with primary lip repair in newborns with cleft lip and palate. Acta Chir Plast 2007;49:83-7.  Back to cited text no. 22
    
23.
Sandberg DJ, Magee WP Jr., Denk MJ. Neonatal cleft lip and cleft palate repair. AORN J 2002;75:490-8.  Back to cited text no. 23
    
24.
Kulkarni KR, Patil MR, Shirke AM, Jadhav SB. Perioperative respiratory complications in cleft lip and palate repairs: An audit of 1000 cases under ‘smile train project'. Indian J Anaesth 2013;57:562-8.  Back to cited text no. 24
[PUBMED]  [Full text]  
25.
Takemura H, Yasumoto K, Toi T, Hosoyamada A. Correlation of cleft type with incidence of perioperative respiratory complications in infants with cleft lip and palate. Paediatr Anaesth 2002;12:585-8.  Back to cited text no. 25
    
26.
Diah E, Lo LJ, Yun C, Wang R, Wahyuni LK, Chen YR, et al. Cleft oronasal fistula: A review of treatment results and a surgical management algorithm proposal. Chang Gung Med J 2007;30:529-37.  Back to cited text no. 26
    
27.
Dufresne CR. Oronasal fistula and nasolabial fistulas. In Bardach J, Morris HL, editors. Multidisciplinary Management of Cleft Lip and Palate. 1st ed. Philadelphia: WB Saunders; 1990. p. 425-36.  Back to cited text no. 27
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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