|Year : 2016 | Volume
| Issue : 1 | Page : 9-13
A prospective, single center analysis of satisfaction following cleft lip and palate surgeries in Southwest Nigeria
Abdurrazaq Olanrewaju Taiwo1, Wasiu Lanre Adeyemo2, Ramat Oyebunmi Braimah3, Adebayo Aremu Ibikunle3
1 Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Web Publication||9-Feb-2016|
Abdurrazaq Olanrewaju Taiwo
Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University, PMB 12003, Sokoto
Source of Support: None, Conflict of Interest: None
Objective: Aim of this study was to assess satisfaction with facial appearance and function following cleft lip and palate (CLP) surgeries. Materials and Methods: The surgical outcome of 70 consecutive patients who had CLP surgeries between October 2008 and December 2009 were prospectively evaluated at least 4 weeks postoperatively. Data collected included age, sex, type of cleft defects and type of surgery done, and postoperative complications. For cleft lip repair, the Pennsylvania lip and nose score was used to assess surgical outcome whereas the integrity of the closure was used for cleft palate repair. Results: A total of 70 subjects were enrolled in this study with 40 females (57.1%) and 30 males (42.9%) (female:male = 1.3:1). The age of the subjects at presentation ranged from 1 day to 26 years. Majority of the study group were infants 74.3% (52) and 25.7% (18) presented after age one. 19 (39.6%) of subjects were operated within the ages of 3 months for lip repair and 10 (45.5%) subjects after 18 months for palate repair. There was a good surgical outcome of 71.4% with an overwhelming parents/subjects satisfaction of 94.8% with the treatment outcome. Twelve cases (15.6%) in which surgical outcome was rated fair, the subjects or their parents were still very satisfied with the surgical outcome. Conclusions: There was a high patient satisfaction irrespective of treatment outcome. This satisfaction reflects not only the technical competence of the cleft surgeons, but also the dedicated performance of other supporting staffs of the hospital.
Keywords: Cleft lip and palate, patient satisfaction, Pennsylvania lip and nose score, von Langenbeck
|How to cite this article:|
Taiwo AO, Adeyemo WL, Braimah RO, Ibikunle AA. A prospective, single center analysis of satisfaction following cleft lip and palate surgeries in Southwest Nigeria. J Cleft Lip Palate Craniofac Anomal 2016;3:9-13
|How to cite this URL:|
Taiwo AO, Adeyemo WL, Braimah RO, Ibikunle AA. A prospective, single center analysis of satisfaction following cleft lip and palate surgeries in Southwest Nigeria. J Cleft Lip Palate Craniofac Anomal [serial online] 2016 [cited 2021 Oct 16];3:9-13. Available from: https://www.jclpca.org/text.asp?2016/3/1/9/175998
| Introduction|| |
Cleft lip and palate (CLP) continues to be one of the major disfiguring and distressful congenital craniofacial deformities with reported incidence of 1 in every 600 live births. ,, Global evidences suggest that it is often accompanied with grave psychological impairment and social stigma. 
Cleft treatment aimed at restoring aesthetics and ensuring adequate speech development are often prolonged and start from childhood and finish in adulthood. Frequent evaluations of these treatments are centered on the clinical outcomes disregarding patient related outcomes such as satisfaction and quality of life that can guarantee long-term compliance with care.
Encouragingly, the paradigm is shifting as many health providers, hospitals, medical institutions, and cleft centers have recognized that satisfaction evaluation offers an excellent chance to gauge the consumers/end users' perspective in the quality of care provided and the providers' success at meeting the clients' expectations. Thereby, making services more client-centered, facilitating efforts to optimize outcome, regulate/modify services, and improve quality. Patient feedback is regarded as an essential and effective tool in marketing health services. Moreover, several researchers have emphasized that patient oriented outcome measurements provide more insights into the patients' views of the impact of treatment, gives thorough outcome assessment and are crucial for improvement of patient care.
Recent studies have demonstrated that patients satisfied with the health service are much likely to be committed to future treatments and would recommend such services and health care provider to others. 
Unfortunately, there is a dearth of research on patients' satisfaction with cleft treatment in our region. Hence, the purpose of this study is to determine patients' satisfaction following CLP surgeries.
| Materials and methods|| |
The study participants were willing consecutive CLP patients recruited from the cleft clinic of Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria, between October 2008 and December 2009. Written informed consent was obtained from each study participants or surrogates. The study was approved by the hospital's Human Research Ethics Committee and was conducted according to the Helsinki declaration.
A total of 70 patients were involved in this study. All treatment was free. Treatment protocol for these patients include lip repair generally at 10 weeks of age and palatal closure was achieved at a minimum age of 9 months.
Surgical repair was carried out by 4 consultants, oral and maxillofacial surgeons, assisted by senior registrars who are locally employed. The lead surgeon determined the surgical technique for each case. All the surgeons were permanently employed local surgeons.
Clinical evaluations of the surgical outcome of the repaired clefts were done at least 4 weeks postsurgery by the 2 investigators.
General and clinical information about the patients were included in the proforma which was divided into preoperative, intraoperative, and postoperative.
For cleft lip repair, outcome was adjudged by the Pennsylvania lip and nose score  as good, fair, or poor.
Pennsylvania lip and nose score
- Good: Nearly imperceptible at conversational distance. No treatment required.
- Fair: Some lip asymmetry noted at conversational distance. Minor reconstructive procedure required.
- Poor: Significant lip asymmetry. Needs complete revision.
- Good: Nearly imperceptible at conversational distance. No treatment required.
- Fair: Tip asymmetry seen mostly on worm's eye tip. Rhinoplasty needed.
- Poor: Nasal asymmetry seen on anteroposterior view, at conversational distance, crooked nose. Reconstructive rhinoplasty needed, i.e., graft might be necessary to achieve correction.
For cleft palate repairs, the outcome was judged based on the integrity of the closure, i.e., presence or absence of fistula using calibrated and validated Vernier caliper.  Where there were difficulties in using the Vernier caliper in children, the fistula was measured on a wooden spatula by placing the spatula on the fistula and marking the fistula edges on the spatula and thereafter transferred the markings on the Vernier caliper for measurement.
The outcome was good when there was no postoperative fistula at the operative site, fair or poor, respectively, when the resultant fistula was less or more than 1 cm in greatest diameter.
Satisfaction with facial appearance and function was assessed qualitatively using a three point Likert scale, i.e., (1) very satisfied, (2) satisfied, and (3) not satisfied.
Data were analyzed using the SPSS for Windows (version 17.0; SPSS Inc., Chicago, IL, USA) statistical software package and presented in descriptive and tabular forms. Comparisons between variables were made to determine the pattern of association using Pearson's Chi-square test and Fisher's exact test. Statistical significance was used as appropriate and set at P ≤ 0.05.
| Results|| |
A total of 70 subjects were enrolled in this study with 40 females (57.1%) and 30 males (42.9%) (female :0 male = 0 1.3:1) [Table 1]. The age of the subjects at presentation ranged from the 1 day to 26 years. Majority of the study group were below 1 year of age (74.3%) (52) [Table 2].
Majority of the families 59 (84.3%) belong to the low socioeconomic class whereas 10 (14.3%) and 1 (1.4%) belonged to the middle and high socioeconomic class, respectively.
Nineteen (39.6%) of subjects were operated within the ages of 3 months for lip repair and 10 (45.5%) subjects after 18 months for palate repair [Table 3].
Clefts lip with or without alveolus/palate were the most commonly seen defects (77.1%) followed distantly by cleft of hard and soft palate (14.3%) whereas the least seen defect was isolated clefts of soft palate (8.6%) [Table 1]. The left side was the most commonly involved side (70.4%) in unilateral cleft lip with or without alveolus and unilateral CLP [Figure 1]. There was no positive family history of cleft in all the cases. Associated congenital anomalies were seen in 15.7% of cases.
|Figure 1: (a) Preoperative isolated cleft lip (b) Postoperative isolated cleft lip repair|
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|Table 3: Age of subjects at time of cleft repair and total surgeries done|
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Esthetic was the most common reason for presentation (37.7%). Seventy-seven primary cleft surgeries were done in 70 subjects; 48 (62.3%) and 29 (37.7%) were cheilorrhaphy and palatorrhaphy, respectively [Table 3]. Sixty-three subjects (90%) had undergone either cheilorrhaphy or palatorrhaphy whereas 7 subjects (10.0%) had both cheilorrhaphy and palatorrhaphy done consecutively at different times [Figure 2].
|Figure 2: (a) Preoperative cleft palate (b) Postoperative cleft palate repair|
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There was a good surgical outcome of 71.4% with an overwhelming parents/subjects satisfaction of 94.8% with the treatment outcome and a complication rate of 19.5%. In 12 cases (15.6%) in which surgical outcome was rated fair, the subjects or their parents were still very satisfied with the surgical outcome [Table 4].
|Table 4: Treatment outcome and subject/parent/ guardian satisfaction with management outcome|
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| Discussion|| |
The dominance of female in the study agrees with previous studies done in West Africa. ,,,,, However, it contrasts with some reports from Ghana and Nigeria that observed a male preponderance. , This present series observed a high frequency of cleft involving the lip , and also showed cleft of the palate as the least common cleft deformity. ,, These agree with several studies from Nigeria and beyond.
This current study revealed predominance of cheilorrhaphy over palatorrhaphy which is in concordance with earlier reports from West Africa sub-region. ,,, The reasons for this finding might be due to higher number of subjects that presented with cleft lip defect than cleft palate defect. ,,,, However, some workers declared that many patients and their families give more weight to esthetic than speech, hence, they present more for lip repair than that of palate.
The result of the study clearly indicates a high overall good treatment outcome comparable to findings from Nigeria and other European cleft centers.  This result might be a reflection of the competence of the center's cleft team. 
Evaluation of patient satisfaction once considered as a soft indicator has become an integral component of healthcare quality management and an important handle for improvement of care. , Kaoje et al. postulated that to guide/draft strategies that would improve healthcare services, identifying what patients' want in contrast to the perceptions and desires of the providers or administrators or policy makers is more invaluable.  Hence, client satisfaction evaluations are an indispensable mean of realizing this objective and amplifying the competitiveness of our cleft centers. The success and quality of cleft surgeries can be succinctly reflected by the level of patients' satisfactions with the treatment outcome. , However, assessing patient satisfaction is challenging owing to its multifaceted dimension. Determinants associated with satisfaction include outcome of care, patient sociodemographics, physical and psychological status, attitudes and expectation of medical care, and demeanor of the facility staff.
Ninety-five percent of these repairs were satisfactory to the patients or parents of the affected children compared with 89% reported from Jos, Nigeria.  Met expectation has been shown to be a potent predictor of patient satisfaction.  Therefore, cleft surgeons should strive to improve their technical skills in cleft repair.
Satisfaction with treatment outcome was generally high in this study, which is similar to many reports. ,, Interestingly, some subjects expressed satisfaction with the treatment outcome despite the fact that the surgical outcome was not rated good. Williams et al. 2001, Semb et al. 2005 and Nollet et al. 2007, in European studies have made similar observations. ,, Plausible reasons given for patients' satisfaction even with poor outcome include the fact that the treatment outcome might resonate with patient expectations or that the surgery itself was an improvement on the initial cleft presentation. , Other reasons could be that patients/parents have belief and profound respect for their care-givers, hence, finds it difficult to criticize their work. 
A study from a developing countries revealed that when client are respected and provider are polite that these have a strong predictive influence on satisfaction.  We also speculate that the free treatment received might have influenced their judgments, but we cannot determine the extent.
The study demonstrates some subjects express satisfaction with the treatment outcome despite unfavorable surgical outcome suggesting that in some cases the level of satisfaction is unrelated to the outcome.  Earlier studies also indicate that other variables have significant influence on client satisfaction. ,, Reports across Africa have disclosed that besides the competence of service providers, the attitude and behavior of other staff can sway the direction of patient satisfaction. ,, Patients place high premium on courtesy, respect, friendliness, and politeness from the clinical staff making communication and information trouble-free.  Furthermore, most patients respond favorably to complete, open, and frank pre-and post-operative discussions tinged with empathy and respect. Hence, these groups are more receptive irrespective of the surgical outcome and are more compliant with future treatments. 
However, sociodemographics determinants such as social status, gender, and age have poor correlation with client satisfaction. Anecdotally, parents/patients perceived that the surgery itself has ameliorated the stigma associated with CLP anomalies in spite of the complication.
Limitations of the study include the free nature of treatment and the African culture, which we suspect might influence our clients not to be too critical of the outcome.  Furthermore, patients' satisfaction with initial cleft appearance before surgery was not evaluated.
| Conclusions|| |
The present study showed a high patient satisfaction irrespective of treatment outcome possibly reflecting not only the technical competence of the cleft surgeons, but also the amiable performance of other supporting staff of the hospital.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
López-Palacio AM, Cerón-Zapata AM, Gómez DF, Dávila-Calle AP, Ojalvo-Arias MA. Nasal changes with nasoalveolar molding in Colombian patients with unilateral cleft lip and palate. Pediatr Dent 2012;34:239-44.
Filho JF, de Almeida AL. Aesthetic analysis of an implant-supported denture at the cleft area. Cleft Palate Craniofac J 2013;50:597-602.
de Buys Roessingh AS, Dolci M, Zbinden-Trichet C, Bossou R, Meyrat BJ, Hohlfeld J. Success and failure for children born with facial clefts in Africa: A 15-year follow-up. World J Surg 2012;36:1963-9.
Raposo-do-Amaral CE, Kuczynski E, Alonso N. Quality of life among children with cleft lips and palates: A critical review of measurement instruments. Bras J Plast Surg 2011;26:639-44.
Kaoje UA, Sambo MN, Oche MO, Saad A, Raji MO, Isah BA. Determinants of client satisfaction with family planning services in government health facilities in Sokoto, Northern Nigeria. Sahel Med J 2015;18:20-6.
Kirschner RE. Measuring Aesthetics Outcome in Cleft Lip Surgery. Presented at Pan-African Congress on Cleft Lip and Palate, Ibadan, Nigeria; 2006.
Diah E, Lo LJ, Yun C, Wang R, Wahyuni LK, Chen YR. Cleft oronasal fistula: A review of treatment results and a surgical management algorithm proposal. Chang Gung Med J 2007;30:529-37.
Adeola DS, Ononiwu CN, Eguma SA. Cleft lip and palate in northern Nigerian children. Ann Afr Med 2003;2:6-8.
Oluwasanmi JO, Adekunle OO. Congenital clefts of the face in Nigeria. Plast Reconstr Surg 1970;46:245-51.
Sowemimo GO. Cleft lip and palate in Nigerians. Niger Med J 1976;6:410-6.
Ademiluyi SA, Oyeneyin JO, Sowemimo GO. Associated congenital abnormalities in Nigeria children with cleft lip and palate. West Afr J Med 1989;8:135-8.
Olasoji HO, Dogo D, Obiano K, Yawe T. Cleft lip and palate in North Eastern Nigeria. Nig Q J Hosp Med 1997;7:209-13.
Ugboko V, Owotade F, Otuyemi O, Adejuyigbe O. Experience with cleft lip and palate patients seen in a Nigerian teaching hospital. Paediatr Dent J 1997;7:41-4.
Orkar KS, Ugwu BT, Momoh JT. Cleft lip and palate: The Jos experience. East Afr Med J 2002;79:510-3.
Donkor P, Plange-Rhule G, Amponsah EK. A prospective survey of patients with cleft lip and palate in Kumasi. West Afr J Med 2007;26:14-6.
Adeyemo WL, Ogunlewe MO, Desalu I, Ladeinde AL, Mofikoya BO, Adeyemi MO, et al.
Cleft deformities in adult and children aged over six years in Nigeria: Reasons for late presentation and management challenges. Clin Cosmet Investig Dent 2009;1:63-9. Available from: http://www.dovepress.com/content/63/1/69
. [Last accessed on 2010 Jan 26].
Aziz SR, Rhee ST, Redai I. Cleft surgery in rural Bangladesh: Reflections and experiences. J Oral Maxillofac Surg 2009;67:1581-8.
Fogh-Andersen P. Inheritance of Harelip and Cleft Palate. Copenhagen: Arnold Busck; 1942.
Iregbulem LM. The incidence of cleft lip and palate in Nigeria. Cleft Palate J 1982;19:201-5.
Onasanya PO. Unpublished work. Cleft Lip and Palate; A Prospective Study of Cases Seen and Treated at the University of Benin Teaching Hospital Over a 3 Years Period. A Part II Dissertation for the Partial Fulfillment of the Award of Fellowship of the Postgraduate Medical College of Nigeria; 2008.
Adeosun OO. Unpublished Work. Cleft Lip and Palate: A Prospective Study of Cases Seen and Treated at the University of Maiduguri Teaching Hospital, A Part II Dissertation for the Partial Fulfillment of the Award of Fellowship of the Postgraduate Medical College of Nigeria; May, 2003.
Nollet PJ, Kuijpers-Jagtman AM, Chatzigianni A, Semb G, Shaw WC, Bronkhorst EM, et al.
Nasolabial appearance in unilateral cleft lip, alveolus and palate: A comparison with Eurocleft. J Craniomaxillofac Surg 2007;35:278-86.
Sinko K, Jagsch R, Prechtl V, Watzinger F, Hollmann K, Baumann A. Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients. Cleft Palate Craniofac J 2005;42:355-61.
Leboeuf M. How to Win Customers and Keep them for Life. New York: Berkeley Publishing Group; 2000.
Urden LD. Patient satisfaction measurement: Current issues and implications. Outcomes Manag 2002;6:125-31.
Donabedian A. Exploration in quality assessment and monitoring: The Definition of Quality and Approaches to its Assessment. Vol. 1. Ann Arbor, MI: Health Administration Press; 1980.
Oosterkamp BC, Dijkstra PU, Remmelink HJ, van Oort RP, Goorhuis-Brouwer SM, Sandham A, et al.
Satisfaction with treatment outcome in bilateral cleft lip and palate patients. Int J Oral Maxillofac Surg 2007;36:890-5.
Khosla RK, Mabry K, Castiglione CL. Clinical outcomes of the Furlow Z-play for primary cleft palate repair. Cleft Palate Craniofac J 2008;45:501-10.
Williams AC, Bearn D, Mildinhall S, Murphy T, Sell D, Shaw WC, et al.
Cleft lip and palate care in the United Kingdom - The clinical standards advisory group (CSAG) study. Part 2: Dentofacial outcomes and patient satisfaction. Cleft Palate Craniofac J 2001;38:24-9.
Semb G, Brattstrom V, Molsted K, Prahl-Andersen B, Zuurbier P, Rumsey N, et al.
The Eurocleft Study: Intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 4: Relationship among treatment outcome, patient/parent satisfaction and the burden of care. Cleft Palate Craniofac J 2005;42:64-8.
Nollet PJ, Katsaros C, van′t Hof MA, Semb G, Shaw WC, Kuijpers-Jagtman AM. Treatment outcome after two-stage palatal closure in unilateral cleft lip and palate: A comparison with Eurocleft. Cleft Palate Craniofac J 2005;42:512-6.
Thompson AG, Suñol R. Expectations as determinants of patient satisfaction: Concepts, theory and evidence. Int J Qual Health Care 1995;7:127-41.
Mendoza Aldana J, Piechulek H, al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bull World Health Organ 2001;79:512-7.
Semb G, Shaw WC. The RPS: A six-center international study of treatment of clefts of the lip and palate: Part 4. Assessment of nasolabial appearance. Cleft Palate Craniofac J 1992;29:409-12.
Ruth EB, Charles K. The Quality of Family Planning and Antenatal Care Services in DISH and Comparison Districts in Uganda.MEASURE Evaluation Bulletin; 2001.
Agha S, Do M. The quality of family planning services and client satisfaction in the public and private sectors in Kenya. Int J Qual Health Care 2009;21:87-96.
Hutchinson PL, Do M, Agha S. Measuring client satisfaction and the quality of family planning services: A comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana. BMC Health Serv Res 2011;11:203.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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