Outcomes of primary unilateral cheiloplastyin same-day surgical settings

Khyber Teaching Hospital Peshawar, Pakistan

Mansoor Khan, M.B.B.S, F.C.P.S (Plast.)

Outcomes of primary unilateral cheiloplastyin same-day surgical settings

ne of the most common congenital craniofacial deformities…o

•Shapira Y, Haklai Z, Blum I et al. Prevalence of non-syndromic orofacial clefts among Jews and Arabs, by type, site, gender and geography: a multi-center study in Israel. IMAJ 2014 Dec;16(12):759-63.

•Kling RR, Taub PJ, Ye X et al. Oral clefting in china over the last decade: 205,679 patients.PlastReconstrSurg Glob Open 2014;2(10):e236.

ncidence is highest in Asians (1/500), followed by Caucasians (1/1000) and Africans (1/2500)I

•Shapira Y, Haklai Z, Blum I et al. Prevalence of non-syndromic orofacial clefts among Jews and Arabs, by type, site, gender and geography: a multi-center study in Israel. IMAJ 2014 Dec;16(12):759-63.

•Kling RR, Taub PJ, Ye X et al. Oral clefting in china over the last decade: 205,679 patients.PlastReconstrSurg Glob Open 2014;2(10):e236.

eported incidence in Pakistan is 1.46 per 1000 live births R

•Elahi MM, Jackson IT, Elahi O et al. Epidemiology of cleft lip and cleft palate in P•akistan. PlastReconstSurg 2004;113:1548-55.

urgical repairs dates back to China’s Qin Dynasty (221-206 BC)S

•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.

Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.

Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

ose & Thompson introduced the basic

technique to build on in early 20th centuryR

uadrilateral/triangular flaps & rotation advancement incorporates lateral lip tissue into the medial lip segment, a concept introduced by Mirault

•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.

Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

Q

c Comb, Cutting & Tajima provided the concept of incorporating primary rhinoplasty

with the lip repair M•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft

lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

or aesthetic evaluation of lip repair, preoperative severity and multiple postoperative nasolabial anthropometric

parameters are considered, making it a challenging job

F

ingle-day surgery is becoming more common for an increasing

number of procedures in different surgical specialities

•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466. •Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the need for routine admission following primary

cleft palate repair: An analysis of 100 consecutive cases. Plast Reconstr Surg.2015;136(4):502e-10e.

S

inancial benefits, fewer SSI rates, expedites patients’ postoperative recovery in the home environment & avoids the psychological effects

of hospitalization

•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466. •Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the need for routine admission following primary

cleft palate repair: An analysis of 100 consecutive cases. Plast Reconstr Surg.2015;136(4):502e-10e.

f

lastic surgery procedures, especially cleft lip and palate

repair, have been no exception to this trend for single-day surgery to become more common

•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466. •Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the need for routine admission following primary

cleft palate repair: An analysis of 100 consecutive cases. Plast Reconstr Surg.2015;136(4):502e-10e.

P

im; To evaluate the preoperative severity and postoperative outcomes of single-day primary unilateral cleft nasoslabial repairA

bjectives: shortening the patients’ hospital stay and decreasing their economic burden on the healthcare facility.O

Methodology

Conducted from January 2011 to December 2014

less than 3 months of age, syndromic associations & co-morbidities, lack of

competent parents/relatives, psychologically unstable, or lived far

from the hospital

EXCLUSION CRITERIA

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

Pre-op evaluation

Mild: Incomplete cleft lip

Moderate: Complete/not wide(Some tissue contact at rest )

Severe: Complete/wide(No tissue contact)

Surgical techniques..

Fisher’s technique

Rotation advancement with uni-limb z-plasty

(Noordhoff’s)

Semi-open rhinoplasty (inverted “U” incision) & Tajima suspension stitch

Patients were kept in OT till maintenance of oxygen saturation

without supplemental oxygen, breathing without difficulty & responsive to verbal

stimulus

post operative recovery/discharge

•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.

atients were monitored in the recovery room till fulfilment of discharge criterias: full alertness, ambulation, pain free & alimentationP•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.

who could drive him home and supervise him for 24 hours with clear verbal & written instructions for contacting the surgical staff in case of pain/vomiting (refractory to the prescribed medications), bleeding, fever, infection, or other concerns.

Discharged under the supervision of at least one mentally/physically capable

escort

Post-op Nasolabial Evaluation System

(NES)…?

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

1. Symmetry at the Cupid’s bow; Distance from the base of the columella to bow’s peak.

2. Nasal symmetry; The shape of nostril, the dome of nose and the distance from the midline of the columella to the alar base.

3. Symmetry of lateral lip; Distance from the alar base to white roll and angle of white roll.

4. Symmetry of the free vermilion;Two measurements should be considered; distance from the Cupid’s bow to free vermilion and from the columella base to free vermilion.

5. The wet and dry vermillion relationship.

Symmetry at the Cupid’s bow; Distance from the base of the columella to bow’s peak.

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

1.

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

Nasal symmetry; The shape of nostril, the dome of nose and the distance from the

midline of the columella to the alar base.

2.

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

Symmetry of lateral lip; Distance from the alar base to white roll and angle of white roll.3.

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

Symmetry of the free vermilion;Two measurements should be considered; distance from the Cupid’s bow to free vermilion and from the columella base to free

vermilion.4.

•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf

The wet and dry vermillion relationship (red-line)

5.

0 ~ Poor 1~ Fair 2 ~ Good

> 2mm 1-2mm < 1mm

Symmetry at the Cupid’s bow; 1

0 ~ Poor 1~ Fair 2 ~ Good

Grossly asymmetrical

Symmetrical size but not shape

Size & shape symmetrical

0 ~ Poor 1~ Fair 2 ~ Good Nasal Symmetry2

Severe asymmetrical

Some asymmetry

Goodsymmetrical

0 ~ Poor 1~ Fair 2 ~ Good

Symmetry of the lateral lip3

0 ~ Poor 1~ Fair 2 ~ Good

clear notch & asymmetry

small notch & bulge

ContinuousSmooth curved

line

Symmetry at of free vermilion; 4

0 ~ Poor 1~ Fair 2 ~ Good

Severe discrepancy some mismatch Good red line

Wet & dry vermillion relationship/redline5

Good 8–10Fair 5–7

Poor 0–4

Outcome score:

Results…

23 primary unilateral cleft lip patients were

included4

ale to female ratio was1.6:1

m

ge from 3 months to 384 monthsa

44.9% mild, 14.9% moderate, and 40.2% severe

Fisher’s anatomical subunit approximation technique was the most

common procedure, followed by Noordhoff’s

technique

postoperative outcome was good in 89.8% of cases,

fair in 9.9% of cases, and poor in 0.2% of

cases

symmetry of the nose was good in 57.4%,

satisfactory in 38.3% & unsatisfactory in 4.3%

of cases

Cleft lip severity versus postoperative outcomes.

Postop.

outcome

Severity of cleft lip

TotalMild Moderate Severe

Poor 0 0 1 1

Fair 3 2 37 42

Good 187(98.4%) 61(96.8%) 132(77.6%) 380

Total 190 63 170 423

Fisher’s repair, 89.4% good overall outcomes,

good Cupid’s bow symmetry 85.4%

Noordhoff’s technique100% good outcomes &

good Cupid’s bow symmetry But results were not statistically significant due to small sample

size in Noordhoff’s group during the study period

Symmetry of nasal deformity

Because we switched from closed technique to semi-open with inverted U incision

Complications rate was 1.18% (n=5) most common was stitch sinus 0.71%,

nasal hematoma (0.24%) LRTI in (0.24%).

Average hospital stay 7.5 hours (6–9 hours).

Hospital cost was reduced by 19% (3800 PKR) Re-admission rate

was 0.24% compared to the reductions of 15%–30% and 40% that have been

reported for the USA and UK, respectively

Cases..

Conclusions..

Mild and severe unilateral cleft lip were the most common deformities

Fisher’s anatomical subunit approximation technique was performed, with satisfactory

postoperative outcomes

Improvement in results was observed over the study period by

including Noordhoff’s technique in the procedure for severe forms

Refinements in the cleft rhinoplasty techniques over

the course of the study improved the results

Single-day primary unilateral cleft cheiloplasty is a cost-effective procedure that did not pose an

additional risk of complications.