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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.