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Early repair for infants with cleft lip and nose
International Journal of Pediatric Otorhinolaryngology (2006) 70, 1785—1790
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Early repair for infants with cleft lip and nose Jiad N. Mcheik a,*, Pierre Sfalli b, Jean M. Bondonny b, Guillaume Levard a a
´diatrique, Centre Hospitalier Universitaire, Cite ´ Hospitalie `re de La Mile ´trie, Chirurgie Pe ˆpital Jean-Bernard B.P. 577, 86021 Poitiers Cedex, France Ho b ´diatrique, Ho ˆpital des Enfants, Centre Hospitalier Universitaire, Chirurgie Pe ´lie Raba-Le ´on, 33076 Bordeaux, France Place Ame Received 31 March 2006; received in revised form 29 May 2006; accepted 1 June 2006
KEYWORDS Cleft lip and nose; Early repair
Summary Objective: To study the results 10 years after early surgical cleft lip and nose repair. Patients and methods: We present the outcome of 123 early cleft lip repairs whose condition was managed in a multidisciplinary team according to a strict protocol. We give the observation results of operations of a single surgeon’s neonatal surgery over a 10-year period in term of aesthetic assessments and dental arch relationships. One hundred and twenty-three patients were operated on during the first 4 weeks of life; a subgroup of 40 child had been operated on at a week or less of age. Results: The results show good aesthetic assessments and dental relationships, with facial growth appropriate for the age. Conclusions: We are currently encouraging early cleft lip and nose repair in the fullterm baby as the good method of management of newborns with cleft. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The optimal time for cleft lip and nose repair is widely accepted to be between 2 and 6 months of age. This current practice is reinforced by the strong recommendations of the majority of authoritative texts on the subject of paediatric surgery in general and cleft lip and palate management specifically. * Corresponding author. Tel.: +33 5 49 44 42 44; fax: +33 5 49 44 38 20. E-mail address: [email protected] (J.N. Mcheik).
Our questioning of these precepts evolved from our own observations of involvement with cleft lip and palate surgery. Having been exposed to neonatal cleft lip and nose repair during training, we had always offered the opportunity for immediate repair to those mothers who wished it. We observed a great satisfaction on most of mothers when repair was accomplished before the baby was discharged from the hospital, during the first week of life. No particular difficulties were encountered when early repair was performed, and the results seemed to be as good as when surgery was delayed.
0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2006.06.004
1786
J.N. Mcheik et al.
Table 1 Type of cleft lip Type of cleft
Cleft lip Right
Early repair Associated cleft palate a
12 3
a
Cleft lip and alveolus Left 16
a
Bilateral 2
a
Right 29 74
a
Left 39
a
Total Bilateral 25
a
123 77
Side
2. Methods These consecutive series included 123 cleft lip and nose repairs performed by the same surgeon between November 1985 and December 1995. The age for operation being determined purely by when the infant was referred for surgery and the parent’s preference. All parents with prenatal diagnosis and early postnatal diagnosis opted for neonatal cleft lip and nose repair. Children with syndromes, late consultations or born prematurely were excluded. In our series, 123 patients were operated on during the first month of life (40 child were operated on during the first week). All of the clefts were closed primarily, and no lip adhesions were performed. The treatment schedule was uniform for all the patients and consisted of neonatal primary rhinocheiloplasty by classic Millard technique (without modifications). The palatoplasty was performed with simultaneous closure of the hard and soft palate and gingivoperiosteoplasty at 6 months. A palatal flap (Veau—Wardill procedure) was used for cleft palate closure. All types of clefts were included (Table 1). Preoperative orthopaedic treatment was not used. For the group, we noted 30 cleft lips with 3 cleft palates, 93 labio-alveolar clefts with 74 cleft palates. General endotracheal anaesthesia was employed in all patients. Inability to intubate, accidental extubation and apnae were noted. For all mothers was offered the choice of breast-feeding their babies immediately following cleft lip and nose repair. The bottle-feeding was used when the breast-feeding was difficult. The cup or syringe were used after palatoplasty. Babies were discharged from the hospital on the 3rd day. Hospital charts and clinic records were reviewed, and the operative morbidity and mortality were tabulated. The quality of the operative result had been evaluated by two plastic paediatric senior surgeons in terms of whether or not the lip and nose needed a subsequent revision or if the initial repair was judged to be satisfactory. We systematically carry out the photographs before and after surgery. The anatomical structures of the lip and the nose were analysed by both surgeons. We noted the nasal form, the deviation of the nose, the lip form and the
facial profile. The facial growth and dental relationships were evaluated by conventional lateral cephalometric radiographs and dental casts. The orthodontic treatment for patients consisted in a palatal device for moulding and positioning the alveolar processes. During the eruption of permanent teeth, a removable orthodontic appliance was used to prevent collapse of the dental arch and to correct dental malpositions. Then the fixed orthodontic appliances in order to form the dental arches in the permanent dentition was used.
Fig. 1 (a) Early unilateral cleft lip repair, (b) a boy with a repaired unilateral cleft lip 1 month after.
Early repair for infants with cleft lip and nose The study was conducted according to French law with the agreement of a consultative ethics committee. A consent form was signed by the patients’ parents.
3. Results One hundred and twenty-three patients had been operated on their first month of life (average of 13.5 days). At the time of the study, the youngest child was 9 and the oldest was 19 years old (average of 13 years-old). Those patients who were operated the first week presented the same results as the entire group. There were no operative deaths and no particular anaesthetic difficulties (inability to intubate, accidental extubation, aspiration). No particular surgical difficulties were met when early repair was
Fig. 2 (a) Early unilateral cleft lip and alveolus repair, (b) a girl with a repaired unilateral cleft lip and alveolus.
1787 performed, and the immediate results seemed good (Figs. 1—3). In one case (bilateral cleft lip and palate) a total postoperative white lip dehiscence was noted at 10 days of live, we realized the revision by Millard procedure again. We do not have any suture abscess. We noted an excellent aesthetic quality of the lip and nose repair (symmetrical cupid’s bow, naturalappearing philtral columns, a philtrum dimple, a well-aligned continuous white roll, and minimal visible scar in the line of the philtral column, ample vermilion and mucosa with a slight central tubercle, normally functioning orbicularis oris muscle with harmonious symmetry, symmetry of the nostrils and nostril sills) (Figs. 4 and 5). In our series 35 cleft lips out of 123 cleft lips (28%) needed minor surgical revision (Table 2), the surgical minor revision procedure was realized between 9 months and 4 years old (average of 20 months). For this group, 35% of patients with bilateral clefts, 34% of patients with labio-alveolar clefts and 13% of patients with cleft lip required minor adjustment of the lip and nose. For the minor surgery, there
Fig. 3 (a) Early cleft lip and palate repair, (b) cleft lip and palate repair 1 week after.
1788
J.N. Mcheik et al.
Fig. 5 (a) Early unilateral cleft lip and alveolus repair, (b) a girl with a repaired unilateral cleft lip and alveolus. Fig. 4 (a) Early unilateral cleft lip repair, (b) a boy with a repaired unilateral cleft lip 4 years after.
were 11% adjustments to both alar cartilage and nasal tip, 11% adjustments to white lip and 78% adjustments to vermilion and vestibule. We used the expander for palatal expansion in 50% of the
Table 2 Surgical adjustments of cleft lip Minor surgery for 35 patients (28%)
Cleft lip (%)
Unilateral labio-alveolar cleft (%)
Bilateral labio-alveolar cleft (%)
Total minor revision Nasal surgery Lip surgery
13 0 9
34 2 30
53 9 50
Early repair for infants with cleft lip and nose patients with clefts have a tendency to maxillary collapse and hypoplasia (class II). Most patients, tending towards class I 2 years after.
4. Discussion Semb et al. [1] reported that the register of the Eurocleft biomed II Project, although incomplete of publication, consisted of 178 cleft teams with 171 different therapeutic protocols for treating patients with unilateral cleft lip and palate. Lewin [2] published the results of a questionnaire sent to all active and candidate members of the American Society of Plastic and Reconstructive surgeons in the United States and Canada and summarized the issue by stating that ‘‘a widely accepted time for the repair of the lip is between six and 12 weeks’’. Since that time, the principal texts dealing with cleft lip and palate management have totally supported the concept of delaying repair for several weeks. The reasoning were based on three main facts: the anaesthetic risk is lower than in neonatal period; that the aesthetic surgical result will be better when the structures are larger; and psychological acceptance of the baby and its appearance will be enhanced by a period of ‘‘living with the defect.’’ Wilhelmsen et al. [3] urged delaying surgery until the child weighed at least 10 pounds, had a haemoglobin of at least 10 g, and a white cell count of less than 10,000. If these guidelines were not observed, the postoperative complication rate was five times higher than when their criteria were met. Stark [4] in plastic surgery and cleft lip and palate, recommended cheiloplasty ‘‘as soon as possible after the first day of life’’, pointing out that ‘‘ the first fortnight is the safest time for surgery,’’ and he observed that the lip grows less than 2 mm of vertical height in the first 3 months of life, casting doubt on the concept that larger structures make easier the surgery. Cannon [5], writing a ‘‘Medical Intelligence’’ editorial for the New England Journal of Medicine, stated that ‘‘the operation . . . may be done within the first 24 h if the baby is healthy in every other respect ‘‘and noted that’’ with proper anaesthesia and adequate supportive treatment, the operation offers no bigger risk than one made several weeks later.’’ Bromley et al. [6], reviewing a 15-years series of cleft lip repairs at the New York Hospital, found no bigger incidence of operative morbidity when surgery was performed in the first week of life than when delayed. Weatherley-White et al. [7], did not note any operative death with 49 patients operated early for cleft lip and there were no statistically significant differences in anaesthetic complication rate between 49 patients operated on
1789 during the 3 weeks of life and 51 patients operated at an older age. These findings are supported by some studies reported in the anaesthetic literature [8—10]. Our study seems to be in accordance with these last points of view. Morbidity, principally anaesthetic-related, did not occur more frequently when surgery was performed in the first month of life than later. In our series no prematurely born infants were operated on before their normal gestational age, any infant was operated with weight less than 2000 g. Since 1985, there have been no anaesthetic complications during cleft lip and nose repair at any age. The ultimate goal of cleft lip surgery is, of course, to produce a lip which looks like as closely as possible to the normal. Numerous critical comparative assessments of various types of procedures have used this yardstick as the principal criterion for success. In these series, the operating surgeon was the same one during 10 years and the operative technique was standard Millard procedure. If one accepts the premise that the need for minor adjustments is a valid dividing line between ‘‘acceptable’’ and ‘‘unacceptable’’ results, then it is clear from our study that very early surgery does not jeopardize the end product and does not increase the likelihood of requiring a second operation. Weatherley-White et al. [7] with 49 patients operated early, 48% of cases required revision and 51 patients operated late, 44% of cases required revision. He noted, the necessity of revision for more dependant on the cleft type than the age of the child at surgery. In his series, virtually all the infants with bilateral clefts required adjustments of the lip and nose; children with labio-alveolar clefts were more likely to need adjustments than those children with cleft lip. The influence of surgery on growth of the facial skeleton is an important factor in cleft surgery. So many authors have reported growth disturbances after surgical therapy of cleft lip, palate and alveolus. Graber et al. [11] reported on reduction in midface growth and maxillary region after closure of alveolar clefts. Law et al. [12], Hagerty et al. [13], Bardach et al. [14], Retsilla et al. [15] and Pruzansky et al. [16] described disturbances in midface growth as a consequence of the closure of the cleft lip. Bardach et al. [17] and Ross [18] showed that the method of lip closure had no significant effect on the extent of the growth disturbance. In our opinion, the main reason for these patients to have better maxillary morphology is the primary surgical reparation with a strict orthodontic treatment. In the management of children with unilateral or bilateral cleft lip and palate, adherence to a strict multidisciplinary protocol and the use of primary surgical techniques that restore function of all
1790 the involved structures, has led to an intermediate outcome that calls for the minimum future intervention and enables these children to reach a near normal final outcome in terms of appearance, dental and craniofacial relationships. The psychological status of the mothers immediately after delivery was more seriously affected by a cleft that was visible rather than the invisible type. Natsume et al. [19], noted the reaction of 100 mothers whose children have been treated between 1976 and 1987. The questionnaire revealed that the mothers thought about suicide. In our department, mothers expressed a preference for neonatal repair and showed a high satisfaction for the result [20].
5. Conclusions The neonatal repair carries minimal morbidity, can give good results and offer distinct advantages to the parents and child [21]. In the absence of definitive evidence of differences in physical outcome between early and later repair, parental preferences should routinely be considered in deciding the timing of this procedure [22]. In the full-term baby with cleft lip and nose without associated malformations, we are currently encouraging early repair.
References [1] G. Semb, W.C. Shaw, Facial growth after different methods of surgical intervention in patients with cleft lip and palate, Acta Odontol. Scand. 56 (1998) 352—355. [2] M.L. Lewin, Management of cleft lip and palate in the united states and Canada, Plast. Reconstr. Surg. 33 (1964) 383. [3] H.R. Wilhelmsen, R.H. Musgrave, Complications of cleft lip surgery, Cleft Palate J. 3 (1966) 223. [4] R.B. Stark, Cleft Palate, Hoeber, New York, 1968. [5] B. Cannon, Current concepts: unilateral cleft lip, N. Engl. J. Med. 277 (1967) 583—585. [6] G.S. Bromley, K.O. Rothaus, D. Goulian, Cleft lip: morbidity and mortality in early repair, Ann. Plast. Surg. 10 (1983) 214—217.
J.N. Mcheik et al. [7] R.C.A. Weatherley-White, D.P. Kuehn, P. Mirett, J.I. Gilman, C.C. Weatherley-White, Early repair and breast-feeding for infants with cleft lip, Plast. Reconstr. Surg. 79 (1987) 879— 885. [8] J. Lerman, S. Robinson, M.M. Willis, G.A. Gregory, Anesthetic requirements for halotane in young children 0—1 month and 1—6 months of age, Anesthesiology 59 (1983) 421—424. [9] L.M.P. Liu, C.J. Cote, N.G. Goudsouzion, J.F. Ryan, S. Firestone, D.F. Dedrick, P.L. Liu, I.D. Todres, Life threatening apnea in infants recovering from anesthesia, Anesthesiology 59 (1983) 506—510. [10] D.J. Steward, Preterm infants are more prone to complications following minor surgery than are term infant, Anesthesiology 56 (1982) 304—306. [11] T. Graber, Craniofacial maorphology in cleft palate and cleft lip deformities, Surg. Gynecol. Obst. 88 (1949) 359—406. [12] F. Law, J. Fulton, Unoperated oral clefts at maturation, Am. J. Public Health 11 (1959) 1517—1524. [13] R.F. Hagerty, M.J. Hill, Facial growth and dentition in the unoperated cleft palate, J. Dent. Res. 42 (1963) 412—420. [14] J. Bardach, W. Partyka, H. Plewinska, Influence of Different Operative Methods on the Occlusion in Cleft Lip and Palate Children, Polish Institute of Medical Publications, 1973. [15] V. Retsila, S. Alhopuro, P. Laine, R. Ranta, Closure of the physiological cleft upper lip in growing rabbits: an example of the effect of the soft tissue changes on jaw growth, Porc. Finn. Dent. Soc. 69 (1973) 217—224. [16] S. Pruzansky, H. Friede, Two sisters with unoperated bilateral cleft lip and palate, age 6 and 4 years, Br. J. Plast. Surg. 28 (1975) 251—257. [17] J. Bardach, K.J. Eisbach, The influence of primary unilateral cleft lip repair on facial growth, Cleft Palate J. 14 (1977) 88—94. [18] R.B. Ross, Treatment variables affecting facial growth in unilateral cleft lip and palate. Techniques of palate repair, Cleft Palate J. 24 (1987) 3—8. [19] N. Natsume, T. Suzuki, T. Kawai, Maternal reactions to the birth of a child with cleft lip and/or palate, Plast. Reconstr. Surg. 9 (1987) 1003—1004. [20] J.N. Mcheik, G. Levard, Neonatal cleft lip repair: psychological impact on mothers, Archives de Pe ´diatrie 13 (2006) 346—351. [21] E. Freedlander, M.H. Webster, R.B. Lewis, M. Blair, S.L. Knight, A.I. Brown, Neonatal cleft lip repair in Ayrshire; a contribution to the debate, Br. J. Plast. Surg. 43 (1990) 197— 202. [22] P. Slade, D.J. Emerson, E. Freedlander, A longitudinal comparison of the psychological impact on mothers of neonatal and 3 month repair of cleft lip, Br. J. Plast. Surg. 52 (1999) 1—5.
www.elsevier.com/locate/ijporl
Early repair for infants with cleft lip and nose Jiad N. Mcheik a,*, Pierre Sfalli b, Jean M. Bondonny b, Guillaume Levard a a
´diatrique, Centre Hospitalier Universitaire, Cite ´ Hospitalie `re de La Mile ´trie, Chirurgie Pe ˆpital Jean-Bernard B.P. 577, 86021 Poitiers Cedex, France Ho b ´diatrique, Ho ˆpital des Enfants, Centre Hospitalier Universitaire, Chirurgie Pe ´lie Raba-Le ´on, 33076 Bordeaux, France Place Ame Received 31 March 2006; received in revised form 29 May 2006; accepted 1 June 2006
KEYWORDS Cleft lip and nose; Early repair
Summary Objective: To study the results 10 years after early surgical cleft lip and nose repair. Patients and methods: We present the outcome of 123 early cleft lip repairs whose condition was managed in a multidisciplinary team according to a strict protocol. We give the observation results of operations of a single surgeon’s neonatal surgery over a 10-year period in term of aesthetic assessments and dental arch relationships. One hundred and twenty-three patients were operated on during the first 4 weeks of life; a subgroup of 40 child had been operated on at a week or less of age. Results: The results show good aesthetic assessments and dental relationships, with facial growth appropriate for the age. Conclusions: We are currently encouraging early cleft lip and nose repair in the fullterm baby as the good method of management of newborns with cleft. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The optimal time for cleft lip and nose repair is widely accepted to be between 2 and 6 months of age. This current practice is reinforced by the strong recommendations of the majority of authoritative texts on the subject of paediatric surgery in general and cleft lip and palate management specifically. * Corresponding author. Tel.: +33 5 49 44 42 44; fax: +33 5 49 44 38 20. E-mail address: [email protected] (J.N. Mcheik).
Our questioning of these precepts evolved from our own observations of involvement with cleft lip and palate surgery. Having been exposed to neonatal cleft lip and nose repair during training, we had always offered the opportunity for immediate repair to those mothers who wished it. We observed a great satisfaction on most of mothers when repair was accomplished before the baby was discharged from the hospital, during the first week of life. No particular difficulties were encountered when early repair was performed, and the results seemed to be as good as when surgery was delayed.
0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2006.06.004
1786
J.N. Mcheik et al.
Table 1 Type of cleft lip Type of cleft
Cleft lip Right
Early repair Associated cleft palate a
12 3
a
Cleft lip and alveolus Left 16
a
Bilateral 2
a
Right 29 74
a
Left 39
a
Total Bilateral 25
a
123 77
Side
2. Methods These consecutive series included 123 cleft lip and nose repairs performed by the same surgeon between November 1985 and December 1995. The age for operation being determined purely by when the infant was referred for surgery and the parent’s preference. All parents with prenatal diagnosis and early postnatal diagnosis opted for neonatal cleft lip and nose repair. Children with syndromes, late consultations or born prematurely were excluded. In our series, 123 patients were operated on during the first month of life (40 child were operated on during the first week). All of the clefts were closed primarily, and no lip adhesions were performed. The treatment schedule was uniform for all the patients and consisted of neonatal primary rhinocheiloplasty by classic Millard technique (without modifications). The palatoplasty was performed with simultaneous closure of the hard and soft palate and gingivoperiosteoplasty at 6 months. A palatal flap (Veau—Wardill procedure) was used for cleft palate closure. All types of clefts were included (Table 1). Preoperative orthopaedic treatment was not used. For the group, we noted 30 cleft lips with 3 cleft palates, 93 labio-alveolar clefts with 74 cleft palates. General endotracheal anaesthesia was employed in all patients. Inability to intubate, accidental extubation and apnae were noted. For all mothers was offered the choice of breast-feeding their babies immediately following cleft lip and nose repair. The bottle-feeding was used when the breast-feeding was difficult. The cup or syringe were used after palatoplasty. Babies were discharged from the hospital on the 3rd day. Hospital charts and clinic records were reviewed, and the operative morbidity and mortality were tabulated. The quality of the operative result had been evaluated by two plastic paediatric senior surgeons in terms of whether or not the lip and nose needed a subsequent revision or if the initial repair was judged to be satisfactory. We systematically carry out the photographs before and after surgery. The anatomical structures of the lip and the nose were analysed by both surgeons. We noted the nasal form, the deviation of the nose, the lip form and the
facial profile. The facial growth and dental relationships were evaluated by conventional lateral cephalometric radiographs and dental casts. The orthodontic treatment for patients consisted in a palatal device for moulding and positioning the alveolar processes. During the eruption of permanent teeth, a removable orthodontic appliance was used to prevent collapse of the dental arch and to correct dental malpositions. Then the fixed orthodontic appliances in order to form the dental arches in the permanent dentition was used.
Fig. 1 (a) Early unilateral cleft lip repair, (b) a boy with a repaired unilateral cleft lip 1 month after.
Early repair for infants with cleft lip and nose The study was conducted according to French law with the agreement of a consultative ethics committee. A consent form was signed by the patients’ parents.
3. Results One hundred and twenty-three patients had been operated on their first month of life (average of 13.5 days). At the time of the study, the youngest child was 9 and the oldest was 19 years old (average of 13 years-old). Those patients who were operated the first week presented the same results as the entire group. There were no operative deaths and no particular anaesthetic difficulties (inability to intubate, accidental extubation, aspiration). No particular surgical difficulties were met when early repair was
Fig. 2 (a) Early unilateral cleft lip and alveolus repair, (b) a girl with a repaired unilateral cleft lip and alveolus.
1787 performed, and the immediate results seemed good (Figs. 1—3). In one case (bilateral cleft lip and palate) a total postoperative white lip dehiscence was noted at 10 days of live, we realized the revision by Millard procedure again. We do not have any suture abscess. We noted an excellent aesthetic quality of the lip and nose repair (symmetrical cupid’s bow, naturalappearing philtral columns, a philtrum dimple, a well-aligned continuous white roll, and minimal visible scar in the line of the philtral column, ample vermilion and mucosa with a slight central tubercle, normally functioning orbicularis oris muscle with harmonious symmetry, symmetry of the nostrils and nostril sills) (Figs. 4 and 5). In our series 35 cleft lips out of 123 cleft lips (28%) needed minor surgical revision (Table 2), the surgical minor revision procedure was realized between 9 months and 4 years old (average of 20 months). For this group, 35% of patients with bilateral clefts, 34% of patients with labio-alveolar clefts and 13% of patients with cleft lip required minor adjustment of the lip and nose. For the minor surgery, there
Fig. 3 (a) Early cleft lip and palate repair, (b) cleft lip and palate repair 1 week after.
1788
J.N. Mcheik et al.
Fig. 5 (a) Early unilateral cleft lip and alveolus repair, (b) a girl with a repaired unilateral cleft lip and alveolus. Fig. 4 (a) Early unilateral cleft lip repair, (b) a boy with a repaired unilateral cleft lip 4 years after.
were 11% adjustments to both alar cartilage and nasal tip, 11% adjustments to white lip and 78% adjustments to vermilion and vestibule. We used the expander for palatal expansion in 50% of the
Table 2 Surgical adjustments of cleft lip Minor surgery for 35 patients (28%)
Cleft lip (%)
Unilateral labio-alveolar cleft (%)
Bilateral labio-alveolar cleft (%)
Total minor revision Nasal surgery Lip surgery
13 0 9
34 2 30
53 9 50
Early repair for infants with cleft lip and nose patients with clefts have a tendency to maxillary collapse and hypoplasia (class II). Most patients, tending towards class I 2 years after.
4. Discussion Semb et al. [1] reported that the register of the Eurocleft biomed II Project, although incomplete of publication, consisted of 178 cleft teams with 171 different therapeutic protocols for treating patients with unilateral cleft lip and palate. Lewin [2] published the results of a questionnaire sent to all active and candidate members of the American Society of Plastic and Reconstructive surgeons in the United States and Canada and summarized the issue by stating that ‘‘a widely accepted time for the repair of the lip is between six and 12 weeks’’. Since that time, the principal texts dealing with cleft lip and palate management have totally supported the concept of delaying repair for several weeks. The reasoning were based on three main facts: the anaesthetic risk is lower than in neonatal period; that the aesthetic surgical result will be better when the structures are larger; and psychological acceptance of the baby and its appearance will be enhanced by a period of ‘‘living with the defect.’’ Wilhelmsen et al. [3] urged delaying surgery until the child weighed at least 10 pounds, had a haemoglobin of at least 10 g, and a white cell count of less than 10,000. If these guidelines were not observed, the postoperative complication rate was five times higher than when their criteria were met. Stark [4] in plastic surgery and cleft lip and palate, recommended cheiloplasty ‘‘as soon as possible after the first day of life’’, pointing out that ‘‘ the first fortnight is the safest time for surgery,’’ and he observed that the lip grows less than 2 mm of vertical height in the first 3 months of life, casting doubt on the concept that larger structures make easier the surgery. Cannon [5], writing a ‘‘Medical Intelligence’’ editorial for the New England Journal of Medicine, stated that ‘‘the operation . . . may be done within the first 24 h if the baby is healthy in every other respect ‘‘and noted that’’ with proper anaesthesia and adequate supportive treatment, the operation offers no bigger risk than one made several weeks later.’’ Bromley et al. [6], reviewing a 15-years series of cleft lip repairs at the New York Hospital, found no bigger incidence of operative morbidity when surgery was performed in the first week of life than when delayed. Weatherley-White et al. [7], did not note any operative death with 49 patients operated early for cleft lip and there were no statistically significant differences in anaesthetic complication rate between 49 patients operated on
1789 during the 3 weeks of life and 51 patients operated at an older age. These findings are supported by some studies reported in the anaesthetic literature [8—10]. Our study seems to be in accordance with these last points of view. Morbidity, principally anaesthetic-related, did not occur more frequently when surgery was performed in the first month of life than later. In our series no prematurely born infants were operated on before their normal gestational age, any infant was operated with weight less than 2000 g. Since 1985, there have been no anaesthetic complications during cleft lip and nose repair at any age. The ultimate goal of cleft lip surgery is, of course, to produce a lip which looks like as closely as possible to the normal. Numerous critical comparative assessments of various types of procedures have used this yardstick as the principal criterion for success. In these series, the operating surgeon was the same one during 10 years and the operative technique was standard Millard procedure. If one accepts the premise that the need for minor adjustments is a valid dividing line between ‘‘acceptable’’ and ‘‘unacceptable’’ results, then it is clear from our study that very early surgery does not jeopardize the end product and does not increase the likelihood of requiring a second operation. Weatherley-White et al. [7] with 49 patients operated early, 48% of cases required revision and 51 patients operated late, 44% of cases required revision. He noted, the necessity of revision for more dependant on the cleft type than the age of the child at surgery. In his series, virtually all the infants with bilateral clefts required adjustments of the lip and nose; children with labio-alveolar clefts were more likely to need adjustments than those children with cleft lip. The influence of surgery on growth of the facial skeleton is an important factor in cleft surgery. So many authors have reported growth disturbances after surgical therapy of cleft lip, palate and alveolus. Graber et al. [11] reported on reduction in midface growth and maxillary region after closure of alveolar clefts. Law et al. [12], Hagerty et al. [13], Bardach et al. [14], Retsilla et al. [15] and Pruzansky et al. [16] described disturbances in midface growth as a consequence of the closure of the cleft lip. Bardach et al. [17] and Ross [18] showed that the method of lip closure had no significant effect on the extent of the growth disturbance. In our opinion, the main reason for these patients to have better maxillary morphology is the primary surgical reparation with a strict orthodontic treatment. In the management of children with unilateral or bilateral cleft lip and palate, adherence to a strict multidisciplinary protocol and the use of primary surgical techniques that restore function of all
1790 the involved structures, has led to an intermediate outcome that calls for the minimum future intervention and enables these children to reach a near normal final outcome in terms of appearance, dental and craniofacial relationships. The psychological status of the mothers immediately after delivery was more seriously affected by a cleft that was visible rather than the invisible type. Natsume et al. [19], noted the reaction of 100 mothers whose children have been treated between 1976 and 1987. The questionnaire revealed that the mothers thought about suicide. In our department, mothers expressed a preference for neonatal repair and showed a high satisfaction for the result [20].
5. Conclusions The neonatal repair carries minimal morbidity, can give good results and offer distinct advantages to the parents and child [21]. In the absence of definitive evidence of differences in physical outcome between early and later repair, parental preferences should routinely be considered in deciding the timing of this procedure [22]. In the full-term baby with cleft lip and nose without associated malformations, we are currently encouraging early repair.
References [1] G. Semb, W.C. Shaw, Facial growth after different methods of surgical intervention in patients with cleft lip and palate, Acta Odontol. Scand. 56 (1998) 352—355. [2] M.L. Lewin, Management of cleft lip and palate in the united states and Canada, Plast. Reconstr. Surg. 33 (1964) 383. [3] H.R. Wilhelmsen, R.H. Musgrave, Complications of cleft lip surgery, Cleft Palate J. 3 (1966) 223. [4] R.B. Stark, Cleft Palate, Hoeber, New York, 1968. [5] B. Cannon, Current concepts: unilateral cleft lip, N. Engl. J. Med. 277 (1967) 583—585. [6] G.S. Bromley, K.O. Rothaus, D. Goulian, Cleft lip: morbidity and mortality in early repair, Ann. Plast. Surg. 10 (1983) 214—217.
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