Lessons Learned from a Single Institution's Eight Years of Experience with Early Cleft Lip Repair

Abstract

Background and Objectives: The traditional approach in managing wide cleft lip deformities involves presurgical nasoalveolar molding (NAM) therapy followed by surgical cleft lip repair between three and six months of age. This institution has implemented an early cleft lip repair (ECLR) protocol where infants undergo primary cleft lip repair between two and five weeks of age without NAM. This study aims to present this institution's ECLR repair protocol over the past eight years from 188 consecutive patients with unilateral or bilateral CL/P deformity. Materials and Methods: Retrospective review was conducted at Children's Hospital Los Angeles evaluating patients who underwent ECLR before three months of age and were classified as American Society of Anesthesiologists (ASA) class I or II from 2015-2022. Anthropometric analysis was performed, and pre- and postoperative photographs were evaluated to assess nasal and lip symmetry. Results: The average age at cleft lip repair after correcting for gestational age was 1.0 ± 0.5 months. Mean operative and anesthetic times were 120.3 ± 33.0 min and 189.4 ± 35.4, respectively. Only 2.1% (4/188) of patients had postoperative complications. Lip revision rates were 11.4% (20/175) and 15.4% (2/13) for unilateral and bilateral repairs, respectively, most of which were minor in severity (16/22, 72.7%). Postoperative anthropometric measurements demonstrated significant improvements in nasal and lip symmetry (p < 0.001). Conclusions: This analysis demonstrates the safety and efficacy of ECLR in correcting all unilateral cleft lip and nasal deformities of patients who were ASA classes I or II. At this institution, ECLR has minimized the need for NAM, which is now reserved for patients with bilateral cleft lip, late presentation, or comorbidities that preclude them from early repair. ECLR serves as a valuable option for patients with a wide range of cleft severity while reducing the burden of care.

Keywords: children; cleft lip; cleft lip and palate; cleft palate; humans; infants; maxilla; nasoalveolar molding; neonate.

Figure 1

Paradigm Shift in the Anesthesia Protocol for Early Cleft Lip Repair in relation to pivotal anesthesia studies: McCann et al. [34], Shukla et al. 2016 [35], and Miller et al. [36].

Figure 2

Preoperative photographs without surgical markings (left) and with surgical markings (right).

Figure 3

Annual proportion of unilateral versus bilateral cases among patients who underwent early cleft lip repair.

Figure 4

Distribution of the time elapsed from initial lip repair to secondary surgery among the twenty early cleft lip repair patients who required revisions.

Figure 5

Preoperative (left) and three-month postoperative (right) photographs of a patient with left unilateral incomplete isolated cleft lip who underwent repair at two weeks of age. Reproduced with permission from Hammoudeh et al. [4], Plastic and Reconstructive Surgery–Global Open; published by Wolters Kluwer Health, Inc., 2017.

Figure 6

Preoperative (left) and 19 month postoperative (right) photographs of a patient with left unilateral complete cleft lip and palate who underwent repair at 18 days of age. Reproduced with permission from Wlodarczyk JR et al. [3], Plastic and Reconstructive Surgery; published by Wolters Kluwer Health, Inc., 2022.

Figure 7

Preoperative (left), 42 month postoperative (middle and right) photographs of a patient with right unilateral complete cleft lip and palate who underwent repair at 13 days of age.