Healthcare use and direct medical costs in a cleft lip and palate population: an analysis of observed and protocolized care and costs.

This study was performed to describe observed healthcare utilization and medical costs for patients with a cleft, compare these costs to the expected costs based on the treatment protocol, and explore the additional costs of implementing the International Consortium for Health Outcomes Measurement (ICHOM) Standard Set for Cleft Lip and Palate (CL/P). Forty patients with unilateral CL/P between 0 and 24 years of age, treated between 2012 and 2019 at Erasmus University Medical Center, were included. Healthcare services (consultations, diagnostic and surgical procedures) were counted and costs were calculated. Expected costs based on the treatment protocol were calculated by multiplying healthcare products by the product prices. Correspondingly, the additional expected costs after implementing the ICHOM Standard Set (protocol + ICHOM) were calculated. Observed costs were compared with protocol costs, and the additional expected protocol + ICHOM costs were described. The total mean costs were highest in the first year after birth (€5596), mainly due to surgeries. The mean observed total costs (€40,859) for the complete treatment (0-24 years) were 1.6 times the expected protocol costs (€25,198) due to optional, non-protocolized procedures. Hospital admissions including surgery were the main cost drivers, accounting for 42% of observed costs and 70% of expected protocol costs. Implementing the ICHOM Standard Set increased protocol-based costs by 7%.

Maxillary arch dimensions, occlusion assessment and space conditions in patients with cleft palate in the period of deciduous dentition-A retrospective study.

PURPOSE: The aim of this study was to evaluate the maxillary arch dimensions, dentoalveolar relationships and spacing conditions in patients with cleft palate in comparison with the control group. METHODS: The subjects consisted of 31 children with cleft palate only (CP) aged 5.5 ± 0.51 (20 with a cleft of hard and soft palate (SHPC group) and 11 with a cleft of soft palate only (SPC group)). In the control group 30 subjects had a normal occlusion at age 5. Maxillary arch dimensions, dentoalveolar relationship according to the Huddard Bodenham index (HBI) and space conditions were compared with the control group. RESULTS: In all variables of maxillary arch dimensions except for total arch height the control group exhibited greater values. Most of the significant differences were on account of differences between the control and the SHPC group, with only three comparisons yielding significant results when comparing the two groups of children with clefts (SHPC vs SPC, IV-IV central: pDunnett T3= 0.0002, 95%CIDifference=-9.9-(-3.18); V-V distopalatal cusps: pDunnett T3= 0.0002, 95%CIDifference=-9.97-(-3.17); Total arch length: pDunnett T3= 0.0014, 95%CIDifference=1.74-7.85). The three groups differed significantly in anterior HBI only (HKruskal-Wallis=15.56, p = 0.0067). The spacing conditions in both jaws were also shown to be significantly dependent on the group of subjects studied (Upper jaw: χ2omnibus= 16.79, p = 0.0018; lower jaw: χ2omnibus= 13.75, p = 0.0102). CONCLUSIONS: The growth of the upper dental arch at the age of five is impeded in participants with CP in comparison to a control group. It is important to assess the effect of cleft subtypes on growth and development to get a better understanding.

Convolutional Neural Network Models for Automatic Preoperative Severity Assessment in Unilateral Cleft Lip.

BACKGROUND: Despite the wide range of cleft lip morphology, consistent scales to categorize preoperative severity do not exist. Machine learning has been used to increase accuracy and efficiency in detection and rating of multiple conditions, yet it has not been applied to cleft disease. The authors tested a machine learning approach to automatically detect and measure facial landmarks and assign severity grades using preoperative photographs. METHODS: Preoperative images were collected from 800 unilateral cleft lip patients, manually annotated for cleft-specific landmarks, and rated using a previously validated severity scale by eight expert reviewers. Five convolutional neural network models were trained for landmark detection and severity grade assignment. Mean squared error loss and Pearson correlation coefficient for cleft width ratio, nostril width ratio, and severity grade assignment were calculated. RESULTS: All five models performed well in landmark detection and severity grade assignment, with the largest and most complex model, Residual Network, performing best (mean squared error, 24.41; cleft width ratio correlation, 0.943; nostril width ratio correlation, 0.879; severity correlation, 0.892). The mobile device-compatible network, MobileNet, also showed a high degree of accuracy (mean squared error, 36.66; cleft width ratio correlation, 0.901; nostril width ratio correlation, 0.705; severity correlation, 0.860). CONCLUSIONS: Machine learning models demonstrate the ability to accurately measure facial features and assign severity grades according to validated scales. Such models hold promise for the creation of a simple, automated approach to classifying cleft lip morphology. Further potential exists for a mobile telephone-based application to provide real-time feedback to improve clinical decision making and patient counseling.

A new two-dimensional sonographic approach to the assessment of the fetal hard and soft palates.

Facial clefts are among the most common congenital defects. Ultrasound (US) imaging of secondary fetal palate, especially the detection of isolated defects, remains challenging. Currently described two-dimensional (2D) and three-dimensional methods are technically demanding and impractical for application during routine fetal anatomy evaluation. As an adjunct method, magnetic resonance imaging can provide additional information but has its limitations. We present a novel 2D US approach using axial and sagittal planes to evaluate the fetal palate and demonstrate the main differences between an intact palate, isolated cleft palate, and a cleft lip with cleft palate.

Assessment of orofacial dysfunction in a group of Polish children with unilateral cleft lip and palate: A preliminary report.

BACKGROUND: Cleft lip and palate (CLP) is a genetic and environmental malformation of the face. The resulting interruption of the tissue in the mouth and nasal cavity undoubtedly impairs basic physiological functions, which impacts the quality of life (Qol) of such patients. OBJECTIVES: To assess orofacial dysfunction using the Nordic Orofacial Test-Screening (NOT-S) in a group of Polish children with unilateral CLP (UCLP). The following hypotheses were presented: 1) orofacial dysfunction is more common in children with UCLP and 2) patients with UCLP have a worse QoL than the control group. MATERIAL AND METHODS: Seventy children at the age of 7-13 years took part in the study. The inclusion criterion was a diagnosis of UCLP. The control group (non-UCLP) was matched by gender and age to the cleft group. The research used the NOT-S questionnaire. RESULTS: In the cleft group, there were statistically significantly more disorders of functions, such as breathing, chewing and swallowing, and drooling; in the NOT-S examination, there were more disorders of the face at rest, facial expression and speech in the cleft group. Comparing the NOT-S total scores, it was found that in the cleft group, there a disorder of at least 1 function was statistically significantly more prevalent than in the control group. Likewise, the median results in the cleft group were 3 points higher than in the control group. CONCLUSIONS: Using the NOT-S survey, it was possible to confirm both hypotheses. Orofacial dysfunction is more common in children with UCLP and this contributes to a worse QoL for them than for children without UCLP.

Assessing speech at three years of age in the cleft palate population: a scoping review of assessment practices.

BACKGROUND: There is no consensus in the UK regarding the types of speech samples or parameters of speech that should be assessed at 3 years of age in children with cleft palate ± cleft lip (CP±L), despite cleft units routinely assessing speech at this age. The standardization of assessment practices would facilitate comparisons of outcomes across UK cleft units; earlier identification of speech impairments-which could support more timely treatments; and more reliable recording of therapy impacts and surgical interventions. AIMS: To explore assessment practices used to assess speech in 3-year-old children with CP±L, including speech parameters, methods of assessment and the nature of the speech sample used. METHODS & PROCEDURES: A broad examination of the literature was undertaken through the use of a scoping review conducted in accordance with Joanna Briggs Institute guidelines. Search terms were generated from a preliminary search and then used in the main search (Medline, CINAHL, Embase, AMED and PsycINFO). MAIN CONTRIBUTION: A combination of approaches (medical, linguistic, developmental and functional) is required to assess CP±L speech at age 3. A developmental approach is recommended at this age, considering the complexity of speech profiles at age 3, in which typically developing speech processes may occur alongside cleft speech characteristics. A combined measure for both nasal emission and turbulence, and an overall measure for velopharyngeal function for speech, show potential for assessment at this age. Categorical ordinal scales are frequently used; the use of continuous scales has yet to be fully explored at age 3. Although single-word assessments, including a subset of words developed for cross-linguistic comparisons, are frequently used, more than one type of speech sample may be needed to assess speech at this age validly. The lack of consensus regarding speech samples highlights a need for further research into the types of speech samples 3-year-olds can complete; the impact of incomplete speech samples on outcome measures (particularly relevant at this age when children may be less able to complete a full sample); the impact of different speech samples on the validity of assessments; and the reliability of listener judgements. CONCLUSIONS & IMPLICATIONS: Whilst a medical model and linguistic approaches are often central in assessments of age-3 cleft speech, this review highlights the importance of developmental and functional approaches to assessment. Cross-linguistic single-word assessments show potential, and would facilitate the comparison of UK speech outcomes with other countries. Further research should explore the impact of different speech samples and rating scales on assessment validity and listener reliability.

Development of a valid and reliable instrument for the assessment of quality of life in parents of children with clefts.

PURPOSE: Orofacial clefts are the most common congenital malformations that affect craniofacial structures. Studies show that they have a major influence on psychological development of the patient, and on their families. A review of the literature showed a lack of specific questionnaires for children and their parents. This study investigated the impact of orofacial clefts in children on the quality of life of their parents. In addition, the results of the treatment and the quality of work of the health team members involved in this process were evaluated. MATERIALS AND METHODS: For the purpose of this study, an original questionnaire was made to analyse the effect of orofacial clefts in children who had undergone surgery on the quality of life of 73 of their parents. The questionnaire consisted of 28 simple statements, which were evaluated with a 5-degree Likert scale (from 1-fully disagree to 5-fully agree), did not require any specific additional clarification, and were easy to complete. RESULTS: Analysis of areas of the questionnaire that applied to the parents, resulted in two subscales, parental social health and child social health, which had satisfactory Cronbach's coefficients (0.907 and 0.897, respectively). However, some issues had a relatively poor coefficient of internal consistency, which justified their expulsion from the final model of the parent questionnaire. CONCLUSION: The questionnaire developed for this study comprised two subscales concerned with the social health of parents/respondents and the social health of adolescents, as perceived by the parents. It was a valid and reliable instrument, and it showed satisfactory quality of life for parents of adolescents with clefts.

Unilateral Cleft Lip Repair: A Quantitative Scale Assessment of Postoperative Lip and Nose Scars Across 2 Operative Techniques.

BACKGROUND: There is no quantitative evidence supporting one unilateral cleft lip (UCL) repair technique over the other with regard to scarring. We sought to evaluate the difference between the extended Mohler and Millard techniques, using 3 scar assessment scales. METHODS: Postoperative frontal and basal photographs of patients undergoing UCL repair were reviewed. Three validated scar assessment scales were used: the Manchester Scar Scale (MSS), modified scar-rating scale (MSRS), and Stony Brook Scar Evaluation Scale. Lip and nose scars were rated by 5 independent raters using each of the scales. Interrater reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Assessment of 116 images for 58 consecutive patients undergoing UCL repair (36 extended Mohler, 22 Millard) was performed. Interrater reliability was excellent for lip scars (ICCs, 0.903 [0.857-0.938] for MSS, 0.913 [0.872-0.944] for MSRS, and 0.850 [0.775-0.902] for SBES) and moderate for nose scar assessment (ICCs, 0.714 [0.579-0.816] for MSS, 0.693 [0.548-0.802] for MSRS, and 0.565 [0.359-0.720] for SBES). No statistically significant difference was found between the extended Mohler and Millard repairs in mean lip scar scores (MSS, 6.983 ± 1.469 vs 6.772 ± 1.175, P = 0.571; MSRS, 5.433 ± 1.530 vs 5.481 ± 1.290, P = 0.902; SBES, 3.633 ± 0.977 vs 3.446 ± 0.995, P = 0.483) or nose scar scores (MSS, 5.644 ± 1.131 vs 5.491 ± 0.689, P = 0.523; MSRS, 4.233 ± 0.987 vs 3.991 ± 0.705, P = 0.320; SBES, 3.933 ± 0.750 vs 4.018 ± 0.486, P = 0.603). CONCLUSIONS: Using 3 validated scar assessment scales, no significant difference was found between the extended Mohler and Millard techniques in terms of lip or nose scars.

Beware the Alar Base Optical Illusion in Assessment of Unilateral Cleft Lip Nasal Deformity.

BACKGROUND: After repair of unilateral cleft lip, lateral drift of the alar base is expected and may require revision. Although the alar base appears wider than on the noncleft side, by measurement it could be symmetric or narrow. Is this an optical illusion? METHODS: This is a retrospective photographic evaluation of children who underwent repair of unilateral complete cleft lip and palate. On submental standardized photographs, raters judged whether the alar base position was wider, equal to, or narrower than on the noncleft side. The true alar base position was measured by photogrammetry and the frequency of alar base misjudgment was assessed. On control photographs, the cleft side alar base was wider than the noncleft side. On test photographs, the cleft side alar base was narrower than the noncleft side. Possible association between misjudgment and nasal features was also evaluated. Data were analyzed using the Fisher's exact test. RESULTS: Three raters assessed 61 patients aged 6 to 9 years and treated between 1995 and 2015. In 77 percent of control photographs, raters correctly judged the cleft side alar base as wider. In 65 percent of test photographs, raters incorrectly judged the alar base position as wider on the cleft side. Asymmetry of nostril outline and a transverse nostril axis were associated with misjudged photographs (p < 0.05). CONCLUSIONS: Alar base assessment can be altered by an optical illusion. Simple anthropometry counters this misperception. Measurement should be repeated after correction of the deviated anterocaudal septum and elevation of the lower lateral cartilage. Thereafter, a decision is made on altering the alar base position. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

The Effectiveness of an International Cleft Mission Model in Asia: An Update.

BACKGROUND: Cleft lip/palate is a congenital craniofacial anomaly affecting patients physically and psychosocially and has contributed to the global burden of surgical disease, especially in underprivileged areas. For 20 years, Noordhoff Craniofacial Foundation (NCF) and the Chang Gung Craniofacial Center (CGCFC) have carried out missions to these areas. Rather than implementing short-term missions that lack proper follow-up care, the team has provided an effective, long-term, and multidisciplinary approach for the treatment of patients with cleft lip/palate. In this study, we evaluate the sustainability and effectiveness of the cleft mission model implemented by NCF and CGCFC. METHODS: Data from the years 1998-2017 were retrieved from the NCF database. All local centers were evaluated by a 3-stage categorization, levels 1 to 3, based on 4 criteria: (1) capacity to carry out independent missions, (2) diversity of cleft-care professionals, (3) diversity of surgical service offered, and (4) collaboration with local hospitals. Support and training of personnel were provided based on deficiency in these criteria. Noordhoff Craniofacial Foundation made close collaborations and partnerships with several organizations that shared its mission for comprehensive cleft care in developing countries. RESULTS: In all, 19 partner cleft teams in 9 different countries were established. In coordination with these teams, NCF and CGCFC have treated 1846 patients across 78 mission trips. To date, 158 personnel from 19 different countries have been successfully trained to provide cleft care in local centers. Most partner cleft teams centers have progressively reached category level 3, including those in the Philippines, Cambodia, and Mongolia. CONCLUSIONS: In order to establish and maintain sustainable cleft care in developing regions, commitment and compassion toward those who lack essential resources are necessary. Noordhoff Craniofacial Foundation and CGCFC have achieved a successful and practicable model through seeding medical personnel in order to provide effective and sustainable cleft care to the regions in need.

Primary Repair in Patients With Unilateral Complete Cleft of Lip and Primary Palate: Assessment of Outcomes.

OBJECTIVE: Asymmetry of median facial structures is a major concern for patients with unilateral cleft lip and palate, and the principal goal of its treatment is to restore symmetry. Unilateral complete cleft of lip and primary palate (UCCLPP) is an uncommon subgroup and rarely reported. Patients with UCCLPP have protruding and deviating premaxilla, rendering a primary repair difficult. This study evaluated consecutive patients with UCCLPP and presented their treatment outcome. METHODS: We assessed 36 patients with UCCLPP and collected clinical information. Surgical repair was performed at 3 months of age by using a modified rotation-advancement method and primary nasal reconstruction. A single surgeon performed all surgical procedures. A postoperative nasal stent was used for 6 months. Follow-up standardized photographs were collected. Landmarks were identified, and nose and lip dimensions measured. The ratios of the corresponding parameters (cleft vs noncleft side) were obtained for evaluating nose and lip symmetry. RESULTS: No surgical complication was noted in any patient. The overall lip and nose outcome after the primary repair were adequate, and all ratios were close to 1. The nostril width was slightly wider on the cleft side, but the alar width and height were acceptable. The lip heights were balanced between the 2 sides. Patients who received presurgical nasoalveolar molding did not show more favorable lip and nose dimensions, except for the medial philtral height. CONCLUSION: Even in the presence of protruding and deviating premaxilla, our patients with UCCLPP obtained adequate lip and nose outcome after undergoing primary lip repair and nasal reconstruction.

Associations between laterality of orofacial clefts and medical and academic outcomes.

Patients with oral clefts have an increased risk of other malformations, syndromes, and lower academic performance in school. Few studies have investigated if laterality of clefts is associated with medical and academic outcomes. Oral clefts have nonrandom laterality, with left-sided clefts occurring approximately twice as often as right-sided clefts. Using a retrospective study design, we examined potential associations of cleft attributes and outcomes in patients with cleft lip with or without cleft palate (CL/P) born in 2003-2010 who were treated at the Seattle Children's Craniofacial Center. The following variables were extracted from medical records: cleft type, medical history, maternal hyperglycemia, other malformations, and the need for academic support at school. We used logistic regression to examine risk of associations with outcomes of interest. Relative to patients with left-sided clefts, patients with bilateral CL/P were more likely to have a syndrome. Patients with nonsyndromic right-sided CL/P had a higher risk (OR and 95%CI: 3.5, 1.3-9.5, and 5.5, 1.9-16.0, respectively) of having other malformations and requiring academic support at school, when compared to patients with left-sided CL/P. Understanding the etiology of oral clefts is complicated, in part because both genetic and environmental factors contribute to the risk of developing a cleft. However, the different outcomes associated with cleft laterality suggest that right-sided clefts may have a distinct etiology. Using laterality to study cleft subgroups may advance our understanding of the etiology of this common birth defect.

A Digital Assessment of the Maxillary Deformity Correction in Infants With Bilateral Cleft Lip and Palate Using Computer-Aided Nasoalveolar Molding.

OBJECTIVES: To evaluate the maxillary alveolar repositioning of the infants with bilateral cleft lip and palate (BCLP) undergoing computer-aided nasoalveolar molding (CAD-NAM). METHODS: A total of 19 BCLP infants undergoing CAD-NAM were recruited as the treatment group, and 21 nonpresurgically treated BCLP patients served as controls. The upper alveolar morphology was measured and evaluated. Changes in all variables between pre- and post-CAD-NAM were compared. RESULTS: By the end of CAD-NAM, significant difference was found in the P-A, P'-A', and L-ideal midline (P < 0.01); in the sagittal dimensions, significant difference was found in the P-TT', P'-TT', I-TT', A-X, and A'-X' (P < 0.01), while in the vertical dimensions, significant difference was found in the alveolus height in the bilateral canine regions (P < 0.01). CONCLUSION: Computer-aided nasoalveolar molding can effectively reduce the cleft gap, correct the alveolar midline deviation, and retract the projection and outward rotation of the premaxilla segment, and normalize the contour of the alveolus.

Comparative Assessment of the Cleft Profile by Patients with Cleft Lip and Palate, Cleft Surgeons, and Lay People.

BACKGROUND: This cross-sectional study aimed to compare subjective assessments among patients with cleft lip and palate (CLP), cleft surgeons, and lay people regarding the soft tissue lateral profile of CLP patients. We also investigated the correlations between subjective assessments and photogrammetric measurements. METHODS: A total of 150 CLP patients who wished to have treatment for their unattractive appearance were randomly selected. A standard lateral profile color photograph was taken. Panels of three cleft surgeons, ten CLP patients, and ten lay people were selected to be assessors. They rated nasal tip projection, nasolabial esthetics, upper and lower lip esthetics, and the profile for each photograph. Three angular measurements (nasal prominence angle, nasolabial angle, and lip angle) were measured for each photograph. Kendall's coefficient of concordance and logistic regression were used for statistical analysis. RESULTS: Kendall's coefficient of concordance of nasal tip projection, nasolabial esthetics, upper and lower lip esthetics, and the profile were 0.734, 0.683, 0.828, and 0.747, respectively (p < 0.001). Lip angle was associated with the profile scores for cleft surgeons and CLP patients (p < 0.001). The nasal prominence angle and lip angle were associated with the profile scores for lay people (p < 0.001). CONCLUSIONS: CLP patients, cleft surgeons, and lay people have similar attitudes to the appearance of CLP patients. Upper and lower lip esthetics is associated with the assessment of the cleft profile that is provided by CLP patients, cleft surgeons, and lay people. In addition, nasal tip projection is another determining factor for lay people. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cleft lip-cleft palate in Zimbabwe: estimating the distribution of the surgical burden of disease using geographic information systems.

OBJECTIVES/HYPOTHESIS: To evaluate the prevalence and unmet need for cleft lip-cleft palate reconstructive surgery by using incidence. Our hypotheses were that the age of presentation to screening clinics will decrease between 2006 and 2012, and the geospatial distribution of cases will expand to a more rural catchment area. STUDY DESIGN: Longitudinal cross-sectional/geospatial distribution study. METHODS: An online, secure database was created from intake forms for children with cleft lip-cleft palate (N=604) in Zimbabwe (2006-2012). Univariate analysis was completed. A linear regression model was fitted to test the time trend of a child's age at the time of presentation. Unique patient addresses (n=411) were matched. Maps presenting cleft diagnosis and presentation year were created with geographic information systems (GIS) software. RESULTS: The median age of presentation was greater for isolated cleft palate (4.2 years, n=106) than isolated cleft lip (1.5 years, n=251) and cleft lip-cleft palate (2.0 years, n=175). Cleft lip cases were mostly left sided with equal gender distribution. The overall age of presentation remained stable (P=.83). The age of children with isolated cleft palate decreased by 0.8 years per surgical trip (P=.01), suggesting the prevalence of unrepaired cleft palate is decreasing due to local and visiting surgeons. The catchment area extended to a less populous area, but clustered around Harare and Bulawayo. CONCLUSIONS: This study gives Zimbabwe-specific evidence that supports reports of the persistent burden of disease requiring attention. The GIS software provided data for the primary needs assessment, which will direct communication to healthcare providers and prospective patients outside of the current catchment area. LEVEL OF EVIDENCE: 3

The financial impact of unrepaired cleft lip and palate in the Philippines.

OBJECTIVES: There are over 96 million people in the Philippines. Close to 77 thousand persons in this country have orofacial clefting. We estimate nearly 64 thousand are unrepaired. Unemployment and underemployment because of the communication disorders associated with unrepaired clefts will affect family income and hence tax revenues. The purpose of this study is to understand the financial impact of unrepaired cleft lip and/or palate on families and identify how that would translate to the Philippine government in tax revenues. METHODS: The incidence of orofacial cleft in the Philippines was estimated to be at least 1 in 750 people, with only 16% anticipated to be repaired under current conditions. Assuming a 21% unemployment rate in subjects with untreated clefts, and a tax rate of 6-12.4%, projected lost personal income and federal tax revenue was calculated. RESULTS: In 2012 alone the financial impact on the families may be as much as $US 73-88 million in lost revenue from unemployment and underemployment. This would cost the government between $8.0 and $9.8 million dollars in lost tax revenue. Over a 20 year period at least $US 1.7 billion dollars in family income would be affected costing the government at least $US 194 million in taxes. CONCLUSION: By appropriately caring for the cleft population tax revenues should increase substantially. The development of the infrastructure for surgical care of this problem would be costly but could be more than offset by revenues. Inattention to surgically correctable causes of communication disorders is not affordable.

Adopted children with cleft lip or palate, or both, require special needs cleft surgery.

In recent years adoption of children with cleft lip, with or without cleft palate (CLP), and other birth defects has become more common. The aim of the present study was to describe the characteristics and initial care and treatment of adopted children with CLP. A total of 25 children were referred to our department between 2008 and 2010, 7 (28%) of whom had bilateral CLP and 16 (64%) had unilateral CLP. Two children had atypical clefts. Twenty of the patients (80%) had been operated on with a lip plasty in China before adoption. Most patients (n = 14) was seen by the cleft team within two months of arrival, and 13 were operated on within a month of the first visit at our department. In total, 22 primary palatoplasties, 6 lip plasties, and 1 lip adhesion were done. There were 5 fistulas (14%) three months after the palatoplasty. On arrival, 11 (44%) of the children were carriers of methicillin-resistant Staphylococcus aureus (MRSA). Adoption of children with CLP creates new challenges for the cleft teams, as we no longer have control over the overall treatment plan as regards preoperative and surgical treatment and timing of the operations. The patients are also often carriers of resistant bacteria, which create nursing challenges. In cases where the child is older than a year and has not been operated on, we advocate that the palatoplasty, or combined lip plasty and palatoplasty, is always given priority so that speech development is not compromised.

The cleft lip evaluation profile (CLEP): a new approach for postoperative nasolabial assessment in patients with unilateral cleft lip and palate.

To assess the postoperative results after primary or secondary operation on unilateral cleft lip and nose, various methods have been published, in which qualitative methods are often based on the opinions of an expert panel and the quantitative methods are based on measurements of different landmarks of the lip and nose. Common problems with the present methods are the associated costs, based on the need for advanced techniques and expertise. Our cleft team now present a simplified, inexpensive, and reproducible protocol to evaluate the cosmetic and functional outcome after operations on the cleft lip and nose, together with the patients. Our protocol has been developed as a guideline to evaluate and score six variables of the lip and seven variables of the nose, including scars, projections of the lips and nose, volumes of the lip, and the alae and septum. The protocol contains series of three photographs of each of the variables that present a good postoperative result, an acceptable result, and finally a result with a clearly visible disfigurement. We also tested the reproducibility and validity of the protocol. Plastic surgeons with no knowledge of the index were approached twice and asked to assess a version with photographs in random order. The evaluation protocol is a simple and cost-effective tool for evaluation of the lip or nose, or both, among patients with repaired unilateral complete cleft lip.