A Closer Look at Delayed Primary Cleft Surgery and Unrepaired Cleft Lip and/or Palate in 5 UK Cleft Centers.

BACKGROUND: There may be many reasons for delays to primary cleft surgery. Our aim was to investigate the age of children undergoing primary cleft lip or primary cleft palate repair in 5 cleft centers within the United Kingdom. Identify the reasons for delayed primary cleft lip repair (beyond 6 months) and delayed primary palate repair (beyond 13 months). Identify children who had a cleft lip and/or palate (CL±P) that was intentionally unrepaired and the reasons for this. METHODS: A retrospective, multicenter review of patients born with a CL±P between December 1, 2012, and December 31, 2016. Three regional cleft centers, comprising of 5 cleft administrative units in the United Kingdom participated. RESULTS: In all, 1826 patients with CL±P were identified. Of them, 120 patients had delayed lip repair, outside the expected standard of 183 days. And, 178 patients in total had delayed palate repair, outside the expected standard of 396 days. Twenty (1%) patients had an unrepaired cleft palate. CONCLUSIONS: This large retrospective review highlights variations between centers regarding the timing of lip and palate surgery and details the reasons stated for delayed primary surgery. A small number of patients with an unrepaired cleft palate were identified. All had complex medical problems or comorbidities listed as a reason for the decision not to operate and 50% had a syndromic diagnosis. The number of patients receiving delayed surgery due to comorbidities, being underweight or prematurity, highlights the importance of the cleft specialist nurse and pediatrician within the cleft multidisciplinary team.

Cleft Palate Outcomes and Prognostic Impact of Palatal Fistula on Subsequent Velopharyngeal Function-A Retrospective Cohort Study.

OBJECTIVE: To assess outcomes from cleft palate repair and define the level of impact of palatal fistula on subsequent velopharyngeal function. DESIGN: A retrospective cohort study. SETTING: A regional specialist cleft lip and palate center within United Kingdom. PATIENTS, PARTICIPANTS: Nonsyndromic infants born between 2002 and 2009 undergoing cleft palate primary surgery by a single surgeon with audited outcomes at 5 years of age. Four hundred ten infants underwent cleft palate surgery within this period and 271 infants met the inclusion criteria. INTERVENTIONS: Cleft palate repair including levator palati muscle repositioning with or without lateral palatal release. MAIN OUTCOME MEASURES: Postoperative fistula development and velopharyngeal function at 5 years of age. RESULTS: Lateral palatal incisions were required in 57% (156/271) of all cases. The fistula rate was 10.3% (28/271). Adequate palatal function with no significant velopharyngeal insufficiency (VPI) was achieved in 79% of patients (213/271) after primary surgery only. Palatal fistula was significantly associated with subsequent VPI (risk ratio = 3.03, 95% confidence interval: 1.95-4.69; P < .001). The rate of VPI increased from 18% to 54% when healing was complicated by fistula. Bilateral cleft lip and palate (BCLP) repair complicated by fistula had the highest incidence of VPI (71%). CONCLUSIONS: Cleft palate repair with levator muscle repositioning is an effective procedure with good outcomes. The prognostic impact of palatal fistula on subsequent velopharyngeal function is defined with a highly significant 3-fold increase in VPI. Early repair of palatal fistula should be considered, particularly for large fistula and in BCLP cases.

Clinical grading system for submucous cleft palate.

Submucous cleft palate is a structural abnormality of the palate. The clinical features vary, as does the functional impairment, which ranges from none to severe. Although there is a poor correlation between the presenting clinical signs and the severity of velopharyngeal insufficiency during speech, a clinical grading system could assist surgical management and allow more meaningful comparisons to be made between outcome studies. The grading system described is based on clinical examination alone and reflects the likely degree of structural abnormality of the musculature of the soft palate.