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345
October-December 2013 / Vol 10 / Issue 4
African Journal of Paediatric Surgery
Surgical outcome and complications following
cleft lip and palate repair in a teaching
hospital in Nigeria
Taiwo O. Abdurrazaq, Adeyemi O. Micheal1, Adeyemo W. Lanre1, Ogunlewe M.
Olugbenga1, Ladeinde L. Akin1
Access this article online
Website:
www.afrjpaedsurg.org
DOI:
10.4103/0189-6725.125447
PMID:
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intRODUCtiOn
A wide range of surgical techniques are used for repairing
cleft lip and palate, and there is no consensus among
surgeons regarding the protocol, timing, and technique
of repair.[1] Measurement of treatment outcome is vital in
estimating the success of cleft management and quality
improvement, especially in the present age, when
evidence-based medical care and treatment guidelines
regarding the best practice is becoming an integral part
of contemporary clinical practice.[2] Many potential
outcomes for comparing cleft lip and palate treatment
have been reported, including dentofacial growth and
development, facial appearance, speech, hearing, nasal
breathing, quality of life, and patient satisfaction.[1,2]
However, there is no agreement among the various
specialists in cleft care regarding which one of these
outcome measures is most important.[3]
Improvements in the appearance of the lip and nose are
the most frequently desired aspects for further treatment
by patients with clefts and their parents.[2] However,
developing a reliable rating for measurement of nasolabial
appearance has remained a challenge. The methods
described for assessment of nasolabial appearance can
be broadly divided into qualitative and quantitative
methods.[4] While the latter aims to analyze objectively
the extent of abnormal morphology and the degree of
disproportion through facial measurements, the former
(qualitative methods) are more subjective, and they
analyze facial aesthetics and appearance impairment
using scales, indices, scoring systems, and rankings.[4]
The goals of palatal surgery are closure of the
communication between the oral and nasal cavities
and construction of a functional velum that allows good
speech production.[5]
There is a growing appreciation of measuring the
outcome of cleft repairs to determine the chance of
ABSTRACT
Background: Measurement of treatment outcome
is important in estimating the success of cleft
management. The aim of this study was to assess
the surgical outcome of cleft lip and palate surgery.
Patients and Methods: The surgical outcome of
131 consecutive patients with cleft lip and palate
surgeries between October 2008 and December
2010 were prospectively evaluated at least 4 weeks
postoperatively. Data collected included information
about the age, sex, type of cleft defects, and type
of surgery performed as well as postoperative
complications. For cleft lip repair, the Pennsylvania
lip and nose (PLAN) score was used to assess the
surgical outcome, while the integrity of the closure
was used for cleft palate repair. Results: A total of 92
patients had cleft lip repair and 64 had palate repair.
Overall, 68.8% cases of cleft lip and palate repair had
good outcomes; 67.9% of lip repairs had good lip and
nose scores, while 70.2% of palatal repair had a good
surgical outcome. Oro-stula was observed in 29.8%
of cleft palate repairs Inter-rater reliability coefcient
was substantially significant. Conclusions: The
fact that 25.7% of those treated were aged >1 year
suggests a continued need to enlighten the public
on the availability of cleft lip and palate expertise
and treatment. Although an overall good treatment
outcome was demonstrated in this study, the nasal
score was poorer than the lip score. Complication rate
of about 14% following surgical repair is consistent
with previous reports in the literature.
Key words: Cleft lip and palate, Pennyslvannia lip
and nose score, von langenbeck
Department of Surgery/Dental and Maxillofacial Surgery, College of
Health Sciences, Usmanu Danfodiyo University/Usmanu Danfodiyo
University Teaching Hospital, Sokoto, 1Oral and Maxillofacial Surgery,
College of Medicine, University of Lagos/Lagos University Teaching
Hospital, Idi-araba, Lagos, Nigeria
Address for correspondence:
Dr. Olanrewaju Abdurrazaq Taiwo,
Department of Surgery, College of Health Sciences,
Usmanu Danfodiyo University, PMB 12003, Sokoto, Nigeria.
E-mail: droataiwo@yahoo.com
Original Article
African Journal of Paediatric Surgery
346 October-December 2013 / Vol 10 / Issue 4
Taiwo,
et al
.: Cleft lip and palate repair
negative consequences, advising patients, predicting
surgical outcomes, generating policies about safe
clinical care, and allocating resources.[6] This has also
been reported to help in objective determination of
surgeon performance.[7] Cleft lip and palate repairs
outcome would serve as a benchmark for comparison
with other cleft centre and may expose critical areas
that require attention and training.[7] This may also
facilitate the attainment of the gold standard in cleft
management and adequate information of patient
about expected treatment outcome after surgery.[6,7]
Moreover, it might also assist in determining the need
for secondary cleft surgery.[8] There are the underlying
needs for follow-up, documentation, and evaluation
of cleft treatment.
There is paucity of studies in Nigeria that have attempted
to comprehensively and objectively document the
surgical management outcome of orofacial clefts.[9-11]
Hence, there is a need for reliable data generation in
surgical management of cleft deformity in a developing
country such as Nigeria.
The findings of this study may help add to the
literature on surgical management of cleft lip and palate
deformity and may serve as a useful tool for healthcare
service providers in assessing the cleft care needs and
provision of adequate facilities for optimal orofacial
cleft treatment delivery in Nigeria.
Patients anD MetHODs
A total of 131 consecutive patients who had undergone
cleft lip and palate surgeries at the Lagos University
Teaching Hospital between October 2008 and December
2010 were enrolled in this study. All eligible subjects
that presented to the clinic for primary repair of
congenital cleft lip and palate deformities were included
in the study. Subjects with acquired cleft deformities
of the lip and palate and all orofacial cleft based on
Tessier’s classification[12] were excluded from the study.
The study was approved by the Research and Ethics
Committee of the Lagos University Teaching Hospital.
Written informed consents were obtained from all the
subjects or their parents/guardian before enrollment
in the study. Prior to this, detailed information and
explanations of the study was provided to each subject
or their parents/guardians. An opportunity for questions
was ensured and appropriate clarifications were given
to each subject or their parents/guardian before the
commencement of the study. Opportunity to withdraw
at any stage of the study was made known to each
subject or their parents/guardian without victimization
or denial of treatment.
Data forms were used to collect the desired information
from the subjects or subjects’ informants such as
age, gender, types of cleft defect, occupation, reason
for presentation, presence of congenital anomalies,
and other relevant details as reflected in Appendix I.
Other data collected include information on type
of surgical intervention, repair technique, peri- and
postoperative complications, and any other relevant
findings (Appendix I). Relevant clinical findings of the
subjects were documented after clinical examination
of the subjects and on subsequent follow-up. Relevant
medical and radiological investigations (full blood
count, chest radiographs, and echocardiography) were
requested when indicated after history taking and
clinical examination.
Cleft lip and palate were classified according to Kernahan
and Stark (1958), as modified by the International
Confederation for Plastic and Reconstructive Surgery
in 1967.[13,14] Clinical photographs were taken of
each patient on presentation, at different stages of
management, and on subsequent review visits within
the study period to illustrate the physical defect
preoperatively and its management outcome.
Routine surgical preoperative workup was done
for the subjects [who met the minimum criteria of
age ≥10 weeks, weight ≥10 pounds (4.5 kg) with a
hemoglobin concentration of 10 gm/dl, and free from
upper respiratory tract infection] before scheduling for
surgical operation. For cleft palate repair, all subject
were aged at least 10 months. All subjects were certified
fit for surgery by the anesthetic team.
Surgical repair was performed under general anesthesia
in most cases; however, some cases of consenting adult
cleft lip were repaired under local anaesthesia using 2%
xylocaine with adrenaline (1:80,000).
Surgical repair was carried out by 4 consultant oral and
maxillofacial surgeons, assisted by senior registrars.
The lead surgeon determined the surgical technique
for each case [Figure 1].
Procedures
1. Unilateral cleft lips (complete or incomplete)
were repaired by Millard rotation advancement[15]
or Tennison Randal[16,17] (Triangular repair)
techniques. Primary closed rhinoplasty was
Taiwo,
et al
.: Cleft lip and palate repair
347
October-December 2013 / Vol 10 / Issue 4
African Journal of Paediatric Surgery
2 Moderate: Some lip asymmetry noted at conversational
distance, requiring minor reconstructive procedures.
3. Severe: Significant lip asymmetry, needing complete
revision.
Nose scoring
1. Mild: Nearly imperceptible at conversational
distance, not requiring any treatment.
2. Moderate: Tip asymmetry seen mostly on worm’s
eye tip, needing rhinoplasty.
3. Severe: Nasal asymmetry seen on anteroposterior
view, at conversational distance, crooked nose.
Reconstructive rhinoplasty was needed, i.e., graft
may be necessary to achieve correction.
For cleft palate repairs, the outcome was judged based
on the integrity of the closure, i.e., on the presence or
absence of fistula. The outcome was good when there
was no postoperative fistula at the operative site, fair or
poor respectively when the resultant fistula was less or
more than 1 cm in greatest diameter, respectively. The
fistula size was determined by using a calibrated and
validated Vernier caliper.[5]
Data analysis
Data was analyzed using the SPSS for Windows
(version 17.0; SPSS Inc., Chicago, IL) statistical
software package[24] and presented in descriptive
and tabular forms. Test of significance was used as
appropriate. P value was set at ≤0.05. An inter-rater
reliability analysis using the Cohen’s kappa statistic
was performed to determine coherence among raters.
ResULts
The study included 62 (47.3%) males and 69 (52.7%)
females. The overall male-to-female ratio was 1:1.1.
Unilateral cleft lip and palate (32.8%) was the most
common defect, followed by cleft lip with or without
alveolus (26.7%). Unilateral cleft lip and palate was
more common in males than in female, whereas
unilateral cleft lip with or without alveolus and cleft
palate was more common in females [Table 1].
A total of 156 surgeries were performed in 131 subjects.
The age of the subjects at the time of surgery ranged
between 3 months and 35 years. Overall, the mean age
(SD) at the time of repair was 7.2 years (10.2). Also,
116 (74.3%) subjects presented in infancy, 29 (18.6%)
presented during childhood, and 11 (7.1%) presented
in adulthood. Further analysis showed that 24 (15.4%)
subjects presented after 6 years of age, of which 18
(11.5%) were cleft palate and the remaining 6 (3.8%)
performed concurrently with all primary unilateral
lip repairs.
2. Bilateral cleft lips were repaired by Millard forked
flap technique.[18,19]
3. Complete/incomplete unilateral or bilateral cleft
palates were repaired with von Langenbeck
palatorraphy[20] modified with intravelar veloplasty[21]
for subjects aged 10–18 months and at time of
presentation for older subjects.
4. Soft palate clefts were repaired by von Langenbeck
technique with intravelar veloplasty for subjects
aged 10-18 months and at time of presentation for
older subjects.
The subjects were reviewed regularly after the surgery
and evaluated not less than 4 weeks following repair.
Clinical evaluation of the surgical outcome of the
repaired orofacial clefts were done not less than
4 weeks after surgery. Prior to the study, the two
observers were trained on the use of the lip and palate
assessment tools. The lip and palate assessment was
done by the first author (primary investigator) and the
second author (supervising surgeon). Disagreement
was resolved by reassessment of the subject until
there was a consensus between the investigator and
the supervising surgeon.
For cleft lip repair, the Pennsylvania lip and nose
(PLAN) score[22,23] was used. Lip and nose score: Surgical
outcome was good when the average score was 1 (no
revision was necessary), fair if it was 2 (minor revision
was indicated), and poor if it was 3 (complete revision
of the surgery was deemed necessary).
Lip scoring
1. Mild: Nearly imperceptible at conversational
distance, not requiring any treatments.
Figure 1: Left unilateral incomplete cleft lip in a subject
Taiwo,
et al
.: Cleft lip and palate repair
African Journal of Paediatric Surgery
348 October-December 2013 / Vol 10 / Issue 4
Table 1: Sex distribution of cleft deformity
Type of cleft Male (%) Female (%) Total (%)
Unilateral cleft lip and
palate
23 (17.6) 20 (15.3) 43 (32.8)
Unilateral cleft lip ±
alveolus
14 (10.7) 21 (16.0) 35 (26.7)
Bilateral cleft lip and
palate
10 (7.6) 8 (6.1) 18 (13.7)
Cleft palate (hard and soft) 6 (4.6) 11 (8.4) 17 (13.0)
Isolated cleft of soft Palate 4 (3.1) 6 (4.6) 10 (7.6)
Bilateral cleft lip 3 (2.3) 3 (2.3) 6 (4.6)
Microform clefts 2 (1.5) 0 (0.0) 2 (1.5)
Total 62 (47.3) 69 (52.7) 131 (100)
Table 2: Age of subjects at the time of lip or palate repair
Frequency %
Lip repair
0-3 months 39 42.4
>3 months to 1 year 25 27.2
>1 year 28 30.4
Total 92 100.0
Palate repair
10-12 months 15 23.4
>12 months to 18 months 15 23.4
>18 months 34 53.2
Total 64 100.0
Table 3: Assessment of clinical outcome for cleft lip and
palate surgeries
Assessment of surgical outcome (%)
Type of surgery Good Fair Poor Total
cleft lip surgery
(lip and nose score)
62 (67.9) 26 (28.4) 4 (3.7) 92 (100)
cleft palate surgery
(palate score)
45 (70.2) 13 (21.1) 6 (8.7) 64 (100)
Overall outcome (%) 107 (68.8) 38 (25.4) 10 (5.8) 156 (100)
Table 4: Lip and nose outcome following lip repair
Clinical outcome (%)
Good Fair Poor Total
Lip score 55 (60.5) 33 (35.8) 4 (3.7) 92 (100)
Nose score 46 (50.6) 42 (45.7) 4 (3.7) 92 (100)
Overall outcome
(lip and nose score)
62 (67.9) 26 (28.4) 4 (3.7) 92 (100)
Table 5: Postoperative complications following primary
cleft lip and palate surgeries
Complications Frequency Percentage (%)
Hypertrophic scar 3 13.7
Oronasal stula 17 77.3
Notching 1 4.5
Dehiscence 1 4.5
Total 22 100.0
were cleft lip. Of the 92 primary lip repairs done, 39
(42.4%) were done within 3 months of age, while 30
(46.8%) of the primary cleft palate repairs (n = 64) were
done within 18 months of age [Table 2].
Each subject underwent a minimum of one surgical
procedure. Ninety two (58%) subjects had lip repair and
64 (41%) had palate repair. Unilateral cleft lips were
repaired using either Millard rotation advancement
technique in 29 (31.5%) subjects or Tennison – Randall
triangular technique in 39 (42.4%) subjects; all bilateral
cleft lip deformities in 24 (26.1%) subjects were repaired
using Millard’s forked flap technique. Three subjects
(2%) were operated under local anesthesia, and all of
it were lip repair.
Of the 156 surgeries, 95 (68.8%) were adjudged to
have a good outcome [Table 3]. When lip and nose
assessment were considered separately for cleft lip
repair assessment, the lip score was better than the
nose score [Table 4]. However, the overall lip and nose
assessment score was lower than the lip score [Table 4].
The inter-rater reliability for the raters was found to be
significantly substantial (k = 0.60, P < 0.05).
There were no cases of peri- or postoperative
mortality recorded in this study. However, 22 (14.1%)
postoperative complications were seen, 17 (13.0%) of
the complications were oronasal fistula (Oronasal fistula
rate = 29.8%), followed by 3 cases of hypertrophic scar
of the lip, wound dehiscence of the nostril floor and lip
notching, respectively [Table 5]. All the hypertrophic
scars occurred in Millard technique of lip repair, and the
notching occurred in the Tennison – Randall technique.
Five (29.4%) of the oronasal fistula occurred in the
anterior hard palate, 8 (47.1%) occurred at the junction
of hard and soft palate, and the remaining 4 (23.5%)
occurred in the soft palate.
The cases of hypertrophic scar were managed
conservatively with satisfactory improvement in scar
quality at 6 months of postoperative review for all cases.
The case of wound dehiscence was resolved by regular
cleaning of the site with gauze soaked in normal saline.
The subject with lip notching subsequently underwent
a successful lip revision. Spontaneous closure or
reduction was achieved in 12 cases of oronasal fistulae.
The other 5 cases of palatal fistulae required surgical
intervention to achieve closure. Adjunct intraoral flaps
(buccal fat pad, n = 3; tongue flap, n = 2) were used in
the repair of the oronasal fistulae.
Taiwo,
et al
.: Cleft lip and palate repair
349
October-December 2013 / Vol 10 / Issue 4
African Journal of Paediatric Surgery
DisCUssiOn
Cleft lip and palate is the most common congenital
defect in the head and neck region.[25,26] In the present
study, cleft deformity was more common in males
than in females. While similar observations have been
reported in the literature,[9,25,27] there are also reports
female preponderance.[10,28] There is no consensus
on the most common type of cleft deformity.[29] This
study however revealed combined unilateral cleft
lip and palate as the most common type of cleft. The
male dominance observed in subjects with cleft lip
and palate in the present study agrees with reports
of several other studies,[9,10] it contrasts sharply with
others [Figures 2 and 3].[25,30]
In the current study, about 75% of subjects presented
before the age of 1 year, and most of these subjects
presented within 3 months of age. This relatively early
presentation is an improvement over earlier studies
done in the same institution.[31,32] Factors responsible
for this relativity may include enhanced cleft treatment
expertise, increased public awareness of cleft lip and
palate, and free cleft treatment available in the hospital.
However, reports from developed countries showed
fewer patients presenting late for surgical repair.[33,34]
One of major reasons for the late presentation of cleft
lip and palate patients in developing countries has
been financial constrain.[35] In a Nigerian study, this
was attributed to the low earnings of most Nigerians
and the poor economic situation of the country. In
a Nepalese study, lack of awareness, remoteness of
available health services, and lack of finance has been
found responsible for late presentation of cleft lip and
palate patients for treatment.[36] Other reasons suggested
are superstition, health belief system of the people, and
the fear of death.[35,36]
It is widely accepted that the repair of cleft lip should
be done in early infancy (aged 10–12 weeks) and cleft
palate repair should be done before speech development
(before 18 months of age).[37,38] Reports of early timely
surgical closure of the cleft lip suggest that there are
improved cosmetic, psychosocial adjustment, and
better quality of life in cleft patient.[33,35,36] Early timely
closure of cleft palate has demonstrated improved
speech outcome, while late palate closure, although
conferring better maxillary growth, has shown poor
speech outcome.[35,36,38] Surgical management of patients
with late or delayed presentation is challenging,
especially during adulthood and adolescence.[35,38]
Aggressive tissue mobilization to achieve closure of
the wide palatal cleft, which may often require adjunct
intraoral flap and relatively greater cost of adult cleft
repair than that of the infant, has been reported in the
literature.[29,33,35,38] Nwoku emphasized that the possible
damage to vital growth centers in the primary operation
of infants and children, such as detachment of vomerine
mucosa, mutilations of the cartilaginous ala, or injuries
of tooth germs, are not an issue in the repair of adult
cleft. On the other hand, adult cleft tend to get larger,
and the closure of especially large clefts of the palate
with local flaps may present some problems.[38] In this
study, while the larger tissue available in adult cleft was
helpful, the large defect especially in the cleft palate was
a hindrance, as observed in an earlier study.[38]
The data that 42.4% cleft lip repair was done within
3 months of age and 46.8% of cleft palate repair
was done under 18 months age are improvements
over previous reports from the same institution.[31]
Sowemimo[32] reported that the time of surgery partly
depend on the age of presentation, available surgical
expertise, and the type of cleft; our results support this
assertion. Another reason might be the availability of
free cleft treatment in the hospital.
Figure 2: Good surgical outcome in repaired right unilateral incomplete
cleft lip Figure 3: Isolated cleft of soft palate in a subject
Taiwo,
et al
.: Cleft lip and palate repair
African Journal of Paediatric Surgery
350 October-December 2013 / Vol 10 / Issue 4
Generally, the repair of cleft lip and palate is performed
under general anesthesia. However, some cases of
cleft lip repair in individuals aged >12 years in our
study were successful under local anaesthesia.[10,11,35]
This study agrees with the reports of some workers
that showed some cases of cleft lip repair can be done
under local anaesthesia.[10,11] This approach has been
demonstrated to be safe, cost effective, and not inimical
to the surgical outcome.[11]
All our subjects met the minimum weight criteria
of 4.5 kg, especially applicable in lip repair. Surgery
was immediately performed once all the criteria were
met. Hence, we did not include predictive variable of
treatment outcome as a factor in the present study;
we hope to incorporate predictive factor of treatment
outcome of cleft repair in a future study.
This study showed a higher proportion of cheilorraphy
than palatorraphy, which is in concordance with
previous African studies.[9-11,27] The reasons for this may
be higher number of cleft involving the lip than palate
in this series as well as that cleft lip repair precedes
palate repair. Furthermore, Orkar et al.,[9] and Olasoji
et al.,[10] observed that parents placed premium on lip
repair than palate repair due to the perceived aesthetic
windfall.
In contrast to studies by Olasoji et al.,[10] and Onasanya[23]
that showed a dominance of Millard technique for
cleft lip repair, both Millard and Tennison–Randall
techniques of cleft lip repair were freely employed
in this study. Some workers prefer the use of Millard
technique in cleft lip repair owing to the ease of mastery,
flexibility, and the minimal loss of lip tissue.[11,23] Millard
technique has however been criticized for its propensity
to cause vertical scarring.[38] Others have, on the other
hand, adopted Tennison–Randall technique in their
cleft lip repair because of its geometrical predictability
and reliability, consistency in decreasing vertical lip
contraction, and its application in wide cleft.[38,39]
The basic demerit of Tennison–Randall method is the
violation of the curved philtral column on the non-cleft
side, which creates a scar that disturbs known anatomic
subunits and the rigid exact presurgical measurements
required [Figures 4 and 5].[39]
Measuring surgical outcomes is vital in estimating
the success of cleft management and quality
improvement.[2,40] Many potential outcomes for
comparing cleft lip and palate treatment have
been reported, including dentofacial growth and
development, facial appearance, speech, hearing, nasal
breathing, quality of life, and patient satisfaction.[41]
However, there is no agreement among the various
specialists in cleft care regarding which one of these
outcome measures is most important.[3] Reports from
various centers suggest a lack of consensus on agreed
methodology for assessing outcomes.[2] Other areas
of debates in cleft outcome measurement include the
timing of measurement and appropriate instrument to
use for the outcome measurement.[3]
Facial appearance has been reported to be an
important outcome of cleft treatment by the patient.[42]
Improvements in the appearance of the lip and nose
are the most frequently desired aspects for further
treatment by patients with clefts and their parents.[43]
Various reports have suggested the central role played
by facial appearance in developing normal peer
relationships, healthy personal adjustment, and
success in school and in career.[41,43,44] However,
developing a reliable rating for measurement
of nasolabial appearance was a challenge in many
studies.[2,40] This has been attributed to the notion
that facial appearance is subjective, complex, and
Figure 4: Good surgical outcome in repaired isolated cleft of soft palate Figure 5: Bilateral cleft lip and palate in a subject
Taiwo,
et al
.: Cleft lip and palate repair
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October-December 2013 / Vol 10 / Issue 4
African Journal of Paediatric Surgery
multivariate.[40,44] It is difficult to objectively and
reliably assess the facial appearance because of
the three-dimensional (3D) components of the face
(transverse, vertical, and sagittal).[2] In addition,
intercenter comparison is hampered by reports on
facial aesthetics using different aesthetic indices.[41]
The PLAN index has been reported in the assessment
of facial aesthetics in cleft lip repair,[22,23] and has
been found to be reliable and valid in facial aesthetic
measurement.[22,23] Also, it has been reported to be
simple to use and reconcile the professional and
public perceptions of facial aesthetics.[22]
Numerous methods of facial aesthetics assessment have
been reported, and they are based on lip and nose form,
facial profile, or dental arch relationship.[41] Assessment of
aesthetic outcome is both quantitative and qualitative.[39]
3D or 2D techniques have been reported in facial
aesthetics measurement.[41] The 3D techniques include
direct clinical analysis, facial casts, stereo-photography,
laser scanning, 3D computed tomography (CT), videos,
subjective qualitative rating scales, photogrammetry,
anthropometric analysis, soft tissue profile analysis,
or GOSLON yardstick.[41] 2D assessment techniques
include standardized photographs and computer image
analysis.[39,41] Anthropometric analyses have been
criticized for ignoring features that the patient consider
relevant, while qualitative scales, although not as
objective as the former, have succeeded in satisfactorily
reconciling the public perception of aesthetic outcome
with that of the clinical findings. However, it must be
noted that no method has achieve wide acceptability,
reliability, and validity.[39]
Assessment of speech quality remains one of most
important outcomes in successful cleft palate surgery.
A number of parameters have been reported to be
relevant to cleft palate speech, such as repair before
speech formation (age: 18-24 months), mobility of the
soft palate, optimal separation of nasal and oral cavities,
intelligibility, and hearing and articulation.
[5,45] Except
the optimal separation of the nasal and oral cavities
and mobility of the soft palate, other parameters
require long-term evaluation. The optimal separation
of the nasal and oral cavities is determined by the
absence of oronasal communication.[5] This has been
reported to cause hypernasality if critical size of 5 mm
is exceeded.[46] The use of Vernier caliper to measure
the dimension of this palatal fistula has been well
validated [Figure 6].[5,45]
Assessing surgical outcome of cleft repair is challenging
due to variability of factors that affect outcome of cleft
surgery.[2,4,40,41,43] These includes the type and severity of
cleft, patient peculiarity, race, experience, and expertise
of the surgeon, timing of the surgery, the technique
adopted in repair and postoperative management.[4,43] In
this study, cleft repairs were evaluated at least 4 weeks
after surgery, by which time, inflammation would have
subsided and healing would have well progressed. The
PLAN scoring system for cleft lip and nose deformities
is a validated, user friendly, and simple technique
post-operative qualitative method for analysis of cleft
lip and nose surgical treatment outcome.[22,23] The
PLAN score separates the lip and nose deformities
into 3 classes, based upon the treatment needed to
correct any residual deformity. For reasons previously
stated, speech remains the gold standard for cleft palate
surgery.[35,36] However, because of the short period of the
study and non-availability of trained speech pathologist,
this important indicator could not be evaluated in the
present study. We hope to get a trained speech therapist
in subsequent follow-up study and continue to monitor
the subjects until when speech can be properly and
objective assessed. However, in the present study, over
50% of cleft palate repair were done after 18 months of
age, which is regarded as detrimental to good speech
outcome in the literature.[45,46]
In addition, two unblinded raters performed the
postoperative assessment of surgical outcome to
minimize observer error. Tobiasen found that multiple
raters’ assessment in cleft repair is more reliable than
in single rater.[44] Multiple raters’ evaluation was
recommended for qualitative variable than single rater
evaluation, because the chance of observer error is
substantially minimized.[47] In the present study, two
unblinded raters were used in the evaluation of lip
repair in contrast to a Nigerian study that employed
a single rater.[23] In addition, the inter-rater reliability
coefficient for the lip and nose scores among the two
raters in this study was substantial, which may possibly
Figure 6: Good surgical outcome in repaired bilateral cleft lip and palate
Taiwo,
et al
.: Cleft lip and palate repair
African Journal of Paediatric Surgery
352 October-December 2013 / Vol 10 / Issue 4
strengthen and make the findings of this study more
reliable.
The overall good treatment outcome demonstrated
noted in this study is comparable to the figures from
several previous studies.[9-11] This might be attributed
to the experience of the surgeons in this centre. The
nasal score was poorer than the lip score in this study,
despite the concurrent rhinoplasty done with primary
lip repair to achieve nasal symmetry. The poor nose
scores recorded in this study may be attributed to the
dissimilarity among the clefts, especially bilateral clefts
nasal deformity, which is more severe than unilateral
and the timing/technique of rhinoplasty. Presently,
there is no consensus on timing of rhinoplasty. While
some authors advocate rhinoplasty at the time of
primary lip repair,[48] as was the case in this study,
others advocate rhinoplasty after the completion of
facial growth to avoid harmful scarring and poor
long-term results.[49] Rhinoplasty can be classified into
closed or open rhinoplasty.[48,49] Technically, a closed
rhinoplasty is simpler than an open rhinoplasty,
however, an open rhinoplasty allows direct vision
and is therefore more accurate approximation of the
lower lateral nasal cartilages and a better approach
for redistributing the central segment tissue.[49] In this
study, closed primary rhinoplasty was the technique
of choice as it is simple to master, less invasive, and
cost effective.
In the present study, von langenbeck palate repair, the
oldest palatorraphy[20] technique, was adopted. It is a
simple technique that does not attempt to lengthen the
palate and has undergone modifications to preserve
the greater palatine vascular pedicle, thus, reducing
scar formation that is inimical to facial growth and
causes velopharyngeal incompetence.[46] Owing to the
limitation of the classical von Langenbeck technique,
the concept of intravelar veloplasty was proposed
following Kriens anatomical studies.[21] This technique
aimed to restore the transverse muscular anatomy of
the soft palate. It frees the levator veil palatinii from
its attachment to the posterior border of the cleft hard
plate and brings it to the midline to be reattached to
its pair. This has improved substantially the issue of
velopharangeal insufficiency and subsequently, speech
[Figures 7 and 8].
Studies have revealed that the modified von Langenbeck
procedure works well in many palatal clefts with
success rates of 51-73% (mean: 60%).[5,50] Our finding
of 70.2% good palate closure is consistent with the
abovementioned figures.
Fillies et al.,[51] reported that cleft surgery in infancy
is occasionally accompanied by severe perioperative
complications. They found that a body weight
of >4.5 kg at the time of surgery, hemoglobin of
>10 g/dl, and white blood cell count of <10,000/ ml
was associated with less risk of complications. This
study did not show any severe or fatal perioperative
complications, possibly due to adherence to the above
strict presurgical requirements criteria and modern
advances in anaesthesia. However, 14.1% postoperative
complication was recorded in this study, which is
consistent with published figures.[9-11,23] The reasons for
this low figure may be attributed to the strict selection
criteria, good preoperative screening of subjects, good
theatre/anesthetic and ward facilities, and competent
surgical/medical staff of the hospital.
Hypertrophic scar, dehiscence, and notching are well-
reported complications of lip repair,[9,38] while oronasal
fistula is the most common complication in palate
repair.[5] Hypertrophic scar rates following cleft lip
repair ranges from 0% to 1.9% in Caucasian studies.[38]
Figure 7: Left unilateral cleft lip and alveolus in a subject
Figure 8: Poor surgical outcome and lip notching in repaired left unilateral
cleft lip and alveolus
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African Journal of Paediatric Surgery
The findings of 3.7% of hypertrophic scar following cleft
lip repair in this series is higher than these published
figures.[11,38] Plausible cause of hypertrophic scar in this
study is the genetic predisposition of these subjects to
this problem. Hypertrophic scars and keloid have been
established to be relatively common among people of
black African descent; the aetiology is however, not
clear [Figure 9].[52]
In this series, there was satisfactory improvement
in scar quality after months of postoperative review
in all the cases of hypertrophic scar without any
active intervention. Measures suggested to prevent
hypertrophic scar include the use of 6-0 atraumatic
sutures and removing alternate sutures on the 4th and
the rest on the 5th postoperative day.[38] Management
of hypertrophic scars varies from observation,
pharmacological to surgical approaches, all with
varying contradictory results.[11,38] Nwoku[38] reported
some success with cortisone cream in the treatment of
hypertrophic scar following cleft lip repair [Figure 10].
The occurrence of oronasal fistula following palate repair
has been attributed to the surgical technique, expertise
of the surgeon, large width of cleft palate, poor wound
healing, tension or absence of multilayered closure, or
infection of the operated site.[5] In this study, the reasons
for oronasal fistula could not be objectively identified.
However, it can be speculated that the large width of
some cleft palate may result in tension closure, which
could have caused the oronasal fistula. However, it is
difficult to conclusively derive from this study whether
the choice of von Langenbeck technique was responsible
for the oronasal fistula occurrence as there were inter-
play of other co-founders intrinsic and extrinsic to the
subjects and surgeons. Hence, a randomized controlled
study may be required to resolve this question. The
junction of the hard and soft palate was the commonest
site of occurrence in this study, and this is consistent
with reports in the surgical literature.[5,50] The 29.8%
rate of oronasal fistula in this study is within reported
figures of 0-63%.[5,46] Management of oronasal fistula
varies from observation to surgery[50] [Figure 11]. In
the early time, following palate repair, the fistula can
be observed and monitored for spontaneous narrowing
or closure.[5,46] Conservative treatment is also indicated
for an asymptomatic fistula.[46,50] It is advised to wait
6-9 months before contemplating any surgical option
to allow proper wound healing.[5] The indications
for fistula repair relate to the associated symptoms,
as described previously. It has been reported that
fistulae causing disturbance in speech should undergo
early repair,[5,45,46] or delayed if possible until the
Figure 10: Good surgical outcome in repaired bilateral cleft lip, alveolus,
and palate
Figure 11: Fair surgical outcome and oronasal communication in repaired
cleft of the hard and soft palate in a adult subject
Figure 9: Bilateral cleft lip, alveolus, and palate in a subject
completion of orthodontic maxillary arch expansion,
when it can be combined with secondary alveolar
bone grafting.[52] Surgical management is a popular
and effective method of closing palatal fistula.[53] Two
layers and tension-free closure have been reported with
immense success.[5,54] Options vary from local flaps to
free tissue transfer.[5] These local flaps include palatal
Taiwo,
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mucoperiosteal flap, buccal flap, tongue flap, and
buccal fat pad.[5,38,45,46,54] Others are tongue, turbinate,
and facial artery musculomucosa flaps.[5,54] Prosthetic
option remains an option in managing those fistulas
not amenable to earlier mentioned treatment regimes.
[55] In this study, there were spontaneous reduction
in some of these fistulae, which rendered some
asymptomatic and facilitated primary surgical closure.
In others, closure was achieved with the mobilization
of local flaps such as buccal fat pad and anterior-based
tongue flap.
The limitations encountered during this study include
the following: The study was time bound, hence, the
subjects in this study could not be evaluated for a
longer period. Long-term evaluation (≥10-20 years)
would made it possible to assess other variables like
speech and facial growth. It would also make the in-
depth assessment of aesthetic possible. Also, speech
assessment could not be performed due to the non-
availability of speech therapist.
In addition, multiple surgeons were involved in the
study. These surgeons have various years of experience
in cleft surgery. The different level of skills possessed
by these surgeons and their adeptness at techniques of
cleft repair may have possibly impacted the outcome of
the cleft surgeries. Although this was not tested in this
study, it might be a focus of future studies.
CONCLUSIONS
Satisfactory surgical outcome and low complication rate
recorded in this study may be a reflection of the close
collaboration and cooperation of the cleft team in our
centre. Regular continuous audit of cleft management
should be encouraged to enhance or improve cleft care.
APPENDIX I
PROFORMA FOR THE STUDY OF THE SURGICAL
MANAGEMENT OF CLEFT LIP AND PALATE
DEFORMITIES AT THE LAGOS UNIVERSITY
TEACHING HOSPITAL
Preoperative Data
Section I
Name of the Subject:…………………………………
Hospital number:……………………………………
Weight:….… Height:…… Date of Birth:…....
Age at the time of presentation:.…………...............
Age at the time of surgery:…...……………………
Sex Male Female
Ethnic group:………………..
Number of children in the family:………………..
Position of the child with cleft in the family:……….
Section II
Gestational history
Full term
Premature
Place of antenatal care:
Hospital Church Mosque
Home Herbal home
Birth weight: ..............
Drugs taken during pregnancy: Folic acid ………
Mother drinking alcohol
during pregnancy
Smoking
Drugs
Antiepileptic
Section III
Age of the father:…………
Age of the mother:………..
Occupation of the father:…………..
Occupation of mother:……………
Socioeconomic status of Subject/Parents/Guardian:
Low Middle High
Consanguinity of parents: Yes [ ] No [ ]
(continued)
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Previous history of clefts in the family: Yes [ ] No [ ]
(a) Presence of cleft in siblings: Yes [ ] No [ ]
If Yes, how many?
(b) Presence of cleft in parents:
Father Yes [ ] No [ ]
If Yes, type of cleft?
Mother Yes [ ] No [ ]
History of cleft in extended family: Yes [ ] No [ ]
Any other congenital anomalies in the extended
family: Yes [ ] No [ ]
Subject’s/or Parent’s/or Guardian treatment
expectation:
Section IV
Types of cleft deformity:
Unilateral cleft lip ± alveolus: Right [ ] Left [ ]
Complete Incomplete Simmonart band
Unilateral cleft lip and palate: Right [ ] Left [ ]
Bilateral cleft lip ± alveolus:
Bilateral cleft lip and palate:
Median cleft lip: [ ]
Isolated cleft palate: Hard [ ] Soft [ ] Both [ ]
Microform [ ] Unilateral [ ] Bilateral [ ]
Submucous [ ]
Diameter of cleft wide: [ ] Narrow [ ]
Other congenital anomalies:
(a)
(b)
(c)
(d)
Associated health problems on presentation:
(a)
(b)
(c)
(d)
Intraoperative
Date of surgery:……………….
Delay in surgery: Yes No
if Yes, Reason for Delay:…………………..
Surgical procedure:
Unilateral cleft lip: Tennison–Randall [ ]
Millard [ ]
Bilateral cleft lip: Millard [ ] Manchester [ ]
Cleft palate: Von-langenbeck [ ] Furlow [ ]
Others [ ]
Duration of Surgery:………...
Complications: ………….
Estimated blood loss:……….........................................
Post-operative
Lengths of hospital stay:……..
Subjectt/Parent/Guardian satisfaction at management
outcome:
Very satisfied [ ]
Satisfied [ ]
Dissatisfied [ ]
PLAN Score:
Lip: Good (1) Fair (2) Poor (3)
Nose: Good (1) Fair (2) Poor (3)
Total score……..
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Quantitative Palatal Score:
Good (no fistula)
Fair (Fistula <1 cm)
Poor (Fistula >1 cm)
Complications
Infection:……
Dehiscence: Partial [ ] Total [ ]
Whistling deformity:……. Others:……..
Fistula: Pre-maxilla [ ] Anterior Hard Palate [ ]
Hard and Soft Palate Junction [ ]
Soft Palate [ ] Uvula [ ]
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