xRead - Treatment of Cleft Lip and Cleft Palate (May 2025)
Volume 153, Number 2 • Cleft Palate Surgery
Fig. 4. Suggested timeline of cleft palate care. Reprinted with permission from Comprehensive Cleft Care: Family Edition , edited by Joseph E. Losee, Richard E. Kirschner, Darren M. Smith, Christin R. Lawrence, and Amy Straub. Boca Raton, FL: CRC Press, Taylor & Francis Group; 2015.
Timing of Surgery and Sequence of Procedures Despite centuries of advancements in cleft palate repair, the timing (early versus late) and sequence of procedures (one- versus two-stage repair) remain widely debated and data exist to support both practices. 23,24 Regarding early versus late repair, the discussion has historically involved a negotiation between improving long term speech outcomes with a single-stage early repair around 12 months of age (level of evi dence: II), 25,26 and mitigating undesirable scarring that may restrict maxillary growth with a two-stage delayed repair (level of evidence: IV). 27 However, level II data suggest that there is no significant clinical difference in facial growth 28,29 or speech outcomes between the two approaches. In the United States, a single-stage repair between 6 and 12 months of age represents 85% of all cleft palate repairs performed by surgeons of the American Cleft Palate-Craniofacial Association. 30 Two recent reports from large databases have shed light on the impact of timing on early ver sus late complications (ie, 30 days 31 versus 2000 days, 32 respectively). Overall, it was found that early repair was associated with worse outcomes at both endpoints. NSQIP patients ( n = 3088) who underwent single-stage repair before 6 months of age experienced a two-fold increase in 30-day complication rates ( P = 0.04) and a four- to five fold increase in readmissions ( P = 0.02) and reop erations ( P = 0.04) within the same timeframe (level of evidence: III). 31 With respect to 2000 day complication rates, a large database project using the IBM MarketScan Commercial Database ( n = 3046) identified that patients were more likely to require a secondary procedure if pri mary repair occurred before 10 months of age. However, patients were 60% less likely to require a secondary procedure if initial repair occurred
establishment of care with a multidisciplinary team that will follow up the child until completion of facial growth. 19–21 Beginning at 3 weeks of age, we institute early feeding evaluation, followed by regular orthodontic surveillance and care through a cleft and craniofacial team. Many patients with clefts are identified prenatally. This is more com mon in patients with cleft lip and palate, as cleft palate alone is more difficult to identify on prena tal ultrasound. Once a cleft palate is identified, we like to see the patient within the first 3 weeks of life. The timeline for care of a child who presents to our multidisciplinary cleft team with isolated cleft palate is shown (Fig. 4). Following adequate pre surgical preparation and clearance of any concur rent medical comorbidities, we prefer cleft palate repair at age 11 to 12 months to provide maximum time for facial growth without compromising speech development. Patients will subsequently be followed up by a multidisciplinary cleft team annually to monitor progression of speech, den tal and orthodontic development, and maxillary growth. Because of the substantial concordance between cleft palate and other congenital anoma lies, it is important for these children to be fully screened for coexisting diseases and syndromes and to obtain medical clearance for surgery, with special consideration of cardiac anesthesia needs and careful management of any airway anomalies. There is a 1.5 times higher risk of cardiac arrest in infants under general anesthesia between the ages of 1 and 12 months, suggesting that timing and medical optimization are important. 22 In addition, it is important for children to be not only medi cally but also nutritionally optimized, and if orally fed, they must be tolerating adequate oral intake with implementation of expected postoperative feeding restrictions on breast and bottle feeding before they ever undergo surgery.
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