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Does Early Referral Lead to Early Repair? Quality Improvement in Cleft Care
Katelyn Kondra, Eloise Stanton, Christian Jimenez
1From the Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA.
Insights
Early cleft lip repair (ECLR) is more common with prenatal diagnosis and consultation. Prenatal diagnosis and consultation significantly increase the likelihood of early cleft lip repair, offering better outcomes for infants with unilateral cleft lip (UCL).
Area of Science:
- Craniofacial surgery
- Pediatric surgery
- Congenital defect research
Background:
- Cleft lip and palate is a common congenital head and neck defect.
- Early cleft lip repair (ECLR) (<3 months) is preferred for unilateral cleft lip (UCL) due to improved outcomes.
- Traditional lip repair (TLR) is typically performed later (3-6 months).
Purpose of the Study:
- To evaluate the correlation between prenatal diagnosis and consultation with the incidence of early cleft lip repair (ECLR).
- To assess referral patterns and their impact on the timing of cleft lip repair.
- To validate whether prenatal diagnosis and consultation lead to ECLR for unilateral cleft lip (UCL).
Main Methods:
- Retrospective review of patients who underwent ECLR or TLR ± NAM from 2009-2020.
- Analysis of repair timing, diagnosis timing, and surgical consultation timing.
- Inclusion criteria: UCL diagnosis, age < 3 months for ECLR or 3-6 months for TLR; exclusion: bilateral cleft lip or craniofacial syndromes.
Main Results:
- 70.1% of patients received a prenatal diagnosis of UCL.
- Only 5.6% of families had prenatal consultations, all of whom underwent ECLR.
- Prenatal diagnosis (P=0.027) and prenatal consultation (P=0.008) were significantly correlated with ECLR.
Conclusions:
- Prenatal diagnosis and consultation are significantly associated with early cleft lip repair (ECLR) for unilateral cleft lip (UCL).
- Education for referring providers on ECLR and prenatal consultation benefits is recommended.
- Facilitating prenatal consultations can help more families access the benefits of ECLR.
Background:
Cleft lip and palate is the most common congenital defect of the head and neck, occurring in 1 of 700 live births. Diagnosis often occurs in utero by conventional or 3-dimensional ultrasound. Early cleft lip repair (ECLR) (<3 months of life) for unilateral cleft lip (UCL), regardless of cleft width, has been the mainstay of lip reconstruction at Children's Hospital Los Angeles since 2015. Historically, traditional lip repair (TLR) was performed at 3 to 6 months of life ± preoperative nasoalveolar molding (NAM). Previous publications highlight the benefits of ECLR, such as enhanced aesthetic outcomes, decreased revision rate, better weight gain, increased alveolar cleft approximation, cost savings of NAM, and improved parent satisfaction. Occasionally, parents are referred for prenatal consultations to discuss ECLR. This study evaluates timing of cleft diagnosis, preoperative surgical consultation, and referral patterns to validate whether prenatal diagnosis and prenatal consultation lead to ECLR.
Methods:
Retrospective review evaluated patients who underwent ECLR versus TLR ± NAM from 2009 to 2020. Timing of repair, cleft diagnosis, and surgical consultation, as well as referral patterns, were abstracted. Inclusion criteria dictated: age < 3 months for ECLR or 3 to 6 months for TLR, no major comorbidities, and diagnosis of UCL without palatal involvement. Patients with bilateral cleft lip or craniofacial syndromes were excluded.
Results:
Of 107 patients, 51 (47.7%) underwent ECLR whereas 56 underwent TLR (52.3%). Average age at surgery was 31.8 days of life for the ECLR cohort and 112 days of life for the TLR cohort. Furthermore, 70.1% of patients were diagnosed prenatally, yet only 5.6% of families had prenatal consults for lip repair, 100% of which underwent ECLR. Most patients were referred by pediatricians (72.9%). Significance was identified between incidence of prenatal consults and ECLR (P = 0.008). In addition, prenatal diagnosis was significantly correlated with incidence of ECLR (P = 0.027).
Conclusions:
Our data demonstrate significance between prenatal diagnosis of UCL and prenatal surgical consultation with incidence of ECLR. Accordingly, we advocate for education to referring providers about ECLR and the potential for prenatal surgical consultation in the hopes that families may enjoy the myriad benefits of ECLR.
