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An Exploratory Analysis of Early Care Differences and Risk of Post-Maxillary Advancement VPI in Individuals With
Sara Kinter1,2,3, Hitesh Kapadia4,5, Srinivas Susarla3,6,7,8
1Department of Pediatrics, Division of Craniofacial Medicine, University of Washington, Seattle, WA, USA.
Insights
Early cleft care at different institutions increases the risk of velopharyngeal insufficiency (VPI) after maxillary advancement. Consistent care at a single center is associated with better outcomes for VPI risk.
Area of Science:
- Craniofacial Surgery
- Pediatric Plastic Surgery
- Speech-Language Pathology
Background:
- Velopharyngeal insufficiency (VPI) is a common complication following primary cleft palate repair.
- Maxillary advancement is a surgical procedure used to correct midface hypoplasia in patients with cleft lip and palate.
- The impact of fragmented versus centralized early cleft care on VPI risk after maxillary advancement is not well-established.
Purpose of the Study:
- To determine if variations in early cleft care, specifically receiving initial palate repair at a different institution versus consistent care at a single center, influence the risk of VPI after maxillary advancement.
Main Methods:
- Retrospective cohort study of 178 adolescents and young adults (AYAs) who underwent maxillary advancement.
- Comparison of VPI rates between patients with early care elsewhere (ECE) and consistent care (CC) at a single institution.
- Analysis using proportional odds regression, controlling for relevant demographic and clinical factors.
Main Results:
- The ECE group had a higher likelihood of post-maxillary advancement VPI (OR 1.46).
- This association was more pronounced in patients with bilateral cleft lip and palate (OR 3.29) and those with a history of VPI surgery (OR 3.06).
- The ECE group also showed a tendency towards shorter velar length.
Conclusions:
- Fragmented early cleft care is associated with an increased risk of VPI following maxillary advancement.
- Centralized, consistent cleft care at a single institution may mitigate VPI risk after maxillary advancement.
- These findings underscore the importance of coordinated, multidisciplinary care in optimizing outcomes for cleft patients.
Abstract:
ObjectiveTo investigate whether differences in early cleft care increase risk of velopharyngeal insufficiency (VPI) after maxillary advancement.DesignRetrospective cohort study.SettingLarge pediatric tertiary care hospital.Patients/ParticipantsAdolescents and young adults (AYAs) with cleft palate (∓cleft lip) who underwent maxillary advancement between 2008 and 2019.Interventions/ComparisonsInitial palate repair at a different institution (early care elsewhere, ECE) versus care at a single institution (consistent care, CC).Main Outcome MeasuresPost-maxillary advancement VPI.ResultsOne-hundred seventy-eight AYAs underwent maxillary advancement, 74 in the ECE group and 104 in the CC group. The ECE group was more likely to be internationally adopted (34% versus 4%), to have a history of VPI surgery (54% versus 32%) and to be older at time of palate repair (mean 25 versus 16 months). Of anatomical measures, only velar length differed, with the ECE group tending to have a shorter velum (mean 26 mm versus 28 mm). Proportional odds regression revealed increased odds of post-operative VPI in the ECE group (OR 1.46, 95% CI 0.75-2.85) relative to the CC group. This relationship was stronger among those with bilateral cleft lip and palate (OR 3.29, 95% CI 0.86-13.52). For patients with history of prior VPI surgery, the odds of post-operative VPI in the ECE group was more than 3 times that in the CC group (OR 3.06, 95% CI 1.08-9.16).ConclusionsVPI after maxillary advancement is more likely among individuals who received early cleft care elsewhere compared to those who underwent all cleft operations at a single center.
