Research Article Retrospective Review of Patients Operated on with Bilateral Cleft Lip ... · 2019. 7. 31. · Cleft Lip through Surgical Outreaches in Kenya F.W.NangoleandS.O.Khainga

Hindawi Publishing CorporationISRN Plastic SurgeryVolume 2013, Article ID 268094, 4 pageshttp://dx.doi.org/10.5402/2013/268094

Research ArticleRetrospective Review of Patients Operated on with BilateralCleft Lip through Surgical Outreaches in Kenya

F. W. Nangole and S. O. Khainga

Department of Surgery, University of Nairobi, P.O. Box 19676, Nairobi 00202, Kenya

Correspondence should be addressed to F. W. Nangole; [email protected]

Received 28 February 2013; Accepted 19 March 2013

Academic Editors: M. Okazaki and E. Raposio

Copyright © 2013 F. W. Nangole and S. O. Khainga. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

This was a study to evaluate the characteristics and outcome of patients operated on with bilateral cleft lip through surgical outreachprograms in Kenya between January 2006 andDecember 2011. Files for fifty-nine patients operated on during the study period wereevaluated. The mean age for surgery was ten months with about forty-five percent of the patients more than one year of age. Nopresurgical orthopaedic devices were utilized on any of the patients. Mulliken surgical technique and the Manchester techniquewere the commonest surgical techniques in equal proportions. An overall complication rate of about 7.5 percent was noted. Inconclusion we noted a delay in the surgical management of the majority of our patients.This resulted in a backlog of cases.There isthus a need to intensify more surgical outreach camps as well as training more surgeons to assist in the management of clefts. Cleftsurgery is a relatively safe surgery that could be carried out in relatively remote centers through surgical outreach programs. Thiswas evidenced by the low complication rates in our series.

1. Introduction

Cleft lip and palate are common congenital malformationswith the overall prevalence ranging between 1 : 500 and1 : 1000 from the various communities [1, 2]. High prevalencerates have beennoted among the nativeAmericans,Orientals,Caucasians, and lastly the Blacks in that order [1–3]. Theprevalence of bilateral cleft lip has been noted to be about 20percent of all cleft lips [1–3].

Bilateral cleft lip has been noted to be twice as hard tomanage and the results twice as disappointing. However, thisis not necessarily true. Many authors have reported verysatisfactory results with bilateral cleft lip surgeries [4, 5].

The best way to manage bilateral cleft lip deformities isthrough themultidisciplinary approach encompassing plasticsurgeons, orthodontists, nutritionists, geneticists, counselors,and maxillofacial surgeons [6, 7]. The reality in many devel-oping countries, however, is that it is almost impossible tocraft such a team given the limited skilled labor force. Whilepresurgical orthopaedic devices may have a positive role inthe management of bilateral cleft lip, these devices are notreadily available in many countries.

In this paper, we present our experience in the manage-ment of this condition in Kenya. Kenya like many developingcountries in Africa has got very few qualified plastic ormaxillofacial surgeons. The majority of them are localized inbig cities. However, most patients with cleft deformities arelocated in rural centres far away from the cities and could thusonly be reached through outreach programs. We present theresults of the patients operated on through such programs inour country.

2. Materials and Methods

This was a retrospective chart review of the patients operatedon by the authors in various outreach facilities in Kenya.The Facilities were St. Elizabeth Mission Hospital, Mukumu(about 300 kilometres from Nairobi), Isiolo District Hospital(300 kilometres From Nairobi), Longonot hospital (100 kilo-metres fromNairobi), and Kapenguria District Hospital (400kilometres from Nairobi).

All files for the patients operated on between January2006 and December 2011 by the authors were reviewed.

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Supplementary information was retrieved from the operat-ing theatre registers and the surgeons’ operations database.Information collected for analysis included any presurgicalintervention measures, age at surgery, type of anesthesiaemployed, surgical procedure employed, duration of surgery,and complications. Cases with inadequate data were excludedfrom the study. Data was analyzed by the SPSS computersoftware for the descriptive statistics.

3. Results

A total of 59 patients operated on between January 2006and December 2011 with bilateral cleft lip were reviewed inthis study. 6 patients were excluded from the study due toinconclusive data leaving 53 patients for the study. The male-to-female ratio of the patients was 1.2 to 1. The age range forthe patients was 3 months to 27 years, with a mean age of2.5 years. Table 1 summarizes the various age groups of thepatients operated on.

All patients were managed as inpatients with a meanhospital stay of five days. No presurgical orthopedic deviceswere utilized on any of the patients. There was no lip adhe-sions surgery. Prophylactic antibiotic cefuroximewas utilizedroutinely for all patients at induction. Oral amoxicillin wasthen given for five days after surgery. Local anaesthesia wasutilized in 5 patients (9 percent of the cases) with the restunder general anaesthesia. The Manchester type of surgerycomprised 52 percent of the surgeries with the Mulliken typeof surgery comprising 48 percent of the surgical procedures.The average duration of surgery for the Manchester type ofsurgery was one hour ten minutes while the Mulliken typeof surgery was one hour forty minutes. The complicationsencountered in this study were partial lip dehiscence in3 patients and postsurgical pneumonia in 1 patient. Nomortalities were encountered. The overall complication ratewas thus 7.5 percent.

4. Discussion

Bilateral cleft lip has been noted in the literature to be twiceas hard to manage with the results half as good. The defectsin the bilateral cleft lip are characterized by the following:

(1) lateral and inferior displacement of the lower lateralcartilages,

(2) fibroadipose depositions between the lower lateralcartilages,

(3) rudimentary/underdeveloped columella,(4) protruded premaxilla,(5) underdeveloped prolabium with no muscular ele-

ments.

All these factors contribute to making the bilateral cleftrepair a more difficult one. Many strategies have beendeveloped to try and rectify some of these defects prior tothe surgery. Among these is the presurgical orthopaedics.The use of presurgical orthopaedics is still controversial witha number of studies either showing that it has no role in

Table 1: Age presentation for the patients operated on.

Age Frequency PercentageLess than 6 months 14 26.56 months–1 year 16 301–5 years 9 175–15 years 8 15>15 years 6 11.5Total 53 100

the management of cleft lip or that it may have deleteriouseffects [8–11]. The main reason for the use of a presurgicalorthopaedic device is to assist on the alignment of thepremaxilla and hence enable easier repair of the muscle. Theother advantage is the assistance in the correction of the nasaldeformity. In all our cases none of these devices were utilized.The main reason for this was the cost and the lack of thetechnical knowhow in making these devices.

A good proportion of our patients were operated on aftertheir first year of life. Most centers in the developed countriesoperate cleft lip at around four months of age, using the ruleof ten as a general guiding principle [5, 12]. This is, however,not the case in the developing countries like ours. Thereare two main reasons for this. One is the “late” diagnosisof cleft deformities and the other is the lack of resources toenable prompt management of cleft deformities. These twofactors have resulted in a backlog of cases inmany developingcountries, as evidenced by an older population of the patientsthat we encountered in this study.

Probably the best way to deal with this backlog of cases isthrough surgical outreach programs as demonstrated in thisstudy. Well-organized programs can be very fulfilling to thepatients and the surgical team as well. Successful outreachprograms require good coordination between the visitingteam and the medical personnel in the facility being visited.Roles and responsibilities must be clearly defined and thehome teammust be comfortable to do the postoperative careand management of the patients.

About half of the cases were operated on in our seriesusing theManchester type of repair with the other half treatedwith theMulliken type of repair. While there was no clear cutguideline on what repair to use, the Mulliken type of repairwas utilized in cases where there was a poorly developedcolumella with severe nasal deformity. The Manchester typeof repair was mainly utilized in incomplete bilateral cleftlip or cases with relatively well-developed columella. Withthese approaches we were able to get good nasal repair in themajority of the cases Figures 1(a), 1(b), 2(a), and 2(b).

The Manchester type of repair is a relatively easy repairto perform with a shorter learning curve as compared to theMulliken or Nagata type of repair. It is also easier to teachand probably better to perform in outreach surgical campsas opposed to the Mulliken surgical technique. It, however,to minimally addresses the nasal deformity and therefore forpatients with severe nasal deformity would always result insuboptimal results. Mulliken type of repair best addresses thenasal deformity in bilateral cleft lip [5]. It encompasses greater

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(a) (b)

Figure 1: A 22-year-old male patient, with bilateral cleft lip before and 2 months after surgery, had a Mulliken type of repair.

(a) (b)

Figure 2: A 6-month-old male child with bilateral cleft lip, before and 6 months after surgery, had a Mullikentype of repair.

dissection of the nose with removal of the fibrofatty tissuesbetween the lower cartilages. This enables the correctionof the splayed lower cartilages allowing for the columellalengthening and recreation of the nasal tip complex. Thesurgerywould thus naturally take longer than theManchestersurgery which does not incorporate more extensive nasaldissection. Its disadvantage is the extra scarring along the alarrim as compared to the Manchester repair.

Our overall complication rate in this series was about7 percent. Partial wound dehiscence was the commonestcomplication, noted in 3 patients.Themuch feared prolabiumflap necrosis with the Mulliken repair was not noted in anypatient. The complication rates in this study compare fairlywell to those from different parts of the world [13, 14].

There was no statistical difference in the complicationsbetween the two surgical procedures employed.

In conclusion, well-planned outreach programs could beeffective in the management of bilateral cleft lip in manydeveloping countries such as Kenya. Bilateral cleft lip surgeryin good hands is a safe surgery and could be managedeffectively in rural and remote parts of the country throughsurgical outreaches. Proper patient selection with the choiceof the appropriate surgical procedure would always result

in good surgical outcome with minimal complications. Oneneeds to acquaint himself to the various surgical optionsavailable and then chooses the appropriate procedure forthe case at hand. In many developing countries surgicaloutreaches are probably the only option for addressing thebacklog of cases. There is, however, a need to train moresurgeons in these countries to be able to perform cleft lipsurgeries more so in the rural areas.

References

[1] M. M. Tolarova and M. M. Cervella, “Classification and birthprevelance of orafacial clefts,” The American Journal of HumanGenetics, vol. 75, pp. 126–137, 1998.

[2] L. A. Croen, G. M. Shaw, C. R. Wasserman et al., “Racialand ethnic variations in the prevalence of orofacial clefts inCalifornia, 1983–1992,” American Journal of Medical Genetics,vol. 79, no. 1, pp. 42–47, 1998.

[3] F. Masaki, Y. Kazuhiko, K. Masayoshi et al., “Clinico-statisticalstudy on Cleft Lip and palate in the past 20 years at the dept oforal & maxillofacial surgery, Nara Medical University,” Journalof Japanese Cleft Palate Association, vol. 28, no. 3, pp. 338–349,2003.

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[4] T. Nakajima, H. Ogata, and H. Sakuma, “Long-term outcomeof simultaneous repair of bilateral cleft lip and nose (a 15 yearexperience),” British Journal of Plastic Surgery, vol. 56, no. 3, pp.205–217, 2003.

[5] J. B. Mulliken, J. K. Wu, and B. L. Padwa, “Repair of bilateralcleft lip: review, revisions, and reflections,” The Journal ofCraniofacial Surgery, vol. 14, no. 5, pp. 609–620, 2003.

[6] N. H. Robin, H. Baty, J. Franklin et al., “The multidisciplinaryevaluation and management of cleft lip and palate,” SouthernMedical Journal, vol. 99, no. 10, pp. 1111–1120, 2006.

[7] S. Takehiko, Y. Atsushi, I. Yoshimichi et al., “Multidisciplinarymanagement for cleft lip and palate patients: a team approachfrom Tohoku University,” Japanese Journal of Plastic and Recon-structive Surgery, vol. 45, no. 2, pp. 117–123, 2002.

[8] C. T. H. Lee, B. H. Grayson, C. B. Cutting, L. E. Brecht, and W.Y. Lin, “Prepubertal midface growth in unilateral cleft lip andpalate following alveolar molding and gingivoperiosteoplasty,”TheCleft Palate-Craniofacial Journal, vol. 41, no. 4, pp. 375–380,2004.

[9] S. Berkowitz, M. Mejia, and A. Bystrik, “A comparison ofthe effects of the Latham-Millard procedure with those ofa conservative treatment approach for dental occlusion andfacial aesthetics in unilateral and bilateral complete cleft lipand palate, part I: dental occlusion,” Plastic and ReconstructiveSurgery, vol. 113, no. 1, pp. 1–18, 2004.

[10] C. A. M. Bongaarts, M. A. vant Hof, B. Prahl-Andersen, I. V.Dirks, and A. M. Kuijpers-Jagtman, “Infant orthopedics has noeffect on maxillary arch dimensions in the deciduous dentitionof children with complete unilateral cleft lip and palate,” TheCleft Palate-Craniofacial Journal, vol. 43, no. 6, pp. 665–672,2006.

[11] A. Uzel andN.Alpastar, “Long-term effects of presurgical infantorthopedics in patients with cleft lip and palate: a systematicreview,”The Cleft Palate-Craniofacial Journal, vol. 48, no. 5, pp.587–595, 2011.

[12] D. R. Millard, “The Embryonic rationale for the primarycorrection of classical congenital clefts of the lip and palate,”Annals of the Royal College of Surgeons of England, vol. 76, no. 3,pp. 150–160, 1994.

[13] A. DeMey, J. Vadoud-Seyedi, F. Demol, andM. Govaerts, “Earlypostoperative complications in primary cleft lip and palatesurgery,” European Journal of Plastic Surgery, vol. 20, no. 2, pp.77–79, 1997.

[14] V. C. Lees and R. W. Pigott, “Early postoperative complicationsin primary cleft lip and palate surgery how soon may wedischarge patients from hospital?” British Journal of PlasticSurgery, vol. 45, no. 3, pp. 232–234, 1992.

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Research Article Retrospective Review of Patients Operated on with Bilateral Cleft Lip ... · 2019. 7. 31. · Cleft Lip through Surgical Outreaches in Kenya F.W.NangoleandS.O.Khainga