Management of Cleft Lip and Palate: A Five Year Review

The child with a cleft palate cannot speak normally, is likely to suffer from earache and deafness, may leak food and fl uids through the nose, and may suffer from malnutrition as a result of an inability to feed properly [2]. It is imperative that surgical treatment to make the patients anatomically, functionally and aesthetically as near normal as possible be performed as soon as the patients are fi t to undergo surgery. Previous studies Abstract


Conclusion:
Combined cleft lip and palate was the commonest cleft deformity. Most patients were one year or younger. Millard's techniques with primary rhinoplasty provided acceptable aesthetic and functional result. Adequate pre-surgical preparation is a requirement for successful cleft palate repair.
on clefts in Kumasi have focussed on the epidemiological and social aspects of the condition [3]. There has been no publication on the surgical techniques used and the outcome of surgical management.

Patients and methods
A fi ve -year retrospective study was undertaken at Komfo Anokye Teaching Hospital (KATH) in Kumasi to document the clinical and epidemiological features, the surgical management and the outcome of treatment of patients presenting with either cleft lip, cleft palate or both, within the period from January 2010 to December 2014. Data on cleft patients were retrieved from the records of the cleft clinic and theatre records and analyzed. Data collected included the name, age, sex, type of cleft, the surgical procedure performed, and the outcome.
Patients with clefts who are referred to Komfo Anokye Teaching Hospital are normally seen at a multi-disciplinary cleft clinic run by a team comprising plastic and maxillofacial surgeons, anaesthetists, paediatricians, orthodontist, speech therapist, nurses and nutritionists [3]. Simple pre-surgical orthopaedics such as elastic traction strapping of a protruding prolabium or closing a palatal defect with an obturator to improve feeding may be done by the orthodontist as early as in the second week. Other problems like malnutrition and infections common especially in cleft palate patients are managed by the nutritionist and paediatricians respectively and the weight gain appropriately monitored. Patients are prepared for cleft lip surgery only when they are three months or older and cleft palate surgery was done after nine months of age [4]. In addition they should have been assessed and found fi t for surgery by the anaesthetist of the cleft team. Patients who were assigned to the authors' team for surgery were entered into the current study.
Unilateral cleft lip was repaired using Millard's rotationadvancement technique [5]. This was combined with closed primary nasal repair using the technique of McComb [6]. For bilateral cleft lip the preferred technique was Millard's onestage repair, where the prolabium was raised off the underlying premaxilla, and superiorly raised forked fl aps created from lateral parts of the prolabium, then turned laterally to run under the alar bases. Muscle bundles from the lateral lip elements were sutured to each other across the midline. The vermillion was reconstructed with lateral turn down fl aps. The philtrum was created with a prolabial fl ap using the technique of Mulliken [7]. Closed primary nasal repair was usually done.
Preliminary procedures such as lip adhesions and staged one sided repairs for bilateral cleft lips were not done as patients might not return for the defi nitive/secondary procedure.
Repair of cleft palate was performed using the single stage two fl ap palatoplasty with intravelar veloplasty, which is a modifi cation of the technique of Veau, Wardill and Kilner (Oxford palatoplasty) [8]. The patients were discharged to the outpatient department (OPD) after fi ve days. Thereafter they were reviewed weekly for one month; two weekly for two months and three monthly afterwards. Wound healing problems, speech defects and other complications were managed during these reviews.

Results
Within the period from January 2010 to December 2014 a total of 150 patients were treated for clefts by the authors' team.
They comprised 58 males and 92 females; a male to female ratio of 1: 1.6. The age distribution of the patients is shown in Table 1. Most (74%) of the patients who were operated upon were children aged 12 months or younger. Seven (4.6%) of the patients were adults who were not aware of the possibility of surgical correction of their deformity; they were identifi ed during cleft surgical outreach programmes.
The ages of the patients ranged from 0.25 to 25 years, mean age of one year (12 months), with standard deviation of 14.5months.
The types of deformity treated, the laterality, and the completeness or otherwise of the defects are depicted in Table 2. The commonest (85, N=150) deformity encountered was combined cleft lip and palate. Isolated cleft palate was the least common (23, N=150) deformity but it was associated with much morbidity (malnutrition, middle ear infections and post-operative wound dehiscence). There was a predominance (83%) of unilateral clefts, of which 46% were left-sided and 71% were complete. There were no cases of median clefts.   Mulliken's [7], modifi cation of Millard's operation enables a one-stage repair with primary correction of the nasal deformity.

Discussion
The repair of bilateral cleft lip is associated with complications such as partial wound dehiscence, oro-nasal fi stula and notching, in some series [15,16].   The considerations in cleft palate repair include the timing of the operation, the type of palatoplasty to be performed, and the effect of the repair on speech, facial growth, and Eustachian tube function. The factors that contribute to the outcome of a palatoplasty include cleft dysmorphogenesis, tissue defi ciency, types of clefts, specifi cs of the surgical repair, surgeon's profi ciency and multidisciplinary care. The two fl ap palatoplasty that was used in this study provides a one stage complete closure of the palate nasal lining and anatomic approximation of the levator muscle complex. Total release and dissection of the abnormal muscle attachments to the malformed skeletal base and proper approximation of the free muscle complex provides the basis for a functional palate [18].
In the current study four (17%) of the cases of repaired isolated cleft palate broke down completely and had to be repaired after three months. Wound infection, made worst by underlying malnutrition, was identifi ed to be the cause. A successful secondary repair was possible only after adequate food supplementation by the nutritionist for three months with correction of anaemia by the paediatrician. In all nine complications occurred in the current series, ranging from partial gaping at the base of the columella to complete disruption of palatal repair, giving an overall complication rate of 6%.
A similar study ( Adesina et al.) [15], involving 80 cleft surgeries in 75 patients revealed a high incidence of partial wound breakdown , vermillion notching and hypertrophic scar formation, giving an overall complication rate of 33%. 60% of these complications occurred with unilateral cleft lip repair, 24% with bilateral cleft lip repair, and 16% with cleft palate [15]. Even though the complication rate in the current study is much lower, probably because of the larger sample size, and there were no complications with bilateral cleft lip repair, the major complication of total disruption of a repaired cleft palate did not occur with the latter. It is therefore apparent from this study that successful palatal repair depends not only on meticulous surgical technique to create intact well perfused fl aps that are approximated across the cleft with minimal tension but also on pre-surgical preparation including providing adequate nutrition, treating infections and providing adequate pre-surgical orthopaedics where available.

Conclusion
The commonest cleft deformity encountered was combined cleft lip and palate, most of which occurred in children younger than one year. The Millard's techniques of cleft lip repair, appropriately modifi ed to include closed primary rhinoplasty, provide acceptable aesthetic and functional result. Successful management of cleft palate deformity requires adequate presurgical preparation for optimal results.