Repair Sequence and Management of the Premaxilla in Patients With Bilateral Cleft Lip and Palate: A Systematic Review of the Literature

Abstract

Background: Bilateral cleft lip and palate (BCLP) remains a difficult surgical problem due to the severely protruding premaxillary segment, with no consensus of optimal treatment sequence in older patients. A systematic review of the literature was performed to assess the current status of BCLP repair based on age. Methods: A PRISMA systematic review of the PubMed, Web of Science, and Embase databases was performed using a series of search terms related to BCLP. Studies were categorized based on the age of presentation, repair sequence, and technique. Results: The database search identified 381 articles. Of these, 72 manuscripts were ultimately included. The lip was repaired first in 1077 patients (86.0%), palate first in 161 patients (12.9%), and simultaneous lip and palate in 14 patients (1.1%). Patients less than 6 months old received lip repair first (n ¼ 959, 98.6%), with complications of unaesthetic appearance (n ¼ 86, 62.3%) and midface retrusion (n ¼ 41, 34.1%) in younger patients and wound dehiscence (n ¼ 8, 40%) in older patients. Primary lip repair was preceded by presurgical orthopedics (n ¼ 760) or lip adhesion (n ¼ 272) to reduce lip tension with nasoalveolar molding (n ¼ 452, 62.9%) or the Latham device (n ¼ 282, 37.1%). In older patients, the palate was repaired first or premaxillary setback (n ¼ 222) was indicated in protruded premaxillae greater than 10 mm, but carried the risk of premaxilla mobility (n ¼ 20, 37.7%) and midface retrusion (n ¼ 10, 18.9%). Conclusion:In younger patients, lip repair is performed first with preoperative orthopedics or lip adhesion. In older patients, the palate is more commonly repaired first compared with the lip; however, there is no difference in complication rate.