This study evaluated outcomes of primary unilateral cleft lip repair performed as single-day surgery in Pakistan. Of 23 patients, most clefts were mild (44.9%) or severe (40.2%). Fisher's technique was most commonly used. Postoperative outcomes were good in 89.8% of cases. Nasal symmetry outcomes improved over the study period. Single-day surgery reduced hospital costs by 19% without increasing complication rates compared to overnight admission. The study demonstrated primary unilateral cleft lip repair can be performed safely and cost-effectively as single-day surgery.

1. Khyber Teaching Hospital Peshawar, Pakistan
Mansoor Khan, M.B.B.S, F.C.P.S (Plast.)
Outcomes of primary
unilateral cheiloplasty
in same-day surgical settings

2. ne of the most common
congenital craniofacial
deformities…
•Shapira Y, Haklai Z, Blum I et al. Prevalence of non-syndromic orofacial clefts among Jews and Arabs, by type, site,
gender and geography: a multi-center study in Israel. IMAJ 2014 Dec;16(12):759-63.
•Kling RR, Taub PJ, Ye X et al. Oral clefting in china over the last decade: 205,679 patients.PlastReconstrSurg Glob
Open 2014;2(10):e236.

3. ncidence is highest in Asians
(1/500), followed by Caucasians
(1/1000) and Africans (1/2500)I•Shapira Y, Haklai Z, Blum I et al. Prevalence of non-syndromic orofacial clefts among Jews and Arabs, by type, site,
gender and geography: a multi-center study in Israel. IMAJ 2014 Dec;16(12):759-63.
•Kling RR, Taub PJ, Ye X et al. Oral clefting in china over the last decade: 205,679 patients.PlastReconstrSurg Glob
Open 2014;2(10):e236.

4. eported incidence in
Pakistan is 1.46 per
1000 live birthsR
•Elahi MM, Jackson IT, Elahi O et al. Epidemiology of cleft lip and cleft palate in P
•akistan. PlastReconstSurg 2004;113:1548-55.

5. urgical repairs dates
back to China’s Qin
Dynasty (221-206 BC)S
•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft
lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.
Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

6. •Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft
lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.
Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.
ose & Thompson
introduced the basic
technique to build on in
early 20th century

7. uadrilateral/triangular flaps &
rotation advancement
incorporates lateral lip tissue
into the medial lip segment, a
concept introduced by
Mirault
•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft
lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.
Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

8. c Comb, Cutting & Tajima
provided the concept of
incorporating primary rhinoplasty
with the lip repair
•Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft
lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J. 2014;16(11):693-6.
Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013;1:53.

9. or aesthetic evaluation of lip
repair, preoperative severity
and multiple postoperative
nasolabial anthropometric
parameters are considered, making it
a challenging job

10. ingle-day surgery is becoming
more common for an increasing
number of procedures in different
surgical specialities
•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.
•Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the need for routine admission following primary
cleft palate repair: An analysis of 100 consecutive cases. Plast Reconstr Surg.2015;136(4):502e-10e.
S

11. inancial benefits, fewer SSI rates,
expedites patients’ postoperative
recovery in the home environment
& avoids the psychological effects
of hospitalization
•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.
•Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the need for routine admission following primary
cleft palate repair: An analysis of 100 consecutive cases. Plast Reconstr Surg.2015;136(4):502e-10e.

12. lastic surgery procedures,
especially cleft lip and palate
repair, have been no exception to
this trend for single-day surgery to
become more common
•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.
•Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the need for routine admission following primary
cleft palate repair: An analysis of 100 consecutive cases. Plast Reconstr Surg.2015;136(4):502e-10e.

13. im; To evaluate the preoperative
severity and postoperative
outcomes of single-day primary
unilateral cleft nasoslabial repair

14. bjectives: shortening the patients’
hospital stay and decreasing their
economic burden on the
healthcare facility.

15. Methodology

16. onducted from
January 2011 to
December 2014

17. less than 3 months of age, syndromic
associations & co-morbidities, lack of
competent parents/relatives,
psychologically unstable, or lived far
from the hospital
EXCLUSION
CRITERIA

18. •Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
Pre-op
evaluation
Mild: Incomplete cleft lip
Moderate:
Complete/not wide
(Some tissue contact at rest )
Severe: Complete/wide
(No tissue contact)

19. Surgical
techniques..

20. Fisher’s
technique

21. Rotation advancement with uni-
limb z-plasty (Noordhoff’s)

22. Semi-open rhinoplasty (inverted
“U” incision) & Tajima
suspension stitch

23. Patients were kept in OT till
maintenance of oxygen saturation
without supplemental oxygen, breathing
without difficulty & responsive to verbal
stimulus
post operative
recovery/discharge
•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.

24. atients were monitored in the
recovery room till fulfilment of
discharge criterias: full
alertness, ambulation, pain free
& alimentation
•Wig J. The current status of day care surgery….a review. Indian J. Anaesth.2005;49(6):459-466.

25. who could drive him home and supervise
him for 24 hours with clear verbal & written
instructions for contacting the surgical staff
in case of pain/vomiting (refractory to the
prescribed medications), bleeding, fever,
infection, or other concerns.
Discharged under the
supervision of at least one
mentally/physically capable
escort

26. Post-op Nasolabial
Evaluation System
(NES)…?

27. •Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
1. Symmetry at the Cupid’s bow; Distance from the
base of the columella to bow’s peak.
2. Nasal symmetry; The shape of nostril, the dome
of nose and the distance from the midline of the
columella to the alar base.
3. Symmetry of lateral lip; Distance from the alar
base to white roll and angle of white roll.
4. Symmetry of the free vermilion;Two
measurements should be considered; distance
from the Cupid’s bow to free vermilion and from
the columella base to free vermilion.
5. The wet and dry vermillion relationship.

28. Symmetry at the Cupid’s bow;
Distance from the base of the columella
to bow’s peak.
•Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
1.

29. •Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
Nasal symmetry; The shape of nostril, the
dome of nose and the distance from the
midline of the columella to the alar base.2.

30. •Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
Symmetry of lateral lip; Distance
from the alar base to white roll and
angle of white roll.3.

31. •Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
Symmetry of the free vermilion;Two measurements
should be considered; distance from the Cupid’s bow to
free vermilion and from the columella base to free
vermilion.4.

32. •Bermudez L. Ciruestetic [Internet]. Bogota:Cirugia plastic;2013[cited 2015 October 16]. Available from
http://www.ciruestetic.com/resources/nasolabiaeval2013red.pdf
The wet and dry vermillion
relationship (red-line)5.

33. 0 ~ Poor 1~ Fair 2 ~ Good
> 2mm 1-2mm < 1mm
Symmetry at the Cupid’s bow;1

34. 0 ~ Poor 1~ Fair 2 ~ Good
Grossly
asymmetrical
Symmetrical size
but not shape
Size & shape
symmetrical
0 ~ Poor 1~ Fair 2 ~ Good
Nasal Symmetry2

35. Severe
asymmetrical
Some
asymmetry
Good
symmetrical
0 ~ Poor 1~ Fair 2 ~ Good
Symmetry of the lateral lip3

36. 0 ~ Poor 1~ Fair 2 ~ Good
clear notch
& asymmetry
small notch
& bulge
Continuous
Smooth curved
line
Symmetry at of free vermilion;4

37. 0 ~ Poor 1~ Fair 2 ~ Good
Severe
discrepancy some mismatch Good red line
Wet & dry vermillion relationship/redline
5

38. Good 8–10
Fair 5–7
Poor 0–4
Outcome score:

39. Results…

40. 23 primary unilateral
cleft lip patients were
included
4

41. ale to female
ratio was1.6:1
m

42. ge from 3 months
to 384 months

43. 44.9% mild, 14.9%
moderate, and
40.2% severe

44. Fisher’s anatomical
subunit approximation
technique was the most
common procedure,
followed by Noordhoff’s
technique

45. postoperative
outcome was good
in 89.8% of cases,
fair in 9.9% of cases,
and poor in 0.2% of
cases

46. symmetry of the nose
was good in 57.4%,
satisfactory in 38.3% &
unsatisfactory in 4.3%
of cases

47. Cleft lip severity versus postoperative outcomes.
Postop.
outcome
Severity of cleft lip
TotalMild Moderate Severe
Poor 0 0 1 1
Fair 3 2 37 42
Good 187(98.4%) 61(96.8%) 132(77.6%) 380
Total 190 63 170 423

48. Fisher’s repair,
89.4% good overall outcomes,
good Cupid’s bow symmetry 85.4%
Noordhoff’s technique
100% good outcomes &
good Cupid’s bow symmetry
But results were not statistically significant due to small sample
size in Noordhoff’s group during the study period

49. Symmetry of nasal deformity
Because we switched from closed technique to semi-open
with inverted U incision

50. Complications rate was 1.18% (n=5)
most common was stitch sinus 0.71%,
nasal hematoma (0.24%)
LRTI in (0.24%).

51. Average hospital stay
7.5 hours (6–9 hours).
Hospital cost was reduced
by 19% (3800 PKR)
Re-admission rate
was 0.24%
compared to the reductions of 15%–30% and 40% that have been
reported for the USA and UK, respectively

52. Cases..

59. Conclusions..

60. Mild and severe
unilateral cleft lip were the
most common deformities

61. Fisher’s anatomical subunit
approximation technique was
performed, with satisfactory
postoperative outcomes

62. Improvement in results was
observed over the study period by
including Noordhoff’s technique in
the procedure for severe forms

63. Refinements in the cleft
rhinoplasty techniques over
the course of the study
improved the results

64. Single-day primary unilateral cleft
cheiloplasty is a cost-effective
procedure that did not pose an
additional risk of complications.