15018752330
发表时间:2015-12-07 浏览次数:484次
Introduction
Cleft lip and cleft palate are the most common craniofacial
abnormalities seen worldwide. The prevalence of these anomalies ranges
from 1:300-1200 live births for cleft lip and 1:2500 for cleft palate. [1]
The history of surgical and aesthetic outcomes of cleft lip repair is
fascinating. The earliest attempts at cleft lip repair in China involved
creating the raw edges and passing straight needles through each side
of the wound. [1] The advent of modern suture materials and improved surgical techniques resulted in acceptable aesthetic outcome. [2]
These congenital deformities have a significant psychological and
socioeconomic effect on both the patient and their family. It often
leads to disruption of psychosocial functioning and decreased quality of
life. [3]
Current surgical repair involves anatomical dissection and geometric
rearrangement of muscle, mucosa, and skin flaps to achieve an improved
functional and cosmetic result.
The type of suture material used
in surgery has been a long-standing debate among surgeons. Many surgeons
prefer nonabsorbable suture material as it is easier to tie, unlikely
to break prematurely, and induces minimal inflammatory response. Others
feel that these issues are not important and prefer absorbable sutures
because they do not have to be removed and thus, decreasing patient's
anxiety and discomfort. [4]
This study aims to compare the cosmetic outcomes and complications of
primary cleft lip repaired with absorbable sutures versus nonabsorbable
sutures. It also aims to identify a feasible surgical technique for
Indian patients.
Methods
This study was conducted at the Smile Train Unit of Department of Cleft
and Craniofacial Surgery at Child Hospital and Research Institute in
Nagpur, India. Patients with cleft lip who presented here from June 2010
to May 2012 were selected for this study with the following inclusion
criteria:
Patients with unilateral primary cleft lip
Patients with 10 weeks age, 10 gm Hb %, and 10 pounds of weight
Patients physically fit to undergo general anesthesia (GA).
A total of 60 patients who met the criteria were included in this study, and they were divided into two groups randomly:
Group 1: (n = 30) Cleft lip repair was performed using absorbable suture (Vicryl Rapid) [Figure 1].
Group 2: (n = 30) Cleft lip repair was performed using nonabsorbable suture (Prolene) [Figure 2].
All patients underwent routine blood tests, and informed consent was
obtained from parents prior to surgery. The study was approved by the
institution's Ethical Committee. All patients underwent standard
Millard's rotational advancement technique by the same surgeon to repair
the cleft lip. Patients were randomized by providing the surgeon with a
sealed envelope that stated the type of suture to be used in the
procedure before entering the operation theater.
All patients in Group 2 required GA or sedation for removal of sutures on 7th postoperative day.
Patients
in both groups were evaluated for postoperative healing, infection
rate, disruption of the wound, wound dehiscence, hypertrophic scar
formation, and postoperative esthetic outcome. Patients were followed
and evaluated at 1 month, 6 months, and 1 year. Patient's photographs
were evaluated by three different people (social worker, surgeon and
patient's mother) using a validated 100 mm cosmesis visual analogue
scale (VAS). In this study, a VAS score of 15 mm or greater was
considered as a clinically significant difference. [5]
Descriptive statistical analysis was used to compare demographics and
wound characteristics of the study groups. Differences between the
groups were analyzed using variance analysis on rank data. VAS with a
clinical difference of 15 mm or less was considered clinically
significant.
Results
The average age of the patient was 3 months. There was no significant difference in the rates of infection which was 6% in this study, wound dehiscence, hypertrophic scar formation. There was no significant difference in the rates of infection, wound dehiscence, and hypertrophic scar formation. The postoperative wound infection was treated by oral amoxicillin in both groups [Table 1]. No significant difference was found in cosmetic outcome in both the groups with mean VAS of 90.3 in Group 1 and 91.7 in Group 2 [Table 2], [Table 3], [Table 4].
Discussion
Orofacial clefts are the most common head and neck congenital
malformations. Cleft lip and cleft palate have significant psychological
and socioeconomic effects on patient and affect their quality of life
thus, requiring a multidisciplinary approach for management. The complex
interplay between genetics and environmental factors plays a
significant role in the formation this anomaly. [1]
The primary goals of surgical repair are to restore normal function for
speech development and facial aesthetics. Different techniques are
employed based on surgeon's expertise and patient's anatomical
variations. These patients undergo multiple surgical interventions at a
very young age which poses a great challenge for the surgeons.
An
understanding of both the physical properties of the material and the
resulting tissue response to the material is important for choosing the
suture material for the procedure. Sutures that are absorbable may
initiate a prominent tissue response and result in suboptimal outcomes
including a persistent scar, tenderness, and suture extrusion. [6]
To the best of our knowledge, there are very few studies reported in
the literature that studied the cosmetic outcomes and complications
after cleft lip using absorbable and nonabsorbable suture materials.
Luck et al. compared the long-term cosmetic outcomes of
absorbable versus nonabsorbable sutures for facial lacerations in
children and concluded that fast-absorbing catgut suture is a viable
alternative to nonabsorbable suture in the repair of facial lacerations
in children. [7],[8] Holger et al.[9] and Karounis et al.[10]
compared the use of absorbable and nonabsorbable suture in traumatic
pediatric lacerations and found no significant difference in the
cosmetic outcome and complication rate.
Al-Abdullah et al.[11]
performed a systematic review of randomized controlled trials that
compared the cosmetic outcomes and complications of traumatic
lacerations and found no statistically significant difference between
absorbable and nonabsorbable sutures in short-term or long-term cosmetic
score, scar hypertrophy, infection rate, wound dehiscence, and wound
redness/swelling. This meta-analysis suggests a lack of large,
methodologically sound study evaluating the effectiveness of absorbable
versus nonabsorbable sutures.
Shinohara et al.[12]
used monofilament nylon as nonabsorbable material and polyglyconate,
polydioxanone as absorbable suture material and found no significant
difference in the cosmetic appearance of the scars. These studies
support the view that absorbable sutures are preferable to nonabsorbable
sutures for primary cleft lip repair. [12],[13] In addition, Collin et al.[14]
published the disadvantages of using nonabsorbable sutures in cleft lip
repair. These include a need for additional dressing, and return to the
hospital for removal of the sutures under sedation or GA. All of these
contribute to distress in the child and potential disruption of the
repair. [14]
This study shows no significant difference between absorbable and
nonabsorbable suture groups considering the cosmetic outcome in primary
cleft lip repair. It has been shown that the VAS is a useful way to
document subjective analysis of cosmetic outcome in this study. [5] As patients' assessment of aesthetic outcome is subjective, the use of VAS in this study was appropriate.
A
motivational factor to use an absorbable suture for cleft lip patients
in this study was to avoid exposure to anesthesia for suture removal
after 7 days. Furthermore, this study shows no clinically significant
differences in cosmetic appearance between absorbable and nonabsorbable
sutures at 1 month, 6 months, and 1 year. The results of this study are
consistent with previously published reports.
This study
demonstrates that there are no long-term differences in cosmetic outcome
and complication rates between absorbable and nonabsorbable sutures in
patients with primary unilateral cleft lip. All the patients enrolled in
this study were operated by one surgeon using absorbable and
nonabsorbable sutures and showed equal results. We recommend the use of
absorbable suture for the closure of primary cleft lip as this technique
saves one additional exposure of the child for the GA for suture
removal.
References
1.Sandberg DJ, Magee WP Jr, Denk MJ. Neonatal cleft lip and cleft palate repair. AORN J 2002;75:490-8.
2.Firth HV, Hurst JA. Clinical approach. In: Genetics. Oxford: Oxford Medical Press; 2006. p. 74-7.
3.Marcusson A, Akerlind I, Paulin G. Quality of life in adults with repaired complete cleft lip and palate. Cleft Palate Craniofac J 2001;38:379-85.
4.Parell GJ, Becker GD. Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Arch Facial Plast Surg 2003;5:488-90.
5.Draaijers LJ, Tempelman FR, Botman YA, Tuinebreijer WE, Middelkoop E, Kreis RW, van Zuijlen PP. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg 2004;113:1960-5.
6.Erel E, Pleasance PI, Ahmed O, Hart NB. Absorbable versus non-absorbable suture in carpal tunnel decompression. J Hand Surg Br 2001;26:157-8.
7.Luck RP, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care 2008;24:137-42.
8.Luck R, Tredway T, Gerard J, Eyal D, Krug L, Flood R. Comparisn of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care 2013;29:691-5.
9.Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med 2004;22:254-7.
10.Karounis H, Gouin S, Eisman H, Chalut D, Pelletier H, Williams B. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med 2004;11:730-5.
11.Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis. Pediatr Emerg Care 2007;23:339-44.
12.Shinohara H, Matsuo K, Kikuchi N. Absorbable and nonabsorbable buried sutures for primary cleft lip repair. Ann Plast Surg 1996;36:44-6.
13.Choudhary S, Cadier MA. Cleft lip repair: rub off the sutures, not the smile! Plast Reconstr Surg 2000;105:1566.
14.Collin TW, Blyth K, Hodgkinson PD. Cleft lip repair without suture removal. J Plast Reconstr Aesthet Surg 2009;62:1161-5.