Perceptions of Surgeons, Parents, and Children: What are the True Indications for Cleft Revision?
Kavitha Ranganathan, M.D., Jeanne Kochkodan, B.S., Michealla Baker, B.S., Niki Matusko, B.S., Christian J. Vercler, M.D., Steven J. Kasten, M.D., Steven R. Buchman, M.D., Jennifer F. Waljee, M.D., M.S..
University of Michigan, Ann Arbor, MI, USA.
PURPOSE: Although revision surgery is an important part of the reconstructive process for children with clefts, the indications for revision are variable. Although assumed that surgeons, children, parents, and lay people define success of a cleft repair similarly, the extent of agreement is unclear. Performing revision when the child is satisfied without recognizing differing perceptions between patients and providers may disempower the child and preclude future revision. The goal of this study was to understand the extent of variation between cleft surgeons, general plastic surgeons, children, parents, and lay people in defining the success of a cleft repair.
METHODS: Children with cleft lip and/or palate (CLCP) (n=100), and their parents (n=100) were surveyed regarding satisfaction with cleft-specific aspects of appearance based on metrics defined by the Cleft Evaluation Profile (CEP). Surgeons (n=10) and lay people (n=10) were given standardized photos of these same children and asked to rate satisfaction with the face, nose, upper lip, and maxilla, features analogous to constructs on the CEP. Cleft surgeons (n=5) and general plastic surgeons (n=5) were surveyed for comparison. We used paired T-tests to compare ratings between groups designed to detect a difference with 80% power and alpha of 0.05.
RESULTS: A total of 100 children with CLCP were included. The average age was 10.29 years, and 52% were male. Children with clefts were significantly more satisfied with their appearance compared to surgeons (nose: 7.75±2.53 vs. 5.67±1.97, p<0.001; lip: 7.72±2.53 vs. 5.98±2.19, p<0.001; maxilla: 8.63±1.65 vs. 6.79±2.30, p<0.001) and lay people (nose: 7.75±2.53 vs. 6.07±2.45, p<0.001; lip: 7.72±2.53 vs. 6.12±2.35, p<0.001; maxilla: 8.63±1.65 vs. 7.41±2.50, p=0.001). Cleft surgeons were significantly less satisfied with cleft-specific aspects of appearance than general plastic surgeons (nose: 5.2±2.01 vs. 6.08±1.88, p=0.03; lip: 5.48±2.05 vs. 6.38±2.28, p=0.001; maxilla: 6.04±2.3 vs. 7.48±2.08, p=0.001). There were no significant differences between lay people and general plastic surgeons’ ratings (nose: 6.02±2.65 vs. 6.08±1.88, p=0.85; lip: 5.9±2.64 vs. 6.38±2.28, p=0.16; maxilla: 7.46±2.67 vs. 7.48±2.08, p=0.96). Children were more satisfied with appearance of the nose than their parents (5.5±1.69 vs. 5.1±1.52, p=0.03), but were similarly satisfied with the lip (5.48±1.69 vs. 5.6±1.49, p=0.54) and maxilla (6.08±1.1 vs. 5.8±1.2, p=0.07). (Figure 1).
CONCLUSION: All groups evaluated expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children are more satisfied with their appearance than other groups, while cleft surgeons have the most stringent criteria for success. In the case of revision surgery, care must be taken to evaluate the perceptions of all stakeholders in defining accurate outcomes. Perceptions of children must be evaluated independently when determining the potential benefit of revision surgery.
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