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The Burden Of Nasoalveolar Molding: Is It The Most Cost-effective Approach To Facilitate Wide Cleft Lip And Nasal Repair?
Jordan Wlodarczyk, M.D., M.S.1, Erik Wolfswinkel, MD1, Artur Fahradyan, MD1, Pedram Goel, BS1, Emma Higuchi2, Claire Rhee1, William Magee, III, MD, DDS, FACS1, Stephen Yen, DDS1, Mark Urata, MD, DDS, FACS1, Jeffery Hammoudeh, MD, DDS, FACS1.
1CHLA, Los Angeles, CA, USA, 2Stanford University, Stanford, CA, USA.

PURPOSE: Over the last three years a shift at our institution has taken place in which patients originally designated for nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. After implementing the ECLR program at CHLA, only a small subset of patients still undergo NAM with the standard surgical timing of repair. The financial and social impact of this potential paradigm shift has not been studied. We sought to examine the financial and cost-effectiveness of the ECLR protocol.
METHODS:
We reviewed records for all patients who underwent NAM as an adjunct to cleft lip repair from November 2011 to June 2018. From November 2011 to February 2014, NAM with standard timing of lip repair was the only intervention offered to patients with wide cleft lip defects. From February 2014 to June 2018, ECLR without adjunctive NAM was offered as an alternative. Retrospective chart review of the two groups was conducted with emphasis on the following variables: NAM and ECLR cleft classifications, NAM dental visits, ECLR length of hospital stay, ECLR patients’ cleft width ratio (CWR), and operative dates. ECLR patients who had a Cleft Width Ratio (CWR), defined as the cleft width/commissure width, of > 0.5 and unilateral complete cleft lip (UCL) were identified as patients who would have originally been offered NAM as an adjunct to their cleft lip repair.
RESULTS:
NAM patients required an average of 11 preoperative dental visits, accounting for $2,132 in lost income per family. The average direct costs of NAM totaled $12,290 for the hospital, physician, and device costs. The cumulative direct cost of NAM over the entire study period was $970,910. ECLR patients underwent lip repair significantly earlier than NAM patients (33 ± 14 days vs. 112.9 ± 28 days, p< 0.001). Following the introduction of ECLR, NAM usage decreased by 48% (52 to 27 patients) and unilateral cleft lip patients undergoing NAM decreased by 86% (35 to 5 patients). 26 patients were diverted from NAM to ECLR resulting in a healthcare cost burden of $319,540 less ($96,830 per year).
CONCLUSION: ECLR without NAM is more cost-effective and results in excellent surgical and aesthetic outcomes. NAM as an adjunct to wide cleft lip and nasal repair is no longer the most cost-effective option at our institution. We believe that ECLR has the potential to decrease the burden of health care costs in the United States.



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