Reducing The Burden Of Care Of Cleft Lip Nasal Deformities Using Early Cleft Lip Repair
Christian Jimenez, BS1,2, Katelyn Kondra, MD1,2, Eloise Stanton, BA1,2, Nicolas Malkoff, BS1, Laya Jacob, BS1, Erik Wolfswinkel, MD2,3, Mark M. Urata, MD, DDS2,4, William P. Magee, MD, DDS2,4, Jeffrey Hammoudeh, MD, DDS2,4.
1Keck School of Medicine, Los Angeles, CA, USA, 2Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA, 3Division of Plastic and Reconstructive Surgery, Oregon Health Science University, Portland, OR, USA, 4Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA.
PURPOSE: Cleft lip nasal deformities are one of the most common congenital anomalies in the United States with recent lifetime cost estimates totaling $101,000 per new diagnosis. Early cleft lip repair (ECLR) (1-3 months of age) for unilateral cleft lip (UCL) has been the mainstay of cleft lip reconstruction at our institution for the past 6 years. Prior to the introduction of ECLR, traditional lip repair (TLR) was performed at 3-6 months of age with or without adjunctive nasoalveolar molding (NAM). This study aims to determine if ECLR is advantageous for reducing the need for cleft lip nasal revisions as the child ages.
METHODS: This is an IRB-approved, retrospective review performed on all patients with UCL nasal deformities ± palate who were non-syndromic and received cleft lip nasal repair by two senior attending surgeons from 2009 to 2021. Clinical and operative reports were examined for demographic and perioperative information. Three-dimensional photographs were reviewed by both senior attending surgeons and an independent distinguished professor in cleft surgery. Hospital and physician costs were determined using CPT codes for major and minor cleft lip revisions to estimate the burden of care.
RESULTS: A total of 111 patients with UCL nasal deformities ± palate underwent TLR and 129 patients underwent ECLR. The average follow-up time was 58 months for the TLR cohort and 25 months for the ECLR cohort. The actual revision rate for TLR, including patients who were recommended revision but did not proceed to surgery was 31.73%; the major and minor revision rate in this cohort was 7.69% and 21.15%, respectively. The recommended revision rate in ECLR was 13.21%, with a major revision rate of 1.89% and a minor revision rate of 7.55%. Excluding patients with follow-up less than 36 months, the TLR cohort (n=69) revision rate was 42.65% and 24.39% in the ECLR cohort (n=41). On average, revision surgery for the ECLR cohort was $32,188 versus $28,047 in the TLR cohort. Our previous analysis has shown that NAM care costs on average $2,132 in lost income per family and $12,290 in direct costs for the hospital, physician, and device. Including NAM care costs into the TLR cohort, the fully-burdened cost of the TLR cohort is $42,469 per patient.
CONCLUSION: Examining patients with follow-up greater than 36 months, there is a 42.81% reduction in total revisions when comparing TLR to ECLR. When evaluating the overall, fully-burdened care of TLR to ECLR, this reduction represents a cost savings of $1,026,106 per 100 patients, which can be redirected into the health care system. This not only represents massive savings in healthcare costs but also translates into an overall decreased surgical burden for the patient and family.
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