Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate

Cleft-Related Revision Procedures: Surgeon Perspectives on Shared Decision-Making and a Decision Aid Prototype

OBJECTIVE

Decision-making for elective cleft lip and nose revisions varies widely, from patient-led decisions to more paternalistic approaches. As these procedures incur additional scarring that may impact future interventions, patients should be equipped to participate in these surgical decisions. We thus developed a decision aid based on international standards, and to ensure methodologic rigor, we sought feedback from other surgeons regarding shared decision-making and potential barriers to adopting the decision aid.

DESIGN

The decision aid was developed based on qualitative patient data, expert opinion, and International Patient Decision Aid Standards (IPDAS). It was first piloted using a "think aloud" approach and subsequently revised. In the present study, this version was presented to a diverse focus group of surgeons. The conversation was audio-recorded and transcribed. The transcription was coded independently by 2 authors, and codes were categorized for theme development.

SETTING

American Cleft Palate-Craniofacial Association meeting, April 2024.

PARTICIPANTS

Focus group of 8 board-certified craniofacial surgeons.

MAIN OUTCOME MEASURES

Surgeon feedback regarding appeal, usefulness, and generalizability of the decision aid.

RESULT(S)

Eight surgeons participated. Mean age was 43 years (SD 5.7), and mean number of years in practice was 9.3 (SD 6.0). Four were female, and 4 were male. Three themes emerged: (1) Appeal to the consumer, (2) Acknowledge the parents, and (3) Consider logistics of decision aid delivery.

CONCLUSIONS

Based on surgeon feedback, the decision aid will be web-based, explicitly recognize the importance of parents, and maximize the likelihood that patients viewing the decision aid are surgical candidates.

Prenatal to Adulthood: The Responsibility of the Speech-Language Pathologist on the Comprehensive Cleft Palate and Craniofacial Team

PURPOSE

Comprehensive cleft care is an important component when caring for a child with cleft palate with or without cleft lip (CP ± L). Speech-language pathologists (SLPs) serve different capacities on comprehensive cleft palate and craniofacial teams.

METHOD

This tutorial highlights the role of the SLP on the cleft palate and craniofacial team from the prenatal consultation to adulthood. This tutorial emphasizes the importance of collaboration between the cleft team SLP and other professionals on a comprehensive cleft team. Additionally, the tutorial provides education for feeding infants with CP ± L and focuses on assessment and treatment of children with CP ± L before and after the palate repair. Finally, this tutorial underscores the importance of working as part of and collaborating with interdisciplinary team members.

RESULTS

SLPs are an essential member of comprehensive cleft teams in addition to other medical providers. SLPs play a critical role on these multidisciplinary teams and are fundamental to the assessment and treatment of feeding, speech, language, and resonance disorders in children with CP ± L.

CONCLUSION

It is critical that SLPs are involved in comprehensive cleft team care from the prenatal consultation through adulthood to monitor resonance, speech, and language development and outcomes.

Translation, Validation, and Cultural Adaptation of CLEFT-Q© for use in Indonesia

OBJECTIVE

To translate and validate CLEFT-Q©, patient-reported outcome measure for patients with cleft lip and/or palate (CL and/or P), into Indonesian. CLEFT-Q© covers the domains of appearance, facial function, health-related quality of life and consists of scales describing outcomes after cleft surgery.

DESIGN

The CLEFT-Q© instrument was translated according to the International Society of Pharmacoeconomics and Outcomes Research guidelines, including translation, cognitive debriefing, and field-testing.

SETTING

Dr. Cipto Mangunkusumo Hospital, Indonesia; independent CL and/or P support groups.

PATIENTS

Patients ages 8-29 with a history of repaired CL and/or P were grouped based on age. Those unable to complete the questionnaire independently were excluded.

INTERVENTIONS

The primary objective was reliable translation of the CLEFT-Q® instrument. Each scale was assessed for its internal consistency (Cronbach's alpha) and validity (inter-item correlation), and sub-group analyses were performed based on age group.

RESULTS

Forward and back translation revealed 25(13.3%) and 12(6.3%) of items were difficult to translate. Cognitive debriefing revealed 10(5.3%) items were difficult to understand, with the lowest reliability on the facial appearance scale (α=0.27). Other scales demonstrated acceptable to excellent reliability (α=0.53-0.68). Field testing revealed acceptable reliability and validity of the translation (α = 0.74-0.92; 69% ideal range of inter-item correlation). Sub-group analyses revealed patients in the <11y.o. and >18y.o. groups had the lowest scores on the "cleft lip scar" scale while those 11-18y.o. had the lowest scores on the "nostrils" scale.

CONCLUSION

Iterative translation and cultural adaptation of CLEFT-Q© into Indonesian demonstrated reliability and validity of the tool, supported by acceptable to excellent internal consistency and ideal inter-item correlation.

Finnish Translation and Linguistic Validation of the CLEFT-Q Questionnaire

OBJECTIVE

Cleft lip and/or palate (CL/P) can have long-lasting effects on the appearance, function, and psychosocial wellbeing of patients. The CLEFT-Q questionnaire is a patient-reported outcomes instrument specifically designed to assess the health-related quality of life of patients with CL/P. The aim of this study was to produce and linguistically validate a Finnish version of the CLEFT-Q questionnaire.

DESIGN

The CLEFT-Q questionnaire was translated into Finnish following guidelines of the International Society for Pharmacoeconomics and Outcomes Research. Pilot testing with cognitive debriefing interviews was conducted on patients of the target age range of the questionnaire, 8-29, and with various cleft types.

RESULTS

The CLEFT-Q questionnaire translated readily into Finnish. A review of the backward translation led to two words being changed. Thirteen patients - ten females and three males - with a median age of 14 years, participated in the cognitive debriefing interviews. The interviews led to further nine word changes. The pilot study data suggested that the performance of the Finnish version of the instrument is in line with the original CLEFT-Q questionnaire.

CONCLUSIONS

The Finnish version of CLEFT-Q produced here is linguistically valid and ready for use in the evaluation of the health-related quality of life of patients with CL/P. However, future work is needed to further assess the validity and the reliability of the CLEFT-Q in the Finnish patient population.

Revisional Techniques for Secondary Cleft Lip Deformities

Secondary deformities of repaired cleft lips are an unfortunate complication despite the meticulous approach of modern primary procedures. Most of these surgeries take place in the patient's early life and must be strategically planned to provide optimal cosmesis with minimal interventions. Depending on the level of severity, treatment of the secondary deformities ranges from noninvasive or minimally invasive techniques to complete revision cheiloplasty. Many novel topical, injectable, and laser therapies have allotted physicians more technical flexibility in treating superficial distortions. Nonetheless, surgical techniques such as diamond excision and adjacent tissue transfer remain popular and useful reconstructive modalities. Deformities involving the orbicularis oris must be completely taken down to allow full access to the muscle. Complete revision cheiloplasty requires recreation of the cleft defect and reconstruction similar to the primary repair. Due to the myriad of presentations of these secondary deformities, familiarity with the various treatments available is imperative for any cleft surgeon.

Patients With a History of Oronasal Fistula Repair Exhibit Lower Oral Health Measured With Patient-Centric Outcomes Measures

INTRODUCTION

Oronasal fistulae following palatoplasty may affect patients' quality of life by impacting their ability to eat, speak, and maintain oral hygiene. We aimed to quantify the impact of previous oronasal fistula repair on patients' quality of life using patient-reported outcome psychometric tools.

METHODS

A cross-sectional study of 8- to 9-year-old patients with cleft palate and/or lip was completed. Patients who had a cleft team clinic between September 2018 and August 2019 were recruited. Participants were divided into 2 groups (no fistula, prior fistula repair). Differences in the individual CLEFT-Q and Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) Oral Health scores between the 2 groups were evaluated using a multivariate analysis controlling for Veau classification and syndromic diagnosis.

RESULTS

Sixty patients with a history of cleft palate were included. Forty-two (70%) patients had an associated cleft lip. Thirty-two (53.3%) patients had no history of fistula and 28 (46.7%) patients had undergone a fistula repair. CLEFT-Q Dental, Jaw, and Speech Function were all higher in patients without a history of a fistula repair; however, none of these differences were statistically significant. The COHIP-SF 19 Oral Health score demonstrated a significantly lower score in the fistula group, indicating poorer oral health (P = .05).

CONCLUSIONS

One would expect that successful repair of a fistula would result in improved function and patient satisfaction, but the consistent trend toward lower CLEFT-Q scores and significantly increased COHIP-SF 19 Oral Health scores in our study group suggests that residual effects linger and that the morbidity of a fistula may not be completely treated with a secondary correction.

Decision-making process to undergo surgery among adolescent patients with cleft lip and/or palate

AIM

As patients with cleft lip and/or palate grow older, the main decision-making process for treatment is likely to shift from a parent-centered to a patient-centered process. However, many adolescent patients have difficulty in treatment decision-making. This study aimed to clarify the decision-making process regarding undergoing surgery among adolescent patients with cleft lip and/or palate.

METHODS

Participants were adolescent patients with cleft lip and/or palate aged 14-18 years who were admitted to a hospital in Japan for surgery. Fourteen patients (six boys, eight girls) and their parents agreed to participate in this study. Data were collected in face-to-face semi-structured interviews. Data were analyzed qualitatively with inductive content analysis.

RESULTS

Fifteen categories were classified into three themes for adolescent patients' decision-making processes regarding undergoing surgery. The three themes were: (a) a doctor's recommendation for surgery, (b) psychological conflict about surgery, and (c) a final decision about surgery.

CONCLUSION

This study's findings suggest that adolescent patients with cleft lip and/or palate were not adequately involved in the decision-making process before undergoing surgery. Medical staff need to explain other treatment options, the risks and benefits of surgery with materials and methods that adolescent patients can understand as part of "a doctor's recommendation for surgery." Medical staff and parents need to encourage adolescent patients to communicate their preferences and values to reduce patients' "psychological conflict about surgery" and adolescent patients' intentions should be considered in "a final decision about surgery."

Saving Face: Patient Strategies to Reduce Stigma and Barriers to Effective Decision-Making Among Children With Cleft Lip

Facial differences associated with cleft lips are often stigmatizing and can negatively impact psychosocial development and quality of life. However, little is known regarding patients' responses to societal expectations of appearance, or how these responses may impact utilization of revision surgery. Thus, patients with cleft lips at least 8 years of age (n = 31) were purposively sampled for semi-structured interviews. After verbatim transcription, first cycle coding proceeded with a semantic approach, which revealed patterns that warranted second cycle coding. The authors utilized an eclectic coding design to capture deeper meanings in thematic analysis. Additionally, survey data from a separate study were examined to evaluate participants' interest in improving appearance. Three major themes emerged, all of which reflected a desire to "save face" when interacting with society: (1) Cultural Mantras, which included societal mottos that minimized the importance of appearance; (2) Toughening Up, wherein the participants downplayed the difficulty of having a cleft; and (3) Deflection, wherein the participants took pride in facial features unrelated to their clefts. Despite these efforts to "save face," 78% of participants expressed interest in improving their appearance in the separate survey data.In conclusion, children with cleft lips try to "save face" when interacting with society by depreciating appearance, making light of clefts, and focusing on non-cleft related features. Paradoxically, many desired improvements of their appearance in an earlier survey. Awareness of these coping strategies is critical, as they may negatively impact surgeon-patient communication and inhibit patients from expressing interest in revision surgery.

The Effect of Cleft Orthognathic and Nasal Reconstruction on Perceived Social Traits

The investigators hypothesized that a layperson’s social perceptions of an adolescent cleft lip and palate (CL/P) patient are more favorable after orthognathic surgery and definitive nasal reconstruction.

Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons

BACKGROUND

Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision.

METHODS

Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05.

RESULTS

The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44).

CONCLUSIONS

All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.

Psychometric findings and normative values for the CLEFT-Q based on 2434 children and young adult patients with cleft lip and/or palate from 12 countries

BACKGROUND

Patients with cleft lip and/or palate can undergo numerous procedures to improve appearance, speech, dentition and hearing. We developed a cleft-specific patient-reported outcome instrument to facilitate rigorous international measurement and benchmarking.

METHODS

Data were collected from patients aged 8-29 years with cleft lip and/or palate at 30 hospitals in 12 countries between October 2014 and November 2016. Rasch measurement theory analysis was used to refine the scales and to examine reliability and validity. Normative CLEFT-Q values were computed for age, sex and cleft type.

RESULTS

Analysis led to the refinement of an eating and drinking checklist and 12 scales measuring appearance (of the face, nose, nostrils, teeth, lips, jaws and cleft lip scar), health-related quality of life (psychological, social, school, speech distress) and speech function. All scales met the requirements of the Rasch model. Analysis to explore differential item functioning by age, sex and country provided evidence to support the use of a common scoring algorithm for each scale for international use. Lower (worse) scores on CLEFT-Q scales were associated with having a speech problem, being unhappy with facial appearance, and needing future cleft-related treatments, providing evidence of construct validity. Normative values for age, sex and cleft type showed poorer outcomes associated with older age, female sex and having a visible cleft.

INTERPRETATION

The CLEFT-Q represents a rigorously developed instrument that can be used internationally to collect and compare evidence-based outcomes data from patients aged 8-29 years of age with cleft lip and/or palate.

Further construct validation of the CLEFT-Q: Ability to detect differences in outcome for four cleft-specific surgeries

BACKGROUND

The CLEFT-Q is a patient-reported outcome measure developed for use in patients with cleft lip and/or palate. A significant indicator of the CLEFT-Q's validity relates to its ability to detect differences between the impact of specific aspects of clefting before and after surgery. This study compares relevant sub-scale scores of the CLEFT-Q for patients requiring four specific surgical treatments against those who either have had surgery or never needed surgery.

METHODS

CLEFT-Q scores and clinical information regarding the past and future need for jaw surgery, lip revision, rhinoplasty, and speech surgery were obtained from the CLEFT-Q field-test data. Eight one-way analysis of variance (ANOVA) models were developed to compare mean scores of relevant CLEFT-Q scales between those who needed surgery, those who have had surgery, and those who never needed surgery. Only patients from high-income countries were included to minimize the impact of any economic confounders that could result in treatment variation. In the rhinoplasly and lip revision models, patients without a cleft lip were excluded. In the jaw surgery and speech surgery models, patients without a cleft palate or alveolus were excluded.

RESULTS

The CLEFT-Q field test included 1938 participants from high-income countries. Participants who needed surgery scored significantly lower (worse) than those who have had surgery in each of the eight relevant CLEFT-Q scales (p < 0.001 in each ANOVA).

CONCLUSION

The ability of the CLEFT-Q to detect differences between groups based on surgical status further supports its validity.

Decision-Making in Cleft-Related Surgery: A Qualitative Analysis of Patients and Caregivers

OBJECTIVE

Preference-sensitive surgical decisions merit shared decision-making, as decision engagement can reduce decisional conflict and regret. Elective cleft-related procedures are often preference sensitive, and therefore, we sought to better understand decision-making in this population.

DESIGN

Semistructured interviews were conducted to elicit qualitative data. A hierarchical codebook was developed through an iterative process in preparation for thematic analysis. Thematic analysis was performed to examine differences between patients and caregivers.

SETTING

Multidisciplinary cleft clinic at a tertiary care center.

PARTICIPANTS

Patients with cleft lip aged 8 and older (n = 31) and their caregivers (n = 31) were purposively sampled. Inability to converse in English, intellectual disability, or syndromic diagnoses resulted in exclusion.

MAIN OUTCOME MEASURES

Preferences surrounding surgical decision-making identified during thematic analysis.

RESULTS

Mean patient age was 12.7 (standard deviation: 3.1). Most had unilateral cleft lip and palate (43.8%). Three themes emerged: Insufficient Understanding of Facial Difference and Treatment, Diversity of Surgical Indications, and Barriers to Patient Autonomy. Almost half of caregivers believed their children understood their clefts, but most of these children failed to provide information about their cleft. Although many patients and caregivers acknowledged that surgery addressed function and/or appearance, patients and caregivers exhibited differences regarding the necessity of surgery. Furthermore, a large proportion of patients believed their opinions mattered in decisions, but less than half of caregivers agreed.

CONCLUSIONS

Patients with clefts desire to participate in surgical decisions but have limited understanding of their facial difference and surgical indications. Cleft surgeons must educate patients and facilitate shared decision-making.

What Matters to Patients With Cleft Lip and/or Palate

Objective:

The goal of treatment for individuals with cleft lip and/or palate (CL/P) is to improve physical, psychological, and social health. Outcomes of treatment are rarely measured from the patient’s perspective. The aim of the study was to develop a conceptual framework for a patient-reported outcome (PRO) instrument for individuals with clefts (CLEFT-Q) by developing an in-depth understanding of issues that individuals consider to be important.

Design:

The qualitative methodology of interpretive description was used. Setting, Participants, and Intervention: We performed 136 individual in-depth interviews with participants with clefts of any age, presenting for cleft care, across 6 countries. Parents were involved if the child was more comfortable. Interviews were audio-recorded, transcribed verbatim, and coded using constant comparison. The data were used to develop a refined conceptual framework.

Results:

Participants described concepts of interest in 3 top-level domains, each of which included subdomains: appearance (face, nose, nostrils, teeth, lips, jaw, cleft lip scar), health-related quality of life (psychological, social, school, speech-related distress), and facial function (speech, eating/drinking). Participants were able to describe changes over time with regard to the 3 domains.

Conclusions:

A conceptual framework of concepts of interest to individuals with CL/P formed the basis of the scales in the CLEFT-Q. Each subdomain represents an independently functioning scale. Understanding what matters to patients is essential in guiding PRO measurement.