• Bruce Richard, Joyce Russell, Siobhan McMahon, and Ron Pigott.
• Western Regional Hospital, Pokhara, Nepal. bruce.richard@bch.nhs.uk
• Cleft Palate Craniofac. J. 2006 May 1;43(3):329-38.

ObjectiveTo compare the outcomes for primary repair of unilateral cleft lip and palate, operating on the soft palate first versus the hard palate first.DesignRandomized controlled trial.SettingThe Regional Cleft Service of West Nepal.PatientsForty-seven consecutive patients with nonsyndromic unilateral cleft lip and palate, of whom 37 were assessed 4 to 6 years after completing primary surgical repair.InterventionsPrimary repair of unilateral cleft lip and palate by two differing sequences: (1) soft palate repair, with hard palate and lip repair 3 months later; and (2) lip and hard palate repair, followed by the soft palate repair 3 months later.Main Outcome MeasuresAnalysis of dental study models, weight gain, and speech recordings.ResultsFour to 7 years after completing the cleft closure, there was no significant difference in facial growth between the two types of repair sequencing. Completing posterior repair first had no effect on anterior alveolar gap width. It narrowed the hard palate gap by reducing the intercanine distance. Anterior repair dramatically closed the anterior alveolar gap, and narrowed the intercanine distance. Comparing anterior alveolar gap width with age at first presentation demonstrated that there was no spontaneous narrowing of the cleft in older children. Completing posterior closure first had a weight gain advantage over anterior closure first. Improved oropharyngeal closure, and thus swallowing, is the likely explanation.ConclusionChanging the sequencing of cleft closure has no demonstrable difference in facial growth at 4 to 7 years after completion of the primary surgery.

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