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BACKGROUND: Standards of cleft care in countries where international adoption rates are high often differ considerably from those in the United States. Children with cleft lip/palate deformities adopted from these countries present to plastic surgeons in the United States in various states of repair and often at ages well beyond accepted treatment norms. The operative and peri-operative needs of these children necessitating surgical intervention upon arrival in the United States are poorly understood.
Methods: We performed a long-term retrospective review of all adopted cleft lip/palate patients presenting to an academic craniofacial referral center. Pre-adoption medical records, craniofacial clinic charts/ACPA database, and operative reports were analyzed for demographic characteristics, pre-adoption history, post-adoption interventions, and outcomes.
Results: Between May, 1993 and August, 2010, 83 adopted children with cleft lip/cleft palate deformities were evaluated in our craniofacial center. Average age at adoption was 30.5 (range 5.0-95.0) months. Originating countries were predominantly China (78.4%), Russia (12.1%), and Ukraine (4.8%). Table 1 describes the diagnoses of our patient population. Pre-adoption medical records were available for 21.8% of patients. 76.4% (n=42) of unilateral cleft lip patients and 73.9% (n=17) of bilateral cleft lip patients were repaired prior to adoption at an average age of 10.8 months (range 5.4-15.5 months). 32.8% (n=22) of cleft palate patients were repaired prior to adoption at an average age of 25.6 (range 8.4-40.0) months. Table 2 describes the post-adoption procedures performed on our patient population. Average age of post-adoption primary repair was 17.8 (range 7.6-23.7) months for unilateral cleft lip deformities, 21.5 (range 8.4-40.0) months for bilateral cleft lip deformities, and 27.9 (range 10.5-85.9) months for cleft palate deformities. There were 6 (27.27%) clinically significant fistulas in patients who underwent pre-adoption palate repair compared to 8 (22.22%) in patients who underwent palate repair post-adoption (p=0.45). Hypernasal speech developed in 9 (40.91%) patients who underwent pre-adoption palate repair compared to 22 (61.11%) patients who underwent palate repair post-adoption (p=0.11), while velopharyngeal insufficiency was observed in 3 (13.64%) patients who underwent pre-adoption palate repair compared to 7 (19.44%) patients who underwent palate repair post-adoption (p=0.43). When assessing the quality of the lip repairs, 28 (47.46%) patients who underwent pre-adoption lip repair compared to 7 (41.18%) patients who underwent lip repair post-adoption (p=0.43) were deemed to have poor aesthetic results that would benefit from revision..
Conclusion: The adopted cleft patient represents a complex and variable population with high rates of revision and delayed presentation. Surgical outcomes are poor in these patients compared to non-adopted populations.

Diagnoses

Diagnoses	Number	Percent
Isolated Cleft Lip	14	16.87
Isolated Cleft Palate	3	3.61
Unilateral Cleft Lip/Palate	45	54.22
Bilateral Cleft Lip/Palate	19	22.89
Submucous Cleft	2	2.41
TOTAL	83	100.00

Post-Adoption Procedures

Post-Adoption Procedures	Number	Percent
Primary Lip Repair
Unilateral Bilateral TOTAL	11 6 17	20.00 26.09 21.79
Lip revision on Pre-Adoption repairs
Unilateral Bilateral TOTAL	7 3 10	16.67 17.65 16.95
Lip revision on Post-Adoption repairs
Unilateral Bilateral TOTAL	3 0 3	27.27 0.00 17.65
Primary Palate Repair	36	53.73
Revision Palate Repair	10	14.93