Answer:
The reference is a chapter by Jeffrey Marsh from Washington University
that condenses his experience over 11 years on 250 patients with secondary
cleft surgery. While doing nothing is not an option for the initial
cleft repair, doing nothing further should be an integral part of the discussion
for secondary cleft surgery. The objectives of secondary cleft surgery
should be maximum physical and psychological benefit for the patient with
minimum disruption for both the patient and the family. Impaired physical
function, such as speech or mastication, usually is considered a relative
absolute indication. Marsh performs secondary lip and nose revision at
three periods: 1) 5-6 years of age before the child enters first grade,
2) the summer between primary-secondary or junior-senior high school change,
and 3) when there are significant psychosocial problems. He stresses
the evaluation should not be whether the lip or nose is normal but whether
the lip or nose concern the child or attract the attention of peers. Interventions
should cease when the patient is well integrated into society without limiting
physical or functional sequelae of the cleft anomaly.