The Cleft Palate Craniofacial Journal

We sought to characterize factors associated with postoperative complications in patients undergoing primary cleft lip repair (CLR).

The National Surgical Quality Improvement Program-Pediatric database was queried to identify patients under 12 months old undergoing CLR using CPT codes. Multivariable analysis was conducted to characterize complications and associated comorbidities.

A multicenter sample.

A total of 11 957 cases (81.9% unilateral CLR and 18.1% bilateral CLR) were identified.

None.

The postoperative outcomes of significance were surgical site infection (SSI), wound dehiscence, and unplanned reintubation within 30 days of CLR.

The cohort had a mean age of 4.7 ± 2.0 months and a median American Society of Anesthesiologists classification of 2. SSIs occurred in 0.6% of cases and were independently associated with bilateral cleft anatomy (OR 2.16, P = .003) and longer anesthesia time (OR per minute: 1.004, P = .009). Wound dehiscence occurred in 0.4% of patients and was independently associated with bilateral cleft anatomy (OR 4.03, P < .001) but was associated with shorter anesthesia duration (OR per minute: 0.991, P < .001). Unplanned reintubation occurred in 0.2% of cases, with these patients having significantly higher rates of multiple comorbidities.

Wound dehiscence, SSI, and unplanned reintubation were rare complications following CLR. Patients with a bilateral cleft lip had increased odds of both SSI and wound dehiscence.

To compare the incidence of ocular abnormalities in patients with metopic craniosynostosis (MCS) treated with cranial vault reconstruction (CVR) versus endoscopic suturectomy (ESC).

Retrospective cohort study using the TriNetX Research Network.

Multi-institutional electronic health record database.

A total of 588 pediatric patients with non-syndromic MCS (441 CVR, 147 ESC) were identified by ICD-10 and CPT codes. Propensity score matching and age adjustment were performed to reduce confounding.

Subjects underwent either CVR or ESC. Ocular and surgical complication outcomes were assessed.

Primary outcome is ocular abnormalities. Secondary outcomes include surgical complications and reoperations.

Ocular abnormalities were present in 40.31% of MCS patients. CVR was associated with a significantly higher incidence compared to ESC (44.67% vs 27.21%; RR = 1.64; 95% CI: 1.23-2.18). CVR patients had greater rates of strabismus (15.19% vs 7.48%; RR = 2.03; 95% CI: 1.10-3.74), ametropia (29.71% vs 11.56%; RR = 2.57; 95% CI: 1.58-4.20), and astigmatism (15.87% vs 2.72%; RR = 5.84; 95% CI: 2.17-15.70). These differences remained significant after adjusting for age and matching by sex, race, and ethnicity. The ESC group showed ocular outcomes comparable to the general pediatric population.

Patients with metopic craniosynostosis have a high rate of ocular abnormalities, and there may be a difference between those who undergo CVR versus ESC. These findings underscore the need for routine ophthalmologic surveillance and future prospective studies are needed to confirm the findings.

This study aims to assess the prevalence, patterns, and distribution of malnutrition among pediatric patients evaluated for cleft surgery in Madagascar.

Design/Setting: This Retrospective cross-sectional study assessed 658 patients who presented for cleft care between 2020 and 2023 during surgical programs of an International Cleft Surgical Non-Profit Organization in Madagascar.

Patient demographics and anthropometry of all patients were measured. The weight-for-length Z score/weight-for-height Z score World Health Organization Growth Chart Z scores, as well as mid-upper arm circumference for patients aged > 6 months to 59 months, were measured and recorded. Patients were grouped based on gender and age.

Of the 658 patients screened for surgery, 96% were malnourished (mild to severe malnutrition), and 83% of the screened patients had to be enrolled in the nutrition program (Z scores ≤ −2standard deviation) for nutritional optimization before surgery could be considered. At the time of this study, 239 patients had received surgery, while 309 were awaiting surgery. The majority had combined cleft lip and palate (59%), and over half of the mothers were unable to breastfeed their children at all due to the cleft condition(s) (53%). The highest prevalence (52.4%) and severity (68.1%) of malnutrition was observed among infants under 6 months old.

The malnutrition status among patients with a cleft lip and/or palate in Madagascar is high (96%, p < .001). When children with cleft conditions who were malnourished (96%) were compared with the under-5 malnutrition status among non-cleft patients (47%) in Madagascar, it was a ratio of 2:1.

Glymphatic dysfunction contributes to CNS pathobiology, including neurodegeneration. We hypothesized that vascularized lymph node transfer (VLNT) augments CSF-interstitial solute clearance and could be translated as a surgical therapy analogous to lymphedema surgery.

Twenty Long-Evans rats were randomized to 3 arms: (1) Craniectomy Control (hemi-craniectomy; VLNT sampled in situ, nontransposed), (2) VLNT Control (intact calvarium; VLNT without craniectomy), and (3) Experimental (hemi-craniectomy + VLNT). One week postsurgery, Evans Blue dye (EBD) was injected into the cisterna magna; at 4 h, right/left cerebrum and cerebellum lysates underwent spectrophotometry at 608 nm. VLNT viability was verified by podoplanin (PDPN) immunohistochemistry.

Two-way ANOVA showed significantly reduced EBD in Experimental vs controls: left hemisphere vs Craniectomy Control P = .0011 and vs VLNT Control P = .0200; cerebellum vs both controls P < .0001. The right hemisphere was lower vs Craniectomy Control (P = .0255) and not different from VLNT Control (P = .3878). VLNT-tissue lysates were higher in Experimental than Craniectomy Control (P = .0028) and VLNT Control (P = .0289), consistent with active lymphatic uptake. PDPN staining confirmed robust lymphatic endothelial labeling in cross-sectional and longitudinal planes.

VLNT significantly enhances putative glymphatic efflux following decompressive craniectomy, recapitulating the therapeutic principle of lymphatic bypass in lymphedema.

These proof-of-concept data support VLNT as a candidate surgical intervention for glymphatic insufficiency and neurodegenerative (ND)-relevant proteostasis/clearance failure. Future studies will optimize timing, node vascularization strategies, and longitudinal outcome measures.

Severe velopharyngeal insufficiency following salvage surgery poses a major challenge for cleft surgeons, particularly when repeated operations have left the soft palate both shortened and densely scarred.

A tendon graft technique for levator veli palatini reconstruction is described, using an autologous palmaris longus (PL) or, when absent, a flexor carpi radialis (FCR) tendon graft to re-establish the muscular function necessary for velopharyngeal closure.

Unlike approaches that only address tissue deficiency, this method restores the levator sling by connecting residual muscle stumps with autologous tendon, thereby reconstituting anatomical continuity. In the present case, PL was absent, and FCR was successfully used as the graft.

Standardized patient-reported outcome measures (PROMs) are rarely used in cleft lip and palate (CL/P) care within New Zealand (NZ). This pilot study sought to obtain a baseline of patient-reported outcomes in NZ and evaluate clinicians’ experiences of implementing PROMs into CL/P services.

A mixed methods cross-sectional design using CLEFT-Q scales. Data were compared to published CL/P CLEFT-Q norms using t-tests, and within-group differences were investigated. Qualitative interviews were analyzed using codebook thematic analysis.

Five CL/P teams in Aotearoa New Zealand.

Patients aged 12+ years (n = 101) were recruited through the five Health NZ CL/P teams between April 2023-March 2024. Five CL/P team members responsible for recruitment participated in an interview at the conclusion of the trial.

Compared with normative data, patients reported more favorable outcomes on speech distress and school function, and poorer psychological function. Speech and social function scores were aligned with CL/P norms. Patients aged 18+ reported the lowest psychological functioning and females reported the lowest social functioning. Clinicians recognized the value of PROMs, yet highlighted concerns about insufficient resourcing to administer, review, and provide follow-up.

Psychological function is indicated as an area of concern, particularly for adults with CL/P. Routine use of PROMs would evaluate change in measures of function over time and enhance patient-centered holistic care. Greater personnel and IT resourcing would facilitate routine implementation of PROMs in CL/P teams.

Unilateral lambdoid synostosis (ULS) is characterized by posterior plagiocephaly with a complex cranial and facial asymmetry. The occipital switch (OS) technique is commonly used to correct the posterior vault deformity, while the occipital neo-bandeau (ON) has been proposed as an adjunct to improve cranial vault proportions. The purpose of this study was to compare post-operative differences in craniofacial morphology between OS and OS + ON in ULS.

A retrospective review of three-dimensional images obtained pre-operatively and at 1-year post-operatively.

Tertiary care pediatric institution.

Twenty-four patients with ULS.

Thirteen patients received OS, and 11 received OS + ON.

Craniometric measurements included anterior, posterior, and height asymmetry ratios; turricephaly index; and nasal and chin deviation.

Both cohorts demonstrated significant post-operative improvements in anterior, posterior, and height asymmetry, as well as nasal and chin deviation (P < 0.05). The OS + ON cohort demonstrated a significant post-operative increase in the turricephaly index (P = 0.039), which was also significantly greater than in the OS-alone group in the intergroup comparison (P = 0.037).

OS with or without ON results in significant improvements in the posterior cranial vault and facial symmetry in patients with ULS. The addition of ON resulted in a significantly greater increase in cranial height, suggesting a role in patients with vertical deficiency.

The goal of this study is to provide an overview of the current clinical practices of cleft teams affiliated to the Dutch Association for Cleft Palate (CP) and Craniofacial anomalies in the Netherlands and in Belgium, with regards to the placement of ventilation tubes in young children with CP.

Cross-sectional survey.

Multicenter study, Oral Cleft Referral Centers of the Netherlands and Belgium.

Ear–nose–throat (ENT) surgeons, plastic surgeons, and language speech pathologists.

Online survey.

The survey questions covered the following topics: audiology assessment before palatoplasty, ventilation tube insertion (VTI) timing, postoperative follow-up visits.

Response rate per center was 100% (11/11 cleft centers), for a total of 21 cleft specialists (44%). Most centers (n = 7/11) establish VTI indication before palatoplasty by means of audiology assessment combined with ENT surgeon examination. Most centers combine VTI with palatoplasty (n = 9/11), and schedule a routine follow-up 2 to 3 months after surgery (n = 7/11).

Although no standardized national or international protocols exist for the diagnosis and treatment of otitis media with effusion in children with CP, most Dutch and both Belgian cleft centers have independently developed local protocols that are largely aligned. Formalizing these into a unified written protocol represents an important next step toward optimizing and standardizing care for this patient population.

The 2^nd Cleft Summit aimed to understand what policies and actions various cleft-centered non-governmental organizations (NGOs) can adopt to achieve sustainable, patient-centered, interdisciplinary cleft care.

A Summit of global leaders in interdisciplinary cleft care.

A two-hour discussion within a three-and-a-half-day International Comprehensive Cleft Care Workshop (CCCW).

Twenty-eight global leaders from various cleft-focused specialties.

The Second Cleft Summit was held to collaboratively improve understanding among global cleft leaders regarding the role and responsibility of NGOs to provide sustainable interdisciplinary cleft care.

The summit's primary objective was to explore and develop strategies to strengthen interdisciplinary cleft care, particularly in resource-limited settings.

Participants agreed on the need to shift NGO focus toward interdisciplinary, patient-centered care that extends beyond a single program to include long-term follow-up. They also strongly encouraged empowering on-site medical providers and teams through bidirectional education (lectures, case discussions) and capacity-building (workshops, simulation). Health system strengthening emerged as a uniformly viable pathway to ensuring sustainable care delivery while diminishing the footprint of international NGOs.

The summit emphasized the need for systemic strengthening of the health delivery infrastructure alongside education and capacity-building. Whenever feasible, NGOs should collaborate with local governments and regional stakeholders through a bidirectional exchange of knowledge and skills.

To identify factors associated with repeated ventilation tube insertion (VTI) in children with cleft palate (CP) who developed otitis media with effusion (OME) before 6 years of age, and to construct a practical risk prediction scoring system.

Retrospective cohort study.

Tertiary care academic hospital.

Medical records of 127 children with CP who underwent both myringotomy with VTI and palatoplasty between 2007 and 2023 were reviewed. Patients were classified into single VTI (n = 55) and repeated VTI (n = 72) groups.

All participants received myringotomy with VTI as standard OME management. Palatoplasty techniques included intravelar veloplasty and double-opposing Z-plasty, with or without hamulus fracture.

Ten potential risk factors were evaluated, including craniofacial syndromes, premyringotomy hearing level, acute otitis media history, cleft type and gap width, middle ear fluid type, tympanic membrane (TM) retraction, surgeon level, palatoplasty technique, and hamulus fracture. Logistic regression was used to develop a predictive scoring system.

Multivariate analysis identified thick middle ear fluid (odds ratio (OR) 3.18, P = .008), TM retraction (OR 4.06, P = .043), and premyringotomy hearing level >40 dB (OR 3.50, P = .010) as independent predictors of repeat VTI. A 0 to 4 point scoring system showed acceptable discrimination (area under the curve = 0.732).

Children with TM retraction, thick middle ear fluid, or hearing loss >40 dB are at higher risk for repeated VTI. This scoring system supports early identification, caregiver counseling, and closer follow-up to optimize middle ear outcomes.

The triad of micrognathia, glossoptosis, and airway obstruction defines Robin sequence (RS). Syndromic RS accounts for about 60% of cases, but whether mandibular “catch-up” growth occurs in these cases remains unclear. The aim of the systematic review was to assess the current literature for evidence of catch-up growth in syndromic RS.

A PRISMA-guided systematic literature review was performed. PubMed was searched for studies describing cases with syndromic RS who underwent conservative (non-surgical) management.

Case reports, case series, and chart reviews containing both the diagnosis of RS and at least one associated syndrome were included. Review articles, non-English publications, and studies lacking sufficient follow-up or clarity on mandibular morphology were excluded.

The review assessed micrognathia, mandibular length, catch-up growth, and the necessity of airway enhancement.

Thirty-four studies met the criteria for inclusion. These studies included clinical information from a total of 202 cases and addressed 20 different syndromes. RS in the context of Stickler syndrome and 22q11.2 deletion syndrome were most frequently reported, with multiple studies suggesting potential for balanced maxillo-mandibular growth or apparent catch-up growth. However, definitive conclusions were limited by small study population, heterogeneous methodologies, and variable follow-up durations.

While additional data are needed, available literature suggests that certain syndromic RS groups may exhibit spontaneous mandibular growth, potentially reducing the need for invasive procedures such as distraction osteogenesis. Prospective research employing standardized cephalometric measures is necessary to identify which syndromic subpopulations and RS types benefit from conservative versus surgical management.

To describe temporal trends in hospital admissions for cleft lip and/or palate (CL/P) repair in Brazil, assess the COVID-19 pandemic impact, examine racial and demographic disparities in length of hospital stay (LOS), and identify regional efficiency patterns.

Retrospective ecological study using nationwide hospital admission data.

Brazilian Unified Health System (SUS), covering public sector inpatient procedures. Participants: 98,998 hospital admissions for CL/P surgical repair from 2008 to 2024.

None (observational analysis of primary/secondary surgical repairs). Main Outcome Measures: Annual admission volumes and trends (annual percent change via Prais–Winsten regression); LOS by race/color (Kruskal–Wallis test); state-level clustering (K-means) based on volume, sex distribution, and mean LOS.

Male predominance (ratio 1.36:1); 70% repairs under age 5. Stable volumes until 33% decline in 2020, with incomplete recovery. Significant racial disparities in LOS (p = .0007), longer among Brown (Parda) and Indigenous children. Heterogeneous state trends; four clusters identified, with São Paulo high-volume/moderate-stay vs. northern low-volume/prolonged-stay.

Brazil has robust CL/P surgical capacity, but racial and profound regional disparities persist, compromising equity and efficiency. Targeted investment in northern regions, decentralized expertise, and standardized protocols are needed to reduce inequities.

To compare palatal mucosal thickness between individuals with and without cleft lip and palate (CLP).

Retrospective observational study.

Tertiary-level craniofacial referral center.

Thirty-eight cone-beam computed tomography (CBCT) scans from individuals without CLP (control group, C) and 60 scans from individuals with CLP (test group, T).

Palatal mucosal thickness was measured in sagittal CBCT slices at the cementoenamel junction (CEJ) of the canine (Ca), first premolar (P1), second premolar (P2), first molar (M1), and second molar (M2). Additional measurements were obtained at 3-mm intervals from the CEJ toward the mid-palatal suture (R3, R6, R9, and R12).

In group C, the thinnest mucosa was observed at M1 (2.95 ± 1.11 mm), whereas P2 showed the greatest thickness (3.72 ± 1.20 mm). In group T, P1 presented the lowest thickness (4.27 ± 1.30 mm), and M2 the highest (4.67 ± 1.93 mm). A significant difference was observed between groups (p < .001). In individuals with CLP, palatal vault height was associated with CAR6 and M1R6, whereas the number of palatoplasties was associated only with P1R6.

In individuals with CLP, the region extending from the distal aspect of the canine to the mesial aspect of the palatal root of the first molar appears to represent the most favorable anatomical region for palatal soft tissue graft harvesting.

To evaluate socioeconomic and geospatial factors at a cleft care center in the Southern United States and assess their impact on outcomes in patients with cleft lip and/or palate (CLP).

Retrospective chart review of patients with CLP, with stratification by neighborhood disadvantage using the University of Wisconsin's Area Deprivation Index (ADI). Univariate analyses compared quartiles.

A cleft care center in the Southern United States.

Inclusion criteria included children with CLP born between 2011 and 2022 who received the entirety of their care at the institution. Exclusion criteria were patients without CLP, those born before 2011, or those who did not complete care at the institution.

No interventions were introduced.

Associations between ADI quartiles and sociodemographic factors, appointment adherence, clinic presentation, hypernasality, and speech surgery incidence.

Significant associations were identified between the most disadvantaged quartile and others for ethnicity (P < .001), primary language (P = .013), insurance status (P = .001), and household income (P < .001). The most disadvantaged quartile had fewer cancellations (P = .002) and presented earlier (P = .050), but had higher rates of hypernasality (P = .005) and speech surgery (P = .046).

Patients in the most disadvantaged quartile demonstrated strong adherence despite socioeconomic and linguistic barriers but had worse speech outcomes. Findings highlight opportunities to address linguistic and cultural barriers to improve cleft care.

To explore the use of shared decision-making (SDM), a collaborative approach to care between healthcare providers, patients, and their families, in cleft lip and/or palate (CL/P) care.

PubMed, CINHAL, Embase, and Dentistry & Oral Sciences Database were searched for studies reporting on SDM in CL/P pediatric care (<19 years). There were no restrictions on date, language, or study design other than case studies and systematic reviews.

A total of 13 studies were included. Overall, parents reported high levels of perceived involvement in SDM. Pediatric patients shared this view, though the desire for SDM was age-dependent with patients expressing a greater desire for involvement as they aged. Qualitative data revealed 4 main themes, including understanding and knowledge of cleft care and treatment, factors influencing decision-making and patient autonomy, psychosocial and emotional dimensions in decision-making, and moral responsibility and identity in decision-making.

The current study highlights that SDM is valued by parents and patients in CL/P care. Further research is needed to understand how SDM can be more clearly integrated into routine CL/P care. Specifically, studies should explore the gap between perceived and actual involvement using standardized SDM measures, as well as identify key barriers and enablers to effective implementation.

To quantify the morphology and asymmetry of the levator veli palatini (LVP) muscle in children with craniofacial microsomia (CFM) and explore associations with velopharyngeal insufficiency (VPI).

Retrospective cohort study.

Pediatric tertiary care center.

Twenty children with CFM who underwent clinically indicated head and neck MRI.

LVP left-right asymmetry, midline velopharyngeal measures, and presence of VPI.

Three participants (15%) had VPI. Significant left-right asymmetry was observed for total LVP length, LVP thickness at velar insertion, and angle of origin (p ≤ .05). Greater differences between most and least affected sides in total LVP length were associated with lower VPI prevalence (PR, 0.58 per 1-mm increase; 95% CI, 0.36–0.93; p = .02). Greater pharyngeal depth predicted higher VPI prevalence (PR, 1.35 per 1-mm increase; 95% CI, 1.07–1.70; p = .01), while increased midline LVP thickness was associated with lower prevalence (PR, 0.76 per 1-mm increase; 95% CI, 0.65–0.90; p = .01).

Children with CFM demonstrate significant asymmetry of the LVP muscle. Shorter total LVP length, thinner midline LVP, and greater pharyngeal depth were associated with higher VPI prevalence, indicating a need for prospective studies to clarify the role of soft-tissue variation in velopharyngeal function.

This study aimed to anatomically evaluate the infraorbital canal (IOC) by comparing patients with cleft lip and palate (CLP) and controls.

Retrospective cross-sectional observational study.

Department of Oral and Maxillofacial Radiology, Faculty of Dentistry.

Sixty-four children and adolescents aged 13–18 years were included: 36 with unilateral CLP (UCLP), 12 with bilateral CLP (BCLP), and 16 controls.

None; purely observational.

Cone-beam computed tomography scans were analyzed bilaterally and grouped as cleft side of UCLP (UCLP-CS), non-cleft side of UCLP (UCLP-NCS), BCLP, and control. Parameters examined included initial and termination diameters of the IOC (D_IOF and D_C), IOC length (IOF-C), direct distance between the infraorbital foramen and groove (IOF-S), distances from the IOC to the midline and lateral nasal cavity wall (MW and LNW), anterior, posterior, and horizontal angles of the IOC, IOC protrusion type and the presence of septa and Haller cells in the maxillary sinus.

There was no significant difference for age and gender between the groups (p = .890 and p = .879). In the UCLP-CS group, the D_C, IOF-C, MW, and LNW values were significantly lower compared to the control group (p = .034, p = .035, p = .007, p = .003, and p = .012). IOF-S values were significantly lower in the UCLP-NCS group compared to the control group (p = .041).

Cleft conditions can affect IOC position and morphology, especially on the cleft side of UCLP patients, and should be considered during surgery or anesthesia.

Having a child with a cleft lip with or without palate (CL ± P) can greatly impact parents’ lives. Retrospective studies have shown that receiving a CL ± P diagnosis is an emotional event, requiring considerable adjustment. However, there has been limited prospective research on how parents experience pregnancy when faced with a prenatal diagnosis of CL ± P. This study aims to examine the experiences of parents during pregnancy, focusing on their concerns and perspectives regarding cleft care, pregnancy, childbirth, and upbringing.

Participants were interviewed between 24 to 39 weeks of gestational age using semi-structured interviews. Data were analyzed using inductive reflexive thematic analysis.

Interviews took place through a videocall, a phone call or face-to-face, following participants’ preferences. Interviews lasted an average of 33 min.

Eleven expectant mothers and 8 expectant fathers were recruited from the cleft team at a university medical center.

Four main themes were identified: “Suspected diagnosis: An emotional rollercoaster,” “After diagnosis: So much information and healthcare professionals,” “No carefree pregnancy,” and “What will the future bring?”. Receiving a prenatal CL ± P diagnosis was experienced as an emotional rollercoaster, accompanied by numerous uncertainties. Parents reported that the cleft care trajectory did not always optimally support them in emotionally processing the diagnosis.

Results highlight a need for specialized cleft care tailored to parental needs and wishes. Specifically, empathetic reactions of healthcare providers are crucial, as well as an additional contact moment for parents before childbirth.