ObjectiveDevelop and apply novel data visualization techniques to analyze longitudinal cleft surgical care and to identify patterns in treatment timing and procedural burden across 2 cleft teams.DesignRetrospective cohort study of operative data using novel data visualization methods.SettingTwo cleft teams in the United States.Patients and ParticipantsPatients with cleft lip and/or palate with operative clinical encounters between 2018 and 2023. Team A had 228 patients and team B had 355.InterventionsVisualization of primary cleft-related surgical procedures which were cleft lip and palate repair, fistula repair, alveolar bone grafting, correction of velopharyngeal insufficiency, orthognathic surgery, and rhinoplasty.Main Outcome Measure(s)Visual interpretation of surgical timing, frequency, volume, and distribution using novel timelines, stacked-bar charts, and ridgeplots.ResultsTimeline visualizations clarified procedural sequencing and highlighted variation in treatment timing by team and phenotype but were too dense for interpretation for a large volume of patients. Stacked-bar charts illustrated procedural volume but lacked temporal insight. Ridgeplots demonstrated both timing of procedures and aggregate team volume.ConclusionsIndividual patient timelines can effectively depict deviation from "ideal" care protocols, but aggregate data may be best depicted by a ridgeplot. These tools may support quality improvement initiatives by transforming raw data into actionable insights and enhancing multidisciplinary team reflection.

Digital Workflow for Customized Nasal Conformers in Cleft Lip Repair: A Technical Note

VATER syndrome is a non-random association of birth defects affecting multiple organ systems, with orofacial clefts uncommonly reported. This study presents a unique case of a patient with VATER syndrome with a bilateral cleft lip and palate who underwent the rare surgical removal of the premaxilla during cleft lip repair, resulting in a large maxillary defect and oronasal fistula. This report highlights the successful use of non-vascularized bone graft in this setting, with 13-month follow-up demonstrating bone consolidation and fistula closure. The case adds to the evidence supporting non-vascularized bone graft for extensive maxillary defects, even with oronasal fistula.

ObjectiveTo investigate operative experiences and perspectives of surgeons presented with cleft lip (CL) and/or palate (CP) in children with life-limiting and terminal illnesses.DesignSurvey study.SettingElectronic.Patients, ParticipantsAmerican Cleft Palate Craniofacial Association surgeon members.InterventionsNone.Main Outcome MeasuresProportion of surgeons who performed cleft lip and/or palate (CL/P) repair, likelihood to operate again, and factors impacting operative decision.ResultsResponse rate was 20.5% (121/589) including 113 surgeons treating CL/P across plastic surgery (63.7%), otolaryngology (23.9%), and oral and maxillofacial surgery (12.4%). More completed CL than CP repairs (59.3% vs 21.2%) for patients with example conditions of holoprosencephaly, cardiac abnormalities, trisomy 13, and trisomy 18. Leading CL repair motivations were "parent/caregiver request" (89.6%, 60/67), "appearance" (62.7%, 42/67), and "feeding" (28.4%, 19/67). Leading CP repair motivations were "parent/caregiver request" (66.7%, 16/24), "feeding" (62.5%, 15/24), and "communication" (54.2%, 13/24). Surgeons who had not attempted CL repair described lacking opportunity (34.8%, 16/46) or unfavorable risk-benefit ratios (37.0%, 17/46) as reasons. A greater proportion of those who had not attempted CP repair cited unfavorable risk-benefit ratios (59.6%, 53/89) versus lacking opportunity (21/89, 23.6%). 100% and 95.8% who repaired CL and CP endorsed they would again.ConclusionsSurgeons more commonly repaired CL than CP in children with life-limiting and terminal illnesses. Nearly all would perform these surgeries again. Respondents who did not repair CP often stated risks outweighed benefits. Studies exploring outcomes of CL/P repair in patients with life limiting and terminal illnesses are scarce. More data are needed to help guide these difficult decisions.

This study aimed to compare the efficacy and safety of midazolam oral solution in children undergoing cleft lip and palate repair surgery. Children aged 4 months to 14 years old were randomly assigned to 3 groups: group A, group B, and group C. Group A received 0.3mg/kg midazolam oral solution, group B received 0.5mg/kg midazolam oral solution, and group C received normal saline 30 min before entering the operating room. The Ramsay Sedation Score (RSS), Mask Acceptance Score (MAS), and Pediatric Anesthesia Emergence Delirium (PAED) scale at the post-anesthesia care unit (PACU) were recorded. The secondary outcomes were the postoperative side effects during the PACU stay and the perioperative hemodynamic fluctuation. Of 75 patients enrolled, 74 completed the study. Compared with group C, groups A and B demonstrated increased RSS, reduced MAS, and PAED scale scores (P < 0.05). Compared with group A, group B exhibited lower PAED scores, longer awakening times, and PACU stays (P < 0.05). No significant differences were observed among the 3 groups in perioperative hemodynamic fluctuation, FLACC scores, extubation times, or postoperative side effects (P > 0.05). These findings supported that midazolam oral solution provides effective preoperative sedation in children undergoing cleft lip and palate repair, improves mask acceptance, and reduces the incidence of emergence agitation. While the 0.5mg/kg dose provides better mask acceptance, adequate sedation, and less emergence agitation than 0.3mg/kg dose, it also requires a slightly longer recovery time and duration of staying PACU.

IntroductionOur group has recently established the first ex vivo cadaveric models to simulate unilateral and bilateral cleft lip surgery. We have shown that these porcine snout disc models are suitable for novice cleft surgeons to understand the basic principles of cleft lip surgery and to practice the essential surgical steps. In this study we want to show that the ex vivo cleft lip models are not only suitable and helpful for residents, but also for students and experienced surgeons with and without experience in cleft surgery.MethodsThree courses were held to evaluate the ex vivo cleft lip models: One for oral and maxillofacial surgeons from German cleft centers and two courses for dental students. All operated on the unilateral and bilateral ex vivo cleft lip models using the Millard technique. Questionnaires were used to assess their subjective opinion of the ex vivo cleft lip models. Tasks for the students were carried out to objectify their learning success. Three-dimensional scans were taken and analyzed using a previously validated intraoral scanner to objectively assess the outcome.ResultsThe ex vivo cleft lip models are suitable for the training of students and experienced surgeons with varying levels of experience in cleft lip repair. Both models were rated as realistic in terms of tissue resemblance, surgical planning, and surgical management. In addition, the specialists rated the models as realistic overall. The models also provide students with several advantages, such as improved surgical skills and a better understanding of cleft surgery. Participants felt that the models should be made available not only to residents, but also to consultants and senior consultants and should be implicated in the dental curriculum.ConclusionThe ex vivo cleft lip models made of porcine snout discs are suitable for a wide range of users starting from students to experienced surgeons to train in cleft lip surgery. The great advantage of these models is that experienced surgeons can work with an inexpensive and readily available model to improve their skills and modify their techniques.

Faltering weight in infants with cleft lip and palate.

A whistle deformity is a common secondary deformity of upper lip volume deficiency in the tubercle following bilateral cleft lip repair. The whistle deformity is a significant aesthetic stigma of bilateral cleft lip repair and challenging to correct. In the most severe situations, it can also lead to functional speech issues due to the inability to seal the lips during plosive consonant sounds. Various secondary surgical methods have been proposed to address secondary tubercle deformities requiring revision surgery. Volume deficiency can occur in the tubercle with any surgical technique used, with some being more prone than others. We present a novel fibroadipose tissue flap to improve tubercle fullness during primary bilateral cleft lip repair using tissue that is otherwise normally discarded. The prolabial augmentation of the upper lip (PAUL) flap is a random pattern fibroadipose flap distally based off the undersurface of the prolabial skin flap. The fibroadipose tissue in the premaxillary segment is preserved, dissected and everted for auto-augmentation of the tubercle. The PAUL flap is inset into a submucosal pocket in the vermilion over the orbicularis muscle repair as one of the final steps of repair. This is an effective adjunct to prevent a whistle deformity and can be used with any skin pattern technique designed for the prolabial skin flap in the primary bilateral cleft lip repair.

Primary surgical repair for a cleft lip is often performed around 3 to 4 months of age. Traditional outcome assessments rely heavily on subjective clinical judgment and structured rating tools such as the Cleft Aesthetic Rating Scale (CARS), both of which are limited by inter-rater variability and lack of scalability. This pilot study explores the feasibility of a deep learning (DL) algorithm to assist in postoperative outcome assessment and identify patients at increased risk for revision following unilateral cleft lip repair. The authors developed a convolutional neural network based on the EfficientNet-B1 architecture, trained on a class-balanced data set of 500 standardized postoperative facial photographs labeled using real-world revision outcomes. Rigorous data preprocessing, augmentation, and validation protocols were used to ensure model robustness. The model achieved an accuracy of 74% and an area under the ROC curve (AUC) of 0.79 on an independent test set, with a recall of 76% for identifying patients needing revision. Confidence score distribution and t-SNE feature space visualization demonstrated reliable class separation and interpretability. Our findings suggest that DL algorithms, when trained on structured clinical data, can offer meaningful support in cleft care. This model serves as an early prototype for AI-assisted triage systems that could aid in identifying revision candidates, particularly in resource-limited or outreach settings. While preliminary, this study highlights the potential for integrating artificial intelligence into routine cleft lip postoperative workflows to improve equity and consistency of care.

Introduction This study aimed to evaluate nasolabial appearance following lip repair using the Cronin technique in patients with complete unilateral cleft lip by utilizing the unilateral cleft lip surgical outcomes evaluation (UCL SOE) scale. Methods Nine evaluators of different backgrounds, including three oral and maxillofacial surgeons, three oral and maxillofacial surgery residents, and three dental nurses, conducted the evaluations. Twenty-four pairs of photographs of patients with unilateral cleft lip who underwent lip repair using the Cronin technique were evaluated. Intra- and inter-evaluator reliability tests were conducted using the intraclass correlation coefficient. Results The intraclass correlation coefficients for each component and the total score revealed that oral and maxillofacial surgeons had very high intraclass correlation coefficients and scored 1.00 on nearly all components, indicating an almost perfect correlation. Conclusion In this study, intra-evaluator and inter-evaluator intraclass correlation coefficient (ICC) showed consistent and reliable results for evaluating the esthetic outcomes of unilateral cleft lip repair using the Cronin lip repair technique; however, differences exist in the assessments between the different groups of evaluators. The evaluation of nasolabial appearance with the UCL SOE scale showed good reliability and consistency regardless of the evaluator's background. In addition, the technique used in this study, the Cronin method, can be recommended for unilateral cleft lip repair.

Background and aims: The symmetrical shape of the nasolabial folds and both nose alae, along with a natural-looking philtrum and Cupid's bow in both static and dynamic phases, as well as a buried scar, are characteristics of the perfect lip restoration. The study's goal was to evaluate the Millard rotational advancement technique and the Fisher anatomical subunit approximation technique for unilateral cleft lip repair. Methods: Prospective study for 30 patients submitted to Palestine Hospital in Sana’a City, Yemen, with unilateral cleft lip deformity between December 2022 and August 2024. The Millard rotational-advancement approach was used to correct fifteen patients with unilateral cleft lip deformity, while the Fisher anatomical subunit approximation technique was used to fix the remaining fifteen. NIH ImageJ software was used to evaluate the patients' postoperative photos using the Steffensen grading criteria. The normal side and the corrected side were compared in terms of lip length, cutaneous line symmetry, vermillion symmetry, scar appearance, Cupid's bow, nostril symmetry, and alar base. Results: A study involving 69.2% males and 38.8% females aged 5-180 months with 30 unilateral cleft lips undergoing Millard and Fisher techniques found that patients with Millard techniques showed better cutaneous line symmetry, vermillion symmetry, and lip length compared to Fisher techniques. However, only 7.7% of patients with Millard procedures showed good Cupid's bow, scar appearance, nasal symmetry, and alar base compared to Fisher techniques. The study suggests that Millard techniques may be more effective in certain cases. Conclusion: In conclusion, there was no discernible change in the anthropometric measurements between the two methods used for unilateral cleft lip repair. According to the study, there are several situations in which applying Millard approaches might be more successful. Peer Review History: Received 7 August 2025; Reviewed 11 September 2025; Accepted 20 October; Available online 15 November 2025 Academic Editor: Dr. Gehan Fawzy Abdel Raoof Kandeel, Pharmacognosy Department, National Research Centre, Dokki, 12622, Giza, Egypt, gehankandeel9@yahoo.com Reviewers: Dr. Sheikh Abdul Khaliq, Department of Pharmacy Practice, Faculty of Pharmacy, Hamdard University, Karachi, Pakistan, drwadhsheikh1974@gmail.com Dr. Taiwo O Elufioye, University of Ibadan, Nigeria, toonitaiwo@yahoo.com

Cleft lip is one of the most common craniofacial congenital malformations and represents a surgical challenge due to its functional, aesthetic, and psychological implications. Its origin is attributed to a disruption in the fusion of the nasomedial and maxillary processes during embryogenesis, leading to an interruption in the continuity of the upper lip, the orbicularis oris muscle, and, in some cases, the nasal base. The goal of surgical treatment is to restore normal anatomy, muscular function, and facial symmetry while achieving a natural and harmonious aesthetic outcome. This report presents the case of a three-month-old male patient with a right unilateral cleft lip, treated using the rotation-advancement technique described by Millard. The procedure was performed under general anesthesia, with anatomical reconstruction of the orbicularis oris muscle, repositioning of the cutaneous flaps, and simultaneous correction of nasal deformity. Postoperative evolution was favorable, without complications, showing proper healing and restoration of lip continuity and nasal symmetry. At six months follow-up, the results were aesthetically satisfactory, with a fine, well-pigmented scar and no retraction. The Millard technique once again demonstrated to be a safe, versatile, and effective surgical option, allowing excellent functional and aesthetic outcomes when executed with precision and respect for anatomical principles. This case emphasizes the importance of early correction of cleft lip, multidisciplinary management, and the application of refined surgical techniques to achieve a comprehensive reconstruction that restores not only anatomy but also function and confidence.

Secondary bilateral cleft lip repair: An orbicularis oris muscle reorientation technique for philtrum reconstruction.

An Overview of Presurgical Management of Cleft Reconstruction.

Orofacial cleft repair: A clinical model for studying genetic contribution to scar severity.

Data-driven surgical planning for cleft lip repair: Optimization of individualized incisions using 3D finite element simulation and clinical translational validation.

Objective: To characterize pediatric patients experiencing unplanned intraoperative extubation (UIE) during cleft lip (CL) and cleft palate (CP) repair and assess postoperative outcomes. Design: Retrospective cohort study using the 2019-2023 National Surgical Quality Improvement Program-Pediatric database. Setting: Multicenter surgical registry of pediatric operations. Patients: Children undergoing CL repair (<1 year) or CP repair (<3 years). Interventions: Not applicable. Main Outcome Measure(s): Incidence of UIE, demographic and operative characteristics, and 30-day postoperative complications. Results: Among 17 047 cases, UIE occurred in 0.37% of CL repairs and 0.20% of CP repairs. Patients who experienced UIE had similar baseline characteristics to those without UIE but demonstrated significantly longer operative and anesthesia times for both procedures. Despite these intraoperative events, no cases of death, pneumonia, or unplanned reintubation occurred postoperatively, and overall 30-day complication rates remained low. Conclusions: UIE during CL and CP repair is rare and not associated with major postoperative complications.

Background/Objectives: Primary cleft lip repair is a procedure to restore lip function and harmonious nasolabial appearance. However, the actual effects on nasolabial appearance have been insufficiently investigated. The aim of this study was therefore to critically review surgical results using well-validated objective and subjective methods and standardised outcome measures. Methods: A total of 26 non-syndromic patients with unilateral cleft lip +/− cleft palate were assessed retrospectively. Uniform 2D photographs of the nasolabial region were objectively analysed using SymNose software. The Cleft Aesthetic Rating Scale was employed for the subjective evaluation by a total of 255 observers with different backgrounds and experience levels in cleft surgery. Results: Significant positive correlation was identified between objective measurement of upper lip asymmetry and subjective assessment (p = 0.02). Furthermore, a significant difference emerged in the assessment of the nasolabial region depending on the rater’s professional background (p < 0.001). A major discrepancy was observed between the rating of maxillofacial consultants and those of laypersons and patients affected by cleft lip +/− cleft palate. Conclusions: The evaluation of attractiveness depends significantly on the professional background of the observer. The more interaction people have with individuals after cleft lip repair, the less they consider the aesthetics conspicuous. Achieving the highest possible postoperative nasolabial symmetry should be a main objective in primary cleft lip repair.

ObjectiveOptimal timing for primary cleft lip (CL) repair remains controversial due to a paucity of literature reporting outcomes. This study sought to identify trends in timing of CL repair over a 10-year period.Design and SettingCross-sectional analysis of the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) between 2013 and 2022.Patients, Participants, InterventionsCL patients undergoing primary CL repair were divided into 4 cohorts based on age (months) at repair: 0 to 3, 3 to 6, 6 to 9, and 9 to 12.Main Outcome MeasureUnivariable statistics, multivariable regressions, and trend analyses were conducted to identify predictors for operation at latter ages and to evaluate trends over time.Results11,585 CL patients were identified with the majority undergoing repair between 3 and 6 months of age (63%). White and Asian patients predominately underwent repair between 0 and 3 months (68% and 5%, respectively), while African American and Hispanic patients underwent repair between 9 and 12 months (12% and 22%, respectively, P < .001). On regression analysis, patients with cardiac risk factors (CRF), asthma, bronchopulmonary dysplasia, developmental delay, CNS abnormalities, and nutritional supplementation (P < .001) were more likely to be repaired at later time intervals. Over the past decade, Hispanic and Asian patients undergoing CL repair increased between 0 and 3 (β = 0.06) and 3 and 6 (β = 0.05) months of age, respectively. Patients with CRF and airway abnormalities also significantly increased between 0 and 3 months.ConclusionThe present study identified an increase in non-White patients and patients with severe comorbidities undergoing early CL repair over a 10-year period. Healthcare professionals should note these trends when treating their own patient populations.

Achieving consistent correction of unilateral cleft lip nasal deformity (uCLND) remains challenging due to the complex interplay between skeletal, soft tissue, and cartilaginous components. This study evaluates intraoperative lower lateral cartilage (LLC) distortions, their distribution, and their associations with cleft characteristics and presurgical infant orthopedics (PSIO), using the modified Tajima incision for direct visualization. Fifty patients undergoing unilateral cleft lip repair with foundation-based primary rhinoplasty were analyzed. Intraoperative LLC distortions were classified based on location (dome, medial crus, lateral crus, or combined) and severity (significant or non-significant). Correlations were assessed with cleft type, PSIO use, and pre-Tajima nasal morphology. LLC distortions were observed in 80% of patients; 45% of these were significant. Dome involvement was most common (60%), especially in incomplete clefts, while combined deformities predominated in complete clefts. Severity was associated with cleft type (P=0.0045), and location was linked to both severity (P<0.001) and laterality (P=0.012). Before tip dissection, unfavorable nostril shape on the non-cleft side appeared in 85.7% of CLA and 80.0% of CLP cases, correlating with cleft type (P<0.001) and location of distortion (P=0.0014). Affected-side morphology predicted both anatomic location (P<0.000001) and severity (P=0.014) of the distortion. PSIO use showed an inverse correlation with the frequency of significant cases (ρ=-0.80). Intraoperative assessment via the modified Tajima incision revealed consistent LLC distortion patterns linked to cleft severity, nasal morphology, and PSIO use.