First Repair is Best: The Facial Growth Consequences of Revision Cleft Surgeries.

Abstract

Surgical scarring has long been hypothesized to contribute to maxillary hypoplasia in patients with cleft lip and palate (CLP), often leading to a need for orthognathic surgery (OGS). This study aimed to identify clinical and surgical factors associated with maxillary hypoplasia in skeletally mature patients with CLP using cephalometric analysis. A retrospective review was performed of CLP patients aged ≥16 years with available cone beam CT scans. Cephalometric measurements were obtained using Mimics software. Patient records were reviewed for cleft morphology, number and type of cleft-related surgeries (ages 0-16), surgical timing, demographics, and history of OGS. Linear and logistic regressions were used to evaluate predictors of maxillary hypoplasia and OGS. Among 106 patients, 47.2% had bilateral CLP and 49.1% underwent OGS. The average number of cleft-related surgeries was 4.28. BCLP patients demonstrated significantly reduced maxillary width compared to UCLP (-2.87 mm, p = 0.001). Increasing total number of surgeries was significantly associated with decreased SNA, ANB, and facial convexity angles (p < 0.001). Surgeries performed between ages 0-5 were significantly associated with decreased SNA, facial convexity angle, and alveolar length (p < 0.02). Linear regression showed that each surgery beyond three predicted a 1.94° reduction in SNA, 0.81° reduction in ANB, and 2.82° reduction in facial convexity angle. Surgical burden was not predictive of OGS. Greater number of cleft-related surgeries, particularly in early childhood, correlates directly with maxillary growth restriction. These findings highlight the importance of optimizing surgical timing and minimizing additional interventions when feasible.