Cranial Nerve Injuries in Orthognathic Surgery: A Review of Literature.

ABSTRACT: Orthognathic surgery is increasingly utilized to correct facial deformities and dental malocclusions, as well as to enhance facial aesthetics. Significant advancements in surgical planning and execution have made it more widespread and accessible. However, unfavorable outcomes or complications can occur, leading to potentially severe and possibly long-term consequences, such as cranial nerve injuries. This literature review investigates the cranial nerve complications associated with orthognathic surgery. We conducted an extensive search across available databases, analyzing relevant studies published up to September 30, 2023. Two authors independently selected articles for full-text review based on their titles and abstracts. The eligible studies reported cranial nerve injuries in individuals who had undergone orthognathic surgery. Our findings highlight the risk of cranial nerve injuries, their possible mechanism, management, and outcomes. It is imperative for surgeons to remain vigilant and informed and to communicate such information during preoperative patient consultation.

Chang Gung Forum: An Exemplary Strategy for Implementing a Multidisciplinary Network of Experts in Craniofacial Anomalies.

INTRODUCTION: The Chang Gung Forum has been dedicated to the care of craniofacial anomalies since 2000. This annual continuing medical education program focuses on orofacial cleft and surgery-first orthognathic surgery by providing up-to-date information and management guidelines. This study explored how the Chang Gung Forum has influenced medical perspectives, decisions, and practices in a multidisciplinary craniofacial team. METHODS: Between 2000 and 2022, 20 Chang Gung Forums have been held. A questionnaire was distributed among 170 attendees who had participated in the forum more than once. The questionnaire collected information on the participants' experiences and levels of satisfaction with the educational program and whether or how it had influenced their clinical practice. RESULTS: Valid responses from 86 attendees (response rate, 50.6%) who had participated more than once were collected and analyzed. The overall satisfaction rate of the Chang Gung Forum based on the respondents' most recent visits was 4.28 ± 0.63 out of 5. Of the respondents, 90.9% acknowledged changes in their clinical practice, with modifications in surgery plans and decisions being the most notable (48.5%). In addition, comprehension increased throughout years of attending the annual forum (P < 0.001). CONCLUSION: The Chang Gung Forum has contributed markedly to the community of congenital craniofacial anomalies. The program will continue providing updated information and influencing the clinical decision-making of health care professionals.

Validating the Modified Small Double Opposing Z-Plasty for Palatal Lengthening in Primary Palatoplasty.

OBJECTIVE: To appraise the degree of intraoperative palatal lengthening with the modified Furlow small double-opposing Z-plasty (sDOZ). DESIGN: Retrospective single-surgeon (R.D.) study. PATIENTS: Nonsyndromic children (n = 167) with Veau types I to IV cleft palates who underwent primary sDOZ palatoplasty. INTERVENTIONS: Intraoperative measurements of palatal lengths and widths were collected using calipers, paper rulers, and metal rulers before the administration of local anesthetic solution and before the removal of the mouth gag (initial and final palatal dimensions, respectively). MAIN OUTCOME MEASURES: Assessment of the intraoperative percentage change (difference between final and initial values) in surface palatal length, straight palatal length, and soft palatal length. Bivariate and multivariate analyses were performed to identify independent predictors (sex, age at surgery, Veau, Kernahan/ Stark, and Randall classifications, widest cleft width, presence of lateral relaxing incision, type of coverage with buccal fat flap, and postoperative complications) of soft palatal lengthening. RESULTS: Surface palatal, straight palatal, and soft palatal lengths had an intraoperative increase of 8%, 14.7%, and 27.7%, respectively. The degree of intraoperative soft palatal lengthening significantly varied among Veau cleft types (I = II < III = IV). Veau type III and cleft lip/palate were independent positive predictors (P < .001) of soft palatal lengthening, while other tested variables were not correlated (P > .05) with this outcome. CONCLUSIONS: Overall intraoperative palatal lengthening occurs with the modified sDOZ palatoplasty, with differences within the spectrum of cleft palate deformity.

Scar Outcome in Unilateral Complete Cleft Lip Repair: A Comparative Analysis of Vertical Lip Lengthening Strategies Using the Rotation-Advancement Concept.

OBJECTIVE: To assess the differences in scar outcomes between modified rotation-advancement techniques proposed by Drs. Mohler and Noordhoff, designed to address issues such as inadequate vertical lip length and scarring on the upper third of the lip in the original rotation-advancement technique. DESIGN: Retrospective single-surgeon (RD) study. PATIENTS: Consecutive non-syndromic children (n = 68) with unilateral complete cleft lip and palate. INTERVENTIONS: Modified Mohler (columellar backcut reconstructed with C flap; n = 34) and modified Noordhoff (lower, medially-created backcut reconstructed with laterally-based triangular skin flap; n = 34) repairs. MEAN OUTCOME MEASURES: Using 12-month postoperative frontal photographs, scar evaluations (overall and superior, middle, and inferior portions of the lip) were appraised by an assessment panel composed by independent professional and nonprofessional raters employing four validated qualitative scar assessment scales: Manchester Scar Scale, modified Scar-Rating Scale, Stony Brook Scar Evaluation Scale, and Visual Analog Scale. Quantitative computerized photogrammetric scar widths of the superior, middle, and inferior portions of the upper lip were also measured. RESULTS: The modified Noordhoff method showed significantly (all P < .001) better scar quality for the overall scar and superior portion of the scar in all four scales compared to the modified Mohler method, with no significant (all P > .05) difference for the middle and lower portions. No significant difference (all P > .05) was observed for photogrammetric scar width measurements. CONCLUSION: The modified Noordhoff technique provided better qualitative results for unilateral complete cleft lip-related scars compared to the modified Mohler technique.

Secondary Bilateral Cleft Rhinoplasty: Achieving an Aesthetic Result.

BACKGROUND: Secondary rhinoplasty in patients with bilateral cleft lip poses ongoing challenges and requires a reliable method for achieving optimal outcomes. OBJECTIVES: The purpose of this study was to establish a safe and effective method for secondary bilateral cleft rhinoplasty. METHODS: A consecutive series of 92 skeletally matured patients with bilateral cleft lip and nasal deformity were included. All had undergone secondary open rhinoplasty, performed by a single surgeon with a bilateral reverse-U flap and septal extension graft, between 2013 and 2021. Medical records of these 92 patients were reviewed to assess the clinical course. A 3-dimensional (3D) anthropometric analysis and panel assessment of 32 patients were performed to evaluate the aesthetic improvement, with an age-, sex-, and ethnicity-matched normal control group for comparisons. RESULTS: The methods showed statistically significant improvement in addressing a short columella (columellar height), short nasal bridge (nasal bridge length), de-projected nasal tip (nasal tip projection, nasal dorsum angle), poorly defined nasal tip (nasal tip angle, dome height, and panel assessment), and transversely oriented nostrils (columellar height, alar width, nostril type). Importantly, these improvements were accompanied by a low complication rate of 4%. However, upper lip deficiency over the upper lip angle and labial-columellar angle remained without significant improvement. CONCLUSIONS: In this study we described effective secondary rhinoplasty, which was composed of a bilateral reverse-U flap and septal extension graft, with acceptable outcome. The 3D anthropometric analysis and panel assessment clarified that our rhinoplasty procedure could bring the nasal morphology in these patients closer to the normal data.

The Rise of Online Medical Education in Craniofacial Surgery.

BACKGROUND: International travel had been radically disrupted by coronavirus disease 2019 (COVID-19), leaving traditional medical conferences on a 2-year hiatus. The International Craniofacial Chang Gung Group (ICC) was thus created to disseminate knowledge related to craniofacial surgery. This study aimed to reveal how webinars fundamentally transformed the traditional format of medical conferences. MATERIALS AND METHOD: In total, 64 ICC webinars held between December 13, 2020, and May 21, 2023, were documented and reviewed. A questionnaire was designed and sent to ICC members. The questionnaire collected information on attitudes and habits relating to videoconferencing in general before and after the start of COVID-19 and on the ICC webinars specifically. Responses were analyzed to inform our understanding of respondents' experience and satisfaction with the webinars. RESULTS: The webinars covered a variety of topics related to craniofacial surgery. In total, 64 webinars were included for analysis. The mean number of attendees at each webinar was 86.7. In total, 111 respondents were more satisfied (4.25 ± 0.72 out of 5) with ICC webinars than with other media of online meetings ( P < 0.001). In total, 89.2% of respondents were willing to continue attending ICC webinars after COVID-19 restrictions have been lifted. CONCLUSIONS: Webinars are an effective format for imparting knowledge, especially in the ICC, and will become key in continuing medical education.

Avoiding Inferior Alveolar Nerve Injury During Sagittal Split Ramus Osteotomy.

Orthognathic surgery is highly effective in improving overall facial esthetics, in addition to achieving an ideal occlusion. Sagittal split ramus osteotomy (SSRO) of the mandible is the mainstay of modern orthognathic surgery, but intraoperative injury to the inferior alveolar nerve (IAN) remains one of the common complications. The authors report a case of 19-year-old male patient with left cleft lip and palate who received orthognathic surgery involving SSRO. The patient's right IAN ran close to the outer cortex of the mandible, but SSRO was successfully performed without injuring the nerve. Detailed preoperative evaluation using computed tomography images is essential. Blind splitting maneuvers during SSRO may cause IAN injury, and direct visualization inside the ramus helps to prevent injury to the nerve. Sagittal split ramus osteotomy could be considered as a viable option even when the IAN runs close to the outer cortex. This article describes SSRO procedures, highlighting the methods to avoid nerve injury.

Single-Splint, 2-Jaw Orthognathic Surgery for Correction of Facial Asymmetry: 3-Dimensional Planning and Surgical Execution.

Three-dimensional (3D) planning of orthognathic surgery (OGS) improves the treatment of facial asymmetry and malocclusion, but no consensus exists among clinicians regarding technical details. This study verified the consistency of authors' workflow and strategies between 3D planning and surgical execution for facial asymmetry. This retrospective study recruited consecutive patients (n=54) with nonsyndromic facial asymmetry associated with malocclusion. The stepwise workflow included orthodontic treatment, 3D imaging-based evaluation, planning, and transferring the virtual of single-splint 2-jaw OGS to actual surgery in all patients. Seven landmark-based measurements were selected for postoperative assessment of facial symmetry. Fifty patients had no anesthetic/surgical-related episode and procedure-related complications. Others experienced wound infection (n=1), transient TMJ discomfort (n=1), and facial numbness (n=3). Two cases had minor residual asymmetry (cheek and chin, respectively), but did not request revisionary bone or soft tissue surgery. Comparisons between the planned and postoperative 3D images with quantitative measurement revealed acceptable outcome data. The results showed a significant increase in facial symmetry at 7 landmark-based postoperative measurements for both male and female. This 3D-assisted pathway of OGS permitted achievement of consistent satisfactory results in managing facial asymmetry, with low rate of complications and secondary management.

Modified Mucosal Reconstruction in Unilateral Complete Cleft of Lip and Primary Palate: Surgical Technique and Practical Strategies.

BACKGROUND: The nasal floor and intraoral lining reconstruction of unilateral complete cleft of lip and primary palate has sparsely been reported. Solution: This article combines the previously-described C-flap mucosal flap and inferior turbinate flap with the newly-described lateral nasal mucosal flap for the mucosal repair of this uncommon subtype of deformity. Valuable practical strategies are offered to optimize the surgical execution within a limited pediatric intranasal surgical access, targeting to minimize tissue trauma and bleeding.

Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair.

Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations.

A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

The Effect of Arch Cartilage Graft and Tajima Reverse U Approach in the Secondary Reconstruction of Unilateral Cleft Lip Nasal Deformity.

ABSTRACT: Secondary cleft lip nasal deformity is complicated with wide spectrum of defect and varied reconstructive procedures. There has been no unanimous solution for a given problem. In case of a localized alar depression in unilateral cleft lip nasal deformity, the conchal cartilage applied as arch graft was proposed. Patients were recruited from database of craniofacial center who received Tajima method and arch cartilage graft. Inclusion criteria were patients with unilateral cleft lip nasal deformity after skeletal maturity. Through a reverse U incision, the lower lateral cartilage was dissected and released from the skin and the contralateral cartilage. The harvested conchal cartilage graft was trimmed to 25 to 30 by 8mm in size, and inserted as arch shape overlying the cleft side lower lateral cartilage. Transdomal fixation sutures were made. Outcome assessment was performed, and the nostril and alar dimensions were measured. Thirty-nine patients were eligible for evaluation of the surgical outcome. Majority of patients underwent simultaneous lip revision (97%). No surgery-related complications were noted in this series. Satisfaction to the nasal reconstruction was reported in 85% of patients. Further minor nasal revisions were performed in 6 patients (15%). Quantitative measurement showed statistically significant improvement in nostril height, alar height and alar width after the surgery. It is concluded that the Tajima reverse U approach plus arch cartilage graft is an effective method for secondary reconstruction of the unilateral cleft lip nasal deformity in selected patients presenting with cleft side alar depression.5.

Aesthetic Enhancement of the Vermilion Using Dermofat Graft in Patients With Cleft Lip Deformity.

BACKGROUND: There is an increasing patient expectation for better esthetics, manifesting through anatomical harmony, projection, and volume of the upper lip relative to the lower lip, in patients with cleft deformity. The aim of this study is to investigate the outcome of vermilion augmentation using autologous dermofat graft (DFG) to enhance the lip using both quantitative and qualitative assessment. METHODS: Patients with secondary cleft lip deformity who received the surgical treatment in our institution from 2015 to 2018 were recruited. Panel assessment was performed on standardized preoperative and postoperative digital photographs. A patient questionnaire was used for the reported outcome. Image processing and analyses were applied to measure the lip change. Statistical analyses were performed. RESULTS: A total of 91 patients were included. The mean age at operation was 22.7 years, and postoperative follow-up was 3.6 years. There were no complications in the study group. The panel assessment showed significant improvement (P < .00001) on upper lip vermilion in both frontal and lateral profile views. Ninety-five percent of patients reported improvement of the upper lip projection and volume. Quantitative image analysis showed an increase in the upper lip vermilion ratio in 97% of the cases in frontal views and improvement of the vermilion projection in 87% of the cases in the superimposed lateral views. CONCLUSIONS: The use of DFG is an effective and reproducible method for vermilion augmentation and aesthetic enhancement in patients presenting with upper lip insufficiency relative to the lower lip.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE: An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach. DESIGN: Retrospective single-surgeon study. PATIENTS: Consecutive nonsyndromic patients (n = 27) with Veau I cleft palate. INTERVENTIONS: Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD). MEAN OUTCOME MEASURES: Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n = 24) was retrieved for comparison purposes. RESULTS: Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P = .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P = .546), age (10.2 ± 1.7 vs 9.6 ± 1.2 months; P = .143), rate of lateral incision (18.5% vs 4.2%; P = .195), and postoperative complication rate (0% vs 0%). CONCLUSION: This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Simultaneous Fat Injection for Nasal Contouring in Orthognathic Patients.

BACKGROUND: Augmentation rhinoplasty with autologous fat grafting is a useful procedure to meet the demand for facial harmonization in the Asian population. We used this procedure during orthognathic surgery to address inadequate dorsum projection. This prospective study was conducted to determine the fat retention rate in patients undergoing simultaneous autologous fat injection augmentation rhinoplasty and orthognathic surgery. METHODS: Nineteen patients were treated with simultaneous bimaxillary orthognathic surgery and autologous fat grafting of the nasal dorsum and tip. The paired t test was used to compare the nasal volumes before and at least 6 months after surgery measured by 3-dimensional computer tomography scans. All measurements were performed twice by the same evaluator at least 2 weeks apart for intrarater consistency. RESULTS: Seventeen patients completed the study. The volume means before and after surgery were 22.3 ± 4.6 cm3 and 23.3 ± 4.7 cm3, respectively, with a mean difference of 1.0 ± 0.3 cm3 (P < .001). The mean retention rate was calculated to be 50.5% ± 7.0% (range: 40.5%-64.7%). Intrarater consistency was high with a Cronbach α of .97 (P < .001) and .98 (P < .001), respectively. CONCLUSION: This prospective study provides objective graft retention measurements for fat injection augmentation rhinoplasty combined with orthognathic surgery. All patients were satisfied with the results and no complications or additional morbidity was noted in the postoperative course. We consider this procedure to be a safe, reliable, and powerful adjunct to improve the aesthetic results of orthognathic surgery.

Three-Dimensional Computer-Assisted Orthognathic Surgery: Traditional Hybrid Versus Full Digital Planning Models.

PURPOSE: Three-dimensional (3D) computer-aided planning has truly revolutionized orthognathic surgery (OGS) treatment, but no study has compared the traditional hybrid and full 3D digital planning models. This study compared these virtual planning models in the treatment of asymmetric maxillomandibular disharmony. METHODS: Young adult patients with an asymmetric skeletal class III deformity who underwent 3D computer-aided 2-jaw OGS using hybrid (alginate dental impression, 2D cephalometric tracings, manual-guided stone model surgery, occlusion setup, and splint fabrication; n = 30) or full digital (laser-scanned dentition, 3D cephalometric tracings, virtual-based occlusion setup and surgery, and computer-generated surgical splint; n = 30) planning models were consecutively recruited. Preoperative and postoperative 3D cephalometric analyses (dental relation, skeletal assessments based on sagittal and frontal views, and soft tissue evaluations) were adopted for intragroup and intergroup comparisons. Postoperative patient-perceived satisfaction with facial appearance was also recorded. RESULTS: Both hybrid and full digital planning groups had significant (all P < 0.05) improvements after surgery with respect to facial convexity, incisor overjet, and frontal symmetry parameters. The full 3D digital planning-based OGS treatment had similar (all P > 0.05) 3D cephalometric-derived outcomes (preoperative, postoperative, and treatment-induced change data) and patient-perceived outcomes compared with the traditional hybrid 3D planning method. CONCLUSIONS: For the decision-making process in selecting the planning model, multidisciplinary teams could consider additional parameters such as patient comfort, storage needs, convenience for data reuse, overall planning time, availability, and costs.

Automatic Assessment of 3-Dimensional Facial Soft Tissue Symmetry Before and After Orthognathic Surgery Using a Machine Learning Model: A Preliminary Experience.

PURPOSE: An objective and quantitative assessment of facial symmetry is essential for the surgical planning and evaluation of treatment outcomes in orthognathic surgery (OGS). This study applied the transfer learning model with a convolutional neural network based on 3-dimensional (3D) contour line features to evaluate the facial symmetry before and after OGS. METHODS: A total of 158 patients were recruited in a retrospective cohort study for the assessment and comparison of facial symmetry before and after OGS from January 2018 to March 2020. Three-dimensional facial photographs were captured by the 3dMD face system in a natural head position, with eyes looking forward, relaxed facial muscles, and habitual dental occlusion before and at least 6 months after surgery. Three-dimensional contour images were extracted from 3D facial images for the subsequent Web-based automatic assessment of facial symmetry by using the transfer learning with a convolutional neural network model. RESULTS: The mean score of postoperative facial symmetry showed significant improvements from 2.74 to 3.52, and the improvement degree of facial symmetry (in percentage) after surgery was 21% using the constructed machine learning model. A Web-based system provided a user-friendly interface and quick assessment results for clinicians and was an effective doctor-patient communication tool. CONCLUSIONS: This work was the first attempt to automatically assess the facial symmetry before and after surgery in an objective and quantitative value by using a machine learning model based on the 3D contour feature map.

Diced Cartilage Rhinoplasty for Cleft Nose Deformities: Determining the Flexibility of the Cartilage Framework.

BACKGROUND: The objective of this trial is to evaluate the flexibility of the cartilaginous component of the cleft nose after diced cartilage rhinoplasty by determining the degree of possible bending in relation to the vertical nasal dorsum axis and to compare with to a control group of the unaffected population. PATIENTS AND METHODS: Fifteen cleft nose patients with diced cartilage rhinoplasty were included in this study, as well as a control group of 15 unaffected individuals. The angle of maximum nasal bending is measured between the basic and maximum bending axis and performed by the same rater twice at least 2 weeks apart to account for intrarater reliability. Study groups were compared with Fisher and independent t test. RESULTS: The maximum bending to the left side was 16.10 ± 5.03 degrees for the study group and 23.95 ± 6.54 degrees for the control group (P = 0.001). The maximum bending to the right side were 16.54 ± 6.73 degrees for the study group and 23.00 ± 8.88 degrees for the control group (P = 0.034). CONCLUSION: Diced cartilage graft injection for dorsal augmentation yields reproducible and esthetically pleasing outcomes with good flexibility and natural feel of the nasal tip. Although there is a significant difference compared with a nonaffected control group in maximum bending capacity, all patients in this study were satisfied with the results.

NAM-help or burden? Intercultural evaluation of parental stress caused by nasoalveolar molding: a retrospective multi-center study.

OBJECTIVES: Nasoalveolar molding (NAM) was developed to facilitate easier treatment and better outcomes for cleft lip and palate (CLP) patients. The aim of this study was to investigate the parental burden and possible intercultural differences of this treatment modality, which is often argued to burden parents to an extraordinary amount. MATERIALS AND METHODS: Standardized questionnaires (available in English, Mandarin, and German) with 15 non-specific and 14 NAM-specific items to be retrospectively answered by Likert scales by parents of unilateral CLP patients with completed NAM treatment. RESULTS: The parents of 117 patients from two treatment centers in Taiwan and Germany were included. A very high level of overall satisfaction was found in both countries with significant intercultural differences in prenatal parent information, feeding problems, dealing with 3rd party's perception, and experienced personal effort. CONCLUSION: NAM is an effective treatment tool for children's CLP deformities and their caregivers in overcoming the feeling of helplessness. Intercultural differences may be due to infrastructural reasons, cultural attitudes and habits, or different public medical education. CLINICAL RELEVANCE: In addition to facilitating easier surgical treatment, NAM can be seen as a powerful coping strategy for parents dealing with a CLP deformity of their child and does not seem to burden them extraordinarily.