Multidisciplinary Presurgical Education: Clinical Impact on Children With Orofacial Clefts Undergoing Maxillary Distraction via Rigid External Distraction.

OBJECTIVE: Treatment of severe maxillary hypoplasia is commonly addressed via distraction osteogenesis with a rigid external device (RED). While effective, this method can be socially stigmatizing in an already vulnerable patient population. To prepare children and their caregivers for life with a RED and decrease peri-operative anxiety, we instituted a multidisciplinary pre-surgical education session (MPES). This educational team involves our cleft care coordinator, child life specialist, orthodontist and plastic surgeon 2 weeks prior to surgery. We reviewed the impact of this intervention by examining clinical outcomes before and after its implementation. DESIGN: From February 2017 to February 2020, a retrospective chart review was performed to include patients with orofacial clefts and maxillary hypoplasia who underwent maxillary distraction osteogenesis with RED at our center before (28 patients) and after (29 patients) the implementation of MPES. RESULTS: MPES was associated with a significantly shorter length of stay compared to controls who did not receive MPES (3.6 vs 3.1 days, p < 0.03) and significantly decreased usage of inpatient narcotic pain medication compared to controls (16.8 morphine equivalents vs 31.8 morphine equivalents, p < 0.02). Our intervention also demonstrated a trend towards decrease in minor complications but did not achieve statistical significance p = 0.32). CONCLUSIONS: Multidisciplinary presurgical education is a beneficial adjunct in the care of patients with orofacial clefts and maxillary hypoplasia undergoing maxillary advancement with a RED.

Implementation of Telehealth in a Pediatric Plastic Surgery Clinic: A Single Center's Response to COVID-19.

BACKGROUND: With limitation of in-person clinical visits due to the COVID-19 pandemic, telehealth has emerged as an important platform to deliver healthcare. Satisfaction with telehealth has been examined previously in the adult plastic surgery population. However, studies examining its use and satisfaction in the pediatric plastic surgery population are limited. In this study, we explore patient/caregiver satisfaction with the rapid institution of telehealth in our pediatric plastic surgery clinic and factors affecting satisfaction scores. METHODS: From March 2020 to February 2021, families of pediatric patients seen via video telehealth in the pediatric plastic surgery clinic at our center were invited to participate in a posttelehealth session survey. Telehealth visits encompassed both preliminary consultations as well as follow-up visits. After appropriate consent was obtained, patients' families completed a posttelehealth survey conveying demographics and satisfaction with telehealth via a 5-point Likert scale. RESULTS: Seventy eight of 131 eligible families elected to participate. Visit types included the following: initial consultations (23.1%), preoperative visits (10.3%), postoperative visits (29.5%), and follow-up visits (37.1%). A total of 80.3% of the respondents were overall satisfied with their telehealth experience. A total of 85.3% of the respondents agreed that telehealth made it easier for them to see their doctor, and 96.7% of the respondents felt using telehealth saved them time in traveling to the clinic. A total of 89.5% of the respondents felt it important for the state of Utah to have a telehealth program available to pediatric patients. CONCLUSIONS: Video telehealth is a useful adjunct in the care of pediatric plastic surgery patients with high caregiver satisfaction.

Frontofacial Reconstruction Technique Modification With Preservation of Blood Supply to the Monobloc Segment.

ABSTRACT: Craniosynostosis syndromes, including Apert Syndrome, Pfeiffer Syndrome, and Crouzon Syndrome, share similar phenotypes, including bicoronal craniosynostosis, midface hypoplasia, hypertelorism, and exorbitism. The standard surgical treatment for these craniofacial abnormalities is monobloc osteotomy with distraction osteogenesis. Complications of this technique include the failure of osteogenesis or resorption of the frontal bone. The authors propose an alternative surgical technique with a frontal arch in continuity with the midface segment to ensure vascularization to anterior and posterior borders of distraction. A case report of an 8-year-old female patient with Apert Syndrome is reported using our technique. Our frontal arch monobloc distraction procedure preserves blood supply to a cranial component of the monobloc segment site that becomes the anterior portion of distraction rather than with the traditional devascularized frontal bone flap. This technique modification should improve osteogenesis outcomes by preventing resorption or failure of bone formation.

Management of sagittal synostosis in the Synostosis Research Group: baseline data and early outcomes.

OBJECTIVE: Sagittal synostosis is the most common form of isolated craniosynostosis. Although some centers have reported extensive experience with this condition, most reports have focused on a single center. In 2017, the Synostosis Research Group (SynRG), a multicenter collaborative network, was formed to study craniosynostosis. Here, the authors report their early experience with treating sagittal synostosis in the network. The goals were to describe practice patterns, identify variations, and generate hypotheses for future research. METHODS: All patients with a clinical diagnosis of isolated sagittal synostosis who presented to a SynRG center between March 1, 2017, and October 31, 2019, were included. Follow-up information through October 31, 2020, was included. Data extracted from the prospectively maintained SynRG registry included baseline parameters, surgical adjuncts and techniques, complications prior to discharge, and indications for reoperation. Data analysis was descriptive, using frequencies for categorical variables and means and medians for continuous variables. RESULTS: Two hundred five patients had treatment for sagittal synostosis at 5 different sites. One hundred twenty-six patients were treated with strip craniectomy and 79 patients with total cranial vault remodeling. The most common strip craniectomy was wide craniectomy with parietal wedge osteotomies (44%), and the most common cranial vault remodeling procedure was total vault remodeling without forehead remodeling (63%). Preoperative mean cephalic indices (CIs) were similar between treatment groups: 0.69 for strip craniectomy and 0.68 for cranial vault remodeling. Thirteen percent of patients had other health problems. In the cranial vault cohort, 81% of patients who received tranexamic acid required a transfusion compared with 94% of patients who did not receive tranexamic acid. The rates of complication were low in all treatment groups. Five patients (2%) had an unintended reoperation. The mean change in CI was 0.09 for strip craniectomy and 0.06 for cranial vault remodeling; wide craniectomy resulted in a greater change in CI in the strip craniectomy group. CONCLUSIONS: The baseline severity of scaphocephaly was similar across procedures and sites. Treatment methods varied, but cranial vault remodeling and strip craniectomy both resulted in satisfactory postoperative CIs. Use of tranexamic acid may reduce the need for transfusion in cranial vault cases. The wide craniectomy technique for strip craniectomy seemed to be associated with change in CI. Both findings seem amenable to testing in a randomized controlled trial.

Management of Tessier Type 3 Cleft With a Novel Reverse Palatal Expander.

ABSTRACT: The purpose of this clinical report is to present the novel management of a type Tessier 3 cleft which was treated using a palatal expander in reverse fashion to reapproximate the craniofacial skeleton allowing for closure of the palate and soft tissue of the cleft. Reapproximation of the bony component of the cleft was achieved without osteotomies and allowed for easier and earlier realignment of the bony and soft tissue components of the cleft. To our knowledge, this is the first use of reverse palatal expansion in the treatment of type 3 Tessier cleft. Reverse palatal expansion made management of this cleft more straightforward and should be considered as a useful adjunct in the management of wide facial clefts.

Serial Posterior Cranial Vault Distraction for the Treatment of Complex Craniosynostosis.

ABSTRACT: Posterior cranial vault distraction is an important modality in the management of craniosynostosis. This surgical technique increases intracranial volume and improves cranial aesthetics. A single procedure is often inadequate in patients with complex multisuture craniosynostosis, as some will go on to develop intracranial hypertension despite the operation. Considering the negative effects of intracranial hypertension, some patients may warrant 2 planned distractions to prevent this scenario from ever occurring. Three patients with complex multiple-suture synostosis and severe intracranial volume restriction (occipital frontal head circumferences [OFCs] <1st percentile) were treated with 2 planned serial posterior cranial vault distractions at the institution between 2013 and 2018. Demographics, intraoperative data, and postoperative distraction data were collected. The OFC was recorded pre- and postdistraction, at 3- and 6-month follow-up appointments. Patients had a corrected average age of 18 weeks at the time of their initial procedure. There was an average of 38 weeks between the end of consolidation and the time for their 2nd distraction procedure. There was an average age of 79 weeks at the time of the 2nd procedure. All patients had a substantial increase in OFC and improvement of the posterior calvarium shape. The average increase in OFC was 5.2 cm after first distraction and 4.3 cm after 2nd distraction. No postoperative complications were encountered. Planned serial posterior cranial vault distraction is a safe and effective strategy for increasing intracranial volume, improving aesthetic appearance, and preventing the consequences of intracranial hypertension in patients with multisuture craniosynostosis and severe intracranial volume restriction.

Sinus Pericranii in Posterior Cranial Vault Distraction.

Anomalous venous connections between the extracranial and intracranial systems are relatively rare. These connections are also known as sinus pericranii (SP) have been reported previously in the setting of various cranial malformations including craniosynostosis. Angiography may be useful in the diagnosis of SP also allowing for differentiation of the dominance of the venous systems. Several methods have been described in the treatment of SP. In isolated cases both endovascular and open approaches have been successful in the treatment of SP. In cases wherein there is synostosis present, both single- and multiple-staged operations have been described. In this article, we describe 2 cases of posterior cranial distraction in the setting of sinus peri cranii.

Evaluation of the Patient-Practitioner Consultation on Surgical Treatment Options for Patients With Craniosynostosis.

INTRODUCTION: Endoscope-assisted craniectomy and spring-assisted cranioplasty with post-surgical helmet molding are minimally invasive alternatives to the traditional craniosynostosis treatment of open cranial vault remodeling. Families are often faced with deciding between techniques. This study aimed to understand providers' practice patterns in consulting families about surgical options. METHODS: An online survey was developed and distributed to 31 providers. The response rate was 84% (26/31). RESULTS: Twenty-six (100%) respondents offer a minimally invasive surgical option for sagittal craniosynostosis, 21 (81%) for coronal, 20 (77%) for metopic, 18 (69%) for lambdoid, and 12 (46%) for multi-suture. Social issues considered in determining whether to offer a minimally invasive option include anticipated likelihood of compliance (23 = 88%), distance traveled for care (16 = 62%) and financial considerations (6 = 23%). Common tools to explain options include verbal discussion (25 = 96%), 3D reconstructed CT scans (17 = 65%), handouts (13 = 50%), 3D models (12 = 46%), hand drawings (11 = 42%) and slides (10 = 38%). Some respondents strongly (7 = 27%) or somewhat (3 = 12%) encourage a minimally invasive option over open repair. Others indicate they remain neutral (7 = 27%) or tailor their approach to meet perceived needs (8 = 31%). One (4%) somewhat encourages open repair. Despite this variation, all completely (17 = 65%), strongly (5 = 19%) or somewhat agree (4 = 15%) they use shared decision making in presenting surgical options. CONCLUSION: This survey highlights the range of practice patterns in presenting surgical options to families and reveals possible discrepancies in the extent providers believe they use shared decision making and the extent it is actually used.

Use of Bone Morphogenetic Protein in Pediatric Cranioplasty With Pre- and Postoperative Radiation Therapy.

INTRODUCTION: Bone morphogenetic protein (BMP) is a signaling protein that has proven efficacy in the setting of bone repair. It has been widely used in orthopedic surgery and is being implemented more in the field of craniofacial surgery, although there is limited report on its use in pediatric patients. CASE: A 6-year-old female with stage IV neuroblastoma with metastasis to the parietal parasagittal calvarium, which had failed to respond to multiple medical therapies, including radiation therapy. The tumor was excised and the defect was replaced with a combination of split calvarial bone graft and rhBMP-2. The patient received post-operative radiation therapy with no reports of complications of the defect site on immediate and long term follow up. CONCLUSION: The use of BMP has the potential to aid in bone generation for high-risk calvarial defects. It can be safe and efficacious to use in the pediatric population; however, future studies should be done to determine the safest and most effective dosing of BMP.

Maxillary Distraction Osteogenesis in a Patient With Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is characterized by brittle bones, premature hearing loss, blue sclera, dental abnormalities, and short stature. Maxillofacial pathology is marked in many OI patients and includes a high incidence of class III malocclusion secondary to a retrusive maxilla relative to both the mandible and cranial base.Review of literature shows that most of the orthognathic surgeries performed in the setting of OI are double jaw surgeries, in the form of maxillary advancement and mandibular setback. However, severe maxillary hypoplasia is usually not correctable with single-stage maxillary advancement. Distraction osteogenesis (DO) is a technique that relies on the normal healing process that occurs between controlled, surgically osteotomized bone segments and it is a relatively widely used technique in modern management of craniofacial conditions.Distraction osteogenesis has been reported in only several patients with OI. There is only 1 previously documented case of maxillary distraction in the craniofacial literature. The authors present here the successful management of a patient with OI and severe class III malocclusion using LeFort I osteotomy and DO with an external rigid distractor.At 12 months follow-up, the patient had no complications and maintained stable maxillary position with normal occlusion, improvement of facial appearance, obstructive airway symptoms, speech, and chewing.This case serves to reinforce the safety and efficacy of DO in patients with OI. The authors did not significantly change our distraction protocol and did not have any complications, therefore the authors believe that DO should be the preferable treatment technique for severe malocclusion in OI patient population.

Modified Lefort Distraction Osteogenesis for the Treatment of Nager Syndrome-Associated Midface Hypoplasia: Technique and Review.

The surgical management of midface hypoplasia in the setting of Nager syndrome remains a significant challenge for craniofacial surgeons. This study describes a novel technique using distraction osteogenesis and modified osteotomies for the treatment of midface bony defects in an 11-year-old child with Nager syndrome.Presurgical 3-dimensional planning was performed to design the osteotomies and placement of distractors. The surgical approach required upper buccal sulcus and extended transconjunctival incisions only. Osteotomies were performed from the pyriform aperture through the orbit to include the lateral orbital wall, with bilateral osteotomy of the zygomas through the anterior arch via the transconjunctival incision. Distraction of the en bloc midface segment was successfully performed using external distractors. Bone grafting was not required. There were no complications.External distraction was well tolerated and there were no intraoperative or postoperative complications. The distractors were removed uneventfully after consolidation. The midface was successfully advanced without the need for bone grafting or bicoronal incision. The occlusal plane was leveled and the aesthetic appearance of the child was improved.Symmetrical midface hypoplasia in the context of Nager syndrome can be successfully corrected with en bloc distraction osteogenesis of the maxilla and bilateral zygomas through modified osteotomies that exclude the upper nasal pyramid. The approach is simplified and the need for bicoronal incision and bone grafting is mitigated in this technique, which the authors have named Lefort 2.5.

Protection of the Temporomandibular Joint During Syndromic Mandibular Distraction With a Novel Condylar Offloading Device.

Mandibular distraction for severe micrognathia in syndromic patients often leads to temporomandibular joint (TMJ) ankylosis, which requires further interventions to regain joint motion. The increased incidence of postdistraction ankylosis is likely related to increased prevalence of preoperative joint pathology in syndromic micrognathic patients. Previous studies have demonstrated that offloading the pressure on the condyle during the distraction process can prevent such TMJ pathology. In this article, the authors describe a successful new method for offloading the condyle to prevent postdistraction ankylosis using an external TMJ offloading device.

The metopic angle: a novel assessment tool of the trigonocephalic frontal deformity and its correction.

While metopic synostosis is typically a straightforward clinical diagnosis, there is no standard objective measurement that can be easily used in the preoperative evaluation and in the subsequent postoperative follow-up. Despite the fact that multiple methods have been previously described, they either lack well-defined landmark points, do not specifically address the frontal vault deformity, or are too cumbersome to be used routinely for clinical applications. We describe the metopic angle as an objective and dependable method for evaluation of the frontal vault contour.Using the STARscanner Laser Data Acquisition System, a portable, noninvasive diagnostic modality, the metopic angle was defined. This angle was used to track postoperative changes and was compared with preoperative values in patients who underwent minimally invasive strip craniectomy for metopic synostosis. To further ensure its validity, the angle was also measured in age-matched control subjects.The metopic angle changed from a preoperative value of 104.9 degrees to 111.3 degrees at 3 months (P = 1.59E-06) and to 114.9 at 1 year postoperatively (P = 2.51E-09) in patients who underwent endoscopic-assisted strip craniectomies for metopic synostosis. The resulting postoperative values were comparable to those obtained in age-matched control subjects with normal cranial vaults.The metopic angle measurement is a rapid, noninvasive, reproducible method for objective measurement of both preoperative deformity and postoperative correction of the frontal bone contour in metopic synostosis.

Early Results on the Efficacy of Demineralized Bone Matrix, Bone Morphogenic Protein, and Freeze-dried Bone Chips in Alveolar Cleft Repair.

Background: Conventional treatment for alveolar cleft repair is done using autologous iliac crest alveolar bone graft (ABG). However, this method may not be ideal in all patients. Analysis of the efficacy of a mixture of demineralized bone matrix (DBX), bone morphogenic protein (rhBMP-2), and freeze-dried bone chips (FDBC) as an alternative for alveolar cleft repair was performed. Methods: Consecutive patients from August 2019 to June 2022 undergoing early alveolar cleft repair, concomitant hard palate and alveolar cleft repair, secondary alveolar cleft repair, and regrafting from a previously failed ABG were analyzed. Computed tomography scans were performed to evaluate graft take at least 6 months postoperatively. Images were reviewed and scored. Alveolar graft height and graft thickness were recorded. A standardized scoring system was developed, with a score of 0 representing no graft take and 3 representing best possible graft take. Results: Fifty-five consecutive alveolar clefts (43 patients) were identified as having undergone ABG and satisfied all the other inclusion criteria. Of these, 29 underwent first time ABG and 26 underwent redo ABG. The mean graft height and graft thickness recorded for all clefts was 2.2 and 2.0, respectively. Conclusions: Early results evaluating the efficacy of ABG using DBX, rhBMP-2, and FDBC show feasibility in regard to both graft height and thickness when using a maxillary computed tomography scan to measure the bone graft take. These results suggest that DBX, rhBMP-2, and FDBC may act as a versatile bone graft material in cleft care, although further studies are needed to determine long-term outcomes.

Endoscopic-assisted correction of metopic synostosis.

Our 6-year experience with correction of metopic synostosis using a minimally invasive endoscopic-assisted technique followed by postoperative cranial vault helmet molding is presented. In addition, a simple, objective method for quantification of the frontal vault contour is described.A total of 16 patients, 13 males and 3 females, with nonsyndromic, single-suture synostosis were included in the study. Patient age at operation averaged 2.9 months and the mean weight was 6 kg. The mean operative time was 79 minutes. The estimated blood loss during the procedure was 82.8 mL. Three patients required blood transfusions (18.7%). There were no significant postoperative complications. The mean hospitalization was 1.6 days. The average surgical cost, including the helmets, was $12,400, in contrast to $33,000 charged for the equivalent open procedure.Very good esthetic results, judged by physical examination and photograph comparison, were obtained in all patients. No relapses were noted. Objectively, the outcome of the operative repair was evaluated using laser scanning. For quantification of the distortion and the postoperative level of correction, the metopic angle was defined and used. This angle changed from preoperative value of 104.9 degrees to 111.3 degrees at 3 months (P = 1.59E-06) and to 114.9 degrees at 1 year postoperatively (P = 2.51E-09).Due to its promising attributes, minimally invasive strip craniectomy emerges as an ideal modality for correction of metopic synostosis. Furthermore, the metopic angle should provide clinicians with an objective measure of the frontal cranial vault deformity and its correction.

Modified Antia-Buch Flap Incorporating an Extended Temporal Scalp Incision.

The Antia-Buch flap is a popular reconstructive method for full-thickness ear defects involving the helical rim. However, scaphal or conchal resection is often required to prevent ear distortion. Noel et al described a modified technique to the Antia-Buch flap, which includes an incision in the temporal scalp and complete detachment of the preauricular helical root to increase mobility of the flap. Since then, no studies have reported on the use of this modification. We report our experience in implementing Noel et al's modification of the Antia-Buch flap for helical rim defects. Methods: The modified technique differs from the original Antia-Buch flap by completely detaching the root of the helix and adding a vertical incision to the temporal scalp to increase mobility of the flap. No scaphal resection is necessary. After complete elevation of the flaps, the flaps are advanced and inset toward each other followed by closure. Results: In our practice, 10 patients have been treated with Noel et al's modification to the Antia-Buch flap. In each of these patients, acceptable reconstruction of the helical rim was able to be achieved. All the patients were pleased with their reconstructive outcome and ear anatomy was able to be successfully maintained. Conclusions: The modified Antia-Buch flap has shown to be an excellent method for large, helical rim defects, creating versatility by adding the temporal scalp incision. Our outcomes with Noel et al's modification to the original Antia-Buch flap support this method as a versatile technique for wide full-thickness helical rim defects.

Novel Custom Maxillary Disimpaction Splint.

LeFort I, II, and III osteotomies are commonly used in complex craniofacial reconstruction. Patients requiring these procedures typically have a craniofacial cleft, other congenital craniofacial deformities, or severe facial trauma. Both the cleft and traumatized palate have poor bony support, which leads to possible complications when the disimpaction forceps are used during the downfracture of the maxilla. Such potential complications include trauma or formation of a fistula of the palatal, oral, or nasal mucosa; trauma to adjacent teeth; and fracture of the palate and alveolar bone. To help prevent these complications, we developed a custom disimpaction splint. The splint is designed to cover the palate and occlusal surfaces to increase retention and minimize splint movement during the maxillary downfracture portion of the surgical procedure. The base of the splint is fabricated from a two-layered biocryl material, and the palatal area is built with soft-cushion rebase material. This allows for a stable grip of the disimpaction forceps blades and provides protective coverage of the cleft, traumatized palate, or alveolar bone graft site during the downfracture. The custom maxillary disimpaction splint has been routinely used in our clinic from September 2019 to the present for LeFort osteotomies in patients with a compromised primary palate. No surgical complications related to the maxillary downfracture have been noted during this period of time. We conclude that the routine use of a custom maxillary disimpaction splint can result in improved outcomes and decreased complications of LeFort osteotomy procedures in patients with cleft and traumatized palate.

Minimally invasive strip craniectomy for sagittal synostosis.

The most common approaches used today for the correction of sagittal synostosis involve large craniectomies and extensive cranial vault remodeling. Although these techniques ultimately yield very good cosmetic results, they have significant drawbacks. They are lengthy, expensive, associated with significant blood loss, universally require transfusions, and often result in prolonged hospitalization.We present here our 5-year experience with correction of sagittal synostosis using the recently described minimally invasive strip craniectomy followed by postoperative cranial vault helmet molding. During this period, we treated a total of 97 children with nonsyndromic single-suture synostosis. The first 46 of 67 children treated for sagittal synostosis had at least 1 year of postoperative follow-up and were included in the analysis. There were 33 boys and 13 girls. Patients' mean age at surgery was 3.1 months, and the mean weight was 6.1 kg. The mean operative time was 75 minutes. The estimated blood loss during the procedure was 56 mL. Eight patients received blood transfusions during surgery (17.4%) and 3 patients received after surgery (6.5%). There were no significant postoperative complications. The mean hospitalization was 2.2 days. Excellent aesthetic outcomes were noted in all patients. The change in cranial index from a preoperative value of 0.7 to 0.8 postoperatively was virtually stabilized 3 months after the surgical intervention. Significantly better correction rates were observed in the youngest patients.Because of its excellent attributes, minimally invasive strip craniectomy followed by postoperative helmet molding is likely to become the preferred treatment modality for the correction of sagittal synostosis.

Mandibular Myofibroma and Severe Trismus: A Complex Case and Review of Complications.

A female child was investigated for insidious onset of temporomandibular joint dysfunction and trismus in the setting of a mandibular myofibroma. Myofibromas, benign mesenchymal neoplasms composed of spindle cells, are rarely found in the oral cavity, most commonly in the mandible. These lesions are historically described as indolent with a high cure rate and minimal recurrence rates following surgical resection. The patient initially presented with concerns regarding snoring, retrognathia, and jaw ankylosis, as well as a history of trouble latching as an infant but without obvious physical deformities. Imaging revealed a large expansile lytic mass of the mandible, but no temporomandibular joint involvement; surgical biopsy evidenced myofibroma, and the lesion was resected. Over the course of disease, the lesion continued to expand, and the patient's maximal incisal opening continued to decrease despite conservative management with jaw physiotherapy; eventually she could not open her mouth despite the absence of joint involvement. Re-exploration along with formal jaw physiotherapy was achieved and optimal jaw opening was maintained. Myofibromas are rare benign desmoid tumors that can present anywhere in the body in solitary and multicentric forms, and previously did not present significant challenges to surgical and medical management. Tumors of the mandible may present with trismus and soft tissue ankylosis, which can mimic temporomandibular joint dysfunction in the absence of joint involvement. Physical therapy, rehabilitation, and soft tissue contracture release are key to management and improving outcomes in oral cancer patients, regardless of tumor pathology.

A Custom Stabilizing Splint for the Management of BLCP with Protruding Premaxilla.

A severely protruding premaxilla in a patient with bilateral cleft lip and palate prevents functional closure of the orbicularis oris muscle and acceptable reconstruction of the nasolabial components during primary cheiloplasty. This is typically corrected with vomerine osteotomy and premaxillary setback, followed by cheiloplasty and rhinoplasty. Due to the risk of vascular compromise to the prolabium and premaxillary segment, the lip and nose repair is often staged after the vomerine osteotomy and premaxillary setback has healed. Stabilizing the premaxillary segment to allow adequate healing has been a topic of interest. Several methods have been described, but each is associated with varying degrees of compromise of the blood supply to the premaxilla. To combat this, the authors created a custom oral splint that effectively maintained the position of the premaxilla with minimal impingement of the blood supply. The authors present two cases in which a two-stage premaxillary setback with a custom-stabilizing oral splint was performed, followed by primary cheiloplasty and rhinoplasty in an age-appropriate and delayed presentation of bilateral cleft lip and palate and protruding premaxilla.