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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.