Scientific Abstract Presentations: Craniomaxillofacial Session 2 Thursday, October 15 Thu, Oct 15 3:30-4:30 p.m. CDT

Background: Although early surgical outcomes of metopic craniosynostosis have been reported, longitudinal comparisons of global and regional craniofacial morphology remain limited. This study evaluates morphologic trajectories following Fronto-Orbital Advancement (FOA), endoscopic strip craniectomy with helmet (ESC + Helmet), and spring-assisted cranioplasty (ESC + Springs) using serial three-dimensional (3D) photogrammetry.

Methods: A retrospective cohort study evaluated patients with isolated metopic craniosynostosis treated with FOA, ESC + Helmet, or ESC + Springs. Cranial morphology was quantified using 3D photogrammetry at baseline and post-operative intervals up to 24 months. Outcomes included global metrics: Cranial Severity Index (CSI), Head Shape Anomaly (HSA), and Craniosynostosis Risk Score (CRS). Regional metrics included Interfrontal Angle (IFA) and Intercanthal Distance/lntertragal (IC/IT) ratio.

Results: 109 patients with isolated metopic craniosynostosis who underwent operative correction were identified, including FOA (n = 62), ESC + Helmet (n = 39), and ESC + Springs (n = 6). At baseline, patients undergoing ESC demonstrated greater severity than FOA, with higher CSI (2.56 vs 1.64; p = 0.03), HSA (1.69 vs 1.06; p < 0.001), IC/IT ratio (0.30 vs 0.26; p < 0.001), and narrower IFA (112.8° vs 116.8°; p = 0.02). Compared with the preoperative intercanthal distance IC/IT proportion (0.23), the ESC + Helmet group demonstrated improvement beginning at 6 months postoperatively (0.24, p = 0.03), with sustained improvement through 2 years (0.24, p = 0.02). Patients undergoing ESC + Springs demonstrated early IC/IT improvement at 6 months (0.22 vs 0.26; p = 0.03), without sustained longitudinal changes at later follow-up timepoints (0.22 at 2 years, p= 0.67). The FOA group did not demonstrate significant post-operative IC/IT changes (0.21 preoperative vs 0.22 at 2 years; p = 0.14). ESC+ Helmet and FOA cohorts demonstrated significant widening of IFA at all postoperative timepoints: 112.48° preoperatively to 138.74° (p < 0.001) and 116.88° to 147.46° at 2 years (p < 0.001), respectively. ESC + Springs did not show an improvement in IFA (121.44° preoperatively to 143.22° at 2 years postoperatively (p = 0.33). Comparing between surgical techniques, ESC + Helmet demonstrated greater IC/IT proportion at 1 year post-operatively compared to FOA (0.24 vs 0.21; p < 0.001). FOA demonstrated a wider IFA compared to ESC + Helmet at 3 months (136° vs 124.86°; p < 0.001), though this difference was no longer significant at 2 years (134.95° vs 140.17°; p = 0.08). Predictive modeling revealed a significant treatment-by-age interaction with an inflection point at approximately 4 months. In infants younger than 4 months, ESC + Helmet was associated with the most favorable predicted postoperative cranial morphology. Beyond 4 months, ESC + Springs and FOA both demonstrated superior predicted outcomes relative to helmet therapy.

Conclusion: FOA and ESC + Helmet demonstrate durable interfrontal angle widening through 2 years, with helmet repair achieving greater long-term intercanthal proportion and frontal angle expansion despite greater baseline morphologic severity. Limited long-term data suggest ESC + Springs may provide less sustained regional correction. Treatment effectiveness demonstrated an age-dependent interaction, supporting individualized operative selection based on baseline severity and age at intervention.

Purpose: Cranial distraction osteogenesis is traditionally performed along standardized posterior or biparietal vectors to address global cranial vault restriction. However, complex cranial insufficiency frequently involves compartment-specific supratentorial or infratentorial volume deficiency that may not be adequately corrected using conventional vector selection alone. Regionally targeted expansion may be required to restore cranial volume while preserving stability of unaffected compartments and protecting critical neurovascular structures. We describe a technical case series applying customized cranial distraction osteogenesis using nontraditional vector configurations aligned to defined anatomical deficiency states: infratentorial crowding, supratentorial transverse deficiency, and supratentorial asymmetric deficiency.

Methods and Materials: A retrospective technical series was performed of pediatric patients undergoing customized cranial distraction osteogenesis between 2023 and 2025. Patients were stratified by primary anatomical deficiency: infratentorial crowding (Chiari malformation type I with posterior fossa restriction), supratentorial transverse deficiency (craniocerebral disproportion), and supratentorial asymmetric deficiency (multi-suture pan-synostosis with regional restriction). Preoperative organization incorporated virtual surgical planning with individualized osteotomy design, device placement, and vector selection directed toward the deficient cranial compartment while minimizing displacement of adjacent stable vault segments. Techniques included posterior vault distraction osteogenesis for infratentorial crowding, biparietal distraction osteogenesis for supratentorial transverse deficiency, and triple-vector multidirectional cranial distraction for asymmetric supratentorial deficiency. Operative parameters, distraction magnitude, complications, and symptom outcomes were analyzed across deficiency categories.

Results: Posterior vault distraction osteogenesis was performed in 8 patients with infratentorial crowding without intraoperative complications and achieved mean posterior expansion of 20.5 ± 5 mm. Symptomatic improvement occurred in 7/8 patients, with reduced headache severity in the remaining patient. Biparietal distraction osteogenesis for supratentorial transverse deficiency was performed in 2 patients using inpatient distraction to approximately 30–32 mm total expansion and resulted in durable headache resolution and functional improvement in both cases, including a patient with and a patient without a ventriculoperitoneal shunt. Triple-vector multidirectional cranial distraction for syndromic multi-suture pan-synostosis was feasible with low blood loss (75 mL), stable hardware positioning on imaging, marked early contour improvement, and no neurologic or shunt-related complications; minor pin-site erythema and bleeding were managed conservatively. No reoperations occurred in this early follow-up series. Customized vector configurations enabled directed regional expansion while maintaining construct stability and avoiding compromise of adjacent cranial compartments.

Conclusions: Customized cranial distraction aligned to defined supratentorial and infratentorial deficiency states enables targeted regional cranial expansion using nontraditional vector configurations. Posterior vault, biparietal, and triple-vector constructs permit treatment of heterogeneous cranial insufficiency within a unified anatomical framework based on anatomical compartment deficiency rather than suture pattern alone. Early outcomes demonstrate feasibility, safety, and high symptom improvement across diverse cranial deficiency patterns. A vector-based classification of cranial insufficiency may facilitate individualized cranial expansion strategies, improve surgical planning, and broaden application of customized distraction osteogenesis in complex cranial vault pathology.

Background: Craniosynostosis is defined as premature fusion of the cranial sutures that restricts growth relative to the fused suture and redirects skull expansion. Endoscopic strip craniectomy (ESC) with postoperative helmet therapy is typically offered to infants younger than 4–6 months, based on assumptions regarding skull malleability and calvarial thickness. Older infants are more commonly treated with open cranial vault remodeling (CVR), in part due to the belief that increasing skull thickness limits the feasibility of endoscopic repair. However, objective data characterizing preoperative calvarial thickness across suture subtypes and surgical approaches are limited. We sought to quantify CT-derived calvarial thickness in isolated single-suture craniosynostosis to determine whether thickness differs by suture subtype and surgical approach, and to evaluate whether age-independent differences exist that may inform surgical candidacy.

Methods: In this retrospective cohort study at a tertiary pediatric center, we included patients with isolated single-suture craniosynostosis who underwent preoperative CT between 2013 and 2025. Cases were classified by suture subtype and subsequent procedure. Following previous neurocranial measurement literature (1), calvarial thickness was measured at 14 predefined anatomic sites (bilateral frontal, anterior parietal, mid-parietal, posterior parietal, mid-occipital, temporal squama, and unilateral occipital protuberance and superior occipital bones) on CT by two trained radiology residents and verified by an attending pediatric radiologist.

Results: The cohort included 70 preoperative CTs for patients with isolated sagittal (n=43; endoscopic n=26, open n=17), coronal (n=14; endoscopic n=9, open n=5) and metopic (n=13; endoscopic n=6, open n=7) craniosynostosis. Despite being significantly younger at the time of imaging (1.9 vs 7.9 months, p<0.001), endoscopic-treated sagittal patients demonstrated greater mean global calvarial thickness than open-treated sagittal patients (3.3mm vs 2.8mm; mean difference +0.50mm, p=0.002). Multiple regional sites showed statistically significantly increased thickness in the endoscopic sagittal group compared with open-treated sagittal patients: left frontal (+0.60mm, p<0.001), right frontal (+0.50mm, p<0.001), left mid-parietal (+0.60mm, p=0.006), right mid-parietal (+0.60mm, p=0.019), left posterior-parietal (+0.80mm, p=0.022), right posterior-parietal (+1.60mm, p<0.001), left temporal squama (+0.70mm, p=0.043), and right temporal squama (+1.00mm, p=0.001). Endoscopic coronal patients had a lower mean global thickness than their open repair counterparts (2.1mm versus 2.6mm, p=0.138) as did endoscopic metopic patients (2.1mm versus 2.6mm, p=0.057). Each mean global calvarial thickness measurement observed in the open-treated sagittal patients fell within the distribution of values observed among endoscopic-treated sagittal patients. In multivariable linear regression limited to sagittal cases, surgical approach remained independently associated with greater average calvarial thickness after adjustment for age (B=+0.645mm, 95% CI 0.239–1.050, p=0.003), whereas age at CT was not a significant predictor (p=0.417).

Conclusion: Endoscopic-treated patients with sagittal craniosynostosis demonstrated a distinct pattern of increased global calvarial thickness compared with open-treated counterparts and other single-suture subtypes, with substantial overlap in thickness distributions between treatment groups. This may potentially be due to regional thickening as a biomarker of greater disease manifestation earlier in life. These findings suggest that age alone may not justify exclusion from endoscopic repair and that selected older infants may remain anatomically suitable candidates depending on calvarial thickness. Objective thickness assessment may help refine surgical decision-making beyond traditional age thresholds.

References: (1). Rowbotham, S.K., Mole, C.G., Tieppo, D. et al. Average thickness of the bones of the human neurocranium: development of reference measurements to assist with blunt force trauma interpretations. Int J Legal Med 137, 195–213 (2023). https://doi.org/10.1007/s00414-022-02824-y

Purpose: Presurgical infant orthopedics (PSIO) is widely utilized to reduce alveolar and soft tissue deformity prior to primary cleft lip and palate repair. This study compares the treatment characteristics, clinical burden, and morphologic efficacy of traditional Nasoalveolar Molding (NAM) versus the Presurgical Lip, Alveolus, and Nose Approximation (PLANA) device.

Methods: A comparative analysis was conducted on patients undergoing PSIO with either NAM or PLANA device from 2023 to 2025 at a tertiary children's hospital. Baseline demographics, cleft phenotypes, and cleft width reductions pre- and post-intervention were analyzed. Statistical analyses included Mann-Whitney U and chi-square tests for continuous and categorical variables, respectively.

Results: A total of 53 patients were included, consisting of 32 in the NAM group and 21 in the PLANA group. Baseline demographics and cleft phenotypes such as cleft type, laterality, and completeness were statistically similar between the cohorts. Patients undergoing PLANA experienced significantly longer travel times to the clinic (80.0 vs. 31.5 minutes, p=0.009) and initiated treatment at an older age for both taping (31.0 vs. 23.0 days, p=0.032) and device fitting (9.0 vs. 6.5 weeks, p=0.002) compared to NAM. However, the NAM cohort required more frequent clinic visits (11 vs. 5 visits, p<0.001). Baseline cleft widths were similar (NAM: 7.21 ± 4.00 mm vs. PLANA: 6.09 ± 4.18 mm, p=0.477). Taping alone yielded a significant reduction in the NAM group (1.82 ± 1.75 mm; p<0.001). Following device fitting, both groups demonstrated significant absolute reductions, with final alveolar cleft widths of 1.45 ± 2.24 mm in the NAM group and 2.73 ± 2.87 mm in the PLANA group (p < 0.001). However, NAM resulted in a significantly greater mean percent reduction in cleft width overall (73.3% vs. 45.8%; p=0.039). Complete closure (0 mm) was achieved in 52.6% of NAM patients compared to 18.2% of PLANA patients (p=0.083).

Conclusion: Although NAM requires more frequent visits, it achieves greater percent cleft width reduction. PLANA remains a practical alternative for patients with geographic or socioeconomic barriers to care, though clinicians should appropriately manage expectations regarding the extent of post-treatment cleft size reduction.

Purpose: The Rule of 10s (≥10 weeks, ≥10 lbs, hemoglobin ≥10 g/dL) guides timing of primary cleft lip and palate repair. This study evaluates global adherence and demographic and regional factors linked to non-adherence.

Methods: A retrospective review of 500 primary cleft lip repairs (2022–2024) was conducted. Demographics, age, weight, and hemoglobin were assessed for Rule of 10s adherence, with chi-square and logistic regression analyzing associations with complications and regional differences.

Results: Among 500 patients undergoing primary cleft lip repair across 19 countries, the mean hemoglobin, weight, and age were 11.6 ± 1.8 g/dL, 25.9 ± 23.9 lbs, and 131.8 ± 319 months. 64 patients (12.8%) did not meet the Rule of 10s, all due to low hemoglobin; all met the age criterion and one failed the weight criterion (0.2%). Adherence differed significantly by country (p<0.001) and region (p<0.001), with Sub-Saharan Africa showing the highest proportion not meeting criteria (27.1%). Logistic regression showed increased odds of meeting the Rule of 10s in Honduras (OR 4.8, p=0.03), Morocco (OR 6.2, p=0.02), and Peru (OR 5.8, p=0.02), and decreased odds in Sub-Saharan Africa (OR 0.3, 95% CI 0.17–0.55, p<0.001).

Conclusion: While most patients met the Rule of 10s before cleft lip repair, over 12% in sub-Saharan Africa did not, largely due to low hemoglobin levels. Findings suggest hemoglobin is a key limiting factor to surgical readiness in LMICs and underscore the need for context-specific strategies to improve preoperative optimization strategies. Persistent regional variation in adherence to the Rule of 10s highlights important gaps in global surgical readiness. Targeted interventions to address modifiable barriers such as preoperative anemia may improve operative safety and access to primary cleft lip worldwide.

PURPOSE: To characterize treatment burden and premature consolidation (PC) in patients undergoing Le Fort I maxillary advancement with rigid external distraction (RED) for cleft-related maxillary hypoplasia at a single institution by quantifying interventions, classifying complications, and evaluating factors associated with PC.

METHODS: This IRB–approved retrospective cohort study included consecutive eligible RED cases between November 2015 and May 2024. The standard starting distraction rate was 1.0 mm/day. When rising soft-tissue resistance or suspected early consolidation was documented clinically (eg, increasing activation effort, reduced advancement per activation, or stalled progression), the treating team escalated the distraction rate (typically 1.5–2.0 mm/day). Treatment burden was defined as clinic-based interventions and operative interventions occurring after the index procedure and before completion of consolidation. Complications were classified as PC, hardware complications, vector/occlusal disturbances, trauma-related events, and device migration. Continuous variables were compared with Student's t test and categorical variables with Fisher's exact test.

RESULTS: Twenty-five patients (ages 9–20 years) underwent RED. Mean latency was 6 days (range 4–9). All patients initiated distraction at 1.0 mm/day; 7 patients (28%) required rate escalation above 1.0 mm/day (range 1.5–2.0 mm/day) during activation to attempt salvage when rising resistance and early consolidation was suspected. PC occurred in 4 patients (16%) and was typically identified in the mid-to-late or late activation phase. Three of 4 PC cases (75%) required unplanned operative re-osteotomy with halo repositioning to resume advancement; in these cases, PC occurred after 58%, 76%, and 89% of the planned activation course, respectively. In the remaining PC case, PC was recognized late and managed nonoperatively by accepting the achieved advancement and transitioning to consolidation with a residual overjet of approximately −5 mm from a baseline −20 mm. Within the rate-escalation subgroup (n=7), patients who developed PC (n=4) had greater negative baseline overjet magnitude than those salvaged without PC (n=3) (13.0 mm vs 8.3 mm, p=0.035) and a higher proportion of bilateral cleft phenotype (75% vs 33%, p=0.486). Syndromic diagnoses were present in 1/4 PC cases (DiGeorge) and 1/3 non-PC cases (Van der Woude); mean age was similar (14.2 vs 13.4 years, p=0.766). Overall, 16 patients (64%) required ≥1 clinic intervention, 9 (36%) required ≥1 operative intervention, and 19 (76%) experienced at least one unplanned intervention. Hardware/device integrity problems occurred in 9 patients (36%), vector/occlusal disturbances in 6 (24%), trauma-related events in 3 (12%), and device migration in 1 (4%). Stable advancement at the end of distraction was documented in all patients.

CONCLUSIONS: In this single center RED cohort, treatment burden was common and was driven primarily by frequent outpatient management of hardware issues and vector/occlusal control, with a substantial minority requiring re-operative interventions. Premature consolidation was uncommon but often required operative intervention, with patients having distraction rate increases above 1 mm/day beforehand. These findings support counseling RED as longitudinal care, defining higher-intensity monitoring for suspected premature consolidation, and standardizing device surveillance to reduce avoidable burden while maintaining the ability of RED to achieve large advancements in severe cleft-related deformity.

REFERENCES: PMID: 17008053 PMID: 11604605 PMID: 9773990

Background: Appropriate treatment of patients with cleft lip and palate (CL/P) requires a multi-disciplinary team approach over many years of treatment. Access to these teams is made even more difficult for patients on government insurance as they continue to face multiple financial and geographic barriers to care. Although Medicaid expansion has sought to close care gaps by increasing eligibility for many and improving procedure cost-sharing, access to providers still remains an obstacle for many low-income families. This study investigates the association between Medicaid provider reimbursement for CL/P related procedures and state-level economic factors that influence access to proper care. Methods: Provider reimbursement rates for 2025 were collected from state websites for the following CPT codes related to CL/P care: D8020 (Phase 1/Limited Orthodontic Treatment of Transitional Dentition), D8080 (Phase 2/Comprehensive Orthodontic Treatment of Adolescent Dentition), and 42210 (Palatoplasty for Cleft Palate with Bone Graft). State-level cost of living index, poverty index, and the number of children enrolled in Medicaid and Children's Health Insurance Program (CHIP) were obtained as of July 2025. Mean reimbursement rates were calculated for each CPT code and compared to demographic factors. States lacking coverage for D8020 or D8080 were excluded, as was TN due to unavailable data. Pearson correlation and linear regression models were used to assess significance of associations between provider reimbursement and demographic factors (p<0.05). Results: D8020 was offered by 54.9% (n=28) of states, while D8080 and 42210 were offered by 82.4% (n=42) and 98% (n=50) of states, respectively. D8080 exhibited significantly moderate negative association with child enrollees in Medicaid/CHIP (-0.375, p=0.014). Weak negative associations were found for D8020 and 42210 between child enrollees in Medicaid and CHIP, but these findings were not significant (-0.113, p=0.566 vs. -0.134, p=0.352). A multiple linear regression model significantly (p<0.001) predicted state-level D8080 Medicaid reimbursement rates explaining 46.9% of variance (Adjusted R²=0.41). Higher D8080 reimbursement was significantly associated with higher cost of living (β = 0.39, p = .007), greater state poverty rates (β = 0.51, p < .001), and Medicaid expansion status (β = 0.27, p = .041). Higher enrollment in Medicaid/CHIP for children was significantly associated with lower D8080 reimbursement (β = –0.53, p < .001). Discussion: Our analysis reveals that provider reimbursement for D8020, 42210, and more significantly, D8080 is lower in states with higher child enrollment in Medicaid/CHIP. Paradoxically, reimbursement for D8080 is higher in states with greater cost of living, poverty, and Medicaid expansion. Although reimbursement appears adequate in areas with financial barriers, it appears to mismatch with pediatric Medicaid demand, potentially disincentivizing provider participation in states where families with cleft and other craniofacial conditions need it most.

PURPOSE Frontal sinus fracture management has historically favored sinus obliteration or cranialization for select injuries, forming the basis of widely cited treatment algorithms (1,2). However, contemporary national operative patterns remain undefined. We hypothesized that real-world practice has shifted away from sinus defunctionalization and that operative intervention is substantially less common than historical teaching suggests. METHODS Adults with frontal sinus fractures (ICD-10 S02.0, S02.19) from 2016–2025 were identified in the TriNetX Global Collaborative Network (~188 million patients). Operative management within 180 days was classified as sinus defunctionalization (obliteration/cranialization; CPT 31085/31080–84) or endoscopic frontal sinusotomy (CPT 31253). Temporal trends were analyzed using Mann-Kendall testing. Postoperative complications were evaluated at 30, 90, and 365 days. RESULTS Among 244,580 adults with frontal sinus fractures, operative sinus-directed intervention was exceedingly rare: 484 underwent defunctionalization and 89 underwent endoscopic surgery (<0.3% combined). Obliteration/cranialization volume declined significantly from 38 to 15 cases annually (p=0.040). Endoscopic procedures increased from 0 to 12 per year and comprised 44% of all sinus-directed operations by 2025. Across all postoperative time windows, complication events were below national reporting thresholds, underscoring both procedural rarity and the limited feasibility of traditional comparative effectiveness analysis. CONCLUSIONS In a 188-million-patient network, operative sinus defunctionalization for frontal sinus fractures is uncommon and declining, while endoscopic management now approaches parity among surgically treated cases. Contemporary national practice appears to diverge from historical operative algorithms (1,2). The extreme infrequency of these procedures highlights the need for multicenter collaboration to define evidence-based surgical thresholds in modern care. REFERENCES 1. Lopez CD, Rodriguez Colon R, Lopez J, Manson PN, Rodriguez ED. Frontal sinus fractures: evidence and clinical reflections. Plast Reconstr Surg Glob Open. 2022;10(4):e4266. doi:10.1097/GOX.0000000000004266 2. Arnold MA, Tatum SA. Frontal sinus fractures: evolving clinical considerations and surgical approaches. Craniomaxillofac Trauma Reconstr. 2019;12(2):85-94. doi:10.1055/s-0039-1678660

Introduction: Nasoalveolar molding (NAM) is a common presurgical adjunct in cleft lip and palate care intended to improve soft tissue tension and reduce alveolar cleft width before primary repair. However, the long-term impact of NAM timing and treatment duration on later secondary surgical needs remains incompletely characterized. This study evaluated whether age at NAM initiation, NAM therapy duration, and pre-NAM cleft width are associated with subsequent septoplasty, rhinoplasty, and orthognathic surgery.

Methods & Materials: A retrospective review of patients with cleft lip and/or palate who underwent NAM at a single tertiary pediatric center from 2005 to 2022 was performed. Patients were excluded if primary cleft care or secondary procedures were performed outside the institution or if follow-up was <5 years. Primary outcomes were secondary septoplasty, rhinoplasty (including open and closed rhinoplasty), and orthognathic surgery following initial cleft repair. For the orthognathic surgery analysis, only patients who were at least 12 years past their initial cleft repair were included. Predictor variables included age at NAM initiation, NAM treatment duration, and pre-NAM alveolar cleft width. Associations were analyzed using regression modeling with odds ratios (ORs), 95% confidence intervals (CIs), and p-values.

Results: Of 220 patients who underwent NAM prior to cleft repair, 137 met the inclusion criteria for final analysis. Age at NAM initiation was not significantly associated with orthognathic surgery (OR 0.984, 95% CI 0.824–1.026, p=0.413), any rhinoplasty (OR 0.991, 95% CI 0.962–1.014, p=0.340), septoplasty (OR 1.022, 95% CI 0.973–1.080, p=0.328), open rhinoplasty (OR 0.983, 95% CI 0.951–1.006, p=0.132), or closed rhinoplasty (OR 1.004, 95% CI 0.969–1.037, p=0.808). In contrast, longer NAM duration was associated with increased odds of orthognathic surgery (OR 1.046, 95% CI 1.024–1.109, p=0.008), any rhinoplasty (OR 1.019, 95% CI 1.005–1.036, p<0.001), and specifically open rhinoplasty (OR 1.022, 95% CI 1.006–1.039, p=0.004), but not septoplasty (OR 1.017, 95% CI 0.996–1.046, p=0.112) or closed rhinoplasty (OR 1.008, 95% CI 0.971–1.029, p=0.624). Greater pre-NAM cleft width was associated with lower odds of orthognathic surgery (OR 0.729, 95% CI 0.633–0.808, p<0.001) and septoplasty (OR 0.836, 95% CI 0.621–0.935, p=0.004), but not with rhinoplasty outcomes.

Conclusions: In this 20-year single-center cohort, age at NAM initiation was not associated with long-term rates of secondary surgical intervention. However, longer NAM treatment duration was associated with a greater likelihood of orthognathic surgery and rhinoplasty, particularly open rhinoplasty. These findings suggest that NAM duration may serve as a clinically relevant marker of cleft severity and/or treatment complexity and should be considered when counseling families and evaluating long-term cleft outcomes.