Implications from precision surgical anatomy for modern craniofacial pediatrics

Orofacial cleft is the most common craniofacial birth anomaly. The comprehensive care of patients with craniofacial anomalies requires a multidisciplinary approach, beginning with prenatal counseling and continuing throughout life.
After birth, presurgical treatments aim to correct the imbalance of forces caused by the cleft. Surgery for cleft repair is usually performed in multiple stages, with cleft lip repair performed first, followed by cleft palate repair. However, several single-stage repair techniques have been developed. This approach involves simultaneous cleft lip and palate repair, thereby reducing the need for additional surgeries. The University Center for Cleft Lip and Palate and Craniofacial Anomalies in Basel has a long-standing history of simultaneous cleft lip and palate repair. However, conducting evidence-based studies on cleft surgery is challenging due to the rarity and variability of the malformation and the many treatment concepts.
As cleft surgery undergoes continuous refinement based on outcome assessment and latest evidence, the primary aim of this PhD project was to quantify the impact on craniofacial growth of simultaneous unilateral cleft lip and palate repair. The study discussed in section 4 compared two cohorts, one with and one without primary alveolar bone grafting, and evaluated craniofacial growth, dental arch relationship, and palatal morphology. Results showed that omitting primary alveolar bone grafting did not improve craniofacial growth outcomes at the patients’ age of 6-11 years, suggesting that other surgical aspects may have a greater impact on craniofacial growth.
The second study, discussed in section 5, aimed to add new evidence for a better understanding of the curved vomerine mucosa in cleft repair. The curved vomer, a key region in unilateral cleft lip and palate, has been a subject of surgical controversy with sparse evidence. The study examined for the first time the histology of curved vomerine mucosa samples and found that they did not exhibit any specific signs of nasal mucosa. This suggests that the use of vomerine mucosa in cleft repair should not be based on fixed physiological beliefs and calls for a rethinking of the anatomy and paved the way for new surgical techniques in this region.
The third study, presented in section 6, assessed a new surgical technique, developed on the findings from section 5 and based on pure anatomic rearrangement of curved vomerine tissue for cleft palate closure. By this, a simultaneous continuous circular two-layer closure of unilateral cleft lip and palate has been achieved. The study assessed the safety, wound healing, and cleft width changes with presurgical passive plate therapy in patients undergoing this new surgical method. This study comprehensively demonstrates the potential of a simultaneous continuous circular closure technique for unilateral cleft lip and palate. However, further research is needed to evaluate long-term outcomes.
Overall, this PhD project aimed to contribute to the understanding and improvement of cleft surgery and outcomes in simultaneous cleft lip and palate repair.