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Plastic surgery is typically involved in the reconstruction of complex wounds of the back resulting from complications of posterior spine surgery. This study examined the temporal relationship of plastic surgery involvement in posterior spine surgery and the effect on postoperative complications. A national insurance-based database was utilized for data collection. Patients who underwent first-instance posterior spine surgery between 2010 and 2019 were included. Ninety-day wound complications, reoperation rates, ED visits, and hospital admissions were compared when plastic surgery closure was done on the same day as index spine surgery and subsequently at different time periods within 1 year. Multivariate logistic regression analysis was utilized to uncover variables that predict plastic surgery consultation. A total of 320,072 posterior spine surgery patients did not have plastic surgery involvement, whereas 1213 patients had plastic surgery intervention either on the same day or within 1 year of the index procedure. Same-day plastic surgery involvement had significantly lower rates of 90-day wound complications compared with within 1 month (25.2% vs. 70.8%, P<0.001). ED visits, hospital admissions, and reoperations were also significantly lower in patients with same-day plastic surgery closure compared with those within 1 month. The odds of plastic surgery consultation were greater with spinal fracture, history of prior spine revision, 3 to 6 vertebral segment fixation, ≥13 vertebral segment fixation, sacral fracture, male sex, and increasing Charlson Comorbidity Index (CCI). Patients undergoing posterior spine surgery may benefit from same-day plastic surgery closure, decreasing the rate of wound complications, hospital admissions, and reoperations.
Conflicts of interest pose a risk to the integrity of clinical research. As part of the Sunshine Act, the Open Payments Program was established to provide transparency in financial relationships between commercial entities and physicians. Previous research indicates disparities between industry payments self-reported by plastic surgeon authors and those disclosed by commercial entities. This study sought to revisit the accuracy of conflict-of-interest disclosures, comparing current trends with previously published data, and introduce a novel automated search tool designed to facilitate future reviews of self-disclosures. Articles from the Aesthetic Surgery Journal and Plastic and Reconstructive Surgery published between 2017 and 2022 were reviewed. Self-reported disclosures for plastic surgeon authors were aggregated and compared against the Open Payments database using Python. A total of 8040 articles were reviewed. After filtering and applying inclusion criteria, 961 unique authors and 4226 authorships were identified. A total of 5802 discrepancies were found, with 78.6% of eligible authors having at least 1 discrepancy. Four percent of the included publications were estimated to contain undisclosed relationships that qualified as conflicts of interest. The median total payments for authors with discrepancies were greater than for authors without discrepancies ($9600 vs. $2500; P<0.001). A discrepancy in self-reporting was more likely to be identified among senior authors (P<0.001). Plastic surgeon authors continue to underreport their financial relationships. Automated screening may help identify disclosure discrepancies and support more complete author self-reporting.
Capsular contracture is a common complication following breast augmentation and a major indication for reoperation. While pocket contamination and aberrant inflammatory processes are suspected causes, a definitive etiology has not been identified. This study investigates if other disorders of aberrant scarring such as Dupuytren disease, hypertrophic scars, and keloids are clinically correlated with developing capsular contracture, as well as the use of certain surgical techniques. A retrospective chart review of patients undergoing breast augmentation at a single institution was conducted. Data were collected on the history of aberrant scarring and use of specific surgical techniques (eg, sizers, Keller Funnel, antibiotic irrigation +/- bacitracin, povidone-iodine). The Fisher exact test was used to assess the statistical significance of patient demographics and surgical technique. Cox regression survival analysis was used to compare the development of capsular contracture between those with and without hypertrophic skin conditions while controlling for patient demographics and surgical factors. A total of 270 patients were identified; 29 patients (10.7%) developed clinically significant capsular contracture within 2 years of surgery. No significant differences were found between the groups regarding the history of Dupuytren disease, hypertrophic scars, or keloids. However, the use of the Keller Funnel was significantly more common in the group without capsular contracture ( P <0.01). The use of sizers, antibiotic irrigation with or without bacitracin, Irrisept, or povidone-iodine showed no significant impact on the incidence of capsular contracture. The use of the Keller Funnel was significantly associated with a lower incidence of capsular contracture, suggesting its benefit in breast augmentation cases. Other factors, such as a history of scarring conditions or the use of different types of irrigation, did not show a significant relationship with the development of capsular contracture. These findings emphasize the importance of the "no touch" surgical technique in reducing the risk of capsular contracture.
In 1988, plastic surgeon Lee Dellon in Annals of Plastic Surgery hypothesized that there was "A Cause for Optimism in Diabetic Neuropathy". He noted that entrapment neuropathy is common in diabetic peripheral neuropathy (DPN) and explained that multiple sites of local nerve entrapment can also produce the classically described clinical picture of progressive and irreversible 'length dependent axonopathy'. This observation has justified for him the use of nerve decompression (ND) surgery for beneficial treatment of DPN pain, diabetic foot ulcer (DFU), ulcer recurrences and their subsequent complications. Subsequent observational and controlled reports have consistently demonstrated post-operative benefit for these problems, but ND has not yet been widely adopted. The lack of an etiologic explanation of the physiology changes which would allow surgery to modify the metabolic disturbances of diabetes has likely been involved in such hesitance. Recent explanations that glycolysis is altered in diabetes through intensified polyol metabolism which produces swollen nerves, local peripheral entrapments and compression neuropathy now provide plausible associations of hyperglycemia with epidermal hypoxia and nutrition deficit. Recognition that nerve enlargements can create secondary fibro-osseous compressions explains the well-known association of diabetes and compression syndromes. Peripheral nerve entrapments damage small c-fibers and produce sympathetic autonomic as well as sensorimotor dysfunction. This explains the diminished skin microcirculation, epidermal hypoxia and nutrition deficit seen in diabetes, DPN, DFU and Charcot neuroarthropathy. Laboratory and clinical evidence has demonstrated that ND in diabetes rejuvenates at least two sympathetically commanded skin microcirculation processes and explains how surgery is producing beneficial results. This article recapitulates the literature which clarifies the processes by which ND surgery can modify painful DPN, DFU occurrence, ulcer healing, DFU recurrence risk, amputations after DFU healing, and bilateral pain relief after unilateral surgery.
Assessing departmental scholarly output remains challenging, as traditional bibliometric metrics incompletely capture academic productivity at the department level and are often poorly suited for year-on-year evaluation. The Departmental Scholarly Index (DSI) provides a framework for evaluating aggregate and publication-adjusted departmental academic output over short-term intervals. This study examined year-on-year changes in DSI within an academic plastic surgery department between academic years (AY) 2024 and 2025. Peer-reviewed publications produced by the Department of Plastic Surgery at a tertiary academic center during AY 2024 and 2025 were retrieved from PubMed. Aggregate DSI was calculated as the sum of journal impact factors across departmental publications following outlier handling, with publication-adjusted DSI defined as aggregate DSI divided by total publications. Year-on-year changes were quantified using absolute and relative percentage differences. A total of 57 in AY 2024 and 138 peer-reviewed articles in AY 2025 were included. Aggregate DSI increased from 142.9 to 298.2, representing a 109% year-on-year increase, with increases in basic science research (19.3 to 45.0), clinical research (83.6 to 162.6), and reviews or commentaries (40.0 to 90.6). In contrast, overall publication-adjusted DSI decreased from 2.51 in AY 2024 to 2.16 in AY 2025, with declines observed in basic science research (6.43 to 2.50) and reviews or commentaries (3.08 to 2.27), while clinical research remained relatively stable (2.04 to 2.03). Utilization of the DSI revealed exponential year-on-year growth in overall departmental academic output. The DSI framework offers a practical approach for longitudinal assessment and benchmarking of departmental academic productivity.
The archival collection of Leonard T. Furlow provides an intimate view into the mind of a surgeon whose contributions shaped modern cleft palate repair. Through a qualitative review of his teaching slides, annotated diagrams, and personal notebooks, this work provides insight into not only the surgical mind of Furlow, but also the broader patterns of creativity that defined his approach to problem solving. This study highlights his emphasis on functional outcomes, evaluation of current techniques, and proposal for new surgical methods. These efforts culminated in the development of the double opposing Z-plasty, a method that redefined surgical management of cleft palate. Beyond surgical knowledge and curiosity, his archives reveal a pattern of broad creativity, with numerous sketches and ideas to improve everyday problems. Together, these materials illustrate Furlow as a lifelong problem-solver, illustrating how curiosity and inventive thinking undermine meaningful surgical innovation.
Hidradenitis suppurativa (HS) is a chronic inflammatory disease of apocrine gland-bearing areas characterized by abscesses, tunneling, scarring, and recurrent flares. Surgical excision is central in refractory disease, but perioperative protocols are variable. We evaluated whether specific perioperative medical therapies are associated with shorter time to documented postoperative wound-healing progress after HS surgery, and whether intraoperative cultures meaningfully guide antibiotic management. We conducted a retrospective cohort study of 194 HS surgeries performed at a quaternary care center between January 1, 2013, and July 1, 2021. We abstracted perioperative medical therapies (including antibiotics and spironolactone), intraoperative culture results, postoperative antibiotics, and healing times from the medical record. Healing was defined as days from surgery to the first follow-up note documenting substantial wound-healing progress. Time to healing was analyzed with Kaplan-Meier survival curves and Cox proportional hazards models. We also examined whether intraoperative cultures were associated with postoperative antibiotic selection. Perioperative trimethoprim-sulfamethoxazole was associated with shorter time to documented healing [hazard ratio (HR) 2.55, 95% CI: 1.46-4.46, P=0.00099]. Preoperative cephalexin was also associated with shorter time to heal (HR: 4.17, 95% CI: 1.40-12.44, P=0.01), whereas postoperative cephalexin was not (HR: 0.89, 95% CI: 0.44-1.79, P=0.74). Perioperative spironolactone was associated with faster healing (HR: 5.72, 95% CI: 2.08-15.74, P=0.00073). Intraoperative cultures were collected in 28% of surgeries, yielded gram-positive, gram-negative, and anaerobic organisms, showed only weak, nonsignificant associations with preoperative antibiotic exposure, and were not significantly associated with postoperative antibiotic choice. Perioperative trimethoprim-sulfamethoxazole, cephalexin, and spironolactone were each associated with shorter time to documented wound-healing progress after HS surgery in this retrospective cohort. Routine intraoperative cultures demonstrated limited observed clinical utility in guiding immediate postsurgical antibiotics. These findings support efforts to streamline perioperative care while de-emphasizing routine intraoperative culture collection in HS surgery.
Facial feminization surgery (FFS) is a key component of gender-affirming care for transfeminine individuals, with the upper third of the face-particularly the forehead, brow complex, and hairline-serving as critical anatomic targets for achieving gender congruence. Subtle alterations to these regions significantly influence gender perception and social integration. This manuscript reviews contemporary surgical strategies for feminizing the upper third of the face, including both osseous and soft tissue approaches. Procedures covered include supraorbital bossing reduction, frontal sinus anterior table setback, orbital rim contouring, brow lifts, and hairline advancement. Consideration is given to preoperative consultation, anatomical variation, classification systems such as the Ousterhout schema, and surgical planning tools including virtual surgical planning utilizing computer-aided design/manufacturing. Feminization of the upper third is generally safe and highly effective when patient-specific factors are accounted for. Virtual surgical planning enhances surgical precision, while endoscopic and open approaches provide tailored access to address individual anatomic needs. Outcomes data reveal high patient satisfaction and low complication rates. When revisions are needed, they are often driven by undercorrection or evolving patient expectations. Complications are typically minor and self-limited; rare but serious risks include mucocele or sinus fistula following anterior table osteotomy. Upper-third FFS is a technically nuanced and outcome-critical aspect of facial gender-affirming care. Evolving surgical techniques and planning tools support safe, individualized interventions. As the field continues to shift toward inclusive, patient-centered standards, the integration of validated transgender-specific outcome measures will be essential for assessing success and optimizing care.
Liposuction is the fourth most performed cosmetic procedure in the United States, increasing from 211,067 procedures in 2020 to 347,782 in 2023. While the estimated complication rate is 2.4%, long-term outcomes remain understudied. Although FDA-approved devices are advertised to consumers with caution of short-term complications, the known long-term sequelae and overall effectiveness are limited. This study quantifies the frequency and types of complications for the most commonly utilized devices. Complaints for 14 FDA-approved liposuction devices-including 5 radiofrequency, 4 laser, 2 ultrasound-assisted, 1 power-assisted, 1 cryosuction, and 1 deoxycholic acid device-from 2020 to 2025 were recorded from the Manufacturer and User Facility Device Experience (MAUDE).The total liposuction procedures documented by the American Society of Plastic Surgeons were obtained from the annual reports 2020-2023 for 6 of these devices. Among 1.8 million procedures, 642 complications were reported (0.04% rate) over the last 5 years. Cryoliposuction accounted for the majority, 72.7% (n = 467/642), with 99% of these complaints linked to paradoxical adipose hyperplasia. Ultrasound-assisted liposuction comprised 13% (n = 84/642), with 54% attributed to machine malfunctions, often due to the liposuction cannula tip breaking off the device (25.5%). Paradoxical rebound (71%) and burns (8.1%) were common. With less than a 1% estimated complication rate, liposuction devices, regardless of mechanism, is relatively safe. Cryoliposuction and ultrasound devices disproportionately contributed to complaints, suggesting technical error or user challenges. Although ineffectiveness and contour deformity are known long-term complications, paradoxical rebound was the most frequent complaint, potentially influenced by patient expectations of effectiveness.1 These findings highlight the need to examine the use of these devices, assess potential complications, and counsel patients' expectations.
Myelomeningocele (MMC) is a severe neural tube defect resulting from incomplete closure of the spinal column during early embryogenesis, often leading to lifelong neurological, urological, and orthopedic impairments. The "two-hit hypothesis" describes both the primary embryologic malformation and progressive in-utero neural injury as contributors to clinical severity. While postnatal repair prevents further exposure of neural tissue, it does not reverse the intrauterine damage already sustained. This manuscript provides a comprehensive review of the historical evolution, surgical techniques, and institutional experience of in-utero MMC repair, with particular emphasis on the pioneering role of Vanderbilt University Medical Center. Key operative advancements-such as the use of bipedicled fasciocutaneous flaps, refined hysterotomy techniques, and multidisciplinary coordination-are discussed alongside postoperative maternal-fetal management and long-term outcomes. The manuscript also examines comparative outcomes between open and fetoscopic approaches, highlighting the challenges, safety profiles, and global expansion of fetal MMC programs. Detailing both historical context and modern innovations, this work aims to underscore the important reconstructive challenges presented by in-utero repair of MMC, and the critical role played by plastic surgery in optimizing fetal MMC repair and advancing care for this complex condition.
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Rare facial clefts are deformities involving the discontinuity of bones and soft tissues in areas of the face and skull not typically affected by common oral clefts. They can be isolated defects or associated with syndromes. The exact cause of these clefts is not well understood because of their rarity and the complexity of craniofacial embryological development. Tessier descriptive classification system is widely used by surgeons and relates specific anatomical defects to the necessary reconstructive surgery. This system uses the orbit as a primary reference point and numbers clefts from 0 to 14, with an additional number 30 for jaw midline clefts. The surgical treatment of these clefts is challenging because of the almost unlimited number of combinations of defects. There is no standard protocol, and long-term results of surgical techniques are sometimes not well-documented. The main goals of treatment are to restore the craniofacial skeleton and reconstruct soft tissues, focusing on symmetry and placing scars along the lines of aesthetic units.
The pathophysiology of keloid formation remains poorly understood, and treatment typically involves multimodal approaches. Previous studies suggest that keloids on the earlobes, head, and neck may be more responsive to radiation than those on other anatomic sites due to putative differences in skin tension and biomechanical properties. However, limited comparative data exist to substantiate these anatomic distinctions in clinical outcomes. To compare recurrence rates, treatment outcomes, and radiation-related side effects between auricular and nonauricular keloids following surgical excision with adjuvant radiation therapy or surgical excision alone. This retrospective cohort study analysed 168 cases with keloids (60 auricular and 108 nonauricular) treated by a single surgeon between January 2020 and May 2024. Of these, 122 patients underwent surgical excision followed by adjuvant radiation therapy, while 46 patients received surgical excision only. Intralesional 5-Fluorouracil and Kenalog was injected across both groups during surgical excision. Demographic and clinical data, including age, sex, race, BMI, keloid site and size, and treatment modality, were collected. Patients were followed up post-treatment to assess recurrence, radiation-related side effects, and treatment response patterns. Auricular keloids were more common in younger patients and significantly smaller in size (median 12 vs. 19.5 mm for nonauricular, P <0.001). The majority of patients received 2100 cGy of radiation. Among those receiving surgery plus radiation, 17.07% of auricular and 16.22% of nonauricular keloids recurred ( P =0.91). In the surgery-only group, recurrence was 47.37% and 44.12%, respectively ( P =0.82). Notably, radiation-related side effects were significantly more frequent in nonauricular sites (37%) compared with auricular (20%) ( P =0.022). Age, sex, race, BMI, and radiation dose did not independently predict recurrence in the final model. Anatomic site did not significantly influence keloid recurrence rates, challenging previous assumptions about site-specific treatment responses, while adjuvant radiotherapy significantly reduced recurrence irrespective of site. Radiation-related side effects were more common in nonauricular locations. Age, sex, race and BMI did not emerge as statistically significant demographic predictors of recurrence in this study. These findings support the routine inclusion of radiotherapy in keloid management and suggest that demographic and treatment factors may outweigh anatomic considerations in predicting outcomes.
Repair of both simple and complex defects in the distal lower leg continues to be a challenging task for reconstructive surgeons because of the local paucity of soft tissue available for transfer. The popular neurocutaneous flap, introduced by Masquelet et al in 1992, has provided a reliable and less technically demanding method for resurfacing defects of the lower leg. We herein present our experience with the versatile design of the distally based saphenous neurocutaneous perforator f lap to provide coverage of complex posttraumatic lower leg defects by harvesting multiple tissue compo-nents in various combinations. Our series comprised 14 patients (11 men, 3 women; average age, 40.4 years; range, 22-58 years) who underwent an average follow-up period of 19.2 months (range, 9-25 months) (Table 1). The distal pivot point was kept at 5 to 7 cm above the tip of the medial malleolus, pre-serving the distal-most perforator, and 4 flaps were taken with massive sub-cutaneous tissue to obliterate the dead space. The procedure was uneventful in 13 patients. Slight venous con-gestion was noted in 1 patient, and secondary healing was achieved by con-servative treatment. The distally based saphenous neurocutaneous perforator flap is an excellent alternative for skin resurfacing of the distal lower leg, with sat-isfactory functional and aesthetic outcomes.
Gender-affirming mastectomy (GAM) often preserves residual breast tissue, conferring an unknown but nonzero risk of breast cancer. However, current breast screening guidelines are inconsistent and lack evidence-based specificity for this population. To date, no study has evaluated how plastic and breast surgeons approach post-GAM cancer surveillance or their confidence in doing so. Therefore, this study aimed to evaluate the practices and perspectives of plastic and breast surgeons regarding breast cancer screening following GAM. A 12-item electronic survey was distributed to 5802 ASPS and 707 ASBrS members (2024-2025), assessing practice profiles, guideline familiarity, screening practices, and provider confidence. The survey was completed by 586 ASPS (25.8% perform GAM) and 101 ASBrS members. In total, 34.1% of respondents were unaware of existing breast cancer screening recommendations for transgender patients while 40.5% reported not adhering to them. In comparing guideline utilization between ASPS and ASBrS members, ASPS members favored WPATH guidelines (ASPS: 31.8%; ASBrS: 11.9%, P < 0.001), whereas ASBrS members favored ACR criteria (ASBrS: 32.7%; ASPS: 12.6%, P < 0.001). For an average risk patient following GAM, ASPS members provided 25 distinct screening recommendations while ASBrS provided 16 distinct screening recommendations. Only 23.8% of providers felt confident in their recommendations. Nearly all respondents (ASPS: 94%, ASBrS: 93.1%) supported development of transgender-specific, evidence-based guidelines. This national, multidisciplinary cross-sectional study reveals substantial variability in screening practices and low provider confidence. Evidence-based, transgender-inclusive guidelines are urgently needed. Advancing inclusive cancer prevention will require data-driven guidelines, provider education, and system-level reforms to ensure equitable care for transgender and gender-diverse individuals.
Ischial pressure sores present a significant reconstructive challenge due to their high recurrence rates and the need for durable soft-tissue coverage. Various reconstructive techniques exist, but no single approach has emerged as superior. This case series introduces a variation of the gluteal myocutaneous flap, the Inferior Gluteal Myocutaneous Crescent V-Y Pendulum Flap, which provides reliable vascularized tissue while optimizing donor site closure. A retrospective review of 6 patients who underwent reconstruction of ischial pressure sores using the inferior gluteal myocutaneous crescent V-Y pendulum flap between 2010 and 2023 was conducted. Surgical technique involved designing a crescent-shaped skin paddle over a segment of inferior gluteal muscle, which was transposed to fill dead space, with the skin donor site closed in a V-Y fashion. Postoperative care emphasized pressure offloading, physical therapy, and close follow-up to monitor for recurrence and complications. The cohort consisted of 6 patients (4 males, 2 females) with chronic immobility. The mean hospital stay was 21.6 days, and all patients were discharged to rehabilitation facilities for continued pressure offloading. There were no intraoperative or postoperative complications, and no recurrences were observed during the follow-up period, which ranged from 2 to 170 months. The Inferior Gluteal Myocutaneous Crescent V-Y Pendulum Flap offers a reliable reconstructive option for ischial pressure sores by utilizing a robust blood supply, optimizing tension-free closure, and reducing dead space. Careful patient selection, adherence to pressure offloading protocols, and multidisciplinary support are crucial for optimal outcomes.
The objective of this study is to describe outcomes of alveolar bone grafting (ABG) and to determine if there is a significant association between age groups and the need for different levels of ABG (tertiary, quaternary). This retrospective study evaluated the outcomes of ABG in 147 nonsyndromic unilateral and bilateral cleft lip and palate patients at a single craniofacial hospital. Patients were divided into 3 age groups: <7 years, 7 to 12 years, and >12 years. A minimally invasive closed technique using cylinder bone extractors was employed. To evaluate the radiographic bone graft using the Chelsea scale, the position of bone tissue relative to teeth adjacent to the cleft was analyzed through radiographic images visualized by 2 cleft orthodontists. The results showed that children aged 7 to 12 years constituted 49.1% of all cases, whereas those <7 years and >12 years accounted for 7.8% and 31.1%, respectively. Bilateral complete clefts exhibited the highest complication rate at 29%, followed by left complete clefts (22.4%) and right complete clefts (12.1%). A statistically significant difference was found in the need for tertiary/quaternary ABG among age groups (Chelsea B, D, E, and F), with a high prevalence in patients >12 years (44.23%) compared to those aged 7 to 12 years (21%) (P < 0.05). In conclusion, considering a broader age range of 9 to 12 years during graft planning can accommodate the variability in developmental stages. This approach may reduce the risk of graft failure by enabling timely interventions that align with the individual's specific developmental timeline, tailored to our individual scenarios.
Upper extremity lymphedema occurs in 40% of patients following breast cancer treatments. In contrast, truncal lymphedema, a common complication of breast cancer treatment, is less understood and underreported. This study has 2 aims: (1) map lymphatic patterns of patients with truncal lymphedema and (2) describe our approach for the application of lymphovenous anastomosis (LVA) for truncal lymphedema and demonstrate the technical feasibility and potential clinical benefit. We retrospectively reviewed 95 patients (173 hemitrunks) following breast cancer treatment who underwent truncal ICG lymphography over 9 years. In 2 cases where conservative measures failed to provide relief, patients were treated with LVA placed inferior to the inframammary fold, directed by lymphographic findings. Dermal backflow was significantly worse in the superior trunk, above the inframammary fold (P < 0.001). Diffuse or absent superficial lymphatic channels were observed in 84% of mastectomy skin flaps. Lymphatic drainage was visualized to the ipsilateral axilla (40%), ipsilateral groin (66%), and contralateral trunk (26%). LVA can be used for surgical treatment of truncal lymphedema when conservative measures are insufficient. Patients treated in our practice had complete relief of symptoms by 12 months with reduced conservative management use, Lymphedema Life Impact Score, and number of infections per year. This work demonstrate that detailed lymphatic mapping enables targeted LVA planning and may offer an effective surgical option for managing breast cancer-related truncal lymphedema.
Challenges in orthodontic management for patients with cleft lip and palate (CLP) center on facial growth deficiencies and oral health. Patients with complete CLP exhibit maxillary arch constriction from an early age, typically more severe in the canine region than in the molar region. Transverse management centers on the maxillary arch and types of expansion. The ability to provide targeted anterior expansion while simultaneously addressing posterior crossbites is crucial for correcting arch constriction in patients with cleft lip and palate. Maxillary constrictions are usually addressed immediately prior to the secondary alveolar bone graft procedure. The instability of maxillary expansion in CLP patients is one reason why expansion is often performed early. Anteroposterior (sagittal) orthopedic management of maxillary deficiencies in patients with CLP still remains a challenge, with decisions on treatment based on timing, indications, and severity. A protocol is presented with favorable results for complicated cases. Early correction of the hypoplastic maxilla in patients with CLP is notoriously followed by substantial skeletal relapse; consequently, protraction undertaken in the deciduous or early-mixed dentition should be reserved for cases in which marked functional impairment, such as hipoacusia, is present. Conversely, when the same orthopedic stimulus is applied in proximity to the pubertal growth spurt, the skeletal correction tends to be considerably more stable. Challenges in pediatric dentistry persist with poor oral hygiene and caries. Without a foundation for stable dentition, the best of orthodontic treatment planning can be compromised. Despite awareness on importance of oral health as it relates to systemic conditions and the additional factors faced with CLP patients, more follow-up is needed. Prevention and frequent follow-up with the pediatric dentist are key.