Integrating Presurgical Orthopedics into Cleft Lip Surgical Planning: A Surgeon-led Conceptual Framework

Presurgical infant orthopedics (PSIO) is an established component of cleft care aimed at attenuating deformity severity and optimizing nasolabial anatomy before primary repair. Traditionally, PSIO-most commonly nasoalveolar molding-has been implemented within multidisciplinary care pathways and considered separately from intraoperative anatomy and surgical decision-making. This conceptual separation may limit how presurgical modifications are interpreted and applied during surgery. We present a surgeon-led, hypothesis-generating conceptual framework that reframes PSIO as an anatomy-driven extension of surgical planning rather than an isolated preparatory phase. The aim of this framework is to integrate presurgical modification with intraoperative anatomical interpretation, allowing presurgical preparation and surgical correction to function as coordinated stages of a single reconstructive strategy. This framework is particularly applicable to simplified PSIO approaches that integrate nasal and labial molding with progressive maxillary segment mobilization, including lip taping, nasal elevators, and presurgical lip-alveolus-nose approximation. The innovation lies in establishing a structured feedback loop between presurgical modification and intraoperative anatomy. With contemporary surgical techniques allowing improved visualization of septal alignment, lower lateral cartilage configuration, and ligamentous attachments, presurgical effects can be interpreted intraoperatively to refine surgical reasoning in real time. This model does not seek to replace orthodontic expertise or multidisciplinary care; rather, it proposes a complementary framework that enhances continuity between treatment phases and supports more integrated surgical planning.