Association of Cleft Phenotype Severity With Childhood Secondary Nasal Intervention Burden and Airway Morbidity Following Primary Cheilorhinoplasty

BACKGROUND: Simultaneous primary cheilorhinoplasty offers early aesthetic and functional benefits, yet the longitudinal childhood surgical burden across cleft phenotype remains poorly defined. This study compared the timing, frequency, and likelihood of childhood secondary nasal intervention following primary simultaneous cheilorhinoplasty. METHODS: A multicenter retrospective study using the Pediatric Health Information System (2004-2025) identified patients 16 years of age or younger who underwent primary cheilorhinoplasty at less than 12 months of age. Patients were stratified by cleft phenotype [unilateral cleft lip (UCL), bilateral cleft lip (BCL), unilateral cleft lip and palate (UCLP), and bilateral cleft lip and palate (BCLP)]. Negative binomial regression, Cox proportional hazards modeling, and multivariable logistic regression evaluated the rate, timing, and probability of secondary nasal intervention before age 16. RESULTS: Of 1291 patients (median follow-up: 8.3 y), secondary intervention rates were significantly higher for UCLP (aIRR: 2.86) and BCLP (aIRR: 3.73) relative to UCL (all P<0.001). BCLP exhibited a 31% higher rate than UCLP (ratio: 1.31; 95% CI: 1.00-1.71; P=0.017). Cox modeling confirmed the earlier revision (UCLP aHR: 3.04; BCLP aHR: 3.70; both P<0.001). Adjusted 15-year cumulative incidence of secondary nasal intervention was 16.5% (UCL), 42.3% (UCLP), and 48.8% (BCLP). UCLP was independently associated with deviated septum (aOR: 3.87; pFDR=0.015) and BCLP with obstructive sleep apnea (aOR: 2.64; pFDR=0.025). Median age at the second nasal procedure was 5.4 years. CONCLUSIONS: Cleft phenotype severity is independently associated with secondary nasal surgical burden. Greater phenotypic severity is linked to earlier, more frequent, and more probable nasal surgery, with burden highest in BCLP, followed by UCLP, relative to UCL.