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Discussion: Limited Evidence for the Effect of Presurgical Nasoalveolar Molding in Unilateral Cleft on Nasal Symmetry A Call for Unified Research

V der Heijden et al. have effectively captured their argument in the title of the preceding article, “Limited Evidence for the Effect of Presurgical Nasoalveolar Molding in Unilateral Cleft on Nasal Symmetry: A Call for Unified Research.” Before offering our discussion of this article, we must report two disclosures. First, our center uses presurgical infant orthopedics in all cleft cases whenever feasible. Presurgical infant orthopedics ideally takes the form of nasoalveolar molding. When nasoalveolar molding is not possible secondary to anatomical or practical concerns, lip adhesion is used as a second-tier means of presurgical infant orthopedics. The consistent use of presurgical infant orthopedics has served as an integral part of achieving satisfactory cleft lip and nose deformity corrections at our center. Although this is an admittedly qualitative assessment, it is based on surgeon and patient satisfaction, in addition to what is believed to be a low rate of revision surgery as compared with that reported in the literature. The second disclosure is that the authors of this discussion do not claim particular expertise in evidence-based medicine. We approach this discussion as clinical pragmatists, not as statisticians. This is to say, we use nasoalveolar molding to facilitate the successful primary operation (particularly in bilateral complete clefts), and we have found it to be a powerful means to this end in our hands. We do not use it to guarantee long-term nasal symmetry, nor do we believe this to be its primary purpose. Nasoalveolar molding is a central part of the cleft care algorithm at our center. We believe the primary goal of its use is to prepare the patient for surgery by turning complete clefts into morphologically “incomplete clefts” and to lessen the cleft lip–nasal deformity (i.e., lengthen the columella). Improved long-term nasal symmetry is not the primary goal of nasoalveolar molding. The assumption is, however, that by making primary surgery less challenging (with either nasoalveolar molding or lip adhesion) and by transforming profound complete clefts into less daunting “incomplete clefts,” better outcomes can be achieved with the primary operation and thus fewer secondary operations will be necessary. From this standpoint, improved long-term nasal aesthetics (and indeed symmetry) is a positive secondary consequence of nasoalveolar molding. In the context of our experience, the pragmatic answer to the question “should nasoalveolar molding be part of the cleft lip treatment plan?” is “yes.” This is because we administer presurgical infant orthopedics with specific goals in mind: to close the alveolar gap and approximate the lip edges, to straighten the nose, and to grow the columella. These goals are routinely achieved with minimal morbidity and a high degree of patient and surgeon satisfaction at our center. There are many barriers, however, to a rigorous evidence-based assessment of this same question. Many variables must be optimized to ensure the maximal efficacious delivery and impact of presurgical infant orthopedics for any given patient. A truncated list of these factors affecting the outcomes of nasoalveolar molding might include the following: variations of technique, timing of intervention, strategies to address individual growth dynamics, the patient’s quality of tissue and response to molding, and compromises made to accommodate socioeconomic hindrances to delivery of care. These variables occur on a patient-