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Presurgical Lip, Alveolus, and Nose Approximation (PLANA) Significantly Improves Preoperative Nasolabial Morphology in Patients with Unilateral Cleft Lip
Paige E. Warner
1, Theresa K. Webster
*2, Albert Y. Truong
2, Thomas A. Imahiyerobo
2, Jill Schechter
1, Naikhoba Munabi
21Columbia University Irving Medical Center, New York, NY; 2Plastic and Reconstructive Surgery, New York Presbyterian - Columbia/Cornell, New York, NY
Background. Nasoalveolar molding (NAM) is a widely used presurgical infant orthopedic (PSIO) modality in patients with cleft lip ± palate (CL/P) though limited by frequent visits, patient discomfort, and financial strain. Presurgical Lip, Alveolus, and Nose Approximation (PLANA) is an emerging PSIO alternative with a simplified protocol of lip taping and nasal stents, requiring just 4-5 visits over 3 months. This study aims to characterize nasolabial and alveolar changes achieved with PLANA.
Methods. A prospective single-center study followed patients under 3 months of age with unilateral CL/P between March 2024 and January 2026. Patients progressed through an 11-week standardized protocol. Pre- and post-treatment columellar angle, nostril width and height, alar base width, and cleft width ratio (CWR) were measured from scaled clinical photos. CWR, a surrogate of cleft severity, was calculated as labial commissure width divided by cleft width. Paired t-tests assessed treatment outcomes.
Results. 13 patients with unilateral CL/P (6 complete, 7 incomplete) were included, with a median age of 16 days at first PLANA stent insertion. No significant complications occurred. PLANA improved columellar angle from 55.6 ± 20.2° to 70.0 ± 7.0° (p=0.005). It also significantly increased cleft-to-non-cleft nostril height ratio (0.6 ± 0.3 to 1.0 ± 0.3, p=0.006), decreased nostril width ratio (2.0 ± 0.7 to 1.6 ± 0.3, p=0.012), and reduced alar base ratio (1.7 ± 0.4 to 1.3 ± 0.2, p=0.001). Nasal symmetry significantly improved, with nostril height, width, and alar base ratios approaching zero on a logarithmic scale (p = 0.008, 0.02, and <0.001, respectively). PLANA also improved CWR (0.4 ± 0.1 mm to 0.3 ± 0.1 mm, p=0.004). Among patients with complete alveolar clefts, the alveolar gap decreased from 9.5 ± 4.9 mm to 1.9 ± 2.3 mm (p=0.007).
Conclusion. PLANA results in 14% improvement in columellar angle, 80% alveolar gap reduction to <2mm, and greater nasal symmetry. With a simplified protocol and proven efficacy, PLANA may be a superior alternative to NAM prior to CL/P repair.
Table 1. Nasolabial measurements at baseline and after PLANA treatment
| Variable | N | Pre-PLANA mean ± SD | Post-PLANA mean ± SD | Mean diff (Post-Pre) ± SD | p-value |
| Nostril Width (cm) |
| Non-cleft (cm) | 11 | 0.49 ± 0.09 | 0.56 ± 0.07 | 0.07 ± 0.08 | 0.012 |
| Cleft (cm) | 12 | 0.95 ± 0.30 | 0.83 ± 0.17 | -0.13 ± 0.19 | 0.040 |
| Cleft-to-non-cleft Ratio | 11 | 2.02 ± 0.73 | 1.55 ± 0.34 | -0.47 ± 0.54 | 0.012 |
| Nostril Height (cm) |
| Non-cleft (cm) | 11 | 0.30 ± 0.08 | 0.52 ± 0.05 | 0.22 ± 0.09 | <0.001 |
| Cleft (cm) | 12 | 0.21 ± 0.12 | 0.55 ± 0.17 | 0.35 ± 0.24 | <0.001 |
| Cleft-to-non-cleft Ratio | 11 | 0.56 ± 0.30 | 1.03 ± 0.31 | 0.47 ± 0.48 | 0.006 |
| Alar Base Length (cm) |
| Non-cleft (cm) | 12 | 0.92 ± 0.10 | 1.07 ± 0.14 | 0.15 ± 0.12 | 0.001 |
| Cleft (cm) | 12 | 1.45 ± 0.28 | 1.36 ± 0.20 | -0.09 ± 0.21 | 0.152 |
| Cleft-to-non-cleft Ratio | 12 | 1.65 ± 0.42 | 1.30 ± 0.18 | -0.35 ± 0.30 | 0.001 |
| Other Nasolabial Measurements |
| Columellar Angle (°) | 13 | 55.63 ± 20.21 | 69.96 ± 7.03 | 14.33 ± 15.11 | 0.005 |
| Alveolar Cleft Gap (mm) | 6 | 9.50 ± 4.85 | 1.92 ± 2.25 | -7.58 ± 4.25 | 0.007 |
| Cleft Width (mm) | 13 | 70.31 ± 249.29 | 72.64 ± 182.85 | 2.33 ± 132.13 | 0.065 |
| Labial Commissure Width (mm) | 13 | 126.15 ± 444.64 | 184.29 ± 443.36 | 58.14 ± 366.11 | 0.576 |
| Cleft Width Ratio (CWR) | 13 | 0.42 ± 0.13 | 0.30 ± 0.11 | -0.12 ± 0.12 | 0.004 |
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