Tele-assisted presurgical infant orthopedics using RAS/SAS protocol for cleft lip and palate in LMICs: a case report

Introduction and importance: Cleft lip and palate (CLP) defects are among the most common birth abnormalities worldwide. The standard of care requires a multidisciplinary approach, including presurgical infant orthopedics (PSIO) and surgical reconstruction. PSIO, which mandates frequent follow-up appointments, often faces significant barriers in low- and middle-income countries (LMICs) due to geographic distance and socioeconomic status, thereby impeding access to essential care. Case presentation: We present a 2-month-old boy with a complete unilateral CLP from a rural area, residing 500 km from the treatment center. We implemented a novel tele-assisted PSIO protocol utilizing a 3D-printed rhinoplasty appliance system (RAS) and sequential alveolar stenting (SAS) to bridge this gap. The RAS/SAS protocol reduced the need for in-person specialized visits to a single session, managing 500 km of geographic displacement through five structured remote consultations, supported by meticulous caregiver training on device adjustments. The PSIO was successful, achieving a reduction in nasal, labial, and palatal defects after 1 month, followed by an uncomplicated unilateral rhinocheiloplasty. Clinical discussion: While nasoalveolar molding is the gold standard, its reliance on weekly visits limits its feasibility in resource-constrained settings. This case suggests that the tele-assisted RAS and SAS protocol is a feasible and cost-effective technique. It maintains the high standards of comprehensive cleft care by transferring adjustment responsibilities to a trained caregiver, who is supervised remotely, thereby overcoming significant logistical challenges. Conclusion: The tele-assisted RAS and SAS protocol suggests a viable, safe, and effective solution for delivering high-quality PSIO care. This approach is crucial for improving access and equity for CLP patients in LMICs.