Correction of unilateral secondary cleft lip nose deformity by a modified Tajima's method and several adjunctive procedures based on severity

Structural Approach to Secondary Repair of the Unilateral Cleft Lip Nasal Deformity

SUMMARY

Management of the unilateral cleft lip nasal deformity is complex because of the underlying significant asymmetry of the lower lateral cartilages and soft tissues of the nasal base. Suturing and grafting techniques may leave the patient with residual asymmetries of the nasal tip and nostrils. Some of this residual asymmetry may be attributable in part to the anchoring effect of the vestibular skin attachments to the lower lateral cartilages. This article discusses the use of lateral crural release, repositioning, and support with lateral crural strut grafts to manage the nasal tip. The technique involves freeing the vestibular skin from the undersurface of the lateral crura and domes and placement of lateral crural strut grafts with or without amputation of the ipsilateral dome and lateral crura to allow precise resuturing to the caudal septal extension graft. This technique is coupled with the use of a caudal septal extension graft to stabilize the nasal base and provide a strong foundation for the repair. Treatment of the nasal base may require skeletal augmentation to aid in creating symmetry of the alar insertions. Costal cartilage is needed in most cases to provide adequate structural support. Nuances in technique are discussed to help maximize outcomes.

Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes

Background: The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges. Objectives: Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair. Methods: This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models. Results: Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2-12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and -0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2-4, 5-7, 8-12, 13-24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015-0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair. Conclusions: In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

Secondary correction of nasal deformities in cleft lip patients using acellular dermal matrix grafting on the nasal tip with open rhinoplasty

Secondary nasal deformities in patients with unilateral cleft lip represent surgical challenges. Open rhinoplasty involving repositioning of the lower lateral cartilage has been shown to be a suitable technique for patients with cleft lip and nose deformities. This study aimed to explore a particular method of rhinoplasty and to assess the aesthetic outcomes for secondary unilateral cleft lip and nose deformities following its use. Fifty-seven patients treated for secondary unilateral cleft lip nasal deformities from January 2012 to December 2018 were enrolled in the study. Open rhinoplasty combined with a reverse-U incision and acellular dermal matrix grafting on the nasal tip was performed in all patients by the same surgeon. In our follow-up study we evaluated the results by measuring angles on photographs and scoring the appearance before and after operation. Data were statistically analysed using the t test. Appearances were improved in all patients. Both the alar base-nasal tip-columellar base angle and the nostril axis angles were smaller postoperatively (p < 0.001). According to the outcome scores, most patients (53/57) agreed that there was an obvious improvement in the appearance of their noses following surgery, and overall they were satisfied with the results of the revision procedure. A distinct improvement in nasal appearance can be achieved with this rhinoplasty. Our surgical method is effective and reliable in patients with secondary unilateral cleft lip and nose deformities, and is worth promoting in the clinic.

Achieving midvault symmetry in unilateral cleft nose deformity rhinoplasty

Background

The objective of the study was to provide aesthetic improvement in unilateral cleft nose deformity by reconstructing the midvault of cleft side alone with unilateral osteotomies, simulating symmetry with the normal side, together with tip reconstruction. While most of the literature emphasizes on tip reconstruction, few of them focus on techniques of repositioning the slanting nasal sidewall, which aids in achieving the desired symmetry. We describe a method of repositioning the bony nasal vault to a more lateral and symmetrical orientation by making unilateral osteotomies.

Results

Eighteen patients of unilateral cleft nose deformity underwent rhinoplasty between March 16 and January 20. All patients had prior primary cleft lip repair. Thirteen patients underwent primary rhinoplasty while 5 underwent secondary rhinoplasty having undergone primary rhinoplasty elsewhere. Follow-up was from 1 to 3 years. Results were evaluated using Rhinoplasty Outcome Evaluation [ROE] Questionnaire, and Asher McDade Aesthetic Index [AMAI] Rating. Pre- and post-operative scores were compared.

All patients were subjectively satisfied. The ROE and AMAI scores showed statistically significant improvement from pre-operative scores.

Conclusion

Obtaining symmetry in cleft nose deformity is a surgical challenge even in experienced hands. Using structural grafts only on the cleft side we attempted to create a near normal symmetry and achieve a natural nasal appearance, with satisfactory improvement from both patient’s and surgeons’ perspective.

Level of evidence

Case series- 4

Use of Septal Cartilage in Rhinoplasty to Correct Nasal Deformity After Unilateral Cleft Lip and Palate Surgery

Background

The most common facial defect is the congenital cleft lip (CL), which can occur with or without a cleft palate (CP). Patients need primary plastic surgery for rehabilitation and esthetics; nevertheless, secondary abnormalities of the lip and nose may develop after primary surgery. These deformities are complex and involve all tissue layers, including the skeletal platform, inner lining, osseocartilaginous structure, and overlying skin. This study evaluated the results of nasal deformity rhinoplasty using septal cartilage in patients with nasal deformities after plastic surgery for unilateral CL and CP.

Methods

This retrospective study was conducted on 21 patients with secondary unilateral CL nasal deformity between June 2015 and August 2016. All patients underwent rhinoplasty with the use of septal cartilage grafts. Pre- and post-operative nasal forms were measured.

Results

The patients had cosmetic problems and impaired nasal airflow due to distorted anatomy. The postoperative nasal forms were improved in all patients. Rhinoplasty using septal cartilage effectively increased the height of the columella and nose and improved the balance of the base width and the length of both sides of the nose. Excellent results were achieved in 18 patients. Three patients showed good results. No patient showed a fair result.

Conclusion

This study demonstrated an effective correction of esthetic deformities and significant improvement in airway patency. A long-term longitudinal study is still required to evaluate the influence of septal cartilage harvesting on face and nasal development until children reach their late teens.

Primary Nasal Correction in Unilateral Cleft Lip: An Ongoing Journey

BACKGROUND

A cleft lip deformity, whether unilateral or bilateral, is usually associated with a deformity of the nose. In present day cleft surgery, it is routine to perform a varying extent of correction of the nasal deformity. There is often relapse and ongoing deformity which warrant further nasal surgery. The authors describe their method of nasal correction which includes using a hypodermic needle to help achieve repositioning and suspension of the nasal cartilages.

MATERIALS AND METHOD

The authors reviewed 100 consecutive cases of unilateral cleft lip who had nasal correction since June 2018. There were 59 males and 41 females with a mean age of 5.5 months. There were 72 complete and 28 incomplete cleft lips. The steps in nasal correction include septal repositioning, sutures to approximate the ala domes, and upper medial crura, suspension of the lower lateral cartilage to the upper lateral cartilage and sutures to approximate the skin, lower lateral cartilage, and mucosa in a sandwich fashion.

RESULTS

The patients were followed up for a range of 9 to 21 months with a mean of 18 months. The correction immediately postop and at 2 weeks follow up was good. However, at 1 year follow up there was some evidence of relapse. The correction achieved was, however, superior to that achieved before this method. None of the relapses were deemed severe enough to warrant further surgery at this stage.

CONCLUSIONS

This method of nasal correction is recommended to achieve superior outcomes in the surgical treatment of unilateral cleft lips.

Single-stage repair of secondary unilateral cleft lip-nose deformity in adults

Correction of cleft lip-nose deformity in adult patients is different from that in children. One-stage correction has proved to be a suitable technique for patients with cleft-lip nose deformity. This study aimed to explore a particular single-stage method and evaluate the effect of simultaneous reparation of secondary unilateral cleft lip-nose deformities. Cleft lip patients who had previously undergone nasolabial surgery with residual poor nasal/lip appearance were included. The alveolar bone defect was repaired with granular costal cortical bone. Lip revision and rhinoplasty were performed using diced costal cartilage. The lip, nose, and alveolar deformities were corrected in one stage. From 2011 to 2017, 53 cases were treated. The vermilion discrepancy was corrected in all cases. Fifty-one patients were successfully treated, with primary healing in the bony recipient area. Cancellous bone exposure occurred in two cases. The wounds were healed after debridement and drainage. Appearances were improved in all patients. The mean change in columella-labial angle ranged from 82.50 to 92.78° (p < 0.001). This one-stage correction appears to have led to a distinct improvement in the nasal tip projection and lip. The method is considered to be effective and reliable in patients with secondary unilateral cleft lip-nose deformities.

Improvement of Aesthetic and Nasal Airway in Patients With Cleft Lip Nasal Deformities: Rhinoplasty With Septal Cartilage Graft and Septoplasty

OBJECTIVE

To assess the improvement of nasal morphologies and ventilation after septal cartilage graft and septoplasty of patients with unilateral cleft lip and palate (UCLP).

DESIGN

Retrospective case-control study.

SETTING

Tertiary stomatology hospital.

PATIENTS

In total, 118 patients with UCLP who had been diagnosed with a secondary nasal deformity and had reconstructive rhinoplasty and/or septoplasty between 2010 and 2015.

MAIN OUTCOME MEASURES

Nasal Obstruction Symptoms Evaluation (NOSE) questionnaire, septum deviated angle, rhinoplasty satisfaction questionnaire, and 3-dimensional photographs.

RESULTS

Average follow-up period was approximately 12 months for both groups. NOSE and 3-dimensional computed tomography (3DCT) analysis demonstrated postoperative improvement in nasal airway function of those patients who underwent rhinoplasty and septoplasty simultaneously ( P < .05). Subjective assessment by patients' visual analog scale (VAS) and objective assessment by 3-dimensional stereophotography demonstrated postoperative improvement in nasal morphologies, particularly the columella deviation angle and nasal depth (representing nasal tip height), which are crucial parameters of nasal aesthetics ( P < .05).

CONCLUSIONS

In patients who underwent simultaneous rhinoplasty and septoplasty, nasal symmetry and ventilation function were significantly improved compared to the control group. Septum grafts could provide nasal tip support for patients with cleft lip. Three-dimensional stereophotogrammetry helped us to better visualize the surgical results. Although the septal cartilage of Asian patients is sometimes insufficient for simultaneous use for multiple grafts, septum grafts in rhinoplasty of patients with cleft lip nasal deformities could give support for nasal tips.

Asian Cleft Rhinoplasty: The Open Structural Approach

BACKGROUND

Asian cleft rhinoplasty is a unique procedure with specific challenges.

OBJECTIVES

This paper presents our experience with the use of an open structural technique for Asian cleft rhinoplasty utilizing a complete autologous approach.

METHODS

An open approach that reconstructs the malpositioned nasal cartilage was utilized. Centrally, the septocolumella graft fixed securely in the midline with extender spreader grafts was utilized to project and lengthen the nose. The dislocated lateral crura on the cleft side was completely detached from the accessory cartilages and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was then reconstructed with the lateral crural strut graft (LCSG). This gave the versatility needed to bring the tip cartilages into a more anatomic and symmetrical position. Tip suturing and grafting was performed and dorsal augmentation achieved through diced cartilage wrapped in deep temporal fascia. At closure, when indicated, a modified Tajima reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base modifications were done as indicated.

RESULTS

From January 2010 to December 2015, 35 Asian patients underwent open cleft rhinoplasty. There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral cleft and 6 were bilateral cleft. The mean follow up was 23 months. All patients were highly satisfied with the functional and aesthetic improvement of the procedure. The complications and revision rates were low.

CONCLUSIONS

The autologous open structural approach can predictably and consistently give excellent results for Asian cleft rhinoplasty. The result attainable is superior to results attainable before adopting this approach for our patients.

LEVEL OF EVIDENCE

4.

Nasal appearance after secondary cleft rhinoplasty: comparison of professional rating with patient satisfaction

OBJECTIVE

The purpose of this study was to compare professional rating and patient satisfaction of nasal appearance after secondary cleft rhinoplasty.

METHOD

We used a cross-sectional study design and enrolled German adults with nonsyndromic unilateral or bilateral cleft lip and/or palate (UCLP and BCLP, respectively) undergoing secondary cleft rhinoplasty from January 2001 to December 2013. The predictor variable was professional rating. The outcome variable was patient satisfaction with postoperative nasal aesthetics. Other study variables included patient age and gender, type of surgery, and patient rating of nasal function. Appropriate descriptive and univariate statistics were computed, and a P value of <0.05 was regarded as statistically significant. Inter-rater reliability was assessed by the use of Cohen's kappa coefficient.

RESULTS

The study sample consisted of 242 adult cleft patients of mean age of 22.1 ± 9.2 years (range 14-64), including 97 females (40 %) and 176 unilateral clefts (73 %). Most of the patients reported good function (82 %) and good aesthetics (74 %). The main professional rating was good aesthetics (65 %). Analysis of inter-observer reliability revealed significant differences between patient satisfaction and professional assessment (κ = 0.385; P < 0.0001).

CONCLUSIONS

Although most of the patients were satisfied with the functional and aesthetic results of secondary cleft rhinoplasty, patient self-assessment of nasal appearance differed from professional assessment.

Dependence of columella development on the technique used for primary cleft lip closure

OBJECTIVE

Primary cleft lip closure can be achieved by use of different types of surgery. The procedures of Millard, Veau, and Delaire are among the techniques most frequently performed worldwide. The factors which affect development of the columella have not been studied, however.

SETTING

University Hospital of Leipzig, Germany, Department of Oral, Craniomaxillofacial and Facial Plastic Surgery.

PATIENTS, PARTICIPANTS

In a comparative, retrospective, non-randomised study, we obtained anthropometric details from photographs of 120 unilateral and bilateral cleft patients after cleft lip closure by use of the techniques of Millard or Veau (n = 60) and Delaire (n = 60). Length and shape of the columella was assessed twice-first at the age of 10 months and again at the age of 10 years. Anthropometric characteristics of columella morphology and development were compared between the two groups.

RESULTS

At the age of 10 months, the ratio of nasal height to width (interalar distance) was significantly different for unilateral and bilateral cases, and results were better for the Delaire groups (p = 0.001 unilateral and p > 0.001 bilateral). This effect was no longer apparent at 10-year follow up. Another index which tended to indicate better results in the Delaire groups was the nasal width index. In the summary of the anthropometric values investigated, however, differences between the Millard or Veau group and the Delaire group were marginal.

CONCLUSION

Cleft lip closure by the technique of Millard for unilateral cleft lips and of Veau for bilateral cases is neither better nor worse than Delaire cheiloplasty for unilateral and bilateral clefts.

Secondary cleft rhinoplasty

The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a formidable challenge for the facial plastic surgeon. The underlying anatomic deformities combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult procedure for even the most experienced surgeons. Numerous techniques for secondary cleft rhinoplasty have been described in the literature over the past several decades, yet the lack of wide adoption of any given technique highlights the great variability seen with this problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or webbing have driven the progressive evolution of techniques developed to correct various aspects of the cleft nasal deformity. Despite the number of techniques that have been published, very few studies have looked specifically at outcomes in secondary cleft rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty.