A morbidity review of children with complete unilateral cleft lip nose at 10 +/- 1 years of age

Comparison of Nasal Symmetry Between Presurgical Nasal Stenting and Postsurgical Nasal Retainer Placement in Unilateral Clefts

The timing of cleft lip nose surgery remains controversial. The less invasive the procedure at the time of primary cleft lip repair, the less the growth and development of the nose is affected. Therefore, the nasal-stenting component of presurgical nasoalveolar molding has increasingly been used. However, not all cleft centers use such treatment. Conventional postsurgical placement of silicone nasal retainers remains popular. No report has yet compared presurgical nasal stenting (preNS) and postsurgical nasal retainer placement (postNR). In this study, postoperative nasal form outcomes after primary lip repair using preNS or postNR in patients with complete unilateral cleft lips, alveoli, and palates were compared. Patients in whom preNS alone was used for 6 months (group I) were compared with those receiving postNR (no preNS) for 6 months after primary nasal cartilage dissection (group II) and controls with no appliance (group III). Nasal anthropometric distances and angular relationships were measured photographically to assess nasal symmetry at 4 years of age in all groups. Compared to group III, groups I and II exhibited significantly greater nostril heights (P = 0.0075, P = 0.0015 respectively) and columellar deviation angles (P = 0.0020, P = 0.0221). Groups I and II did not differ significantly. No significant between-treatment difference in terms of nasal symmetry between preNS and postNR was observed. However, both treatments afforded significantly better results than no treatment. Since older infants tend to resist the placement of nasal devices, preNS is more feasible in this age group.

Facial and Nasolabial Aesthetics of Complete UCLP Submitted to 2-Stage Palate Repair With Vomer Flap

OBJECTIVE

To evaluate the aesthetics of nasolabial appearance and facial profile of children with unilateral cleft lip and palate (UCLP) submitted to 2-stage palate repair with vomerine flap.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Forty patients with UCLP, mean age of 7.81 years of both sexes, rehabilitated at a single center by 1 plastic surgeon.

INTERVENTIONS

Lip and anterior palate repair with nasal alar repositioning was performed at 3 to 6 months of age by Millard technique and vomer flap, respectively. Posterior palate was repaired at 18 months by Von Langenbeck technique.

MAIN OUTCOME MEASURE(S)

Four cropped digital facial photographs of each patient were evaluated by 3 orthodontists to score the nasolabial aesthetics and profile. Frequencies of each score as well means and medians were calculated. Kappa test was used for evaluating inter- and intrarater reproducibility.

RESULTS

The nasal form and deviation was scored as good/very good in 70%, fair in 22.5%, and poor in 7.5% of the sample. The nasal-subnasal aesthetic was considered good/very good in 55%, fair in 30%, and poor in 15% of the sample. The lip vermilion border and the white part of surgical scar aesthetics were good/very good in 77.5% and 80%, fair in 17.5% for both categories, and poor in 5% and 2.5% of the cases, respectively. In all, 67.5% showed convex facial profile, 20% was straight, and 12.5% was concave profile.

CONCLUSIONS

Two-stage palatoplasty presented an adequate aesthetical results for the majority of patients with UCLP in the mixed dentition.

Determination of Facial Symmetry in Unilateral Cleft Lip and Palate Patients from Three-Dimensional Data: Technical Report and Assessment of Measurement Errors

Objective

To assess measurement errors of a novel technique for the three-dimensional determination of the degree of facial symmetry in patients suffering from unilateral cleft lip and palate malformations.

Design

Technical report, reliability study.

Setting

Cleft Lip and Palate Center of the University of Erlangen-Nuremberg, Erlangen, Germany.

Patients

The three-dimensional facial surface data of five 10-year-old unilateral cleft lip and palate patients were subjected to the analysis. Distances, angles, surface areas, and volumes were assessed twice.

Main Outcome Measures

Calculations were made for method error, intraclass correlation coefficient, and repeatability of the measurements of distances, angles, surface areas, and volumes.

Results

The method errors were less than 1 mm for distances and less than 1.5° for angles. The intraclass correlation coefficients showed values greater than .90 for all parameters. The repeatability values were comparable for cleft and noncleft sides.

Conclusion

The small method errors, high intraclass correlation coefficients, and comparable repeatability values for cleft and noncleft sides reveal that the new technique is appropriate for clinical use.

Comparative Study of Early Secondary Nasal Revisions and Costs in Patients With Clefts Treated With and Without Nasoalveolar Molding

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

Nasal asymmetry in unilateral cleft lip and palate

OBJECTIVES

Comparison of nasal asymmetry between unilateral cleft lip and palate (UCLP) patients with and without nasal correction at primary repair. Assessment of the value of Symnose as a routine research tool.

PARTICIPANTS

75 ten-year-old UCLP patients who underwent primary lip repair by one of two techniques: classical Millard with primary nasal correction (n = 30) or modified Millard without nasal correction (n = 45). Control group of ten-year-old school children (n = 45).

METHODS

Nasal asymmetry of participants was measured from facial photographs taken in two views: frontal and basal. The Symnose computer program was used to calculate asymmetry for three parameters: front perimeter (FP), base perimeter (BP) and nostrils (N). Total asymmetry was also calculated. Each image was traced on three separate occasions and a mean of the three measurements was calculated.

RESULTS

BP, N and total asymmetry were significantly greater in UCLP patients without nasal correction compared to both controls and patients with correction (BP = 12.73% v 4.90% v 6.75%, N = 47.73% v 15.83% v 30.75%, total = 81.87% v 46.43% v 54.68%, p ≤ 0.001). FP asymmetry was significantly greater in controls than all UCLP patients (22.87% v. 18.18% and 15.07%, p = 0.001 and p = 0.008). BP measurements have a higher degree of repeatability than FP and N (Coefficient of repeatability = 5.99, 17.02 and 16.47, respectively).

CONCLUSIONS

Primary nasal correction produces greater nasal symmetry during childhood from the basal view. Symnose is a simple method of objectively measuring asymmetry in UCLP, however improvements are required before it can be considered a useful research tool.

Nasolabial symmetry following Tennison-Randall lip repair: a three-dimensional approach in 10-year-old patients with unilateral clefts of lip, alveolus and palate

AIM

To assess the degree of facial symmetry in patients suffering from unilateral cleft lip, alveolus and palate (UCLAP) by determining differences between the cleft and the non-cleft hemifaces from 3D surface data.

PATIENTS AND METHODS

In twenty-two 10-year-old UCLAP patients, who had the lip repaired using the Tennison-Randall technique and did not undergo further revisional surgery, differences were determined between landmarks, surface areas of the upper lip vermilion and nostrils and virtual volumes of midface, nose and upper lip for cleft and non-cleft sides, separately, after having established a plane of symmetry calculated from optical 3D facial surface data.

RESULTS

Statistically significant differences could be found between cleft and non-cleft sides for the nasal landmarks G(lat), G(sup) and La(med), the nostril angle and the virtual volume of the nose (p(Glat)=0.011, p(Gsup)<0.0005, p(Lamed)=0.002, p(nostril angle)=0.036 and p(nose volume)<0.0005, resp.).

CONCLUSION

Analysis of 3D data shows that complete nasal symmetry is difficult to achieve with Tennison-Randall's lip repair without revisional surgery. Further trials on larger populations of patients will allow a more comprehensive and consistent analysis of the consequence of different methods for cp repair in order to identify the techniques with the best outcome in terms of facial symmetry.

Patient evaluation of outcomes of external rhinoplasty for unilateral cleft lip and palate

Thirty-five patients (range 16-59 years) with cleft-lip nasal deformity treated by external rhinoplasty were evaluated for satisfaction and perception of outcomes. Treatment involved alar base relocation and augmentation of the asymmetric nasal tip with auricular cartilage grafts. The patients completed a satisfaction survey and interview at the 2-year follow-up visit. A visual analogue scale (VAS) numbered 0-10 was also used by the patients to grade outcome compared to preoperative appearance at 4 anatomic sites. Prior to surgery, the nasal tip was perceived as being most deformed (15/35), followed by alar position (12/35) and nasal apertures (8/35). The site on the nose most improved by surgery was the tip (15), followed by alar position (10), symmetry of nostrils (6) and dorsum (4). The highest VAS score was for the tip (8.32), followed by alar position (7.59), dorsum (7.41) and symmetry of nostrils (6.73). No patients suffered long-term pain for more than 2 months following surgery. All patients were prepared to undergo such procedure for a second time, if necessary. The unilateral cleft-lip nasal deformity can be improved in the eyes of the patient, using the combination of external rhinoplasty with alar base relocation, where necessary, and auricular cartilage augmentation of the nasal tip.

Primary cleft nasal repair: the composite V-Y flap with extended mucosal tab

A method of primary cleft lip nasal repair utilizing a medially based composite alar flap with a mucosal tab extension is presented. The procedure modifies, with a 5- to 6-mm mucosal tab extension, a previously described chondromucosal flap technique. Most cases were done concurrent with a modified Tennison lip repair. The flap consists of the lateral crus of the alar cartilage, together with its vestibular lining. The flap is advanced medially so the dome provides the tip support for the affected side of the nose. The goal is to restore symmetry, obviating the need for future major nasal surgery. Experience with this technique in 32 patients over 4 years is reported. Although encouraged by our results, it is anticipated significant percentage of patients will still benefit from secondary nasal surgery when their nasal growth is complete.

Bilateral one-stage rotation advancement technique for Saudi children with isolated bilateral incomplete cleft lip: low revision rate despite multiple imperfections

The author is unaware of any article published in the English literature during the past 25 years that addresses specifically the results of surgery in isolated bilateral incomplete cleft lip deformity. The current study presents the outcome and investigates the surgical revision rate in 10 consecutive Saudi children with this deformity. Surgery was performed by the same surgeon using the bilateral one-stage rotation advancement technique. No primary nasal correction was performed in any of the patients. There were no immediate postoperative complications. Only one patient was offered a revision, but the parents refused and stated that they were happy with the result. No secondary lip or nasal correction was suggested or planned for any of the other patients. A panel of 10 medical students was asked to assess the surgical results using a 10-point scale. The one patient who was offered a revision obtained the lowest grade (mean score, 7.5 points). The remaining patients had a mean score that ranged between 7.9 points and 9.3 points. It appears that the multiple imperfections and asymmetries observed in the postoperative photographs were not thought to be severe enough to warrant surgical revision.

Unilateral cleft lip repair--state of the art

OBJECTIVE

A number of surgical techniques are utilized to correct the unilateral cleft lip, including variations of the rotation-advancement technique. This attests to the variability of the original deformity and the esthetic and functional results from any one technique, especially those based on traditional geometric rearrangement of the skin and associated tissues.

RESULTS

Most recent advances in cleft lip repair have occurred in two main areas. The morphological result has been improved by functional muscular reconstruction of the lip with or without orthopedic molding. Early correction of the nasal deformity has also been readvocated based on newer principles with excellent results demonstrated.

CONCLUSION

Further work continues in these areas and improved outcomes will continue to be seen along with a clearer understanding of surgical affects on growth and development.

The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results

This is an assessment of one surgeon's 15-year experience (1981-1995) using the Millard rotation-advancement principle for repair of unilateral complete cleft lip and nasal deformity. All infants underwent a prior labio-nasal adhesion. Since 1991, dentofacial orthopedics with a pin-retained (Latham) appliance was used for infants with a cleft of the lip and palate. Technical variations are described, including modifications in sequence of closure. A high rotation and releasing incision in the columella lengthens the medial labial element and produces a symmetric prolabium with minimal transgression of the upper philtral column by the advancement flap. Orbicularis oris muscle is everted, from caudad to cephalad, to form the philtral ridge. A minor variation of unilimb Z-plasty is used to level the cleft side of Cupid's bow handle, and cutaneous closure proceeds superiorly from this junction. The dislocated alar cartilage is visualized though a nostril rim incision and suspended to the ipsilateral upper lateral cartilage. Symmetry of the alar base is addressed in three dimensions, including maneuvers to position the deviated anterior-caudal septum, configure the sill, and efface the lateral vestibular web. Secondary procedures were analyzed in 105 consecutive patients, both revised (n = 30) and unrevised (n = .75). The possible need for revision in the latter group was determined by panel assessment of six indicators of nasolabial asymmetry, documented by frontal and submental photographs. In the entire study period, a total of 80 percent of children required or will need nasal revision, and a total of 42 percent required or will require labial revision. In the last 5 years, as compared with the earlier decade, there was a significantly diminished incidence of patients requiring labial revision (54 percent to 21 percent) and alar suspension (63 percent to 32 percent). These improvements are attributable to technical refinements and experience, although dentofacial orthopedics may also have played a role.

Symmetry and morbidity assessment of unilateral complete cleft lip nose corrected with or without primary nasal correction

OBJECTIVE

Unilateral complete cleft lip patients treated with or without a primary nasal correction at the time of cleft lip repair were compared to evaluate the relevance of early surgical correction of the nose by using two assessments: nasal symmetry and morbidity.

DESIGN, SETTING, PATIENTS

The no nasal correction group (NNC, n = 19) was operated by surgeon A using the Millard technique. The primary nasal correction group (PNC, n = 9) was operated by surgeon B combining the modified Millard technique with a columellar lift and alar mobilization. Symmetry was assessed on two sets of standardized photographs at 9 years of age using a computer-assisted analysis. Both cleft groups were compared with normal controls (NC, n = 20). The computer method included area and angular measurements. Morbidity was assessed by the number of procedures on the vermilion, the lip, and/ or nose for revisional surgery up to the age of 9 (NNC, n = 26; PNC, n = 12).

RESULTS

No significant differences in symmetry were found between the NNC and PNC groups regarding the area and angular measurements. With regard to the area measurements, both cleft groups produced a significant asymmetry when compared to the NC group. Concerning the angular measurements, however, the NNC group differed significantly from the NC group, whereas such a difference could not be noted between the PNC group and NC group. With respect to morbidity, no revisional procedures were performed in the PNC group. The number of revisional procedures in the NNC group was 16 in 10 patients.

CONCLUSION

Results are presented that favor, up to the age of 9 years, a primary nasal correction at the time of cleft lip repair.

The relevance of extracorporeal septoplasty in cleft nose correction

The aim of this paper is to delineate the importance of the correction of the nasal septum when attempting to improve the nasal shape and function in patients with cleft lip and palate (CLP) deformity. The particular problems of the nasal shape in CLP patients are assessed. Various approaches for adequate correction are reviewed and discussed. The method of extracorporeal septoplasty is presented in detail. This method was used between 1982 and 1997 in 141 out of 332 CLP patients who required septoplasties and appears particularly suited for this purpose since it offers the possibility of reconstructing an almost normal septum. This is necessary in order to achieve both a functionally and an aesthetically good result. Our experience over the past 16 years confirms the advantages of this approach.

Primary repair of the unilateral cleft lip nose: completion of a longitudinal study

The first 10 consecutive unilateral cleft subjects operated on in 1975 by a technique of primary cleft nose correction, developed by the author (HKM), were reviewed at ages 10 and 18. No further nasal surgery had been performed on these cases. The anteroposterior and inferior facial appearances of each of the cases have been published for evaluation. A computer-based method of measuring nasal asymmetry was used to objectively analyze the results and compare them with normal and cleft control faces that were age matched. The results support the observation that nasal growth of the cleft side of the nose is unaffected by early primary nasal surgery and that the vertical shortening of the nose by the alar lift technique is preserved into adult life. Residual nostril asymmetry from septal deviation persists into adulthood.

A comparison of computer versus panel assessment of two groups of patients with cleft lip and palate

A computer-based system of assessing asymmetry was used to compare standardised photographs of primarily corrected cleft noses, uncorrected cleft noses and control (normal) noses. A significant difference was found between control and cleft groups for both upper nasal perimeter (p < 0.001) and nostril outline (p = 0.001), and between uncorrected and corrected noses for upper nasal perimeter (p = 0.03) but not for nostril outline (p = 0.99). Comparing the results achieved by panel assessment (Cussons et al., 1992) with this of the same patients revealed some discordance related to the influence of extraneous factors on panel decisions. Panel assessment is needed in the evaluation of overall appearance, whilst the computer method is able to assess the results of different techniques, and from different centres, on specific features where symmetry is a major objective of surgical technique.