A preliminary report on one stage open tip rhinoplasty at the time of lip repair in bilateral cleft lip and palate: the Alor Setar experience

Prospective study of nasal growth in bilateral cleft lip and palate patients after naso-alveolar moulding and primary columella lengthening compared to controls at 5, 10 and 20 years

INTRODUCTION

A short columella, wide nostrils and a flat nasal tip are common features in patients with bilateral complete cleft lip and palate (BCLP). The objective of this study was to evaluate nasal morphology during growth in patients treated with naso-alveolar moulding (NAM) and primary surgical columella lengthening (PCL) compared with matched non-cleft individuals.

STUDY DESIGN

Prospective longitudinal case-control study.

PARTICIPANTS AND METHODS

Thirty-four consecutively treated BCLP patients at 5 and 10 years and at the end of growth (19.7 ± 2.0 years) were compared through normalized photogrammetry to a control of 34 age and sex-matched non-cleft individuals. Regression Models for Panel Data assessed how nasal measurements were influenced by surgery, age and gender.

RESULTS

Nasal protrusion was equal to non-cleft controls at all ages. Length of the columella was also comparable to controls at 5 and 10 years, but significantly shorter at the end of growth. Inter-alar and nasal tip width and nasolabial angle were significantly wider than controls at all ages: More than 60% of the patients have asked for correction of the nasal width, but no early surgery for columella lengthening was needed.

CONCLUSIONS

NAM and PCL have provided a nasal projection close to that of non-cleft individuals until adulthood, while length of the columella was physiological at 5 and 10, but shorter than controls at age 20. Width of the nasal tip and width of the alar bases were significantly wider than the controls and eventually required secondary nasal width correction in over two thirds of the sample.

Gingivosupraperiosteoplasty following Presurgical Maxillary Orthopedics Is Associated with Normal Midface Growth in Complete Unilateral and Bilateral Cleft Patients at Mixed Dentition

BACKGROUND

Passive orthodontic appliances and gingivosupraperiosteoplasty are adjuncts that can be used by surgeons at the time of primary cleft lip repair. These treatments, along with the surgical technique of cleft lip and palate repair, may impact midface growth. The objective of this study was to describe the authors' protocol for unilateral and bilateral cleft lip repair and to evaluate midfacial growth in a cohort of patients at mixed dentition who had undergone presurgical passive orthodontic appliance therapy and gingivosupraperiosteoplasty at the time of unilateral and bilateral cleft lip repair.

METHODS

Fifteen complete unilateral and 15 complete bilateral cleft lip and palate patients underwent passive orthodontic appliance treatment and primary lip repair with gingivosupraperiosteoplasty. Lateral cephalograms were analyzed by three blinded reviewers. Mean cephalometric measurements at mixed dentition were compared to cephalometric values for noncleft patients, unilateral cleft lip and palate patients who did not undergo gingivoperiosteoplasty or presurgical treatment, and unilateral cleft lip and palate patients who underwent gingivoperiosteoplasty/nasoalveolar molding with independent samples t tests.

RESULTS

Mean cephalometric values were within age-specific normal values for sella-nasion-A point, sella-nasion-B point, A point-nasion-B point, and facial axis. Eighty-seven (13/15) percent of unilateral cleft lip and palate patients and 93 percent (14/15) of bilateral cleft lip and palate patients did not exhibit skeletal class III malocclusion. There was no significant difference between cephalometric values for our patients and patients who did not receive gingivosupraperiosteoplasty or presurgical treatment or who underwent the gingivoperiosteoplasty/nasoalveolar molding protocol.

CONCLUSIONS

Presurgical passive orthodontic appliances, combined with gingivosupraperiosteoplasty at the time of lip repair, leads to normal maxillary development in most patients at mixed dentition. Assessment of midface growth at skeletal maturity is required.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening

OBJECTIVE

The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM).

SETTING AND PATIENTS

A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults.

RESULTS

Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width.

CONCLUSIONS

Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Determination of Ethnic Variation in Infant Nasolabial Anthropometry Using 3D Photographs: Implications for Bilateral Cleft Lip Nasal Correction

OBJECTIVE

We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients.

METHODS

Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P < .05.

RESULTS

Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P = .9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P = .02]; ac-ac [C-AA; P = .00; H-AA; P = .04]; al-al [C-AA; P = .00; H-AA; P = .001]) and labial length (sn-ls [C-AA; P = .041]; sn-sto [C-AA; P = .005]; Cphs-Cphi L [C-AA; P = .013]; Cphs-Cphi R [C-AA; P = .015]). Interrater reliability was good to excellent and significantly correlated for all measures.

CONCLUSIONS

African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction.

Nasolabial appearance of bilateral cleft lip repair at five years of age. Comparing techniques of modified advancement-rotation (Delaire) with Manchester repair: a retrospective cohort study

The techniques used to repair bilateral cleft lip have evolved over time, yet little data exist to compare outcomes using the various techniques. The aim of this study was to retrospectively evaluate and compare the aesthetic outcomes of two types of complete bilateral cleft repair: advancement rotation and a historic cohort repaired with the Manchester technique. A total of 32 consecutive patients who had complete repair of bilateral cleft lips were identified retrospectively from our centre using inpatient records. The first 16 (born between 1994 and 2005) underwent the Manchester repair, the second 16 (born between 2006 and 2010) a Delaire modified advancement rotation technique. Standardised photographs were taken at five years post repair and cropped to isolate the nasolabial component. Appearance outcomes were assessed by 20 members of the cleft and plastic surgery team, who were each asked to rate all 32 images using the Asher-McDade five-point scale. A chi squared test was used to determine whether there was a statistically significant difference in cleft scores between the two approaches. There was a mean (SD) of 2.8 (1.02) in the advancement rotation group and a mean (SD) of 3.1 (1.07) in the Manchester group. There was a statistically significant difference in the distribution of scores in the advancement rotation group compared with the Manchester group, with lower scores (better results) in the advancement rotation group (p=0.003). This study demonstrates that the advancement rotation technique for the repair of bilateral cleft lip defects resulted in a superior nasolabial appearance when directly compared with the Manchester repair at 5 years of age.

Surgical Nasoalveolar Molding: A Rational Treatment for Bilateral Cleft Lip Nose and Systematic Review

Background:

The purpose of this study was to evaluate the surgical outcome after using primary surgery to address bilateral cleft lip nose and palate deformities. In addition, the authors performed a systematic review to evaluate the effects of the nasoalveolar molding on non-syndromic bilateral cleft lip and palate.

Methods:

A prospective cohort study on a surgeon’s surgical outcome of 25 consecutively performed primary bilateral cleft lip nasal deformity repairs was conducted and a systematic review of the literature for studies published until December 2019 was done to evaluate the effect of presurgical NAM on nasolabial aesthetics and alveolar gap.

Results:

Since 2014, 25 consecutive patients with complete bilateral cleft have undergone primary anatomical repair of the cleft nasal deformity using primary cheilorhinoplasty. The average columella length was 4.3 ± 1.3 mm. The average ratio of the columella height to nasal height was 0.48 mm 1 year postoperatively and 0.52 mm 5 years postoperatively. Statistically significant differences have been observed between the pre and postoperative alveolar and palatal gaps after using primary cheiloplasty or bilateral lip adhesion. After systematic literature searching, 14 identified studies were qualified for the final analysis, which included 433 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.

Conclusions:

The results of this study suggest that the proposed primary cheilorhinoplasty is a good alternative to improve nose appearance and alveolar gap in patients with primary bilateral cleft lip nose and palate deformity. Based on the available scientific evidence, definitive conclusions about the effectiveness of presurgical Naso Alveolar Molding on nasolabial aesthetics cannot be drawn. Quality of the included articles were too low to make a conclusion.

Management of the Nasal Deformity in the Unilateral Cleft of the Lip and Nose

Cleft rhinoplasty is a demanding, technique-sensitive procedure. Part art, part science; it poses several probing questions to the surgeon. The unilateral cleft nasal deformity is a distinct entity because the pursuit of symmetry in the unilateral cleft nose makes the repair much more challenging. The advent of nasoalveolar moulding, the gaining popularity of primary (early) nasal repair and greater refinements in secondary (definitive) rhinoplasty techniques have contributed to better nasal results in unilateral cleft repair. Yet, some obstacles remain. This paper aims to discuss the anatomy of the unilateral cleft nose, enumerate aims and objectives of repair at every stage, and to demonstrate the evolution and varied rationale of management of nasal deformities in the unilateral cleft lip and nose.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding

BACKGROUND

Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results.

METHODS

We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated.

RESULTS

We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils.

CONCLUSION

The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

The conchal butterfly graft in secondary reconstruction of the bilateral cleft lip nasal deformity

OBJECTIVES

The bilateral cleft nasal deformity is characterized by a short columella and a broad, flattened nasal tip. Secondary correction is challenging and often complicated by skin envelope scarring and hypoplastic alar cartilages. Adequate and durable tip projection requires a procedure that adequately augments the nasal tip and maximizes tip support. We describe a novel technique for secondary correction of this deformity in the immature pediatric population.

METHODS

The conchal butterfly graft technique utilizes a folded cartilage construct to simultaneously increase tip projection and provide tip support. A retrospective review of 19 consecutive patients with bilateral cleft lip who underwent secondary tip rhinoplasty utilizing our technique over a 7-year period was conducted. Charts were reviewed for age at operation, length of follow-up and secondary revision procedures. Pre- and post-operative photographs were compared using two different methods to assess the degree of change and overall aesthetic result. Three plastic surgeons who previously were unfamiliar with the technique independently rated seven nasal tip characteristics. Nasal tip projection (NTP) was then measured objectively by two widely utilized methods: the Goode method and the Baum method-modified by Powell.

RESULTS

Long lasting correction of the bilateral cleft nasal deformity was achieved utilizing this technique in 19 patients over a 7-year period with a mean length of follow-up of 5.4 years. We demonstrate augmented nasal tip projection that approaches ideal relationships from both relative measurement and survey data.

CONCLUSION

The conchal butterfly graft technique is effective for reconstruction of the bilateral cleft nasal deformity, and in our experience, has resulted in long lasting nasal projection and overall improved facial balance.

A novel technique using a subcutaneously pedicled islanded prolabial flap for the secondary correction of bilateral cleft lip and nasal deformity

Context:

The bilateral cleft lip and nose deformity frequently requires lip revision surgery at the time of secondary rhinoplasty. The goal is to achieve an adequate philtrum with a well-shaped Cupid's bow, white roll alignment and a central vermilion tubercle.

Aims:

We have devised a new technique of using prolabial tissue tailored as an island of skin based on a subcutaneous pedicle for the secondary reconstruction of the philtral aesthetic unit in patients with bilateral cleft lip nasal deformity.

Settings and Design:

This technique was used in 21 patients from March 2012 to August 2015. All patients had undergone primary lip repair at other institutions and required lip revision with simultaneous rhinoplasty.

Subjects and Methods:

The objective criteria considered in the post-operative evaluation by the authors included improvement of philtral ridge projection, symmetry of philtral column and nasal sill and white roll continuity. The ten individual parameters were given a score from 1 to 4 (with 1 = lowest and 4 = highest for each individual parameter) and the total score was rated as 31–40 = excellent, 21–30 = good, 11–20 = fair and 0–10 = Poor. The patients' overall satisfaction was assessed at 6 months postoperatively to record their impression of the aesthetic improvement after our procedure.

Results:

The follow-up period ranged from 6 months to 3 years. The prolabial flap had no post-operative complications. The authors' assessment judged 15 (71.4%) patients as having an excellent outcome and 6 (28.5%) patients as having a good outcome. All patients expressed subjective satisfaction with the post-operative appearance of their upper lip and rated their results as improved and overall satisfaction scoring was high.

Conclusions:

This technique is a new addition to the repertoire of procedures which already exist for the correction of bilateral cleft lip nose deformity. It is safe, reliable and has a good aesthetic outcome with no significant morbidity.

Long-Term Nasal Growth after Primary Rhinoplasty for Bilateral Cleft Lip Nose Deformity: A Three-Dimensional Photogrammetric Study with Comparative Analysis

Nasal deformity is associated with congenital cleft lip and palate. Primary rhinoplasty for reconstruction of the nasal deformity at the time of bilateral cleft lip repair is a controversial issue in cleft care due to traditional teaching concerning the potential impairment of nasal growth. This study assessed long-term nasal growth in patients with bilateral cleft lip and palate who underwent primary rhinoplasty by a single surgeon between 1995 and 2002 and reached skeletal maturity (n = 39; mean: 19 ± 2 years). Normal age-, gender-, and ethnicity-matched subjects (n = 52) were enrolled for comparative analyses. Three-dimensional nasal photogrammetric measurements (10 linear, 4 angular, 6 proportional, 1 surface area, and 1 volume parameter) were collected from patients with bilateral cleft lip and palate and normal subjects. Patients who underwent rhinoplasty presented with significantly (all p < 0.05) smaller nasal tip projection and nasal tip angles, but greater values for nasal dorsum length, nasal protrusion, alar width, columellar height, dome height, columellar angle, labiocolumellar angle, nasal tip height ratio, nasal index, alar width/intercanthal distance ratio, and alar width/mouth width ratio compared to normal subjects. There were no differences (all p > 0.05) in nasal height, tip/midline deviation, nasal dorsum angle, dome-to-columella ratio, columella height/alar width ratio, area surface, and volume parameters between the two groups. This study shows that primary rhinoplasty performed in patients with bilateral cleft lip and palate during infancy does not result in deficiency of the nasal dimensions relative to controls.

Bilateral cleft lip repair with simultaneous premaxillary setback and primary limited rhinoplasty

Background

Functional closure of the orbicularis oris muscle and esthetic reconstruction of nasolabial components are impossible in patients with severely deformed premaxilla. Here, we review a surgical strategy for patients with unremedied premaxilla retrospectively.

Results

Vomerine ostectomy and premaxillary setback with nasolabial repair were performed in 12 patients with bilateral cleft lip and palate. The mean age of patients was 21.7 months. The extent of ostectomy varied between 3 and 11 mm. There were no serious complications from defective perfusion to the premaxilla or the philtral flap. The follow-up period ranged from 2 to 25 months. Proper positioning of the premaxilla and satisfactory nasolabial esthetics were achieved in all patients.

Conclusions

We performed nasolabial repair after premaxillary setback without jeopardizing the premaxillary segment or the philtral flap. Our surgical strategy could be recommended in poor socio-economic circumstances due to the cost effectiveness of limiting the number of surgeries.

One-Stage versus Two-Stage Repair of Asymmetric Bilateral Cleft Lip: A 20-Year Retrospective Study of Clinical Outcome

BACKGROUND

Both one- and two-stage approaches have been widely used for patients with asymmetric bilateral cleft lip. There are insufficient long-term outcome data for comparison of these two methods. The purpose of this retrospective study was to compare the clinical outcome over the past 20 years.

METHODS

The senior author's (L.J.L.) database was searched for patients with asymmetric bilateral cleft lip from 1995 to 2015. Qualified patients were divided into two groups: one-stage and two-stage. The postoperative photographs of patients were evaluated subjectively by surgical professionals and laypersons. Ratios of the nasolabial region were calculated for objective analysis. Finally, the revision procedures in the nasolabial area were reviewed. Statistical analyses were performed.

RESULTS

A total of 95 consecutive patients were qualified for evaluation. Average follow-up was 13.1 years. A two-stage method was used in 35 percent of the patients, and a one-stage approach was used in 65 percent. All underwent primary nasal reconstruction. Among the satisfaction rating scores, the one-stage repair was rated significantly higher than two-stage reconstruction (p = 0.0001). Long-term outcomes of the two-stage patients and the unrepaired mini-microform deformities were unsatisfactory according to both professional and nonprofessional evaluators. The revision rate was higher in patients with a greater-side complete cleft lip and palate as compared with those without palatal involvement.

CONCLUSIONS

The results suggested that one-stage repair provided better results with regard to achieving a more symmetric and smooth lip and nose after primary reconstruction. The revision rate was slightly higher in the two-stage patient group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The "Anatomical Balance Correction" for Secondary Cleft Lip Nasal Deformities

Secondary cleft lip nasal deformities corrective procedures are still a major concern for the maxillofacial surgeons.

Photometric Evaluation in Adolescence of Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening

OBJECTIVE

Nasal stigma in patients with bilateral cleft lip and palate (BCLP) are a short columella and a flattened nasal tip.

DESIGN

The aim of this study was to evaluate the aesthetics of adolescents with BCLP, operated with a modified Cutting primary columella lengthening technique, associated to a modified Grayson orthopedic nasoalveolar molding (NAM).

SETTING AND PATIENTS

72 BCLP patients were operated with this approach. Standardized photographic records were taken every 2 years. A group of 23 patients between 12 and 13 years of age was compared through normalized photogrammetry to a matched control of 23 noncleft adolescents.

RESULTS

Nasal protrusion and length of the columella were very close to normal. On the other hand, nasolabial angle and interalar width were still excessively wide compared to the noncleft sample.

CONCLUSIONS

NAM and primary columella lengthening in BCLP has allowed to avoid traditional secondary columella lengthening at 5 to 6 years of age and given the patients a more pleasing, near-normal nasolabial appearance until adolescence. Some of the patients will require correction of the nasal width at a later stage.

Longitudinal Photogrammetric Analysis of the Columellar-Labial Angle following Primary Repair of Bilateral Cleft Lip and Nasal Deformity

BACKGROUND

The changing nasolabial dimensions after repair of bilateral cleft lip and nasal deformity can be documented by anthropometry; however, the columellar-labial angle is rarely measured.

METHODS

This is a study of white patients who had synchronous repair of bilateral cleft lip performed by one surgeon (J.B.M.). The columellar-labial angle was measured on lateral photographs with the subject in neutral head position. Average values for columellar-labial angle at two or more time points were analyzed with a general estimating equation and cubic modeling. Values for complete and incomplete bilateral cleft lips were compared to each other and to Farkas' norms. Direct anthropometric measurements of intraoperative columellar length were compared to the postoperative columellar-labial angle using Pearson correlation analysis.

RESULTS

Eighty-five patients were studied (64 complete and 21 incomplete clefts). The average photographic follow-up interval was 10 years (range, 1.8 to 19.5 years). The columellar-labial angle in bilateral complete clefts was significantly greater than in incomplete forms (p = 0.002). Although the angles decreased with time, they remained significantly greater than Farkas' normative values in both cleft groups (all p < 0.05). There was no correlation between the magnitude of columellar lengthening achieved during primary nasal correction and the postoperative columellar-labial angle.

CONCLUSIONS

An obtuse columellar-labial angle can occur following synchronous nasolabial repair of a bilateral cleft lip, particularly in patients with a complete deformity. Although the angle narrows in time, it remains 1 to 2 SD greater than normal values. Secondary nasal correction may be needed if there is excessive tip rotation after completion of growth and orthognathic surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Long-term comparison of the results of four techniques used for bilateral cleft nose repair: a single surgeon's experience

BACKGROUND

The purpose of this study was to evaluate progressive changes in surgical techniques and results, aiming for improved nasal shape in primary bilateral cleft rhinoplasty.

METHODS

This is an institutional review board-approved retrospective study. Ninety-one consecutive patients with bilateral complete cleft lip underwent primary cheiloplasty with four different techniques of nasal reconstruction from 1992 to 2007 as follows: group I, primary rhinoplasty alone; group II, nasoalveolar molding alone; group III, nasoalveolar molding plus primary rhinoplasty; group IV, nasoalveolar molding plus primary rhinoplasty with overcorrection; and group V, patients without cleft lip. The surgical results were analyzed using photographic records obtained at age 3 years. Four measurements and one angle measurement were obtained. A panel assessment was obtained to grade the appearance of the surgical results.

RESULTS

The results are expressed in order from groups I through V. The nostril height-to-width ratio was 0.49, 0.59, 0.62, 0.78, and 0.82, respectively. The nasal tip height-to-nasal width ratio was 0.29, 0.39, 0.49, 0.57, and 0.60. The columella height-to-nasal width ratio was 0.11, 0.18, 0.22, 0.27, and 0.28. The dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.10. The nostril area ratio was 1.2, 1.17, 1.13, 1.11, and 1.07. The nasolabial angle was 144.95, 143.98, 121.98, 120.99, and 100.88. Finally, group IV had the best panel assessment.

CONCLUSIONS

The results revealed that group IV had the best overall result. Presurgical nasoalveolar molding followed by primary rhinoplasty with overcorrection resulted in a nasal appearance that was closer to the patients without cleft lip.

Modern tenets for repair of bilateral cleft lip

The understanding of the bilateral cleft lip and associated nasal deformity has evolved over the last 30 years to a point where there now exists general agreement regarding the goals, principles, and strategies for operative repair. This article presents modern tenets for repair of bilateral cleft lip and describes a logical approach to correction of the different possible subtypes.

Unfavourable results in the repair of the cleft lip

Introduction:

Unfavorable results in unilateral and bilateral cleft lip repair are often easy to spot but not always easy to prevent as to treat. We have tried to deal with the more common problems and explain possible causes and the best possible management options from our experience.

Unilateral cleft lip repair:

Unfavorable results immediately after repair involve Dehiscence and Scaring. Delayed blemishes include vermillion notching, a short lip, deficiency in the height of the lateral vermillion on the cleft side, white roll malalignment, oro-vestibular fistula, the cleft lip nose deformity, a narrow nostril and a “high-riding” nostril. We analyze the causes of these blemishes and outline our views regarding the treatment of these.

Bilateral cleft lip:

Immediate problems again include dehiscence as also loss of prolabium or premaxilla. Delayed unfavorable results are central vermillion deficiency, a lip that is too tight, bilateral cleft lip nose deformity, problems with the premaxilla and maxillary growth disturbances. Here again we discuss the causation of these problems and our preferred methods of treatment.

Conclusion:

We have detailed the significant unfavorable results after unilateral and bilateral cleft lip surgery. The methods of treatment advocated have been layer from our own experience.

Contemporary concepts for the bilateral cleft lip and nasal repair

The bilateral cleft lip and nasal deformity presents a complex challenge for repair. Surgical techniques continue to evolve and are focused on primary anatomic realignment of the tissues. This can be accomplished in a single-stage or two-stage repair early in infancy to provide a foundation for future growth of the lip and nasal tissue. Most cleft surgeons currently perform a single-stage repair for simplifying patient care. Certain institutions utilize presurgical orthopedics for alignment of the maxillary segments and nasal shaping. Methods for the bilateral cleft lip repair are combined with various open and closed rhinoplasty techniques to achieve improved correction of the primary nasal deformity. There is recent focus on shaping the nose for columellar and tip support, as well as alar contour and alar base position. The authors will present a new technique for closure of the nasal floor to prevent the alveolar cleft fistula. Although the alveolar fistula is closed, alveolar bone grafting is still required at the usual time in dental development to fuse the maxilla. It is paramount to try and minimize the stigmata of secondary deformities that historically have been characteristic of the repaired bilateral cleft lip. A properly planned and executed repair reduces the number of revisions and can spare a child from living with secondary deformities.

Assessment of deformities of the lip and nose in cleft lip alveolus and palate patients by a rating scale

INTRODUCTION

Labial and nasal deformities have always been a fundamental problem in the treatment of cleft lip, alveolus and palate patients. The primary surgical treatment of nasolabial area is of paramount importance in order to obtain both an esthetical correction of the deformity and a progressive and a balanced development of mid-face. In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analyzed and the relevant role of the perinasal, perioral muscular balance and the inborn dislocation of the alar cartilages are presented.

PATIENTS AND METHODS

50 CLAP patients were analyzed, 40 UCLP and 10BCLP. The lip repair was done by modification of Millard's technique. The severity of the cleft appearance was evaluated pre and post operatively, according to a pre-agreed visual rating scale. There are 4° of severity of the deformity pre operatively (mild, moderate, severe and very severe) and post operatively 5 categories of outcome (excellent,very good, good, satisfactory and poor), depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts.

RESULTS

In the 40 UCLP patients, 8 excellent, 10 very good, 16 good and 6 satisfactory results were obtained following primary cheiloplasty. In 10 BCLP patients 1 very good, 7 good, 1 satisfactory and 1 poor result were obtained.

CONCLUSIONS

During the primary repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. Abnormalities in the insertion of the nasolabial muscles with their abnormal function contribute to the cleft nose deformities. Therefore the reconstruction not only the orbicularis muscle but also of the paranasal muscles is therefore important for a symmetrical growth of the nose. Separate suture of intrinsic orbicularis oris provide a better shape to the vermillion. The position of the alar cartilage plays an important role for the symmetry of the nose. It is necessary to place the alar base symmetrically in three dimensions.

Presurgical presentation of columellar features, nostril anatomy, and alveolar alignment in bilateral cleft lip and palate after infant orthopedics with and without nasoalveolar molding

OBJECTIVES

(1) To evaluate quantitative differences in presurgical presentations of alveolar alignment and nostril anatomy of infants with BCLP treated with nasoalveolar molding (NAM) from those treated with maxillary infant orthopedics only (IO) and (2) to detect interrelationships between presurgical nasoalveolar anatomy, age at lip surgery, age of commencing, and durations of alveolar and nasal molding.

METHODS

A retrospective analysis was conducted on nasal-alveolar measurements and presurgical treatment records of infants with BCLP who received lip repair by a single surgeon in a tertiary-care, referral teaching hospital consecutively from 2000 to 2009 after undergoing NAM (n  =  29; 51 nostrils) or IO (n  =  17; 32 nostrils). Paired t tests analyzed nostril and alveolar symmetry in each group. Intergroup comparisons were made by linear mixed-model regression analyses. Pearson's correlation tests were conducted to detect significant interrelationships within groups.

RESULTS

Significant between-group differences were noted in alveolar irregularity (NAM: 3.58 ± 1.02 mm; IO: 7.31 ± 1.28 mm; p < .01), columellar length (NAM: 2.88 ± 0.27 mm; IO: 1.48 ± 0.34 mm; p < .001), columellar width (NAM: 6.10 ± 0.21 mm; IO: 6.88 ± 0.26 mm; p < .01), columellar length/width ratio (NAM: 0.48 ± 0.05; IO: 0.20 ± 0.07; p < .05), and columellar angle (NAM: 0.98 ± 1.1°; IO: 3.69 ± 1.37°; p < .05). Differences in age of commencing presurgical orthopedics, lip surgery, and treatment durations were not significant. Better-aligned alveolar segments in the NAM group did not statistically correlate with nostril dimensions. Alveolar irregularity and nostril height in the IO group strongly correlated.

CONCLUSIONS

Infants who received NAM had longer columellae and better-aligned alveolar segments than those who received only IO. Other nostril dimensions were not significantly different.

Bilateral cleft lip nasal deformity

Bilateral cleft lip nose deformity is a multi-factorial and complex deformity which tends to aggravate with growth of the child, if not attended surgically. The goals of primary bilateral cleft lip nose surgery are, closure of the nasal floor and sill, lengthening of the columella, repositioning of the alar base, achieving nasal tip projection, repositioning of the lower lateral cartilages, and reorienting the nares from horizontal to oblique position. The multiplicity of procedures in the literature for correction of this deformity alludes to the fact that no single procedure is entirely effective. The timing for surgical intervention and its extent varies considerably. Early surgery on cartilage may adversely affect growth and development; at the same time, allowing the cartilage to grow in an abnormal position and contributing to aggravation of deformity.

Some surgeons advocate correction of deformity at an early age. However, others like the cartilages to grow and mature before going in for surgery. With peer pressure also becoming an important consideration during the teens, the current trend is towards early intervention.

There is no unanimity in the extent of nasal dissection to be done at the time of primary lip repair. While many perform limited nasal dissection for the fear of growth retardation, others opt for full cartilage correction at the time of primary surgery itself. The value of naso-alveolar moulding (NAM) too is not universally accepted and has now more opponents than proponents. Also most centres in the developing world have neither the personnel nor the facilities for the same. The secondary cleft nasal deformity is variable and is affected by the extent of the original abnormality, any prior surgeries performed and alteration due to nasal growth.

This article reviews the currently popular methods for correction of nasal deformity associated with bilateral cleft lip, it's management both at the time of cleft lip repair and also secondarily, at a later date. It also discusses the practices followed at our centre.

Bilateral cleft lip and nose repair

Over the last three decades bilateral cleft lip and nose repair has been characterised by a trend towards more detailed reconstruction of the nasolabial muscles together with simultaneous correction of the deformity. An understanding of the true nature of the nasal deformity in bilateral cleft lip and palate (BCLP) has gradually emerged, and has inspired new approaches to their repair. This article discusses recent trends and controversies in primary cheilorhinoplasty for BCLP.

Primary bilateral one-stage cleft lip/nose repair: 40-year Dallas experience: part I

A 40-year experience with a proven protocol of repair for primary bilateral cleft lip/nose is presented. The Dallas surgical protocol for primary bilateral cleft lip/nose repair depends on the anatomy of the deformity. In cases of complete and partial bilaterally symmetric cleft lip, alveolus, and palate, 1-stage lip closure was performed at 3 months of age. In cases of asymmetric or incomplete bilateral clefts, an extremely small prolabium (<6 mm in vertical height), or a displaced or severely projected premaxilla, a 2-stage lip closure is more feasible ("Primary Bilateral Cleft Lip/Nose Repair Part II"). Primary nasal reconstruction was at 1 year of age. Early nasal reconstruction eliminates severe secondary deformity and the need for major early surgery. Orthognathic surgery was performed in approximately 40% of the senior surgeon's bilateral cleft patients to achieve optimal facial balance and aesthetics. Ten completed cases are presented with their long-term outcomes. The long-term outcomes of speech, occlusion, and facial balance are good to excellent in most of our bilateral patients. But in many cases, outcome of the lip/nose is still unsatisfying in the senior author's opinion compared with the results of unilateral cleft patients. These long-term outcomes are determined by the severity of the cleft deformity, primary repair technique, secondary surgery, and, most important, a protocol performed by a multidisciplinary experienced team until growth is complete. This technique should be considered in the treatment of all bilateral clefts, depending on the anatomy and team availability.

Primary rhinoplasty by open approach with repair of bilateral complete cleft lip

Nasal deformities inherent to a cleft are challenging. A controversy existed regarding the best time to correct these nasal problems. Now, there is a consensus that these nasal deformities are better to be dealt with along with repair of cleft lip.Primary cheilorhinoplasty involves proper reconstruction of clefted musculoaponeurotic complex by placing the muscles in their proper anatomic-physiologic orientation through careful identification, dissection, and mobilization of paranasal and labial musculature. In short, cleft repair is a muscle repair that enhances the establishment of a normal nasolabial complex. Delicate dissection and accurate repositioning of the lower alar cartilages during a primary lip repair will definitely help to establish a normal nasal shape. The nasal tissues must be supported with accurately placed sutures either by an open or a closed approach. The author prefers the open approach as published by Trott and Mohan (Br J Plast Surg 1993;46:215-222) with modifications because it has the added advantage for the identification and proper repositioning of the lower alar cartilages by accurately placed sutures under direct vision and the incisions of this procedure can be carried out through hidden rim incisions without any residual scars even in the colored population who were offered with this technique. Silicone nostril retainers, if available, during the immediate postoperative period will definitely promote the proper contours and the patency of the nostrils.Since 1994, the author has been performing this technique for patients with complete unilateral and bilateral cleft lip, which were presented separately. Patients with incomplete cleft lip were not included in this study because the nasal deformities were minimal, although the technique can be adopted for the correction of incomplete cleft lip nasal deformity also. Till December 2007, a total of 142 children with complete bilateral cleft lip with gross nasal deformities have been operated on and followed up.

Primary bilateral two-stage cleft lip/nose repair: part II

The Dallas surgical protocol for primary bilateral cleft lip/nose repair depends on the anatomy of the deformity. In cases of asymmetric bilateral clefts, an extremely small prolabium (<6 mm in vertical high) or a displaced premaxilla, a 2-stage lip repair was performed. At the same time, assessment of the tissue available for the columella determined the approach to the nose. In this part, the technique of 2-stage lip/nose repair of the bilateral cleft lip and palate is reviewed, and the long-term outcomes are presented.

Photometric evaluation of bilateral cleft lip and palate patients after primary columella lengthening

OBJECTIVE

To evaluate the results in terms of nasal esthetics of children with bilateral cleft lip and palate, operated with the Cutting primary columella lengthening technique, associated with Grayson orthopedic nasoalveolar molding, and to compare them with the nasal aspects of children with bilateral cleft lip and palate operated with a traditional approach and to an age-matched sample of normal Caucasian children.

DESIGN

Normalized photogrammetry.

SETTING

Regional Center for CLP, Department of Maxillo-Facial Surgery, San Paolo Hospital, Milan.

PATIENTS

Three groups of patients 5 years of age. Cutting group: 18 patients treated with the Grayson-Cutting technique. Delaire group: 18 patients treated with the traditional Delaire technique. Normal children: 40 normal preschool children.

RESULTS

With the Cutting-Grayson technique, the columella length, nasal tip angle, and protrusion are greatly improved compared with the previous protocol and are close to normal. On the other hand, the nasolabial angle and interalar distances are still excessively wide in both samples.

CONCLUSIONS

Although this is not a long-term study, at this time none of the patients operated with this technique have needed secondary columella lengthening. On the other hand, although certainly improved, the nasal anatomy obtained is far from normal.

Long-term results in the bilateral cleft lip repair by Mulliken's method

PURPOSE

To evaluate long-term results in the bilateral cleft lip repair by Mulliken's method, using anthropometric measurements, we assessed the growth of the nose and upper lip after the operation by comparing with those from 30 children without bilateral cleft lip.

MATERIALS AND METHODS

Forty-four patients had their bilateral cleft lip and nasal deformity repaired simultaneously by Mulliken's method during the period from July 1997 to December 2007. Of these patients, 15 patients had bilateral complete cleft lip, 17 patients had bilateral incomplete cleft lip, and 12 patients had a mixed type of complete and incomplete bilateral cleft lip.To follow up on the growth of the lips and nose after the operation, the following 6 anthropometric measurements were analyzed: nasal tip protrusion, nasal width, columellar length, upper lip height, cutaneous lip height, and vermilion mucosa height.

RESULTS

In most patients, nasal length, nasal tip projection, columellar length, and upper lip shape were appropriate. Nasal tip protrusion, nasal width, upper lip height, and vermilion-mucosal height were within normal limit. However, columellar length and cutaneous lip height were relatively shorter than the average values of children without bilateral cleft lip.

CONCLUSIONS

By performing Mulliken's method, we can achieve natural lip and nasal shape, harmonious Cupid's bow, appropriate nasal projection, and natural philtrum.

Nasal tip complications of primary cleft lip nasoplasty

BACKGROUND AND PURPOSE

Complications of primary nasoplasty, at the time of definitive primary cheiloplasty, are underreported in the literature. This study endeavors to examine the occurrences of these complications at our cleft-craniofacial center, in an effort to identify causative factors and management strategies. A case series of patients with postoperative nasal complications after primary cleft lip nasal surgery is presented.

METHODS

A retrospective chart review of primary cleft lip nasal repairs was conducted at our cleft-craniofacial center between January 2003 and December 2007. Consecutive cases of 3 staff surgeons were evaluated. Specific data points included number and type of complications, subsequent required interventions, and relevant history, with particular attention paid to the details of the primary nasoplasty.

RESULTS

Eighty-six primary cleft lip nasoplasties were completed between the years 2003 and 2007. Six complications (6.9%) related to the primary cleft lip nasoplasty were identified. Four patients (4.6%) experienced nasal tip infections; all 4 required surgical drainage. Twenty-four patients (27.9%) undergoing primary cleft lip and nose repair had postoperative nostril conformers placed, and 2 (8.3%) of them experienced complications deemed conformer related.

CONCLUSIONS

Postoperative nasal complications of primary cheiloplasty occur and are likely underreported. In this series, complications resulted from infection, often occurring late, and secondary to the use of nostril conformers. Surgeon awareness and caregiver education, to identify the early signs of postoperative nasal complications, are critical to the successful treatment of these occurrences. Although this study did not intend on examining antibiotic use, the significance of nasal tip infections might support the regular use of antibiotics in this population, and the use of postoperative nostril conformers must be followed closely.

A new modified forked flap with subcutaneous pedicles for adult cases of bilateral cleft lip nasal deformity: from normalization to aesthetic improvement

In adult cases of bilateral cleft lip nasal deformity, an esthetically satisfying result can not be obtained only by manipulation inside the nose with the nasal tip pointing upward. The nasal tip should be made in a more anterior direction for nasal esthetic improvement. Additional tissue beyond the nose is needed, and the forked flap is a useful method in such cases. However, the blood circulation of long and narrow flaps containing the scar, especially after open rhinoplasty, is unstable. We have developed a new long and narrow forked flap that has a more stable blood circulation. The forked flap was made using two subcutaneous pedicles attached to the periphery of the each flap. We applied this flap to five adult cases of bilateral cleft lip nasal deformity. Four of the cases had the scar associated with the flying bird incision, and one case required no treatment after the primary repair. All the flaps took without signs of partial necrosis. In all cases, the nasal tip was projected forward with adequate columella elongation, and the profile was esthetically improved. In the final stage of correction for adult cases of bilateral cleft lip nasal deformity, this method, making maximum use of the tissue containing the scar in not only the white lip but also the vermilion, is very effective. It is very important to obtain nasal esthetic improvement for the adult patient with bilateral cleft lip nasal deformity.

Bilateral cleft lip and nasal repair

SUMMARY

The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.

Recent advances in presurgical molding in cleft lip and palate

PURPOSE OF REVIEW

Although many protocols for treating infants with cleft lip and palate have been successful, the severely wide deformities often require a multidisciplined team approach. Maxillary appliances have been used for 50 years; however, nasal molding is a relatively recent development that has shown progress but not without stalwart criticism.

RECENT FINDINGS

Presurgical nasal alveolar molding is an evolving technique in the treatment of cleft lip and palate. Used properly, molding can create improved nasal symmetry in unilateral cases and columellar lengthening in bilateral cases. Some regression of improvement is often seen in the following years due to differential growth patterns within the nasal subunits. The nasal septal and columellar deviation seen in unilateral cleft lip and palate can also be improved with a novel device.

SUMMARY

Although traditional repair of the cleft lip and nasal deformity is often adequate, severely wide clefts are amenable to a variety of presurgical measures. Presurgical nasal alveolar molding in children with cleft lip and palate allows repositioning of the maxillary alveolus and surrounding soft tissues in hopes of reducing wound tension and improving results. These techniques can be extremely challenging but an excellent addition to a cleft lip and palate team's armamentarium.

Management of bilateral cleft lip and nasal deformity

PURPOSE OF REVIEW

Management of bilateral cleft lip and nasal deformity can be a challenging task. This paper provides an overview of bilateral cleft lip and nasal deformity with an updated review of current management issues in the literature.

RECENT FINDINGS

The Centers for Disease Control and Prevention recently reported that orofacial clefts are now the most common birth defect. While this statistic may be disheartening, the increased prevalence brings the problem to light at the forefront of the medical community, thus gaining more support and resources. Many techniques have been described for repair of bilateral cleft lip and nasal deformity. A recent advancement in presurgical orthopedics is the use of nasoalveolar molding to narrow wide clefts.

SUMMARY

Surgical management of bilateral cleft lip and nasal deformity poses a challenge to the skill and judgment of the cleft surgeon. Although techniques continue to evolve over the decades, the basic principles of cleft surgery remain the same. The main principles are to achieve an appropriate philtral size and shape, to position the cartilages in a more optimal position, and to attain muscular continuity and symmetry for optimal appearance and function. Thus, while keeping the basic principles in mind, management of bilateral cleft lip and nasal deformity becomes a valuable and rewarding experience for the surgeon, patient and caregiver.

[Nasal deformity after bilateral cleft lip repair]

Primary nasal deformity is characterized by apparent prolabio-columellar skin shortness due to alar cartilage dislocation worsened by lack of muscular support. The secondary deformation retains part of the initial deformity, sometimes even worsened by the primary lip repair. Multiple surgical lengthening techniques were used in nasal defect correction, suggesting both technical complexity and unsatisfactory results. Indeed, columellar insufficiency has more to do with abnormal columello-apical skin distribution due to alar mispositioning than an effective lack of skin. Secondary correction by open rhinoplasty allowing careful cartilage reconstruction of the nose tip seems to be widely accepted. However, the nasal defect can be limited by performing a primary intervention focusing on two principles: columellar lengthening by early alar repositioning and simultaneous lip and nose repair.

Combining the Cutting and Mulliken methods for primary repair of the bilateral cleft lip nose

BACKGROUND

Since 1990, primary bilateral cleft nasal reconstruction has been focused on placing the lower lateral cartilages into normal anatomical position. Of the four major techniques in this class, the Cutting (i.e., retrograde) method and the Mulliken method have been most successful. The retrograde method makes no external nasal incisions, but requires either preoperative or postoperative nasal molding to achieve maximum benefit. Mulliken's technique does not require molding, but leaves the footplates of the medial crura in the depression above the projecting premaxilla associated with the diminutive anterior nasal spine. Leaving the footplates in place also prevents adequate approximation of the alar bases. In this article, the two methods are combined to achieve the benefits of both.

METHODS

We report our experience with the retrograde nasal approach associated with marginal rim incisions (Mulliken method) in a series of 25 consecutive bilateral cleft lip cases simultaneous with lip repair. We performed a retrograde approach through membranous septum incisions elevating a prolabial-columellar flap. To facilitate alar cartilage manipulation we added bilateral marginal rim incisions. Nasal width, columella length and width, tip projection, and nasolabial angle were analyzed after a minimum of 2 years after surgery. These were compared with a normal, age-matched, control group. We also examined nostril symmetry and marginal nostril scars.

RESULTS

Columellar length was not statistically significantly different from that of the control group (p = 0.122442). Nasal width, columellar width, tip projection, and nasolabial angle were all significantly greater in the cleft group than normal (p < 0.001). No hypertrophied scars were found associated with the marginal rim scar.

CONCLUSIONS

Adding the Mulliken approach allows alar cartilage manipulation to be performed more easily than when using the retrograde approach alone. Tip projection and alar base narrowing are facilitated using the combined technique rather than the Mulliken approach alone. Prolabial flap manipulation is safe using this combined approach, even in cases with a severely projected premaxilla. We believe that the combined approach is safe and yields better long-term results than either technique alone.

Mulliken method of bilateral cleft lip repair: anthropometric evaluation

BACKGROUND

Simultaneous surgical correction of bilateral cleft lip and nasal deformity is becoming more common. This is a major change from the conventional strategy of secondary nasal correction.

METHODS

Thirty patients with bilateral cleft lip and nasal deformity were repaired using the Mulliken method between July of 1997 and December of 2002. This series was composed of 10 infants with bilateral complete cleft lip, 12 with bilateral incomplete cleft lip, and eight with bilateral asymmetric cleft lip, defined as complete on one side and incomplete on the other. A preoperative orthopedic appliance was employed in five infants who had severe collapse of the lateral maxillary segments. Mean age at the time of repair was 3.8 months.

RESULT

Postoperative results were evaluated anthropometrically. The mean follow-up period was 3.8 years (range, 1.2 to 5.5 years). Nasal tip protrusion was low; interalar dimension was wide; columellar length was slightly short; upper cutaneous labial height was short; and vermilion-mucosal height was near normal. All anthropometric values approached controls by 5 years.

CONCLUSION

Our modified Mulliken method is effective in correction of all forms of bilateral cleft lip and nasal deformity. Further evaluation is needed for possible differences in outcome based on race and age at the time of operation.

Improved nasal tip projection in the treatment of bilateral cleft nasal deformity

The cleft nose deformity in bilateral cleft lip and palate patients with severely flattened alar cartilages, a short, scarred columella, and thickened skin is a reconstructive challenge. The Wolfe double-arch tip rhinoplasty technique was compared with a cartilage release and tip grafting technique to determine the optimal modality for tip projection and columella lengthening. Patients with significant bilateral cleft nasal deformities and previous bilateral cleft lip repairs were divided into two groups (n = 22). Group 1 (double-arch) patients underwent an open rhinoplasty using conchal cartilage grafts to create a columellar strut and new lower lateral arches placed over the existing arches (n = 12). In group 2 (release and tip graft), the lower lateral cartilages were released, and nasal tip grafting was performed (n = 10). Preoperative and 6-month postoperative measurements, including (1) columellar length, (2) alar base-nasal tip-columellar base (ATC) angle, and (3) lateral tip projection, were compared. The lateral tip projection is the perpendicular distance between the nasal tip and a line created from the connection of points at the nasion to the subnasale. In group 1 (double arch), the mean columella length increased 47.2%, whereas in group 2 (release and tip graft), it only increased 14.1%. The ATC angle had a mean decrease or narrowing of 26.7 degrees in group 1, compared with a 12.5 degrees decrease in group 2. Lateral tip projection improvement was greater in group 1 (52.2% increase) compared with group 2 (19.9% increase). The authors' data showed that for the difficult bilateral cleft nasal deformity with significant tip flattening, the double-arch tip rhinoplasty provides improved nasal tip projection.

The change in the appearance of the vermilion border region caused by the difference of the design in symmetric bilateral incomplete cleft lip repair

In the widely performed methods for repair of bilateral cleft lips, such as Mulliken and Trott methods, the formation of the median tubercle is done with the mucocutaneous flaps from the lateral lips. By this manoeuver, a visible horizontal scar just above the white skin roll of the philtral region tends to result, especially among Asian patients. To avoid the formation of this visible scar, we changed our design in such a way that mucosal flaps, instead of mucocutaneous flaps, are elevated from the lateral lips, and the prolabial white skin roll is preserved to become the final philtral white skin roll. By this change in design, the horizontal scar is shifted to the inferior edge of the vermilion border. In the past 8 years, we have performed this refined method along with the conventional one. In the present study, the five cases of symmetric bilateral incomplete cleft lip from each of the two groups are evaluated: one group with the mucocutaneous flaps and the other with the mucosal flaps. From the review of the cases, it was noted that when the philtral region is formed with the mucocutaneous flaps, the horizontal scar tends to be visible. On the other hand, when it is formed with the mucosal flaps, the scar is less conspicuous, although the white skin roll sometimes becomes less-defined. The refined method involving mucosal flaps from the lateral lips produces a better-accepted appearance concerning the prolabial horizontal scar in the symmetric bilateral incomplete cleft lip repair.

Reduction of midfacial periosteal perfusion failure by subperiosteal versus supraperiosteal dissection

PURPOSE

Detachment of soft tissue is a prerequisite for cleft repair. Recent experimental studies have indicated that supraperiosteal rather than subperiosteal soft tissue detachment causes midfacial hypoplasia, although, the cause has not been clarified yet. We hypothesized that microcirculatory dysfunction may be responsible for hypoplasia development, and established in rabbits an experimental model to study the differences in nutritive perfusion of midfacial periosteum in dependency on the applied technique of soft tissue detachment.

MATERIALS AND METHODS

In anesthetized New Zealand White rabbits a cranially broadly based rectangular soft tissue flap was intraorally circumcised on the anteromedial aspect of the maxilla. After either supraperiosteal or subperiosteal soft tissue detachment fluorescence microscopy allowed quantitative in vivo analysis of the nutritive perfusion of midfacial periosteum.

RESULTS

Microscopic analysis of individually perfused capillaries showed that blood flow was comparable in supraperiosteally and subperiosteally dissected maxillary periosteum. Nonetheless, both dissection techniques were associated with a remarkable capillary perfusion failure. However, the functional capillary density, which indicates the number of perfused capillaries per tissue area and thus the overall quality of capillary perfusion, was found significantly ( P < .05) lower in supraperiosteally than in subperiosteally dissected periosteum.

CONCLUSION

Using a new model for in vivo quantification of periosteal perfusion in the maxilla of rabbits, periosteal perfusion was found significantly more deteriorated after supraperiosteal compared with subperiosteal soft tissue detachment. The marked reduction of periosteal microcirculatory perfusion failure after subperiosteal soft tissue detachment may contribute to the clinically observed protection from manifestation of midfacial hypoplasia after cleft repair.

Bilateral cleft lip

The surgeon's objectives are normal nasolabial appearance and normal speech. The principles for synchronous repair of bilateral cleft lip have been established, and the techniques continue to evolve. Primary repair impairs maxillary growth, but little can be done at this time except to practice gentle craftsmanship and to minimize tension on the lower labial closure. The cutaneous lip should never be reopened for revision, and the number of secondary procedures involving the nasal cartilages should be kept to a minimum. Many adolescents with repaired bilateral cleft lip need maxillary advancement to improve projection of the nasal tip, to protrude the upper lip, and to attain normal sagittal skeletal harmony. With expected improvements in the technology of distraction osteogenesis, maxillary advancement may someday become as acceptable as orthodontic treatment.

A pastiche for the cleft lip nose

An approach to primary and secondary repair for the cleft lip nasal deformity is presented in a brief form. The approach borrows from a large number of sources, hence the use of the term "pastiche." The sources include Millard, McComb, Anderl, Mulliken, and Cutting; Gunther, Rohrich, and Tebbetts; and Burget and Menick. A single case from each of the following cleft categories is presented and discussed: primary complete unilateral cleft, primary incomplete asymmetric bilateral cleft, primary complete bilateral cleft, and a secondary bilateral cleft. A description of the treatment method, its rationale, and a discussion are given for each category. There are a great number of varieties of the cleft lip malformation, but the principles presented can be applied to all of them.