The Residual Cleft Lip Nasal Deformity

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

Role of cartilage correcting sutures in single-stage secondary rhinoplasty for unilateral cleft lip nose deformity

Introduction:

The purpose of this study is to highlight the role of cartilage correcting suture in single-stage surgical correction for secondary unilateral cleft lip nose deformity with three-dimensional observations of preoperative and postoperative nasal forms.

Material and Methods:

Between July 2017 and June 2019, 18 consecutive patients of unilateral cleft lip nose deformity aged between 16 and 28 years underwent surgical correction. The corrective procedure of nose involved columellar lengthening, medial and lateral nasal osteotomies along with augmentation of premaxilla by bone graft at premaxilla, and alar base wedge resections. Focus was laid to correct nasal cartilaginous framework using tip sutures along with repositioning of lower lateral cartilages, fixation of the alar cartilage complex to the septum, and the upper lateral cartilages. We investigated the following surgical interventions and nasal tip suture techniques, which were transdomal suture, interdomal suture, lateral crural mattress suture, columella septal suture, and intercrural suture.

Results:

We achieved adequate esthetic and functional results in all the patients without any morbidity.

Conclusion:

This concept of simultaneous approach toward complete single-stage correction of secondary cleft lip nasal deformity incorporating various cartilage suture using 5-0 nylon in developing nation like ours, where the patient presents late with complex conditions showed promising esthetic and functional outcome.

Effect of Dichotomous Conchal Cartilage Transplantation on Correction of Unilateral Cleft Lip Nasal Deformity

BACKGROUND

Autologous conchal cartilage is becoming increasingly popular as a source of material for secondary reconstruction. The aim of this study was to verify the effect of dichotomous autologous conchal cartilage transplantation in the treatment of unilateral cleft lip nasal deformity.

METHODS

Eighteen patients (10 males and 8 females) with unilateral cleft lip nasal deformity treated from August 2018 to August 2019 were selected for the study. The cut C-shaped conchal cartilage was trimmed into a strip shape and a shield shape and transplanted into the alar cartilage and the tip of the nose, respectively. The effect of the operation was evaluated in terms of patient satisfaction, two-dimensional linear quantitative results, and three-dimensional spatial differences after the operation.

RESULTS

During follow-up from 6 months to 2 years, the nasal appearance of 18 patients was significantly improved. The postoperative patient satisfaction survey revealed more than 93% satisfaction for each research index. Two-dimensional linear quantitative analysis revealed that the height of the nasal columella and nostril was significantly increased and that the nasal base and breadth were significantly decreased after the operation. Evaluation of the three-dimensional spatial difference between the unaffected side and the affected side before and after the operation revealed a significant decrease in the difference in the soft tissue volume between the unaffected side and the affected side (P < 0.05).

CONCLUSIONS

Dichotomous autologous conchal cartilage transplantation is an ideal method for the treatment of unilateral cleft lip nasal deformity.

Using three-dimensional nasal forms to compare definitive unilateral cleft lip nose correction with/without a cross-lap joint cartilage graft technique

To compare three-dimensional (3D) nasal forms after definitive correction of unilateral cleft lip (UCL)-nose using an extended spreader cartilage graft with/without a cross-lap joint cartilage graft technique. Twenty-four patients with UCL who underwent definitive nose correction using an extended spreader cartilage graft with a cross-lap joint technique (CLJ group) and fifteen patients with UCL who underwent nose correction without a cross-lap joint technique (non-CLJ group) were enrolled in this study. Pre- and postoperative 3D nasal forms were compared between the two groups. The CLJ group demonstrated more successful recovery of the nasal tip and anterior nasal ridge in the center of the face (P < 0.01), and the higher nasal tip was maintained for more than 1 year (P = 0.008). The differences in the cephalo-caudal heights of the nasal alar groove and curvatures of the alar groove arch were successfully improved in both CLJ and non-CLJ groups. The nasal angles on lateral profiles did not change in either group. An extended spreader cartilage graft with a cross-lap joint technique facilitates satisfactory recovery of the nasal tip in the center of the face and a higher nasal tip, avoiding over-projection in the definitive correction of UCL-nose.

Mechanical analyses of critical surgical maneuvers in the correction of cleft lip nasal deformity

The relapse of nasal deformity is a challenge for modern correction of cleft lip. A comprehensive understanding in the biomechanical perspective of both the formation and correction of the cleft lip nasal deformity would lead to improved stability of the corrective outcome. In this study, a finite element model of secondary cleft lip nasal deformity was constructed, on which two critical corrective maneuvers were mimicked in the form of force-loading. The intercrural suture was simulated by a force loaded at the intermediate crus of the alar cartilage directing anteriorly and medially, and the suture suspending the alar cartilage to the upper lateral cartilage was simulated by a force loaded at the lateral crus directing superiorly and medially. The equivalent von-mises stress and the total deformation consequent to different patterns of loading were captured. Our biomechanical analyses suggested that the intercrural suture at the nasal tip might be more effective in generating widespread morphological change than the suspension suture, but left much higher level of stress within the skin envelope if placed too high. Synergistic effect was observed between the two sutures in both the resultant deformation and stress. In addition, our simulations were partially supported by clinical photogrammetry data.

Cleft Lip and Palate: An Experience of a Developing Center in Egypt

BACKGROUND

Cleft lip and palate is the most common congenital anomaly in the head and neck region. These clefts are not just a distortion of the normal appearance, but they may impose a major influence on the whole patient's life, both functionally and psychologically. Clefts affect feeding, teething, hearing, speech, and social communication. The incidence of cleft lip and palate is variable in different countries and different communities. The surgical correction of cleft lip and palate went through many evolutions, but still there is no single universal protocol of repair; however, many European countries have adopted national protocols and have established cleft centers for the management and follow up of affected population.

PATIENT AND METHODS

In this study, the problem of cleft lip and palate in the area of upper Egypt was presented through the records of patients admitted to the Department of Plastic Surgery at the Sohag University Hospital in a 15-year period (2001-2015).

RESULTS

A total number of 1318 patients, who were admitted and had been operated upon in our department, were included in this study. The majority of patients presented to the department with a primary disease, yet 14.7% (194 patients) of them were first presented for a secondary interference after being operated upon elsewhere. A total number of 1923 surgical procedures were performed.

Clinical and 3-Dimensional Analyses of Nasal Forms After Secondary Correction of Cleft Lip-Nose Deformities Using Extended Spreader Cartilage Graft With a Cross-Lap Joint Technique

PURPOSE

A surgical strategy for definitive cleft lip-nasal correction that stably provides symmetric and natural nasal forms has not been established to date. The purpose of this study was to describe our surgical techniques and 3-dimensional (3D) assessment results after the definitive correction of cleft lip-nose deformity using an extended spreader cartilage graft with a cross-lap joint technique to achieve a rigid strut for lower lateral cartilage repositioning to obtain a desirable nasal tip projection.

PATIENTS AND METHODS

This study enrolled 14 patients with unilateral cleft lip (UCL) with or without cleft palate and 8 patients with bilateral cleft lip (BCL) with or without cleft palate who underwent definitive nose correction and were followed for 1 to 3 years. All patients were treated by open rhinoplasty, repositioning of the lower lateral cartilage, use of an extended spreader cartilage graft with a cross-lap joint technique for nasal tip support, and medial-upward advancement of nasolabial components with vestibular expansion by a free mucosal graft. For the BCL nose, pedicle flaps from rim skin were used for columella lengthening. Preoperative and postoperative nasal forms were 3-dimensionally analyzed by use of 3D images serially obtained in 12 patients.

RESULTS

The postoperative nasal forms were satisfactorily improved in all patients, without any serious postoperative complications. Preoperative and postoperative 3D analyses showed a significantly projected nasal tip in the postoperative noses of patients in both the UCL group and the BCL group (P < .01 and P < .05, respectively) and a sharper nasal tip angle in the BCL group (P < .05). Lateral deviation of the nasal tip was significantly improved in the center of the face in patients in the UCL group (P < .01).

CONCLUSIONS

The results of this study suggest that the extended spreader cartilage graft using the cross-lap joint graft technique is useful to provide a desirable projection of the nasal tip in the center of the face on definitive correction of both UCL and BCL nose deformities.

Cleft lip nose correction combining open rhinoplasty with the Dibbel technique

Cleft lip nose rhinoplasty is a challenging procedure because of the different presentation and severity of the deformity. Due to this presentation type, there is still no standard procedure correcting all the components of the deformity although a number of techniques have been published in literature. In this study, the effectiveness of the combination of open rhinoplasty and the Dibbel technique with nasal sill augmentation was evaluated. We hereby report our experience with 7 patients who had unilateral cleft lip nose deformity with slumped lower lateral cartilage and underprojected and deformed dome, operated on between September 2010 and April 2013 by 1 surgeon. The mean age of the patients at the time of surgery was 24.5 years (18-38 years) and the patients were followed up for an average of 18.5 months (6-31 months). All patients were operated on with open rhinoplasty and Dibbel technique combination with nasal sill augmentation. Frontal, lateral, oblique, and basilar photographs were obtained preoperatively and postoperatively for each patient. Nasal projection, columella height, nasolabial angle, nasal sill symmetry, and base width were measured on the photographs for comparison of preoperative and postoperative results. All patients' medial and lateral cantus distances were used for photographic standardization. The results demonstrated that there was a statistically significant increase in nasal projection (2.13 ± 0.28 mm preoperatively versus 2.31 ± 0.08 mm postoperatively; P = 0.018), columella height (1.07 ± 0.25 mm preoperatively versus 1.21 ± 0.18 mm postoperatively; P = 0.028), nostril apex height (1.11 ± 0.15 mm preoperatively versus 1.22 ± 0.11 mm postoperatively, P < 0.028), nasolabial angle (77.71 ± 8.74 mm preoperatively versus 91.33 ± 6.49 mm postoperatively; P < 0.05), and nasal sill symmetry (0.42 ± 0.15 mm preoperatively versus 0.27 ± 0.07 mm postoperatively; P < 0.05), and a significant decrease of alar width (2.35 ± 0.44 mm versus 2.16 ± 0.32 mm postoperatively; P = 0.018) on the affected side in response to surgery. The results of this study demonstrated that the Dibbel technique and open rhinoplasty combination with nasal sill augmentation is an effective and safe method for the correction of cleft lip nose deformity in respect to nasal symmetry.

Objective tools to analyze the lower lateral cartilage in unilateral cleft lip nasal deformities

Correction of cleft lip nasal deformity is an elusive goal. A controversy exists regarding the cause of the deformity, and therefore, there is a controversy of how to correct the deformity. Extrinsic theory is based on the presence of deformational forces from outside. The intrinsic theory is associated with deficiency of the lower lateral cartilage. The aim of this study was to use new objective tools to compare morphologically and histologically between the lower lateral cartilages of cleft and noncleft sides in patients with unilateral cleft lip nasal deformity. This study included 16 patients. They were operated on to correct unilateral cleft lip nasal deformity. Length, width, and thickness of lateral crura of the lower lateral cartilages of cleft and noncleft sides were measured. Punch biopsies from the middle part of the caudal ends of lateral crura were taken and sent for histologic and immunohistochemical studies. The lateral crura of the cleft side were significantly wider and shorter and tend to be thinner than those of the noncleft side. There was no significant difference in the chondroblast, chondrocyte, and total cellular number in the lower lateral cartilage of the cleft and noncleft sides. There was significantly less glycosaminoglycan content in the ground matrix of the lower lateral cartilage of cleft side. In conclusion, the use of digital sliding caliber in measuring the diminutions of the lower lateral cartilage and image analyzer to quantify the proteoglycans, glycosaminoglycans, fibroblast growth factor 18, and collagen content is very effective objective tools to compare the cleft and noncleft alar cartilage.

A preliminary study on the hard-soft tissue relationships among unoperated secondary unilateral cleft nose deformities

OBJECTIVE

The aim of this study was to explore the bone-soft tissue relationships around the nasolabial area in uncorrected secondary unilateral cleft nose deformities.

STUDY DESIGN

Measurements taken from photographs and cone-beam computerized tomography (CBCT) results were derived and paired up to represent the deformity features of bone and soft tissue, respectively.

RESULTS

All soft tissue measurements were significantly smaller than the corresponding bone measurements. Various bone-soft tissue correlation patterns were observed in different measurement pairs.

CONCLUSIONS

The adopted photography-CBCT combined measurement method appeared to be reliable in evaluating the hard-soft tissue relationships in the nasolabial area. In unoperated unilateral cleft nose deformities, bony deformities would decide the soft tissue contours, and soft tissue in turn could camouflage the underlying bone deformities in various patterns and scale, making the external configuration less deformed than its bone basis.

3-dimensional analyses of outcomes following secondary treatment of unilateral cleft lip nose deformity

OBJECTIVE

To analyze the 3-dimensional nasal forms after secondary treatment of unilateral cleft lip nose deformity.

PATIENTS AND METHODS

Thirteen Japanese adolescents with severe nose deformity associated with unilateral complete cleft lip with/without palate underwent definitive nose correction at the Department of Oral and Maxillofacial Surgery, Kagoshima University Hospital, and were followed for 1 to 3 years. Twenty healthy Japanese age-matched adolescents were included as controls. All patients were treated by open rhinoplasty through bilateral reverse-U incision and transcolumellar incision, correction of the columellar base with/without septoplasty, columellar strut graft, and medial-upward advancement of nasolabial components with vestibular expansion using a free mucosal graft. Pre- and postoperative nasal forms were measured using a 3-dimensional noncontact laser scanner. Angular and linear measurements, symmetry of the alar groove arch, and deviation of the nasal midline were analyzed.

RESULTS

Comparison of pre- with postoperative 3-dimensional nasal forms showed that postoperative nasal height was significantly increased (P < .01) but still shorter than that of controls. The significant preoperative differences in the nasal dorsal angle (P < .05) and bilateral alar groove arch (P < .01) disappeared after the operation. The deviation of the nasal midline was improved in the lower half of the nose (P < .05) postoperatively. There were no serious complications in any patients.

CONCLUSIONS

These surgical procedures can provide a symmetric and protruded nasal form, but there remain some differences between postoperative patients and healthy Japanese subjects.

Surgical technique for secondary correction of unilateral cleft lip-nose deformity: clinical and 3-dimensional observations of preoperative and postoperative nasal forms

PURPOSE

Despite recent developments in cleft surgery, a surgical method for secondary correction of unilateral cleft lip-nose deformity has not yet been established. The purpose of this study was to describe the surgical techniques for secondary correction of unilateral cleft lip-nose deformity with 3-dimensional (3D) observations of preoperative and postoperative nasal forms.

PATIENTS AND METHODS

Secondary corrections of unilateral cleft lip-nose deformity were performed on 13 patients with a complete unilateral cleft lip and palate, and these patients were followed up for 1 year to more than 3 years. All patients were treated by open rhinoplasty through a bilateral reverse-U incision and transcolumellar incision, correction of the columella base with/without septoplasty, nasal tip cartilage graft, and medial-upward advancement of nasolabial components with vestibular expansion by free mucosal graft. Preoperative and postoperative nasal forms were observed by use of photos and 3D data obtained serially.

RESULTS

The postoperative nasal forms were improved in all patients. The preoperative 3D color images indicated asymmetry of the alar groove and nasal tip visually. The top of the alar groove on the cleft side was dislocated distally and downwardly, resulting in a small snub ala. The postoperative 3D color images showed symmetric nasal forms with the adequately recovered nasal tip projection and the appropriate circle of the nasal ala groove on the cleft side. There were no serious postoperative complications.

CONCLUSIONS

Repositioning of the nasalis muscle and sufficient expansion of the nasal vestibule as well as reconstruction of nasal cartilages are important for correction of unilateral cleft lip-nose deformity.

MOC-PS(SM) CME article: late cleft lip nasal deformity

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the components of unilateral and bilateral secondary or delayed cleft lip nasal deformity. 2. Design and execute the surgical correction more logically. 3. Minimize the risks and better manage complications and suboptimal outcomes.

SUMMARY

Rhinoplasty remains one of the most challenging plastic surgery procedures, and patients with a cleft lip nose deformity pose an even greater challenge. The biggest enigmas are achievement of caudal nose congruity and creation of symmetric nostrils. This article reviews the factors to consider when assessing a patient for correction of secondary cleft lip nasal abnormalities and the surgical techniques available to correct the deformities. Some of the components of the unilateral cleft lip nose deformity include asymmetric tip, short columella, long lateral crus, flat nostril, wide alar base, caudal positioning of the nostril floor on the cleft side, and a short and deviated columella. The common features of bilateral cleft lip nose deformity include short columella, underprojected tip, flat alae, and wide and often asymmetric and horizontal nostrils. While an endonasal approach can improve these noses, the most success is attained through an open technique. Systematic reorientation of distorted nasal architecture, especially the lower lateral cartilages, and creation of a balanced platform for the lower lateral cartilages constitute some of the cardinal principles for correcting the cleft lip nose deformities. Potential complications and ways to minimize them are discussed.

Comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using conchal composite grafts

INTRODUCTION

Anatomical abnormalities and heterogeneous tissue deficiencies of the bilateral cleft lip nasal deformity challenges the cranio-maxillofacial plastic surgeon to create a functional, yet aesthetically pleasing nose. The authors propose a comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using composite conchal grafts.

PATIENTS

Five children with bilateral cleft lip nasal deformities had nasal reconstruction using conchal composite grafts, averaging 5 years in age at time of surgery. Patient follow-up averaged 21 months.

METHODS

An open tip rhinoplasty was performed using a 'V' shaped columellar incision. The conchal composite graft was obtained from the lateral aspect of the ear and was used to reconstruct the lateral alar mucosal defects. Conchal cartilage was used as a columellar strut. The columellar skin was closed in a 'V-Y' fashion, giving greater columellar length.

RESULTS

Visual inspection confirmed that the cleft lip nasal deformity was improved in all patients. There were no postoperative complications. All patients had complete composite graft take with minimal donor site morbidity and deformity.

CONCLUSIONS

This comprehensive rhinoplasty technique improves the abnormalities found in bilateral cleft lip nasal deformity by using the successful aspects of other methods and introducing the composite conchal graft.

Correction of the nose in patients with unilateral cleft lip with composite grafts

We used composite conchal cartilage graft for columellar lengthening in eight patients with unilateral cleft lip and a nasal deformity. In 16 patients we used a buccal mucosal graft to line the nasal vestibule. We also used corrective procedures such as alveolar bone grafting for closure of palatal fistulas, septoplasty, malar augmentation, nasal osteotomy, and Le Fort I osteotomy to deal with associated deformities. Grafts took well with no loss and no donor site morbidity. In the follow up of 8 months-3 years, corrections were found to be stable and satisfying to all the patients. Only by replacing deficient tissues with similar tissues and putting them in the proper anatomical position can long term consistent and reliable results be achieved in the correction of nasal deformities associated with unilateral cleft lip.

Treatment of the unilateral cleft lip nasal deformity

The lack of tip projection on the affected side of a unilateral cleft lip nasal deformity can be difficult to correct due to lack of adequate structural support. A new technique for the correction of the unilateral cleft lip nasal deformity is described. The key components of the technique involve the use of a dorsally angulated unilateral spreader graft on the cleft side and the use of an L-shaped septal graft to provide support to the cleft nasal tip.

Tertiary and Salvage Rhinoplasties Using the Open Rhinoplasty Approach

This paper reviews the results of 26 tertiary and salvage rhinoplasties, all managed by the open technique. Typically, the endonasal approach has been recommended for these difficult cases because of concerns with skin viability, and the belief that scarred nasal skin will not redrape satisfactorily. Minimal undermining has also been promoted to reduce the risk of graft shifting. Each deformity presented in this review was managed with an open exposure. There were no problems with skin viability or redraping. Cartilage grafts were required less often, and when needed, were sewn precisely into place. Tissue swelling could take 12 to 18 months to settle. This paper reinforces the need for careful preoperative planning. Potential surgical pitfalls are examined.

A model for the cleft lip nasal deformity

The underlying pathology of the cleft lip nasal deformity has yet to be fully realized, and cleft lip rhinoplasty continues to challenge the reconstructive surgeon. A new model is proposed, which is composed of elements that represent known anatomical structures of the nose. These structures are considered elemental to the mechanism of the primary cleft lip nasal deformity. The lobule is reduced to four arches. Five points on the skull provide foundations for these arches, which react interdependently to extrinsic forces and positional change. When certain changes are imposed on the model, predictable alterations in the configuration of the model imitate the observed deformities in the spectrum of the cleft lip nasal deformity, unilateral and bilateral, mild through severe. The model is described with illustrations, anatomic dissection, physical models, and selected clinical cases. A better understanding of the mechanisms of the cleft nasal deformities can be obtained through analysis of the model.