The cleft-lip nose

Secondary Cleft Rhinoplasty

Secondary cleft rhinoplasty remains a challenging operation that requires an understanding of the aberrant anatomy in cleft lip nasal deformity as well as the ability to adapt various techniques suited to the needs of each patient. In this article, we review some of the classically described approaches in cleft rhinoplasty and different strategies to address the nasal subunits. Presurgical adjuncts, surgical interventions before facial skeletal maturity, and patient reported outcome measures are also discussed.

The Effectiveness of Releasing the Lower Lateral Cartilage Through Intranasal Z-plasty Incision on the Vestibular Web During Secondary Correction of Nasal Deformities in Complete Unilateral Cleft Lip and Palate

The primary goal in the secondary correction of unilateral cleft lip nose deformity is to achieve symmetry of the nose and nostril. This study aimed to investigate the efficacy of freeing the lower lateral cartilage from the pyriform ligament through an intranasal Z-plasty incision on the vestibular web in adult patients with complete unilateral cleft lip and palate. Thirty-six patients with complete unilateral cleft lip and palate, who underwent open rhinoplasty between August 2014 and December 2021, were identified retrospectively. Five parameters for nose form and nostril symmetry were measured on basal views through 2-dimensional photographic analysis. The patients were divided into subgroups with or without septoplasty. Cleft-to-non-cleft ratios between the Z (13 patients) and non-Z groups (23 patients) were compared using the Mann-Whitney U test. The mean follow-up was 12.9 months (6-31 mo). In the Z group, there were significant differences between the preoperative and postoperative values for nostril angulation, regardless of septoplasty (all P <0.05). Despite septoplasty, significant differences in the postoperative changes in nostril angulation were found between the Z and non-Z groups (all P <0.05). Intranasal Z-plasty on the plica vestibularis is an effective technique for releasing the lower lateral cartilage, improving the nostril asymmetry in cleft lip nose deformity.

Mixed Dentition Period Follow-up of Primary Unilateral Cleft Nose Deformity Repair

Background

Recently, there has been an increased acceptance of the primary cleft rhinoplasty providing acceptable outcomes. Nose reconstruction, and specifically cleft nose deformity, should be addressed based on this philosophy. The purpose of this study was to evaluate surgical outcomes during the mixed dentition period after primary surgery to address unilateral cleft lip nose deformity based on the proposed technique.

Methods

This is a retrospective cohort study. Thirty-two primary complete unilateral cleft lip patients were operated on by a single surgeon using the V-Y-Z cleft rhinoplasty. This method combines a composite V-Y advancement flap with lateral Z-plasty. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements performed under general anesthesia during primary cleft palatoplasty and alveolar bone graft. The outcomes were evaluated through anthropometric measurements of the repaired nose during the mixed dentition period of follow-up, and no type of presurgical management was performed for any of the patients.

Results

Total nasal symmetry has been observed in 34.37% of patients at 7 years or more and 40.62% at 1-year follow-up. Nonstatistically significant differences were observed during follow-up, and major revision requirement (>3 mm of asymmetry in any of the nose measurements) was observed in 9.37% of patients.

Conclusions

The proposed primary cleft rhinoplasty is a good approach to improve nasal appearance in patients with complete unilateral cleft lip and palate.

Primary Cleft Rhinoplasty with Custom Suture Needle for Alar Cartilage Repositioning in Unilateral Cleft Lip Patients: 3D Nasal Analysis

OBJECTIVE

Primary nasal correction has been demonstrated to be a beneficial practice for patients with unilateral cleft lip and palate. However, there is currently no consensus among cleft surgeons regarding the ideal approach to addressing the malpositioned cartilages. This study aims to introduce a new surgical technique for repositioning deformed lower lateral cartilage during primary cleft rhinoplasty, which involves using a customized suture needle.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

This retrospective study included 51 patients with unilateral cleft lip and palate who underwent primary rhinoplasty during the labial repair.

MAIN OUTCOME MEASURES

A morphological analysis of the nose was conducted using three-dimensional (3D) photographs. The cleft-to-noncleft side ratios of various nasal parameters, including nasal tip volume, nostril width, height, and area, were calculated at three time points: preoperative (T0), 3 months postoperative (T1), and 1 year postoperative (T2).

RESULTS

Significant improvement (p < 0.05) was observed in the cleft-to-noncleft side ratios of nasal volume and nostril parameters. The nasal volume ratio and nostril height ratio remained stable, with no significant differences between the T1 and T2 periods. The nostril width ratio increased from 0.96 ± 0.13 at T1 to 1.05 ± 0.16 at T2, indicating an appropriate degree of surgical overcorrection of nasal width during primary lip repair.

CONCLUSION

Primary cleft rhinoplasty using a Chang's needle allows direct suture placement in the intercartilaginous region with minimally invasive approach, thereby preserving growth potential of the nose and restoring the nasal symmetry.

A comprehensive review of surgical techniques in unilateral cleft lip repair

Unilateral cleft lip is a common congenital anomaly that affects the appearance and function of the upper lip and nose. Surgical repair of cleft lip aims to restore the normal anatomy and functionality of the affected structures. In recent years, several advances have been made in the field of cleft lip repair, including new surgical techniques and approaches. This comprehensive review discusses the surgical management of patients with unilateral cleft lip and palate and provides step-by-step instructions for the surgical procedures.

Assessing the Impact of Transcutaneous Maxillary Distraction Osteogenesis on Pharyngeal Airway Volume in Children with Cleft Lip and Palate: A 3D Evaluation Study

Cleft lip and cleft palate (CLCP) patients often have a retrusive maxilla and a severe skeletal Class III malocclusion, which can result in velopharyngeal insufficiency (VPI). The aim of this study was to evaluate the changes in the volume of the 3D airway in CLCP children after maxilla distraction using the transcutaneous maxillary distraction osteogenesis (TMDO) method. 15 children with bilateral or unilateral CLCP were included in the study. 3D CBCT images were taken before and after distraction and were segmented and reconstructed to create a 3D airway model. The airway was divided into three regions: the upper, oropharyngeal, and hypopharyngeal airway. Pearson correlation tests were used to assess correlations between volume changes and corresponding skeletal and dental landmark movements (Point N, ANS, A, B, Pog, U1, and L1). The results showed that the ANS point advanced 9.85 ± 3.60 mm, and the A point advanced 14.22 ± 4.57 mm. The total airway volume change increased by 2535.06 ± 2791.80 mm3. However, there was no significant correlation between the A/ANS/U1 and the three different airway regions. Only B/Pog/L1 showed a positive correlation with these airway regions, with a high correlation between B/Pog/L1 and the hypopharyngeal airway region. TMDO can result in greater anterior advancement of the maxilla and an increase in airway volume, but the changes in bony landmarks did not show a strong positive correlation with the increase in airway volume as expected. Further investigation is needed to analyze the influence of surrounding soft tissue on the changes in airway volume.

Bilateral Cleft Lip Repair: Lessons from History

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the bilateral cleft lip and nasal deformity and associated anatomical variations. 2. Understand the history and evolution of the bilateral cleft lip repair. 3. Understand the key principles of the surgical repair.

SUMMARY

This article describes characteristics of the bilateral cleft lip and nasal deformity and its management, including presurgical orthopedics, operative techniques, and postsurgical care.

Primary Cleft Rhinoplasty: Surgical Outcomes and Complications Using Three Techniques for Unilateral Cleft Lip Nose Repair

BACKGROUND

This study represents a single surgeon's 10 years of experience addressing unilateral cleft lip and palate nose deformity. The purpose was to compare surgical outcomes and related complications using 3 different techniques to improve nasal shape in primary unilateral cleft rhinoplasty.

METHODS

This retrospective study with Institutional Ethical Committee approval compares 3 groups of patients with unilateral cleft lip nose and palate who were operated on using different techniques from 2007 to 2017. Surgical outcomes were analyzed by physical examination at least 1 year after primary rhinoplasty. Anthropometric measurements were obtained for the cleft and noncleft sides of the nose.

RESULTS

Approach with general analysis indicated differences among the 3 techniques. The author's comparative study revealed differences in nose symmetry and related complications, including increased recurrence of nose deformity using the modified McComb technique. Better short-term nose symmetry was observed using Potter technique and the V-Y-Z rhinoplasty.

CONCLUSIONS

Potter approach and the V-Y-Z techniques achieve better short-term nose symmetry than the McComb method. Complications were less common in the group of patients operated on using the modified McComb technique. Additional studies are required to evaluate functional and long-term outcomes after primary rhinoplasty using the proposed methods.

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.

Schneiderian Membrane Thickness Is Increased in Patients With Cleft Lip and Palate

OBJECTIVE

Patients with cleft lip and palate (CLP) are more likely to have sinusitis. The purpose of this study is to determine whether patients with CLP have thickening of the Schneiderian membrane. Specific aims were to (1) compare Schneiderian membrane thickness in patients with CLP to noncleft controls, (2) evaluate whether membrane thickening is associated with cleft side in patients with unilateral cleft lip and palate (UCLP), and (3) evaluate if age and sex are predictors of mucosal thickening.

DESIGN

Case-control study.

SETTING

Tertiary care center.

PATIENTS

Patients with CLP and controls.

MAIN OUTCOME MEASURE

The primary outcome variable was maximum Schneiderian membrane thickness measured on cone beam computed tomography. The primary predictor variable was the presence of a cleft. Additional variables were cleft phenotype, age, and sex.

RESULTS

There were 225 patients with CLP and 93 controls. Median mucosal thickness was 2.4 mm in cleft group and 0.0 mm in controls (P = .006). In cleft group, 56.7% of sinuses had mucosal thickness >2.0 mm compared to 38.2% in controls (P = < .004). Pathologic membrane thickening (>4.0 mm) was significantly higher in cleft group (P = .005). No statistically significant difference in mucosal thickness between cleft and noncleft sides in patients with UCLP. Linear regression showed no association between age or sex and Schneiderian membrane thickness.

CONCLUSION

Schneiderian membrane thickening is more common in patients with CLP and is not associated with the side of the cleft in patients with UCLP.

Component Restoration in the Unilateral Intermediate Cleft Tip Rhinoplasty: Technique and Long-Term Outcomes

BACKGROUND

The intermediate cleft tip rhinoplasty is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. The authors describe and evaluate long-term outcomes of that approach for the unilateral cleft lip and palate patient based on the concept of individual restoration of each abnormal anatomical component.

METHODS

Photomorphometric analyses of unilateral cleft lip and palate patients (n = 50) who underwent intermediate cleft tip rhinoplasty using the component restoration technique were evaluated preoperatively (time 0) and postoperatively at less than 1 year (time 1), 1 to 3 years (time 2), and more than 3 years (time 3) and compared to age-matched unilateral cleft lip and palate control patients. Nasal relationships (alar symmetry, nasal tip protrusion-to-alar base width ratio, and height-to-width dimensions for the cleft and noncleft nostrils) were compared over time using a linear mixed-effect model.

RESULTS

At time 0, both groups demonstrated similar nasal relationships, with the exception of a wider cleft-side nostril in relationship to height in the rhinoplasty group. The component restoration technique improved all four nasal relationships at all postoperative time points compared with time 0 in a statistically significant manner, whereas control patients did not demonstrate significant changes at the corresponding ages. Long-term differences at time 3 revealed a trend toward improved alar symmetry and cleft-side and non-cleft-side nostril dimensions, and a significant improvement in the nasal tip protrusion-to-alar base width ratio in intermediate cleft tip rhinoplasty-treated versus control patients (p = 0.002).

CONCLUSION

The component restoration technique for the unilateral intermediate cleft tip rhinoplasty improves nasal relationships toward normal immediately and in a sustained manner for at least 3 years.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Evaluation of the Effectiveness of an Alar Transfixion Suture for the Correction of a Vestibular Web and Alar-Facial Groove: A Photogrammetric Analysis

BACKGROUND

Alar transfixion sutures are commonly used for vestibular web correction. The purpose of this study was to evaluate the long-term results of the use of alar transfixion sutures in patients with a unilateral cleft lip nasal deformity using photogrammetric analysis.

METHODS

The study included 42 patients who were divided into child and adult groups. A total of 4 measurement items were evaluated from a basal view by photogrammetry using standardized clinical photographic techniques preoperatively, immediately postoperatively, 3 months postoperatively, and 6 months postoperatively.

RESULTS

When the preoperative and last postoperative values were compared, no significant changes in any measurement items were noted in the adult group. In the child group, the proportional index (the ratio of the cleft side to the noncleft side) of the alar slope line inclination was significantly increased, but other measurement items showed no significant change. When the measurement items were compared between time points, no significant changes in any measurement items were noted in the adult group. In the child group, the proportional indexes of the alar length, the width between the subnasale and the alare, and the webbing degree were significantly decreased immediately postoperatively compared with the preoperative values. However, these significant changes were diminished at 3 months postoperatively. The proportional index of the alar slope line inclination was significantly increased at 3 months postoperatively compared with the preoperative value, but the significant change was diminished at 6 months postoperatively.

CONCLUSIONS

The alar transfixion suture procedure is not effective for correcting a vestibular web and alar-facial groove.

Management of the Cleft Nasal Tip: An Overview of Classic Techniques and Strategies

The challenges of cleft reconstruction have been present for centuries. However, understanding of the cleft nasal tip and the evolution of techniques decidedly began in the 20th century and refinement continues into the present day. Although a multitude of technical descriptions and case series have been published, a compendium of seminal techniques, which have shaped modern thought, has not been compiled in the literature. In this review, we discuss the anatomical disturbances in the cleft nasal tip anomaly, the timing and strategy of tip correction, and the major classic techniques for management of the cleft nasal tip. In addition, we have categorized the classic techniques into concepts that they embody.

Presurgical Orthopedic Treatment Using Modified Nostril Retainers in Patients With Unilateral Cleft Lip With or Without Cleft Palate

This study aimed to present a new technique for presurgical orthopedic treatment of patients with unilateral cleft lip with or without cleft palate (UCL±P) by means of modified nostril retainers manufactured using a special mold with soft acrylic or orthodontic acrylics material. Nasal molding with the modified nostril retainer is considerably effective and comfortable for the patient.

Asian Cleft Rhinoplasty: The Open Structural Approach

BACKGROUND

Asian cleft rhinoplasty is a unique procedure with specific challenges.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4.

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.

Inferior Turbinate Asymmetry Is a Feature of the Unilateral Complete Cleft Lip and Palate Nasal Deformity

PURPOSE

Patients with unilateral complete cleft lip and palate (UCLP) have a characteristic bilateral septal deformity, and septal deviation can be associated with turbinate hyperplasia, leading to paradoxical nasal obstruction. The purpose of the present study was to measure and compare the bony and mucosal dimensions of the inferior turbinate on the cleft and non-cleft sides in patients with UCLP.

PATIENTS AND METHODS

We implemented a retrospective cohort study of patients with UCLP who had undergone computed tomography (CT) scan between 2002 to 2013. Subjects who had undergone nasal revision, septoplasty, turbinectomy, or Le Fort I osteotomy before the imaging date were excluded. The primary predictor variable was the subject side (cleft vs noncleft side), and the primary outcome variable was the turbinate cross-sectional area. The secondary predictor variables included the site of measurement along the sagittal axis of the turbinate (anterior, middle, posterior) and tissue type (turbinate whole, bone, mucosa). The Wilcoxon signed rank test for paired samples compared the turbinate dimensions on the cleft and noncleft sides, with statistical significance set at P ≤ .05.

RESULTS

The sample included 53 patients (32 females and 21 males). The inferior turbinates were measured bilaterally on CT images obtained at a mean age of 12.2 ± 0.8 years. The inferior turbinate on the noncleft side was significantly larger in both bone and mucosa (P = .003). This relationship did not change when controlling for age and gender.

CONCLUSIONS

The results of the present study have confirmed bony and mucosal enlargement of the inferior turbinate on the noncleft side in patients with UCLP. This might contribute to bilateral nasal obstruction and should be considered during treatment planning for nasopharyngeal and orthognathic surgery.

Correction of the vestibular web during primary repair of unilateral cleft lip

BACKGROUND

After repair of cleft lip and nasal deformity, a lateral vestibular web is often evident on submental view. The authors describe the five components of this web (i.e., piriform rim, upper lateral cartilage, lower lateral cartilage, vestibular lining, and alar base) and present their technique for primary nasal correction and prevention.

METHODS

Labial repair follows the Millard rotation-advancement principle. Nasal correction addresses the vestibular web: (1) centralization of deviated anterocaudal septum; (2) elevation of inferiorly positioned medial crus in the C-flap; (3) endonasal advancement and fixation of displaced alar base; (4) excision of excess vestibular lining; (5) release of tethered lateral crus from the piriform ligament; and (6) anatomical fixation of dislocated lower lateral cartilage to the contralateral middle crus and ipsilateral upper lateral cartilage.

RESULTS

Intraoperative dissection exposes the framework of the vestibular web as the lower (caudal) edge of the displaced lateral crus lying beneath expanded vestibular lining.Sixty-two consecutive patients had primary cleft nasal repair focused on the architectural components of the vestibular web. Nostril stenting was not used; the nostril rim scar was hidden and no patients had nostril stenosis.

CONCLUSION

The vestibular web seen after repair of a cleft lip has bony, cartilaginous, and soft-tissue elements and can be prevented during primary correction of the cleft nasal deformity.

Positioning the caudal septum during primary repair of unilateral cleft lip

BACKGROUND

Since 1995, the senior surgeon has straightened the deviated anterocaudal septum in all infants undergoing primary repair of unilateral complete cleft lip/palate.

METHODS

A retrospective assessment was done on 17 patients who did not have septal correction and 17 patients who did have septal correction at the time of nasolabial repair. Operative reports were reviewed, and secondary procedures on the nose were documented.Posterior-anterior cephalograms were used to measure septal deviation from the midline, angle of septal deviation, and width of the inferior turbinate on the noncleft side. The angle subtended by the superior and inferior segments of the cartilaginous septum was measured at the point of maximal septal deviation.

RESULTS

The uncorrected group had a mean maximal septal deviation from the midline of 5.8 mm compared with 4.1 mm in the corrected group (P < 0.01). The uncorrected group had a mean width of the contralateral inferior turbinate of 12.7 mm compared with 10.2 mm in the corrected group (P < 0.01). The uncorrected group had a mean subtended angle of 137.8 degrees compared with 147.9 degrees in the corrected group (P < 0.01).

CONCLUSIONS

Positioning the anterior caudal septum during primary repair of unilateral complete cleft lip results in less septal deviation and a smaller contralateral turbinate as documented by posteroanterior cephalometry in adolescence.

Primary correction of nasal deformity in unilateral incomplete cleft lip: a comparative study between three techniques

INTRODUCTION

Nasal deformities secondary to incomplete cleft lip are often underestimated in terms of their severity with resultant sub-optimal treatment. Constant refinements have led to the evolution of different surgical techniques in our institution for the treatment of these deformities. This study compared three different techniques in achieving nasal asymmetry for patients with unilateral incomplete cleft lip.

METHODS

Sixty-six patients who had primary correction of incomplete cleft lip nasal deformities at the age of 3 months were reviewed later at the age of 5 or 6. The patients were divided into three groups as according to the surgical treatment received: Group I (n=21) underwent a closed rhinoplasty with cartilage dissection and repositioning through lip incisions; Group II (n=25) underwent a semi-open rhinoplasty technique with cartilage dissection through bilateral rim incisions; and Group III (n=20) received a semi-open rhinoplasty technique through a Tajima incision on the cleft side and a rim incision on the contralateral side. Using photo-analysis, a total of seven measurements were obtained comparing the cleft side with the non-cleft sides, including bilateral nostril height, nostril width, height-to-width ratio, medial dome height, nasal sill height, nostril area, nasolabial angle and nostril axis.

RESULTS

All the patients benefitted from primary correction of their incomplete cleft lip and nasal deformities. In addition, Group III patients achieved superior results over Groups I and II in terms of nostril height ratio and nostril axis (p<0.005).

CONCLUSION

Primary correction of the nasal deformity is an important component of surgery at the time of lip correction. Our results indicated that a semi-open rhinoplasty technique accompanied by the Tajima incision provides the best overall nasal symmetry.

Nasal changes after presurgical nasoalveolar molding (PNAM) in the unilateral cleft lip nose

PURPOSE

Nasal reconstruction for patients with unilateral cleft lip and palate (UCLP) is a challenge for the reconstructive surgeon. Presurgical nasoalveolar molding (PNAM) was introduced to reshape the cleft nasal structures prior to lip repair. This study analyzed two-dimensional nasal changes before and after PNAM in patients with complete UCLP.

METHODS

Thirty UCLP patients (19 males; 11 females) who received PNAM before lip repair were included in this study. PNAM was applied for 100 days. Nasal casts were obtained before and after PNAM. Frontal and 45° standardized digital photographs were taken from all casts, and a photogrammetric analysis (16 linear, six angular, and two area measurements) was performed. Paired Student's t tests were used to search for differences by time, and time versus side (cleft versus noncleft).

RESULTS

Significant reduction of cleft columella deviation with an increase in columella length, nostril height, and axial inclination on the cleft side were recorded. This resulted in an increase in the projection of the nasal tip. The noncleft measurements remained without significant changes. The cleft nostril area increased significantly more than the noncleft side by 90% with PNAM treatment. Significant normal growth changes were observed in nasal width and nasal height.

CONCLUSION

A favorable reshaping of the nose after PNAM was achieved, resulting in an improvement in form before lip surgery. These changes lead to improved nasal symmetry before primary lip and nasal reconstruction in UCLP patients.

Primary unilateral cleft lip repair

The unilateral cleft lip is a complex deformity. Surgical correction has evolved from a straight repair through triangular and quadrilateral repairs to the Rotation Advancement Technique of Millard. The latter is the technique followed at our centre for all unilateral cleft lip patients. We operate on these at five to six months of age, do not use pre-surgical orthodontics, and follow a protocol to produce a notch-free vermillion. This is easy to follow even for trainees. We also perform closed alar dissection and extensive primary septoplasty in all these patients. This has improved the overall result and has no long-term deleterious effect on the growth of the nose or of the maxilla. Other refinements have been used for prevention of a high-riding nostril, and correction of the vestibular web.

Long-term evaluation of elongating columella using conchal composite graft in bilateral secondary cleft lip and nose deformity

BACKGROUND

A short columella is one of the most severe problems in bilateral cleft lip and nose deformity. In particular, with tissue insufficiency or scar contracture on the upper lip, it is very hard to achieve a good nasal profile with conventional methods.

METHODS

One hundred thirty-seven patients with a short columella were operated on from February of 1987 to December of 2008. The average age at operation was 7.3 years. The conchal cartilage was harvested. The preauricular or postauricular skin-subcutaneous fat composite tissue was harvested. Through a transcolumellar incision, the conchal cartilage was inset and the defect was covered with skin-fat composite tissue. The serial nasal profiles were evaluated before and after surgery. Also, the postoperative nasal profiles were compared with normal profiles. The postoperative color difference with surrounding skin was measured by the L*a*b* photographic analysis method.

RESULTS

The mean height and width of skin-subcutaneous fat composite tissue were 9.81 and 22.14 mm, respectively. The preoperative and postoperative measuring for columella height was 5.1 + or - 1.1 mm and 14.2 + or - 1.5 mm. The columella-lip angle was 120.30 + or - 12.97 preoperatively degrees and 98.76 + or - 10.98 degrees postoperatively, whereas the angle of columellar-alar triangle was 111.56 + or - 11.39 degrees and 97.91 + or - 11.49 degrees, respectively. None of the postoperative profiles were different from those of normal Korean people of the same age except in the 0- to 6-year-old group (p < 0.05). The color match was best with preauricular composite tissue. Complications included total necrosis in three cases and partial necrosis in 12 cases that were treated conservatively.

CONCLUSION

Elongating columella using a composite graft can be a satisfying alternative, especially for a severe short columella with upper lip tissue deficiency.

Subnasale flap for correction of columella base deviation in secondary unilateral cleft lip nasal deformity

OBJECTIVE

To present the effects of subnasale (SN) flap on the correction of deviated columella base in patients with secondary unilateral cleft lip nasal (UCLN) deformity.

PATIENTS AND METHODS

The patients were 6 adult Koreans with cleft cases (mean age, 29.1 y; range, 20-43 y; 1 man and 5 women; secondary UCLN deformity with columella base deviation). After the open rhinoplasty with the Padovan incision had been completed for correction of the secondary UCLN deformity, the SN flap was used for correction of the deviated columella base. The design of the SN flap started from the central portion of the SN region that will be the reconstructed columella and extended to the nasal floor in the larger nostril site. Then, the SN flap was transposed into the smaller nostril site. The columella skin was also elevated and placed into the larger nostril site with the distal end inserting into the donor site. The patients' follow-up period was 16 to 40 months.

RESULTS

The SN flap after the open rhinoplasty with the Padovan incision resulted in minimal scarring on the donor and recipient sites. The deviated columella base was straightened in all cases. During the surgical follow-up period, there was no recurrence of the columella base deviation in any patient and no other noteworthy complications were found.

CONCLUSIONS

For correction of the columella base deviation in patients with secondary UCLN deformity, the SN flap can be a viable treatment option.

A novel cleft rhinoplasty procedure combining an open rhinoplasty with the Dibbell and Tajima techniques: a 10-year review

BACKGROUND

The authors assessed the safety and efficacy of a novel cleft rhinoplasty procedure that combines an open rhinoplasty with the Dibbell and Tajima techniques.

METHODS

A single-surgeon, 10-year, retrospective review was conducted of all unilateral cleft lip rhinoplasties (n = 157). Nonsyndromic patients undergoing a combined open incision/Dibbell/Tajima procedure and who had follow-up of greater than 8 months were included. Thirty-five patients were identified. Standardized patient photographs were studied in 18 patients who had both preoperative and 1-year postoperative photographs. Farkas normal values were applied to the medial canthal distance; from this value, metric measurements of changes in alar base width, columellar height, and nostril apex height were derived.

RESULTS

There were no complications secondary to skin envelope ischemia or cartilage graft infection. The revision rate was 11 percent for alar base position, 3 percent for depressed lower lateral cartilage, and 3 percent for nostril apex overhang. After the procedure, there was a statistically significant decrease in alar base width (19.9 mm versus 18.2 mm; p < 0.01) and an increase in columellar height (8.37 mm versus 9.59 mm; p = 0.02) and nostril apex height (4.70 mm versus 5.44 mm; p = 0.02) on the affected side. The differences in alar base width, columellar height, and nostril apex height between the affected and nonaffected sides all decreased significantly postoperatively.

CONCLUSIONS

The combined open rhinoplasty/Dibbell/Tajima procedure is safe, has a low revision rate, and is associated with a statistically significant decrease in alar base width, an increase in columellar height and nostril apex height, and a greater symmetry of nasal form.

Postoperative nasal forms after presurgical nasoalveolar molding followed by medial-upward advancement of nasolabial components with vestibular expansion for children with unilateral complete cleft lip and palate

PURPOSE

The management for primary unilateral cleft lip nose deformities has not yet been established. In this study, short-term postoperative nasal forms after presurgical nasoalveolar molding (NAM) followed by primary lip repair for children with complete unilateral cleft lip and palate (UCLP) were evaluated and compared with the nasal forms achieved by treatment without nose correction.

PATIENTS AND METHODS

Fifteen patients with complete UCLP who were treated in our department and followed up for more than 1 year (range 1 to 5 yrs) were enrolled. All subjects underwent presurgical orthopedic treatment with NAM, followed by lip repair using Cronin's triangular flap method with medial-upward advancement of nasolabial components with vestibular expansion. Postoperative nasal forms including nostril height and width ratio, ratio of the height of the top of the alar groove, and curvature of the appropriate circle of the nasal ala were evaluated using color photographs. Fifteen patients with complete UCLP who underwent presurgical orthopedic treatment using a Hotz plate followed by lip repair without nose correction served as controls.

RESULTS

The comparison of postoperative nasal forms demonstrated that the nostril height and width ratio and the height of the top of the alar groove in the correction group were significantly superior compared with those of the controls.

CONCLUSIONS

Our management of cleft lip nose will provide good nasal forms with minimum invasion in patients with UCLP. Long-term follow-up will be necessary to clarify effects on the growth of nasal tissues reconstructed in infancy.

Nasoalveolar molding improves long-term nasal symmetry in complete unilateral cleft lip-cleft palate patients

BACKGROUND

Nasoalveolar molding was developed to improve dentoalveolar, septal, and lower lateral cartilage position before cleft lip repair. Previous studies have documented the long-term maintenance of columella length and nasal dome form and projection. The purpose of the present study was to determine the effect of presurgical nasoalveolar molding on long-term unilateral complete cleft nasal symmetry.

METHODS

A retrospective review of 25 consecutively presenting nonsyndromic complete unilateral cleft lip-cleft palate patients was conducted. Fifteen patients were treated with presurgical nasoalveolar molding for 3 months before surgical correction, and 10 patients were treated by surgical correction alone. The average age at the time of follow-up was 9 years. Four nasal anthropometric distances and two angular relationships were measured to assess nasal symmetry.

RESULTS

All six measurements demonstrated a greater degree of nasal symmetry in nasoalveolar molding patients compared with the patients treated with surgery alone. Five symmetry measurements were significantly more symmetric in the nasoalveolar molding patients and one measurement demonstrated a nonsignificant but greater degree of symmetry compared with the patients treated with surgery alone.

CONCLUSIONS

The data demonstrate that the lower lateral and septal cartilages are more symmetric in the nasoalveolar molding patients compared with the surgery-alone patients. Furthermore, the improved symmetry observed in nasoalveolar molding-treated noses during the time of the primary surgery is maintained at 9 years of age.

Primary simultaneous lip and nose repair in the unilateral cleft lip and palate

BACKGROUND

"Do not touch the nose in primary repair of the unilateral cleft lip and palate!" In the past, this dogmatic attitude caused functional and aesthetic (psychological) problems for the child until secondary corrections during adolescence were performed. In the 1950s, surgeons started to correct at least a few features of the nasal deformity and to develop radically corrective measures. Since 1970, a new and very comprehensive concept of correction has been used at the authors' department of plastic and reconstructive surgery.

METHODS

Methods of primary nasal repair by various surgeons are presented chronologically. The main features of the authors' strategy are special incision lines, extensive mobilization of all dislocated structures, straightening of the deviated septum, correction of the deformed ala and nasal tip, induction of bone growth in hypoplastic areas under the alar base and along the piriform aperture, and a special suture technique of the orbicularis muscle to form a better philtrum.

RESULTS

Improvement of the aesthetic and functional results can be achieved with this type of nasal repair. Since 1970, approximately 500 patients have been operated on with this method at the authors' hospital and elsewhere, with 80 percent showing satisfactory results and 20 percent revealing deficiencies. Severe nasal deformities, which were common when no primary repair was applied, were not observed. This observation period provides evidence that no growth retardation occurs.

CONCLUSIONS

Because of the good results of this method and the lack of growth retardation, this approach is to be recommended. It also benefits children in underdeveloped countries, where frequent surgery is not possible.

Methods of assessment of cleft-related facial deformity: a review

OBJECTIVE

To review the stimulus media, measurements and scoring system, rater's characteristics, and facial region used in assessment of the appearance of cleft-related deformity.

METHODS

A review of the literature was conducted using MedLine from January 1966 to June 2003. Key orthodontic journals and The Cleft Palate-Craniofacial Journal were hand searched as well.

RESULTS

Most studies used a static two-dimensional means of assessment. Direct clinical assessment, three-dimensional media, or both have been used to a lesser extent. Only one study utilized all three assessment media. Three studies, however, attempted to compare the direct clinical assessment with that obtained using two-dimensional media. Most of the studies demonstrated that appearance of the cleft-related deformity could be measured by a variety of judges. The reliability and validity of the three different media as methods of assessment have received limited attention. The facial area assessed has varied from the full face, nasolabial area, or specific features of the lip or nose.

CONCLUSIONS

Wide variation exists in the study design related to assessment of cleft-related deformity. An internationally agreed objective method of assessment for this facial deformity is required. A three-dimensional, rather than a two-dimensional, means of assessment should be adopted.

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

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

Unilateral cleft lip-nose repair--long-term outcome

Good to excellent results have consistently been achieved by the authors in primary unilateral cleft lip-nose repair. Modifications and improvements in their original technique have led to better symmetry and balance, with less scarring. This technique, when performed by experienced surgeons, yields consistent, predictable, and achievable outcomes for all patients with unilateral cleft lip and nose, where normal appearance and function at conversational distance is the standard of care. The achievement of excellence in soft tissue and skeletal restoration optimizing each patient's growth potential depends on a surgical-orthodontic-speech-oriented treatment plan. Long-term outcomes demonstrating consistently good to excellent results can be achieved using this primary technique if it is backed up with a dedicated, multidisciplinary ongoing treatment protocol.

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.

Resorbable internal splint: an adjunct to primary correction of unilateral cleft lip-nasal deformity

There is usually some relapse in position of the alar cartilage after primary repair of unilateral cleft lip. Therefore, preoperative or postoperative external splinting has been recommended to supplement either closed or open suspension of the alar cartilage. The authors present a method using a resorbable internal nostril splint to shield the positioned alar cartilage from deformational forces caused by scar, and thus avoiding the problems associated with external splinting. An internal nasal splint was placed in 15 infants during repair of unilateral complete cleft lip and nasal deformity. The nasal morphology was compared with that of 15 control patients who had the same nasolabial procedure without internal splinting. Average follow-up time was 20.4 months (range, 4 to 30 months). Photogrammetric analysis showed that asymmetry of the alar contours averaged 8.6 percent in the splinted patients, as compared with 23 percent for controls (p <0.01). Thus, alar asymmetry was decreased two-thirds in the splinted group. An internal resorbable nasal splint is an adjunct to open alar suspension in primary repair of the unilateral cleft lip nasal deformity. An internal nasal splint protects the corrected alar cartilage longer than an external splint and eliminates drawbacks, such as necrosis, cutaneous depression of the nostril sill, and patient noncompliance. This strategy of temporary internal support of healing cartilage has other applications.

Nasal morphology and shape parameters as predictors of nasal esthetics in individuals with complete unilateral cleft lip and palate

OBJECTIVE

The purpose of this study was to assess the ability of shape parameters of nasal morphology to predict esthetics in individuals with complete unilateral cleft lip and palate (CUCLP).

METHODS

This retrospective study involved 28 patients with repaired CUCLP. Nostril morphology was analyzed using nose casts and a video-imaging technique. Calculated shape parameters included area, perimeter, centroid, angle of the principal axis, major and minor moments of area, anisometry, bulkiness, lateral offset, and three-dimensional internostril angles. Esthetics was assessed using a panel of six orthodontists who rated nasal esthetics from frontal, lateral, basal, and three-quarters view slides and from nose casts. Correlations between esthetics and the shape parameters were completed using the entire group as well as using two statistically determined subsets: those with the best and those with the worst esthetics.

RESULTS

Nasal esthetics was related to only the perimeter and bulkiness parameter ratios. Symmetry of the perimeters between the right and left nostrils positively correlated with better esthetics using the entire sample group while symmetry of bulkiness between the right and left nostrils positively correlated with better esthetics using both the entire sample group and the best and worst subsets.

CONCLUSIONS

Only perimeter and bulkiness showed positive correlations with nasal esthetics. The group of parameters used to assess nostril morphology had neither significant correlation with-nor predictive power for-esthetics. Thus, an assessment of the entire nasal surface topography in three dimensions needs to be completed and assessed with respect to predictability of nasal esthetics.

Unilateral cleft lip repair--state of the art

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

Cleft lip nose correction with onlay calvarial bone graft and suture suspension in Oriental patients

To correct the secondary cleft lip nose deformity in Oriental patients, many alar cartilage mobilization and suspension techniques have been developed. However, these techniques have critical limitations. One of the limitations is the suspension vector, and another is suspension power. The suspension vector is from inferior to superior and from the deformed alar cartilage to the normal alar cartilage. Thus, the vector is not suitable for normal nasal tip projection. The suspension power is not satisfactory because Oriental people have underdeveloped, thin alar cartilages and thick skin. So, the suspended, deformed alar cartilage may relapse and pull the normal alar cartilage to the deformed side. To overcome these limitations, the authors use the cantilever calvarial bone graft for tip projection; it also serves as a strong, rigid framework for cartilage and soft-tissue suspension. Using these techniques, the authors can create normal nasal tip projection and a normal looking nasal aperture.

Spiradenoma arising in a nevus sebaceus of Jadassohn: case report and literature review

Nevus sebaceus (NS) of Jadassohn is usually a verrucous plaque on the scalp or face that arises secondary to disordered development of epithelial, pilar, sebaceous, and apocrine structures. The emergence of neoplasia is a late stage in the natural history of NS. Although most neoplastic proliferations are benign, several malignant tumors have arisen in this lesion. We describe the first case of a benign spiradenoma arising in an NS on the scalp in a 72-year-old Caucasian woman. Reexcision was recommended to prevent the development of a second neoplastic process and to avoid the rare occurrence of a malignant transformation of the existing neoplasia. The patient declined reexcision and remains under observation. The spectrum of tumors arising in NS are described and are categorized according to behavior. Syringocystadenoma papilliferum is the most commonly observed benign growth, whereas basal cell carcinoma is the most frequently seen malignant process. The signs of tumor development (benign or malignant) within an NS are reviewed, and treatment recommendations are provided. The clinical course of rare and unique aggressive neoplasms originating in NS is summarized.

Long-term effects of nasoalveolar molding on three-dimensional nasal shape in unilateral clefts

OBJECTIVE

This objective of this study was to determine the effect of presurgical nasoalveolar molding on long-term nasal shape in complete unilateral clefts.

DESIGN

The study was retrospective, and the subjects were chosen at random. Nasal casts of the subjects were scanned in three dimensions. Each nose was best fit to its mirror image, and a numerical asymmetry score was determined.

SETTING

All patients were treated at the Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, New York.

PATIENTS

The study subjects (n = 10) were selected from a group that had undergone presurgical nasal molding in conjunction with alveolar molding. The control subjects (n = 10) were selected from a group that had undergone presurgical alveolar molding alone.

INTERVENTIONS

All subjects underwent presurgical orthopedic treatment until the age of approximately 4 months at which time the primary surgery was performed.

MAIN OUTCOME MEASURE

The nasal shape following nasal molding should be more symmetrical than if molding had not been done.

RESULTS

The mean asymmetry index for the nasoalveolar molding group was 0.74, and the control group was 1.21. This difference was statistically significant (p < .05).

CONCLUSIONS

Presurgical nasoalveolar molding significantly increases the symmetry of the nose. The increase in symmetry is maintained long term into early childhood. The limitations of this study include (1) asymmetry alone is not an adequate shape result in most situations, (2) the children evaluated in this study were not fully grown, and (3) the control group was not age matched.

Evaluation of the results of delayed rhinoplasty in cleft lip and palate patients. Functional and aesthetic implications and factors that affect successful nasal repair

Patients born with cleft lip and palate (CLP) present with a variety of nasal deformities. These are either congenital or iatrogenic. Our aim was to establish a correlation between aesthetic and functional nasal impairments in patients with CLP whose nasal reconstruction had been delayed. Fifty-four randomly selected patients with CLP deformities, all of whom had delayed nasal repairs were evaluated objectively, aesthetically in three planes, and functionally for symptoms of nasal obstruction, chronic maxillary sinusitis, and olfactory disturbances. Aesthetically the patients were analysed from 1:1 life-size full face, profile, and submental-vertex photographs, and full skull cephalograms. Nasal patency was assessed by rhinomanometry. The presence of chronic maxillary sinusitis and olfactory disturbances were deduced from the history. The degree of nasal dismorphism correlated with the severity of nasal functional impairments. Delayed nasal repairs in patients with CLP did not produce satisfactory aesthetic or functional results, probably because growth was retarded and midfacial development was disturbed at the time of delayed rhinoplasty and resulted in asymmetry. In CLP the nose should be repaired during the early primary cheilorhinoplasty, as this is essential for the restoration of a normally functioning and aesthetically pleasing nose.

Function of the nasal muscles in normal subjects assessed by dynamic MRI and EMG: its relevance to rhinoplasty surgery

The external nose is generally considered to have a relatively static shape. Movement of the nose and the potential for change of external shape and the internal airway have been assessed by (1) cadaver dissection and (2) dynamic studies during a standardized series of facial expressions in 13 subjects; video recording of the movement of skin markers, electromyography, and moving magnetic resonance images. A standard description of muscle anatomy is presented. The dynamic investigations indicated the following. Video analysis showed the components of muscle action: dilatation, constriction of the nostril, depression of the tip, vertical contraction in the bridge, and elevation of the alar, in different expressions. Electromyography confirmed muscle actions during expression and phonation. Magnetic resonance imaging demonstrated large changes in the external shape of the nose and nasal aperture due to muscle actions. Muscle function should be given greater consideration in aesthetic and cleft rhinoplasty.

Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair

We present a new combined approach to primary bilateral cleft lip, nose, and alveolus repair using presurgical nasoalveolar molding combined with a one-stage lip, nose, and alveolus repair. Presurgical alveolar molding is used to bring the protruding premaxilla back into proper alignment with the lateral segments in the maxillary arch. Presurgical nasal molding produces tissue expansion of the short columella and nasal lining. A coordinated surgical approach involves a one-stage repair of the lip, nose, and alveolus. The nasal repair uses a retrograde approach in which the prolabial flap and columella are reflected over the nasal dorsum by continuing the dissection behind the prolabium up the membranous septum and over the septal angle. Tissues are dissected out from between the tip cartilages, and the domes are sutured together in the midline. This method joins a new class of bilateral cleft repairs that place the primary emphasis on correction of the deformity of the nasal tip cartilages.

Objective evaluation of the Tajima secondary cleft lip nose correction

The early and late results of the Tajima cleft nose correction were objectively measured by computer on 24 unilateral complete cleft lip and palate patients (age range 5-29 years, median 14). Follow-up records were divided into early (within 3 months), intermediate (3 months to 1 year) and late (1 year+); the longest follow-up was 4.2 years. Comparison of the preoperative records with the early and intermediate follow-up photographs showed an improvement in symmetry (Wilcoxon signed rank, P < 0.01). In the late follow-up group the deformity recurred and the nasal shape could not be statistically separated from the preoperative appearance. A group of 25 normal control faces showed no changes, whilst 20 control cleft patients had some worsening of nasal symmetry over the same time scale. Analysis of the components of the corrected noses showed the best improvement (and later relapse) was in dome symmetry.

Functional primary closure of cleft lip

A technique of primary closure of the cleft lip is described. It is based on a complete understanding of the anatomy of the entire facial musculature such that it can be restored to normality and so encourage normal function and development.