Development of the cleft lip nose

Comparison of Cleft Lip Nasal Deformities Between Lesser-Form and Incomplete Cleft Lips: Implication for Primary Rhinoplasty

OBJECTIVE

This study investigated various manifestations of nasal deformities in lesser-form cleft lips, including the minor-form, microform, and mini-microform, by photogrammetric comparison with incomplete cleft lips.

DESIGN

Retrospective study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A total of 160 patients with unrepaired unilateral incomplete cleft lips ranging from lesser-form to two-thirds way clefts.

MAIN OUTCOME MEASURES

The severity of nasal deformities was assessed by photogrammetric measurements of linear and angular variables. The symmetry ratio between the cleft and non-cleft sides was obtained by measuring various nasal parameters and comparing them among the different labial cleft groups.

RESULTS

The degree of nasal deformities increased with the extent of labial clefts among the 3 labial cleft groups (lesser-form, halfway, and two-thirds way clefts) in terms of alar base width ratio (1.102, 1.197, 1.309; P < .05), nostril width ratio (1.287, 1.387, 1.551; P < .05), and columellar angle (11.5, 14.45, 18.197; P < .05). Each parameter indicated lesser-form, halfway, and two-thirds way clefts, respectively. However, only the lateral lip height ratio (0.942, 0.851, 0.87; P < .05) and nostril width ratio (1.207, 1.35, 1.29; P < .05) significantly differed among the 3 subgroups. Each parameter indicated mini-microform, microform, and minor-form, respectively.

CONCLUSIONS

The cleft nasal deformities in lesser-form cleft lip present comparable severities among its subtypes, which implies that the extent of the labial cleft is not correlated with nasal deformities. Each nose in the lesser form cleft should be individually assessed for primary rhinoplasty and requires tailored correction.

Subphenotyping and Classification of Cleft Lip and Alveolus in Adult Unoperated Patients: A New Embryological Approach

OBJECTIVE

Previously, a new embryological classification was introduced subdividing oral clefts into fusion and/or differentiation defects. This subdivision was used to classify all subphenotypes of cleft lip with or without alveolus (CL±A). Subsequently, it was investigated whether further morphological grading of incomplete CLs is clinically relevant, and which alveolar part is deficient in fusion/differentiation defects.

DESIGN

Observational cohort study.

SETTING

Three hundred fifty adult unoperated Indonesian cleft patients presented themselves for operation. Cephalograms, dental casts, and intraoral and extraoral photographs-eligible for the present study-were used to determine morphological severity of CL±A.

PATIENTS

Patients with unilateral or bilateral clefts of the primary palate only were included.

MAIN OUTCOME MEASURES

Clefts were classified-according to developmental mechanisms and timing in embryogenesis-as fusion and/or differentiation defects. Grades of incomplete CLs were related to the severity of alveolar clefts (CAs) and hypoplasia, and permanent dentition was used to investigate which alveolar part is deficient in fusion/differentiation defects.

RESULTS

One hundred eight adult patients were included. All subphenotypes-96 unilateral and 12 bilateral clefts-could be classified into differentiation (79%), fusion (17%), fusion-differentiation (2%), or fusion and differentiation (2%) defects. The various grades of incomplete CLs were related to associated CAs and hypoplasia, and all alveolar deformities were located in the premaxillae.

CONCLUSIONS

This study showed that all CL±A including the Simonart bands can be classified, that further morphological grading of incomplete CLs is clinically relevant, and that the premaxilla forms the deficient part in alveolar deformities.

Congenital Midline Sinus of the Upper Lip

An extremely rare patient of congenital midline sinus of the upper lip in a 2-year-old boy is presented. The sinus was located on the midline of the philtrum just below the base of the columella. Surgical removal of the sinus was performed via an extra- and inraoral approach. Histopathological examination of the resected sinus revealed it to be lined by keratinized stratified squamous epithelium with sebaceous glands and hair follicles. Three postulates can account for the formation of the congenital midline sinus of the upper lip: the fusion theory, the merging theory, and the invagination theory. However, the etiology of this rare abnormality remains obscure.

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 comparative study of the medial crura of alar cartilages in unilateral secondary cleft nasal deformity: the validity of medial crus elevation

The purpose of this study was to confirm whether the medial crus on the cleft side is primarily hypoplastic compared with the noncleft side and to evaluate the displacement of the medial crus on the cleft side presenting the validity of the "medial crus elevation" method. Thirty unilateral cleft lip nasal deformity patients underwent medial crus elevation. The thickness, width, and length of the medial crus on both sides were measured. The difference in the height of both foot plates was also measured. There were no significant differences between the cleft and noncleft sides in width, thickness, or length except proximal thickness. The foot plate on the cleft side was displaced downward. The medial crus on the cleft side is not hypoplastic, and it is merely displaced downward. These results show the validity of the medial crus elevation method for the correction of secondary nasal deformities in cleft patients.

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.

Histological comparison of the alar nasal cartilages in unilateral cleft lip

Patients with unilateral cleft lip display characteristic nasal changes that are independent of the degree of deformity. Defenders of the intrinsic theory consider these deformities to be due to embryogenic alterations of the alar nasal cartilages. Those that propose the extrinsic theory defend the thesis that the deformity is due to disorganization of the perioral muscles deformed by the cleft. The purpose of this study is to contribute histological evidence to help clarify the issue.

PATIENTS AND METHODS

Specimens of the lateral portion of both the healthy and the cleft side of the alar cartilages were obtained from 18 patients. These uniformly cut specimens were stained by hematoxylin and eosin. Samples from 2 patients were excluded due to imperfections. The same pathologist examined all the slides. He was unaware of the origins of the specimens; he counted the number of chondrocytes and quantified the cartilage matrixes.

RESULTS

All data was analyzed statistically, and no significant statistical differences were apparent, either in the number of chondrocytes or the cartilage matrix between the healthy side and the cleft side.

DISCUSSION

These results apparently support the group that defend the extrinsic theory; nevertheless, the doubt about the composition of the cartilage matrix remains, not only concerning the glycosaminoglycans that compose them, but also regarding elastin and collagen and its linkages that can cause different degrees of collagen consistency.

A comparative study of the lateral crus of alar cartilages in unilateral cleft lip nasal deformity

To confirm whether or not the alar cartilage of the unilateral cleft lip nose is primarily hypoplastic as compared with the noncleft side, 35 unilateral cleft lip nasal patients who had no previous nasal surgery underwent direct measurement of the lateral crus of alar cartilage on both sides during their nasal tip plasties. Both lower lateral cartilages were dissected freely, and the thickness was measured at the intercrural, middle, and distal portions. The width was measured at the widest portion, and the length was measured from the intercrural point to the distal end. Two-mm-punch biopsies were obtained from each cartilage for histologic study. The lateral crus of the cleft side was no smaller than that of the noncleft side. Histologically, no difference was ascertained. In conclusion, we think the lateral crus of the alar cartilage of the cleft side is not hypoplastic. Therefore, external factors such as soft-tissue defect or external abnormal vector force are more attributable than intrinsic factors to the development of cleft lip nasal deformity.

Pierre Robin syndrome: characteristics of hearing loss, effect of age on hearing level and possibilities in therapy planning

Hearing loss was studied in 22 patients with Pierre Robin syndrome (PRS) aged three to 12 years (median 5.0 years). The results were compared to those obtained in 62 patients with isolated cleft palate (ICP) aged one to 27 years (median 5.5 years). Hearing loss was more frequently found in PRS (73.3 per cent) than in ICP (58.1 per cent) patients (p = 0.02). PRS patients had more ears with moderate (21-40 dB) and severe (> 40 dB) hearing loss, disturbing their social contact, with no tendency to normalization with age (Spearman r = 0.065). In contrast to PRS, ICP patients showed a significant tendency to hearing level normalization with ageing (Spearman r = -0.453; p = 0.001). Planigraphs of temporal bones showed inadequately developed pneumatization of the mastoid bone in all PRS patients and in most ICP patients. No malformation of the inner or middle ear was found in either group. PRS patients have a significantly higher risk of conductive hearing loss than those with ICP. Use of tympanostomy (ventilation) tubes is therapy of choice in patients with Pierre Robin syndrome, and it should be introduced as early as possible, even at the same time as palatoplasty.

The embryological, developmental and functional importance in the repair of the nasal musculature to reduce the deformity of the cleft lip nose

The latent ability of nasal growth to correct developmental deformities when caused by a deforming force has been shown in nasal dermoids where early surgery by removing the deforming elements allows subsequent growth of the nasal bones and cartilages to correct the abnormality. An embryological study into the nasal musculature has shown both an orbicularis and dilator system to be present. The correction of the abnormal musculature in the cleft lip nose by removing the deforming connections and realigning the muscles allows subsequent growth the possibility of producing normal development. Primary surgery in the cleft lip nose has not shown any detrimental growth patterns and correction of the nasal musculature should therefore be carried out at the time of the primary lip correction.