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

Characterizing Cleft Rhinoplasty Across Skeletal Maturity: A Systematic Review of Terminology and Surgical Techniques

OBJECTIVE

The purpose of this study is to assess cleft rhinoplasty terminology across phases of growth.

DESIGN/SETTING

A systematic review was performed on cleft rhinoplasty publications over 20 years.

INTERVENTIONS

Studies were categorized by age at surgical intervention: infant (<1 year); immature (1 to 14 years); mature (>15 years).

MAIN OUTCOME MEASURES

Collected data included terminology used and surgical techniques.

RESULTS

The 288 studies included demonstrated a wide range of terminology. In the infant group, 51/54 studies used the term "primary." In the immature group, 7/18 studies used the term "primary," 3/18 used "secondary." In the mature group, 2/33 studies used the term "primary," 16/33 used "secondary," 2/33 used "definitive," 5/33 used terms such as "mature," "adult," and "late," and 8/33 did not use terminology.

SURGICAL TECHNIQUE ASSESSMENT DEMONSTRATED

cleft rhinoplasty at infancy used nostril rim or no nasal incision, immature rhinoplasty used closed and open rhinoplasty incisions; and mature rhinoplasty used a majority of open rhinoplasty. Infant and immature cleft rhinoplasty incorporated septal harvest or spur removal in <10% of cases, whereas these procedures were common in mature rhinoplasty. No studies in infants or immature patients used osteotomies or septal grafts, common techniques in mature rhinoplasty.

CONCLUSIONS

Current terminology for cleft rhinoplasty is varied and inconsistently applied across stages of facial development. However, cleft rhinoplasty performed at infancy, childhood, and facial maturity are surgically distinct procedures. The authors recommend the terminology "infant," "immature," and "mature" cleft rhinoplasty to accurately describe this procedure within the context of skeletal growth.

Septoplasty During Primary Cleft Lip Reconstruction: A Historical Perspective and Scoping Review

BACKGROUND

Traditional surgical approaches excluded septoplasty at primary cleft lip reconstruction due to concerns about restricted nasal and midfacial growth. Modern opinion in the treatment of cleft lip has increasingly employed primary septoplasty; this scoping review and historical perspective aims to chronicle the evolution of septoplasty in patients born with cleft lip and palate and discuss current evidence.

METHODS

The historical perspective explicitly contrasts American and European perceptions of septoplasty in cleft lip deformity and the competing anatomical theories of the role of the septum on midfacial and nasal growth. For the scoping review, articles were extracted from Embase, PubMed, and Medline, as well as manual searches of reference lists. Results were compiled, grouped, and appraised by date, outcomes, and historical significance. Inclusion criteria consisted of children who underwent primary septoplasty for any indication and were followed up on outcomes of facial growth and nasal function. Literature reviews, opinion articles, case reports, guidelines, or studies not available in English or online were excluded.

RESULTS

Evolving anatomical theories relating to midfacial growth in the mid-late 20th century underpinned a progressive ideological shift on the safety and efficacy of septoplasty in children. This is supported by our scoping review, which included 23 articles mutually selected for inclusion by 2 blinded assessors. Several competing methods have been employed to measure endpoints on facial growth and nasal function, but generally indicate primary septoplasty is successful in improving nasal function and preserving midfacial growth.

CONCLUSION

Perceptions towards septoplasty on facial growth in the pediatric population have transformed significantly and suggest a growing acceptance of primary septoplasty techniques in patients born with a cleft lip.

"Primary Correction of the Cleft Nasal Septum: A Systematic Review"

Patients affected by cleft lip and palate have a characteristic nasal deformity; however, the treatment timeline varies amongst providers. There has been a shift from a more conservative approach to earlier intervention in order to allow for more normal development of the nose. Form, function, and future development all must be considered. For this reason, this investigation was undertaken to present the current literature available on the effects to all aspects of primary septoplasty in the cleft nasal deformity.

An initial list of 222 papers was identified, and it was determined that 16 papers fit the inclusion criteria. Studies were included in which the initial age of operation for the majority of patients was between 3 and 12 months and in which patients underwent septal repositioning at the time of cleft lip repair. These papers were all reviewed by a single author initially, and the results recorded. All results were then verified by a second author for accuracy and completeness.

Symmetry was found to be improved by primary septoplasty. Growth was not found to be impaired in any study; data was insufficient to indicate that growth was improved. Obstruction was improved as determined both by imaging, endoscopy, and patient survey. Finally, reoperation rates occurred at an acceptable rate not exceeding that of primary rhinoplasty without septoplasty.

Primary septoplasty leads to better aesthetic symmetry and function of the cleft nose without impairing growth. This change is maintained into adulthood often without the need for revisionary surgery.

Novel classification system for adult Asian secondary bilateral cleft lip with nasal deformity that guides surgical strategy

BACKGROUND

Bilateral cleft lip is a congenital defect often accompanied by secondary lip and nose deformity. The current classification system for secondary cleft lip deformity has limitations in guiding surgical planning. In this article, we report a method for secondary bilateral cleft lip classification that can guide surgery on the basis of the pathological anatomy of the columellar and upper lip.

METHODS

Photographs of patients were retrospectively classified into four types on the basis of the ratio of columellar height to alar base width (CH/AW) and upper lip protrusion (UP) to lower lip, as follows: type I - with CH/AW ≥ 0.2 and UP ≥ 0; type II - with CH/AW ≥ 0.2 and UP <0; type III - with CH/AW < 0.2 and UP ≥0; type IV - with CH/AW < 0.2 and UP < 0. Surgical treatments and the change of the nasal profile were documented.

RESULTS

A total of 105 patients from January 2008 to December 2018 were included in this study. The nasal profile was significantly improved in type III and IV patients with postoperative CH/AW values close to normal. The upper lip was distinctively retruded in type II and IV patients before treatment, and the postoperative view revealed improved upper lip protrusion with UP values close to normal. Ninety-eight patients reported satisfactory outcomes after treatment.

CONCLUSIONS

The new classification method described provides key information regarding the deformity of different types of secondary bilateral cleft lip patients and provides clear guidance for surgical planning on the basis of the anatomical defect of each type.

The Burden of Care of Nasoalveolar Molding: An Institutional Experience

Nasoalveolar molding (NAM) is an early presurgical intervention to facilitate primary cleft lip repair by reducing cleft severity and improving labial and nasal form. However, it continues to be associated with the burden of care that influences access and completion of therapy. The authors, therefore, aim to determine the burden of care of NAM therapy for families seeking treatment at a high-volume urban cleft center. A retrospective study of all patients undergoing primary cleft repair between 2012 and 2020 was performed. Patients were grouped based on whether or not NAM therapy was offered. Variables including physical, psychosocial, and financial factors were assessed. Two hundred and thirty patients underwent primary cleft repair between 2012 and 2020. Of these, 176 patients were indicated for NAM, with 4% discontinuing, and 54 patients did not undergo NAM. The 169 patients who completed NAM had a mean duration of treatment of 13.6±8.8 wks consisting of 15±6 scheduled NAM adjustment visits and 1±1 unscheduled visit made urgently to assess caregiver concerns. The mean travel distance was 28.6±37.1 miles. Eighty-four percent of caregivers were married, and 16% did not have English as a primary language. Though 57% had private insurance, 43% of patients received charity support for their treatment. NAM is a finite presurgical intervention that requires caregivers to participate in patient care for approximately three months of their early life. The decision to pursue NAM should be considered alongside the burden of care for caregivers to complete treatment.

"Septoplasty" Performed at Primary Cleft Rhinoplasty: A Systematic Review of Techniques and Call for Accurate Terminology

OBJECTIVE

Primary cleft nasal repair can include septal reconstruction. We hypothesize that primary cleft septoplasty and adult septoplasty have fundamental differences that render these procedures as distinct surgical entities.

DESIGN

Systematic review of the PubMed, Cochrane, and Embase databases performed on pediatric cleft and general adult septoplasty techniques through December 2021. (PROSPERO ID CRD42022295763).

MAIN OUTCOME MEASURES

Collected data included information on septal dissection, septal detachment, and management of the bony and cartilaginous septum.

RESULTS

Twenty-eight pediatric cleft septoplasty and 229 adult septoplasty studies were included. Dissection in primary cleft septoplasty was limited to the anterocaudal septum, while secondary cleft septoplasty and adult septoplasty techniques entailed wide exposures of the cartilaginous septum with or without exposure of the perpendicular plate of the ethmoid. In primary cleft septoplasty, detachment of the septum was mostly limited to the nasal spine and anterior base of the cartilaginous septum, while secondary cleft septoplasty and adult septoplasty included detachment from the vomer, and ethmoid. In the few reports of cartilage excision during primary cleft septoplasty, removal was limited to the anterior inferior border of the septum, while secondary cleft septoplasty and adult septoplasty included excision of the cartilaginous and bony septum.

CONCLUSION

Primary cleft septoplasty is distinct from septoplasty performed on facially mature patients. More specifically, septal dissection and detachment are limited to the anterior caudal area during primary lip repair, with rare removal of cartilage or bone. Given these differences, the authors suggest the term "septal reset" to describe septoplasty performed during primary cleft nasal repair.

Utilization of images and three-dimensional custom-made nostril retainer fabricate for patients with cleft lip and cleft lip nose deformities at Siriraj Hospital: preliminary phase

A prospective study utilizing image analysis to assess nostril openings in post-operative patients with cleft lip and cleft lip nose deformities. This preliminary study seeks to employ two-dimensional (2D) images to fabricate a custom-made nostril retainer. This study was performed at Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand. This study included 30 healthy volunteers and 15 patients with cleft lip and cleft lip nose deformities. The nostril opening width and height for all participants were measured, and photographs were taken. An image analysis application was used to fabricate a three-dimensional (3D) custom-made nostril retainer. The mean differences between the direct measurements of the nostril aperture and the measurements obtained through the program did not exceed 2 mm in terms of nostril height, width, or columella. Two-dimensional photographs can be used to create a custom-made, three-dimensional nostril retainer. This retainer allows post-operative patients to maintain their nares without needing to visit the hospital, thereby reducing the cost of care.

Influence of the Number of Revision Surgeries and Nasal Symmetry After Final Rhinoplasty for Patients With Cleft Lip

The effects of operative intervention on vertical nasal growth in patients with unilateral cleft lips (CLs) are well described. However, the factors influencing nasal symmetry have not been sufficiently evaluated. Therefore, this study aimed to study the factors that cause difficulties in obtaining nasal symmetry postoperatively in patients with CLs. We conducted a retrospective analysis using data from patients with CLs who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on the patients' sex, cleft type, number and time of revision surgery, palatal fistula incidence, and history of the pharyngeal flap and orthognathic surgery. Nasal symmetry was analyzed as the symmetrical ratio after the final touch-up surgery, and multivariate analysis was conducted using binary logistic regression to determine the factors affecting nasal symmetry. This study included 89 patients with unilateral CL. Multivariate analysis revealed that complete cleft lip and palate ( P < 0.05, odds ratio = 4.37) and repeated revision surgery ( P < 0.05, odds ratio = 9.28) were significant predictors of the final nasal symmetry. Our study showed that cleft type and the number of revision surgeries were identified as important factors for obtaining nasal symmetry after final touch-up rhinoplasty. Revision surgery may be necessary to relieve patients' psychological stress due to nasal deformity, suggesting that this dilemma needs to be overcome.

Long-Term Outcome of Primary Rhinoplasty with Overcorrection in Patients with Unilateral Cleft Lip: Avoiding Intermediate Rhinoplasty

BACKGROUND

No consensus exists regarding the timing or technique of rhinoplasty for correction of the unilateral cleft lip nose deformity, with few studies examining the long-term effects of a single technique. This study appraised the long-term outcomes of primary rhinoplasty using the Tajima technique for overcorrection in a cohort of patients with unilateral cleft lip nose deformity after attaining skeletal maturity.

METHODS

Consecutive nonsyndromic patients with unilateral cleft lip nose deformity ( n = 103) who underwent primary rhinoplasty with overcorrection by a single surgeon between 2000 and 2005 were reviewed. Patients with unilateral cleft lip and nasal deformity who underwent primary rhinoplasty (but with no overcorrection) ( n = 30) and noncleft individuals ( n = 27) were recruited for comparison. Outcomes were assessed through FACE-Q scales evaluating satisfaction with appearance of nose and nostrils (two scales) and computer-based objective photogrammetric analysis of nasal symmetry (nostril height, nostril width, nostril area, alar height, and alar width parameters).

RESULTS

Significant differences (all P < 0.001) were observed between the Tajima and non-Tajima groups for all but one photogrammetric nasal parameter (nostril area), with the Tajima group demonstrating closer mean values to the noncleft group. The Tajima and noncleft groups demonstrated no significant difference (all P > 0.05) for scores of FACE-Q nose and nostrils scales.

CONCLUSION

This study indicated that the patients who underwent primary rhinoplasty with overcorrection had improved results with no necessity for intermediate rhinoplasty, emphasizing that the procedure is an effective approach to correct the unilateral cleft nose deformity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Primary Cleft Rhinoplasty: A Systematic Review of Results, Growth Restriction, and Avoiding Secondary Rhinoplasty

BACKGROUND

Primary rhinoplasty during correction of unilateral cleft lip continues to be a topic of debate because of concerns that early nasal intervention may affect nasal and maxillary development over the long term. This study aims to determine the volume and quality of evidence for and against primary unilateral cleft rhinoplasty.

METHODS

A systematic review was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were pulled from PubMed and EMBASE and screened by title and abstract. Studies with human participants undergoing rhinoplasty at the time of unilateral cleft lip repair and some evaluation of the nasal outcome were included. Studies with a large proportion of syndromic patients, case reports, editorials, letters, reviews, studies exclusive to bilateral clefts, and studies not available in English were excluded. Those that met criteria were then systematically reviewed.

RESULTS

Twenty-five articles were included. Ten articles that assessed the results of primary rhinoplasty subjectively all supported cleft lip repair with primary rhinoplasty. Sixteen articles assessed the results of primary rhinoplasty objectively, with 15 supporting primary rhinoplasty during cleft lip repair. Eight of nine studies that evaluated nasal growth and development over time found no restriction in nasal development. Five studies with a follow-up period of at least 6 years found that the percentage of patients who avoided revision rhinoplasty ranged from 43% to 100%. There were significant risks of bias in the majority of studies.

CONCLUSION

The majority of studies reviewed support that primary rhinoplasty during unilateral cleft lip repair results in good outcomes with limited or no effect on nasal growth.

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

Cleft Rhinoplasty: Does Timing and Utilization of Cartilage Grafts Affect Perioperative Outcomes?

BACKGROUND

The purpose of this study was to evaluate the epidemiology and perioperative complications of different reconstructive strategies to correct cleft nasal deformity, with particular attention paid to type and timing of cartilage grafting.

METHODS

Retrospective cohort study was conducted of cleft rhinoplasty performed between 2012 and 2017 in North America utilizing the American College of Surgeons National Surgical Quality Improvement Program- Pediatric hospital network. Medical/surgical complications, reoperations, and readmissions within 30 days postoperatively were analyzed with appropriate statistics.

RESULTS

During the study interval, 3317 pediatric patients underwent cleft rhinoplasty, with 8.0% involving the use of cartilage grafts. Ear cartilage was significantly more commonly used for intermediate repair, whereas rib cartilage was more commonly used for late repair (P=0.006). Overall, rhinoplasties with ear cartilage grafts had shorter procedure durations than those without cartilage grafts (P=0.005), whereas those with rib cartilage grafts had increased procedure duration (P<0.001). The use of cartilage grafts was not associated with increased complications in either intermediate or late cleft rhinoplasty. Patients with bilateral clefts were more likely to undergo rhinoplasty with cartilage grafts overall (P=0.047) and with cartilage grafts for late reconstruction (P=0.039).

CONCLUSIONS

Ear cartilage is most frequently utilized for intermediate repair, whereas rib cartilage is most frequently utilized for late repair during cleft rhinoplasty. Ear cartilage grafts are associated with significantly decreased procedure duration, whereas rib cartilage grafts are associated with significantly increased procedure duration. Not surprisingly, cleft rhinoplasty is relatively safe, with a 2% overall short-term complication rate.

Evolving Trends in Unilateral Cleft Lip Repair Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) began collecting data from unilateral cleft lip (UCL) corrections in 2011 as a component of the continuous certification process. We evaluated these data to understand practice patterns in UCL repair, in the United States, and whether these practice patterns had changed over the past 9 years.

METHODS

Tracer data for UCL correction were reviewed from its inception in October 2011 through 2016 and compared to UCL cases between 2017 and March 2020. Trends in practice patterns were evaluated against literature reviews meant to coincide with the ABPS continuous certification data.

RESULTS

A total of 520 cases were included from October 2011 to March 2020. Median age of UCL repair was 4 months and 66% of patients were male. Fifty-one percent of cases presented with a complete cleft lip. There was a decrease in postoperative adverse events when data from 2011 to 2016 was compared to 2017 to 2019 (P = 0.020). Revisions were the most common postoperative adverse event (2%). There was a decrease in nasoalveolar molding from 25% to 12% (P < 0.001) and 56% of total cases underwent a concurrent primary cleft rhinoplasty. The rate of gingivoperiosteoplasty at the time of primary cleft lip repair also fell (9% versus 1%; P < 0.001).

CONCLUSIONS

This article reviews tracer data obtained by the ABPS for UCL repair. The American Board of Plastic Surgery tracer data provides a national, cleft lip-specific database with longer follow-up times than other large databases.

How to Get Consistently Good Results in Cleft Lip Repair

This article serves as a practical guide for plastic surgeons focusing on repair of primary cleft lip and nasal deformity. We discuss the key anatomic disruption present in cleft lip and nasal deformity and the goals of primary repair. In addition, our preferred surgical technique for unilateral and bilateral cleft lip and nasal deformity is summarized along with technical pearls and pitfalls.

Primary Nasal Correction in Unilateral Cleft Lip: An Ongoing Journey

BACKGROUND

A cleft lip deformity, whether unilateral or bilateral, is usually associated with a deformity of the nose. In present day cleft surgery, it is routine to perform a varying extent of correction of the nasal deformity. There is often relapse and ongoing deformity which warrant further nasal surgery. The authors describe their method of nasal correction which includes using a hypodermic needle to help achieve repositioning and suspension of the nasal cartilages.

MATERIALS AND METHOD

The authors reviewed 100 consecutive cases of unilateral cleft lip who had nasal correction since June 2018. There were 59 males and 41 females with a mean age of 5.5 months. There were 72 complete and 28 incomplete cleft lips. The steps in nasal correction include septal repositioning, sutures to approximate the ala domes, and upper medial crura, suspension of the lower lateral cartilage to the upper lateral cartilage and sutures to approximate the skin, lower lateral cartilage, and mucosa in a sandwich fashion.

RESULTS

The patients were followed up for a range of 9 to 21 months with a mean of 18 months. The correction immediately postop and at 2 weeks follow up was good. However, at 1 year follow up there was some evidence of relapse. The correction achieved was, however, superior to that achieved before this method. None of the relapses were deemed severe enough to warrant further surgery at this stage.

CONCLUSIONS

This method of nasal correction is recommended to achieve superior outcomes in the surgical treatment of unilateral cleft lips.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns

BACKGROUND

The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons.

METHODS

An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care.

RESULTS

Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time.

CONCLUSIONS

Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

Photogrammetric Outcomes of Primary Nasal Correction in Unilateral Cleft Lip Patients: Early Childhood Results From a Single Surgeon's Experience

BACKGROUND

Concerns of nonlasting results and potential nasal growth damage precluded cleft nasal correction at the time of initial cleft lip repair. Our goal was to evaluate the outcome of primary cleft nasal correction in our patients with unilateral cleft lip.

METHODS

A retrospective review of patients with complete and incomplete unilateral cleft lip who underwent primary cleft nasal correction from 2010 to 2017 by the same surgeon was performed. The cleft-to-noncleft nostril height, width, one-fourth medial part of nostril height, nasal sill height, and nostril area ratios, as well as inner nostril height-to-width ratios were determined from standard basilar view photographs taken in different time points (T1, <3 months; T2, 3-12 months; T3, 12-36 months; and T4, >36 months after surgery). A 5-point visual analog scale (1 = worst, 5 = best) was used to assess each patient's nose appearance.

RESULTS

Seventy-two patients were identified (66.7% male, 51.3% with a complete cleft lip). Average visual analog scale scores T1-T4 were 3.88 ± 0.85, 3.72 ± 0.93, 3.54 ± 0.99, and 3.40 ± 0.71, respectively. Intraclass correlation ranged from 0.61 to 0.94. A significant decrease [mean difference (SD)] was found for cleft-to-noncleft nostril width ratio [0.15 (0.18)] from T1 to T2, and an increase for one-fourth medial height ratio [-0.09 (0.07)] and for inner nostril height-to-width ratio in the noncleft side [-0.23 (0.25)] from T1 to T3. Thirteen patients required secondary surgical revision.

CONCLUSION

Based on photogrammetry, primary cleft nasal correction in our patients with unilateral cleft lip achieved acceptable and stable outcomes during early childhood.

An Analysis of Aesthetic Refinements in 120 Secondary Cleft Rhinoplasties

BACKGROUND

Secondary cleft nose rhinoplasty remains a challenging procedure. Cartilage memory and scar contraction are problematic factors. The need for more detailed procedures for secondary reconstruction in this patient population has arisen. Contemporary refinements demonstrate a highly structured approach. We conducted a retrospective study evaluating the aesthetic results of cleft patients who underwent secondary rhinoplasty.

METHODS

In a retrospective study, a photometric analysis of cleft patients operated in the period 2003-2011 was conducted. Reconstructive methods were documented. Pre- and postoperative photographs of cleft rhinoplasty patients were evaluated using a standardized protocol. Nostril width ratio, columellar angle, tip projection ratio, and nasolabial angle served as objective instruments. The Unilateral Cleft Lip Surgical Outcomes Evaluation score was chosen for external photometric rating and rated blindly by 2 external individual plastic surgeons as independent nonbiased reviewers. The interrater and intrarater reliabilities were calculated using the Cohen kappa coefficient (κ).

RESULTS

A total of 120 secondary rhinoplasties in 85 uni- and bilateral cleft patients could be included. Mean follow-up was 20 months. A total of 60 (71%) patients needed additional bone grafting (chin/pelvis), and 23 (27%) patients a LeFort I osteotomy. In one third of the secondary rhinoplasties, a medial and/or lateral osteotomy was performed (34%). In one fourth (24%), an external septoplasty was considered necessary. In 55% (47 patients) of the cases, a columellar strut was used. Excluding bone grafts, a total of 173 other grafts (mean of 2 grafts/patient) were applied. Postoperative measurements for nostril width ratio and columellar angle were statistically significant. A structured approach with contemporary refinements is described in detail. Intra- and interrater reliabilities for photometric assessment according to the Unilateral Cleft Lip Surgical Outcomes Evaluation score are shown.

CONCLUSIONS

A structured approach for secondary cleft rhinoplasty yields satisfying, reproducible, and stable results.

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

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

Unilateral Cleft Lip Nasal Deformity: Three-Dimensional Analysis of the Primary Deformity and Longitudinal Changes following Primary Correction of the Nasal Foundation

BACKGROUND

Objective assessment of the unilateral cleft lip nasal deformity and the longitudinal changes with treatment is critical for optimizing cleft care.

METHODS

Consecutive patients undergoing cleft lip repair and foundation-based rhinoplasty were included (n = 102). Three-dimensional images preoperatively, postoperatively, and at 5 years of age were assessed and compared to age-matched controls. Images were normalized to standard horizontal, craniocaudal, and anteroposterior axes.

RESULTS

Cleft subalare was similar in position relative to controls but was 1.6 mm retrodisplaced. Subnasale was deviated 4.6 mm lateral to midline and had the greatest displacement of any landmark. Noncleft subalare was displaced 2.3 mm laterally. Regression analysis with deviation of subnasale from the midline as a dependent variable revealed progressive lateral displacement of noncleft subalare, narrowing of noncleft nostril, and intercanthal widening. Surgery corrected nasal base displacements along all axes, resulting in landmark positions similar to controls. Symmetry of nasal base correction persisted at 5-year follow-up, with no recurrent cleft alar base retrusion, regardless of initial cleft type.

CONCLUSIONS

Unilateral cleft lip nasal deformity may be "driven" by displacement of the anterior nasal spine and caudal septum. The cleft alar base is normal in position but retruded, whereas the noncleft alar base is displaced laterally. Changes with surgery involve anterior movement of the cleft alar base but also include medial movement of the noncleft alar base and columella. Symmetry of correction, including alar base retrusion, was stable over time and did not rely on alveolar bone grafting.

Primary Rhinoplasty Does Not Interfere with Nasal Growth: A Long-Term Three-Dimensional Morphometric Outcome Study in Patients with Unilateral Cleft

BACKGROUND

Primary rhinoplasty has not been universally adopted because the potential for nasal growth impairment remains an unsolved issue in cleft care. This study's purpose was to assess the long-term effects of primary rhinoplasty performed by a single surgeon in a cohort of patients with a unilateral cleft lip nose deformity.

METHODS

Three-dimensional nasal morphometric measurements (linear, angular, proportional, surface area, and volume) were collected from consecutive patients (cleft group, n = 52; mean age, 19 ± 1 year) who had undergone primary rhinoplasty with the use of the Noordhoff approach between 1995 and 2002 and reached skeletal maturity. Normal age-, sex-, and ethnicity-matched subjects (control group, n = 52) were identified for comparative analyses.

RESULTS

No significant differences (all p > 0.05) were observed for most measures, including nasal height, alar width, nasal dorsum angle, columellar angle, columellar-labial angle, nasal tip/height ratio, nasal index, alar width/intercanthal distance ratio, nasal surface area, and nasal volume. The cleft group displayed significantly (all p < 0.05) lower nasal bridge length and nasal tip projection, and greater nasal protrusion, tip/midline deviation, nasal tip angle, nasal tip protrusion width index, and alar width/mouth ratio values than the control group.

CONCLUSIONS

Primary rhinoplasty does not interfere with nasal growth as measured by three-dimensional photogrammetric analysis. Further imaging studies are required for the assessment of development in other anatomical nasal structures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty

BACKGROUND

Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to "upright the nose," without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse.

METHODS

Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison.

RESULTS

Significant changes in anthropometric and morphometric measurements occurred following surgery. Postoperative form was similar to controls immediately after surgery and at 5 years. Nasal corrections were satisfactory, and only two patients have elected to undergo revision. When subjects were grouped according to cleft type, we found the same trends. When comparing different methods of nasal sidewall reconstruction or septoplasty, we found no differences. Alveolar cleft width was a significant predictor of worse preoperative and postoperative form.

CONCLUSIONS

Significant nasal correction can be achieved by means of reconstruction of nasal foundation, without nasal tip dissection. Preservation of tissue planes may allow for easier secondary revision, if necessary.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Efficacy of morpho-functional repair in management of different morphological variants of unilateral complete cleft lip

BACKGROUND

To study the surgical outcome in various morphological variants of unilateral complete cleft lip in our high volume centre over a period of 4 years, using Morpho-Functional technique in all cases by indirect two dimensional photographic analysis.

METHODS

In this prospective cohort study, 749 patients with Unilateral Cleft Lip with palate were included over a period of 4 years from January 2010 to December 2014. All Subjects underwent surgery before the age of 1 year with the follow-up two dimensional photographs taken at 4 years post-operatively. Eight measurements were performed on the photographs. All parameters were measured on both Cleft & Non cleft sides and the ratio was considered with the normal side as the base line. Shapiro-Wilk and Kolmogrov-Smirnoff tests were used to confirm that the data was normally distributed. One way ANOVA was done to find out if there were any significant differences amongst the different groups along various parameters, respectively. Further Tukey post hoc analysis was done to confirm where the differences occurred between groups.

RESULTS

None of the groups showed any statistical differences on any parameters. There were minor variations between the different groups due to the ranging morphology of the defect but overall satisfactory to good results were seen on all measured parameters evaluated.

CONCLUSION

This shows that the Morphofunctional technique, with its combinations & modifications of various school of thought, is versatile enough to achieve good surgical outcomes despite the wide variations seen in size and type of defects in unilateral cleft lip. This comes about because of the comprehensive nature of the technique & the balance that it creates among the affected structures.

The Microsurgical Approach in Primary Cleft Rhinoplasty-An Anthropometric Analysis

PURPOSE

Oral and maxillofacial surgeons use different approaches to repair the nasal deformity of patients with a cleft lip deformity, differing in technique and timing. The aim of this longitudinal study was to analyze a new surgical technique to treat the cleft nasal deformity at 4 to 6 weeks of life using a microscope.

MATERIALS AND METHODS

Twenty-seven newborn patients with a cleft lip deformity were treated by primary repair of the nasal deformity using a microscope at 4 to 6 weeks of life. The procedure includes a columellar incision, alar cartilage plication sutures according to Daniel (Plast Reconstr Surg 103:1491, 1999), and trans-columellar sutures. All patients were photographed at specific time points up to 1 year after surgery. Established angles and distances were analyzed and compared with normal values of age-matched children by Farkas (Anthropometry of the Head and Face [ed 2]. New York: Lippincott Williams and Wilkins, 1994).

RESULTS

All parameters improved through surgery and showed stable values at follow-up assessments. Almost ideal values concerning symmetry, as indicated by columellar deviation and nostril comparison, were obtained. Measurements of nasal morphology were similar to established norm values.

CONCLUSION

The authors recommend the early treatment of cleft nasal deformity using microscopic surgery because it shows stable and symmetrical results at least up to 1 year after surgery. Clinical observations up to adolescence suggest no growth disturbance or deterioration of nasal shape.

Personal technique for definite repair of complete unilateral cleft lip: modified Millard technique

Background

Millard’s rotation-advancement repair, which is used by many surgeons, can make a natural philtral column, but most surgeons use a modification of the rotation-advancement flap. The purpose of this article is to introduce a modification utilized by the authors and to provide detailed surgical procedure.

Methods

We retrospectively reviewed 82 patients’ medical records and presented surgical technique and outcomes. The main features of the authors’ strategy are emphasizing horizontal length of the lip, orbicularis oris muscle duplication for improving the definition of the philtral column, overcorrection of domal portion than the non-cleft side in order to compensate for the recurrence during growth. Two judges rated two times the appearance of the patients’ nose and lip using Asher-McDade aesthetic index. Intra- and interobserver reliabilities were determined using Cohen’s kappa statistics.

Results

All patients recovered eventually after surgery; however, two patients have a minor complications (wound infection in one patient, wound disruption due to trauma in the other patient). The improvement of the aesthetic results can be achieved with this modified Millard technique. Total mean scores of the Asher-McDade index was 2.08, fair to good appearance. The intraobserver reliabilities were substantial to almost perfect agreement and the interobserver reliabilities were moderate to almost perfect agreement.

Conclusion

We modified Millard method for repair of complete unilateral cleft lip. The surgical outcomes were favorable in long-term follow-up. We hope our technique will serve as a guide for those new to the procedure.

[Septoplasty during primary unilateral cleft lip repair]

Primary repair of cleft lip and palate has become a nasal and lip repair. In the aim to improve our nasal results on symmetry we perform an extensive septoplasty to put the nose in a good shape and a median axis. This septoplasty without resection of cartilage does not cause growth disorders to the nose and it promotes maxillary growth by improving early nasal breathing. It can prevent secondary rhinoplasty, source of new scars (externally, fork). But rhinoplasty will increase the incidence of scar contraction, thus shaping with a nasal conformer is essential.

Primary Overcorrection of the Unilateral Cleft Nasal Deformity: Quantifying the Results

BACKGROUND

Because primary nasal correction by the time of lip repair has been incorporated into the treatment approach, many patients have benefitted from this combined procedure. However, primary nasal correction cannot guarantee an excellent result. Although overcorrection has been mentioned as a treatment rationale of the unilateral cleft lip nasal deformity, a detailed approach and quantitative evidence of the rationale are rare. This study evaluates whether overcorrection in the primary repair results in a quantitative improvement in nasal appearance.

PATIENTS AND METHODS

In this retrospective study, the inclusion criteria were patients with complete unilateral cleft lip and palate who underwent primary lip and nose repair by the age of 3 to 4 months. Primary nasal overcorrection was achieved by application of muscle to septal base suture, alar cinching suture and Tajima reversed U incision method. Patients were further divided into an overcorrected (n = 19) and nonovercorrected group (n = 19). The following parameters were identified on basilar photos of all patients taken at least 12 months after repair, ratios of cleft to noncleft side in each patient were taken and the mean for each parameter calculated: Ac angle (ACA/ACA'), alar height (AH/AH'), alar width (AW/AW'), nostril height (NH/NH`), nostril width (NW/NW'), and columellar deviation from the midline (CD/NW). The means of the overcorrected and nonovercorrected groups were then compared using the t test.

RESULTS

From all investigated measuremens, Alar height (AH/AH': overcorrected, 0.983 to nonovercorrected, 0.941; P = 0.03) and nostril height ratio (NH/NH') (NH/NH': covercorrected, 0.897 to nonovercorrected, 0.680; P = 0.003) showed statistically significant differences favoring the overcorrected group at least 12 months after surgery.

CONCLUSIONS

Primary nasal overcorrection including muscle to columella base suture, alar cinch suture, and Tajima method resulted in quantitatively more long-term symmetric alae and nostril height compared to nonovercorrected patients.

Evidence-Based Medicine: Secondary Correction of Cleft Lip Nasal Deformity

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the components of unilateral and bilateral cleft lip nasal deformity. 2. Assess the deformity. 3. Design a treatment plan for secondary correction of cleft lip nasal deformity. 4. Discuss methods for managing suboptimal outcomes.

SUMMARY

Correction of cleft lip nasal deformity has been addressed in this Maintenance of Certification/Continuing Medical Education series a number of times-a testament to the complexity of the topic. In this addition to the series, the authors provide a principle-based approach toward management of unilateral and bilateral cleft lip nasal deformity with an emphasis on timing intervention, role for intermediate correction, and methods for cleft rhinoplasty after completion of nasal growth.

Evolution of my philosophy in the treatment of unilateral cleft lip and palate

At the end of 50-year-long clinical activity, the evolution of my approach to the treatment of unilateral cleft of the lip and palate is discussed. I had several teachers in this field (Rusconi, Reherman, Perko, Delaire, Talmant, Sommerlad and others) and I introduced in my approach what I considered to be improvements from all of them. My current protocol is related to the anatomy of the cleft: for wide clefts a two-stage protocol is applied (1° step: soft palate and lip and nose repair; 2° step: hard palate repair with gingivoalveoloplasty); for narrow cleft (less than 1 cm at the posterior border of hard palate) an "all in one" protocol is performed with or without gingivoalveoloplasty (in accordance to the presence or absence of contact between the stumps at alveolar level). The most important details regarding surgery of the lip and palate are discussed. Robust data collection on speech and skeletal growth is still needed to determine whether the "all in one" approach can be validated as the treatment of choice for unilateral complete lip and palate cleft in selected cases.

A Reliable Method to Measure Lip Height Using Photogrammetry in Unilateral Cleft Lip Patients

There is still no reliable tool to determine the outcome of the repaired unilateral cleft lip (UCL). The aim of this study was therefore to develop an accurate, reliable tool to measure vertical lip height from photographs. The authors measured the vertical height of the cutaneous and vermilion parts of the lip in 72 anterior-posterior view photographs of 17 patients with repairs to a UCL. Points on the lip's white roll and vermillion were marked on both the cleft and the noncleft sides on each image. Two new concepts were tested. First, photographs were standardized using the horizontal (medial to lateral) eye fissure width (EFW) for calibration. Second, the authors tested the interpupillary line (IPL) and the alar base line (ABL) for their reliability as horizontal lines of reference. Measurements were taken by 2 independent researchers, at 2 different time points each. Overall 2304 data points were obtained and analyzed. Results showed that the method was very effective in measuring the height of the lip on the cleft side with the noncleft side. When using the IPL, inter- and intra-rater reliability was 0.99 to 1.0, with the ABL it varied from 0.91 to 0.99 with one exception at 0.84. The IPL was easier to define because in some subjects the overhanging nasal tip obscured the alar base and gave more consistent measurements possibly because the reconstructed alar base was sometimes indistinct. However, measurements from the IPL can only give the percentage difference between the left and right sides of the lip, whereas those from the ABL can also give exact measurements. Patient examples were given that show how the measurements correlate with clinical assessment. The authors propose this method of photogrammetry with the innovative use of the IPL as a reliable horizontal plane and use of the EFW for calibration as a useful and reliable tool to assess the outcome of UCL repair.

Measuring Symmetry in Children With Cleft Lip. Part 2: Quantification of Nasolabial Symmetry Before and After Cleft Lip Repair

OBJECTIVE

The first part of this study validated an automated computer-based method of identifying the three-dimensional midfacial plane in children with unrepaired cleft lip. The purpose of this second part is to develop computer-based methods to quantify symmetry and to determine the correlation of these measures to clinical expectations.

PARTICIPANTS

A total of 35 infants with unrepaired unilateral cleft lip and 14 infant controls.

INTERVENTIONS

Six computer-based methods of quantifying symmetry were developed and applied to the three-dimensional images of infants with unilateral cleft lip before and after cleft lip repair and to those of controls.

MAIN OUTCOME MEASURE

Symmetry scores for cleft type, changes with surgery, and individual subjects ranked according to cleft severity were assessed.

RESULTS

Significant differences in symmetry scores were found between cleft types and found before and after surgery. Symmetry scores for infants with unilateral cleft lip approached those of controls after surgery, and there was a strong correlation with ranked cleft severity.

CONCLUSIONS

Our computer-based three-dimensional analysis of nasolabial symmetry correlated with clinical expectations. Automated processing made measurement convenient. Use of these measures may help to objectively measure cleft severity and treatment outcome.

The Millard Rotation-Advancement Cleft Lip Repair: 50 Years of Modification

Since its inception in 1955, Millard's rotation-advancement repair has been one of the most popular techniques used in the care of patients with a cleft lip. Over the past half century, Millard's repair has evolved and laid the foundation for many other repair techniques that have followed in its footsteps. This publication compares Millard's rotation-advancement technique to the various repairs used today. The purpose of this article is to lend perspective as to the impact of Millard repair over the past 50 years in the treatment of cleft lip.

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.

[Cleft rhinoplasty, from primary to secondary surgery]

Despite fifty years of statistics, congresses, publications, the cleft nose remains an enigma to the great majority of cleft specialists. Most of the published papers give recipes to camouflage the cleft deformity, very few are concerned by the functional anatomy and its relation with facial growth. The complexity of the matter, the results frequently disappointing, the lack of awareness of the necessity of early nasal breathing, and the academic condemnation of any imperfect attempt to correct the nose at the time of the first operation have led to resignation. For the last forty years, we have been involved in a careful and obstinate research about the early correction of the cleft nose deformity. We wish to present our conclusions in this chapter with at least 17 years of follow-up. They are as following: in cleft patients the nasal cartilages are only deformed. We can achieve sub periosteal and sub perichondrial dissections by 6 months of age without being harmful for facial and nasal growth. Repositioning accurately the nasal structures is enough if we are able to control the healing process and prevent endonasal wound contraction. We have not to do any compromise and favor one function with regard to the others, nasal ventilation being the most important for a good facial growth. In a word, nasal pediatric surgery is necessary at the time of the first operation from 6 months of age and should be carried on with a double demand, aesthetic and functional. To achieve this goal, we must have a sound knowledge of the cleft nose deformity, of the adequate surgical techniques and of the logic chronology to reach the best result. The nose repair cannot be limited to the nasal cartilages. The whole nasal structure is concerned especially its bony framework, the width of which at the level of the piriform orifice and the nasal floor depends on the outcomes of any surgical step that it would relate to the lip, palate or alveolar closure. Interaction of all these factors calls for an appropriate answer in adequation with the diagnosis of the deformity and a coherent answer as we know that any local action may induce an unfavorable chain reaction and should integrate a global and logic project. After the primary surgery, additional correction for aesthetic or functional purpose as well, may be useful during the period of growth. For cleft teenagers or adults, the rhinoplasty can simply be indicated for harmonization after a good primary nasal correction and optimal facial growth. On the contrary, the rhinoplasty may be more or less a complex operation for the usual and severe deformities. In the last case, the diagnosis must take into account all the residual deformities, even the labial and alveolar ones, and the treatment plan integrate all the principles and techniques of the primary surgery. What has not been done at the time of the primary surgery, should be done secondarily: all the structures are present, only deformed and embedded in scarred tissues. Primary or secondary cleft rhinoplasty must be undertaken by surgeons accustomed to cleft patients, but also trained in the other fields of nasal surgery, aesthetic and reconstructive.

Evidence-based medicine: The cleft lip nasal deformity

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Describe the components of unilateral and bilateral secondary cleft lip nasal deformity. (2) Discuss current methods of assessing the deformity and outcomes. (3) Discuss primary treatment options including the use of preoperative orthopedics, nasal molding techniques, and the primary cleft rhinoplasty. (4) Design a treatment plan for cleft patients that will optimize the outcome of nasal appearance and function. (5) Discuss the evidence regarding outcomes of current practices, and describe areas where more research is needed.

SUMMARY

This is the third Maintenance of Certification article on the secondary cleft lip nose deformity. In the first article, Guyuron defined the deformities and described techniques for the definitive (adult) rhinoplasty. The second article, by Zbar and Canady, presented evidence regarding the assessment, surgical treatment, and outcomes from the literature published between 1999 and 2009. In this article, the authors summarize important points from the first two articles and then concentrate on the evidence for the following topics: (1) methods currently used in evaluating the severity of the deformities; (2) methods used in evaluating outcomes of different treatments; (3) benefits of rhinoplasty performed at the time of the lip repair and evidence for the effect of rhinoplasties performed after infancy but before maturity; (4) presurgical orthopedics and nasoalveolar molding; (5) common surgical techniques used in primary cleft rhinoplasties; and (6) impact of the nasal deformity on quality of life. Overall, there is little high-level evidence regarding the outcomes of cleft nasal deformity treatment, leaving much room for future study.

Four-dimensional changes of nasolabial positions in unilateral cleft lip and palate

OBJECTIVE

The aim of this study was to analyze the accurate three-dimensional positions and positional changes of the lip and nose in patients with unilateral cleft lip and palate.

METHODS

Sixty-three patients with unilateral complete cleft lip and palate (UCLP) and 96 patients with isolated cleft palate were retrospectively enrolled. Facial casts of all subjects taken immediately before and after cheiloplasty and before palatoplasty were used. Three-dimensional values of 12 landmarks were measured by electronic caliper and parallel milling machine. Independent-samples t test was used in analyzing positional differences between UCLP and control, and 2-way analysis of variance was selected in analyzing positional changes among UCLP groups. The threshold of significance was set at 0.05.

RESULTS

Superiorly dislocated christa philtri (Cph) (P < 0.001), subalae (Sa) (P < 0.001), and nostril tip (Nt) (P < 0.001) were partially corrected and still dislocated (P < 0.05, P < 0.001, P < 0.001) immediately after operation, but Cph (P = 0.322) and Cph' (P = 0.081) developed caudally to normal about 10 months after primary surgery. In sagittal dimension, lip and nose, especially Cph' (P < 0.001), Sa' (P < 0.001), and Nt' (P < 0.001) on the cleft side, dislocated dorsally before operation. Immediately after operation, Sa' (P = 0.456) and Nt' (P = 0.067) were normal in sagittal projection, but Cph' was corrected partially and still insufficient (P < 0.001). Unfortunately, sagittal projections of all nasolabial structures, Cph (P < 0.001), Sa' (P < 0.001), Nt (P < 0.001), Cph' (P < 0.001), Sa' (P < 0.05), and Nt' (P < 0.001), decreased significantly and were insufficient after operation.

CONCLUSIONS

In vertical dimension, nasolabial displacements were corrected partially by primary surgery, and catching-up growth happened since then. Insufficient sagittal projections of the lip and nose were corrected successfully by lip repair, but lip repair itself had adverse effects on nasolabial sagittal growth.

Unilateral cleft lip repair

Modern cleft surgery requires four-dimensional and functional anatomic understanding of the cleft (and noncleft) lip, nose, and alveolus. Some techniques for nasolabial repair rely more on precise anatomic geometry, whereas others afford the surgeon a more flexible design. Consistent anthropometry enables accurate assessment and reporting of long-term outcomes; such reports are needed to guide perioperative care, delineate optimal repair principles, and resolve ongoing controversies.

Unfavourable results in the repair of the cleft lip

Introduction:

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

Unilateral cleft lip repair:

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

Bilateral cleft lip:

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

Conclusion:

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

Unilateral cleft lip: principles and practice of surgical management

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

Effect of primary correction of nasal septal deformity in complete unilateral cleft lip and palate on the craniofacial morphology

PURPOSE

To assess the long-term effect of primary correction of the nasal septum during lip repair in unilateral complete cleft lip and palate on the craniofacial morphology.

MATERIAL, SUBJECTS, METHODS

The study material consisted of 54 lateral cephalograms made at the ages 7-22, including 28 cephalograms of patients from a study group (aged 7-14 years) after a primary correction of the nasal septum during lip closure and 26 cephalograms of patients from a control group (aged 12-22 years) operated on without septal correction. All cephalograms have been analysed with regard to skeletal, dental and soft-tissue relationships. Data distribution has been checked using Shapiro-Wilk test (α = 0.05). Student t-test was used to compare values of normal distribution and for the latter - Mann-Whitney test.

RESULTS

The comparison of all cephalometric values between the study and control groups revealed a statistically significant (α = 0.05) difference only for H (p = 0.0267), 1+: NB angle (p = 0.0175) and 1+: NA (mm) (p = 0.0249). Each of the three cephalometric measurements mentioned were greater in the study than in the control group.

CONCLUSION

No negative effect from the primary nasal septum correction on maxillary development could be found in the study group.

Fifteen-Year Follow-Up Results of Presurgical Orthopedics Followed by Primary Correction for Unilateral Cleft Lip Nose in Program SEHATI in Indonesia

Objective : To assess long-term effects of nasal correction in infancy on nasal form and growth in patients with unilateral cleft lip, alveolus, and palate (UCLP). Design : Retrospective longitudinal study. Patients : Seventeen patients with complete UCLP treated in Program SEHATI in Harapan Kita Children and Maternity Hospital, Indonesia, and followed for approximately 15 years were enrolled. Interventions : Subjects received presurgical orthopedics using a Hotz's plate and simultaneous primary lip and nose repair in which the lower lateral cartilage was repositioned through a reverse-U incision. Main Outcome Measures : Preoperative and postoperative nasal forms, including the nostril height and width ratio, the ratio of the height of the top of the alar groove, and the ratio of nostril surface areas were analyzed using color photos taken serially. One-way analysis of variance was used for statistical analyses. Results : The nostril height and width ratio and the height of the alar groove were significantly improved postoperatively and maintained for 15 years. The mean ratio of nostril surface areas was 1.01 ± 0.12 fifteen years postoperatively, and there was no significant difference from the ratio 1 year postoperatively. The major persistent deformities were septal deviation and a small skin web on the nostril rim. Conclusions : Our primary cleft lip nose correction has provided an acceptable nose form and absence of disturbance of the nasal growth in patients with UCLP. However, the repositioning of the nasal cartilage at infancy might not eliminate the need for secondary correction after puberty.

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.

Rhinoplasty for cleft and hemangioma-related nasal deformities

PURPOSE OF REVIEW

To provide a concise review of recent articles on rhinoplasty approaches for cleft nasal deformity and nasal hemangiomas published in 2008-2010.

RECENT FINDINGS

Cleft nasal deformity rhinoplasty approaches have undergone further refinements as well as new development in techniques and surgical principles to minimize recurrent cleft nasal deformities. There is a paucity of studies addressing cleft septal deformity although there appears to be a greater emphasis on functional outcome in cleft rhinoplasty. Complications from primary cleft rhinoplasty and presurgical nasoalveolar molding were also reported. Similarly, nasal hemangioma rhinoplasty approaches have undergone further modifications with open rhinoplasty and subunit approaches gaining wider acceptance.

SUMMARY

There are several new studies that compare different rhinoplasty techniques to determine which approaches offer superior surgical outcomes; however, there needs to be a greater acceptance of objective measurements when assessing surgical results to identify a uniform surgical protocol and technique for both cleft rhinoplasty and nasal hemangiomas.

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.

Primary correction of nasal septal deformity in unilateral clefts during lip repair-a long-term study

OBJECTIVE

The aim of this study was to assess the long-term effect of primary septal correction carried out during lip closure on the nasal septum. MATERIALS, SUBJECTS, AND METHODS: Before primary septal correction was introduced, specimens from the septal cartilage and the anterior nasal spine of 10 deceased newborns and infants were analyzed with the aid of a light microscope to verify the presence of any growth zone. The study group comprised 91 children with unilateral clefts who had undergone primary lip repair with septal correction. The control group comprised 29 children with unilateral clefts operated on without primary septal correction. The appearance of the nasal septum was assessed on extraoral photographs in the second week of life and then 10 to 14 years postoperatively.

RESULTS

Morphologic examination revealed fibrous connective tissue with no signs of growth between the cartilaginous septum and bone. At long-term examination, the study group was found to have a nasal septum that was straight in 75 (83%), moderately deviated in 14 (15%), and severely deviated in two (2%) patients, whereas in the control group, the septum was considered straight in four (14%) children, moderately deviated in 11 (38%), and severely deviated in 14 (48%).

CONCLUSIONS

Primary septal correction may be considered safe because no growth zone exists between the septal cartilage and the anterior nasal spine. Careful primary nasal septal correction improves nose shape in a way that allows normal growth.