Evidence-based medicine: The cleft lip nasal deformity

Long-term Results and Efficacy of Intermediate Rhinoplasty in Patients With Unilateral Cleft Lip: A Single Surgeon's Experience

Intermediate rhinoplasty, the correction of cleft lip nose deformities, is performed between the time of primary and secondary rhinoplasties, which is at ~6 years of age. Although intermediate rhinoplasty reduces psychological stress in school-aged children through improvements in appearance, studies on intermediate rhinoplasty are scarce. Hence, in this study, we aimed to evaluate the long-term outcomes of intermediate rhinoplasty in patients with unilateral cleft lip. Twenty-three patients with unilateral cleft lip who underwent intermediate rhinoplasty without primary rhinoplasty from 1997 to 2004 were enrolled in this retrospective study. They were categorized into total, male, and female groups. Photogrammetric analysis of 9 proportional, 5 angular, and 6 nostril-related parameters was performed using photographs that were taken after skeletal maturity had been reached; these parameters were compared with those of normal controls. The cleft group had significantly lower dome-to-columellar ratio, nasal sill ratio, labial-columellar angle, nostril width ratio, nostril height (base) ratio, nostril one-fourth medial part ratio, and nostril area ratio measurement and significantly higher alar width/mouth width ratio, columella height/alar width ratio, nasal tip protrusion/alar base width ratio, nasal dorsum angle, and nostril dimension in the cleft side values than the control group. After intermediate rhinoplasty, significant nasal improvement was achieved, including sufficient nasal tip projection, nasal height, nasal protrusion, and a relatively symmetric nasal tip without tip deviation. Intermediate rhinoplasty may contribute to reducing the psychosocial stress of school-aged children with unilateral cleft lip.

Current Treatment Progress of Unilateral Cleft Lip Nasal Deformities

INTRODUCTION

Secondary nasal deformity following unilateral cleft lip is a common facial congenital malformation. Due to its complex treatment, there is currently no unified treatment plan in clinical practice. Dysplasia of cartilage, dislocation of muscles, and dysplasia of maxilla are the main causes of secondary nasal deformities of unilateral cleft lip. This article provides a comprehensive summary of the perioperative period and treatment process of unilateral cleft lip nasal deformities, aiming to find better clinical treatment guidance for patients with unilateral cleft lip and nasal deformity.

METHODS

A review of numerous previous studies on unilateral cleft lip nasal deformity, particularly within the last five years, was conducted to gather information on treatment strategies and perioperative care for unilateral cleft lip rhinoplasty.

CONCLUSION

Currently, there is still no unified final surgical method for the correction and treatment of unilateral cleft lip nasal deformity. In terms of surgical timing, simultaneous primary rhinoplasty and lip repair are gradually being recognized internationally, while intermediate rhinoplasty can be considered when it affects the patients social and psychological life. Patients with severe initial nasal deformity require multiple revisions. Secondary rhinoplasty remains the ideal treatment for final correction of secondary nasal deformities in unilateral cleft lip.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous Rib Cartilage Reconstruction After Silicone Implant Removal in a Patient With Bilateral Cleft Lip and Palate: A Case Report

Cleft lip rhinoplasty (CLR) corrects nasal deformities in cleft lip and palate patients. However, limitations exist in some countries like Japan regarding the use of silicone implants for CLR. While historical reports mention their use since the 1980s, long-term data is lacking. This case report describes a 53-year-old Japanese woman with bilateral cleft lip and palate who received a CLR with a silicone implant over 30 years ago. The implant calcified, causing nasal dorsum skin hardening and thinning, raising concerns of extrusion. To prevent potential extrusion, the implant was removed and replaced with autologous seventh rib cartilage grafts. Various grafting techniques were used for basal support, dorsal augmentation, and nasal tip refinement. The postoperative evaluation showed excellent results with no complications. This case highlights the importance of long-term follow-up after CLR with silicone implants and advocates for autologous rib cartilage as a reliable alternative. Reporting such cases is crucial for informing patient management and research on the long-term safety of silicone implants in CLR.

"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.

Measuring the Unilateral Cleft Lip Nasal Deformity: Lateral Deviation of Subnasale Is a Clinical and Morphologic Index of Unrepaired Severity

OBJECTIVE

Objective measurement of pre-operative severity is important to optimize evidence-based practices given that the wide spectrum of presentation likely influences outcomes. The purpose of this study was to determine the correlation of objective measures of form with a subjective standard of cleft severity.

DESIGN

3D images were ranked according to severity of nasal deformity by 7 cleft surgeons so that the mean rank could be used as the severity standard.

PATIENTS

45 patients with unilateral cleft lip and 5 normal control subjects.

INTERVENTIONS

Each image was assessed using traditional anthropometric analysis, 3D landmark displacements, and shape-based analysis to produce 81 indices for each subject.

MAIN OUTCOME

The correlation of objective measurements with the clinical severity standard.

RESULTS

Lateral deviation of subnasale from midline was the best predictor of severity (0.86). Other strongly-correlated anthropometric measurements included columellar angle, nostril width ratio, and lateral lip height ratio (0.72, 0.80, 0.79). Almost all shape-based measurements had tight correlation with the severity standard, however, dorsum deviation and point difference nasolabial symmetry were the most predictive (0.84, 0.82).

CONCLUSIONS

Quantitative measures of severity transcend cleft type and can be used to grade clinical severity. Lateral deviation of subnasale was the best measure of severity and may be used as a surrogate of uncoupled premaxillary growth; it should be recorded as an index of pre-operative severity with every cleft lip repair. The correlation of other measures evaluated clarify treatment priorities and could potentially be used to grade outcomes.

Volumetric assessment of the nose after primary unilateral cleft rhinoplasty using Laberge's technique

BACKGROUND

There is a lack of standardized surgery for cleft rhinoplasty. We felt that the technique described by Dr Louise Caouette Laberge is an ideal way to approach this problem, thus we tried to quantify the outcome of surgery by volumetric assessment.

MATERIAL AND METHOD

We recorded 3D images using an Artec scanner and performed volume calculations of the cleft side and noncleft side of the nose. These readings were taken once in the preoperative and then 2 weeks postoperative. Another scan of the face was performed 2 years after the surgery to compare the volumes of the cleft and noncleft side nostril.

RESULTS

Of the 31 patients with unilateral cleft lip operated on (mean age 3-8 months), we found a significant increase in the cleft side volume at 3 weeks postoperative from 3.95 mm3 to 5.65 mm3 (p < 0.001 on paired t-test). A repeat scan done on the study population at 2 years postoperative found that the mean volume of the cleft side was 30.43 mm3 (standard deviation [SD], 2.49) and that of the normal side was 30.82 mm3 (SD, 2.51). An independent t-test found that there was no significant difference between the two volumes (p > 0.05) CONCLUSION: The use of volumetric data in the evaluation of postoperative outcomes provides an objective criterion for assessing the aesthetics as well as the growth. Our study concludes that the Laberge technique provides a good aesthetic outcome with minimal scarring for the management of cleft nose and lip with the anterior palate.

The Effect of Arch Cartilage Graft and Tajima Reverse U Approach in the Secondary Reconstruction of Unilateral Cleft Lip Nasal Deformity

ABSTRACT

Secondary cleft lip nasal deformity is complicated with wide spectrum of defect and varied reconstructive procedures. There has been no unanimous solution for a given problem. In case of a localized alar depression in unilateral cleft lip nasal deformity, the conchal cartilage applied as arch graft was proposed. Patients were recruited from database of craniofacial center who received Tajima method and arch cartilage graft. Inclusion criteria were patients with unilateral cleft lip nasal deformity after skeletal maturity. Through a reverse U incision, the lower lateral cartilage was dissected and released from the skin and the contralateral cartilage. The harvested conchal cartilage graft was trimmed to 25 to 30 by 8 mm in size, and inserted as arch shape overlying the cleft side lower lateral cartilage. Transdomal fixation sutures were made. Outcome assessment was performed, and the nostril and alar dimensions were measured. Thirty-nine patients were eligible for evaluation of the surgical outcome. Majority of patients underwent simultaneous lip revision (97%). No surgery-related complications were noted in this series. Satisfaction to the nasal reconstruction was reported in 85% of patients. Further minor nasal revisions were performed in 6 patients (15%). Quantitative measurement showed statistically significant improvement in nostril height, alar height and alar width after the surgery. It is concluded that the Tajima reverse U approach plus arch cartilage graft is an effective method for secondary reconstruction of the unilateral cleft lip nasal deformity in selected patients presenting with cleft side alar depression.

Current Surgical Practice for Children Born with a Cleft lip and/or Palate in the United Kingdom

OBJECTIVE

This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate (CL ± P) in the United Kingdom (UK).

DESIGN

Data forms completed at the time of surgery included details on timing, technique, and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires.

SETTING

Data were obtained from the Cleft Collective, a national longitudinal cohort study.

PATIENTS

Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children.

RESULTS

The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips (UCL) were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips (BCL) were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bimodal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties (P < .001) and a 5 to 7-day postoperative regime used more commonly for soft palatoplasties (P < .001). Perioperative steroids were used more commonly in palatoplasties than cheiloplasties (P < .001) but tranexamic acid use was equivalent (P = .73).

CONCLUSIONS

This study contributes to our understanding of current cleft surgical pathways in the UK and will provide a baseline for analysis of the effectiveness of utilized protocols.

Alar Base Augmentation Using Vomerine Bone Graft in Patients With Cleft Lip Nasal Deformity

BACKGROUND

Although many trials have been made to augment the unilateral alar base depression, the ultimate aesthetic satisfaction has proven difficult to achieve. In our study, we present a novel submucosal dissection technique to harvest the vomer bone and use it as an onlay graft to correct the alar base depression.

METHODS

We collected a prospective cohort study of 11 patients with unilateral cleft lip nasal deformity. Using CorelDRAW X7 software, we obtained perioperative clinical photographs to analyze the nostril and lateral lip morphometric measurements on the cleft side. Computed tomography scans were used to assess the required graft's volume and to detect resorption. We performed vomerine ostectomy and placed and fixed the bone graft in with a lag screw over the alar base depression.

RESULTS

The nostril width showed a significant increase, in addition to the height/width ratio. The columellar angle with the lateral lip height increased remarkably, with a general improvement in the nasal tip aesthetics.

CONCLUSIONS

The vomer bone graft has been shown to correct the lateral and inferior disorientation of the alar base and improve the nostril and nasal tip aesthetic measurements. The vomer bone is therefore a sufficient bone source for grafting with high viability and no resorption.

Preoperative analysis of upper lip in patients with upper cleft lip/palate before lip repair

Background

The postoperative morphological appearances vary widely patients with unilateral cleft lip with or without cleft palate (UCL/P), whether it is complete or incomplete cleft. The main reason of bilateral lip asymmetry after cleft lip surgery lies in the lack of personalized measurement and design before surgery. In this study, we aim to individually investigate areas of the upper lip on cleft and non-cleft sides in patients with unilateral cleft lip with or without cleft palate (UCL/P).

Methods

Ninety-two patients with UCL/P (group 1: <1 year, group 2: 1–2 years) were included in the study. Group 1 included 37 patients with incomplete UCL/P and 29 with complete UCL/P; group 2 included 11 and 15 patients, respectively. The total area of the upper lip on the cleft side (Q8) was divided into Q3, Q4, and Q5 (further divided into a1 and a2), and the upper lip on the non-cleft side (Q7) was divided into Q2 and Q1 (further divided into A1 and A2). Area ratios between the cleft and the non-cleft sides were calculated, and certain parameters were tested for correlations with these ratios.

Results

Values of Q8/Q7 were partially overlapped between patients with complete and incomplete UCL/P. Significant correlations were noted between differences in height of the philtrum column (a–h) and the prolabial area ratio between the cleft and the non-cleft side (Q3/Q2) (P=0.032). Moreover, a significant correlation was noted between a1/A1 and the ratio of the lateral labial area between the cleft and the non-cleft side (Q5/Q1) (P=0.001).

Conclusions

The conventional classification of unilateral cleft lip as incomplete and complete does not completely and accurately reflect individual malformations. Therefore, it is necessary to analyze unilateral cleft lips individually to determine the repair technique and to predict postoperative outcomes.

Revisiting the unrepaired unilateral cleft lip and nasal deformity using 3D surface image analysis: A data-driven model and its implications

BACKGROUND

Current descriptions of the unilateral cleft lip and nasal deformity (uCLND) are based upon limited sample sets and subjective observations. While those descriptions are inconsistent and contradictory, theoretical models, including Hogan's "tilted tripod" and Fisher's "nasal arch forms", have never been tested. Given that favorable outcomes of treatment remain elusive, detailed study of the deformity is critical in devising better treatments. The purpose of this study was to develop a data-driven three-dimensional (3D) model of uCLND that spans the spectrum of presentation and involves a pervasive underlying mechanism.

METHODS

We studied 3D images of 100 infants with unrepaired cleft lip at 6 months of age. Objective assessment included the landmark positions, anthropometric dimensions, and shape-based measures. Cleft severity was stratified by the lateral displacement of subnasale, so that a model could be developed using linear regression.

RESULTS

With progressive deviation of subnasale, the non-cleft alar base moved lateral, the cleft alar base was left posterior, and the nasal dorsum followed the caudal septum (deviating towards the non-cleft side). The "twist" resulted in opposing cleft alar dome collapse, non-cleft alar ring constriction (the non-cleft nasal sill narrowed, lateral genu rose, and alar-cheek junction became more acute), and displacement of the philtrum from midline.

CONCLUSIONS

Our study not only supports theoretical models of uCLND but also clarifies vectors of change and reveals significant non-cleft side alterations. On the basis of our findings, the objectives of treatment should involve centralization of the columella and philtrum and rebalancing the nose by untwisting the orthogonal displacement of the alar bases.

Prosthetic Rehabilitation of a Repaired Cleft Palate with Use of a Two-Part Hinged Magnet Retained Removable Prosthesis

The presence of a cleft lip and palate is associated with a number of complications and the oral rehabilitation for the improvement of speech, function and esthetics can involve conventional and surgical orthodontics, distraction osteogenesis, fixed and removable prosthodontics, providing obturation of open defects if required. This clinical report describes the prosthodontic management of a patient with a repaired cleft lip and palate with significant maxillary hypoplasia and primary concern of aesthetics with the use of a two-part hinged magnet retained removable prosthesis.

Diced Cartilage Rhinoplasty for Cleft Nose Deformities: Determining the Flexibility of the Cartilage Framework

BACKGROUND

The objective of this trial is to evaluate the flexibility of the cartilaginous component of the cleft nose after diced cartilage rhinoplasty by determining the degree of possible bending in relation to the vertical nasal dorsum axis and to compare with to a control group of the unaffected population.

PATIENTS AND METHODS

Fifteen cleft nose patients with diced cartilage rhinoplasty were included in this study, as well as a control group of 15 unaffected individuals. The angle of maximum nasal bending is measured between the basic and maximum bending axis and performed by the same rater twice at least 2 weeks apart to account for intrarater reliability. Study groups were compared with Fisher and independent t test.

RESULTS

The maximum bending to the left side was 16.10 ± 5.03 degrees for the study group and 23.95 ± 6.54 degrees for the control group (P = 0.001). The maximum bending to the right side were 16.54 ± 6.73 degrees for the study group and 23.00 ± 8.88 degrees for the control group (P = 0.034).

CONCLUSION

Diced cartilage graft injection for dorsal augmentation yields reproducible and esthetically pleasing outcomes with good flexibility and natural feel of the nasal tip. Although there is a significant difference compared with a nonaffected control group in maximum bending capacity, all patients in this study were satisfied with the results.

Reducing the Cleft Nose Deformity in Bilateral Cleft Lip Repair

Repair of a bilateral cleft lip and nose deformity remains a challenge. The nose remains the main persisting stigma for patients, deserving an equal amount of attention as the lip during the repair. We share 3 technical principles to help achieve the optimal nasolabial result and minimize cleft nose deformity after bilateral cleft lip repair. Firstly, cephalad rotation of C-flaps from the prolabium is used to define the nasolabial angle. Secondly, the nasal base and contour is set before the lip repair, as the vectors and tension of nasal repair differ from the vector and tension of the orbicularis oris muscle closure. Thirdly, different suspension and shaping stitches are used to define alar shape and position after lower lateral cartilage release, avoiding additional scars.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: A 14-Year Review of Maintenance of Certification Tracer Data From the American Board of Plastic Surgery

OBJECTIVE

To evaluate evolving practice patterns in secondary cleft rhinoplasty.

DESIGN

Retrospective review of data submitted during Maintenance of Certification (MOC).

SETTING

Evaluation of MOC data from the American Board of Plastic Surgery.

PARTICIPANTS

Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns.

INTERVENTIONS

Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period.

MAIN OUTCOME MEASURES

Practice patterns were compared to EBM trends during the study period.

RESULTS

A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007).

CONCLUSIONS

These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

Correction of secondary unilateral cleft lip nasal deformity in adults using lower lateral cartilage repositioning, columellar strut, and onlay cartilage graft on the nasal tip with open rhinoplasty combined with reverse-U incision

A rhinoplasty technique involving lower lateral cartilage (LLC) repositioning and grafting of ear cartilage allows for nasal lengthening and nasal tip mobility. For better esthetic outcomes in patients with cleft lip nasal deformity (CLND), we combined cosmetic nasal tip plasty with standard techniques. We performed open rhinoplasty combined with reverse-U incision and V-Y plasty in 62 patients with secondary unilateral CLND from October 2013 to June 2018. Both LLCs were isolated, repositioned, approximated medially, and advanced with a Medpor strut, followed by tip suture technique. To further project and enhance the nasal tip and columella, application of ear cartilage onlay graft was used. As adjunctive procedures, septoplasty or osteotomy was carried out for correction of septal or nasal bone deviations, respectively. Photogrammetric evaluations of patients and statistical analyses were performed. Average age at operation was 23.5 years (range: 18-42 years). Of the 62 patients, 15 underwent dorsal augmentation with silicone implant. Two-layer conchal cartilage onlay grafting was performed to manage tip height. Outcomes in 34 patients were analyzed with pre- and postoperative photography. Nasal tip projection increased, alar base width index decreased, and alar and columellar symmetry significantly improved. No Medpor implant exposure or other adverse outcomes occurred. The proposed technique is effective for correcting secondary unilateral CLND and achieving a satisfying nasal appearance in adults.

Radiologic Evaluation of the Influence of Cleft Treatment on Nasal Dorsum Growth

OBJECTIVE

The study addresses whether the growth of the nasal dorsum is disturbed by cleft treatments, for cleft lip only (CL) and cleft lip with cleft palate (CLP).

DESIGN

A total of 576 patients with cleft (278 CL, 298 CLP) and 333 individuals without orofacial clefts were retrospectively enrolled. Cleft lip only group was treated with a modified Millard technique combined with Tajima incision for rhinoplasty at 3 to 6 months. The CLP group underwent the same lip repair technique and then underwent a Sommerlad palatoplasty at 9 to 12 months. Lateral cephalometric radiographs of all individuals were taken to evaluate the nasal length and nasal dorsum height. Dunn test was used to analyze the difference (P < .001).

RESULTS

Compared with control, in CL, nasal bone angle and nasal dorsum angle increase by age similarly (5-18 years, P > .05); the total dorsum is significantly shorter (5-18 years, P < .001), while the upper nasal dorsum length is similar (except in 5-6 years), and the lower nasal dorsum is shorter (5-18 years, P < .001). In CLP, nasal bone angle develops insufficiently as children grow (8-18 years, P < .001); the nasal dorsum angle is notably smaller (5-18 years, P < .001); nasal bone length is not significantly different except 11 to 13 years (P < .05); nasal dorsal length is similar at skeletal maturity (17-18 years, P > .05), although it is shorter during 8 to 16 years (P < .05); the upper nasal dorsum is overdeveloped (14-18 years, P < .05), whereas the lower nasal dorsum is underdeveloped (5-18 years, P < .001).

CONCLUSION

Treatments in both CL and CLP could be the important factors in disturbing the growth of cartilaginous portion of the nasal dorsum (including nasal tip) and the nasal dorsum height.

Three-Dimensional Analysis of Bilateral Cleft Lip and Palate Nasal Deformity

OBJECTIVE

This cross-sectional study utilizes 3-dimensional analysis to assess nasal morphology in patients with bilateral cleft lip and palate (BCLP) compared to controls across the timeline of cleft care.

DESIGN

Retrospective comparative cross-sectional study.

SETTING

Tertiary pediatric academic institution.

PATIENTS AND PARTICIPANTS

One hundred and twelve patients with BCLP and an equal number of age and sex-matched control participants.

MAIN OUTCOME MEASURE(S)

Nasolabial angle, nasal length, nasal protrusion, columella length, columella width, nasal tip width, alar width, and alar base width were collected at each time point. The measurements were collected pre-nasoalveolar molding (NAM) therapy, post-NAM therapy, post-primary cleft rhinoplasty, 1 year, 5 years, 10 years, and 15 years of age.

RESULTS

Nasolabial angle and nasal tip width were significantly different from controls from pre-NAM through 15 years of age time points. Nasal length was not significantly different at any time point. Alar width and alar base width were significantly different from pre-NAM through 10 years of age time points. Nasal protrusion, columella length, and columella width were significantly different from pre-NAM through 5 years of age time points.

CONCLUSIONS

This study demonstrates that three-dimensional photogrammetry is effective in assessing the changes in nasal morphology that occur throughout the course of care in patients with BCLP from before cleft lip repair to the completion of nasal growth.

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.

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.

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.

Validation of a Unilateral Cleft Lip Surgical Outcomes Evaluation Scale for Surgeons and Laypersons

BACKGROUND

A standardized evaluation tool is needed for the assessment of surgical outcomes in cleft lip surgery. Current scales for evaluating unilateral cleft lip/nose (UCL/N) aesthetic outcomes are limited in their reliability, ease of use, and application. The Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE) scale measures symmetry of 4 components and sums these for a total score. The purpose of this study was to validate the SOE as a reliable tool for use by both surgeons and laypersons.

METHODS

Twenty participants (9 surgeons and 12 laypeople) used the SOE to evaluate 25 sets of randomly selected presurgical and postsurgical standardized photographs of UCL/N patients. Interrater reliability for surgeon and laypeople was determined using an intraclass correlation coefficient (ICC).

RESULTS

Individual surgeons and laypeople both reached an ICC in the "fair to good" range (ICC = 0.42 and 0.59, respectively). Averaging 2 evaluators in the surgeon group improved the ICC to 0.58 and in the laypeople group to 0.74, respectively. Averaging 3 evaluators increased the ICC for surgeons to the "good" range (ICC = 0.71) and the ICC for laypeople to the "very good" range (ICC = 0.82).

CONCLUSIONS

Surgeon and layperson raters can reliably use the SOE to assess the aesthetics results after surgical repair of UCL/N, and improved reliability and reproducibility is achieved by averaging the scores of multiple reviewers.

The effects of Y-shaped conchal cartilage transplantation on the correction of nasal deformity secondary to cleft lip and its influence on mental health

Patients who undergo corrective surgery for cleft lip are known to be at risk for subsequently developing secondary nasal deformity. The aim of this study was to investigate the effects of Y-shaped conchal cartilage transplantation on the correction of nasal deformity secondary to cleft lip and its influence on mental health. Sixteen patients with nasal deformity secondary to cleft lip admitted to The First People's Hospital Xuzhou (Xuzhou, China) from February 2014 to February 2015 were selected for the study. Conchal cartilage was taken from the patients and made into a Y-shaped stent, which was then transplanted into the nasal columella. The surgical outcomes and patient satisfaction were evaluated and HADS was used to compare the preoperative and postoperative mental health. After the affected side of the nose was corrected, the nasal profiles of 12 patients were significantly improved, the height of nasal columella and nostril was significantly increased, the nasal base and breadth were significantly shorter than those before operation and the nose wing-nasal breadth index on the affected side was significantly increased compared to that before operation and the differences were statistically significant (P<0.05). The satisfaction of each index after the operation was more than 90%. The mental health of patients after operation was notably improved compared to before operation and the difference was statistically significant (P<0.05). After the correction of secondary nasal deformity to cleft lip through Y-shaped conchal cartilage transplantation, the shape of the nasal tip was stable without the recurrence of deformities or distortion on the donor site of the auricle. Y-shaped conchal cartilage transplantation is an ideal treatment method for the moderate and severe secondary nasal deformity to cleft lip and effective perioperative mental intervention can improve the patient's mental health status, an outcome that is worth popularizing in clinical applications.

Correlation between Nasoalveolar Molding and Surgical, Aesthetic, Functional and Socioeconomic Outcomes Following Primary Repair Surgery: a Systematic Review

OBJECTIVES

The authors performed a systematic review to evaluate the potential beneficial effects of the nasoalveolar molding appliance on nonsyndromic unilateral clefts of the lip and/or palate prior to primary lip repair.

MATERIAL AND METHODS

A literature search was performed using three electronic databases (PubMed, Embase, Web of Science) and three journals ("Cleft Palate-Craniofacial Journal", "Plastic and Reconstructive Surgery Journal" and "American Journal of Orthodontics and Dentofacial Orthopaedic") from January 1980 to April 2017. Data extraction was performed with tables treating different subjects: surgical, aesthetical, functional, socio-economical effects of nasoalveolar molding (NAM) appliances and the evolution of NAM appliances, especially three-dimensional technology.

RESULTS

Of the 145 articles retrieved in the literature surveys, 28 were qualified for the final analysis and 20 studies were excluded because of their small sample size (less than 10 patients) and/or too long follow-up (exceeded 18 months). Four randomized controlled trials were available. Although literature allowed discussing the short-term benefits of NAM appliance and the three-dimensional technology, scientific evidence is lacking.

CONCLUSIONS

Based on the results, nasoalveolar molding appliances have positive surgical, aesthetical, functional and socio-economical effects on unilateral clefts of the lip and/or palate treatment before the primary repair surgeries. Three-dimensional technology results in a more efficient and predictable nasoalveolar molding appliance treatment. However, nasoalveolar molding appliance effect in a short term remains unclear with the available literature. Further studies that integrate three-dimensional technology in a large scale are still needed.

Component columella augmentation in cleft nose rhinoplasty: a preliminary study

The purpose of this study was to evaluate the outcome of a component columella augmentation technique in cleft nose rhinoplasty. This prospective study included rhinoplasty procedures in bilateral cleft nose patients treated by component columella augmentation technique. After surgery, all patients were followed up daily for the first week, and then at 1 month and 6 months postoperative. The following four parameters were assessed: nasal tip projection, infratip lobule length, infratip lobule-to-base distance, and columella-labial angle. Thirteen rhinoplasty patients were included. Tip projection was increased (5.6±3.5mm) in all cases postoperatively (P<0.05); the increase was seen mostly in the lobule-to-base length (4.5±0.4mm), with a minimal change in lobule length (1.1±3.6mm). Preoperative and postoperative lobule lengths were not statistically different (P>0.05). With this technique, it is not necessary to involve the upper and lower lips. Therefore, the non-aesthetic vertical scars and tissue distortion that may occur with local flaps are easily avoided. Compared to composite augmentation, each part of the deformity (cartilage and skin) is precisely and separately restored with this technique.

Assessment of Labionasal Structures in Patients With Unilateral Cleft Lip

INTRODUCTION

Unilateral cleft lip (UCL) patients have lip and nose deformities that must be addressed during lip repair. Currently, devices to achieve lip and nose improvements have been developed. The most researched presurgical molding device is the nasoalveolar molding (NAM), which has shown favorable results. However, clinical observation shows that unilateral cleft patients, even without molding devices, achieve spontaneous improvements. The aim of this study is to compare morphological and symmetry changes in nose and lip, between patients less than 30-day old and those submitted to cheiloplasty, at 6 months of age.

MATERIALS AND METHODS

A total of 27 UCL patients with 2 photographs were selected. The pictures were taken from frontal view and nasal base view at 2 distinct moments: before 30 days of life (t1) and at 6 months of age, during cheiloplasty surgery (T2). Images were analyzed with indirect measurement to assess lip and nose dimensions and nasal symmetry. ImageJ software was used to perform the analyses.

RESULTS

A total of 20 patients (P < 0.05) had an average cleft width reduction of 15% [standard deviation (SD) ± 11%]. A 55% average increase (SD ± 29%) was observed in nostril height of cleft side in 16 of patients (P < 0.05). There was an reduction in facial asymmetry of nostril width (P < 0.05), from 95% (SD ± 90%) (t1) to 59% (SD ± 50) (T2). Also, nasal base width asymmetry (P < 0.05) was decreased from 64% (SD ± 66%) (t1) to 40% (SD ± 29%) (T2).

CONCLUSION

Facial growth causes a natural improvement on cleft morphological changes and nasal symmetry.

Nasal appearance after secondary cleft rhinoplasty: comparison of professional rating with patient satisfaction

OBJECTIVE

The purpose of this study was to compare professional rating and patient satisfaction of nasal appearance after secondary cleft rhinoplasty.

METHOD

We used a cross-sectional study design and enrolled German adults with nonsyndromic unilateral or bilateral cleft lip and/or palate (UCLP and BCLP, respectively) undergoing secondary cleft rhinoplasty from January 2001 to December 2013. The predictor variable was professional rating. The outcome variable was patient satisfaction with postoperative nasal aesthetics. Other study variables included patient age and gender, type of surgery, and patient rating of nasal function. Appropriate descriptive and univariate statistics were computed, and a P value of <0.05 was regarded as statistically significant. Inter-rater reliability was assessed by the use of Cohen's kappa coefficient.

RESULTS

The study sample consisted of 242 adult cleft patients of mean age of 22.1 ± 9.2 years (range 14-64), including 97 females (40 %) and 176 unilateral clefts (73 %). Most of the patients reported good function (82 %) and good aesthetics (74 %). The main professional rating was good aesthetics (65 %). Analysis of inter-observer reliability revealed significant differences between patient satisfaction and professional assessment (κ = 0.385; P < 0.0001).

CONCLUSIONS

Although most of the patients were satisfied with the functional and aesthetic results of secondary cleft rhinoplasty, patient self-assessment of nasal appearance differed from professional assessment.

Pitfalls and solutions in virtual design of nasoalveolar molding plates by using CAD/CAM technology--A preliminary clinical study

PURPOSE

Computer-assisted design and computer-aided manufacturing (CAD/CAM) technology in nasoalveolar molding (NAM) should save time and manpower and reduce family input in cases of cleft lip and palate.

MATERIAL AND METHODS

Intraoral casts from 12 infants with complete unilateral cleft lip and palate were taken immediately after birth (T1) and after (T2) NAM treatment, digitalized, and transformed into STL data. The infants were randomized into Group 1 (n = 6) receiving conventional NAM treatment or Group 2 receiving CAD/CAM NAM (n = 6). We analyzed the following variables by using Geomagic software: intersegmental alveolar distance (ISAD); intersegmental lip distance (ISLD); nostril height cleft/noncleft (NHc/nc); nasal width cleft/noncleft (NWn/nc); and columella deviation angle (CDA).

RESULTS

In both groups, all variables except NHnc and NWnc were changed significantly between T1 and T2. The analysis of the mean differences of the variables in Group 1 and 2 showed no significant differences, with a comparable incidence of clinical alterations such as skin or mucosal irritations.

CONCLUSION

NAM plates can be produced virtually by using CAD/CAM technology. The CAD/CAM NAM results show no significant differences from the conventional technique. We present our clinically usable virtual CAD/CAM workflow for producing a basic NAM plate.

Edge locked stitching between nostril ala and lateral cartilages with a mucochondrial Z-plasty in correction of unilateral cleft nasal deformity in secondary rhinoplasty

BACKGROUND

Ala and nostril collapse are most raised complaints in secondary deformity of unilateral cleft patients. While a lot of techniques have been introduced so far, the purpose of this study was to evaluate the effectiveness of edge locked stitching between nostril ala and lateral cartilages with mucochondrial Z-plasty to correct the collapse in lower lateral cartilage in the ala and nostril shaping.

METHODS

Fifty-seven patients with unilateral cleft nasal deformities were recruited. They all had primary surgery before and were left with nasal deformities. Based on the anatomic understanding, we operated on all the patients using edge locked stitching between nostril ala and lateral cartilages with a mucochondrial Z-plasty to correct the abnormal lateral collapse of nostril deformities.

RESULTS

All the patients had an improvement in the shape of the ala and nostril immediately after the surgery. Follow-up at 6 months (or later) showed no severe relapse.

CONCLUSION

The edge locked stitching between nostril ala and lateral cartilages with mucochondrial Z-plasty is effective to correct ala and nostril deformities in unilateral cleft.

Description of total population hospital admissions for cleft lip and/or palate in Australia

BACKGROUND

Orofacial clefts are a group of frequently observed congenital malformations often requiring multiple hospital admissions over the lifespan of affected individuals. The aim of this study was to describe the total-population hospital admissions with principal diagnosis of cleft lip and/or palate in Australia over a 10 year period.

METHODS

Data for admissions to hospitals were obtained from the Australian Institute of Health and Welfare National Hospital Morbidity Database (July 2000 to June 2010). The outcome variable was a hospital separation with the principal diagnosis of cleft palate, cleft lip or cleft lip and palate (ICD-10-AM diagnosis codes Q35-Q37 respectively). Trends in rates of admission and length of stay by age, gender and cleft type were investigated.

RESULTS

A total of 11, 618 admissions were identified; cleft palate (4,454; 0.22 per 10,000 people per year), cleft lip (2,251; 0.11) and cleft lip and palate (4,913; 0.25). Admission age ranged from birth to 79 years with males more frequently admitted. Most admissions occurred prior to adolescence in cleft palate and cleft lip and through to late teens in cleft lip and palate, declining for all groups after 25 years.

CONCLUSIONS

This study identified population level trends in hospital separations for orofacial cleft diagnosis in Australia.

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.