Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty

Poly Lactic-co-Glycolic Acid Absorbable Plate Graft for Secondary Rhinoplasty in Asian Patients with Unilateral Cleft Lip Nose Deformity

INTRODUCTION

In secondary cleft lip and nasal deformity (CLND) correction, structural grafts are commonly used to control the nasal tip and restore the symmetry of the ala. However, the septal cartilage in Asians often weak and small. Biocompatible absorbable materials are alternatives to autologous grafts. This study assessed the surgical outcomes and complications of poly lactic-co-glycolic acid (PLGA) plate grafts in secondary CLND correction.

METHODS

This study was retrospectively analyzed for patients who underwent secondary rhinoplasty for unilateral CLND correction between March 2015 and November 2020. Using open rhinoplasty, the PLGA plate was grafted as a columellar strut. Clinical photographs taken at the initial (T0) and follow-up visits (T1: short-term, T2: long-term) were analyzed and anthropometric parameters, such as nostril height and width, dome height, and tip height, were measured.

RESULTS

Twenty-four patients were included in this study. The mean T1 and T2 periods were 1.0 ± 0.4 and 15.5 ± 3.1 months, respectively. The nostril height ratio increased from 0.78 ± 0.12 at T0 to 0.88 ± 0.08 at T1 and 0.86 ± 0.09 at T2 (p < 0.001; Relapse ratio -2.6 ± 6.7%). The tip height ratio increased from 0.60 ± 0.07 (T0) to 0.66 ± 0.05 (T2) (Relapse ratio -3.7 ± 3.0%).

CONCLUSIONS

The PLGA plate graft provided stable nasal tip projection and alar symmetry without major complications. It can be a good option for patients lacking available septal and concha cartilages or apprehensive of additional scarring.

Chang Gung Forum: An Exemplary Strategy for Implementing a Multidisciplinary Network of Experts in Craniofacial Anomalies

INTRODUCTION

The Chang Gung Forum has been dedicated to the care of craniofacial anomalies since 2000. This annual continuing medical education program focuses on orofacial cleft and surgery-first orthognathic surgery by providing up-to-date information and management guidelines. This study explored how the Chang Gung Forum has influenced medical perspectives, decisions, and practices in a multidisciplinary craniofacial team.

METHODS

Between 2000 and 2022, 20 Chang Gung Forums have been held. A questionnaire was distributed among 170 attendees who had participated in the forum more than once. The questionnaire collected information on the participants' experiences and levels of satisfaction with the educational program and whether or how it had influenced their clinical practice.

RESULTS

Valid responses from 86 attendees (response rate, 50.6%) who had participated more than once were collected and analyzed. The overall satisfaction rate of the Chang Gung Forum based on the respondents' most recent visits was 4.28 ± 0.63 out of 5. Of the respondents, 90.9% acknowledged changes in their clinical practice, with modifications in surgery plans and decisions being the most notable (48.5%). In addition, comprehension increased throughout years of attending the annual forum (P < 0.001).

CONCLUSION

The Chang Gung Forum has contributed markedly to the community of congenital craniofacial anomalies. The program will continue providing updated information and influencing the clinical decision-making of health care professionals.

"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.

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

Background

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

Methods

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

Results

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

Conclusions

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

Primary Cleft Rhinoplasty: 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.

Use of Septal Cartilage in Rhinoplasty to Correct Nasal Deformity After Unilateral Cleft Lip and Palate Surgery

Background

The most common facial defect is the congenital cleft lip (CL), which can occur with or without a cleft palate (CP). Patients need primary plastic surgery for rehabilitation and esthetics; nevertheless, secondary abnormalities of the lip and nose may develop after primary surgery. These deformities are complex and involve all tissue layers, including the skeletal platform, inner lining, osseocartilaginous structure, and overlying skin. This study evaluated the results of nasal deformity rhinoplasty using septal cartilage in patients with nasal deformities after plastic surgery for unilateral CL and CP.

Methods

This retrospective study was conducted on 21 patients with secondary unilateral CL nasal deformity between June 2015 and August 2016. All patients underwent rhinoplasty with the use of septal cartilage grafts. Pre- and post-operative nasal forms were measured.

Results

The patients had cosmetic problems and impaired nasal airflow due to distorted anatomy. The postoperative nasal forms were improved in all patients. Rhinoplasty using septal cartilage effectively increased the height of the columella and nose and improved the balance of the base width and the length of both sides of the nose. Excellent results were achieved in 18 patients. Three patients showed good results. No patient showed a fair result.

Conclusion

This study demonstrated an effective correction of esthetic deformities and significant improvement in airway patency. A long-term longitudinal study is still required to evaluate the influence of septal cartilage harvesting on face and nasal development until children reach their late teens.

Three-Dimensional Anthropometry for Evaluating Reliability of Worm's Eye View Photographs of Unilateral Cleft Lip Nasal Deformity

BACKGROUND

Worm's eye view photograph has been widely used for anthropometric analysis. However, it is difficult to secure objectivity because it cannot be captured at a constant head-up degree. This study aimed to analyze whether anthropometric nasal measurements in worm's eye view differ from the actual values.

METHODS

A total of 40 patients with unilateral cleft lip nasal deformities were included. The 30° and 60° head-tilted two-dimensional (2D) photographs were captured from the three-dimensional (3D) images. The real measurements were obtained from 3D images and 2D measurements were obtained from the captured images. The cleft/non-cleft side ratios of the nostril height, width, and alar base width were compared between 3D and 2D images.

RESULTS

There was a significant difference in the nostril height between the 3D and 30° values (3D = 0.82, 30° = 0.92, P < 0.001) but no meaningful difference was noted between the 3D and 60° values (3D = 0.82, 60° = 0.84, P = 0.31). There was no significant difference in the nostril width among the 30°, 60°, and 3D values. A significant difference was found in the alar base width between the 3D values and both the 30° (3D = 0.998, 30° = 1.04, P = 0.026) and 60° (3D = 0.998, 30° = 1.03, P = 0.029) values.

CONCLUSIONS

This study demonstrates that 2D photographs do not accurately reflect actual values. The nostril height and alar width ratio can be changed depending on the head-up position. The 3D systems are more accurate and less affected by the subject's head position. Therefore, the 3D imaging system is advocated for the anthropometric analysis of unilateral cleft lip nasal deformity.

Update in Unilateral Cleft Lip Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the unilateral cleft lip and nasal deformity and associated anatomical variations. 2. Understand the history and evolution of the unilateral cleft lip repair. 3. List different presurgical treatment options. 4. Differentiate between surgical techniques.

SUMMARY

This article describes characteristics of the unilateral cleft lip and nasal deformity and its management, including presurgical orthopedics, operative techniques, and postsurgical care. The rotation-advancement and straight-line repairs are discussed in detail, as are the current concepts in primary cleft nose repair.

Safety of Irradiated Homologous Costal Cartilage Graft in Cleft Rhinoplasty

BACKGROUND

Autologous cartilage grafts have a low risk of infection and extrusion in cleft rhinoplasty. However, harvesting autologous cartilage involves donor-site morbidity and increased time under anesthesia. Irradiated homologous costal cartilage grafts may be an effective alternative.

METHODS

A retrospective study was performed on patients with a history of cleft lip who underwent rhinoplasty for cleft nasal deformity at Johns Hopkins Hospital from 2009 to 2018. Patients were excluded if their rhinoplasty did not involve a cartilage graft.

RESULTS

One hundred sixty-five cleft rhinoplasties (patient age, 2 to 72 years; 52 percent female) were performed. Median follow-up time was 256 days; 30 percent were revision operations. Ninety-six procedures (58 percent) used irradiated homologous costal cartilage grafts, with the remaining using autologous cartilage. Complications resulted from 18 procedures (11 percent), seven (10 percent) involving autologous cartilage and 11 (12 percent) involving irradiated homologous costal cartilage. Most autologous cartilage complications (86 percent) required operative intervention, versus seven of 11 (64 percent) for irradiated homologous costal cartilage. Complications associated with irradiated homologous costal cartilage included infection (n = 5), warping (n = 2), and extrusion (n = 1), while two patients with autologous cartilage experienced collapse and one each experienced resorption, warping, and hypertrophic donor-site scarring. There was no difference between groups regarding complication rate or complications requiring operative intervention (p = 0.3 and p = 0.5, respectively).

CONCLUSIONS

Irradiated homologous costal cartilage grafts are equally safe and effective as autologous cartilage for use in cleft rhinoplasty. These grafts are readily available and eliminate donor-site morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Modified Use of Costal Cartilage in Asians for the Correction of Nostril Asymmetry in Unilateral Secondary Cleft Lip Nasal Deformity

BACKGROUND

Weak alar cartilage and lack of soft tissue on the cleft side are considered to be the main critical factors leading to the asymmetry of bilateral nostrils. The costal cartilage can provide strong structural support and can be used to maintain long-term stability of nostril shape after surgical correction. With the advancement in rhinoplasty techniques, the application and understanding of costal cartilage in cleft lip nasal deformity is still on going. Herein, we present our technique of applying costal cartilage to provide nostril support and correct asymmetry in Asian patients with unilateral secondary cleft lip nasal deformity.

METHODS

Ninety-seven patients who underwent nostril asymmetry correction from January 1, 2013, to October 31, 2018, were analyzed retrospectively. Modified integrative alar cartilage strut and diced nostril augmentation with costal cartilage were implemented to improve the collapsed and flat cleft-side nostril. The release and restoration of muscle and bone were also performed when required. Surgical outcomes were analyzed based on the comparison of nostril parameters, the shape and contour, and symmetry of bilateral nostrils after surgery. During postoperative follow-up, the patients' satisfactions with the corrective outcomes were also investigated.

RESULTS

All patients received the corrective operations with complete survival of all implanted cartilages. The nostril width was narrower in postoperative group (P < 0.05). The nostril height and long axis angle were higher postoperatively (P < 0.05). After correction, the proportion of moderate type increased from 13.4% to 80.4%, whereas the proportion of horizontal type decreased from 86.6% to 17.5%. The symmetry score on the nostril parameters manifested the rate of high score (AS >3) in postoperative groups were 84.5%, 93.8%, and 87.6% for width, height, and angle of the long axis, respectively. They were higher compared with those of preoperative group (0%). More than 95% of the patients were satisfied with the overall aesthetic outcome of the surgery.

CONCLUSIONS

Through ameliorating its constructive technology and optimizing its filling form, the modified use of costal cartilage displayed excellent correction effects in the width, height, and long axis angle asymmetry of Asian patients' nostril. Precise and comprehensive rhinoplasty technique is the cornerstone for achieving satisfactory long-term aesthetic outcomes, especially in severe cases, such as secondary cleft lip nasal deformity.

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.

Cartilage Grafting Outcomes in Intermediate and Definitive Cleft Rhinoplasty

OBJECTIVE

To compare cartilage grafting outcomes in intermediate versus definitive cleft rhinoplasty.

DESIGN

A retrospective chart review was conducted. The χ² and Fisher exact tests were used for statistical analyses. Results were considered statistically significant at P < .05.

PARTICIPANTS

All subjects who underwent revision cleft rhinoplasties between July 2011 and June 2019 were included. Subjects with syndromic conditions were excluded.

RESULTS

A total of 46 subjects with a cleft nose deformity underwent 65 rhinoplasty procedures. The ages averaged 17 years (range 5-50) with 34 (73.9%) males and 12 (26.1%) females. In the intermediate group, 6 (28.6%) subjects required cartilage grafting as part of 6 cleft rhinoplasties, whereas 15 (71.4%) subjects underwent a total of 26 cleft rhinoplasties that did not require grafting. In the definitive group, 18 (76%) subjects required cartilage grafting over 21 cleft rhinoplasties, whereas 7 (24%) subjects underwent a total of 9 cleft rhinoplasties where cartilage grafting was not required. The difference between the number of subjects requiring cartilage grafting in the intermediate versus the definitive group was statistically significant (P = .007). Ear concha and nose were the most frequently used cartilage donor sites, with no observed complications.

CONCLUSIONS

Cartilage grafting was significantly more common in the definitive rhinoplasty group. Intermediate cleft rhinoplasty during the 5- to 13-year age period was effective, with a low-risk profile. In our experience, ear concha and nose were the preferred cartilage donor sites, with effective results and an excellent safety profile.

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.

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.

Secondary Cleft Rhinoplasty in 1720 Patients: Are National Practices Consistent With Guidelines?

OBJECTIVE

To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally.

DESIGN

Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis.

SETTING

National Surgical Quality Improvement Program-Pediatric Database.

PARTICIPANTS

A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair.

INTERVENTIONS

No relevant intervention.

MAIN OUTCOMES AND MEASURES

Age, demographics, comorbidities, and associated procedures.

RESULTS

Over 5 consecutive years, 1720 patients underwent secondary cleft lip rhinoplasty nationally. Mean patient age was 9.3 ± 5.3 years. Unilateral cleft rhinoplasty patients were older (9.0 years) than bilateral patients (7.8 years; P = .001). Rib grafting was performed in 6.3% of patients at a mean age of 10.6 years with a higher proportion of Asian and female patients. Auricular grafts were more commonly performed by otolaryngology than plastic surgery. The most common adjunct procedures included secondary cleft lip revision (33.1%) and tympanostomy tube placement (10.2%). When subdividing by type of cleft rhinoplasty, tip rhinoplasty was performed at a mean age of 7.3 years compared to rhinoplasty with osteotomies and a major septal component at 12.1 years (P < .001).

CONCLUSIONS

This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.

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

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

Association between three-dimensional measurements of the unilateral cleft lip nasal deformity and maxillary alveolar morphology: A retrospective study

BACKGROUND

It is debatable whether rhinoplasty is necessary during a primary operation for cleft lip. However, many surgeons believe that rhinoplasty should be performed simultaneously for severe deformities. We investigated whether alveolar cleft severity is involved in nasal deformity.

METHODS

Forty-three patients were assessed for alveolar cleft severity using maxillary plaster models prepared during primary cheiloplasty. We conducted morphological assessments of nasal deformities using three-dimensional photogrammetry. Patients were divided into two groups according to alveolar cleft severity: group A, overlap of the alveolar segments; group B, nonoverlap of the alveolar segments. Nasal asymmetry was assessed by measuring distances between landmarks around the nostrils and the columellar angle. These measurements were compared between the groups. The correlations between the columellar angle and the ratios of the five cleft side/non-cleft side distances and the correlation of each ratio were analyzed.

RESULTS

Groups A and B included 21 and 22 patients, respectively. Group A demonstrated superior deviation of the alar base on the non-cleft side than that of the alar base on the cleft side (p < 0.05). No other statistically significant differences were observed. Group A had more severe nasal deformity. Columellar angle and nostril base width demonstrated correlation.

CONCLUSION

In an uncorrected, unoperated unilateral cleft lip nasal deformity, alar base deformity is affected by deformity of the alveolar segments.

A New Paradigm in Cleft Lip Procedural Excellence: Creation and Preliminary Digital Validation of a Lifelike Simulator

Simulation is becoming an increasingly important tool for hands-on surgical education in a no-risk environment. Cleft lip repair is a common procedure where precise technique is needed to achieve optimal outcome, making it an ideal candidate for simulation. A digital simulated patient with a typical unilateral complete cleft lip and alveolus was constructed using existing three-dimensional imaging studies. Key surface and internal anatomical elements were characterized in detail. A prototype high-fidelity simulator was constructed with silicone and synthetic polymers over a supportive scaffold, piloted by three surgeons using multiple techniques, and digitally compared to real patients. All surgeons completed key steps of a cleft lip repair on the simulator and found it approximated the haptics and anatomy of a cleft lip. Surface change and anthropometric movements accomplished on the simulator were similar for all three surgeons. In digital comparison to analogous real patient data, the simulator anthropometric movements and topographic change were similar to real nasolabial movement. A high-fidelity cleft lip simulator provides "on-demand" opportunity to realistically practice all steps of a cleft lip repair, with implications for overcoming volume-outcome relationship challenges of diminishing operative experience for resident surgeons.

Septal anchoring suture: a key suture to improve the nasolabial symmetry in unilateral cheiloplasty

Since 2008, a septal anchoring suture has been used in unilateral cleft lip repair at Chang Gung Memorial Hospital in order to stabilize the lateral lip centrally. This study compared the symmetry of two groups of patients: those treated with and without an anchoring suture. Multiple standardized direct and photographic facial measurements were performed on the faces of all patients pre-cheiloplasty and at 5 years post-cheiloplasty. The degree of nasolabial symmetry was evaluated by comparing the ratios of measurements of the cleft vs. non-cleft sides. The ratio of change in these measurements was also compared postoperatively. The vertical lip length ratio approached 1 in the septal anchoring suture group, which differed significantly from the group without the suture (0.968 vs. 0.873, P<0.001). As expected, the horizontal lip length and central lip height ratios showed no statistically significant change. The ratio of change from pre- to postoperative also showed a significant improvement (P=0.028) in the vertical lip length of the group with the septal anchoring suture compared to the one without. The septal anchoring suture is a useful method to correct the tendency of the lip to shift to the cleft side.