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

Secondary Bilateral Cleft Rhinoplasty: Achieving an Aesthetic Result

BACKGROUND

Secondary rhinoplasty in patients with bilateral cleft lip poses ongoing challenges and requires a reliable method for achieving optimal outcomes.

OBJECTIVES

The purpose of this study was to establish a safe and effective method for secondary bilateral cleft rhinoplasty.

METHODS

A consecutive series of 92 skeletally matured patients with bilateral cleft lip and nasal deformity were included. All had undergone secondary open rhinoplasty, performed by a single surgeon with a bilateral reverse-U flap and septal extension graft, between 2013 and 2021. Medical records of these 92 patients were reviewed to assess the clinical course. A 3-dimensional (3D) anthropometric analysis and panel assessment of 32 patients were performed to evaluate the aesthetic improvement, with an age-, sex-, and ethnicity-matched normal control group for comparisons.

RESULTS

The methods showed statistically significant improvement in addressing a short columella (columellar height), short nasal bridge (nasal bridge length), de-projected nasal tip (nasal tip projection, nasal dorsum angle), poorly defined nasal tip (nasal tip angle, dome height, and panel assessment), and transversely oriented nostrils (columellar height, alar width, nostril type). Importantly, these improvements were accompanied by a low complication rate of 4%. However, upper lip deficiency over the upper lip angle and labial-columellar angle remained without significant improvement.

CONCLUSIONS

In this study we described effective secondary rhinoplasty, which was composed of a bilateral reverse-U flap and septal extension graft, with acceptable outcome. The 3D anthropometric analysis and panel assessment clarified that our rhinoplasty procedure could bring the nasal morphology in these patients closer to the normal data.

LEVEL OF EVIDENCE: 3

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.

Open rhinoplasty in secondary cleft nose deformity with suture techniques

Background: Correction of secondary cleft nose deformity is one of the most important portions in the management of cleft lip patients. Various techniques have been introduced to achieve adequate shape, balance, and symmetry of anatomical landmarks. None of these methods can claim to universally solve all aspects of the problems encountered in secondary cleft deformity surgery. Some authors overlook the aspect of functional rehabilitation with regard to nasal respiratory pathway problems, which is present in over 90% of the patients. This study aimed to evaluate the aesthetic and functional improvements of the authors’ non-destructive technique.Methods: With over 15 years of experience, open rhinoplasty was performed, which included total remodeling of the deformed lower lateral cartilage using several suture fixation techniques without any graft or implantation with septo-turbinoplasty. A total of 150 questionnaires were sent by e-mail, but 55 completed questionnaires were returned. Surgical outcomes were evaluated using questionnaire responses, and outcomes were divided into five categories each for esthetic and functional analyses.Results: The satisfaction rate ranged from 75 % to 98%, which means “more or less,” “very much,” and “absolutely yes” in the esthetic and functional viewpoints.Conclusion: The results of this study strongly recommend performing the suture fixation technique and functional rehabilitation simultaneously for cleft lip/nose correction.

Component Restoration in the Bilateral Intermediate Cleft Tip Rhinoplasty

SUMMARY

The intermediate cleft tip rhinoplasty is frequently performed during childhood to address nasal tip anomalies in cleft patients before the most critical period of psychosocial development. The authors previously described the component restoration intermediate cleft tip rhinoplasty technique for the unilateral cleft nose, which was developed to systematically address the lining deficiency, cleft lower lateral cartilage malpositioning, and cleft lateral cartilage weakness using a combination of lower lateral cartilage release, lateral cartilage repositioning, and placement of an auricular composite chondrocutaneous graft. In this work, the authors evaluate the utility of this technique to the bilateral cleft nose. Preoperative and postoperative (mean ± SD, 18.6 ± 10.8 months) photographs of bilateral cleft patients treated with the component restoration intermediate cleft tip rhinoplasty (n = 7) were evaluated using photogrammetric measurements and aesthetic assessments. From preoperatively to postoperatively, the columella length-to-alar width ratio on basal photographs increased (0.19 ± 0.05 versus 0.28 ± 0.05; p = 0.001). On lateral view, the columella-labial angle decreased from preoperatively to postoperatively [138 degrees (interquartile range, 132 to 144 degrees) versus 123 degrees (interquartile range, 122 to 139 degrees); p = 0.04]. Aesthetic ratings performed by four blinded observers also improved from preoperatively to postoperatively (1.6 ± 0.8 versus 2.4 ± 0.7; p = 0.004). As a comparison, bilateral cleft nose patients who did not undergo intermediate cleft tip rhinoplasty (n = 3) of similar ages were subjected to the same photogrammetric and aesthetic analyses, which showed no differences from preoperatively to postoperatively. In combination, the current work suggests that the component restoration technique in the bilateral intermediate cleft tip rhinoplasty improves nasal tip support and aesthetic outcomes.

Change in nostril ratio after cleft rhinoplasty: correction of nostril stenosis with full-thickness skin graft

Background

Patients with secondary deformities associated with unilateral cleft lip and nose might also suffer from nostril stenosis due to a lack of tissue volume in the nostril on the cleft side. Here, we used full-thickness skin grafts (FTSGs) to reduce nostril stenosis and various methods for skin volume augmentation. We compared the changes in the symmetry of both nostrils before and after surgery.

Methods

From February 2016 to January 2020, 34 patients underwent secondary cheiloplasty and open rhinoplasty for secondary deformities of the unilateral cleft lip and nose with nostril stenosis. FTSG was used on the nostril floor, nasal columella, and alar inner lining. The measured nasal profile included the nostril surface, nostril circumference, width of the nostril floor, and distance from the alar-facial groove to the nasal tip. The “overlap area,” which was defined as the largest overlapping area when the image of the cleft nostril was flipped to the left and right and overlaid on the image of the normal side nostril, was also calculated. The degree of symmetry was evaluated by dividing the value of the cleft side by that of the normal side of each measured profile and expressed as “ratios.”

Results

The results of all profile ratios, except for the nostril floor width, became significantly close to 1, which represents full symmetry. The overlap area ratio improved from 62.7% to 77.3%, meaning that the length and width of the nostril as well as the overall shape became similar (p<0.05).

Conclusion

When performing cleft rhinoplasty with nostril stenosis, FTSG is useful to achieve symmetry in the nostril size and shape. Skin grafting is simpler to perform than the other types of local flap, and the results are generally satisfactory.

The conchal butterfly graft in secondary reconstruction of the bilateral cleft lip nasal deformity

OBJECTIVES

The bilateral cleft nasal deformity is characterized by a short columella and a broad, flattened nasal tip. Secondary correction is challenging and often complicated by skin envelope scarring and hypoplastic alar cartilages. Adequate and durable tip projection requires a procedure that adequately augments the nasal tip and maximizes tip support. We describe a novel technique for secondary correction of this deformity in the immature pediatric population.

METHODS

The conchal butterfly graft technique utilizes a folded cartilage construct to simultaneously increase tip projection and provide tip support. A retrospective review of 19 consecutive patients with bilateral cleft lip who underwent secondary tip rhinoplasty utilizing our technique over a 7-year period was conducted. Charts were reviewed for age at operation, length of follow-up and secondary revision procedures. Pre- and post-operative photographs were compared using two different methods to assess the degree of change and overall aesthetic result. Three plastic surgeons who previously were unfamiliar with the technique independently rated seven nasal tip characteristics. Nasal tip projection (NTP) was then measured objectively by two widely utilized methods: the Goode method and the Baum method-modified by Powell.

RESULTS

Long lasting correction of the bilateral cleft nasal deformity was achieved utilizing this technique in 19 patients over a 7-year period with a mean length of follow-up of 5.4 years. We demonstrate augmented nasal tip projection that approaches ideal relationships from both relative measurement and survey data.

CONCLUSION

The conchal butterfly graft technique is effective for reconstruction of the bilateral cleft nasal deformity, and in our experience, has resulted in long lasting nasal projection and overall improved facial balance.

Nasal columella reconstruction - A comprehensive review of the current techniques

The nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischaemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques.

Lipofilling in patients with a cleft lip (and palate) - a pilot study assessing functional outcomes and patients' satisfaction with appearance

INTRODUCTION

Lipofilling of the upper lip as secondary treatment in patients with a cleft lip (and palate) (CL ± P) has been proposed to improve projection and volume especially in profile view. The purpose of the present study was to document differences in functional (i.e. logopaedic) and self-reported aesthetic outcomes by comparing pre- and postoperative results after lipofilling of the upper lip in patients with CL ± P.

METHODS

Eight Dutch-speaking youngsters and young adults (three women, five men) with CL ± P were included. The median age was 19 years (range: 14-24 years). Logopaedic outcomes (i.e. assessment of orofacial myofunctional behavior, articulation and lip strength) and self-reported aesthetic outcome (i.e. patients' satisfaction using the Cleft Evaluation Profile) were determined.

RESULTS

Neither for lip strength and orofacial myofunctional behavior nor for articulation statistically significant differences were found when comparing measurements before and after lipofilling. Regarding patients' satisfaction, a statistically significant increased self-evaluation of appearance in profile was found after lipofilling.

CONCLUSION

Regarding functionality, the present study did not find any differences when comparing outcomes before and after lipofilling. Nevertheless, patients were more satisfied with appearance in profile after performance of this technique. As this is a small sample study, further research and long-term follow-up studies are necessary.

Columella Elongation Surgery Outcome in Complete Bilateral Cleft Lip and Palate

Background:

The evaluation of surgical outcomes is needed to achieve excellence in nasal reconstruction of patients with complete bilateral cleft lip and palate (BCLP). The study objective is to evaluate the quality of nasal aesthetics after the columella elongation surgery.

Methods:

The sample of this study consisted of 70 patients with complete BCLP, operated on columella elongation surgery and analyzed at 6 to 12 years. The system for evaluation of nasal appearance after the columella elongation surgery was performed by objective and subjective analyses.

Anthropometric Measurements:

Four anthropometric nose measurements were performed directly on the faces, and the same was performed in control group (60 children without oral clefts), paired by age and sex with the experimental group. The measurements were repeated 3 times (triplicate).

Subjective Analysis:

Scores to evaluate nasal width, nasal tip projection, and length of the columella were applied before and after the columella elongation surgery by 5 raters from the rehabilitation team. Interrater and intrarater agreement was calculated by means of the kappa test.

Results:

Nasal width in BCLP group was higher when compared to the control group (P < 0.05). Nasal tip projection (subnasal–pronasal) and columella length (subnasal–columella) were decreased in BCLP group compared to that of the controls (P < 0.05). Columella width was similar in both study groups (P > 0.05). All scores of nasal aesthetics significantly improved after the columella elongation surgery.

Conclusions:

Nose of the patients with BCLP is wider, is less projected, and has the shorter columella compared to that of the noncleft subjects. After secondary columella elongation surgery in BCLP, nasal width, nasal projection, and columella length significantly improved.

Effects of Human Adipose-Derived Stem Cells on the Survival of Rabbit Ear Composite Grafts

Background

Composite grafts are frequently used for facial reconstruction. However, the unpredictability of the results and difficulties with large defects are disadvantages. Adipose-derived stem cells (ADSCs) express several cytokines, and increase the survival of random flaps and fat grafts owing to their angiogenic potential.

Methods

This study investigated composite graft survival after ADSC injection. Circular chondrocutaneous composite tissues, 2 cm in diameter, from 15 New Zealand white rabbits were used. Thirty ears were randomly divided into 3 groups. In the experimental groups (1 and 2), ADSCs were subcutaneously injected 7 days and immediately before the operation, respectively. Similarly, phosphate-buffered saline was injected in the control group just before surgery in the same manner as in group 2. In all groups, chondrocutaneous composite tissue was elevated, rotated 90 degrees, and repaired in its original position. Skin flow was assessed using laser Doppler 1, 3, 6, 9, and 12 days after surgery. At 1 and 12 days after surgery, the viable area was assessed using digital photography; the rabbits were euthanized, and immunohistochemical staining for CD31 was performed to assess neovascularization.

Results

The survival of composite grafts increased significantly with the injection of ADSCs (P<0.05). ADSC injection significantly improved neovascularization based on anti-CD31 immunohistochemical analysis and vascular endothelial growth factor expression (P<0.05) in both group 1 and group 2 compared to the control group. No statistically significant differences in graft survival, anti-CD31 neovascularization, or microcirculation were found between groups 1 and 2.

Conclusions

Treatment with ADSCs improved the composite graft survival, as confirmed by the survival area and histological evaluation. The differences according to the injection timing were not significant.

Nasal Base Retraction: A Treatment Algorithm

BACKGROUND

Nasal base retraction results from cephalic malposition of the alar base in the vertical plane, which causes disharmony of the alar base with the rest of the nose structures. Correcting nasal base retraction is very important for improved aesthetic outcomes; however, there is a limited body of literature about this deformity and its treatment.

OBJECTIVES

Create a nasal base retraction treatment algorithm based on a severity classification system.

METHODS

This is a retrospective case review study of 53 patients who underwent rhinoplasty with correction of alar base retraction by the senior author (S.T.). The minimum follow-up time was 6 months. Levator labii alaque nasi muscle dissection or alar base release with or without a rim graft on the effected side were performed based on the severity of the alar base retraction. Aesthetic results were assessed with objective grading of preoperative and postoperative patient photographs by two independent plastic surgeons. Functional improvement was assessed with patient self-evaluations of nasal patency. Also, a rhinoplasty outcomes evaluation (ROE) questionnaire was distributed to patients.

RESULTS

Comparison of preoperative and postoperative photographs demonstrated that nasal base asymmetry was significantly improved in all cases, and 85% of the patients had complete symmetry. Nasal obstruction was also significantly reduced after surgery (P < 0.001). The majority of patients reported satisfaction (92.5%), with an ROE total score greater than or equal to 20.

CONCLUSIONS

New techniques and a treatment algorithm for correcting nasal base retraction deformities that will help rhinoplasty surgeons obtain aesthetically and functionally pleasing outcomes for patients.

LEVEL OF EVIDENCE 4

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.

An Innovative Technique for Columellar Reconstruction using 'Flip-Over' Buccal Mucosa Flap

Loss of columella is a significant deformity and its reconstruction proves to be quite difficult. An 18-year-old lady had loss of columella due to burn while steam inhalation at a young age and required reconstruction for the same. Labial mucosa has been used as a source of tissue for columellar reconstruction since long. We describe a modification of the buccal mucosal flap to manage a difficult case of columellar deficiency. The buccal mucosa flap was used to cover the columellar defect in the usual manner in the first stage and in second stage, along with division of the base, the residual length of the mucosal flap was used to add to the thickness of columella by doubling it on itself.

Rhinoplasty for the Cleft Lip and Palate Patient

Septorhinoplasties in cleft patients are challenging procedures to perform for even the most experienced surgeon. Unilateral cleft rhinoplasties present a unique challenge given that the tissue bed has had previous manipulation and scarring is found around the tissue matrix, making it typically necessary to place several sturdy cartilaginous grafts to provide structural support. Rib graft provides an abundance of cartilage that can be used for multiple areas. The ability to manipulate and adjust the thickness of the cartilage strut allows for improved integrity of the graft to resist deformation and warping from the formant scar tissue.

Columella Lengthening with a Full-Thickness Skin Graft for Secondary Bilateral Cleft Lip and Nose Repair

Background

Various techniques for lengthening short columellae have been used for bilateral cleft nose repair. However, previous methods have not yielded satisfactory results. We performed a full-thickness skin graft to lengthen short columellae during secondary cleft nose repair in adult patients.

Methods

Ten bilateral cleft lip and nose patients underwent secondary cheiloplasty with open rhinoplasty between July 2008 and August 2014. The patients underwent a full-thickness skin graft on the medial crura to elongate the columella. The average age of the patients at the time of surgery was 22.2 years. Nasal profiles were evaluated before and after the operation using the photogrammetric method.

Results

The nasal profiles were improved in all patients, and all skin grafts were well taken, with the exception of one patient. Columellar height, nostril height, and columella-lip angle increased, and nasal width decreased significantly. The ratios of columellar height to nasal height, columellar height to nasal width, and nasal height to nasal width increased to a statistically significant extent.

Conclusions

Columella lengthening with a full-thickness skin graft is a simple and effective method for the repair of severely short columellae in bilateral cleft nose patients. We had satisfactory outcomes, with good color matching and aesthetically pleasing contours.

Secondary cleft rhinoplasty

The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a formidable challenge for the facial plastic surgeon. The underlying anatomic deformities combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult procedure for even the most experienced surgeons. Numerous techniques for secondary cleft rhinoplasty have been described in the literature over the past several decades, yet the lack of wide adoption of any given technique highlights the great variability seen with this problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or webbing have driven the progressive evolution of techniques developed to correct various aspects of the cleft nasal deformity. Despite the number of techniques that have been published, very few studies have looked specifically at outcomes in secondary cleft rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty.

Long-term comparison of the results of four techniques used for bilateral cleft nose repair: a single surgeon's experience

BACKGROUND

The purpose of this study was to evaluate progressive changes in surgical techniques and results, aiming for improved nasal shape in primary bilateral cleft rhinoplasty.

METHODS

This is an institutional review board-approved retrospective study. Ninety-one consecutive patients with bilateral complete cleft lip underwent primary cheiloplasty with four different techniques of nasal reconstruction from 1992 to 2007 as follows: group I, primary rhinoplasty alone; group II, nasoalveolar molding alone; group III, nasoalveolar molding plus primary rhinoplasty; group IV, nasoalveolar molding plus primary rhinoplasty with overcorrection; and group V, patients without cleft lip. The surgical results were analyzed using photographic records obtained at age 3 years. Four measurements and one angle measurement were obtained. A panel assessment was obtained to grade the appearance of the surgical results.

RESULTS

The results are expressed in order from groups I through V. The nostril height-to-width ratio was 0.49, 0.59, 0.62, 0.78, and 0.82, respectively. The nasal tip height-to-nasal width ratio was 0.29, 0.39, 0.49, 0.57, and 0.60. The columella height-to-nasal width ratio was 0.11, 0.18, 0.22, 0.27, and 0.28. The dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.10. The nostril area ratio was 1.2, 1.17, 1.13, 1.11, and 1.07. The nasolabial angle was 144.95, 143.98, 121.98, 120.99, and 100.88. Finally, group IV had the best panel assessment.

CONCLUSIONS

The results revealed that group IV had the best overall result. Presurgical nasoalveolar molding followed by primary rhinoplasty with overcorrection resulted in a nasal appearance that was closer to the patients without cleft lip.

Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience

INTRODUCTION

Composite grafts for nasal reconstruction have been around for over a century but the opinion on its virtues and failings keeps vacillating with a huge difference on the safe size of the graft for transfer. Alar margin and columellar defects are more distinct than dorsal nasal defects in greater difficulty in ensuring a good aesthetic outcome. We report our series of 19 consecutive patients in whom a composite graft was used to reconstruct a defect of alar margin (8 patients), alar base (7 patients) or columella (4 patients).

PATIENTS AND METHODS

Patient ages ranged from 3-35 years with 5 males and 14 females. The grafts to alar margin and base ranged 0.6-1 cm in width, while grafts to columella were 0.7-1.2 cm. The maximum dimension of the graft in this series was 0.9 mm x 10 mm. Composite grafts were sculpted to be two layered (skin + cartilage), three layered wedges (skin + cartilage + skin) or their combination (two layered in a portion and three layered in another portion). All grafts were cooled in postoperative period for three days by applying an indigenous ice pack of surgical glove. The follow up ranged from 3-9 months with an average of 4.5 months.

RESULTS

All of our 19 composite grafts survived completely but they all shrank by a small percentage of their bulk. Eleven patients rated the outcome between 90-95% improvement. We noticed that composite grafts tended to show varied pigmentation in our patients, akin to split skin grafts.

CONCLUSION

In our opinion, most critical to graft survival is its size and the ratio of the marginal raw area to the graft bulk. We recommend that graft width should not exceed 1 cm to ensure complete survival even though larger sized grafts have been reported to survive. We recommend cooling of the graft and justify it on the analogy of 'warm ischemia time' for a replantation, especially in warmer climes like ours in India. We have outlined several considerations in the technique, with an analysis of differing opinions that should facilitate a surgeon in making an informed choice.

Evaluation of the use of auricular composite graft for secondary unilateral cleft lip nasal alar deformity repair

The purpose of this study is to evaluate the surgical outcome after using composite grafts for secondary cleft lip nasal deformities. A retrospective cohort study of one surgeon's outcome of 35 consecutive performed secondary cleft lip nasal deformity repair. Thirty-five patients with secondary nose deformity related to unsatisfactory cleft lip repair were operated using the proposed surgical technique since 2008. All these patients met the study criterion of having anthropometric measurements performed at least one year postoperatively. Measurement of nostril size was performed at the right and left side of the nose, preoperatively and at least one year postoperatively. The study found statistically significant differences between the preoperatory and postoperatory nose measurements. In addition, we have not found statistically significant differences between the cleft and noncleft nostril sizes measured at least one year postoperatively. The findings suggest that the proposed technique is a good alternative to address secondary nose deformity related to cleft lip primary repair.

Conchal Cartilage Graft for Correction of Bilateral Cleft Lip Nasal Deformities during Childhood

Background:

Various methods for primary repair of bilateral cleft lip have been developed, but they often produce inadequate results, such as an upturned nose or a short columella. We perform primary lip repair with muscle reconstruction to correct depression of the nasal floor and inferoposterior displacement of the alar base. Then, open rhinoplasty to project the nasal tip is performed during childhood. This article describes the methods and results of open rhinoplasty for bilateral cleft lip patients.

Methods:

Open rhinoplasty with a modified forked flap is performed. The harvested conchal cartilage is grafted as a strut to strengthen and extend the septum. The lower lateral cartilages are sutured to the grafted cartilage and fixed in the correct position. Before skin closure, the tips of the 2 V flaps of the forked flap and the reverse V-flap between the forked flap are trimmed. Three trapezoidal flaps are sutured to the base of the columella. Thirty patients with bilateral cleft lip nasal deformities have undergone surgery. The operative results of 15 of 30 patients were evaluated photogrammetrically.

Results:

The nose was refined and more projected. The nasolabial angle and the nasal tip projection were improved. The reformed configuration was well maintained for many years. Photogrammetric analysis demonstrated increases in both the nasal height-to-width ratio and the nostril height-to-width ratio and a decrease in the nasolabial angle.

Conclusions:

Open rhinoplasty during childhood using 3 trapezoidal flaps and conchal cartilage graft improves bilateral cleft lip nasal deformities effectively.

Large auricular chondrocutaneous composite graft for nasal alar and columellar reconstruction

BACKGROUND

Among the various methods for correcting nasal deformity, the composite graft is suitable for the inner and outer reconstruction of the nose in a single stage. In this article, we present our technique for reconstructing the ala and columella using the auricular chondrocutaneous composite graft.

METHODS

From 2004 to 2011, 15 cases of alar and 2 cases of columellar reconstruction employing the chondrocutaneous composite graft were studied, all followed up for 3 to 24 months (average, 13.5 months). All of the patients were reviewed retrospectively for the demographics, graft size, selection of the donor site and outcomes including morbidity and complications.

RESULTS

The reasons for the deformity were burn scar (n=7), traumatic scar (n=4), smallpox scar (n=4), basal cell carcinoma defect (n=1), and scar contracture (n=1) from implant induced infection. In 5 cases of nostril stricture and 6 cases of alar defect and notching, composite grafts from the helix were used (8.9×12.5 mm). In 4 cases of retracted ala, grafts from the posterior surface of the concha were matched (5×15 mm). For the reconstruction of the columella, we harvested the graft from the posterior scapha (9×13.5 mm). Except one case with partial necrosis and delayed healing due to smoking, the grafts were successful in all of the cases and there was no deformity of the donor site.

CONCLUSIONS

An alar and columellar defect can be reconstructed successfully with a relatively large composite graft without donor site morbidity. The selection of the donor site should be individualized according to the 3-dimensional configuration of the defect.

The Correction of a Secondary Bilateral Cleft Lip Nasal Deformity Using Refined Open Rhinoplasty with Reverse-U Incision, V-Y Plasty, and Selective Combination with Composite Grafting: Long-term Results

Background

This article presents long-term outcomes after correcting secondary bilateral cleft lip nasal deformities using a refined reverse-U incision and V-Y plasty or in combination with a composite graft in order to elongate the short columella.

Methods

A total of forty-six patients underwent surgery between September 1996 and December 2008. The age of the patients ranged from 3 to 19 years of age. A bilateral reverse-U incision and V-Y plasty were used in 24 patients. A composite graft from the helical root was combined with a bilateral reverse-U incision in the 22 patients who possessed a severely shortened columella. The follow-up period ranged between 2 and 10 years.

Results

A total of 32 patients out of 46 were evaluated postoperatively. The average columella length was significantly improved from an average of 3.7 mm preoperatively to 8.5 mm postoperatively. The average ratio of the columella height to the alar base width was 0.18 preoperatively and 0.29 postoperatively. The postoperative basal and lateral views revealed a better shape of the nostrils and columella. The elongated columella, combined with a composite graft, presented good maintenance of the corrected position with no growth disturbance. A composite graft showed color mismatching in several patients. Twenty-six patients demonstrated no alar-columella web deformity and satisfactory symmetry of the nostrils. Four patients experienced a drooping and overhanging of the corrected alar-columella web.

Conclusions

A bilateral reverse-U incision with V-Y plasty or in combination with a composite graft was effective in correcting secondary bilateral cleft lip nasal deformity.

Correction of unilateral secondary cleft lip nose deformity by a modified Tajima's method and several adjunctive procedures based on severity

BACKGROUND

It is generally accepted that the developmental deficiency of the unilateral perinasal skeleton, cartilages, and skin originates from the secondary cleft nasal deformity. To date, numerous attempts have been made to correct these deformities, but no clinical data are available about the simpler, comprehensive, and patient-customized methods for correction of the secondary cleft nasal deformity. In the correction of Asian patients with secondary cleft nasal deformity, the clinical experience with the simplified Tajima method and several adjunctive procedures based on the severity of the disorder were retrospectively reviewed.

METHODS

During the period January 1982 to May 2009, 197 consecutive patients underwent repair through the modified Tajima method followed by several adjunctive procedures.

RESULTS

These series had no recurrence requiring surgery except for cases in which the nasal ala was depressed to some extent. The mean degree of patient satisfaction as rated on the 5-point Global Aesthetic Improvement Scale (GAIA) was 3.88 ± 0.59.

CONCLUSIONS

Various types of surgical procedures were performed using the modified Tajima method depending on the degree of alar cartilage displacement. These procedures were effective in achieving symmetry of the nasal tip for patients with secondary unilateral cleft lip.