Primary Cleft Rhinoplasty: Surgical Outcomes and Complications Using Three Techniques for Unilateral Cleft Lip Nose Repair

Cleft Lip Repair and Primary and Intermediate Cleft Rhinoplasties

The cleft lip is one of the most common craniofacial abnormalities seen worldwide. The lip and primary rhinoplasty repairs are performed together in a single surgery for patients aged 3 to 6 months. The intermediate rhinoplasty has fallen out of favor due to more advanced approaches at primary rhinoplasty. However, it still plays a role in addressing severe nasal airway obstruction or correcting anatomic differences causing emotional distress from social ridicule. The article reviews the incidence of cleft lip, discusses its development and variant anatomy, and examines the approaches to surgical repair of the cleft clip, primary and intermediate rhinoplasties.

Secondary Cleft Rhinoplasty

Secondary cleft rhinoplasty remains a challenging operation that requires an understanding of the aberrant anatomy in cleft lip nasal deformity as well as the ability to adapt various techniques suited to the needs of each patient. In this article, we review some of the classically described approaches in cleft rhinoplasty and different strategies to address the nasal subunits. Presurgical adjuncts, surgical interventions before facial skeletal maturity, and patient reported outcome measures are also discussed.

Application of Auricular Cartilage-Skin Graft in the Reconstruction of Unilateral Cleft Lip Nasal Deformity

BACKGROUND

Autologous cartilage grafts are increasingly used in the treatment of cleft lip nasal deformity, but nasal alar retraction caused by lining defects often occurs after surgery. We designed a new graft to treat unilateral cleft lip nasal deformity while avoiding nasal alar retraction.

METHODS

Nineteen patients in our hospital underwent unilateral cleft lip nasal deformity repair surgery with an auricular cartilage-skin graft. The effect of surgery was evaluated in four aspects: satisfaction with postoperative appearance, nasal aesthetic subunit indices, position of the nasal alar rim and three-dimensional spatial difference.

RESULTS

Overall satisfaction with each index was above 90%. The nasal tip angle and nasolabial angle of patients were significantly smaller after surgery than before surgery (P < 0.01). The height of the nostril on the affected side and the length of the nasal columella were greater after surgery than before surgery (P < 0.01). The spatial differences in soft tissue between the unaffected side and the affected side after surgery were significantly smaller than before surgery (P < 0.01). According to the follow-up results of 1-2 years, there were no significant retraction of the nasal alar rim (P > 0.05) and no obvious auricular deformity. All patients had a noticeable improvement in their nasal appearance.

CONCLUSION

The auricular cartilage-skin graft, which can not only improve the appearance of the nose but also avoid nasal alar retraction, is an ideal graft to cure unilateral cleft lip nasal deformity.

LEVEL OF EVIDENCE IV

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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.

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.

Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes

Background: The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges. Objectives: Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair. Methods: This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models. Results: Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2-12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and -0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2-4, 5-7, 8-12, 13-24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015-0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair. Conclusions: In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

Postoperative Nasal Conformers in Cleft Rhinoplasty: Are They Efficacious?

BACKGROUND

Lip and nose symmetry the goal of repair of unilateral cleft lip and different preoperative and postoperative treatments have been developed with this purpose. The objective of this study was to compare 2 techniques used for primary cleft lip nose repair.

MATERIALS AND METHODS

This is an retrospective study between 2 groups of patients with unilateral cleft lip and palate who underwent primary nasolabial repair either with or without postoperative nasal conformers. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements under general anesthesia during primary cleft palate repair.

RESULTS

Our comparative study did not find a statistically significant difference regarding percentile indexes of nasal asymmetry between the 2 groups. Major revision requirement (>3 mm of asymmetry in any of the nose measurements) was observed in 3.84% of nasal conformer group and 4.65% of the group without nasal conformers.

CONCLUSIONS

The results obtained from this study provides showed that placement of postoperative nasal conformers did not improve nasal symmetry in patients with unilateral cleft lip and palate. Based on these findings and available scientific evidence, definitive conclusions about the effectiveness of these devices on nasal symmetry after unilateral cleft lip nose repair cannot be drawn.

Nasal symmetry after different techniques of primary lip repair for unilateral complete cleft lip with or without cleft of the alveolus and palate: A systematic review

The aim of this systematic review was to establish the effect of different surgical repairs for the lip on nasal symmetry. PubMed, Scopus, Embase, Cochrane CENTRAL, and Ovid databases search was performed initially for only English-language articles, in patients with unilateral complete cleft lip with or without cleft alveolus and palate (UCCLAP) who were younger than 1 year of age and undergoing cleft lip repair, and are published from the earliest data available up to December 31, 2020. The primary outcome variable was nasal symmetry, with reported complications being secondary variables. A qualitative synthesis was provided. A total of 19,828 records were obtained, and 17 articles were selected for final review. Assessment of the risk of bias of the included randomized controlled trials (RCTs) (N-1) was done with the Cochrane Risk of Bias 2 (RoB-2) tool, and the ROBINS-I tool was used for non-randomized studies (n = 14). Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to evaluate the quality of the body of evidence. The majority of the included studies compared the triangular repair with the rotation advancement (RA) techniques, and preferred RA or its modifications. In terms of the nasal symmetry, the Fisher repair proved to be superior to the RA technique. Neither RA nor straight line repair was superior to one another. The Delaire technique may be preferred over the modified RA. Also, satisfactory outcomes were observed with simultaneous lip-nose repair. This systematic review examined a plethora of techniques, and the heterogeneity between studies was very high regarding type of surgery, method of nasal symmetry assessment, and length of follow-up, thus producing low-quality evidence; therefore, results should be interpreted with caution. Future research requires RCTs with larger sample sizes and appropriate length of follow-up, and surgeries preferably performed by a single experienced surgeon.

Oropharyngeal Dysbiosis Affects Postoperative Tissue Reparative Capacity In Patients With Congenital Disorders Of Maxillofacial Region

Background — One of the main causes of hyperergic postoperative tissue response could be a prolonged opening in the septum between normally isolated anatomical regions, e.g., of the nasal cavity and oropharynx in patients with congenital disorders of maxillofacial region, which leads to anomalous exchange of their microbiotas. Objective — The objective of this study was to determine the composition of culturable facultative anaerobic microbiota of oronasopharyngeal mucosa, and to identify cytokine profiles in patients with congenital disorders of maxillofacial region in both preoperative and postoperative periods. Methods and Results — Our study is based on the results of examining the children with unilateral congenital cleft of upper lip (CL) before and after surgery, as well as examining the children with simultaneous unilateral congenital cleft of upper lip and palate (CLP) before and after primary rhinocheiloplasty. We used ELISA to determine the content of interleukin-10 (IL-1β) and interleukin-10 (IL-10) in the samples of blood serum and mucosal surfaces. The study of culturable microflora was conducted in patients before the surgery and during a postoperative period, specifically at one, three, six, and twelve months. Isolation of pure bacterial cultures was performed via conventional bacteriological methods followed by identification using MALDI-TOF testing. Before the surgery, microbial colonization was observed at significantly higher levels in CLP children than in healthy children. After the surgery, microbiological indicators partially came to normal values solely in CL patients. Local IL-1β concentrations remained significantly higher than those found in healthy subjects. In terms of postoperative dynamics, blood plasma antioxidant activity declined below normal values in CLP patients. Conclusion — Our study demonstrated the need for preoperative eradication of potential pathogens (e.g., Staphylococcus aureus, Klebsiella spp., Candida spp. and Streptococcus spp.), preferably, via using non-antibiotic approaches, such as probiotics and phage therapy, as well as supportive integrative therapy (e.g., using antioxidants).

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty

PURPOSE

Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty.

METHODS AND MATERIALS

A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models.

RESULTS

The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone.

CONCLUSIONS

Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

The Evolution of Unilateral Cleft Lip Repair

ABSTRACT

The understanding of cleft lip etiology and approaches for surgical repair have evolved over time, allowing for improved ability to restore form and function. The variability of cleft lip presentations has necessitated a nuanced surgical approach with multidisciplinary cleft care. The earliest documentation of unilateral cleft lip repair predates the 19th century, with crude outcomes observed before the advent of curved incisions and advancement flaps. In the 20th century, straight line, quadrilateral flap, and triangular flap repairs were introduced to mitigate post-repair surgical scarring, increase lip length, and restore the symmetry of the Cupid's bow. Towards the latter part of the century, the development of rotation-advancement principles allowed for improved functional and aesthetic outcomes. Future technical improvements will continue to address the goals of lip and nasal symmetry, muscular continuity, precise scar concealment, and improved patient satisfaction in an increasing range of cleft phenotypes and during subsequent years of growth.

Surgical Nasoalveolar Molding: A Rational Treatment for Bilateral Cleft Lip Nose and Systematic Review

Background:

The purpose of this study was to evaluate the surgical outcome after using primary surgery to address bilateral cleft lip nose and palate deformities. In addition, the authors performed a systematic review to evaluate the effects of the nasoalveolar molding on non-syndromic bilateral cleft lip and palate.

Methods:

A prospective cohort study on a surgeon’s surgical outcome of 25 consecutively performed primary bilateral cleft lip nasal deformity repairs was conducted and a systematic review of the literature for studies published until December 2019 was done to evaluate the effect of presurgical NAM on nasolabial aesthetics and alveolar gap.

Results:

Since 2014, 25 consecutive patients with complete bilateral cleft have undergone primary anatomical repair of the cleft nasal deformity using primary cheilorhinoplasty. The average columella length was 4.3 ± 1.3 mm. The average ratio of the columella height to nasal height was 0.48 mm 1 year postoperatively and 0.52 mm 5 years postoperatively. Statistically significant differences have been observed between the pre and postoperative alveolar and palatal gaps after using primary cheiloplasty or bilateral lip adhesion. After systematic literature searching, 14 identified studies were qualified for the final analysis, which included 433 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.

Conclusions:

The results of this study suggest that the proposed primary cheilorhinoplasty is a good alternative to improve nose appearance and alveolar gap in patients with primary bilateral cleft lip nose and palate deformity. Based on the available scientific evidence, definitive conclusions about the effectiveness of presurgical Naso Alveolar Molding on nasolabial aesthetics cannot be drawn. Quality of the included articles were too low to make a conclusion.

The Surgical Nasoalveolar Molding: A Rational Treatment for Unilateral Cleft Lip Nose Deformity and Literature Review

The purposes of this study were to evaluate surgical outcomes after primary surgery to address unilateral cleft lip, nose, and palate deformities and to perform a review of the literature to evaluate the effects of nasoalveolar molding (NAM) plus primary surgical repair on nonsyndromic unilateral cleft lip and palate.

METHODS

A cohort study of 37 primary complete unilateral cleft lip nasal deformity repairs was performed by a single surgeon. The outcomes were anthropometric measurements of the repaired lip, nose, and alveolar cleft width at the age of 1 and 5 years. A review of the literature was performed for studies published until March 2020 to evaluate the effect of presurgical NAM on nasolabial aesthetics.

RESULTS

Statistically significant differences were observed between pre- and postoperative columellar angle and alveolar cleft width. A total of 308 studies were identified, and 8 were included in the final analysis of 684 patients. The overall study quality was low according to the Oxford Centre of Evidence-Based Medicine, and GRADE level of evidence was low.

CONCLUSIONS

Primary cheilorhinoplasty alone is a good approach to improve nose appearance and alveolar gap in patients with unilateral cleft lip nose and palate deformity. Definitive conclusions about the effectiveness of presurgical NAM cannot be drawn. Available scientific evidence is not sufficient to demonstrate that combined use of presurgical nasoalveolar molding and primary surgery provides better nasolabial aesthetic outcomes than does primary surgery alone.

Rotational Composite Flap Technique for Primary Incomplete Cleft Nose Deformity

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Background:

Nasal deformities accompanying unilateral incomplete cleft lip have minor skeletal and soft tissue deficiencies compared with deformities associated with unilateral complete cleft lip. Extended dissection and surgical incisions (often required for nasal deformities in complete cleft lip) are not recommended to address deformities accompanying incomplete cleft lip. The purpose of this study is to describe an innovative method involving a rotational composite flap for nasal repair in patients with unilateral cleft lip.

Methods:

Since 2016, 49 consecutive patients with unilateral incomplete cleft lip have undergone primary anatomical repair of accompanying nasal deformities. The technique involves a skin incision along the marginal and intercartilaginous borders to create a V-shaped composite flap consisting of vestibular skin and alar cartilage. Rotational mobilization of the composite flap creates a triangular raw surface laterally, which is closed by advancement of the vestibular skin.

Results:

This innovative method, which is based on the use of a rotational composite vestibular flap, achieves proper symmetry of the repaired nose.

Conclusion:

The herein described composite flap rhinoplasty is a good surgical option, which provides a good overall nasal symmetry in patients with nasal deformities accompanying unilateral incomplete cleft lip.