Afroze incision for functional cheiloseptoplasty

"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.

An ex vivo model for education and training of unilateral cleft lip surgery

BACKGROUND

Unilateral cleft lip surgery is a complex procedure, and the outcome depends highly on the surgeon's experience. Digital simulations and low-fidelity models seem inadequate for effective surgical education and training. There are only few realistic models for haptic simulation of cleft surgery, which are all based on synthetic materials that are costly and complex to produce. Hence, they are not fully available to train and educate surgical trainees. This study aims to develop an inexpensive, widely available, high-fidelity, ex vivo model of a unilateral cleft lip using a porcine snout disc.

METHODS

A foil template was manufactured combining anatomical landmarks of the porcine snout disc and the anatomical situation of a child with a unilateral cleft. This template was used to create an ex vivo model of a unilateral cleft lip from the snout disc. Millard II technique was applied on the model to proof its suitability. The individual steps of the surgical cleft closure were photo-documented and three-dimensional scans of the model were analysed digitally. Sixteen surgical trainees were instructed to create a unilateral cleft model and perform a unilateral lip plasty. Their self-assessment was evaluated by means of a questionnaire.

RESULTS

The porcine snout disc proved highly suitable to serve as a simulation model for unilateral cleft lip surgery. Millard II technique was successfully performed as we were able to perform all steps of unilateral cleft surgery, including muscle suturing. The developed foil-template is reusable on any porcine snout disc. The creation of the ex vivo model is simple and inexpensive. Self-assessment of the participants showed a strong increase in comprehension and an eagerness to use the model for surgical training.

CONCLUSIONS

A porcine snout disc ex vivo model of unilateral cleft lips was developed successfully. It shows many advantages, including a haptic close to human tissue, multiple layers, low cost, and wide and rapid availability. It is therefore very suitable for teaching and training beginners in cleft surgery and subsequently improving surgical skills and knowledge. Further research is needed to finally assess the ex vivo model's value in different stages of the curriculum of surgical residency.

Closure of cleft lips with Pfeifer's wave line technique does not inhibit upper lip growth: A retrospective study

The aim of this study is to describe the growth of the upper lip after reconstruction with a Pfeifer wave-line incision in patients with unilateral and bilateral cleft lip and palate (CL/P) in the long term. This was a longitudinal, monocentric, retrospective study. Metric standardized lip length measurements were taken annually from the age of 6 months to the age of 16 years. Defined anatomical points were determined which describe the lip length from the nasal entrance to the highest point of the Cupid's bow. The lip length of the unaffected side in unilateral cleft patients was taken as control. A total of 234 patients with cleft lip with/without cleft palate (CL/P) were included in the study. At the time of the primary surgery, the medial sides in unilateral clefts were 2-4 mm and the lateral sides 1.5-2 mm shorter than the normal unaffected side (p≤0.001). Two main periods of growth, one during childhood (first to sixth years) and one during adolescence (12th-16th years) were seen. At the age of 16 years, the end of the observation period, the lip length in unilateral clefts resulted in a clinically not noticeable shortening of the cleft side (0.37±0.26 mm). There was no correlation between lip length development and primary cleft width at the time of primary cleft lip surgery at 6 months. The upper lip in patients with bilateral clefts developed symmetrically without any obvious asymmetry. Both sides showed a lip length difference of 0.1±0.05 mm at the age of 16 years (p=0.1). Compared to the upper lip length of the control group, bilateral clefts showed a slight tendency toward a longer upper lip (p=0.52). Within the limitations of the study it seems that when lip length development is a priority in cleft lip surgery, Pfeifer wave-line procedure is good option to achieve symmetric results in unilateral and bilateral cleft lip surgery and, therefore, is a relevant option among a variety of other techniques.

Strategy for Correction of the Whistling Deformity in Secondary Cleft Lip Reconstruction

Background:

Following primary repair of a cleft lip, patients present with many facial deformities. One of the commonly observed sequelae of cleft lip repair is a whistling deformity. This retrospective study was carried out to evaluate the outcomes following correction of whistling deformities in secondary cleft lip reconstruction.

Methods:

We retrospectively reviewed the hospital records of patients with various whistling deformities who underwent repair from April 1989 to March 2018; 2 surgeons performed the repair using either the double movable mucomuscular complex flaps technique, modified Abbe flap technique, or Abbe flap technique. The postoperative anatomical structure and aesthetic effects of the surgery were evaluated.

Results:

In total, 136 patients were included in this study. Among these patients, 60 (44.2%) had a grade I whistling deformity and 47 (34.5%) had a grade II deformity and repair was performed using the double movable mucomuscular complex flaps technique and modified Abbe flap transfer technique, respectively, whereas the Abbe flap transfer technique was used in 16 patients (11.8%) and 13 patients (9.5%) with a grade III and grade IV whistling deformity, respectively. All patients were found to have normal postoperative anatomical structures and aesthetic effects of the upper lip, with all patients experiencing mild to moderate postoperative edema of the upper lip, and 29 cases (21.3%) developed an inconspicuous scar.

Conclusion:

The repair technique should be chosen based on the type of whistling deformity.

Three-Dimensional Analysis of Craniofacial Structures of Individuals With Nonsyndromic Unilateral Complete Cleft Lip and Palate

ABSTRACT

Cleft lip and palate (CLP) is one of the most common congenital deformities. Primary surgeries at an early age result in scar formation, which may impede the growth of craniofacial structures of the maxilla. Orthodontist's role in the management of individuals with CLP is important and starts from the time of birth. The knowledge of craniofacial structures in individuals with a cleft is essential for treatment planning. The purpose of this study was to analyze and compare craniofacial structures of cleft and noncleft side of individuals with non-syndromic unilateral complete cleft lip and palate (NSUCCLP) using cone-beam computed tomography (CBCT). CBCT scans of individuals with NSUCCLP (n = 42) were retrieved from the databases of two cleft centers, which followed the same protocols for timing and type of primary surgeries and secondary alveolar bone grafting (SABG). DICOM files of CBCT scans were integrated into Dolphin 3D software, and analysis was carried out in multiplanar views. The craniofacial structures of individuals with NSUCCLP were analyzed using fourteen parameters. Measurements were also recorded between the cleft and noncleft sides for comparison. The volume of the maxilla was generated by isolating it from adjacent structures on a 3D reconstructed model. MAWC, MAWPM1, MAWPM2, MAWM1, and MV of the cleft side was less than noncleft side (P < 0.05). MHP @ N Aper is less on the noncleft side (P < 0.05). There is an asymmetry of structures around the dentoalveolar and nasal region; however, asymmetries were not affected at deeper structures of the craniofacial region of individuals with NSUCCLP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rhinoplasty for cleft and hemangioma-related nasal deformities

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Primary septoplasty in the repair of unilateral complete cleft lip and palate

BACKGROUND

The purpose of this study was to assess and compare nasal symmetry in patients who underwent correction of a complete unilateral cleft lip using the Afroze incision without and with primary septoplasty using a standardized two-dimensional photographic analysis.

METHODS

A prospective cohort study of 190 consecutive patients with complete unilateral cleft lip and alveolus with cleft palate treated with or without septoplasty using the Afroze incision technique was conducted at a high-volume center. Eighty-two patients operated on without primary septoplasty and 76 patients operated on with primary septoplasty were evaluated. Nasal symmetry was compared between patients using two-dimensional photographic analysis. Ratios between the cleft side and the non–cleft side for five parameters were used to assess symmetry: alar base–to–interpupillary line distance, columella-to–Cupid's bow distance, nostril gap area, nostril width, and nostril height. The Mann-Whitney U test was used to calculate differences between the two groups.

RESULTS

Patients operated on with primary septoplasty showed more nasal symmetry compared with patients operated on without septoplasty. This difference was statistically significant for columella-to–Cupid's bow distance, nostril gap area, and nostril height (p = 0.008, p < 0.001, and p < 0.001, respectively) and for the distance between alar base and the alar base–to–interpupillary line distance (p = 0.145) the difference was present but not statistically significant. For nostril width, no difference was found (p = 0.850).

CONCLUSION

Patients treated with primary septoplasty showed better results in terms of nasal symmetry when analyzed using two-dimensional photographic analyses.