Repair of bilateral cleft lip: review, revisions, and reflections

Primary Premaxillary Setback and Repair of Bilateral Complete Cleft Lip: Indications, Technique, and Outcomes

Objective

To analyze indications and outcomes for primary premaxillary setback.

Design

Retrospective.

Setting

Academic children's hospital.

Patients

All children with bilateral complete cleft lip age ≤2 years of age who had premaxillary setback by one surgeon (1992 to 2011).

Results

Twenty-five patients with bilateral complete cleft lip underwent primary premaxillary setback at an average age of 9 months; the mean follow-up was 47 months. There were three indications: failed dentofacial orthopedics (n = 9), delayed referral precluding manipulation (n = 10), and intact secondary alate (n = 6). Of 19 patients with bilateral complete cleft lip/palate, primary setback was combined with nasolabial repair (n = 11), adhesions (n = 2), or palatoplasty (n = 6). Patients who had nasolabial closure and setback were significantly younger than those who had combined palatal closure and setback (6.5 versus 16 months, P = .01). No patient exhibited postoperative premaxillary instability. Serial anthropometry showed similar growth of nasolabial features after both primary setback (n = 9) and active dentofacial orthopedics (n = 35).

Conclusions

Primary premaxillary ostectomy and setback permits synchronous bilateral nasolabial-alveolar closure or alveolar-palatal repair in a child with intact secondary palate. This procedure should be considered whenever dentofacial orthopedics cannot be accomplished. Speech is paramount in an older child; setback with palatal closure is scheduled before nasolabial repair. Disturbance of midfacial growth is likely following primary premaxillary ostectomy and setback in patients with bilateral complete cleft lip/palate; however, most already need maxillary advancement. Furthermore, premaxillary setback permits proper primary nasolabial design and construction in appreciation of expected changes with growth.

Comparative Study of Early Secondary Nasal Revisions and Costs in Patients With Clefts Treated With and Without Nasoalveolar Molding

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

Triangular with Ala Nasi (TAN) II repair of unilateral cleft lips with severe nasal deformity

BACKGROUND/INTRODUCTION

With our previous technique called triangular with ala nasi (TAN) repair, we combined the superiorities of these 2 popular techniques by approaching the skin, as in Tennison-Randall, and the muscle and nose, as in Millard. Although good results have been obtained in most patients, cleft lip nose (CLN) deformity could not entirely be corrected particularly in serious cleft patients. Therefore, we revised the technique, called the TAN II repair, by adding some nasal maneuvers including the bivectoral suspension sutures, alar buckling resection, and alar web resection.

METHODS

Forty-two consecutive patients (26 male and 16 female) with unilateral cleft lips were operated on using the TAN II technique in the last 5 years. The mean age at repair was 11.95 months (range, 3 to 120). The postoperative outcomes were assessed subjectively by Williams test and objectively by Lindsay-Farkas method.

RESULTS

The mean follow-up time was 16.3 months. No early complication involving hematoma, infection, wound dehiscence, or partial or total flap loss was encountered. The recoveries of 92.42% and 88.89% on average, when compared with the noncleft side, were obtained postoperatively.

CONCLUSIONS

With these modifications, the TAN II technique was able to correct the severe unilateral CLN deformities. We obtained good to excellent outcomes in late postoperative follow-up by means of a long-term suspension effect.

Update on primary cleft lip rhinoplasty

PURPOSE OF REVIEW

The optimal timing and techniques utilized to address the nasal deformity of the cleft lip continue to raise challenges and debate for the surgical community. There has been a shift in the paradigm addressing the nasal deformity to a more proactive approach. The goal of this article is to provide an update of the latest techniques for primary cleft rhinoplasty.

RECENT FINDINGS

A medical literature search was performed specifically targeting primary cleft rhinoplasty in order to review the current strategies implemented, including presurgical orthopedics, surgical incisions, reconstruction, and suture techniques.

SUMMARY

Today primary rhinoplasty is performed widely with many investigators reporting improved esthetic and functional outcomes. Both endonasal and external rhinoplasty approaches have been described for the unilateral and bilateral deformity. Goals include closure of the nasal floor and sill, symmetry of the alar base, and symmetry of the lower lateral cartilages with appropriate projection of the dome. Recent literature supports that rhinoplasty performed at the time of the primary cleft lip closure may reduce the frequency and magnitude of required intermediate and definitive rhinoplasty operations.

Evaluation of the results of simultaneous open rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity

AIMS

We aimed to evaluate the results of simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity by means of a newly developed software-based method.

PATIENTS AND METHODS

A total of 16 patients with the bilateral cleft lip nasal deformity received Abbe flap and simultaneous open rhinoplasty between 2004 and 2010. The mean age of the patients was 21 years, and the average follow-up time was 2.4 years. After the open rhinoplasty procedure, the upper lip was reconstructed with the Abbe flap. Preoperative and postoperative photographs that had been taken laterally were evaluated by using Adobe Photoshop(®) CS4 and Adobe InDesign(®) software. The length of the columella and the relative changes of the most anterior point of the upper lip to the vertical plane tangent to the most anterior point of the lower lip were measured in pixels on standardized preoperative and postoperative images. The differences were calculated and compared as a percentage (%).

RESULTS

There was no flap loss and associated problems. The measurements of columellar length revealed an average increase of 51.8 ± 11.3%, while the relative change of the most anterior point of the upper lip revealed an average increase of 68.6 ± 11.2%.

CONCLUSION

The results of the treatment modality were successfully evaluated by a newly developed software-based method.

Modern tenets for repair of bilateral cleft lip

The understanding of the bilateral cleft lip and associated nasal deformity has evolved over the last 30 years to a point where there now exists general agreement regarding the goals, principles, and strategies for operative repair. This article presents modern tenets for repair of bilateral cleft lip and describes a logical approach to correction of the different possible subtypes.

Anatomic Severity, Midfacial Growth, and Speech Outcomes in Van der Woude/Popliteal Pterygium Syndromes Compared to Nonsyndromic Cleft Lip/Palate

OBJECTIVE

To summarize the clinical characteristics and surgical and speech outcomes for patients with Van der Woude/popliteal pterygium syndromes (VWS/PPS) and to compare them with a historic cohort of patients with nonsyndromic cleft lip/cleft palate (CL/P).

DESIGN

Retrospective chart review.

SETTING

Tertiary care center.

PATIENTS

All patients with VWS/PPS seen at Boston Children's Hospital from 1979 to 2012: 28 patients with VWS (n = 21)/PPS (n = 7) whose mean age was 17.3 ± 10.4 years, including 18 females (64%) and 10 males (36%); 18 patients (64%) had a family history of VWS/PPS.

MAIN OUTCOME MEASURES

Cleft type, operative procedures, speech, and midfacial growth. Data were compared with historic cohorts of patients with nonsyndromic CL/P treated at one tertiary care center.

RESULTS

There were 24 patients (86%) with CP±L, Veau types I (n = 4, 17%), II (n = 4, 17%), III (n = 5, 21%), and IV (n = 11, 46%). Nine patients (38%) had palatal fistula after palatoplasty. Fourteen of 23 (61%) patients with CL/P age 5 years or older had midfacial retrusion, and 10 (43%) required a pharyngeal flap for velopharyngeal insufficiency. Fisher's exact test demonstrated higher frequencies of Veau type IV CP±L (P = .0016), bilateral CL±P (P = .0001), and complete CL±P (P < .0001) in VWS/PPS compared with nonsyndromic patients. Incidences of midfacial retrusion (P = .0001), palatal fistula (P < .0001), and need for pharyngeal flap (P = .0014) were significantly greater in patients with VWS/PPS.

CONCLUSIONS

Patients with VWS/PPS have more severe forms of labiopalatal clefting and higher incidences of midfacial retrusion, palatal fistula, and velopharyngeal insufficiency following primary repair as compared with nonsyndromic CL/P.

Primary repair of cleft lip and nasal deformity

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the relevant anatomy and embryology that contribute to the cleft lip and nasal deformity. 2. Differentiate among the various forms of cleft lip, including microform, minor form, incomplete, complete, and bilateral. 3. List the options for presurgical infant orthopedics. 4. Describe the techniques and the expected outcomes of primary cleft lip and nasal repair.

SUMMARY

The authors describe cleft lip and its surgical management. They address the anatomy, forms, techniques, and outcomes of this complex and challenging deformity.

Repair of bilateral incomplete cleft lip: techniques and outcomes

BACKGROUND

Primary repair of bilateral incomplete cleft lip appears to be uncomplicated but requires attention to technical details in the third dimension in anticipation of changes in the fourth dimension.

METHODS

Direct anthropometry was used to document nasolabial dimensions before and immediately after repair in 51 infants with bilateral incomplete cleft lip. Technical details were analyzed in 48 patients; serial anthropometry was plotted in 22 male patients aged 2 to 20 years and compared to Farkas's normal growth lines. Revisions were also documented (n = 46).

RESULTS

Nasal width was made narrow and widened to normal by adolescence. Nasal tip protrusion was elongated and grew parallel to normal. Columellar length was constructed above normal, lengthened slowly in childhood, and was slightly short by adulthood. The Cupid's bow was designed narrow, widened slightly, and maintained normal dimension in adulthood. The upper philtrum was tapered and remained less wide than the lower philtrum. Although maximum available cutaneous prolabium was used in repair, it was short postoperatively and philtral height failed to exhibit catchup growth. The median tubercle was constructed overly full, but growth frequently fell behind in adolescence; 39 percent of patients required secondary augmentation. Total upper labial height closely followed the normal growth curve.

CONCLUSIONS

Serial anthropometry documented postoperative changes in nasolabial dimensions compared with normal growth lines. Repair of bilateral incomplete cleft lip requires primary correction of nasal and labial features based on their differential growth.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Contemporary concepts for the bilateral cleft lip and nasal repair

The bilateral cleft lip and nasal deformity presents a complex challenge for repair. Surgical techniques continue to evolve and are focused on primary anatomic realignment of the tissues. This can be accomplished in a single-stage or two-stage repair early in infancy to provide a foundation for future growth of the lip and nasal tissue. Most cleft surgeons currently perform a single-stage repair for simplifying patient care. Certain institutions utilize presurgical orthopedics for alignment of the maxillary segments and nasal shaping. Methods for the bilateral cleft lip repair are combined with various open and closed rhinoplasty techniques to achieve improved correction of the primary nasal deformity. There is recent focus on shaping the nose for columellar and tip support, as well as alar contour and alar base position. The authors will present a new technique for closure of the nasal floor to prevent the alveolar cleft fistula. Although the alveolar fistula is closed, alveolar bone grafting is still required at the usual time in dental development to fuse the maxilla. It is paramount to try and minimize the stigmata of secondary deformities that historically have been characteristic of the repaired bilateral cleft lip. A properly planned and executed repair reduces the number of revisions and can spare a child from living with secondary deformities.

Correction of secondary bilateral complete cleft lip and whistling deformities: the advance and rearrangement of the bilateral lip tissues

BACKGROUND

This report introduces a new method for correcting secondary deformities of bilateral complete cleft lip (BCCL) and assesses its short-term results.

METHODS

In this series, 30 patients (21 males and 9 females) ages 4-27 years (mean age 14 years, 2 months) who had previously undergone surgery to correct BCCL using the lateral columellar flap method or the straight-line method were treated using the authors' new curved-line method. Points were marked, and curved lines were used to link the points, with subsequent rearrangement of the lip tissues. Photographic documentation of lip heights was obtained before and after surgery, and short-term patient satisfaction was evaluated using a questionnaire.

RESULTS

At 6 months, the mean increases in central upper vermilion height and the vermilion heights of Cupid's bow points were 152 ± 20% (central upper vermilion), 87 ± 34% (left Cupid's bow point), and 91 ± 5% (right Cupid's bow point) (P ≤ 0.05). Of the 30 patients, 21 were very satisfied with their results, whereas seven patients graded their results as good.

CONCLUSIONS

The technique of advancing and rearranging the bilateral lip tissues is a simple and effective method for correcting secondary deformities of BCCL.

Repair of bilateral cleft lip and its variants

The surgeon who lifts a scalpel to repair a bilateral cleft lip and nasal deformity is accountable for: 1) precise craftsmanship based on three-dimensional features and four-dimensional changes; 2) periodic assessment throughout the child's growth; and 3) technical modifications during primary closure based on knowledge gained from long-term follow-up evaluation. These children should not have to endure the stares prompted by nasolabial stigmata that result from outdated concepts and technical misadventures. The principles for repair of bilateral complete cleft lip have evolved to such a level that the child's appearance should be equivalent to, or surpass, that of a unilateral complete cleft lip. These same principles also apply to the repair of the variants of bilateral cleft lip, although strategies and execution differ slightly.

A 12-year anthropometric evaluation of the nose in bilateral cleft lip-cleft palate patients following nasoalveolar molding and cutting bilateral cleft lip and nose reconstruction

BACKGROUND

Patients with bilateral cleft lip-cleft palate have nasal deformities including reduced nasal tip projection, widened ala base, and a deficient or absent columella. The authors compare the nasal morphology of patients treated with presurgical nasoalveolar molding followed by primary lip/nasal reconstruction with age-matched noncleft controls.

METHODS

A longitudinal, retrospective review of 77 nonsyndromic patients with bilateral cleft lip-cleft palate was performed. Nasal tip protrusion, alar base width, alar width, columella length, and columella width were measured at five time points spanning 12.5 years. A one-sample t test was used for statistical comparison to an age-matched noncleft population published by Farkas.

RESULTS

All five measurements demonstrated parallel, proportional growth in the treatment group relative to the noncleft group. The nasal tip protrusion, alar base width, alar width, columella length, and columella width were not statistically different from those of the noncleft, age-matched control group at age 12.5 years. The nasal tip protrusion also showed no difference in length at 7 and 12.5 years. The alar width and alar base width were significantly wider at the first four time points.

CONCLUSIONS

This is the first study to describe nasal morphology following nasoalveolar molding and primary surgical repair in patients with bilateral cleft lip-cleft palate through the age of 12.5 years. In this investigation, the authors have shown that patients with bilateral cleft lip-cleft palate treated at their institution with nasoalveolar molding and primary nasal reconstruction, performed at the time of their lip repair, attained nearly normal nasal morphology through 12.5 years of age.

Bilateral cleft lip and nose repair

Over the last three decades bilateral cleft lip and nose repair has been characterised by a trend towards more detailed reconstruction of the nasolabial muscles together with simultaneous correction of the deformity. An understanding of the true nature of the nasal deformity in bilateral cleft lip and palate (BCLP) has gradually emerged, and has inspired new approaches to their repair. This article discusses recent trends and controversies in primary cheilorhinoplasty for BCLP.

Long-term results after using dynamic presurgical nasoalveolar remodeling technique in patients with unilateral and bilateral cleft lips and palates

OBJECTIVE

To evaluate the effects and durability of results after using dynamic presurgical nasoalveolar remodeling in patients with unilateral and bilateral cleft lips and palates.

METHOD

Dynamic presurgical nasoalveolar remodeling technique does not rely on the relatively static force exerted by the orthopedic plate held in place by means of tape or adhesives. The principle behind this procedure is the use of the force generated during suction and swallowing to produce the remodeling effects on the nasal structures. The nasal component acts not only on the nasal structures but also in the lip function by stimulating labial muscle contraction. Direct anthropometry performed before primary reconstruction of the lip and nose and 1 year later posterior to surgery suggests that results are permanent.

CONCLUSIONS

When the dynamic presurgical nasoalveolar remodeling protocol is instituted early, it can avoid memory cartilage fixation. Changes incorporated to the nasal extension allowed us to obtain better results, elevating the nasal tip, remodeling the depressed cleft side alar cartilages in unilateral cases, and repositioning and correcting the positional alteration of the nasal cartilages building a new columella in bilateral cases. In addition, comfort and tolerance of patients has been improved, and adjustments needed during follow-up have been simplified, significantly reducing the consultation time and increasing the interval between appointments. The obtained outcome facilitates primary surgical cleft lip and nose reconstruction and improves surgical results.

Neuroembryology and functional anatomy of craniofacial clefts

The master plan of all vertebrate embryos is based on neuroanatomy. The embryo can be anatomically divided into discrete units called neuromeres so that each carries unique genetic traits. Embryonic neural crest cells arising from each neuromere induce development of nerves and concomitant arteries and support the development of specific craniofacial tissues or developmental fields. Fields are assembled upon each other in a programmed spatiotemporal order. Abnormalities in one field can affect the shape and position of developing adjacent fields. Craniofacial clefts represent states of excess or deficiency within and between specific developmental fields. The neuromeric organization of the embryo is the common denominator for understanding normal anatomy and pathology of the head and neck. Tessier's observational cleft classification system can be redefined using neuroanatomic embryology. Reassessment of Tessier's empiric observations demonstrates a more rational rearrangement of cleft zones, particularly near the midline. Neuromeric theory is also a means to understand and define other common craniofacial problems. Cleft palate, encephaloceles, craniosynostosis and cranial base defects may be analyzed in the same way.

A new modified forked flap with subcutaneous pedicles for adult cases of bilateral cleft lip nasal deformity: from normalization to aesthetic improvement

In adult cases of bilateral cleft lip nasal deformity, an esthetically satisfying result can not be obtained only by manipulation inside the nose with the nasal tip pointing upward. The nasal tip should be made in a more anterior direction for nasal esthetic improvement. Additional tissue beyond the nose is needed, and the forked flap is a useful method in such cases. However, the blood circulation of long and narrow flaps containing the scar, especially after open rhinoplasty, is unstable. We have developed a new long and narrow forked flap that has a more stable blood circulation. The forked flap was made using two subcutaneous pedicles attached to the periphery of the each flap. We applied this flap to five adult cases of bilateral cleft lip nasal deformity. Four of the cases had the scar associated with the flying bird incision, and one case required no treatment after the primary repair. All the flaps took without signs of partial necrosis. In all cases, the nasal tip was projected forward with adequate columella elongation, and the profile was esthetically improved. In the final stage of correction for adult cases of bilateral cleft lip nasal deformity, this method, making maximum use of the tissue containing the scar in not only the white lip but also the vermilion, is very effective. It is very important to obtain nasal esthetic improvement for the adult patient with bilateral cleft lip nasal deformity.

Evaluation of secondary functional cheilorhinoplasty during growth of cleft patients with residual lip and nasal deformities

PURPOSE

The aim of the study was to evaluate the clinical outcomes of secondary functional cheilorhinoplasty of residual lip and nasal deformities caused by muscular deficiency in cleft patients.

PATIENTS AND METHODS

During a 4-year period, 31 patients underwent cheilorhinoplasty, including complete reopening of the cleft borders and differentiated mimic muscle reorientation. In 21 patients, remarkable residual clefts of the anterior palate were also closed. Simultaneous alveolar bone grafting was performed in 15 patients. The minimum follow-up was 1 year. Cosmetic features evaluated were spontaneous facial appearance and changes in position of the nasal floor and the philtrum. The width of the alar base was measured. For functional outcomes, deficiency during mimic movements was evaluated, using standardized photographs taken preoperatively and postoperatively. The final results, judged according to defined criteria with several clinical factors, were compared.

RESULTS

Cosmetic and functional improvement was achieved in all patients. In young patients (aged 4 to 9 years), the improvements were noteworthy. There were no differences in outcomes between the groups with and without simultaneous grafting, except for unilateral cases with minor muscular deficiency, in whom bone grafting before cheilorhinoplasty led to better results.

CONCLUSION

In cases of major muscular deficiency, early cheilorhinoplasty should be performed at age 7 years, without waiting for the usual timing of bone grafting. In minor and moderate cases, the operation can ideally be done in combination with bone grafting.

Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate

BACKGROUND

Bilateral cleft lip-cleft palate is associated with nasal deformities typified by a short columella. The authors compared nasal outcomes of cleft patients treated with banked fork flaps to those of patients who underwent nasoalveolar molding and primary retrograde nasal reconstruction.

METHODS

A retrospective review of 26 consecutive patients with bilateral cleft lip-cleft palate was performed. Group 1 patients (n = 13) had a cleft lip repair and nasal correction with banked fork flaps. Group 2 patients (n = 13) had nonsurgical columellar elongation with nasoalveolar molding followed by cleft lip closure and primary retrograde nasal correction. Group 3 patients (n = 13) were age-matched controls. Columellar length was measured at presentation and at 3 years of age. The number of nasal operations was recorded to 9 years. The Kruskal-Wallis and Tukey-Kramer tests were used for statistical analysis.

RESULTS

Initial columellar length was 0.49 +/- 0.37 mm in group 1 and 0.42 +/- 0.62 mm in group 2. Post-nasoalveolar molding columellar length was 4.5 +/- 0.76 mm in group 2. By 3 years of age, columellar length was 3.03 +/- 1.47 mm in group 1, 5.98 +/- 1.09 mm in group 2, and 6.35 +/- 0.99 mm in group 3. Group 2 columellar length was significantly greater (p < 0.001) than that of group 1 and not statistically different from that of group 3 (p > 0.05). All group 1 patients (13 of 13) needed secondary nasal surgery. No nasoalveolar molding patients (zero of 13, group 2) required secondary nasal surgery.

CONCLUSION

Nonsurgical columellar elongation with nasoalveolar molding followed by primary retrograde nasal reconstruction restored columellar length to normal by 3 years and significantly reduced the need for secondary nasal surgery.

Bilateral cleft lip and nasal repair

SUMMARY

The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.

Simultaneous harvesting of cancellous iliac bone for alveolar cleft closure and dermis for augmentation of median tubercle

Children with repaired cleft lip/palate require secondary closure of the alveolar cleft and, often, nasolabial revision. We describe a technique performed in 61 patients for harvesting bone for the alveolar defect and dermis for augmentation of the median tubercle, taking both from the posterior iliac region. The advantages of the posterior approach are as follows: (1) the same donor site is used for cancellous bone and dermal graft and (2) the child's appearance is improved along with alveolar cleft grafting.

Assessment of the cleft nasal deformity using a regression equation

OBJECTIVE

The purpose of this study is to propose an objective and simple method for assessing surgical outcomes of cleft nasal deformity using two-dimensional digital images.

DESIGN

Five plastic surgeons evaluated slides of 20 normal and 65 repaired cleft nasal deformities using the full range of values from 0 to 100 with 10-point intervals. Five laypersons rated 12 parameters per image from the same data set using the developed assessment tool. Correlation coefficients between the parameter values and the surgeons' grades were obtained to find the best matches, and a regression equation was formulated using those. The reproducibility of the proposed method used by the laypersons was compared with that of the subjective grades made by the surgeons.

RESULTS

The mean correlation coefficient among the evaluated grades by the five laypersons using the proposed method was higher (.90) than that for the subjectively determined grades from the five plastic surgeons (.80). The grade reproducibility of the patients by the laypersons (9.6%) was also better than that by the surgeons (14.6%).

CONCLUSIONS

The proposed assessment tool, including the regression equation, allows laypersons as well as surgeons to perform simple, reproducible, quantitative, and objective assessments of the surgical outcomes for cleft nasal deformity using two-dimensional photographs.

Management of bilateral cleft lip and nasal deformity

PURPOSE OF REVIEW

Management of bilateral cleft lip and nasal deformity can be a challenging task. This paper provides an overview of bilateral cleft lip and nasal deformity with an updated review of current management issues in the literature.

RECENT FINDINGS

The Centers for Disease Control and Prevention recently reported that orofacial clefts are now the most common birth defect. While this statistic may be disheartening, the increased prevalence brings the problem to light at the forefront of the medical community, thus gaining more support and resources. Many techniques have been described for repair of bilateral cleft lip and nasal deformity. A recent advancement in presurgical orthopedics is the use of nasoalveolar molding to narrow wide clefts.

SUMMARY

Surgical management of bilateral cleft lip and nasal deformity poses a challenge to the skill and judgment of the cleft surgeon. Although techniques continue to evolve over the decades, the basic principles of cleft surgery remain the same. The main principles are to achieve an appropriate philtral size and shape, to position the cartilages in a more optimal position, and to attain muscular continuity and symmetry for optimal appearance and function. Thus, while keeping the basic principles in mind, management of bilateral cleft lip and nasal deformity becomes a valuable and rewarding experience for the surgeon, patient and caregiver.

Analysis of the cleft-lip nose in submental-vertical view, Part I--reliability of a new measurement instrument

BACKGROUND

Objective evaluation of nasal form and symmetry in cleft patients is difficult. The aim of this study was to establish a computer analysis of nasal form and symmetry (intranasal symmetry and symmetrical position of the nose), in order to evaluate primary and secondary cleft rhinoplasty outcomes.

MATERIAL AND METHODS

Indirect anthropometric measurements were performed on digital photographs processed by Photoshop 7.0 (Adobe Systems Inc., San Jose, California) with the help of Scion Image software (National Institutes of Health, Maryland, USA). For assessing intranasal symmetry, the ratio of nasal tip projection to total nasal width, the ratio of nostril widths, the ratio of nostril heights, the ratio of mid-alar widths and nostril symmetry were determined. Bifidity of the nose, columellar deviation and angulations of the nostrils were also measured. For assessing the symmetrical position of the nose, the ratio of the distances of alar points to the endocanthial lines and nasal base inclination were determined. The reliability of this analysis was tested by using submento-vertical photographs of bilateral cleft noses, of which the lips were primarily operated on by different techniques and different surgeons in Zurich and Bruges.

RESULTS

There were highly significant intraobserver (ICC=0.994) and interobserver reliabilities (ICC=0.893).

CONCLUSION

This nasal analysis is appropriate for comparing results of different surgical techniques.

[Nasal deformity after bilateral cleft lip repair]

Primary nasal deformity is characterized by apparent prolabio-columellar skin shortness due to alar cartilage dislocation worsened by lack of muscular support. The secondary deformation retains part of the initial deformity, sometimes even worsened by the primary lip repair. Multiple surgical lengthening techniques were used in nasal defect correction, suggesting both technical complexity and unsatisfactory results. Indeed, columellar insufficiency has more to do with abnormal columello-apical skin distribution due to alar mispositioning than an effective lack of skin. Secondary correction by open rhinoplasty allowing careful cartilage reconstruction of the nose tip seems to be widely accepted. However, the nasal defect can be limited by performing a primary intervention focusing on two principles: columellar lengthening by early alar repositioning and simultaneous lip and nose repair.

Combining the Cutting and Mulliken methods for primary repair of the bilateral cleft lip nose

BACKGROUND

Since 1990, primary bilateral cleft nasal reconstruction has been focused on placing the lower lateral cartilages into normal anatomical position. Of the four major techniques in this class, the Cutting (i.e., retrograde) method and the Mulliken method have been most successful. The retrograde method makes no external nasal incisions, but requires either preoperative or postoperative nasal molding to achieve maximum benefit. Mulliken's technique does not require molding, but leaves the footplates of the medial crura in the depression above the projecting premaxilla associated with the diminutive anterior nasal spine. Leaving the footplates in place also prevents adequate approximation of the alar bases. In this article, the two methods are combined to achieve the benefits of both.

METHODS

We report our experience with the retrograde nasal approach associated with marginal rim incisions (Mulliken method) in a series of 25 consecutive bilateral cleft lip cases simultaneous with lip repair. We performed a retrograde approach through membranous septum incisions elevating a prolabial-columellar flap. To facilitate alar cartilage manipulation we added bilateral marginal rim incisions. Nasal width, columella length and width, tip projection, and nasolabial angle were analyzed after a minimum of 2 years after surgery. These were compared with a normal, age-matched, control group. We also examined nostril symmetry and marginal nostril scars.

RESULTS

Columellar length was not statistically significantly different from that of the control group (p = 0.122442). Nasal width, columellar width, tip projection, and nasolabial angle were all significantly greater in the cleft group than normal (p < 0.001). No hypertrophied scars were found associated with the marginal rim scar.

CONCLUSIONS

Adding the Mulliken approach allows alar cartilage manipulation to be performed more easily than when using the retrograde approach alone. Tip projection and alar base narrowing are facilitated using the combined technique rather than the Mulliken approach alone. Prolabial flap manipulation is safe using this combined approach, even in cases with a severely projected premaxilla. We believe that the combined approach is safe and yields better long-term results than either technique alone.

Mulliken method of bilateral cleft lip repair: anthropometric evaluation

BACKGROUND

Simultaneous surgical correction of bilateral cleft lip and nasal deformity is becoming more common. This is a major change from the conventional strategy of secondary nasal correction.

METHODS

Thirty patients with bilateral cleft lip and nasal deformity were repaired using the Mulliken method between July of 1997 and December of 2002. This series was composed of 10 infants with bilateral complete cleft lip, 12 with bilateral incomplete cleft lip, and eight with bilateral asymmetric cleft lip, defined as complete on one side and incomplete on the other. A preoperative orthopedic appliance was employed in five infants who had severe collapse of the lateral maxillary segments. Mean age at the time of repair was 3.8 months.

RESULT

Postoperative results were evaluated anthropometrically. The mean follow-up period was 3.8 years (range, 1.2 to 5.5 years). Nasal tip protrusion was low; interalar dimension was wide; columellar length was slightly short; upper cutaneous labial height was short; and vermilion-mucosal height was near normal. All anthropometric values approached controls by 5 years.

CONCLUSION

Our modified Mulliken method is effective in correction of all forms of bilateral cleft lip and nasal deformity. Further evaluation is needed for possible differences in outcome based on race and age at the time of operation.

The central lip flap and nasal mucosal rotation advancement: important aspects of composite correction of the bilateral cleft lip nose deformity

The columella, nasal tip, lip relationship in the secondary bilateral cleft deformity remains an enigma and a great challenge for the cleft surgeon. A subset of patients with bilateral cleft lip still require columellar lengthening and nasal correction, despite the advances in preoperative orthopedics and primary nasal corrections. An approach to correct this deformity is described. This consists of (1) lengthening the columella by a central lip advancement flap; (2) open rhinoplasty, allowing definitive repositioning of lower lateral cartilages, ear cartilage grafting to the tip and columella when necessary; (3) nasal mucosal advancement; (4) alar base narrowing; and (5) reconstruction of the orbicularis oris as required. Depending on the individual assessment of the patients, some of these steps were not performed, leaving the nasal mucosal advancement the most important aspect of the reconstruction. In a consecutive series of 72 patients with repaired bilateral cleft lip and palate, 17 patients have been treated with nasal mucosal rotation advancement and followed up for a maximum period of 10 years. With the use of this technique, the secondary bilateral cleft lip nose deformity has been successfully corrected.

Bilateral cleft lip

The surgeon's objectives are normal nasolabial appearance and normal speech. The principles for synchronous repair of bilateral cleft lip have been established, and the techniques continue to evolve. Primary repair impairs maxillary growth, but little can be done at this time except to practice gentle craftsmanship and to minimize tension on the lower labial closure. The cutaneous lip should never be reopened for revision, and the number of secondary procedures involving the nasal cartilages should be kept to a minimum. Many adolescents with repaired bilateral cleft lip need maxillary advancement to improve projection of the nasal tip, to protrude the upper lip, and to attain normal sagittal skeletal harmony. With expected improvements in the technology of distraction osteogenesis, maxillary advancement may someday become as acceptable as orthodontic treatment.

Neural tube programming and craniofacial cleft formation. I. The neuromeric organization of the head and neck

This review presents a brief synopsis of neuromeric theory. Neuromeres are developmental units of the nervous system with specific anatomic content. Outlying each neuromere are tissues of ectoderm, mesoderm and endoderm that bear an anatomic relationship to the neuromere in three basic ways. This relationship is physical in that motor and sensory connections exist between a given neuromeric level and its target tissues. The relationship is also developmental because the target cells exit during gastrulation precisely at that same level. Finally the relationship is chemical because the genetic definition of a neuromere is shared with those tissues with which it interacts. The model developed by Puelles and Rubenstein is used to describe the neuroanatomy of the neuromeres. Although important details of the model are currently being refined it has immediate clinical relevance for practicing clinicians because it permits us to understand many pathologic states as relationships between the brain and the surrounding tissues. Relationships between the processes of neurulation and gastrulation have been presented to demonstrate the manner in which neuromeric anatomy is established in the embryo. We are now in a position to describe in detail the static anatomic structures that result from this system. The neuromeric 'map' of craniofacial bones, dermis, dura, muscles, and fascia will be the subject of the next part of this series.