Nasal symmetry: a 10-year comparison between the Pigott and McComb nasal correction

Primary Cleft Rhinoplasty: A Systematic Review of Results, Growth Restriction, and Avoiding Secondary Rhinoplasty

BACKGROUND

Primary rhinoplasty during correction of unilateral cleft lip continues to be a topic of debate because of concerns that early nasal intervention may affect nasal and maxillary development over the long term. This study aims to determine the volume and quality of evidence for and against primary unilateral cleft rhinoplasty.

METHODS

A systematic review was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were pulled from PubMed and EMBASE and screened by title and abstract. Studies with human participants undergoing rhinoplasty at the time of unilateral cleft lip repair and some evaluation of the nasal outcome were included. Studies with a large proportion of syndromic patients, case reports, editorials, letters, reviews, studies exclusive to bilateral clefts, and studies not available in English were excluded. Those that met criteria were then systematically reviewed.

RESULTS

Twenty-five articles were included. Ten articles that assessed the results of primary rhinoplasty subjectively all supported cleft lip repair with primary rhinoplasty. Sixteen articles assessed the results of primary rhinoplasty objectively, with 15 supporting primary rhinoplasty during cleft lip repair. Eight of nine studies that evaluated nasal growth and development over time found no restriction in nasal development. Five studies with a follow-up period of at least 6 years found that the percentage of patients who avoided revision rhinoplasty ranged from 43% to 100%. There were significant risks of bias in the majority of studies.

CONCLUSION

The majority of studies reviewed support that primary rhinoplasty during unilateral cleft lip repair results in good outcomes with limited or no effect on nasal growth.

Lessons from behavioral lateralization in olfaction

Sensory information, sampled by sensory organs positioned on each side of the body may play a crucial role in organizing brain lateralization. This question is of particular interest with regard to the growing evidence of alteration in lateralization in several psychiatric conditions. In this context, the olfactory system, an ancient, mostly ipsilateral and well-conserved system across phylogeny may prove an interesting model system to understand the behavioral significance of brain lateralization. Here, we focused on behavioral data in vertebrates and non-vertebrates, suggesting that the two hemispheres of the brain differentially processed olfactory cues to achieve diverse sensory operations, such as detection, discrimination, identification of behavioral valuable cues or learning. These include reports across different species on best performances with one nostril or the other or odorant active sampling by one nostril or the other, depending on odorants or contexts. In some species, hints from peripheral anatomical or functional asymmetry were proposed to explain these asymmetries in behavior. Instigations of brain activation or more rarely of brain connectivity evoked by odorants revealed a complex picture with regards to asymmetric patterns which is discussed with respect to behavioral data. Along the steps of the discussed literature, we propose avenues for future research.

Early Assessment of Dental Arch Development in Repaired Unilateral Cleft Lip and Unilateral Cleft Lip and Palate versus Controls

Objective

To evaluate dental arch relationships and dimensions, relative to an age matched noncleft sample, in Caucasian 3-year-old children with repaired unilateral cleft lip (UCL) or unilateral cleft lip and palate (UCLP).

Design

Prospective, cross-sectional, case-control study performed in Scotland, U.K.

Participants

Eleven children with repaired unilateral cleft lip, 16 children with repaired unilateral cleft lip and palate, and 78 children as controls.

Main Outcome Measures

Dental arch relationships and linear arch dimensions.

Results

Prevalence of Class III incisor relationship was 31.3% in children with unilateral cleft lip and palate compared with 9.1% in children with unilateral cleft lip. A buccal crossbite was present in 36% of children with unilateral cleft lip, compared with 75.6% of children with unilateral cleft lip and palate. Mean linear maxillary arch dimensions did not differ significantly between children with unilateral cleft lip and the controls. Except for second intermolar width, statistically significant differences existed in mean linear maxillary arch dimensions between the unilateral cleft lip and the unilateral cleft lip and palate groups; the mean linear maxillary arch dimensions were significantly greater in the control group than in the unilateral cleft lip and palate group. The mean cleft-affected anterior quadrant length appeared to be the arch dimension with the greatest power of discrimination among the three groups. There were no significant differences in mean linear mandibular arch dimensions among the three groups.

Conclusions

Anterior crossbite was almost three times more common in the unilateral cleft lip and palate group than in the unilateral cleft lip group. Mean linear maxillary arch dimensions differed significantly between the unilateral cleft lip and palate group and the control group. There were no significant differences in mean linear maxillary arch dimensions between unilateral cleft lip and controls or between mean linear mandibular arch dimensions for unilateral cleft lip, unilateral cleft lip and palate, and controls.

Quantitative measurement of symmetry from photographs following surgery for unilateral cleft lip and palate

A computer-based program is presented to be used with digitized frontal and basal photographs. SymNose enables the user to quantify asymmetry of the front view of the lip and nose and of the nose from the base view, using the area of mismatch of one side reflected over the other. There is a facility to transfer results to a spreadsheet. The program is simple and quick to use and runs on Apple Macintosh OSX 10.4 or later, power and Intel-based systems. The outline of a feature can be drawn using the mouse or digitizing pad. The program, together with Help files, is available from the authors.

Nasal asymmetry in unilateral cleft lip and palate

OBJECTIVES

Comparison of nasal asymmetry between unilateral cleft lip and palate (UCLP) patients with and without nasal correction at primary repair. Assessment of the value of Symnose as a routine research tool.

PARTICIPANTS

75 ten-year-old UCLP patients who underwent primary lip repair by one of two techniques: classical Millard with primary nasal correction (n = 30) or modified Millard without nasal correction (n = 45). Control group of ten-year-old school children (n = 45).

METHODS

Nasal asymmetry of participants was measured from facial photographs taken in two views: frontal and basal. The Symnose computer program was used to calculate asymmetry for three parameters: front perimeter (FP), base perimeter (BP) and nostrils (N). Total asymmetry was also calculated. Each image was traced on three separate occasions and a mean of the three measurements was calculated.

RESULTS

BP, N and total asymmetry were significantly greater in UCLP patients without nasal correction compared to both controls and patients with correction (BP = 12.73% v 4.90% v 6.75%, N = 47.73% v 15.83% v 30.75%, total = 81.87% v 46.43% v 54.68%, p ≤ 0.001). FP asymmetry was significantly greater in controls than all UCLP patients (22.87% v. 18.18% and 15.07%, p = 0.001 and p = 0.008). BP measurements have a higher degree of repeatability than FP and N (Coefficient of repeatability = 5.99, 17.02 and 16.47, respectively).

CONCLUSIONS

Primary nasal correction produces greater nasal symmetry during childhood from the basal view. Symnose is a simple method of objectively measuring asymmetry in UCLP, however improvements are required before it can be considered a useful research tool.

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.

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.

A comparison of three methods of repairing the hard palate

OBJECTIVE

To compare growth, speech, and nasal symmetry outcomes of three methods of hard palate repair.

PATIENTS

Consecutive available records of children born with unilateral bony complete cleft lip and palate over the period 1972 to 1992.

INTERVENTIONS

Identical management of lip, nose, alveolus, and soft palate. Hard palate repair by Cuthbert Veau (CV) from 1972 to 1981, von Langenbeck (vL) from 1982 to 1989, or medial Langenbeck (ML) from 1989 to 1991.

OUTCOME MEASURES

For growth: GOSLON yardstick or 5-year model index. For speech: articulation test. Nasal anemometry. For nasal symmetry: Coghlan computer-based assessment. All these measures were developed during the period of data collection but not for this project.

RESULTS

There was a strong trend toward more favorable anteroposterior maxillary growth with the change from CV to vL to ML techniques. This fell short of statistical significance because of the small sample size. There was a significant reduction in cleft-related articulation faults (p =.01) considered to be related to improved arch form. In the absence of improved rates of velopharyngeal insufficiency or nasal symmetry, increased surgical experience was discounted as a significant contribution to improved growth and articulation outcomes.

CONCLUSIONS

Reduced periosteal undermining and residual exposed palatal shelf from CV to vL to ML improved incisor relationships and articulation.

A 20 year audit of nose-tip symmetry in patients with unilateral cleft lip and palate

The purpose of this study was to audit the process and outcome in terms of nasal-tip symmetry of the first 20 patients with unilateral complete cleft lip and palate treated by the Pigott alar leapfrog primary nasal correction in the early 1970s and followed for 20 years. Symmetry was assessed using the Coghlan computer-based analysis of frontal and basal views to determine the stability of the correction. The Abyholm technique of alveolar bone grafting was performed in 12 of the 20 patients. Various other secondary procedures have been performed on the nose tip and septum to improve the airway or appearance. Photographs were taken within one year of ages 5, 10, 15 and 20 years, and the lower border of the nose, the alar domes and the nostrils were assessed. To assess the overall change from 5 years to 20 years, both views were available for 17 patients. No significant change was found in the lower border or nostril symmetry, but significant deterioration at the P< 0.01 level was found on the basal view. We assessed the 10, 15 and 20 year views of all 12 patients who had undergone alveolar bone grafting to determine early and late changes. No significant benefit was found from alveolar bone grafting or minor secondary procedures for appearance. Consequently, our criteria for undertaking minor adjustments to improve appearance have become more stringent. We consider that objective reporting of appearance should become essential in peer-reviewed journals.

Symmetry and morbidity assessment of unilateral complete cleft lip nose corrected with or without primary nasal correction

OBJECTIVE

Unilateral complete cleft lip patients treated with or without a primary nasal correction at the time of cleft lip repair were compared to evaluate the relevance of early surgical correction of the nose by using two assessments: nasal symmetry and morbidity.

DESIGN, SETTING, PATIENTS

The no nasal correction group (NNC, n = 19) was operated by surgeon A using the Millard technique. The primary nasal correction group (PNC, n = 9) was operated by surgeon B combining the modified Millard technique with a columellar lift and alar mobilization. Symmetry was assessed on two sets of standardized photographs at 9 years of age using a computer-assisted analysis. Both cleft groups were compared with normal controls (NC, n = 20). The computer method included area and angular measurements. Morbidity was assessed by the number of procedures on the vermilion, the lip, and/ or nose for revisional surgery up to the age of 9 (NNC, n = 26; PNC, n = 12).

RESULTS

No significant differences in symmetry were found between the NNC and PNC groups regarding the area and angular measurements. With regard to the area measurements, both cleft groups produced a significant asymmetry when compared to the NC group. Concerning the angular measurements, however, the NNC group differed significantly from the NC group, whereas such a difference could not be noted between the PNC group and NC group. With respect to morbidity, no revisional procedures were performed in the PNC group. The number of revisional procedures in the NNC group was 16 in 10 patients.

CONCLUSION

Results are presented that favor, up to the age of 9 years, a primary nasal correction at the time of cleft lip repair.

Outcome analysis of a modified Tajima procedure

Secondary nasal correction of cleft patients is acknowledged to be a difficult problem. There are many different operations but few objective assessments of their results. We have evaluated the results of a modified Tajima operation by use of the Bristol computer technique. Eighteen patients were followed up for a mean of 33 months (range 10-56). Measures of asymmetry were obtained for different photographic views, preoperatively and at later postoperative visits. In all views there was a significant improvement in shape in the early postoperative photos. This same improvement was also seen when comparing preoperative to late postoperative results i.e. this initial improvement is maintained over time. There was no significant difference between the early and late postoperative views. In this small series the modified Tajima technique has given statistically significant lasting improvement. However, few other operations have been objectively assessed and hence comparison is difficult. We advocate the use of the computer technique for other procedures to allow meaningful comparisons between them.

A panel based assessment of early versus no nasal correction of the cleft lip nose

There is a need to be able to assess the overall result in a significant series of cases of a method of management of the cleft lip and nose deformity in order to avoid "best case" reporting often used to introduce new techniques. The present study was performed by a panel placing standardised base view photographs in rank order. The photographs were of 10-year-old subjects of whom 15 were normal controls, 22 were from the Rikshospitalet, Oslo, all of whom had no primary nasal correction and 25 from Frenchay Hospital, Bristol, who all had radical primary nasal correction. Ranking was performed for upper nasal perimeter symmetry, nostril outline symmetry and for overall aesthetic appearance. Analysis of the results showed a significant difference between the three groups, with the corrected noses showing better symmetry. Inter and intraobserver correlations were very close. The limitations of a ranking and marking method of panel assessment are discussed, and a computerised method is presented in subsequent papers.