Comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using conchal composite grafts

Let-Down Rhinoplasty in Patients With Cleft Lip Nose

BACKGROUND AND OBJECTIVES

Rhinoplasty in patients with cleft lip nose (CLN) deformity is challenging. Cleft lip nose deformity primarily affects the nasal tip, columella, nostrils, alar base, floor, and septum. The needs of patients with CLN are quite different from those of patients who undergo primary rhinoplasty. Recently, the dorsal preservation rhinoplasty technique has gained popularity. We applied this technique to patients with CLN deformity to obtain better aesthetic and functional results.

PATIENTS AND METHODS

Ten consecutive patients with indication for primary CLN reconstruction underwent let-down rhinoplasty. Rhinoplasties were performed using either the closed or open approach, with costal cartilage grafts and full-thickness skin grafts. A rhinoplasty outcome evaluation questionnaire was used to assess the results. Moreover, the use of the same questionnaire in prior patients allowed us to compare results between our previous and new techniques.

RESULTS

The study included 6 female and 4 male patients, with ages ranging from 18 to 25 years. Only 1 patient had a history of bilateral cleft lip. Seven patients had a history of left-sided cleft lip, and 2 patients had right-sided cleft lip. Open-approach let-down rhinoplasty with costal cartilage grafts and full-thickness skin grafts was performed in 8 patients, whereas closed-approach let-down rhinoplasty with costal cartilage grafts was performed in 2 patients. Columellar struts and affected-side onlay costal cartilage grafts were used in all patients. All patients reported being satisfied with the let-down rhinoplasty outcome, and none complained of functional problems. However, nostril symmetry was not observed in some patients, particularly in patients who underwent closed-approach rhinoplasty.

CONCLUSIONS

Combining open approach, full-thickness skin graft, costal cartilage graft, and let-down rhinoplasty shows promising and satisfactory outcomes in patients with CLN. However, further studies are required to confirm this observation.

Component Restoration in the Bilateral Intermediate Cleft Tip Rhinoplasty

SUMMARY

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

Cartilage Grafting Outcomes in Intermediate and Definitive Cleft Rhinoplasty

OBJECTIVE

To compare cartilage grafting outcomes in intermediate versus definitive cleft rhinoplasty.

DESIGN

A retrospective chart review was conducted. The χ² and Fisher exact tests were used for statistical analyses. Results were considered statistically significant at P < .05.

PARTICIPANTS

All subjects who underwent revision cleft rhinoplasties between July 2011 and June 2019 were included. Subjects with syndromic conditions were excluded.

RESULTS

A total of 46 subjects with a cleft nose deformity underwent 65 rhinoplasty procedures. The ages averaged 17 years (range 5-50) with 34 (73.9%) males and 12 (26.1%) females. In the intermediate group, 6 (28.6%) subjects required cartilage grafting as part of 6 cleft rhinoplasties, whereas 15 (71.4%) subjects underwent a total of 26 cleft rhinoplasties that did not require grafting. In the definitive group, 18 (76%) subjects required cartilage grafting over 21 cleft rhinoplasties, whereas 7 (24%) subjects underwent a total of 9 cleft rhinoplasties where cartilage grafting was not required. The difference between the number of subjects requiring cartilage grafting in the intermediate versus the definitive group was statistically significant (P = .007). Ear concha and nose were the most frequently used cartilage donor sites, with no observed complications.

CONCLUSIONS

Cartilage grafting was significantly more common in the definitive rhinoplasty group. Intermediate cleft rhinoplasty during the 5- to 13-year age period was effective, with a low-risk profile. In our experience, ear concha and nose were the preferred cartilage donor sites, with effective results and an excellent safety profile.

Component Restoration in the Unilateral Intermediate Cleft Tip Rhinoplasty: Technique and Long-Term Outcomes

BACKGROUND

The intermediate cleft tip rhinoplasty is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. The authors describe and evaluate long-term outcomes of that approach for the unilateral cleft lip and palate patient based on the concept of individual restoration of each abnormal anatomical component.

METHODS

Photomorphometric analyses of unilateral cleft lip and palate patients (n = 50) who underwent intermediate cleft tip rhinoplasty using the component restoration technique were evaluated preoperatively (time 0) and postoperatively at less than 1 year (time 1), 1 to 3 years (time 2), and more than 3 years (time 3) and compared to age-matched unilateral cleft lip and palate control patients. Nasal relationships (alar symmetry, nasal tip protrusion-to-alar base width ratio, and height-to-width dimensions for the cleft and noncleft nostrils) were compared over time using a linear mixed-effect model.

RESULTS

At time 0, both groups demonstrated similar nasal relationships, with the exception of a wider cleft-side nostril in relationship to height in the rhinoplasty group. The component restoration technique improved all four nasal relationships at all postoperative time points compared with time 0 in a statistically significant manner, whereas control patients did not demonstrate significant changes at the corresponding ages. Long-term differences at time 3 revealed a trend toward improved alar symmetry and cleft-side and non-cleft-side nostril dimensions, and a significant improvement in the nasal tip protrusion-to-alar base width ratio in intermediate cleft tip rhinoplasty-treated versus control patients (p = 0.002).

CONCLUSION

The component restoration technique for the unilateral intermediate cleft tip rhinoplasty improves nasal relationships toward normal immediately and in a sustained manner for at least 3 years.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Component columella augmentation in cleft nose rhinoplasty: a preliminary study

The purpose of this study was to evaluate the outcome of a component columella augmentation technique in cleft nose rhinoplasty. This prospective study included rhinoplasty procedures in bilateral cleft nose patients treated by component columella augmentation technique. After surgery, all patients were followed up daily for the first week, and then at 1 month and 6 months postoperative. The following four parameters were assessed: nasal tip projection, infratip lobule length, infratip lobule-to-base distance, and columella-labial angle. Thirteen rhinoplasty patients were included. Tip projection was increased (5.6±3.5mm) in all cases postoperatively (P<0.05); the increase was seen mostly in the lobule-to-base length (4.5±0.4mm), with a minimal change in lobule length (1.1±3.6mm). Preoperative and postoperative lobule lengths were not statistically different (P>0.05). With this technique, it is not necessary to involve the upper and lower lips. Therefore, the non-aesthetic vertical scars and tissue distortion that may occur with local flaps are easily avoided. Compared to composite augmentation, each part of the deformity (cartilage and skin) is precisely and separately restored with this technique.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

BACKGROUND

A short columella is one of the most severe problems in bilateral cleft lip and nose deformity. In particular, with tissue insufficiency or scar contracture on the upper lip, it is very hard to achieve a good nasal profile with conventional methods.

METHODS

One hundred thirty-seven patients with a short columella were operated on from February of 1987 to December of 2008. The average age at operation was 7.3 years. The conchal cartilage was harvested. The preauricular or postauricular skin-subcutaneous fat composite tissue was harvested. Through a transcolumellar incision, the conchal cartilage was inset and the defect was covered with skin-fat composite tissue. The serial nasal profiles were evaluated before and after surgery. Also, the postoperative nasal profiles were compared with normal profiles. The postoperative color difference with surrounding skin was measured by the L*a*b* photographic analysis method.

RESULTS

The mean height and width of skin-subcutaneous fat composite tissue were 9.81 and 22.14 mm, respectively. The preoperative and postoperative measuring for columella height was 5.1 + or - 1.1 mm and 14.2 + or - 1.5 mm. The columella-lip angle was 120.30 + or - 12.97 preoperatively degrees and 98.76 + or - 10.98 degrees postoperatively, whereas the angle of columellar-alar triangle was 111.56 + or - 11.39 degrees and 97.91 + or - 11.49 degrees, respectively. None of the postoperative profiles were different from those of normal Korean people of the same age except in the 0- to 6-year-old group (p < 0.05). The color match was best with preauricular composite tissue. Complications included total necrosis in three cases and partial necrosis in 12 cases that were treated conservatively.

CONCLUSION

Elongating columella using a composite graft can be a satisfying alternative, especially for a severe short columella with upper lip tissue deficiency.

Rhinoplasty to correct nasal deformities in postseptoplasty patients

BACKGROUND

Although not so common, septoplasty carries the risk of inducing nasal deformity such as saddle nose and deviated nose. Surgical correction for those deformities is a formidable task to deal with, because the septal cartilage framework was already weakened due to previous procedure. This study was designed to examine various causes and effective techniques of rhinoplasty for correction of nasal deformities after septoplasty.

METHODS

Subjects comprised 19 patients who developed nasal deformities after septoplasty. Pre- and postoperative photographs were analyzed by two rhinoplastic surgeons. Anthropometric measurements of the external nose before and after surgery were made using frontal and lateral photographs to objectively evaluate outcomes.

RESULTS

Intraoperative analysis showed that 5 patients had weak L-struts and 13 patients had displaced caudal septa. Septum was reconstructed using costal cartilage in 13 cases. Spreader grafting was performed in 13 patients and caudal septal extension grafts were performed in 10 patients. All but 1 patient had successful functional and esthetic outcomes. In the saddle nose group, all parameters except nasolabial angle were significantly improved. In the deviated nose group, curved deviated angles were completely corrected, whereas the linear deviated angle was not.

CONCLUSION

Loss of caudal septal support appears to be a major reason for nasal deformity after septoplasty. The best surgical approach for septal cartilage framework reconstruction appears to involve the use of bilateral spreader or septal extension grafts using costal cartilage.

Analysis of the cleft lip-nose in the submental-vertical view. Part II. Panel study: which is the most important deformity?

BACKGROUND

In part I, we presented an anthropometric measurement instrument that uses standardized facial pictures in the submental-vertical view, Adobe Photoshop 7.0, and Scion Software for Windows to determine both form and symmetry of the cleft nose. This instrument was found to be both reliable and universally suitable for comparing results of cleft rhinoplasties. However, the quality of the overall result needs to be based on weights assigned to different measurable parameters/deformities. Therefore, we carried out a panel study to evaluate the relative importance of the different parameters/deformities according to the parents of the patients.

MATERIALS AND METHODS

A questionnaire with both pictorial and textual representations of 10 distinct nasal cleft deformities was sent twice to the parents of 14 complete unilateral and 14 complete bilateral cleft lip-nose patients. The deformities were rank-ordered by the parents, and the responses were analyzed for intraobserver and interobserver reliabilities.

RESULTS

The most important deformity according to both groups was the asymmetric position of the nose within the facial frame. Alar position was also important whereas nostril form was least important. There was fair test reliability for both intraobserver and interobserver rankings.

CONCLUSION

Rankings of the different nasal cleft deformities by the parents of cleft patients are reproducible and, hence, a useful preparatory guide for surgeons.

Modified forked flap for controlling columella length in cleft lip open rhinoplasty

BACKGROUND & PURPOSE

Suturing the columellar flap after open rhinoplasty often reduces the tip projection gained, especially in patients with cleft lip deformity, in whom the columella is usually short and inelastic. A modification of the classical forked flap is proposed for controlling the tension created by the columellar suture.

PATIENTS

Five patients aged from 17 to 35 years underwent surgery in the previous 2 years using the described techniques.

METHODS

The columella incision followed the classic tepee shape, although the inverted V was extremely narrow and long, with its arms extending beyond the columellar rims, stopping at the base of the vestibule, then making acute angles and heading vertically towards the nostril tip, and continuing into the nostrils as normal marginal incisions. Consequently, a complete "W" was used, in which the lateral angles and arms lay in the nostrils, while the central inverted V was in the columella. The rhinoplasty was performed as planned and a triple "V-Y" suture was made.

RESULTS

The technique provided real lengthening of the columella or, at least, it closed the columellar incision without tension, thereby preserving the tip projection.

CONCLUSIONS

In open rhinoplasty on patients with cleft lip involvement a triple V-Y columellar suture preserves the surgically obtained columella length.