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

The Four-line Algorithm for the Treatment of Unilateral Cleft Lip

Background

Several factors affect the outcome of a repaired unilateral cleft lip (UCL). Some of these, like the surgeon's expertise, are hard to evaluate, whereas others can be better evaluated objectively using the cleft severity index and the surgical technique used.

Methods

This study includes patients of Operation Smile Ecuador and was done in 2 parts. The retrospective part uses the medical records of 298 patients with UCL treated by Operation Smile Ecuador from January 2015 to December 2017. The correlation of the photographed measurements, surgical technique, and evolution of the patients was studied. In the prospective part, the participant surgeons of this article applied the algorithm to 136 patients treated from January 2018 to December 2019.

Results

In the retrospective study, the resulting symmetry varied significantly among most Unilateral Cleft Asymmetry Index presurgical classifications, and 34% of the results were deficient. The four-line algorithm was developed using the case-technique analysis of the retroactive study. The algorithm was applied in the prospective part, which resulted in no deficient cases and 81% optimal results. There were significantly better results after applying the four-line algorithm for patients classified as Unilateral Cleft Asymmetry Index degrees III and IV (P < 0.001 and P = 0.041, respectively).

Conclusions

Even though the cleft severity in the UCL is an important prognostic factor, the results of this study show that there are no universal surgical techniques to achieve optimal results. The four-line algorithm proposes to use a case-specific surgical technique to achieve the best functional and aesthetic result for our patients.

Primary Rhinoplasty for Unilateral Cleft Lip: A Long-Term Cohort Assessment of Aesthetic and Anthropometric Outcomes

The decision to undertake rhinoplasty maneuvers during cleft lip repair remains controversial. Little data compare long-term outcomes with and without primary rhinoplasty (PR). This study compared nasolabial outcomes in cohorts with unilateral cleft lip (UCL) treated with and without PR at the Children's Hospital of Philadelphia using standardized aesthetic and anthropometric assessments.

Retrospective cohort study.

Tertiary care pediatric hospital.

Patients who underwent lip repair for UCL.

Cleft lip repair with and without PR.

Anthropometric analyses and crowdsourced aesthetic assessments using Americleft nasolabial appearance reference scales and pairwise comparisons.

Among 208 patients, 155 (74.5%) and 53 (25.5%) underwent lip repair with and without PR at 4.5 ± 1.1 months. Primary rhinoplasty (β = 0.345, P = .037) and a lower Cleft Lip Severity Index (β = -0.341, P < .001) predicted superior pairwise rank at 4.9 ± 1.9 years of age. History of PR predicted decreased columellar deviation angle (CDA) (β = -2.375, P = .019) and improved nostril symmetry (β = 0.111, P = .038). Increased columellar-labial angle (r = 0.27, P = .002), improved nostril symmetry (r = -0.23, P = .01), and decreased CDA (r = -0.45, P < .001) correlated with superior ratings. Patients with ˂20 days of postoperative nasal stenting had inferior lateral ratings (2.4 ± 0.6 vs 2.1 ± 0.5, P = .005). Those who underwent surgery at ˂5.3 months had inferior nasal projection (Goode's ratio 0.56 ± 0.09 vs 0.62 ± 0.08, P = .006).

Primary rhinoplasty for UCL offers superior aesthetic results in early childhood by layperson and anthropometric assessments. Specific improved characteristics from PR-CDA and nostril symmetry-most greatly influence layperson perception of nasal appearance. Older age at surgery predicted increased nasal projection, while prolonged nasal stenting predicted superior profile appearance.

Comprehensive repair of the alveolar cleft using cortical and cancellous bone layers: A retrospective study

To retrospectively review the clinical effect of comprehensive treatment of alveolar cleft (CTAC) using the mandible as the bone source. Patients with alveolar clefts who met the inclusion criteria were subjected to a CTAC protocol that included the following: (1) preoperative orthodontic treatment for creating good soft-tissue conditions; (2) 'area-like grafting' with subperiosteal osteogenic chin bone instead of cartilaginous osteogenic iliac bone; (3) simulation of normal bone anatomy via a sandwich-like bone graft consisting of 'cortical bone + cancellous bone + cortical bone'; and (4) strong internal fixation to ensure initial bone block stability. At 6 months postoperatively, the titanium plate was removed and cone-beam computed tomography was performed to evaluate the surgical results. A total of 54 patients underwent treatment with the CTAC protocol. The average age at the initial operation was 10.3 ± 2.1 years, and the average hospital stay was 2.8 ± 0.6 days. At 6 months postoperatively, 49 patients (90.7%) showed good clinical results. The transplanted bone block formed a 'cortical bone + cancellous bone + cortical bone' structure similar to that of the normal jawbone. A mature bone bridge formed, and the impacted permanent teeth continued to erupt and enter the bone graft area. CTAC is a comprehensive restorative solution for alveolar cleft repair that integrates multiple concepts, including orthodontics, embryology, anatomy, and improvements to surgical methods. The method is easy to perform, causes little surgical trauma, and shows a stable success rate, and is thus worth promoting.

Comparing definitive unilateral cleft rhinoplasty with and without diced-cartilage alar-base augmentation: A retrospective cohort study

This retrospective cohort study aimed to compare the long-term aesthetic outcomes and satisfaction of patients who underwent two techniques of definitive unilateral cleft rhinoplasty. The two cohorts, comprising patients with mature unilateral cleft deformity, were managed with definitive rhinoplasty, either with or without diced-cartilage alar-base and peri-alar augmentation (ABPA). Thirty patients were included in each cohort. Anthropometric measurements, complications, patient satisfaction scores, and third-party surgeon assessment scores were reviewed. In both cohorts, anthropometric parameters improved. Rhinoplasty with ABPA was the superior cohort in terms of columellar length (10.3 ± 1.0 in the cohort with ABPA, compared with 7.9 ± 0.6 in the cohort without ABPA; p < 0.001), alar-base angle (0.2 ± 0.2, compared with 4.3 ± 0.3; p < 0.001), and columellar deviation (2.5 ± 1.4, compared with 10.3 ± 2.1; p < 0.001). This cohort also had more symmetry in nostril height and nostril width (p < 0.001), a lower recurrence rate (one case compared with 22 cases; p < 0.001), a higher patient satisfaction score (p = 0.002), and a higher surgeon assessment score (p < 0.001, Cronbach's alpha = 0.706, Kendall's coefficient of concordance = 0.787). Within the limitations of this study, it appears that the described technique for augmenting the alar-base and peri-alar maxillary area is manageable, and yields consistent long-term results.