A dynamic nostril splint in the surgery of the nasal tip: technical innovation

Efficacy of Post-Surgical Nostril Retainer (PSNR) in patients with UCLP Treated with Pre-Surgical NasoAlveolar Molding (NAM) and Primary Cheiloplasty-Rhinoplasty

OBJECTIVE

The aim of this investigation is to determine if the nasal form of patients with unilateral cleft lip and palate (UCLP) treated with pre-surgical nasoalveolar molding (NAM) therapy, primary lip-nose surgery, and post-surgical Nostril Retainer (PSNR) is different from patients treated with pre-surgical NAM and primary lip and nose surgery alone.

DESIGN

A cross-sectional, retrospective review of 50 consecutive non-syndromic patients with UCLP: 24 treated with NAM and primary lip-nose surgery followed by PSNR (Group I) compared to 26 patients treated with NAM and primary lip-nose surgery without PSNR (Group II). Polyvinyl siloxane nasal impressions were performed at the average age of 12 months and 6 days. Bilateral measurements of alar width at maximum convexity, total alar base width, nasal tip projection, columella length, and nostril aperture width and height were recorded. Statistical comparison of cleft versus non-cleft side nasal measurements were performed within Group I and Group II, as well as comparison of the difference between the two groups.

RESULTS

Cleft side nasal dimension was statistically significantly better in Group I than Group II across all measures except nasal projection (P<0.05). Group I showed less difference between the cleft and non-cleft side in all six measurements than Group II (p<0.05).

CONCLUSION

There is a significant difference in the nasal shape of patients who underwent PSNR compared to those that did not. The patients who used PSNR showed better nasal shape at the average age of 12 months than the control group.

Custom nasal stent and columellar reconstruction after a rhinoplasty complication: A clinical report

Nostril stenosis is typically caused by retraction and contraction after trauma or infection, although loss of nasal tissue is not common during rhinoplasty. This clinical report describes the fabrication of a nasal stent to replace the lost columella and a columella prosthesis for a patient who had had reconstructive surgery for nasal valve collapse and a missing columella. The stent established a comfortable means of nasal air exchange that was also esthetically acceptable. The stent also provided the necessary support for the nasal tissue before further nasal reconstructive surgeries.

Quality of life and nasal splints after primary cleft lip and nose repair: Prospective assessment of information and tolerance

Splints are commonly used after primary cleft surgery in order to secure the position of the nasal cartilages. Although the importance of splints is more and more stressed in the literature, many questions remain unanswered relative to the psychological impact of this device on children and families. Two questionnaires, Information and Tolerance, were used in order to measure the quality of life (QoL) associated with the use of nasal splints after primary cleft surgery. Information assessed the understanding of the parents the day before the procedure. Tolerance assessed their experience 3 months after splint placement. We prospectively included 41 consecutive patients from a Paris cleft center, 21 consecutive patients from a Russian center (Moscow) and 10 consecutive patients form a another French center (Nantes). In Paris and Nantes, an initial fixed splint was placed during the procedure until day 10, and then replaced by a removable splint for a period of 4 months. In the Moscow group, removable splints were used primarily for a total period of 4 months. Three types of removable splints were considered: commercial anatomical self-retentive splints (Nose-Fit™, Moscow, Russian Federation), in-house anatomical self-retentive splints and commercial Talmant-type splints requiring taping (Sebbin, Boissy-l'Aillerie, France). The data was analyzed as Likert scales and internal consistency was assessed using the Cronbach coefficient. Age at surgery, uni- or bilateral cleft, type of splint, number of splint changes and complications were tested against the scores of the questionnaires using multivariate models. We did not find correlations between the factors assessed by the multivariate analysis and the splint type. Information and Tolerance scores were high and showed satisfactory QoL associated with the use of splints. The internal consistency of the combination of the two forms was good. While the effects of splints on nasal morphology still need to be confirmed based on a controlled prospective study, we show here that this device is well tolerated by families and is not associated with specific complications.

The "Anatomical Balance Correction" for Secondary Cleft Lip Nasal Deformities

Secondary cleft lip nasal deformities corrective procedures are still a major concern for the maxillofacial surgeons.

Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty

BACKGROUND

Since 2006, the authors have explored the option of using septal cartilage as an alar rim graft on the cleft side during primary rhinoplasty to improve nasal symmetry. The aim of this study was to compare the nasal shape with or without rim graft.

METHODS

A total of 98 patients with unilateral complete cleft lip and palate were included; 39 patients had septal cartilage as the rim graft, and 59 patients did not. Measurements of the nostril height, nostril width, one-fourth medial part of nostril height, nostril area, nasal dome height, and nostril axis were obtained on the cleft and noncleft sides. Ratios of these measurements were calculated. These ratios were then compared between the graft and nongraft groups. The levels of asymmetry were categorized into four levels-less than 5 percent, 5 to 10 percent, 10 to 15 percent, and greater than 15 percent-based on the percentages deviated from perfect symmetry (100 percent). Panel assessment was also performed. Nasolabial angle and tip projection ratio were measured for the comparison of nasal growth.

RESULTS

The nostril height, height-to-width ratio, and nasal dome height were higher in the graft group (p = 0.003, p < 0.001, and p < 0.001, respectively). The graft group showed more consistency regarding the nostril shape and axis, and the differences were statistically significant (p < 0.05). The nasolabial angle and tip projection ratio showed no significant difference between the two groups.

CONCLUSION

This preliminary study suggests that the use of a primary septal cartilage graft may offer better support at the alar rim and improve the long-term outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Post septorhinoplasty custom-made unilateral nasal stent for nasal cleft deformity

CONTEXT

Nasal cleft deformity is a complicated problem. Utilization of nasal stent in post septorhinoplastyaims at establishing and maintaining airway patency, tissue position, and reduces tissue contracture after surgery.

CASE REPORT

A 16-year-old female patient presented with history of surgical reconstruction of congenital cleft lip and cleft palate with secondary septorhinoplasty of nasal cleft deformity. Patient was referred for nasal stent 1 week after septorhinoplasty. This case report provides a novel technique for fabrication of esthetic nasal stent after postseptorhinoplasty for secondary cleft nose deformity correction.

CONCLUSION

This case report presents a simple, convenient technique for nasal stent fabrication for prevention of restenosis for cleft nose deformity post secondary septorhinoplasty. Provision of nasal stent allows breathing, maintains esthetics, comfort, nasal patency, and contour with minimal discomfort.

Nasal tip complications of primary cleft lip nasoplasty

BACKGROUND AND PURPOSE

Complications of primary nasoplasty, at the time of definitive primary cheiloplasty, are underreported in the literature. This study endeavors to examine the occurrences of these complications at our cleft-craniofacial center, in an effort to identify causative factors and management strategies. A case series of patients with postoperative nasal complications after primary cleft lip nasal surgery is presented.

METHODS

A retrospective chart review of primary cleft lip nasal repairs was conducted at our cleft-craniofacial center between January 2003 and December 2007. Consecutive cases of 3 staff surgeons were evaluated. Specific data points included number and type of complications, subsequent required interventions, and relevant history, with particular attention paid to the details of the primary nasoplasty.

RESULTS

Eighty-six primary cleft lip nasoplasties were completed between the years 2003 and 2007. Six complications (6.9%) related to the primary cleft lip nasoplasty were identified. Four patients (4.6%) experienced nasal tip infections; all 4 required surgical drainage. Twenty-four patients (27.9%) undergoing primary cleft lip and nose repair had postoperative nostril conformers placed, and 2 (8.3%) of them experienced complications deemed conformer related.

CONCLUSIONS

Postoperative nasal complications of primary cheiloplasty occur and are likely underreported. In this series, complications resulted from infection, often occurring late, and secondary to the use of nostril conformers. Surgeon awareness and caregiver education, to identify the early signs of postoperative nasal complications, are critical to the successful treatment of these occurrences. Although this study did not intend on examining antibiotic use, the significance of nasal tip infections might support the regular use of antibiotics in this population, and the use of postoperative nostril conformers must be followed closely.

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

INTRODUCTION

Anatomical abnormalities and heterogeneous tissue deficiencies of the bilateral cleft lip nasal deformity challenges the cranio-maxillofacial plastic surgeon to create a functional, yet aesthetically pleasing nose. The authors propose a comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using composite conchal grafts.

PATIENTS

Five children with bilateral cleft lip nasal deformities had nasal reconstruction using conchal composite grafts, averaging 5 years in age at time of surgery. Patient follow-up averaged 21 months.

METHODS

An open tip rhinoplasty was performed using a 'V' shaped columellar incision. The conchal composite graft was obtained from the lateral aspect of the ear and was used to reconstruct the lateral alar mucosal defects. Conchal cartilage was used as a columellar strut. The columellar skin was closed in a 'V-Y' fashion, giving greater columellar length.

RESULTS

Visual inspection confirmed that the cleft lip nasal deformity was improved in all patients. There were no postoperative complications. All patients had complete composite graft take with minimal donor site morbidity and deformity.

CONCLUSIONS

This comprehensive rhinoplasty technique improves the abnormalities found in bilateral cleft lip nasal deformity by using the successful aspects of other methods and introducing the composite conchal graft.

Resorbable internal splint: an adjunct to primary correction of unilateral cleft lip-nasal deformity

There is usually some relapse in position of the alar cartilage after primary repair of unilateral cleft lip. Therefore, preoperative or postoperative external splinting has been recommended to supplement either closed or open suspension of the alar cartilage. The authors present a method using a resorbable internal nostril splint to shield the positioned alar cartilage from deformational forces caused by scar, and thus avoiding the problems associated with external splinting. An internal nasal splint was placed in 15 infants during repair of unilateral complete cleft lip and nasal deformity. The nasal morphology was compared with that of 15 control patients who had the same nasolabial procedure without internal splinting. Average follow-up time was 20.4 months (range, 4 to 30 months). Photogrammetric analysis showed that asymmetry of the alar contours averaged 8.6 percent in the splinted patients, as compared with 23 percent for controls (p <0.01). Thus, alar asymmetry was decreased two-thirds in the splinted group. An internal resorbable nasal splint is an adjunct to open alar suspension in primary repair of the unilateral cleft lip nasal deformity. An internal nasal splint protects the corrected alar cartilage longer than an external splint and eliminates drawbacks, such as necrosis, cutaneous depression of the nostril sill, and patient noncompliance. This strategy of temporary internal support of healing cartilage has other applications.

Cleft lip: unilateral primary deformities

The understanding and management of all aspects of unilateral cleft lip deformities continue to evolve. Just as we are entering the era of exciting advances in the understanding of the pathogenesis of craniofacial disorders, expansion of our understanding of the dynamic relationships of the structural and soft-tissue components of cleft deformities has assisted surgeons in achieving progressively improved and consistent outcomes for these patients. The anatomic and physiologic complexity of unilateral cleft lip deformities has been recognized for centuries, and generations of researchers have cumulatively contributed to our current understanding. This article examines the history, classification, anatomy, and controversies in the surgical management of unilateral cleft lip deformities, allowing surgeons to formulate a reasoned, longitudinal management plan for their patients on the basis of the available current data.

Polyvinylsiloxane dental bite registration material used to splint a composite graft of the nasal rim

We describe the construction of a nostril splint made from heavy body silicone-based dental impression material. This bio-compatible material supported a large chondrocutaneous auricular graft during early healing. The splint immobilized and maintained the shape of the alar rim and was further used nightly during the expected period of wound contraction.