Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair

Between unity and disparity: current treatment protocols for common orofacial clefts in European expert centres

There is considerable variability in the management of common orofacial clefts across Europe, reflecting differing opinions on optimal treatments. An updated overview of treatment protocols for orofacial clefts across 26 expert centres in the European Reference Network CRANIO is presented here. A structured questionnaire was distributed to map the surgical protocol and additional standard procedures for cleft palate (CP), unilateral cleft lip and palate (UCLP), and bilateral cleft lip and palate (BCLP). A surgical protocol was defined as the unique combination of a sequence of standard surgeries, their timing, and the surgical techniques employed. Overall, 33 unique surgical protocols for CP, 54 for UCLP, and 51 for BCLP were identified. Notable findings included the trend towards early hard palate closure, uniform timing of lip closure, and the popularity of primary cleft rhinoplasty. Nevertheless, practice variations were most pronounced in the timing of alveolar closure, the number of standard surgeries, and the application of additional standard procedures. This study highlights the diversity of treatment protocols across Europe, despite considerable convergence of treatment practices over time. To allow for further convergence, establishing objective criteria for protocol selection, adequate documentation of customizations, and consensus on the terminology of surgical techniques, are necessary.

Prospective study of nasal growth in bilateral cleft lip and palate patients after naso-alveolar moulding and primary columella lengthening compared to controls at 5, 10 and 20 years

INTRODUCTION

A short columella, wide nostrils and a flat nasal tip are common features in patients with bilateral complete cleft lip and palate (BCLP). The objective of this study was to evaluate nasal morphology during growth in patients treated with naso-alveolar moulding (NAM) and primary surgical columella lengthening (PCL) compared with matched non-cleft individuals.

STUDY DESIGN

Prospective longitudinal case-control study.

PARTICIPANTS AND METHODS

Thirty-four consecutively treated BCLP patients at 5 and 10 years and at the end of growth (19.7 ± 2.0 years) were compared through normalized photogrammetry to a control of 34 age and sex-matched non-cleft individuals. Regression Models for Panel Data assessed how nasal measurements were influenced by surgery, age and gender.

RESULTS

Nasal protrusion was equal to non-cleft controls at all ages. Length of the columella was also comparable to controls at 5 and 10 years, but significantly shorter at the end of growth. Inter-alar and nasal tip width and nasolabial angle were significantly wider than controls at all ages: More than 60% of the patients have asked for correction of the nasal width, but no early surgery for columella lengthening was needed.

CONCLUSIONS

NAM and PCL have provided a nasal projection close to that of non-cleft individuals until adulthood, while length of the columella was physiological at 5 and 10, but shorter than controls at age 20. Width of the nasal tip and width of the alar bases were significantly wider than the controls and eventually required secondary nasal width correction in over two thirds of the sample.

Secondary Bilateral Cleft Rhinoplasty: Achieving an Aesthetic Result

BACKGROUND

Secondary rhinoplasty in patients with bilateral cleft lip poses ongoing challenges and requires a reliable method for achieving optimal outcomes.

OBJECTIVES

The purpose of this study was to establish a safe and effective method for secondary bilateral cleft rhinoplasty.

METHODS

A consecutive series of 92 skeletally matured patients with bilateral cleft lip and nasal deformity were included. All had undergone secondary open rhinoplasty, performed by a single surgeon with a bilateral reverse-U flap and septal extension graft, between 2013 and 2021. Medical records of these 92 patients were reviewed to assess the clinical course. A 3-dimensional (3D) anthropometric analysis and panel assessment of 32 patients were performed to evaluate the aesthetic improvement, with an age-, sex-, and ethnicity-matched normal control group for comparisons.

RESULTS

The methods showed statistically significant improvement in addressing a short columella (columellar height), short nasal bridge (nasal bridge length), de-projected nasal tip (nasal tip projection, nasal dorsum angle), poorly defined nasal tip (nasal tip angle, dome height, and panel assessment), and transversely oriented nostrils (columellar height, alar width, nostril type). Importantly, these improvements were accompanied by a low complication rate of 4%. However, upper lip deficiency over the upper lip angle and labial-columellar angle remained without significant improvement.

CONCLUSIONS

In this study we described effective secondary rhinoplasty, which was composed of a bilateral reverse-U flap and septal extension graft, with acceptable outcome. The 3D anthropometric analysis and panel assessment clarified that our rhinoplasty procedure could bring the nasal morphology in these patients closer to the normal data.

LEVEL OF EVIDENCE: 3

Presurgical management trends and nasoalveolar molding usage for infants with cleft lip and palate in the capital of a developing country

BACKGROUNDS

Nasoalveolar molding (NAM) application is among presurgical management (PSM) techniques used for infants with cleft lip and palate (CLP). It helps to approximate the palatal cleft and to reshape the nasoalveolar complex prior to primary lip repair. This study aimed to explore types of PSM and the dental speciality provision for infants with CLP in Baghdad. The status of NAM usage and surgeons' perceptions toward NAM usage were assessed.

MATERIALS AND METHODS

This is a cross-sectional paper-based questionnaire study that collected responses of surgeons perform primary lip and nose repair regarding PSM. The questionnaire was distributed amongst public and private hospitals in Baghdad. Twenty surgeons were enrolled (only those surgeons who perform primary repair for infants with CLP); two females and eighteen males.

RESULTS

The majority of participants' responses suggested that the majority of infants with CLP were provided with baby feeding plates and lip straps. Six surgeons reported that a percentage of their patients who have been provided with NAM. PSM in Baghdad was mostly supplied by orthodontists and plastic surgeons, and the next most likely providers were prosthodontists. 82.35% of the surgeons found that primary surgical repair procedures were easier with NAM than for the other infants. The rest have not perceived any differences.

CONCLUSIONS

Orthodontists, surgeons and prosthodontists were involved in providing PSM. Baby feeding plates and lip straps were the most common PSM in Baghdad, although NAM is not uncommon. Most surgeons believe that using NAM made surgical procedures easier and permitted the prediction of surgical outcomes.

Primary rhinoplasty in patients with bilateral cleft lip: Longitudinal results and comparison between closed and semi-open approaches

BACKGROUND

Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty.

METHODS

Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed.

RESULTS

In the comparative analysis at preschool age, semi-open rhinoplasty significantly improved the typical nasal deformities, including transversely oriented wide nostrils, short columella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age.

CONCLUSION

This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity

BACKGROUND

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP).

METHODS

A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP.

RESULTS

Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery.

CONCLUSION

Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Evaluation of Facial Esthetics Following NAM Versus CAD/NAM in Infants With Bilateral Cleft Lip and Palate: A Randomized Clinical Trial

OBJECTIVE

The aim is to compare the facial esthetics following nasoalveolar molding (NAM) versus computer-aided design NAM (CAD/NAM) in patients with bilateral cleft lip/palate (CLP).

DESIGN

The trial is a randomized comparative trial with a 1:1 allocation ratio.

PARTICIPANTS

Thirty infants with bilateral complete cleft lip and palate were recruited.

INTERVENTIONS

Patients were randomized between NAM and CAD/NAM groups. The treatment steps described by Grayson were followed for the NAM group. In the CAD/NAM group, digitized maxillary models were made to create a series of modified virtual models, which were used to fabricate the molding plates using 3-dimensional printing technology. The nasal stents were then added to the intraoral plates following the Grayson method. The study lasted for 4 months.

MAIN OUTCOMES

The assessment of the changes observed in the interlabial gap and nasolabial esthetics was done using standardized 2-dimensional photographs. The correlation between dental arch changes and extraoral facial esthetics was studied.

RESULTS

Both modalities showed improvement in nasolabial esthetics before the lip surgery. No statistically significant difference was found between NAM and CAD/NAM groups in any of the assessed variables.

CONCLUSIONS

Both interventions were effective in the management of infants with bilateral CLP.

Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study

BACKGROUND

Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature.

PATIENTS AND METHODS

A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis.

RESULTS

A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient.

CONCLUSION

Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Effect of One-Stage Bilateral Cleft Lip, Nose, and Alveolus Repair Following Nasoalveolar Molding on the Premaxilla Position at Preadolescence: An 8-Year Retrospective Study

BACKGROUND/PURPOSE

This paper describes the changes in maxillary arch morphology in infants with bilateral cleft lip and palate (BCLP) following nasoalveolar molding (NAM) and with follow up to assess the need for secondary alveolar bone grafting (ABG) and premaxillary repositioning surgery at preadolescence.

METHODS/DESCRIPTION

Treatment records of infants with BCLP treated with NAM between 2003 and 2013 were reviewed. Patients with complete BCLP who underwent NAM and had complete sets of maxillary casts at T 0 pre-NAM (mean = 27 days), T 1 post-NAM (mean = 6 months and 5 days), and T 2 before palate surgery (mean = 11 months and 15 days) were included. The sample comprised 23 infants (18 male, 5 female). Casts were digitized and analyzed using three dimensional software. The need for secondary ABG and premaxillary repositioning surgery was assessed at preadolescent follow-up (mean = 8.3 years).

RESULTS

Cleft width was reduced on average by 4.73 mm (SD±3.15 mm) and 6.56 mm (SD±4.65) on the right and left sides, respectively. At T 1, 13 (56.52%) patients underwent bilateral gingivoperiosteoplasty (GPP), 8 (34.78%) patients unilateral GPP, and 2 patients (8.7%) did not undergo GPP. 34/46 clefts sites (73.91%) underwent GPP while 12 (26.08%) did not. At preadolescent follow-up of 19 patients, 7 patients (36.84%) did not need ABG on either side, 8 (42.10%) needed ABG on 1 side, and 4 (21.05%) needed ABG on both sides. None of the patients needed premaxillary repositioning surgery.

CONCLUSIONS

Nasoalveolar molding treatment significantly improves the position of the premaxilla before primary repair, and there is a significant reduction in the need for secondary ABG and premaxillary repositioning surgery at preadolescence.

Bilateral Cleft Lip Repair: Lessons from History

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the bilateral cleft lip and nasal deformity and associated anatomical variations. 2. Understand the history and evolution of the bilateral cleft lip repair. 3. Understand the key principles of the surgical repair.

SUMMARY

This article describes characteristics of the bilateral cleft lip and nasal deformity and its management, including presurgical orthopedics, operative techniques, and postsurgical care.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening

OBJECTIVE

The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM).

SETTING AND PATIENTS

A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults.

RESULTS

Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width.

CONCLUSIONS

Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Determination of Ethnic Variation in Infant Nasolabial Anthropometry Using 3D Photographs: Implications for Bilateral Cleft Lip Nasal Correction

OBJECTIVE

We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients.

METHODS

Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P < .05.

RESULTS

Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P = .9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P = .02]; ac-ac [C-AA; P = .00; H-AA; P = .04]; al-al [C-AA; P = .00; H-AA; P = .001]) and labial length (sn-ls [C-AA; P = .041]; sn-sto [C-AA; P = .005]; Cphs-Cphi L [C-AA; P = .013]; Cphs-Cphi R [C-AA; P = .015]). Interrater reliability was good to excellent and significantly correlated for all measures.

CONCLUSIONS

African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction.

Three-Dimensional Nasolabial Changes After Nasoalveolar Molding and Primary Lip/Nose Surgery in Infants With Bilateral Cleft Lip and Palate

OBJECTIVE

Utilize 3-dimensional (3D) photography to evaluate the nasolabial changes in infants with bilateral cleft lip and palate (BCLP) who underwent nasoalveolar molding (NAM) and primary reconstructive surgery.

DESIGN

This is a retrospective serial longitudinal study of consecutively enrolled infants from September 2012 to July 2016 with BCLP who underwent NAM before primary lip and nose reconstructive surgery. It included infants who had digital 3dMD stereophotogrammetry records at initial presentation (T1), completion of NAM (T2), and 3 weeks following primary repair (T3). Twelve infants fulfilled the inclusion criteria. 3dMD Vultus software was used to orient images and plot 16 nasolabial points with x, y, z coordinates to obtain the linear and angular measurements. Nasal form changes were measured and analyzed between T1 (0.5 months old), T2 (5 months old), and T3 (6 months old). Intraclass correlation coefficient was performed for intrarater reliability. Averaged data from the 3D images was statistically analyzed from T1 to T2 and T2 to T3 with Wilcoxon tests. Unaffected infant norms from the Farkas publication were used as a control sample.

RESULTS

After NAM therapy, statistically significant changes in the position of subnasale and labius superius improved nasolabial symmetry. Both retruded after NAM were displaced downward after NAM and surgical correction with respect to soft tissue nasion. The nasal tip's projection was maintained with NAM and surgical correction. The columella lengthened from 1.4 to 4.71 mm following NAM.

CONCLUSIONS

There was a significant improvement in the nasolabial anatomy after NAM, and this was further enhanced after primary reconstructive surgery.

The Nasoalveolar Molding Cleft Protocol: Long-Term Treatment Outcomes from Birth to Facial Maturity

BACKGROUND

The authors present outcomes analysis of the nasoalveolar molding treatment protocol in patients with a cleft followed from birth to facial maturity.

METHODS

A single-institution retrospective review was conducted of cleft patients who underwent nasoalveolar molding between 1990 and 2000. Collected data included surgical and orthodontic outcomes and incidence of gingivoperiosteoplasty, alveolar bone grafting, surgery for velopharyngeal insufficiency, palatal fistula repair, orthognathic surgery, nose and/or lip revision, and facial growth.

RESULTS

One hundred seven patients met inclusion criteria (69 with unilateral and 38 with bilateral cleft lip and palate). Eighty-five percent (91 of 107) underwent gingivoperiosteoplasty (unilateral: 78 percent, 54 of 69; bilateral: 97 percent, 37 of 38). Of those patients, 57 percent (52 of 91) did not require alveolar bone grafting (unilateral: 59 percent, 32 of 54; bilateral: 54 percent, 20 of 37). Twelve percent (13 of 107) of all study patients underwent revision surgery to the lip and/or nose before facial maturity (unilateral: 9 percent, six of 69; bilateral: 18 percent, seven of 38). Nineteen percent (20 of 107) did not require a revision surgery, alveolar bone grafting, or orthognathic surgery (unilateral: 20 percent, 14 of 69; bilateral: 16 percent, six of 38). Cephalometric analysis was performed on all patients with unilateral cleft lip and palate. No significant statistical difference was found in maxillary position or facial proportion. Average age at last follow-up was 20 years (range, 15 years 4 months to 26 years 10 months).

CONCLUSIONS

Nasoalveolar molding demonstrates a low rate of soft-tissue revision and alveolar bone grafting, and a low number of total operations per patient from birth to facial maturity. Facial growth analysis at facial maturity in patients who underwent gingivoperiosteoplasty and nasoalveolar molding suggests that this proposal may not hinder midface growth.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nasolabial appearance of bilateral cleft lip repair at five years of age. Comparing techniques of modified advancement-rotation (Delaire) with Manchester repair: a retrospective cohort study

The techniques used to repair bilateral cleft lip have evolved over time, yet little data exist to compare outcomes using the various techniques. The aim of this study was to retrospectively evaluate and compare the aesthetic outcomes of two types of complete bilateral cleft repair: advancement rotation and a historic cohort repaired with the Manchester technique. A total of 32 consecutive patients who had complete repair of bilateral cleft lips were identified retrospectively from our centre using inpatient records. The first 16 (born between 1994 and 2005) underwent the Manchester repair, the second 16 (born between 2006 and 2010) a Delaire modified advancement rotation technique. Standardised photographs were taken at five years post repair and cropped to isolate the nasolabial component. Appearance outcomes were assessed by 20 members of the cleft and plastic surgery team, who were each asked to rate all 32 images using the Asher-McDade five-point scale. A chi squared test was used to determine whether there was a statistically significant difference in cleft scores between the two approaches. There was a mean (SD) of 2.8 (1.02) in the advancement rotation group and a mean (SD) of 3.1 (1.07) in the Manchester group. There was a statistically significant difference in the distribution of scores in the advancement rotation group compared with the Manchester group, with lower scores (better results) in the advancement rotation group (p=0.003). This study demonstrates that the advancement rotation technique for the repair of bilateral cleft lip defects resulted in a superior nasolabial appearance when directly compared with the Manchester repair at 5 years of age.

Evaluation of the Clinical Effectiveness of Nasoalveolar Molding (NAM) Using Grayson Method Versus Computer-Aided Design NAM (CAD/NAM) in Infants With Bilateral Cleft Lip and Palate: A Randomized Clinical Trial

OBJECTIVE

The aim is to compare between the clinical effectiveness of nasoalveolar molding (NAM) versus the computer-aided design NAM (CAD/NAM) in patients with bilateral clefts.

DESIGN

The trial is a randomized comparative trial with 1:1 allocation ratio.

PARTICIPANTS

Thirty infants with bilateral complete cleft lip and palate were recruited.

INTERVENTIONS

Patients were randomized between NAM and CAD/NAM groups. The treatment steps described by Grayson were followed for the NAM group. In the CAD/NAM group, digitized maxillary models were made to create series of modified virtual models which were used to fabricate the molding plates using 3-dimensional printing technology. The nasal stents were then added to the plates following Grayson method. The study lasted for 4 months.

MAIN OUTCOMES

The primary outcome was to evaluate the changes in the intersegment cleft gap. Secondary outcomes included the analysis of the maxillary arch in transverse, anteroposterior, and vertical dimensions as well as the premaxillary deviation and rotation. Chair side time was assessed for both methods.

RESULTS

Both modalities decreased the intersegment cleft gap. The CAD/NAM plates caused more reduction in the total arch length by 1.99 mm (-3.79 to 0.19, P = .03) as compared to the NAM treatment. No differences were found between groups in the transverse and vertical maxillary arch changes.

CONCLUSIONS

Both interventions were effective in narrowing the cleft gap. Similar maxillary changes were found in both groups. The CAD/NAM modality required less chair side time compared to the NAM treatment.

Bilateral Complete Cleft Lip Repair: A Step-by-Step Video Series

Surgeons-in-training learning how to perform cleft surgery should not only acquire a broad repertoire of technical details but also master the proper execution of techniques based on the modern principles of bilateral cleft lip repair with synchronous reconstruction of cleft nose deformity. This article describes a bilateral complete cleft lip repair by adopting these principles, plus a modified composition of mucosal flaps for the nasal floor and intraoral linings, including the prolabial mucosal flap, C-flap mucosal flap, inferior turbinate mucosal flap, and lateral nasal mucosal flap. The accompanying four-part video series presents the step-by-step approach for design and execution of this alternative technique.

Adherence frequency of CANDIDA ALBICANS on nasoalveolar molding (NAM) appliances

BACKGROUND AND METHOD

The aim of this prospective study was to evaluate the adherence frequency of Candida albicans and non-albicans Candida species in newborn babies with Cleft Lip and Palate (CLP) who receive presurgical orthopedic therapy with Nasoalveolar Molding (NAM) appliances. This study comprised of 25 CLP newborns including 8-right unilateral, 8-left unilateral and 7-bilateral CLP. First swab samples were taken from the hard palate when the baby was referred and renewed after 3 days. Following the 7th day of delivery of NAM appliance, the swab samples were retaken from both the hard palate and the NAM appliance. Samples were renewed with 2-month intervals. The last swab samples were taken one month after the surgery. Oral swabs were cultured on CHROMagar Candida medium for the growth of yeasts.

RESULTS

There were no statistically significant differences between the time points regarding C. albicans proliferation frequency and severity rates on the palate. No significant difference was found due to the type of cleft and sex in terms of candidal colonization. A constant increase in proliferation frequency of non-albicans on the palatal mucosa was observed between all of the time points. Although the results were insignificant, there was a constant increase in C. albicans proliferation which presented a decrease following primary lip surgery.

CONCLUSION

The appliance might not only cause an increase in the colonization of C. albicans but also provide the continuation of the colonization. Therefore, mouth cleaning is important even after primary lip surgery.

Three-Dimensional Analysis of Bilateral Cleft Lip and Palate Nasal Deformity

OBJECTIVE

This cross-sectional study utilizes 3-dimensional analysis to assess nasal morphology in patients with bilateral cleft lip and palate (BCLP) compared to controls across the timeline of cleft care.

DESIGN

Retrospective comparative cross-sectional study.

SETTING

Tertiary pediatric academic institution.

PATIENTS AND PARTICIPANTS

One hundred and twelve patients with BCLP and an equal number of age and sex-matched control participants.

MAIN OUTCOME MEASURE(S)

Nasolabial angle, nasal length, nasal protrusion, columella length, columella width, nasal tip width, alar width, and alar base width were collected at each time point. The measurements were collected pre-nasoalveolar molding (NAM) therapy, post-NAM therapy, post-primary cleft rhinoplasty, 1 year, 5 years, 10 years, and 15 years of age.

RESULTS

Nasolabial angle and nasal tip width were significantly different from controls from pre-NAM through 15 years of age time points. Nasal length was not significantly different at any time point. Alar width and alar base width were significantly different from pre-NAM through 10 years of age time points. Nasal protrusion, columella length, and columella width were significantly different from pre-NAM through 5 years of age time points.

CONCLUSIONS

This study demonstrates that three-dimensional photogrammetry is effective in assessing the changes in nasal morphology that occur throughout the course of care in patients with BCLP from before cleft lip repair to the completion of nasal growth.

The conchal butterfly graft in secondary reconstruction of the bilateral cleft lip nasal deformity

OBJECTIVES

The bilateral cleft nasal deformity is characterized by a short columella and a broad, flattened nasal tip. Secondary correction is challenging and often complicated by skin envelope scarring and hypoplastic alar cartilages. Adequate and durable tip projection requires a procedure that adequately augments the nasal tip and maximizes tip support. We describe a novel technique for secondary correction of this deformity in the immature pediatric population.

METHODS

The conchal butterfly graft technique utilizes a folded cartilage construct to simultaneously increase tip projection and provide tip support. A retrospective review of 19 consecutive patients with bilateral cleft lip who underwent secondary tip rhinoplasty utilizing our technique over a 7-year period was conducted. Charts were reviewed for age at operation, length of follow-up and secondary revision procedures. Pre- and post-operative photographs were compared using two different methods to assess the degree of change and overall aesthetic result. Three plastic surgeons who previously were unfamiliar with the technique independently rated seven nasal tip characteristics. Nasal tip projection (NTP) was then measured objectively by two widely utilized methods: the Goode method and the Baum method-modified by Powell.

RESULTS

Long lasting correction of the bilateral cleft nasal deformity was achieved utilizing this technique in 19 patients over a 7-year period with a mean length of follow-up of 5.4 years. We demonstrate augmented nasal tip projection that approaches ideal relationships from both relative measurement and survey data.

CONCLUSION

The conchal butterfly graft technique is effective for reconstruction of the bilateral cleft nasal deformity, and in our experience, has resulted in long lasting nasal projection and overall improved facial balance.

Evaluation of a Digital Protocol for Pre-Surgical Orthopedic Treatment of Cleft Lip and Palate in Newborn Patients: A Pilot Study

The aim of this study was to evaluate the accuracy, invasiveness and impact on clinical results of a digital oral impression protocol in the pre-surgical orthopedic treatment (PSOT) of newborn cleft lip and palate (CLP) patients undergoing primary alveolar surgical repair. Six patients were divided, according to impression technique used, into a digital (intraoral scanner (IOS)) and a non-digital (tray and putty (T&P)) group. Parents considered IOS impressions to be less invasive, compared to T&P impressions. The clinician that took all the impressions considered the IOS to be less stressful compared to the T&P method. In two T&P patients, the impression was repeated because some important anatomical details were missing, in one case due to patient regurgitation during the first attempt. No impression was repeated, and any adverse event was reported in the IOS group. There were no significant differences between these two protocols in pre-surgical alveolar gap reduction and surgical challenge. The study results indicate that this digital protocol can accelerate the production process of the passive molding plate with an instantaneous transmission of the digital impression to the dental lab, maintaining the same accuracy level and clinical outcomes of classical techniques and reducing the invasiveness of impression taking, avoiding any risk of impression material ingestion or inhalation.

Dynamic Nasolabial Growth After Primary Surgery for Patients With Bilateral Cleft Lip: A Five-Year Follow-Up Study

PURPOSE

Bilateral complete cleft lip (BCCL) causes severe tissue deficit and usually requires multiple revisions after primary repair. In the present study, we aimed to illustrate the nasolabial changes after primary BCCL correction.

PATIENTS AND METHODS

The present retrospective cohort study compared patients who had undergone BCCL and palate (BCCLP) and cleft palate only (CPO). All included patients had undergone surgery at the same treatment center (West China Hospital of Stomatology) from 2007 to 2012. The patients returned for follow-up surgery at 6 months and 5 years after their primary repair surgery. We retrieved the facial plaster casts of the enrolled patients and recorded the key nasolabial measurements. The outcome variables included the prolabial length (PL), peak distance, nasal width, and columellar length (CL). The data were analyzed using a general linear model for repeated measures, and the linear association was tested using SPSS. The level of testing efficiency (P value) was set at .05.

RESULTS

A total of 160 patients, 80 who had undergone BCCLP and 80 CPO controls, were included. All nasolabial measurements in the BCCLP group had increased during the 5-year follow-up period. The PL of the BCCLP group had increased more quickly than the PL of the CPO group (P = .000 < .05), but the CL had increased nearly as much (P = .270).

CONCLUSIONS

For the primary correction of bilateral cleft lip nose deformity, dissection and repositioning of the cleft lip and nose did not significantly inhibit the growth of the nasolabial region in the first 5 years after surgery. Nose deformities should not remain uncorrected after primary surgical repair. In contrast, cleft surgeons should focus on the finer adjustment of columella with less doubt regarding adverse effects.

Long-Term Nasal Growth after Primary Rhinoplasty for Bilateral Cleft Lip Nose Deformity: A Three-Dimensional Photogrammetric Study with Comparative Analysis

Nasal deformity is associated with congenital cleft lip and palate. Primary rhinoplasty for reconstruction of the nasal deformity at the time of bilateral cleft lip repair is a controversial issue in cleft care due to traditional teaching concerning the potential impairment of nasal growth. This study assessed long-term nasal growth in patients with bilateral cleft lip and palate who underwent primary rhinoplasty by a single surgeon between 1995 and 2002 and reached skeletal maturity (n = 39; mean: 19 ± 2 years). Normal age-, gender-, and ethnicity-matched subjects (n = 52) were enrolled for comparative analyses. Three-dimensional nasal photogrammetric measurements (10 linear, 4 angular, 6 proportional, 1 surface area, and 1 volume parameter) were collected from patients with bilateral cleft lip and palate and normal subjects. Patients who underwent rhinoplasty presented with significantly (all p < 0.05) smaller nasal tip projection and nasal tip angles, but greater values for nasal dorsum length, nasal protrusion, alar width, columellar height, dome height, columellar angle, labiocolumellar angle, nasal tip height ratio, nasal index, alar width/intercanthal distance ratio, and alar width/mouth width ratio compared to normal subjects. There were no differences (all p > 0.05) in nasal height, tip/midline deviation, nasal dorsum angle, dome-to-columella ratio, columella height/alar width ratio, area surface, and volume parameters between the two groups. This study shows that primary rhinoplasty performed in patients with bilateral cleft lip and palate during infancy does not result in deficiency of the nasal dimensions relative to controls.

Early Weight Gain in Infants With Cleft Lip and Palate Treated With and Without Nasoalveolar Molding: A Retrospective Study

OBJECTIVE

To assess weight gain of infants with cleft lip and/or palate (CL ± P) treated with nasoalveolar molding (NAM).

DESIGN

Retrospective, case-control chart review.

SETTING

Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon.

PATIENTS, PARTICIPANTS

Infants with nonsyndromic CL ± P and noncleft controls.

INTERVENTIONS

Prior to primary lip surgery, NAM was either included (+NAM) or not included (-NAM) in the cleft treatment protocol.

MAIN OUTCOME MEASURE(S)

Weight gain and percentage weight gain relative to initial weight were compared among +NAM, -NAM, and control groups from birth to 7 months and from birth to 36 months.

RESULTS

Comparing +NAM and -NAM groups, no significant difference in weight or percentage weight gain was found in either time window. Compared to controls, from birth to 7 months, both CL ± P groups weighed less (P < .001), while percentage weight gain was greater for the +NAM (P < .001) and did not differ for -NAM. From birth to 36 months relative to controls, weight for +NAM showed no significant difference and -NAM weighed less (P < .01), while percentage weight gain was greater for both CL ± P groups (P < .001).

CONCLUSIONS

Comparisons of CL ± P infants treated with and without NAM showed that with the NAM appliance, despite its added complexity, there was no adverse impact on weight gain. Comparisons to noncleft, control infants suggests that NAM treatment may have a beneficial impact on weight gain.

A Personal Approach to Bilateral Cleft Lip Repair

Dr Michael B. Lewis has been using his personal approach to bilateral cleft lip (BCL) repair for 30 years to achieve a loose, pouting upper lip, a 90-degree columellar-labial angle, and a projecting nasal tip. This article describes technique and results.

Fascial Graft Repair of Wide Bilateral Cleft Lip Deformity

Wide bilateral cleft lip deformity reconstruction represents a special difficulty as it affects the lip, nose, and maxillary segments making single-stage reconstruction sometimes unobtainable. Many surgical and nonsurgical techniques have been prescribed to facilitate the definitive repair. Although some of these techniques proved to be useful, they have their inherent limitations and add another treatment step with all its possible complications and costs. The authors present a new method to address muscle layer repair in 1-stage procedure. It entails using fascial graft obtained from the temporalis muscle fascia or fascia lata, to reconstruct orbicularis oris lip muscle. Seven patients of wide bilateral cleft lip deformity (mean 17 mm) with a mean age of 4.4 months were subjected to single-stage lip reconstruction. After measuring the defect between both lateral muscle segments in front of the premaxilla intraoperatively ensuring that direct muscle repair could not be obtained, a fascial graft was harvested and sutured to both muscle edges. The authors found that, regardless the defect size or premaxilla protrusion, all wide clefts could be reconstructed satisfactorily in 1 stage procedure. No serious postoperative complications have been encountered in the lip or donor areas. Early follow-up reporting of the patients revealed stable repair. However more follow-up is still needed to assess late sequelae. In conclusion, fascial graft muscle repair of wide bilateral cleft lip deformity enables early 1-stage lip reconstruction without tension. The added donor morbidity is minimal and well tolerated.

Three-Dimensional Soft Tissue Nasal Changes After Nasoalveolar Molding and Primary Cheilorhinoplasty in Infants With Unilateral Cleft Lip and Palate

OBJECTIVE

To quantify 3-dimensional (3D) nasal changes in infants with unilateral cleft lip with or without cleft palate (UCL±P) treated by nasoalveolar molding (NAM) and cheilorhinoplasty and compare to noncleft controls.

DESIGN

Retrospective case series of infants treated with NAM and primary cheilorhinoplasty between September, 2012 and July, 2016. Infants were included if they had digital stereophotogrammetric records at initial presentation (T1), completion of NAM (T2), and following primary cheilorhinoplasty (T3). Images were oriented in 3dMD Vultus software, and 16 nasolabial points identified.

PATIENTS

Twenty consecutively treated infants with UCL±P.

INTERVENTIONS

Nasoalveolar molding and primary cheilorhinoplasty.

MAIN OUTCOME MEASURES

Anthropometric measures of nasal symmetry and morphology were compared in the treatment group between time points using paired Student t tests. Postsurgical nasal morphology was compared to noncleft controls.

RESULTS

Nasal tip protrusion increased, and at T3 was 2.64 mm greater than noncleft controls. Nasal base width decreased on the cleft side by 4.01 mm after NAM and by 6.73 mm after cheilorhinoplasty. Columellar length of the noncleft to cleft side decreased from 2:1 to 1:1 following NAM. Significant improvements in subnasale, columella, and nasal tip deviations from midsagittal plane were observed. Treatment improved symmetry of the alar morphology angle and the nasal base-columella angle between cleft and noncleft sides.

CONCLUSIONS

Three-dimensional analysis of UCL±P patients demonstrated significant improvements in nasal projection, columella length, nasal symmetry, and nasal width. Compared to noncleft controls, nasal form was generally corrected, with overcorrection of nasal tip projection, columella angle, and outer nasal widths.

Comparative Analysis of Three-Dimensional Nasal Shape of Casts from Patients With Unilateral Cleft Lip and Palate Treated at Two Institutions Following Rotation Advancement Only (Iowa) or Nasoalveolar Molding and Rotation Advancement in Conjunction With Primary Rhinoplasty (New York)

OBJECTIVES

To compare 3-dimensional nasal symmetry in patients with UCLP who had either rotation advancement alone or nasoalveolar molding (NAM) followed by rotation advancement in conjunction with primary nasal repair.

DESIGN

Pilot retrospective cohort study.

MATERIALS AND METHODS

Nasal casts of 23 patients with UCLP from 2 institutions were analyzed; 12 in the rotation advancement only group (Iowa) and 11 in the NAM, rotation advancement with primary nasal repair group (New York). Casts from patients aged 6 to 18 years were scanned using the 3Shape scanner and 3-dimensional analysis of nasal symmetry performed using 3dMD Vultus software, Version 2507, 3dMD, Atlanta, GA. Cleft and noncleft side columellar height, nasal dome height, alar base width, and nasal projection were linearly measured. Inter- and intragroup analyses were performed using t tests and paired t tests as appropriate.

RESULTS

A statistically significant difference in mean-scaled 3-dimensional asymmetry index was found between groups with group 1 having a larger measure of asymmetry (4.69 cm³) than group 2 (2.56 cm³; P = .02). Intergroup analysis performed on the most sensitive linear measure, alar base width, revealed significantly less asymmetry on average in group 2 than in group 1 ( P = .013).

CONCLUSION

This study suggests the NAM followed by rotation advancement in conjunction with primary nasal repair approach may result in less nasal asymmetry compared to rotation advancement alone.

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.

Photometric Evaluation in Adolescence of Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening

OBJECTIVE

Nasal stigma in patients with bilateral cleft lip and palate (BCLP) are a short columella and a flattened nasal tip.

DESIGN

The aim of this study was to evaluate the aesthetics of adolescents with BCLP, operated with a modified Cutting primary columella lengthening technique, associated to a modified Grayson orthopedic nasoalveolar molding (NAM).

SETTING AND PATIENTS

72 BCLP patients were operated with this approach. Standardized photographic records were taken every 2 years. A group of 23 patients between 12 and 13 years of age was compared through normalized photogrammetry to a matched control of 23 noncleft adolescents.

RESULTS

Nasal protrusion and length of the columella were very close to normal. On the other hand, nasolabial angle and interalar width were still excessively wide compared to the noncleft sample.

CONCLUSIONS

NAM and primary columella lengthening in BCLP has allowed to avoid traditional secondary columella lengthening at 5 to 6 years of age and given the patients a more pleasing, near-normal nasolabial appearance until adolescence. Some of the patients will require correction of the nasal width at a later stage.

Initial experiences with NAM-assisted primary repair of the BCLP deformity

BACKGROUND

Primary surgical repair of the bilateral cleft lip and palate (BCLP) deformity is challenging. Infant Orthopedic (IO) procedures are often used to assist surgical reconstruction of normal anatomy. Nasoalveolar molding (NAM) is a presurgical infant orthopedic procedure that attempts to reduce the cleft nasal deformity, in addition to the lip and alveolus, leading to an esthetic primary surgical repair.

OBJECTIVE

NAM provides the surgical team with a better foundation for an easier and more esthetic single stage repair at the level of nose in addition to the lip and alveolus.

METHOD

Infant nasal cartilages are amenable to correction with NAM in the first few weeks of infancy when they retain their plasticity. NAM-assisted surgical repair of a complete BCLP infant is discussed. Postoperatively nasal stents were used to retain results and minimize relapse.

RESULTS

NAM helped correct premaxillary deviation and protrusion, reduce alveolar cleft width and improve the nasal morphology prior to surgery in the BCLP infant.

CONCLUSIONS

NAM helped reduce the severity of the cleft deformity in the BCLP infant and facilitated an easier and esthetic single stage primary surgical repair.

Presurgical Nasoalveolar Molding of Bilateral Cleft Lip and Palate Infants: An Orthodontist's Point of View

Nonsyndromic complete cleft lip and palate deformity is primarily functional, then esthetic, and finally but not least importantly, a dental challenge. Feeding and facial appearance are important during the first years of a newborn. Nutrition is universally provided by passive feeding plates. If the Cleft Team prefers to use active plates, alveolar molding combined with nasal approaches in infants is the best method to improve esthetics to date. Orthodontists are predominantly responsible for achieving both the goals. After those difficulties have been met in early days of the life, dentists are mainly responsible for the treatment thereafter. If the infants have a dentoalveolar unity without any fistulas and correctly aligned maxillary deciduous teeth, this is a real success. Therefore, this article is an overview of presurgical infant orthopedics and its contribution to subsequent dental practice.

Does a Premaxillary Setback and Lip Adhesion Have a Negative Impact on Lip Outcome in Bilateral Cleft Patients?

BACKGROUND

The early premaxillary setback and lip adhesion remains as a controversial maneuver in the treatment of bilateral cleft lip and palate patients. This study aimed to assess extent of preoperative deformity and lip outcomes during the first year after surgery in bilateral cleft patients who underwent premaxillary setback and lip adhesion and to compare to those with primary lip repair.

METHODS

A retrospective observational study was conducted of 16 nonsyndromic consecutive bilateral complete cleft lip patients (with and without Simonart band), who underwent primary cleft lip repair. Patients were allocated in group 1 without premaxillary setback and group 2 with premaxillary setback and lip adhesion. Preoperative and postoperative linear measurements were used for intergroup and intragroup comparisons.

RESULTS

Cutaneous lip height of patients in group 2 significantly (P < 0.05) improved after combined premaxillary setback and lip adhesion and primary cleft lip repair. There were no significant (all P > 0.05) differences in intragroup 1 comparisons, and in intergroup comparisons.

CONCLUSION

Bilateral cleft patients with a protruded and deviated premaxilla over 10 mm discrepancy of the lateral maxillary achieved noninferior lip symmetry 1 year postoperatively compared with patients with less severe original deformity.

Effect of Preoperative Nasal Retainer on Nasal Growth in Patients with Bilateral Incomplete Cleft Lip: A 3-Year Follow-Up Study

Background

The purpose of this study was to evaluate changes in nasal growth after the implementation of a preoperative nasal retainer in patients with bilateral incomplete cleft lip.

Methods

Twenty-six infants with bilateral incomplete cleft lip and cleft palate were included in the study. A preoperative nasal retainer was applied in 5 patients from the time of birth to 2.6–3.5 months before primary cheiloplasty. Twenty-one patients who were treated without a preoperative nasal retainer were placed in the control group. Standard frontal, basal, and lateral view photographs were taken 3 weeks before cheiloplasty, immediately after cheiloplasty, and at the 1- and 3-year postoperative follow-up visits. The columella and nasal growth ratio and nasolabial angle were indirectly measured using photographic anthropometry.

Results

The ratio of columella length to nasal tip protrusion significantly increased after the implementation of a preoperative nasal retainer compared to the control group for up to 3 years postoperatively (P<0.01 for all time points). The ratios of nasal width to facial width, nasal width to intercanthal distance, columellar width to nasal width, and the nasolabial angle, for the two groups were not significantly different at any time point.

Conclusions

Implementation of a preoperative nasal retainer provided significant advantages for achieving columellar elongation for up to 3 years postoperatively. It is a simple, reasonable option for correcting nostril shape, preventing deformities, and guiding development of facial structures.

Evidence-Based Medicine: Secondary Correction of Cleft Lip Nasal Deformity

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the components of unilateral and bilateral cleft lip nasal deformity. 2. Assess the deformity. 3. Design a treatment plan for secondary correction of cleft lip nasal deformity. 4. Discuss methods for managing suboptimal outcomes.

SUMMARY

Correction of cleft lip nasal deformity has been addressed in this Maintenance of Certification/Continuing Medical Education series a number of times-a testament to the complexity of the topic. In this addition to the series, the authors provide a principle-based approach toward management of unilateral and bilateral cleft lip nasal deformity with an emphasis on timing intervention, role for intermediate correction, and methods for cleft rhinoplasty after completion of nasal growth.

Longitudinal Photogrammetric Analysis of the Columellar-Labial Angle following Primary Repair of Bilateral Cleft Lip and Nasal Deformity

BACKGROUND

The changing nasolabial dimensions after repair of bilateral cleft lip and nasal deformity can be documented by anthropometry; however, the columellar-labial angle is rarely measured.

METHODS

This is a study of white patients who had synchronous repair of bilateral cleft lip performed by one surgeon (J.B.M.). The columellar-labial angle was measured on lateral photographs with the subject in neutral head position. Average values for columellar-labial angle at two or more time points were analyzed with a general estimating equation and cubic modeling. Values for complete and incomplete bilateral cleft lips were compared to each other and to Farkas' norms. Direct anthropometric measurements of intraoperative columellar length were compared to the postoperative columellar-labial angle using Pearson correlation analysis.

RESULTS

Eighty-five patients were studied (64 complete and 21 incomplete clefts). The average photographic follow-up interval was 10 years (range, 1.8 to 19.5 years). The columellar-labial angle in bilateral complete clefts was significantly greater than in incomplete forms (p = 0.002). Although the angles decreased with time, they remained significantly greater than Farkas' normative values in both cleft groups (all p < 0.05). There was no correlation between the magnitude of columellar lengthening achieved during primary nasal correction and the postoperative columellar-labial angle.

CONCLUSIONS

An obtuse columellar-labial angle can occur following synchronous nasolabial repair of a bilateral cleft lip, particularly in patients with a complete deformity. Although the angle narrows in time, it remains 1 to 2 SD greater than normal values. Secondary nasal correction may be needed if there is excessive tip rotation after completion of growth and orthognathic surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Orthodontic management of patients with cleft lip and palate

The management of patients with cleft lip and cleft palate requires prolonged orthodontic and surgical treatment and an interdisciplinary approach in providing them with optimal esthetics, function, and stability. This paper describes an update on the current concepts and principles in the treatment of patients with cleft lip and palate. Sequencing and timing of orthodontic/orthopedic and surgical treatment in infancy, early mixed dentition, early permanent dentition, and after the completion of facial growth will be discussed.

Anthropometric Effect of Mucoperiosteal Nostril Floor Reconstruction in Complete Cleft Lip

OBJECTIVE

The primary objective of this study was to investigate whether growth impairment in children with cleft lip is caused by reconstructing the nostril floor using lateral nasal and premaxillary mucoperiosteal flaps. The effects on growth and symmetry of tip rhinoplasty at the time of initial repair, as well as cleft sidedness are similarly investigated.

METHODS

An Institutional Review Board approved, retrospective, single-center study at an academic children's hospital from July 2005 to 2010 was designed. Seventy-four patients with unilateral cleft lip ± palate were followed postsurgical repair of the cleft lip deformity. Serial digital photographs from clinical encounters were analyzed. Anthropometric measurements of 10 soft tissue landmarks were extracted from anteroposterior and submental vertex views at serial visits; growth velocities, defined as c = Δd/Δt, were generated using linear mixed models on selected measurements to study time-related changes on growth. The effects on growth and symmetry of primary tip rhinoplasty on perinasal landmarks and nostril floor reconstruction with medial and lateral nasal mucoperiosteal flaps on perioral and perinasal landmarks were analyzed. Proxies for midfacial height (en-al) and maxillary height (al-ch) were used to evaluate the effect of mucoperiosteal dissection, whereas nostril width, height, and angle were used as proxies to evaluate the effects of tip rhinoplasty.

RESULTS

Seventy-four patients met the inclusion criteria. Midface height (En-Al) growth velocity was 0.014 mm/month and maxillary height (Al-Ch) was relatively stable at -0.0059 mm/month with no difference between the subgroups. Nostril height growth was -0.0046 mm/month, nostril width was 0.03 mm/mo, and nostril angle -0.09 °/mo showed no difference between patient with or without primary tip rhinoplasty. Patients with complete cleft showed more asymmetry than those with incomplete clefts in lip and maxillary landmarks at T0 (P < 0.001).

CONCLUSIONS

Mucoperiosteal reconstruction of the nostril floor at the time of lip repair does not affect anthropometric growth velocities over a 5-year follow-up. Within the limitations of the selected landmarks, primary tip rhinoplasty did not significantly improve symmetry at 5 years, but also did not affect the growth of the nose. Patients with complete clefts display more postoperative asymmetry than those with incomplete clefts.

[Primary treatment of cleft lip and palate. Its fundamental principles]

If the multiplicity of functional protocols of cleft lip and palate treatment has been bewildering, it is now a source of learning. The lessons we can draw from them assist us to choose the best age for the primary surgery and a chronology that prevents the palate from the worst scaring. Eventually, with 18 years of follow-up, the best functional achievement comes unexpectedly from an ambitious primary rhinoplasty that had till now been condemned. Not only do the patients have good appearance and social integration, but the nasal mode of breathing established at the time of the primary surgery favors a good facial growth without any compromise. Reciprocally, all the interacting functions benefit from a nasal ventilation.

A Real-Time Local Flaps Surgical Simulator Based on Advances in Computational Algorithms for Finite Element Models

BACKGROUND

This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator.

METHODS

A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user's surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of $2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals.

RESULTS

Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses.

CONCLUSIONS

A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general.