A model for the cleft lip nasal deformity

Cleft Lip Repair and Primary and Intermediate Cleft Rhinoplasties

The cleft lip is one of the most common craniofacial abnormalities seen worldwide. The lip and primary rhinoplasty repairs are performed together in a single surgery for patients aged 3 to 6 months. The intermediate rhinoplasty has fallen out of favor due to more advanced approaches at primary rhinoplasty. However, it still plays a role in addressing severe nasal airway obstruction or correcting anatomic differences causing emotional distress from social ridicule. The article reviews the incidence of cleft lip, discusses its development and variant anatomy, and examines the approaches to surgical repair of the cleft clip, primary and intermediate rhinoplasties.

State of the art: The Unilateral Cleft lip and Nose Deformity and Anatomic Subunit Approximation

The anatomic subunit approximation approach to unilateral cleft lip repair was developed over 20 years ago. While the underlying principles of the repair are unchanged, its description has been simplified, additional landmarks and creases have been added, and objective analysis of perioperative changes have provided better clarity regarding goals and desired alterations. We review recent insights regarding the deformity; describe the repair in a simplified manner; and link a stepwise approach to foundation-based primary rhinoplasty as a part of the avenue to creating nasolabial balance and harmony.

Rhinoplasty in Patients with Cleft Lip Nasal Deformity: Correcting the Alar Base

The characteristic cleft nasal deformity presents several challenges for the rhinoplasty surgeon attempting to provide the optimal nasal function and appearance for their patient. One of the difficulties with cleft rhinoplasty is how best to address the malposition alar base. The purpose of this review is to evaluate the various surgical approaches and techniques for properly repositioning the alar base for cleft patients. Outcomes are ultimately dependent on individual patient factors, anatomy, surgical technique, and surgeon experience. Below, we will review the variety of techniques used, the evidence supporting certain techniques, and our preferences.

Measuring the Unilateral Cleft Lip Nasal Deformity: Lateral Deviation of Subnasale Is a Clinical and Morphologic Index of Unrepaired Severity

OBJECTIVE

Objective measurement of pre-operative severity is important to optimize evidence-based practices given that the wide spectrum of presentation likely influences outcomes. The purpose of this study was to determine the correlation of objective measures of form with a subjective standard of cleft severity.

DESIGN

3D images were ranked according to severity of nasal deformity by 7 cleft surgeons so that the mean rank could be used as the severity standard.

PATIENTS

45 patients with unilateral cleft lip and 5 normal control subjects.

INTERVENTIONS

Each image was assessed using traditional anthropometric analysis, 3D landmark displacements, and shape-based analysis to produce 81 indices for each subject.

MAIN OUTCOME

The correlation of objective measurements with the clinical severity standard.

RESULTS

Lateral deviation of subnasale from midline was the best predictor of severity (0.86). Other strongly-correlated anthropometric measurements included columellar angle, nostril width ratio, and lateral lip height ratio (0.72, 0.80, 0.79). Almost all shape-based measurements had tight correlation with the severity standard, however, dorsum deviation and point difference nasolabial symmetry were the most predictive (0.84, 0.82).

CONCLUSIONS

Quantitative measures of severity transcend cleft type and can be used to grade clinical severity. Lateral deviation of subnasale was the best measure of severity and may be used as a surrogate of uncoupled premaxillary growth; it should be recorded as an index of pre-operative severity with every cleft lip repair. The correlation of other measures evaluated clarify treatment priorities and could potentially be used to grade outcomes.

Achieving midvault symmetry in unilateral cleft nose deformity rhinoplasty

Background

The objective of the study was to provide aesthetic improvement in unilateral cleft nose deformity by reconstructing the midvault of cleft side alone with unilateral osteotomies, simulating symmetry with the normal side, together with tip reconstruction. While most of the literature emphasizes on tip reconstruction, few of them focus on techniques of repositioning the slanting nasal sidewall, which aids in achieving the desired symmetry. We describe a method of repositioning the bony nasal vault to a more lateral and symmetrical orientation by making unilateral osteotomies.

Results

Eighteen patients of unilateral cleft nose deformity underwent rhinoplasty between March 16 and January 20. All patients had prior primary cleft lip repair. Thirteen patients underwent primary rhinoplasty while 5 underwent secondary rhinoplasty having undergone primary rhinoplasty elsewhere. Follow-up was from 1 to 3 years. Results were evaluated using Rhinoplasty Outcome Evaluation [ROE] Questionnaire, and Asher McDade Aesthetic Index [AMAI] Rating. Pre- and post-operative scores were compared.

All patients were subjectively satisfied. The ROE and AMAI scores showed statistically significant improvement from pre-operative scores.

Conclusion

Obtaining symmetry in cleft nose deformity is a surgical challenge even in experienced hands. Using structural grafts only on the cleft side we attempted to create a near normal symmetry and achieve a natural nasal appearance, with satisfactory improvement from both patient’s and surgeons’ perspective.

Level of evidence

Case series- 4

Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity

BACKGROUND

Secondary cleft rhinoplasty presents some of the most challenging cases of both cosmetic and functional nasal deformities. Understanding the anatomy and growth abnormality seen with the cleft nasal deformity helps to tailor surgical management. This article seeks to expand on the application of current concepts in secondary rhinoplasty for unilateral cleft lip nasal deformity.

METHODS

The authors review nasal analysis in the cleft rhinoplasty patient and provide the surgical management for each aspect in the secondary cleft rhinoplasty.

RESULTS

The secondary rhinoplasty was divided into seven areas: piriform hypoplasia, septal reconstruction, dorsal reshaping, tip reshaping, tip projection, alar reshaping, and alar repositioning. Surgical management for each is provided.

CONCLUSION

Secondary cleft rhinoplasty requires an understanding of the structural dysmorphology, and the use of cosmetic, functional, and secondary rhinoplasty techniques for its successful management.

Role of cartilage correcting sutures in single-stage secondary rhinoplasty for unilateral cleft lip nose deformity

Introduction:

The purpose of this study is to highlight the role of cartilage correcting suture in single-stage surgical correction for secondary unilateral cleft lip nose deformity with three-dimensional observations of preoperative and postoperative nasal forms.

Material and Methods:

Between July 2017 and June 2019, 18 consecutive patients of unilateral cleft lip nose deformity aged between 16 and 28 years underwent surgical correction. The corrective procedure of nose involved columellar lengthening, medial and lateral nasal osteotomies along with augmentation of premaxilla by bone graft at premaxilla, and alar base wedge resections. Focus was laid to correct nasal cartilaginous framework using tip sutures along with repositioning of lower lateral cartilages, fixation of the alar cartilage complex to the septum, and the upper lateral cartilages. We investigated the following surgical interventions and nasal tip suture techniques, which were transdomal suture, interdomal suture, lateral crural mattress suture, columella septal suture, and intercrural suture.

Results:

We achieved adequate esthetic and functional results in all the patients without any morbidity.

Conclusion:

This concept of simultaneous approach toward complete single-stage correction of secondary cleft lip nasal deformity incorporating various cartilage suture using 5-0 nylon in developing nation like ours, where the patient presents late with complex conditions showed promising esthetic and functional outcome.

The Effects of Alar Base Augmentation in Secondary Unilateral Cleft Lip Nasal Deformity

ABSTRACT

In unilateral cleft lip and palate patients, the alar base is displaced inferoposterolaterally due to the depression of the pyriform aperture in the cleft side, and the drooping of the nostril rim is provoked by displacement of the alar base. This study was conducted between May 1998 and December 2012. In total, 82 patients with secondary unilateral cleft lip nasal deformities were treated using alar base augmentation. The patients were divided into two groups according to the degree of their preoperative alar base asymmetry. Patients with alar base asymmetry <3 mm were treated with a soft tissue augmentation procedure. Those with alar base asymmetry >3 and <6 mm were treated with a bony augmentation procedure. Soft tissue augmentation was conducted in 42 patients, and bony augmentation was conducted in 40 patients. In the soft tissue augmentation group, the degree of alar base asymmetry was improved from 2.42 ± 0.38 mm preoperatively to 0.45 ± 0.21 mm postoperatively (P  < 0.05). In the bony augmentation group, the degree of alar base asymmetry was improved from 4.33 ± 0.50 mm preoperatively to 0.81 ± 0.20 mm postoperatively (P  < 0.05). In the amount of alar base augmentation, there were statistically significant differences between the soft tissue augmentation group and the bony augmentation group (P  < 0.05). This clinical study shows that secondary cleft lip nasal deformities can be corrected with alar base augmentation using soft tissue and bony augmentation and that these procedures can provide reliable, satisfactory, and safe clinical outcomes.

Alar Base Augmentation Using Vomerine Bone Graft in Patients With Cleft Lip Nasal Deformity

BACKGROUND

Although many trials have been made to augment the unilateral alar base depression, the ultimate aesthetic satisfaction has proven difficult to achieve. In our study, we present a novel submucosal dissection technique to harvest the vomer bone and use it as an onlay graft to correct the alar base depression.

METHODS

We collected a prospective cohort study of 11 patients with unilateral cleft lip nasal deformity. Using CorelDRAW X7 software, we obtained perioperative clinical photographs to analyze the nostril and lateral lip morphometric measurements on the cleft side. Computed tomography scans were used to assess the required graft's volume and to detect resorption. We performed vomerine ostectomy and placed and fixed the bone graft in with a lag screw over the alar base depression.

RESULTS

The nostril width showed a significant increase, in addition to the height/width ratio. The columellar angle with the lateral lip height increased remarkably, with a general improvement in the nasal tip aesthetics.

CONCLUSIONS

The vomer bone graft has been shown to correct the lateral and inferior disorientation of the alar base and improve the nostril and nasal tip aesthetic measurements. The vomer bone is therefore a sufficient bone source for grafting with high viability and no resorption.

Revisiting the unrepaired unilateral cleft lip and nasal deformity using 3D surface image analysis: A data-driven model and its implications

BACKGROUND

Current descriptions of the unilateral cleft lip and nasal deformity (uCLND) are based upon limited sample sets and subjective observations. While those descriptions are inconsistent and contradictory, theoretical models, including Hogan's "tilted tripod" and Fisher's "nasal arch forms", have never been tested. Given that favorable outcomes of treatment remain elusive, detailed study of the deformity is critical in devising better treatments. The purpose of this study was to develop a data-driven three-dimensional (3D) model of uCLND that spans the spectrum of presentation and involves a pervasive underlying mechanism.

METHODS

We studied 3D images of 100 infants with unrepaired cleft lip at 6 months of age. Objective assessment included the landmark positions, anthropometric dimensions, and shape-based measures. Cleft severity was stratified by the lateral displacement of subnasale, so that a model could be developed using linear regression.

RESULTS

With progressive deviation of subnasale, the non-cleft alar base moved lateral, the cleft alar base was left posterior, and the nasal dorsum followed the caudal septum (deviating towards the non-cleft side). The "twist" resulted in opposing cleft alar dome collapse, non-cleft alar ring constriction (the non-cleft nasal sill narrowed, lateral genu rose, and alar-cheek junction became more acute), and displacement of the philtrum from midline.

CONCLUSIONS

Our study not only supports theoretical models of uCLND but also clarifies vectors of change and reveals significant non-cleft side alterations. On the basis of our findings, the objectives of treatment should involve centralization of the columella and philtrum and rebalancing the nose by untwisting the orthogonal displacement of the alar bases.

Management of the Nasal Deformity in the Unilateral Cleft of the Lip and Nose

Cleft rhinoplasty is a demanding, technique-sensitive procedure. Part art, part science; it poses several probing questions to the surgeon. The unilateral cleft nasal deformity is a distinct entity because the pursuit of symmetry in the unilateral cleft nose makes the repair much more challenging. The advent of nasoalveolar moulding, the gaining popularity of primary (early) nasal repair and greater refinements in secondary (definitive) rhinoplasty techniques have contributed to better nasal results in unilateral cleft repair. Yet, some obstacles remain. This paper aims to discuss the anatomy of the unilateral cleft nose, enumerate aims and objectives of repair at every stage, and to demonstrate the evolution and varied rationale of management of nasal deformities in the unilateral cleft lip and nose.

Unilateral Cleft Lip Nasal Deformity: Three-Dimensional Analysis of the Primary Deformity and Longitudinal Changes following Primary Correction of the Nasal Foundation

BACKGROUND

Objective assessment of the unilateral cleft lip nasal deformity and the longitudinal changes with treatment is critical for optimizing cleft care.

METHODS

Consecutive patients undergoing cleft lip repair and foundation-based rhinoplasty were included (n = 102). Three-dimensional images preoperatively, postoperatively, and at 5 years of age were assessed and compared to age-matched controls. Images were normalized to standard horizontal, craniocaudal, and anteroposterior axes.

RESULTS

Cleft subalare was similar in position relative to controls but was 1.6 mm retrodisplaced. Subnasale was deviated 4.6 mm lateral to midline and had the greatest displacement of any landmark. Noncleft subalare was displaced 2.3 mm laterally. Regression analysis with deviation of subnasale from the midline as a dependent variable revealed progressive lateral displacement of noncleft subalare, narrowing of noncleft nostril, and intercanthal widening. Surgery corrected nasal base displacements along all axes, resulting in landmark positions similar to controls. Symmetry of nasal base correction persisted at 5-year follow-up, with no recurrent cleft alar base retrusion, regardless of initial cleft type.

CONCLUSIONS

Unilateral cleft lip nasal deformity may be "driven" by displacement of the anterior nasal spine and caudal septum. The cleft alar base is normal in position but retruded, whereas the noncleft alar base is displaced laterally. Changes with surgery involve anterior movement of the cleft alar base but also include medial movement of the noncleft alar base and columella. Symmetry of correction, including alar base retrusion, was stable over time and did not rely on alveolar bone grafting.

Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty

BACKGROUND

Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to "upright the nose," without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse.

METHODS

Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison.

RESULTS

Significant changes in anthropometric and morphometric measurements occurred following surgery. Postoperative form was similar to controls immediately after surgery and at 5 years. Nasal corrections were satisfactory, and only two patients have elected to undergo revision. When subjects were grouped according to cleft type, we found the same trends. When comparing different methods of nasal sidewall reconstruction or septoplasty, we found no differences. Alveolar cleft width was a significant predictor of worse preoperative and postoperative form.

CONCLUSIONS

Significant nasal correction can be achieved by means of reconstruction of nasal foundation, without nasal tip dissection. Preservation of tissue planes may allow for easier secondary revision, if necessary.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Dynamic changes in nasal symmetry after presurgical nasoalveolar molding in infants with complete unilateral cleft lip and palate

BACKGROUND

Presurgical nasoalveolar molding (PNAM) technique gave a new perspective to presurgical infant orthopedics. Nasal reconstruction presents a challenge for the plastic surgeons in case of patients with unilateral cleft lip and palate (UCLP). PNAM facilitates the reshaping of the nasal cartilage and molding of maxillary arch preoperatively. This therapy not only aids the surgical repair of lip but also enhances the overall postsurgical results with negligible postoperative scar.

AIM

The aim of the study was to analyze nasal changes before and after PNAM in patients with complete UCLP.

MATERIALS AND METHODS

This was a retrospective review of 22 ULCP patients who underwent PNAM before lip surgeries. A series of standard basilar view photographs in 1:1 ratio were taken, and linear measurements were done directly on the photographs.

RESULTS

After PNAM therapy, there was highly significant increase in the nostril height, nostril dome height, and columella length (P < 0.001*) and highly significant reduction in the nostril width and nasal basal width (P < 0.001*).

CONCLUSION

Significant improvement in the nasal symmetry was found after PNAM therapy in patients with complete UCLP.

Biomechanical analyses of common suspension sutures in primary cleft lip rhinoplasty

Background

For a better understanding of common suspension sutures during primary cleft lip nasal rhinoplasty, the biomechanical consequences of those sutures need to be demonstrated.

Methods

A finite element model of the infant specimen was established. The closure of cleft lip and four different specific suspension sutures were simulated by loading different forces on the model: 1. F1 to simulate the suture fastening both medial crura together; 2. F2 to simulate the suture which sewed both medial crura and the non-cleft-side upper lateral cartilage together; 3. F3 to simulate the suture elevating the alar cartilage cranially; 4. F4 to simulate the suture elevating the alar cartilage superiorly. The deformation and stress distribution consequent to each maneuver were analyzed in details.

Results

The deviation of columella was restored through the closure of cleft lip. Different suspension sutures had different biomechanical effects on the nasal structure. All suspension sutures had the function on elevating the alar cartilage. F2 had no function on restoring the collapse of the nasal tip. The suture which fastened both medial crura together leaded to the lowest stress on the skin envelope.

Conclusions

Each suspension suture had its characteristics respectively. The simulation suggested that F1, the suture which fastened both medial crura, could be the most potential maneuver for cleft lip rhinoplasty because it can symmetrically restore the shape of the nose without incurring a significant increase in stress.

Three Dimensional Rhinoplasty and Nasal Airway Improvement in Cleft-Nose Deformity

Septorhinoplasty is particularly challenging among revision surgeries for cleft sequelae. The challenge of cleft septorhinoplasty is mainly due to the complex anatomy of nose, deformity of each of its components and the difficulty and lack of clarity in surgical management. From 2014 to 2017, 26 patients with cleft lip nose deformity were operated by the same cleft team. The study was conducted to assess the improvement in nasal airway and appearance following secondary rhinoplasty with extracorporeal septoplasty. Post operatively each patient was evaluated using the standard modified rhinoplasty outcome evaluation questionnaire, a validated instrument that aids in stratifying patients according to their subjective response. All patients reported great relief of nasal obstruction and improved breathing. More than 80% of our patients were satisfied with improved aesthetics and reported better self-confidence. Secondary cleft rhinoplasty with extracorporeal septoplasty surgery significantly improves the cosmesis and nasal airway opening, subsequently giving them improved self-confidence.

Multimodal Characterization of the Mature Septal Deformity and Airspace Associated with Unilateral Cleft Lip and Palate

BACKGROUND

The nasal deformity that accompanies cleft conditions is often acknowledged as the most difficult obstacle to restoring facial balance in affected children. Despite considerable progress in the treatment of cleft lip and palate, the outcomes of cleft septorhinoplasty have proven variable and difficult to predict, possibly because of incomplete understanding of the underlying anatomical deformities. The authors sought to characterize unilateral cleft septal and dorsal deformities through a detailed morphologic model based on photogrammetric, qualitative, and quantitative computerized tomographic image analysis.

METHODS

Twenty-five consecutive patients with a unilateral cleft nasal deformity without prior septorhinoplasty were included.

RESULTS

Dorsal angulation, as measured by the nasal dorsal angle, consistently deviated away from the cleft side at a mean angle of 8.9 degrees. In a majority of patients, the septal deformity was complex and consistent in the anterior and middle regions of the airspace, but variable in the posterior region. Finally, discrete sites of potential nasal obstruction were noted in the anterior, middle, and posterior regions along the acoustic axis. Considerable variation was seen in the anterior and posterior regions, with potential obstructions variably on both the cleft and noncleft sides.

CONCLUSION

The authors' results underscore the importance of subject-specific analysis in cleft septorhinoplasty to address multiple potential sites of nasal obstruction.

Association between three-dimensional measurements of the unilateral cleft lip nasal deformity and maxillary alveolar morphology: A retrospective study

BACKGROUND

It is debatable whether rhinoplasty is necessary during a primary operation for cleft lip. However, many surgeons believe that rhinoplasty should be performed simultaneously for severe deformities. We investigated whether alveolar cleft severity is involved in nasal deformity.

METHODS

Forty-three patients were assessed for alveolar cleft severity using maxillary plaster models prepared during primary cheiloplasty. We conducted morphological assessments of nasal deformities using three-dimensional photogrammetry. Patients were divided into two groups according to alveolar cleft severity: group A, overlap of the alveolar segments; group B, nonoverlap of the alveolar segments. Nasal asymmetry was assessed by measuring distances between landmarks around the nostrils and the columellar angle. These measurements were compared between the groups. The correlations between the columellar angle and the ratios of the five cleft side/non-cleft side distances and the correlation of each ratio were analyzed.

RESULTS

Groups A and B included 21 and 22 patients, respectively. Group A demonstrated superior deviation of the alar base on the non-cleft side than that of the alar base on the cleft side (p < 0.05). No other statistically significant differences were observed. Group A had more severe nasal deformity. Columellar angle and nostril base width demonstrated correlation.

CONCLUSION

In an uncorrected, unoperated unilateral cleft lip nasal deformity, alar base deformity is affected by deformity of the alveolar segments.

A New Paradigm in Cleft Lip Procedural Excellence: Creation and Preliminary Digital Validation of a Lifelike Simulator

Simulation is becoming an increasingly important tool for hands-on surgical education in a no-risk environment. Cleft lip repair is a common procedure where precise technique is needed to achieve optimal outcome, making it an ideal candidate for simulation. A digital simulated patient with a typical unilateral complete cleft lip and alveolus was constructed using existing three-dimensional imaging studies. Key surface and internal anatomical elements were characterized in detail. A prototype high-fidelity simulator was constructed with silicone and synthetic polymers over a supportive scaffold, piloted by three surgeons using multiple techniques, and digitally compared to real patients. All surgeons completed key steps of a cleft lip repair on the simulator and found it approximated the haptics and anatomy of a cleft lip. Surface change and anthropometric movements accomplished on the simulator were similar for all three surgeons. In digital comparison to analogous real patient data, the simulator anthropometric movements and topographic change were similar to real nasolabial movement. A high-fidelity cleft lip simulator provides "on-demand" opportunity to realistically practice all steps of a cleft lip repair, with implications for overcoming volume-outcome relationship challenges of diminishing operative experience for resident surgeons.

Recapitulation of Unilateral Cleft Lip Nasal Deformity on Normal Nasal Structure: A Finite Element Model Analysis

Cleft lip nasal deformity has been challenging to plastic surgeons. A better understanding of the biomechanical aspect of the cleft nose would contribute to a better correction. In this study, finite element model of a normal nose was constructed and loaded with forces to recapitulate the unilateral cleft lip nasal deformity. Tether at the alar base was simulated by a laterally directed force at the lateral crus, and tether at the columella base by a posteriorly directed force at the medial crus. The equivalent von-Mises stress and the total deformation consequent to different patterns of loading were captured. In accordance with clinical observations, unilaterally loaded forces caused deformation on both sides of the nose. A correlation between the patterns of loading and different cleft lip nasal deformities was documented in detail. When set at the same force magnitude, tether at the columella base led to more extensive changes in the nasal morphology and higher level of stress than at the alar base. Clear identification of major pathological tethers in the nasolabial region might lead to more accurate and stable correction of cleft lip nasal deformities.

Objective Assessment of the Unilateral Cleft Lip Nasal Deformity Using Three-Dimensional Stereophotogrammetry: Severity and Outcome

BACKGROUND

Optimization of care to correct the unilateral cleft lip nasal deformity is hampered by lack of objective measures to quantify preoperative severity and outcome. The purpose of this study was to develop a consensus standard of nasal appearance using three-dimensional stereophotogrammetry; determine whether anthropometric measurements could be used to quantify severity and outcome; and determine whether preoperative severity predicts postoperative outcome.

METHODS

The authors collected facial three-dimensional images of 100 subjects in three groups: 45 infants before cleft lip repair; the same 45 infants after cleft lip repair; and 45 children aged 8 to 10 years with previous repairs. Five additional age-matched unaffected control subjects were included in each group. Seven expert surgeons ranked images in each group according to nasal appearance. The rank sum score was used as consensus standard. Anthropometric analysis was performed on each image and compared to the rank sum score. Preoperative rank and anthropometric measurements were compared to postoperative rank.

RESULTS

Interrater and intrarater reliability was excellent (intraclass correlation coefficient, >0.76; Pearson correlation, >0.75) on each of the three image sets. Columellar angle, nostril width ratio, and lateral lip height ratio were highly correlated with preoperative severity and moderately correlated with postoperative nasal appearance. Postoperative outcome was associated with preoperative severity (rank and anthropometric measurement).

CONCLUSIONS

Consensus ranking of preoperative severity and postoperative outcome can be achieved on three-dimensional images. Preoperative severity predicts postoperative outcomes. Columellar angle, nostril width ratio, and lateral lip height ratio are objective measures that correlate with consensus ratings by surgeons at multiple ages.

Achievement in Nasal Symmetry after Cheiloplasty in Unilateral Cleft Lip and Palate Infants Treated with Presurgical Nasoalveolar Molding

Background:

The presurgical nasoalveolar molding (PNAM) technique gave a new perspective to presurgical infant orthopedics. Nasal reconstruction presents a challenge for the treating surgeons in case of patients with unilateral cleft lip and palate (UCLP). PNAM facilitates the reshaping of the nasal cartilage and molding of maxillary arch preoperatively.

Aims and Objective:

The aim and objective of the present retrospective study was to analyze two-dimensional nasal changes before and after PNAM in patients with complete UCLP.

Materials and Method:

Twenty-two ULCP patients who underwent PNAM before lip surgery were considered in this study. A series of standard basilar view photographs in 1:1 ratio were taken and linear measurements were done digitally.

Results:

After PNAM therapy, there was a significant increase in nostril height (P = 0.003) and highly significant increase in columella length (P = 0.001). There was also a highly significant decrease in nostril width (P = 0.001) and a significant decrease in nasal basal width (P = 0.02).

Conclusion:

There was a significant increase in nostril height and columella length and a significant decrease in nostril width and nasal basal width on the cleft side when treated with PNAM therapy in patients with complete UCLP. Hence, this therapy helps in improving the nasal symmetry in such patients and also aids in surgical procedures.

Biomechanical simulation of correcting primary unilateral cleft lip nasal deformity

For better outcomes of the primary correction of cleft lip nasal deformity, it is important to clarify the specific morphological and biomechanical consequences of major surgical maneuvers during cleft lip nose correction. In this study, a finite element model was established basing on the micro-MRI imaging of an infant specimen with unilateral complete cleft lip deformity. Alar base adduction was simulated as a medially-directed force on the lateral crus (F1); columella straightening was simulated as a laterally-directed force on the medial crus (F2); and nasal tip enhancement was simulated as an anteriorly-directed force on the intermediate crus (F3). The deformation and stress distribution consequent to each force vector or different force combinations were analyzed in details. Our biomechnical analyses suggested that W\when loaded alone, the three forces generated disparate morphological changes. The combination of different force loadings generated obviously different outcomes. F3 generated the most intensive stress when compared to F1 and F2. When F2 was loaded on top of F1-F3 combination, it further relieved nasal deviation without incurring significant increase in stress. Our simulation suggested that alar base adduction, columella straightening, and nasal tip elevation should all be included in a competent cleft lip nose correction.

Lateral Crural Reinforcement in Secondary Cleft Lip Nasal Deformity Through a Combined Lateral Crural Turn-over Flap and Strut Graft

BACKGROUND

Secondary cleft lip nasal deformity is a complex deformity, and the variety of recommended techniques used to correct this deformity attests to it. Much of the nasal deformity can be attributed to an abnormal lower lateral cartilage. This study presents our experience with applying a lateral crural turnover flap with a sandwiched strut graft in adjunct with other procedures to correct unilateral secondary cleft lip nasal deformity.

METHODS

A retrospective review was conducted of 20 cases of unilateral cleft lip patients undergoing secondary rhinoplasty with lateral crural turnover flap with strut graft. Nostril base augmentation, columellar strut, suture techniques, and alar base reduction were performed as needed. Anthropometric analysis and subjective grading of the postoperative results were performed to evaluate the effect of the procedure on nostril symmetry.

RESULTS

At long-term follow-up of 1 year, the symmetry for cleft side and noncleft side nostril height, width, and angulation of long axis of nostril improved after surgery. Subjective evaluation revealed improved results for all patients.

CONCLUSIONS

The lateral crural turnover flap with sandwiched strut graft is a useful technique for reinforcing, repositioning, and reshaping the lower lateral cartilage in cleft lip patients with hyperconcave lateral crus and hypoplastic pyriform margin. Combined with other techniques, the nostril is increased in height, decreased in width, and thus satisfactory symmetry is obtained.

Mechanical analyses of critical surgical maneuvers in the correction of cleft lip nasal deformity

The relapse of nasal deformity is a challenge for modern correction of cleft lip. A comprehensive understanding in the biomechanical perspective of both the formation and correction of the cleft lip nasal deformity would lead to improved stability of the corrective outcome. In this study, a finite element model of secondary cleft lip nasal deformity was constructed, on which two critical corrective maneuvers were mimicked in the form of force-loading. The intercrural suture was simulated by a force loaded at the intermediate crus of the alar cartilage directing anteriorly and medially, and the suture suspending the alar cartilage to the upper lateral cartilage was simulated by a force loaded at the lateral crus directing superiorly and medially. The equivalent von-mises stress and the total deformation consequent to different patterns of loading were captured. Our biomechanical analyses suggested that the intercrural suture at the nasal tip might be more effective in generating widespread morphological change than the suspension suture, but left much higher level of stress within the skin envelope if placed too high. Synergistic effect was observed between the two sutures in both the resultant deformation and stress. In addition, our simulations were partially supported by clinical photogrammetry data.

Modifications in Presurgical Nasoalveolar Molding Treatment of Bilateral Cleft Lip and Palate Patients With Severely Malpositioned Premaxillae

OBJECTIVE

The aim of this study was to evaluate a modified presurgical nasoalveolar molding (PNAM) treatment for patients with bilateral cleft lip and palate (BCLP) with severely malpositioned premaxillae.

SETTING

This study was conducted at the Faculty of Dentistry, Department of Orthodontics, Ege University, Bornova, Izmir, Turkey.

METHOD

Retention arms were manufactured using a mold that we developed, and prefabricated retraction apparatuses were applied to the plaster model obtained from the patient. During the acrylic curing process, the flanges of the appliances were elongated into the sulcus without including the premaxilla. The premaxilla was aligned with the midline with an elastic band system, and the lip hanger was constructed with 0.023-in stainless steel wire. Elastic bands were stretched between the retraction apparatuses and the lip hanger based on the desired force. Nasal stents were added to the retention arms when the cleft width was reduced to less than 6 mm.

CONCLUSION

The modified PNAM treatment enabled faster derotation of the premaxilla and earlier initiation of retraction. The prefabricated retraction apparatus and retention arm provided efficient PNAM for patients with BCLP.

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.

Prospective Patient-Related Outcome Evaluation of Secondary Cleft Rhinoplasty Using a Validated Questionnaire

OBJECTIVE

To evaluate patient satisfaction and quality of life following secondary cleft rhinoplasty.

DESIGN

Prospective consecutive patient, single unit, single surgeon study.

SETTING

Spires Cleft Centre, Salisbury, Wilshire, United Kingdom, and private practice.

PATIENTS, PARTICIPANTS

56 (27 secondary cleft rhinoplasty) patients completed evaluation forms preoperatively and 3 to 6 months postoperatively.

INTERVENTIONS

Subjective assessment was performed using a validated Rhinoplasty Outcomes Evaluation (ROE) questionnaire. This instrument comprises six questions that capture three quality-of-life domains: physical, mental/emotional, and social.

MAIN OUTCOME

Rhinoplasty outcomes evaluation scores were calculated (range = 0 to 100) to indication satisfaction with rhinoplasty outcomes.

RESULTS

Average age was 28 years (range = 18 to 59 years). There was a significant subjective improvement in the total ROE evaluation scores from 28 ± 10 to 80 ± 11 (P < .01) in secondary cleft rhinoplasty. Similar results were achieved in noncleft rhinoplasty 34 ± 9 to 84 ± 9 (P < .01). Specific scores for nasal aesthetic appearance improved from 0.3 ± 0.2 to 3.2 ± 0.3 (P < .01) in secondary cleft rhinoplasty. No significant change was seen in breathing capacity in secondary cleft rhinoplasty (from 2.7 ± 0.3 to 3.2 ± 0.2; P = .29). All patients said they would undergo the procedure again.

CONCLUSION

Our results demonstrate high patient satisfaction after cleft rhinoplasty with particular regard to cosmetic appearance. These results are similar to those for noncleft rhinoplasty. We would recommend the use of this simple and quick validated outcome tool with all rhinoplasty patients.

Correction of the cleft nasal deformity: from infancy to maturity

The cleft nasal deformity remains the most likely stigma of the cleft to remain plainly visible despite vigorous and repeated attempts at correction. This deformity is present at birth, but evolves over time. Certain aspects can be treated early, but some, such as the dorsal and septal deformity continue to develop as facial growth proceeds through adolescence. This article presents a conceptual mechanism and a philosophy of conservative reliable gains starting at the primary operation, with the long-term view of achieving definitive correction at maturity. Cogent planning of longitudinal care of the deformity from infancy leads to solid, predictable results.

Unilateral cleft lip: principles and practice of surgical management

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

Cleft nasal deformity and rhinoplasty

The cleft nasal deformity is a complex challenge in plastic surgery involving the skin, cartilage, mucosa, and skeletal platform. Ever since Blair and Brown first described the intricacies of the cleft pathology in 1931, the appropriate approach has been extensively debated in the literature with respect to timing, technique, and extent of surgical intervention. In this article, the authors review the literature and summarize the various modalities for achieving a successful rhinoplasty in the patient with a cleft nasal deformity.

Presurgical presentation of columellar features, nostril anatomy, and alveolar alignment in bilateral cleft lip and palate after infant orthopedics with and without nasoalveolar molding

OBJECTIVES

(1) To evaluate quantitative differences in presurgical presentations of alveolar alignment and nostril anatomy of infants with BCLP treated with nasoalveolar molding (NAM) from those treated with maxillary infant orthopedics only (IO) and (2) to detect interrelationships between presurgical nasoalveolar anatomy, age at lip surgery, age of commencing, and durations of alveolar and nasal molding.

METHODS

A retrospective analysis was conducted on nasal-alveolar measurements and presurgical treatment records of infants with BCLP who received lip repair by a single surgeon in a tertiary-care, referral teaching hospital consecutively from 2000 to 2009 after undergoing NAM (n  =  29; 51 nostrils) or IO (n  =  17; 32 nostrils). Paired t tests analyzed nostril and alveolar symmetry in each group. Intergroup comparisons were made by linear mixed-model regression analyses. Pearson's correlation tests were conducted to detect significant interrelationships within groups.

RESULTS

Significant between-group differences were noted in alveolar irregularity (NAM: 3.58 ± 1.02 mm; IO: 7.31 ± 1.28 mm; p < .01), columellar length (NAM: 2.88 ± 0.27 mm; IO: 1.48 ± 0.34 mm; p < .001), columellar width (NAM: 6.10 ± 0.21 mm; IO: 6.88 ± 0.26 mm; p < .01), columellar length/width ratio (NAM: 0.48 ± 0.05; IO: 0.20 ± 0.07; p < .05), and columellar angle (NAM: 0.98 ± 1.1°; IO: 3.69 ± 1.37°; p < .05). Differences in age of commencing presurgical orthopedics, lip surgery, and treatment durations were not significant. Better-aligned alveolar segments in the NAM group did not statistically correlate with nostril dimensions. Alveolar irregularity and nostril height in the IO group strongly correlated.

CONCLUSIONS

Infants who received NAM had longer columellae and better-aligned alveolar segments than those who received only IO. Other nostril dimensions were not significantly different.

Surgical technique for secondary correction of unilateral cleft lip-nose deformity: clinical and 3-dimensional observations of preoperative and postoperative nasal forms

PURPOSE

Despite recent developments in cleft surgery, a surgical method for secondary correction of unilateral cleft lip-nose deformity has not yet been established. The purpose of this study was to describe the surgical techniques for secondary correction of unilateral cleft lip-nose deformity with 3-dimensional (3D) observations of preoperative and postoperative nasal forms.

PATIENTS AND METHODS

Secondary corrections of unilateral cleft lip-nose deformity were performed on 13 patients with a complete unilateral cleft lip and palate, and these patients were followed up for 1 year to more than 3 years. All patients were treated by open rhinoplasty through a bilateral reverse-U incision and transcolumellar incision, correction of the columella base with/without septoplasty, nasal tip cartilage graft, and medial-upward advancement of nasolabial components with vestibular expansion by free mucosal graft. Preoperative and postoperative nasal forms were observed by use of photos and 3D data obtained serially.

RESULTS

The postoperative nasal forms were improved in all patients. The preoperative 3D color images indicated asymmetry of the alar groove and nasal tip visually. The top of the alar groove on the cleft side was dislocated distally and downwardly, resulting in a small snub ala. The postoperative 3D color images showed symmetric nasal forms with the adequately recovered nasal tip projection and the appropriate circle of the nasal ala groove on the cleft side. There were no serious postoperative complications.

CONCLUSIONS

Repositioning of the nasalis muscle and sufficient expansion of the nasal vestibule as well as reconstruction of nasal cartilages are important for correction of unilateral cleft lip-nose deformity.

Objective measurements for grading the primary unilateral cleft lip nasal deformity

BACKGROUND

The purpose of this prospective study was to develop and validate an objective means of grading the presurgical unilateral cleft lip nasal deformity. Our hypotheses are that expert cleft surgeons can reliably rank patients according to their subjective assessment of the degree of unilateral cleft lip nasal deformity and that objective anthropometric measurements correlate consistently with this subjective assessment.

METHODS

Forty consecutive infants with unilateral cleft lip nasal deformity were subjectively ranked according to the degree of deformity on standardized presurgical photographs by four senior cleft surgeons. Internal agreement was assessed. Correlations between presurgical anthropometric parameters and the subjective panel rankings were determined. To test the reproducibility of subjective ranking, a random subset of images (n = 15) was also ranked by four external expert cleft surgeons of international reputation.

RESULTS

There was extremely high agreement of subjective ranking by the expert panels (interclass correlation coefficient, 0.95 for the internal panel and 0.94 for the external panel) and between the two panels (interclass correlation coefficient, 0.97). The nostril width ratio was the most predictive of both internal and external rank scores (r = 0.76, p < 0.0001; and r = 0.81, p = 0.0003, respectively). The columellar angle was also highly predictive of both internal and external expert rank scores (r = 0.73, p < 0.0001; and r = 0.79, p = 0.0005, respectively).

CONCLUSIONS

Experts are reliably able to subjectively rank patients according to the degree of nasal deformity. Measures of the columellar angle and the nostril width ratio vary in a linear fashion with the perceived deformity and may serve as independent and objective indicators of presurgical severity of unilateral cleft lip nasal deformity.

Evaluation of cleft lip bony depression of piriform margin and nasal deformity with cone beam computed tomography: "retruded-like" appearance and anteroposterior position of the alar base

BACKGROUND

As the nasal platform, the piriform margin is considered the most important nasal structure. An insufficient bony structure has been suggested to be the major factor in secondary nasal deformities such as the "depressed alar base." It is unclear, however, how the piriform margin is depressed or how bony depression influences nasal shape.

METHODS

Using cone beam computed tomography, the anteroposterior positions of the cleft-side piriform margin and alar base were compared with those of the noncleft side in 52 postoperative unilateral cleft lip patients with no alveolar bone graft. Patients were divided based on cleft type into either the unilateral cleft lip, alveolus, and palate group or the unilateral cleft lip and alveolus group.

RESULTS

In all cases, the cleft-side piriform margin was depressed. The anteroposterior position of the alar base was related to the piriform depression in both groups. However, in contrast with bony depression, the cleft-side alar base was located more anteriorly than the non-cleft-side alar base in 35 of 52 patients.

CONCLUSIONS

The authors' study suggests that bony depression does not necessarily lead to postoperative alar depression. The postoperative cleft lip alar position can be maintained independently of the collapsed lesser segment of the maxilla. In addition, in many cleft lip newborns the cleft alar crease is hypoplastic, and the paranasal triangle is easily elevated by operative manipulation because of the muscular dysfunction. This shallowness leads to a "retruded" appearance. For improvement, preservation of the paranasal triangle and alar crease plasty are important.

The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study

The purpose of this study was to assess the progressive changes of nasal symmetry, growth, and relapse after presurgical nasoalveolar molding and primary cheiloplasty in unilateral complete cleft lip/palate infants. Twenty-five consecutive complete unilateral cleft lip/palate infants were included. All the infants underwent nasoalveolar molding before primary cheiloplasty. Standard 1:1 ratio basilar photographs were taken before and after nasoalveolar molding, 1 week after cheiloplasty, and yearly for 3 years. Linear measurements were made directly on the photographs. The results of this study revealed that the nasal asymmetry was significantly improved after nasoalveolar molding and was further corrected to symmetry after primary cheiloplasty. After the primary cheiloplasty, the nasal asymmetry significantly relapsed in the first year postoperatively and then remained stable and well afterward. The relapse was the result of a significant differential growth between the cleft and noncleft sides in the first year postoperatively. To compensate for relapse and differential growth, the authors recommend (1) narrowing down the alveolar cleft as well as possible by nasoalveolar molding, (2) overcorrecting the nasal vertical dimension surgically, and (3) maintaining the surgical results using a nasal conformer.

Facial characterization of infants with cleft lip and palate using a three-dimensional capture technique

OBJECTIVE

To characterize the soft tissue features of infants with unilateral cleft lip (UCL) and unilateral complete cleft lip and palate (UCLP) prior to primary surgery and compare with noncleft controls.

DESIGN

Prospective controlled capture of the facial morphology of infants using a noninvasive three-dimensional stereophotogrammetry method.

PARTICIPANTS

23 children with presurgical cleft: 11 UCL (M = 6, F = 5); 12 UCLP (M = 9, F = 3), and 21 noncleft controls (M = 7, F = 14) were imaged at approximately 3 months of age (range 10 to 16 weeks).

MAIN OUTCOME MEASURE

Accurate, repeatable quantification of facial soft tissues in infants with clefts prior to surgery.

RESULTS

Significant differences (p <.05) were found between the UCLP group and UCL and control groups in anatomical and soft nose width, cleft-side alar wing length, and nasal tip horizontal displacement. Both cleft groups were significantly different from controls and from each other in cleft-side nostril dimensions, alar wing angulation, columella angle, and alar base to corner of mouth dimension; alar base width; and soft tissue defect in nose and the lip and philtrum length bordering the cleft. Significant differences between clefts and controls were identified in the nostril and philtrum on the noncleft side.

CONCLUSIONS

The use of children with UCL as controls for UCLP studies is inappropriate. This technique overcame the limitations of direct measurement of infant faces to aid the surgeon in the planning and subsequent re-evaluation of surgical rationale.

Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate

The purpose of this study was to analyze the geometry of the primary cleft lip nasal deformity using three-dimensional computerized tomography in a group of 3-month-old infants with complete unilateral cleft lip and palate before surgical intervention. Coordinates and axes were reconfigured after the three-dimensional image was oriented into neutral position (Frankfurt horizontal, true anteroposterior, and vertical midline). Display and measurement of skin surface and osseous tissues were achieved by adjusting the computed tomographic thresholds. S-N, N-ANS, S-N-O, and S-N-ANS were measured from true lateral views. Biorbital (LO-LO), interorbital (MO-MO), intercanthal (en-en), and nasal (al-al) widths were measured from the anteroposterior view. The bony alveolar cleft width was measured from the inferior view. The study group was divided into two groups on the basis of skeletal alveolar cleft width: six patients with clefts narrower than 10 mm and six patients with clefts wider than 10 mm. Only the S-N-ANS angle differed between the two groups, i.e., it was greater in the group with the wider clefts (p < 0.05). Coordinates of six landmarks at the base of the nose [sellion (se), subnasale (sn), cleft-side and noncleft-side subalare (sbal-cl and sbal-ncl), and the most posterior point on the lateral piriform margins (PPA-CL and PPA-NCL)] were obtained for analysis of the nasal deformity. On average, the subnasale point was anterior to sellion and deviated to the noncleft side; the cleft-side sbal point was more medial, posterior, and inferior than the noncleft-side sbal point; and the PPA point on the cleft-side piriform margin was more lateral, posterior, and inferior than the PPA point on the noncleft side. These discrepancies were not universally observed. However, in all patients, four findings were observed without exception (p < 0.01): (1) subnasale (sn) was deviated to the noncleft side (mean distance from midline, 5.0 mm; range, 2 to 9.5 mm), (2) the cleft-side alar base (sbal-cl) was more posterior than the noncleft-side alar base (sbal-ncl) (mean difference, 3.6 mm; range, 1 to 5.5 mm), (3) the noncleft-side alar base (sbal-ncl) was further from the midline than the cleft-side alar base (sbal-cl) (mean difference in lateral distances of sbal-ncl and sbal-cl from the midline, 2.8 mm; range, 0.5 to 7 mm), and (4) the cleft-side piriform margin (PPA-CL) was more posterior than the noncleft side piriform margin (PPA-NCL) (mean difference, 2.1 mm; range, 0.5 to 4 mm). In conclusion, the nasal deformity in unilateral cleft lip and palate that has not been operated on is characterized by these four features and increased S-N-ANS angle with increased alveolar cleft width.