Cartilage Grafting Outcomes in Intermediate and Definitive Cleft Rhinoplasty

Bony Septal Grafts Enhance Aesthetic Subunits and Ventilation in Unilateral Cleft Lip Nasal Deformity

BACKGROUND

East Asian patients with unilateral cleft lip and nasal deformity (UCLND) have severe septal deviated. An innovated septal reconstruction method using both perpendicular plate of ethmoid (PPE) and cartilage septum may improve ventilation and achieve similar aesthetic improvements as septal reconstruction using costal cartilage.

METHODS

Patients with UCLND who underwent septal reconstruction using PPE or costal cartilage in the same period were retrospectively included in a 1:1 ratio. Comparison of preoperative and postoperative differences in NOSE and ROE scales and changes in scores between the two groups were made. Changes in nasal airway morphology and ventilatory function were analyzed using computational fluid dynamics in a case using PPE.

RESULTS

A total of 24 patients were included for analysis. Patients undergoing septal reconstruction using PPE showed significant improvement in NOSE scores and ROE scores. The improvement in ROE scores was similar to patients undergoing septal reconstruction using costal cartilage. Computational fluid dynamics analysis showed that septal reconstruction using PPE improved the patient's bilateral nasal airway morphology and flow symmetry.

CONCLUSIONS

The combined application of PPE and septal cartilage to reconstruct the nasal septum in East Asian patients with UCLND is effective to improve the ventilation function and nasal airway symmetry. This strategy can achieve aesthetically similar results to septal reconstruction using costal cartilage.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Long-Term Outcome of Secondary Cleft Rhinoplasty in Patients with Secondary Nasal Deformity: Optimal Indications for Tajima Technique

BACKGROUND

The authors investigated the timing of and indications for the Tajima reverse-U incision for correcting secondary unilateral cleft nasal deformities.

METHODS

Nonsyndromic patients with secondary cleft lip and nasal deformity who received Tajima reverse-U incision rhinoplasty were grouped by age (4 to 13 years, n = 56; 13 to 18 years, n = 22; older than 18 years, n = 18) and severity of deformity (mild deformity, n = 7; moderate deformity = 22; severity deformity = 67) during 5-year follow-up. FACE-Q assessment and nasal symmetry measurements were used in this study.

RESULTS

Ninety-six patients completed the FACE-Q assessment for the nose and nostril. The results showed higher satisfaction with nostril appearance 1 week after surgery (85.95 ± 13.01) compared with before surgery (79.72 ± 11.89), maintained at the 5-year follow-up (82.61 ± 14.06). Significant differences were observed in 5 nasal parameters (nasal height ratio, one-fourth media part of nostril height ratio, nasal sill height ratio, columellar angle, and inner nostril height-to-width ratio [cleft]) at 1 week postoperatively, and the corrected outcome of the Tajima technique was maintained 5 years after surgery in the 4- to 13-year age group. The same statistically significant changes were found in nasal sill height ratio in the mild deformity group and nostril width ratio, one-fourth media part of nostril height ratio, columellar angle, and inner nostril height-to-width ratio (cleft) in the moderate deformity group.

CONCLUSION

The Tajima procedure was beneficial for preadolescent children and children with mild to moderate unilateral cleft nasal deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Current Treatment Progress of Unilateral Cleft Lip Nasal Deformities

INTRODUCTION

Secondary nasal deformity following unilateral cleft lip is a common facial congenital malformation. Due to its complex treatment, there is currently no unified treatment plan in clinical practice. Dysplasia of cartilage, dislocation of muscles, and dysplasia of maxilla are the main causes of secondary nasal deformities of unilateral cleft lip. This article provides a comprehensive summary of the perioperative period and treatment process of unilateral cleft lip nasal deformities, aiming to find better clinical treatment guidance for patients with unilateral cleft lip and nasal deformity.

METHODS

A review of numerous previous studies on unilateral cleft lip nasal deformity, particularly within the last five years, was conducted to gather information on treatment strategies and perioperative care for unilateral cleft lip rhinoplasty.

CONCLUSION

Currently, there is still no unified final surgical method for the correction and treatment of unilateral cleft lip nasal deformity. In terms of surgical timing, simultaneous primary rhinoplasty and lip repair are gradually being recognized internationally, while intermediate rhinoplasty can be considered when it affects the patients social and psychological life. Patients with severe initial nasal deformity require multiple revisions. Secondary rhinoplasty remains the ideal treatment for final correction of secondary nasal deformities in unilateral cleft lip.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Improvement in nasal airway obstruction after secondary rhinoplasty for cleft lip: A systematic review

BACKGROUND

The purpose of the study was to comprehensively review the improvement in nasal airway obstruction after secondary rhinoplasty for cleft lip.

METHODS

The search was conducted on PubMed, Embase, and Scopus databases for relevant studies published within the past twenty years. Inclusion criteria encompassed patients undergoing secondary rhinoplasty with cleft lip nasal deformity and some evaluation of the nasal outcome.

RESULTS

A thorough analysis of available studies identified 29 articles that met the inclusion criteria for final assessment. Seven (24.1%) studies were classified as Therapeutic Ⅱ (T II) according to the American Society of Plastic Surgeons level of evidence scale, while the majority were categorized as T III (17.2%), T IV (51.7%), and T V (6.9%). Subjective methods were employed in 21 articles to measure nasal ventilation outcomes, whereas 8 studies utilized objective methods. Overall findings from all included studies consistently indicated an improvement in nasal ventilation post-surgery.

CONCLUSIONS

Although there is no consensus regarding the impact of secondary rhinoplasty on nasal airway obstruction in cleft lip patients, this review suggests that it can effectively alleviate such obstructions. We conducted an anatomical analysis to investigate the impact of various surgical techniques on nasal ventilation to provide recommendations for postoperative ventilation assessment.

National Trends in Microtia Repair Cost and Hospital Length of Stay

Microtia can have deleterious impacts on the functional, psychological, and aesthetic outcomes of affected young children. Reconstructive procedures can alleviate these negative outcomes and significantly improve the quality of life for patients; however, the cost and length of hospital stay (LOS) for such procedures and the factors that impact them have not been well-characterized. This study seeks to understand the hospital-level (institution type, size, and geographic region) and patient-level factors (race, age, and insurance status) that impact cost and LOS in patients who undergo microtia reconstructive surgery. A retrospective data analysis was conducted utilizing the National Inpatient Sample (NIS) database for the years 2008 to 2015. Inclusion criteria included patients who had an International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for microtia (744.23) as well as a procedure for microtia correction (186×/187×). A total of 714 microtia repair cases met the inclusion criteria and were sampled from the NIS database. Microtia repair cost was significantly increased on the West Coast compared with the Northeast ($34,947 versus $29,222, P =0.020), increased with patient age ($614/y, P =0.012), and gradually increased from 2008 to 2015 ($25,897-$48,985, P <0.001). Microtia LOS was significantly increased with government-controlled hospitals compared with private hospitals (1.93 versus 1.39 d, P =0.005), increased with patients on Medicaid compared with private insurance (2.33 versus 2.00 d, P =0.036), and overall decreased with patient age (-0.07 d/y, P =0.001). The results not only identify the multifactorial impacts that drive cost and LOS in microtia repair but provide insights into the financial and medical considerations patients and their families must navigate.

Outcomes of Open Rhinoplasty for Unilateral Cleft Patients using Photogrammetric Analysis - An Evaluative Study

Introduction

Secondary cleft rhinoplasty is a challenge due to the complex anatomy of the nose, with structural deformity and difficulty in surgical management. This study aimed to evaluate the effect of an anatomical-based approach on enhancing tip and alar symmetry in secondary unilateral cleft rhinoplasty using photogrammetric evaluation.

Methods

The study was conducted on 57 adult patients seeking rhinoplasty after primary repair of congenital unilateral cleft lip deformity. All patients were operated upon using an external open rhinoplasty approach using an anatomical-based surgical technique. The cases were periodically followed up at three, six, 12 and 18 months for both aesthetic and functional outcomes with photogrammetric analysis of facial profile using the software Mirror Suite programme to compare before and after the surgical procedure.

Results

The photogrammetric analysis showed a significant improvement of facial angles (P = 0.05). The nasofrontal angle changed from a median of 146° to 132.5°, nasolabial angle of 73° to 95°, nasofacial angle of 21.5° to 32° and nasomental angle of 105° to 130°. The rotation angle of the nasal tip showed a significant cephalic rotation with a mean increase of the tip elongation of 1.8 cm achieved per lateralised millimetre.

Discussion

Secondary rhinoplasty in unilateral cleft deformities needs accurate evaluation of the anatomical and pathological abnormalities. Open approach is preferred with using costal cartilage graft allowing adequate columellar lengthening, maxillary enhancement and alar repositioning which leads to optimise the definition, projection and cephalic rotation with better stabilisation and symmetry of the nasal tip.

Sociodemographic Disparities in Access to Cleft Rhinoplasty

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Evaluation of the Multiple Tissue Factors in the Cartilage of Primary and Secondary Rhinoplasty in Cleft Lip and Palate Patients

Cleft lip and palate (CLP) is one of the craniofacial defects. The objective of this study was to identify the differences in appearance between the tissue factors in cartilage of CLP patients after primary and secondary rhinoplasty. Immunohistochemistry was performed with MMP-2, MMP-8, MMP-9, TIMP-2, IL-1α, IL-10, bFGF, and TGFβ1. The quantification of the structures was performed using a semi-quantitative census method. MMP-2, -9, IL-1a, and bFGF demonstrated higher number of positive cells in patients, while the number of MMP-8, IL-1a, -10 and TGFβ1 cells was higher or equal in the control subjects. The only statistically significant difference between CLP-operated patients was found in the TIMP-2 group, where the primary CLP patient group had a higher number of TIMP-2 positive chondrocytes than the secondary CLP patient group (U = 53.5; p = 0.021). The median value of the primary CLP group was ++ number of TIMP-2 positive chondrocytes compared to +++ in the secondary CLP group. No statistically significant difference was found between primary and secondary rhinoplasty patients for other tissue factors. Commonly, the rich expression of different tissue factors suggests a stimulation of higher elasticity in cleft affected cartilage. The statistically significant TIMP-2 elevation in primary operated cartilage indicates an impact of the selective tissue remodeling for hard tissue.