Definitive repair of the unilateral cleft lip nasal deformity

The majority of patients with a unilateral cleft nasal deformity still benefit from additional nasal surgery in their teenage years, despite having undergone a primary nasal repair. However, the secondary nasal deformity of these patients stands in sharp contrast to those of children who have not benefited from primary repair. The authors' algorithm for the definitive correction of these secondary deformities considers the differences in these two patient groups and defines their indications for rib cartilage grafts and their method of using septal and ear cartilage in the repair. Balancing the muscle forces on the septum and alar cartilage is emphasized in both the primary and secondary repair. Both cartilage malposition and hypoplasia of the lower lateral cartilage complex have been identified as factors contributing to the deformity.     

Nonsurgical correction of nasal deformity in unilateral complete cleft lip: a 6-year follow-up.

Nasal deformity in unilateral cleft lip and palate patients increases with time, tongue malposition being one of the causes. Some authors have emphasized the role of nasal and adjacent facial musculature as active extrinsic agents. Another cause of alar deformity can be the lack of a proper foundation because of a maxillary hypoplasia in the region of the pyriform foramen. If alar collapse occurs, the septum bends convexly toward the cleft side. Tissues are soft and plastic during the neonatal period. Once the infant is about 3 months of age, it becomes difficult to correct the nasal deformity. Therefore, any resource used from the first day, and mainly during the first 15 days of life, will be useful to prevent the increasing deformity and to avoid the surgical correction. A controlled clinical trial was planned to compare the anthropometric measurements of the nasal region in two series of patients with unilateral complete cleft lip. In the first group, we included 44 patients who came to our clinic during the first 2 days of life and the second group consisted of 47 patients who were more than 15 days of age at the time of the first consultation. To provide control data for the evaluation of the results after 6 years of follow-up in both series of cleft patients, we also included a third group of 48 healthy 6-year-old children. A nasal component added to the occlusal prostheses was only used in the first group up to the time of surgery. The same surgeon performed a Millard II procedure with muscular reposition as described by Delaire in all the patients. Nasal measurements taken with a caliper, obtained directly from plaster models by using surface impressions of the babies, were confirmed by a laser three-dimensional measuring device. The statistical comparison between both series showed a significant increase of the columellar length in the first group. A 6-year follow-up to compare growth and cosmetic results of the nose revealed a better and permanent nasal nostril symmetry and no alar cartilage luxation in the patients who had had the nasal component. These results highlight the importance of the early treatment and allow us to suggest the nasal prostheses as a way to prevent the increasing nasal deformity, to help nasal remodeling, to obtain columellar elongation, and to avoid or decrease the need for primary surgery of the cleft nose.     

Primary repair of bilateral cleft lip and nasal deformity.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. List five principles that guide synchronous repair of bilateral complete cleft lip and nasal deformity. 2. Explain how different growth rates for the principal nasolabial features are applied during primary repair. 3. Describe two approaches for positioning the alar cartilages to form the columella. 4. Discuss the influences on referral patterns for a newborn with bilateral cleft lip. --Traditional repair of bilateral cleft lip focused on labial closure but accentuated the nasal deformities, which were addressed later. By the end of the past century, single-staged labial closure had replaced the old multistaged procedures and the technical emphasis had begun to shift from secondary to primary nasal correction. Now, presurgical maxillary orthopedics sets the bony foundation for synchronous nasolabial repair and for closure of the alveolar clefts. The study of normal nasolabial growth and the typical stigmata of the conventional methods provides the necessary foreknowledge to guide surgical sculpture in three dimensions and to anticipate the fourth dimension. The convergence of several forces are changing referral lines for children born with bilateral cleft lip. These include affirmation of centers of excellence, surgeons' self-regulation, prenatal diagnosis, economics of health-care delivery, and increasing parental sophistication. These pressures are not necessarily in conflict. Care by a subspecialized plastic surgeon and experienced team is in the best interests of the child and the third-party payer.     

The residual unilateral cleft lip nasal deformity: a three-phase correction technique

The author presents a three-phase correction technique for the residual unilateral cleft lip nasal deformity. This procedure involves a sculpting excision of the alar rim, use of this alar rim as an interpositional flap in lengthening the columella, and augmentation of the nasal tip and perialar sulcus with a free ear conchal cartilage graft. The concept has been incorporated in the revisionary surgery program of 74 patients over a period of 5 years with a minimal follow-up of 2 years. The majority of the patients are operated on between the ages of 5 and 7 years based on the concept of a need for a "tidy appearance" by first grade.     

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.     

Primary correction of unilateral cleft lip nasal deformity: a 10-year review

A 10-year follow-up of patients who underwent primary correction of their cleft lip nasal deformity is presented. These are the first 10 consecutive patients who were treated following a change in treatment plan in 1973. Primary correction of the cleft lip nasal deformity essentially consists in elevating the displaced alar cartilage at the time of lip repair. There has been no interference with nasal growth, and the position of the alar cartilages and nasal tip has been maintained.     

Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation

Previously it was thought that primary correction of nasal deformity in cleft lip patients would cause developmental impairment of the nose. It is now widely accepted that simultaneous correction of the cleft lip nasal deformity has no adverse effect on nasal growth. Thus, the authors tried to evaluate the results of primary correction of cleft lip in Asian patients. Of 412 cases of cleft lip, 195 cases were corrected by means of the conventional method from June of 1992 to June of 1997, and 217 cases were corrected by simultaneous rhinoplasty from July of 1997 to October of 2001. The average patient age was 3 months. Photographs and anthropometric evaluation were used to evaluate the results. Nasal tip projection, columellar length, and nasal width were measured in 60 randomized normal children, 30 randomized children treated with the conventional method, and 30 randomized children with primary nasal repair. Data were analyzed using t tests, and the level of significance was 5 percent (p < 0.05). In cases of simultaneous repair, nasal tip projection and columellar length were increased 24.8 percent and 28.8 percent, respectively. Nasal width was increased 12.3 percent in the cases of simultaneous repair and 12.6 percent in the cases without primary rhinoplasty. Simultaneous repair of cleft lip and nasal deformity in Asian patients showed that more symmetry of nostril and nasal dome projection and better correction of buckling and alar flaring were achieved. More balanced growth and development of the alar complex was achieved, and no interference with nasal growth was encountered.     

Anatomy of the nasal cartilages of the unilateral complete cleft lip nose

The purpose of this study was to disclose the relationship between the anomaly of the cartilaginous framework and the nasal deformity of cleft lip. The noses of six stillborn infants with unilateral complete cleft lip were carefully dissected. The size and weight of the lower lateral cartilages were measured to determine whether there was a significant difference between the normal and involved sides. The position of the nasal cartilages was observed, and the distance between them was measured to determine whether they were normal. The surgical dissection revealed that the lower lateral cartilages from both sides were asymmetrical in three dimensions, indicating the displacement of the lower lateral cartilage on the involved side. There was displacement of the cartilaginous septum and the upper lateral cartilage. The statistical evaluation did not demonstrate a significant difference between weight and size of the two sides. One of the major causative factors of nasal deformity is displacement of the nasal cartilages. There is no hypoplasia of nasal cartilage in newborn infants with cleft lip.     

Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late

It is universally acknowledged that correction of a cleft lip nasal deformity continues to be a difficult problem. In developing countries, it is common for patients with cleft lip deformities to present in their early or late teens for correction of severe secondary lip and nasal deformities retained after the initial repairs were carried out in infancy or early childhood. Such patients have never had the benefit of primary nasal correction, orthodontic management, or alveolar bone grafting at an appropriate age. Along with a severe nasal deformity, they present with alveolar arch malalignments and anterior fistulae. In the study presented here, a strategy involving a complete single-stage correction of the nasal and secondary lip deformity was used.In this study, 26 patients (nine male and 17 female) ranging in age from 13 to 24 years presented for the first time between June of 1996 and December of 1999 with unilateral cleft lip nasal deformity. Eight patients had an anterior fistula (diameter, 2 to 4 mm) and 12 patients had a secondary lip deformity. An external rhinoplasty approach was used for all patients. The corrective procedures carried out in a single stage in these patients included lip revision; columellar lengthening; repair of anterior fistula; augmentation along the pyriform margin, nasal floor, and alveolus by bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; fixation of the alar cartilage complex to the septum and the upper lateral cartilages; augmentation of nasal dorsum by bone graft; and alar base wedge resections. Medial and lateral nasal osteotomies were performed only if absolutely indicated. The median follow-up period was 11 months, although it ranged from 5 to 25 months. Overall results have been extremely pleasing, satisfactory, and stable.In this age group (13 years of age or older), it is not fruitful to use a technique for nasal correction that corrects only one facet of the deformity, because no result of nasal correction can be satisfactory until septal deviations and maxillary deficiencies are addressed along with any alar repositioning. The results of complete remodeling of the nasal pyramid are also stable in these patients because the patients' growth was nearly complete, and all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that aesthetically good results are achievable even if no primary nasal correction or orthodontic management had been previously attempted.     

Primary definitive nasal correction in patients presenting for late unilateral cleft lip repair

Almost 25 percent of unilateral cleft lip and palate patients present with their deformity in their teens or later years in the developing world. Because more than 80 percent of the world population lives in the developing world, the established protocol for repair of these deformities is not applicable to these patients. Despite the magnitude, there are no significant reports in the literature that deal with this problem. Several issues need to be addressed, but the author limits himself here to the correction of the nasal deformity. The patients at this age are very much concerned with the aesthetic outcome. Procedures described hitherto for primary nasal correction in infants are not successful in restoring nasal shape and symmetry at this late age of presentation. Our experience with radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late prompted us to extend the concept by undertaking a definitive primary correction of the nasal deformity in cleft patients presenting late. Twenty-two patients with unilateral cleft lip deformity (nine male patients and 13 female patients) with ages ranging from 13 to 22 years, presenting between August of 1997 and December of 2000, are included in this study. Of these, 11 patients had a cleft of the lip alone, eight also had a cleft of the alveolus, and three had a cleft of the palate continuous with the cleft lip. All patients showed some maxillary hypoplasia. An external rhinoplasty with lip repair was carried out in all patients. The corrective procedures on the nose included columellar lengthening; augmentation along the pyriform margin, nasal floor, and alveolus using bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; and augmentation of nasal dorsum by bone graft. Clinical follow-up ranged from 4 to 24 months, and the median follow-up period was 13 months. Results have been very good, and much better than results seen earlier with other primary rhinoplasty techniques. While repairing unilateral cleft lip in adolescents, the author thinks it would be most appropriate to address the entire gamut of the deformity in a single stage, provide complete vector reorientation, and augment the hypoplastic elements by autologous tissue. It is not just the fear of poor follow-up, but that merely correcting the lip deformity in these patients without attempting definitive rhinoplasty, in the author's opinion, would be insufficient surgical intervention.     

Asymmetric incision for open rhinoplasty in cleft lip nasal deformity.

One of the problems in the correction of the unilateral cleft lip nasal deformity is the alar web deformity on the mediosuperior side of the nostril. A number of methods for the correction of the alar web deformity have been introduced, but no single procedure has been identified as the standard. In this report, the incision line of the open rhinoplasty was modified and the alar web deformity was corrected by using an incision and closure. Open rhinoplasty with the asymmetric incision was performed on 18 patients with unilateral cleft lip nasal deformity. The incision line used in the normal side was the usual intranasal rim incision line and that used for the columella was the transcolumella incision line. For the cleft side, an intranasal rim incision line was plotted after the rim was lifted upward with forceps to achieve symmetry of the nasal tip. After removal of the forceps, the incision line of the cleft side was displaced outside the nostril. After such an incision, the alar cartilage mobilization and suspension were performed with or without the conchal cartilage graft. All patients used nasal retainers for 6 months after the procedures. So far, satisfactory results have been obtained with the modification of the incision line for open rhinoplasty. This method is unique in designing the incision line, and its procedure is rather simple. The postoperative follow-up period has been 12 to 26 months. A long-term follow-up is still needed, especially in growing children.