Bilateral Cleft Lip Nasal Deformity Research Articles

Inverted V-Y and fibrofatty Flap technique for columellar lengthening and tip augmentation in adults post bilateral cleft lip nasal deformity

Inverted V-Y and fibrofatty Flap technique for columellar lengthening and tip augmentation in adults post bilateral cleft lip nasal deformity

Correction of a Secondary Bilateral Cleft Lip Nasal Deformity in Adults Using Repositioning of Both Lower Lateral Cartilages and Nasal Tip Plasty Through an Open Bilateral Reverse-U Incision.

Correcting a secondary bilateral cleft lip nasal deformity is very complex with many challenges due to its complexity. This study presents the surgical results after correcting a secondary bilateral cleft lip nasal deformity using isolation and repositioning of the lower lateral cartilages, the columellar strut, and an onlay graft on the nasal tip. Eighteen patients who had bilateral cleft lip nasal deformities and who had surgery performed between September 2013 and December 2019 were included in this study. The age of the patients ranged between 19 and 52 years. Open rhinoplasty with bilateral reverse-U incision was performed. The lower lateral cartilages were isolated and repositioned. Nasal tip support is provided using a columellar strut with a septal cartilage or Medpor strut. In the vertical component of the nasal tip, a conchal cartilage graft was used. The mean follow-up period was 2 years (ranging from 1 to 6 years). Fourteen of the 18 patients underwent photogrammetric evaluation. After surgery, the projection of the nasal tip and angle increased, but nasal bridge length decreased. The columella-labial angle significantly increased by 10.1% after surgery which was statistically significant (P < 0.05). The angle between the nostril axes significantly decreased by 46.2% postoperatively and also reached statistical significance (P < 0.05), indicating that the displaced alar base and lower nostril sill improved and the major axis of the nostril changed more vertically oblique. All patients were pleased with their surgical results. The proposed technique was highly effective in correcting secondary bilateral cleft lip nasal deformities in adults.

Surgical Nasoalveolar Molding: A Rational Treatment for Bilateral Cleft Lip Nose and Systematic Review.

Background:The purpose of this study was to evaluate the surgical outcome after using primary surgery to address bilateral cleft lip nose and palate deformities. In addition, the authors performed a systematic review to evaluate the effects of the nasoalveolar molding on non-syndromic bilateral cleft lip and palate.Methods:A prospective cohort study on a surgeon’s surgical outcome of 25 consecutively performed primary bilateral cleft lip nasal deformity repairs was conducted and a systematic review of the literature for studies published until December 2019 was done to evaluate the effect of presurgical NAM on nasolabial aesthetics and alveolar gap.Results:Since 2014, 25 consecutive patients with complete bilateral cleft have undergone primary anatomical repair of the cleft nasal deformity using primary cheilorhinoplasty. The average columella length was 4.3 ± 1.3 mm. The average ratio of the columella height to nasal height was 0.48 mm 1 year postoperatively and 0.52 mm 5 years postoperatively. Statistically significant differences have been observed between the pre and postoperative alveolar and palatal gaps after using primary cheiloplasty or bilateral lip adhesion. After systematic literature searching, 14 identified studies were qualified for the final analysis, which included 433 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.Conclusions:The results of this study suggest that the proposed primary cheilorhinoplasty is a good alternative to improve nose appearance and alveolar gap in patients with primary bilateral cleft lip nose and palate deformity. Based on the available scientific evidence, definitive conclusions about the effectiveness of presurgical Naso Alveolar Molding on nasolabial aesthetics cannot be drawn. Quality of the included articles were too low to make a conclusion.

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

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. Retrospective comparative cross-sectional study. Tertiary pediatric academic institution. One hundred and twelve patients with BCLP and an equal number of age and sex-matched control participants. 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. 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. 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

ObjectivesThe 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. MethodsThe 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. ResultsLong 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. ConclusionThe 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.

Clinical treatment of nostril stenosis deformities secondary to bilateral cleft lip nasal correction

Objective This article reported a patient with severe bilateral nostril stenosis secondary to bilateral cleft lip nasal deformity correction surgery. Methods The surgical procedure included columellar flap and local soft tissue flap was transferred to nasal inside, columellar was narrowed, reconstruction of nasal dome, increased nostrils height and nasal vestibular mucosa area. Results Effective improvement of nasal profile and reduction of ventilation features obstacles was observed. Nasal retainer was used for half a year postoperatively. After two years＇ follow-up, it showed good results. Conclusions This article is to introduce the therapeutic process and detailed literature review of clinical study of nostril stenosis abnormalities. Key words: Cleft lip; Cleft palate; Congenital abnormalities; Bilateral complete cleft lip and palate; Nostril stenosis; Local flaps

Cleft Rhinoplasty Study and Evolution.

Most patients with a cleft lip will have a cleft lip nasal deformity. The nasal deformities are complex and are difficult to surgically correct as a result of the anatomical issues and deficiencies. In this study, the authors analyzed and reviewed nasal pathology and surgical maneuvers in patients with cleft lip nasal deformity treated by the senior author over the past 15 years. A retrospective review was performed on patients who underwent a rhinoplasty for a cleft nasal deformity from the years of 2002 to 2017. Patients were stratified by unilateral and bilateral cleft lip. For each variable, comparisons were made between unilateral and bilateral cases. 39 patients had a unilateral cleft lip nasal deformity, while 17 had a bilateral cleft lip nasal deformity. Patients with a unilateral cleft nasal deformity had a significantly higher incidence of vestibular stenosis and septal deviation. Regarding surgical maneuvers, unilateral cleft lip patients had a relatively higher utilization of septoplasty, spreader grafts, and alar grafts compared to bilateral cleft lip patients. Bilateral cleft lip patients had a relatively higher utilization of dorsal hump reduction, columella strut grafts, and nasal tip grafts. These differences were not statistically significant. Unilateral cleft lip patients had a statistically significant higher use of alveolar support at the time of rhinoplasty. The rhinoplasty operation in patients with cleft lip nasal deformity is uniquely challenging and rewarding. This operation has undergone an evolution in our own practice and has led to improved outcomes for these patients.

Simultaneous reconstruction of columella and philtrum using prolabial flap combined with Abbe flap in secondary bilateral cleft lip and nasal deformity

Open rhinoplasty and Abbe flap techniques are traditionally useful tools for the reconstruction of secondary bilateral cleft lip nasal (BCLN) deformity. We aimed to investigate the long-term outcomes of simultaneous columella and philtrum reconstruction using prolabial flap combined with Abbe flap in secondary BCLN deformity.From January 2009 to July 2014, 26 patients (17 males and 9 females; mean age 21 years) with secondary BCLN deformity were recruited. All patients had severe short columella and philtrum deficiency. The whole superiorly based prolabial flap was harvested and trimmed for columella reconstruction. An Abbe flap from the central lower lip was elevated to reconstruct the esthetic philtral unit. No flap necrosis occurred postoperatively. The average follow-up was 2.7 years. The columella length was 4.7 ± 1.3 mm preoperatively and 10.4 ± 2.1 mm postoperatively. The philtrum length increased to 14.4 ± 2.6 mm postoperatively from a preoperative 8.9 ± 2.4 mm. Regarding the overall impression of the reconstruction, 22 patients ranked it as very good or good.In secondary BCLN deformity, the prolabial flap combined with Abbe flap technique is an effective alternative for the treatment of severe short columella complicated with severe philtrum deficiency.

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

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. 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.

Lengthening the columella of severe secondary bilateral cleft lip nasal deformity by using skin cartilaginous tissue flaps on superior border of bilateral nostril

Objective To introduce the method of lengthening the columella of severe secondary bilateral cleft lip nasal deformity by using skin cartilaginous tissue flaps on the superior border of bilateral nostril. Methods We adopted the method of using the skin cartilaginous tissue flaps on the superior border of bilateral nostril associated with alar cartilages reduction to lengthen the columella in 40 patients with severe secondary bilateral cleft lip nasal deformity. All patients were followed up for 5-28 months, with an average period of 15.3 months. The treatment outcomes were evaluated by a questionnaire in postoperative follow-up. Results All the 40 patients had achieved satisfactory lengthening of columella and there were no major complications. The questionnaire results showed 36 patients with excellent and 4 patients with good. Conclusions Lengthening the columella of severe secondary bilateral cleft lip nasal deformity by using skin cartilaginous tissue flaps on the superior border of bilateral nostril is a relatively simple and safe method with good effect. Key words: Bilateral cleft lip; Nasal deformity; Nasal columella; Alar cartilage

Evaluation of the results of simultaneous open rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity

We aimed to evaluate the results of simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity by means of a newly developed software-based method. A total of 16 patients with the bilateral cleft lip nasal deformity received Abbe flap and simultaneous open rhinoplasty between 2004 and 2010. The mean age of the patients was 21 years, and the average follow-up time was 2.4 years. After the open rhinoplasty procedure, the upper lip was reconstructed with the Abbe flap. Preoperative and postoperative photographs that had been taken laterally were evaluated by using Adobe Photoshop(®) CS4 and Adobe InDesign(®) software. The length of the columella and the relative changes of the most anterior point of the upper lip to the vertical plane tangent to the most anterior point of the lower lip were measured in pixels on standardized preoperative and postoperative images. The differences were calculated and compared as a percentage (%). There was no flap loss and associated problems. The measurements of columellar length revealed an average increase of 51.8±11.3%, while the relative change of the most anterior point of the upper lip revealed an average increase of 68.6±11.2%. The results of the treatment modality were successfully evaluated by a newly developed software-based method.

Evidence-based medicine: The cleft lip nasal deformity.

After studying this article, the participant should be able to: (1) Describe the components of unilateral and bilateral secondary cleft lip nasal deformity. (2) Discuss current methods of assessing the deformity and outcomes. (3) Discuss primary treatment options including the use of preoperative orthopedics, nasal molding techniques, and the primary cleft rhinoplasty. (4) Design a treatment plan for cleft patients that will optimize the outcome of nasal appearance and function. (5) Discuss the evidence regarding outcomes of current practices, and describe areas where more research is needed. This is the third Maintenance of Certification article on the secondary cleft lip nose deformity. In the first article, Guyuron defined the deformities and described techniques for the definitive (adult) rhinoplasty. The second article, by Zbar and Canady, presented evidence regarding the assessment, surgical treatment, and outcomes from the literature published between 1999 and 2009. In this article, the authors summarize important points from the first two articles and then concentrate on the evidence for the following topics: (1) methods currently used in evaluating the severity of the deformities; (2) methods used in evaluating outcomes of different treatments; (3) benefits of rhinoplasty performed at the time of the lip repair and evidence for the effect of rhinoplasties performed after infancy but before maturity; (4) presurgical orthopedics and nasoalveolar molding; (5) common surgical techniques used in primary cleft rhinoplasties; and (6) impact of the nasal deformity on quality of life. Overall, there is little high-level evidence regarding the outcomes of cleft nasal deformity treatment, leaving much room for future study.

Conchal Cartilage Graft for Correction of Bilateral Cleft Lip Nasal Deformities during Childhood.

Background:Various methods for primary repair of bilateral cleft lip have been developed, but they often produce inadequate results, such as an upturned nose or a short columella. We perform primary lip repair with muscle reconstruction to correct depression of the nasal floor and inferoposterior displacement of the alar base. Then, open rhinoplasty to project the nasal tip is performed during childhood. This article describes the methods and results of open rhinoplasty for bilateral cleft lip patients.Methods:Open rhinoplasty with a modified forked flap is performed. The harvested conchal cartilage is grafted as a strut to strengthen and extend the septum. The lower lateral cartilages are sutured to the grafted cartilage and fixed in the correct position. Before skin closure, the tips of the 2 V flaps of the forked flap and the reverse V-flap between the forked flap are trimmed. Three trapezoidal flaps are sutured to the base of the columella. Thirty patients with bilateral cleft lip nasal deformities have undergone surgery. The operative results of 15 of 30 patients were evaluated photogrammetrically.Results:The nose was refined and more projected. The nasolabial angle and the nasal tip projection were improved. The reformed configuration was well maintained for many years. Photogrammetric analysis demonstrated increases in both the nasal height-to-width ratio and the nostril height-to-width ratio and a decrease in the nasolabial angle.Conclusions:Open rhinoplasty during childhood using 3 trapezoidal flaps and conchal cartilage graft improves bilateral cleft lip nasal deformities effectively.

Correction of Cleft Lip Nose Deformity With Rib Cartilage

Correction of cleft lip nasal deformities (CLND) is often unsatisfactory because of problems resulting from cartilage weakness and strong soft tissue forces. Therefore, strong cartilaginous support, such as rib cartilage, is mandatory. The authors describe placement of rib cartilage grafts to create a more symmetric and aesthetically acceptable repair of CLND with improved nasal air flow. Two groups of patients, including those with unilateral and bilateral CLND, underwent operations with different sources of autologous cartilage. Group 1 received grafts from the septum and ear, whereas group 2 received grafts from the septum and ribs. Results were evaluated by 2 independent physicians who rated improvement between pre- and postoperative photographs. There were significant differences in postoperative improvement between patients who received septal/ear cartilage grafts and those who received septal/rib cartilage grafts in both unilateral and bilateral cases (P = .028 and P = .043, respectively). The authors' results demonstrate that rib cartilage has a positive effect on the aesthetic outcome of CLND operations and provides a strong support structure for correcting this deformity with minimal postoperative complications.

The Combination of Modified Small Forked Flap and Tajima Incision in the Reconstruction of Bilateral Cleft Lip Nasal Deformities

The Combination of Modified Small Forked Flap and Tajima Incision in the Reconstruction of Bilateral Cleft Lip Nasal Deformities

The Correction of a Secondary Bilateral Cleft Lip Nasal Deformity Using Refined Open Rhinoplasty with Reverse-U Incision, V-Y Plasty, and Selective Combination with Composite Grafting: Long-term Results

BackgroundThis article presents long-term outcomes after correcting secondary bilateral cleft lip nasal deformities using a refined reverse-U incision and V-Y plasty or in combination with a composite graft in order to elongate the short columella.MethodsA total of forty-six patients underwent surgery between September 1996 and December 2008. The age of the patients ranged from 3 to 19 years of age. A bilateral reverse-U incision and V-Y plasty were used in 24 patients. A composite graft from the helical root was combined with a bilateral reverse-U incision in the 22 patients who possessed a severely shortened columella. The follow-up period ranged between 2 and 10 years.ResultsA total of 32 patients out of 46 were evaluated postoperatively. The average columella length was significantly improved from an average of 3.7 mm preoperatively to 8.5 mm postoperatively. The average ratio of the columella height to the alar base width was 0.18 preoperatively and 0.29 postoperatively. The postoperative basal and lateral views revealed a better shape of the nostrils and columella. The elongated columella, combined with a composite graft, presented good maintenance of the corrected position with no growth disturbance. A composite graft showed color mismatching in several patients. Twenty-six patients demonstrated no alar-columella web deformity and satisfactory symmetry of the nostrils. Four patients experienced a drooping and overhanging of the corrected alar-columella web.ConclusionsA bilateral reverse-U incision with V-Y plasty or in combination with a composite graft was effective in correcting secondary bilateral cleft lip nasal deformity.

Primary Repair of the Bilateral Cleft Lip Nose: A Long-Term Follow-Up

The author previously published a method of primary repair of bilateral cleft lip nasal deformity using an open tip rhinoplasty to enable correction of the displaced and deformed alar cartilages. The first 10 consecutive children who had this treatment have been followed through to adulthood. They are now 18 to 19 years old, and the long-term results of this primary nasal repair are reviewed. In general, the repair has been effective and stable. There has been no interference with growth. In most cases, the external nasal scars are barely noticeable. In primary treatment of the bilateral cleft lip nose, an open tip rhinoplasty enables accurate replacement of the alar cartilages and correction of the deformity. It justifies the creation of an external scar that is usually unnoticeable.

A New Modified Forked Flap With Subcutaneous Pedicles for Adult Cases of Bilateral Cleft Lip Nasal Deformity

In adult cases of bilateral cleft lip nasal deformity, an esthetically satisfying result can not be obtained only by manipulation inside the nose with the nasal tip pointing upward. The nasal tip should be made in a more anterior direction for nasal esthetic improvement. Additional tissue beyond the nose is needed, and the forked flap is a useful method in such cases. However, the blood circulation of long and narrow flaps containing the scar, especially after open rhinoplasty, is unstable. We have developed a new long and narrow forked flap that has a more stable blood circulation. The forked flap was made using two subcutaneous pedicles attached to the periphery of the each flap. We applied this flap to five adult cases of bilateral cleft lip nasal deformity. Four of the cases had the scar associated with the flying bird incision, and one case required no treatment after the primary repair. All the flaps took without signs of partial necrosis. In all cases, the nasal tip was projected forward with adequate columella elongation, and the profile was esthetically improved. In the final stage of correction for adult cases of bilateral cleft lip nasal deformity, this method, making maximum use of the tissue containing the scar in not only the white lip but also the vermilion, is very effective. It is very important to obtain nasal esthetic improvement for the adult patient with bilateral cleft lip nasal deformity.

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

Anatomical abnormalities and heterogeneous tissue deficiencies of the bilateral cleft lip nasal deformity challenges the cranio-maxillofacial plastic surgeon to create a functional, yet aesthetically pleasing nose. The authors propose a comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using composite conchal grafts. Five children with bilateral cleft lip nasal deformities had nasal reconstruction using conchal composite grafts, averaging 5 years in age at time of surgery. Patient follow-up averaged 21 months. An open tip rhinoplasty was performed using a 'V' shaped columellar incision. The conchal composite graft was obtained from the lateral aspect of the ear and was used to reconstruct the lateral alar mucosal defects. Conchal cartilage was used as a columellar strut. The columellar skin was closed in a 'V-Y' fashion, giving greater columellar length. Visual inspection confirmed that the cleft lip nasal deformity was improved in all patients. There were no postoperative complications. All patients had complete composite graft take with minimal donor site morbidity and deformity. This comprehensive rhinoplasty technique improves the abnormalities found in bilateral cleft lip nasal deformity by using the successful aspects of other methods and introducing the composite conchal graft.

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited.

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.