Bilateral Cleft Nasal Deformity Research Articles

Three-dimensional Anthropometric Analysis of Racial and Ethnic Differences in Unilateral and Bilateral Cleft Nasal Deformity.

This study used three-dimensional measurements to provide a nasolabial analysis of patients with unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and controls across different races and ethnicities. A retrospective comparative study. Tertiary care pediatric institution. The study included 90 patients with UCLP, 43 patients with BCLP, and 90 matched controls. Patients are separated as self-identified Caucasian, Hispanic, or African American. Nasal length, nasal protrusion, columellar height, columellar width, tip width, alar width, alar base width, nasolabial angle, upper lip length, philtrum length, nostril height, and nostril width. All UCLP groups had significantly greater columella and tip widths and decreased nasolabial angles than controls. All BCLP groups had significantly greater columella width, tip width, nasolabial angle, and nostril widths. Upper lip length, philtrum length, and nostril height were significantly decreased in BCLP compared to controls. Across UCLP groups, African Americans had significantly decreased nasal protrusion and columella height and a significantly increased columella width compared to Caucasians and Hispanics. Alar and alar base widths were significantly different between all groups. Across BCLP groups, the Caucasian nostril width was significantly less than the African Americans. These findings suggest that when correcting nasolabial characteristics in patients with cleft lip, it is important to consider racial and ethnic differences to achieve a normal appearance. Specifically, goals for alar width, alar base width, nasal tip, and projection should be tailored to the patient's race and ethnicity.

3D Infant Orthopedic Nasal Molding System for Improved Outcomes in Cleft Nasal Deformity

The cleft nasal deformity is a hallmark feature in infants with cleft lip and palate and includes deviation of the caudal septum, slumping of the ipsilateral lower lateral cartilage, and obstructed nasal breathing. Presurgical orthopedic protocols have been developed and refined over several decades now, with limited evidence supporting their long-term efficacy, particularly with respect to the nasal form. Some limitations relate to variabilities in studies and data outcome measures. We have designed a novel method of presurgical orthopedic molding using separate nasal and intraoral components. The independent nasal device, called the Rhinoplastic Appliance System, is introduced in this technique article and shown to have distinct biomechanical advantages for the unilateral and bilateral cleft nasal deformity, both presurgically before lip repair, and postsurgically for nostril maintenance. As with CAD/CAM technologies for the intraoral plate component of traditional NAMs, we believe digital preparation of RAS devices, combined with separate oral appliances, can allow for more effective and reproducible presurgical infant cleft molding with less operator dependence and family/patient burden.

Three-Dimensional Anthropometric Analysis of Racial and Ethnic Differences in Unilateral and Bilateral Cleft Nasal Deformity

BACKGROUND: Prior studies have demonstrated variation in nasolabial indices across racial and ethnic groups. Anthropometric data on the racial and ethnic differences in the cleft nasal deformity at the age for definitive rhinoplasty can provide a foundation for operative planning. This study used three-dimensional stereophotogrammetry measurements to provide a comprehensive nasolabial analysis of patients with unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and controls across multiple races and ethnicities. METHODS: A retrospective review of three-dimensional images of patients with UCLP and BCLP captured before orthognathic surgery or definitive cleft rhinoplasty was performed. The patients were separated by self-reported identifiers as Caucasian, Hispanic, or African American. Twelve measurements (millimeters) were collected: dorsum length, nasal protrusion, columellar height, columellar width, tip width, alar width, alar base width, nasolabial angle, upper lip length, philtrum length, nostril height, and nostril width. An equal number of age, sex, race, and ethnicity matched control patients were analyzed. Two-sample t tests were performed (P < 0.05). RESULTS: Total patients included 90 UCLP, 43 BCLP, and 90 controls. UCLP Caucasians, Hispanics, and African Americans similarly had significantly greater columellar width and tip width and lesser nasolabial angle than respective controls. Caucasian UCLP alar width (33.66 ± 3.12) and alar base width (33.66 ± 3.51) were significantly greater than matched controls (31.21 ± 2.54; 31.33 ± 2.18). Hispanic UCLP alar width (37.52 ± 3.46) and alar base width (36.77 ± 2.81) were significantly greater than matched controls (35.00 ± 3.20; 35.13 ± 3.08). African American UCLP alar width (41.63 ± 3.43) and alar base width (41.93 ± 3.78) were not significantly different from matched controls (39.17 ± 3.35; 40.56 ± 3.97). BCLP Caucasians, Hispanics, and African Americans similarly had significantly greater columellar width and tip width than respective controls. Caucasian BCLP alar width (37.66 ± 0.77), alar base width (38.06 ± 0.65), and nostril width (12.54 ± 1.68) were significantly greater than matched controls (31.21 ± 2.54, 31.33 ± 2.18, 10.34 ± 1.01). Hispanic BCLP alar width (38.75 ± 3.79), alar base width (38.73 ± 3.35), and nostril width (13.23 ± 2.13) were significantly greater than matched controls (35.00 ± 3.20; 35.13 ± 3.08; 11.92 ± 2.13). African American BCLP alar width (40.88 ± 3.92), alar base width (40.56 ± 3.97), and nostril width (13.01 ± 2.07) were not significantly different from matched controls (39.17 ± 3.35; 40.56 ± 3.97; 14.00 ± 1.45). Across UCLP groups the African American group had significantly less nasal protrusion (17.84 ± 1.38) and columellar height (8.96 ± 0.85) and significantly greater columellar width (9.56 ± 1.58) than Caucasians (20.18 ± 1.93, 10.57 ± 1.45, 8.48 ± 1.07), and Hispanics (21.14 ± 2.12, 10.83 ± 1.96, 8.26 ± 1.51). Caucasian alar width (33.66 ± 3.12), alar base width (33.66 ± 3.51), and affected nostril width (10.80 ± 1.51) were significantly lesser than Hispanics (37.52 ± 3.46, 36.77 ± 2.81, 12.04 ± 2.28) and the same measures in both Caucasians and Hispanics were significantly lesser than African Americans (41.63 ± 3.43, 41.93 ± 3.78, 13.96 ± 2.43). Across BCLP groups, there were no significant difference in measurements. CONCLUSIONS: The UCLP deformity differs between groups in alar width and alar base width. African Americans further differ in nasal protrusion, columellar height, and columellar width. The BCLP deformity does not differ between groups. The findings demonstrate that when correcting alar width, alar base width, tip refinement, and projection racially and ethnically congruent goals should be used to better approximate normal appearance.

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.

Secondary Cleft Rhinoplasty

The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a formidable challenge for the facial plastic surgeon. The underlying anatomic deformities combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult procedure for even the most experienced surgeons. Numerous techniques for secondary cleft rhinoplasty have been described in the literature over the past several decades, yet the lack of wide adoption of any given technique highlights the great variability seen with this problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or webbing have driven the progressive evolution of techniques developed to correct various aspects of the cleft nasal deformity. Despite the number of techniques that have been published, very few studies have looked specifically at outcomes in secondary cleft rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty.

Columella Lengthening in Bilateral Cleft Lip Nasal Deformity-Comparison of Five Different Methods

Background: Patients with bilateral cleft lip often have nasal deformity. Controversy regarding primary versus secondary columella lengthening in terms of cosmetic outcome remain unsolved. Furthermore, there are few comparative studies to evaluate different methods for secondary columella lengthening. Aim and Objectives: The purpose of the study is to compare 5 different columella lengthening surgery (primary columella lengthening using island C-flap, the forked-flap method, composite graft, the Cronin's method, and open-tip V-Y rhinoplasty) in terms of the aesthetic result and revision rate. Materials and method: Within a period of 20 years, we retrospectively reviewed 146 patients with bilateral cleft nasal deformity undergoing columella lengthening surgery using one of the five above-mentioned techniques. The minimum follow-up period was 6 months and the patient age at final evaluation ranged from 4 years 8 months to 30 years. Aesthetic outcome was evaluated using 3 point scoring system as follows: 3 points indicating good result, 2 points indicating average result and 1 point indicating poor result. Thirty eight of all patients underwent repeated revisions; the primary aesthetic results of the 108 patients without revisions and the final aesthetic results of all 146 patients were recorded and mean scores were obtained for statistic analyses. Results: For aesthetic results, there was statistical significance among groups; the composite graft group had the worst aesthetic result with a mean score of 1.69 and open-tip V-Y rhinoplasty yielded the best results with a mean aesthetic score of 2.60. The rate of repeated revisions ranged from 5% (open-tip) to 52% (primary columella lengthening using island C-flap). For final aesthetic results, there was also statistical significance among groups; open-tip V-Y rhinoplasty was also superior in final aesthetic results (mean score=2.62) Conclusions: Because of its high revision rate, island C-flap primary columella lengthening is not recommended as a routine procedure for patients with bilateral cleft lip. As for the four secondary columella lengthening techniques used in our patients, open-tip rhinoplasty achieves best aesthetic result, has lowest rate of revision and should be considered as the option of choice.

Improved Nasal Tip Projection in the Treatment of Bilateral Cleft Nasal Deformity

The cleft nose deformity in bilateral cleft lip and palate patients with severely flattened alar cartilages, a short, scarred columella, and thickened skin is a reconstructive challenge. The Wolfe double-arch tip rhinoplasty technique was compared with a cartilage release and tip grafting technique to determine the optimal modality for tip projection and columella lengthening. Patients with significant bilateral cleft nasal deformities and previous bilateral cleft lip repairs were divided into two groups (n = 22). Group 1 (double-arch) patients underwent an open rhinoplasty using conchal cartilage grafts to create a columellar strut and new lower lateral arches placed over the existing arches (n = 12). In group 2 (release and tip graft), the lower lateral cartilages were released, and nasal tip grafting was performed (n = 10). Preoperative and 6-month postoperative measurements, including (1) columellar length, (2) alar base-nasal tip-columellar base (ATC) angle, and (3) lateral tip projection, were compared. The lateral tip projection is the perpendicular distance between the nasal tip and a line created from the connection of points at the nasion to the subnasale. In group 1 (double arch), the mean columella length increased 47.2%, whereas in group 2 (release and tip graft), it only increased 14.1%. The ATC angle had a mean decrease or narrowing of 26.7 degrees in group 1, compared with a 12.5 degrees decrease in group 2. Lateral tip projection improvement was greater in group 1 (52.2% increase) compared with group 2 (19.9% increase). The authors' data showed that for the difficult bilateral cleft nasal deformity with significant tip flattening, the double-arch tip rhinoplasty provides improved nasal tip projection.

Correction of the cleft-lip nasal deformity.

Correction of the cleft-lip nasal deformity is a difficult task that requires a clear understanding of the associated complex anatomic abnormalities. These deformities tend to accentuate as nasal growth continues. Primary tip rhinoplasty in the unilateral deformity improves nasal tip symmetry and decreases the need for intermediate surgery. Intermediate rhinoplasty in the bilateral deformity is performed when nasal tip projection is markedly diminished. In both the unilateral and bilateral deformity, definitive rhinoplasty utilizing the open-structure rhinoplasty approach allows maximum exposure for placement of structural grafts to improve tip projection, definition, support, and function. In this article, the pathologic anatomy of the unilateral and bilateral cleft nasal deformity is described. The philosophy and timing of repair are discussed. Finally, the techniques used by the authors to address both the aesthetic and functional problems are outlined.

Primary Nasoplasty In Unilateral And Bilateral Cleft Nasal Deformity

A six-step nasoplasty for the primary correction of the unilateral and bilateral cleft nasal deformity is presented. A review of the evolution of primary nasal reconstruction and preliminary results of the method are described and illustrated.

Correction of the bilateral cleft lip nasal deformity: evolution of a surgical concept.

The origin of the nasal deformity of a bilateral complete cleft lip is both primary (deformation/malformation) and secondary (postoperative distortion). This is an interim report of a personal evolution from staged correction of the bilateral cleft nasal deformity to synchronous repair of the nose and the lip and premaxillary-maxillary clefts. The anatomic concept is that, because of the malpositioned alar cartilages, the columella only appears to be short in an infant with bilateral cleft lip. The technical stratagems to model the nose are: (1) alignment of the premaxilla and (2) anatomic placement of the alar cartilages with sculpturing of the overlying soft tissue.