Cleft Lip Rhinoplasty Research Articles

The Potter Technique for Cleft Lip Rhinoplasty

The Potter Technique for Cleft Lip Rhinoplasty

Augmentation rhinoplasty in cleft lip nasal deformity: preliminary patients' perspective.

The correction of cleft lip nasal deformity is challenging and there have been numerous methods described in the literature with little demonstrated technical superiority of one over another. The common clinical issues associated with cleft lip nasal deformity are its lack of symmetry, alar collapse on the affected side, obtuse nasal labial angle, short nasal length, loss of tip definition, and altered columella show among others. We carried out augmentation of cleft lip rhinoplasties with rib graft in 16 patients over the one-year study period. Each of these patients was reviewed and given questionnaire before and after surgery to evaluate their response on the outcome to the approach. Preoperatively, nasal asymmetry is the main complaint (14/16, 87.5%) among our series of patients. Postoperatively, 12 (75%) patients out of the 16 reported significant improvement in their nasal symmetry with the other four marginal. All patients reported excellent nasal projection postoperatively with good nasal tip definition. Our series of patients reported overall good satisfaction outcome and will recommend this procedure to other patients with cleft lip nasal deformity. In conclusion, augmentation of cleft lip rhinoplasty can be employed to achieve perceivable and satisfactory outcome in patients with cleft lip nasal deformity.

Update on primary cleft lip rhinoplasty

The optimal timing and techniques utilized to address the nasal deformity of the cleft lip continue to raise challenges and debate for the surgical community. There has been a shift in the paradigm addressing the nasal deformity to a more proactive approach. The goal of this article is to provide an update of the latest techniques for primary cleft rhinoplasty. A medical literature search was performed specifically targeting primary cleft rhinoplasty in order to review the current strategies implemented, including presurgical orthopedics, surgical incisions, reconstruction, and suture techniques. Today primary rhinoplasty is performed widely with many investigators reporting improved esthetic and functional outcomes. Both endonasal and external rhinoplasty approaches have been described for the unilateral and bilateral deformity. Goals include closure of the nasal floor and sill, symmetry of the alar base, and symmetry of the lower lateral cartilages with appropriate projection of the dome. Recent literature supports that rhinoplasty performed at the time of the primary cleft lip closure may reduce the frequency and magnitude of required intermediate and definitive rhinoplasty operations.

Alar Web in Cleft Lip Nose Deformity

The correction of alar webbing in unilateral cleft lip nose deformity is challenging because of progressive distortions in the alar web region during the period of growth. Alar webbing is a persistent universal deformity in both the primary and secondary cleft lip noses. The purpose of this article is to study the alar web deformity in adult patients with unilateral cleft lip noses. Twenty-five patients aged 13 years and older presenting with unilateral cleft nasal deformity were included. Preoperative and postoperative measurements of the nose, along with detailed intraoperative recording of the deformed anatomy, were done. Preoperative magnetic resonance imaging was also done in selected cases. Transcolumellar open rhinoplasty was performed in all the cases, and nasal septal straightening with centralization was done. Cleft alar base augmentation was done using bone graft to restore symmetry of the nasal tripod. Both the cleft and noncleft alar cartilages were extensively mobilized from the skin and mucosal sides. The overgrown and caudally slumped cleft-side alar cartilage was resected caudally and was then resuspended in a symmetrical position with the noncleft alar cartilage. A midline-strut septal cartilage extension graft was used to restore the tip aesthetics. The skin overlying the alar web was in-rolled after semilunar cartilage resection, and skin excision was also done to restore symmetry with the opposite vestibule. The remaining secondary cleft nasal and lip deformities were corrected depending upon the specific presenting pathologic abnormality. The cleft alar cartilage was found to be caudally displaced in all the cases. The caudal border of the lateral crus was prolapsing in the cavity of the vestibule on the superomedial aspect and was tenting the skin in the area of the weak triangle, producing the characteristic alar web deformity. In the study group, the maximum width of the cleft alar cartilage at the level of the lateral crus was increased by approximately 4 mm when compared with the noncleft alar cartilage. The before- and after-rhinoplasty surgery results were objectively assessed using a patient, surgeon, and independent observer survey. The cosmetic result of the nasal tip complex was found to be very good and good (90%), satisfactory (5%), and poor (5%) in patients. The alar web in unilateral cleft lip nose deformity is the result of caudal overgrowth and migration of the alar cartilage. The caudal edge of the prolapsed lateral crus overhangs the cleft-side nasal aperture on its superomedial aspect, producing this deformity. Satisfactory correction of this deformity should envisage caudal resection and repositioning of the dislocated alar cartilage along with caudal resection of the lateral crus with in-rolling of the skin after resection to achieve symmetric results in unilateral cleft lip rhinoplasty.

Cleft Lip and Cleft Rhinoplasty Complications

Complications resulting from cleft lip and cleft rhinoplasty surgery are usually due to errors in surgical planning and technique. The various secondary deformities resulting from cleft lip and cleft rhinoplasty surgeries are reviewed and management options discussed.

High patient satisfaction after secondary rhinoplasty in cleft lip patients

We surveyed the subjective outcome of secondary rhinoplasty in cleft lip patients. Questionnaires were sent to 38 patients who had undergone a secondary rhinoplasty. A total of 30 questionnaires were returned and analyzed. Patients were asked to score their preoperative and postoperative nasal function and form. The validated Rhinoplasty Outcome Evaluation (ROE) questionnaire was supplemented with questions on the subjective burden of the procedure and general satisfaction. In parallel, the objective aesthetic outcome was judged by 2 surgeons using preoperative and postoperative photographs. There was a significant subjective improvement in ROE scores (from 39.3 ± 3.1 to 73.1 ± 2.0, p < 0.001), and in specific scores for nasal aesthetical appearance (from 3.6 ± 0.3 to 7.9 ± 0.2, p < 0.0001) and breathing capacity (from 4.9 ± 0.4 to 6.8 ± 0.3, p < 0.01). Subjective improvement in nasal aesthetics was generally evaluated to be better than improvement in nasal breathing. In retrospect, all patients would undergo the procedure again. Patient satisfaction did not correlate with the surgeon's appreciation of the aesthetic outcome of the rhinoplasty. Patient satisfaction after secondary rhinoplasty in cleft lip patients is high and comparable to that of non-cleft lip rhinoplasty patients.

The Unrecognized Skeletal Components of the Cleft Lip Nose Deformity

Sir: We read with great interest the article entitled “Definitive Repair of the Unilateral Cleft Lip Nasal Deformity” by Dr. Byrd et al. on secondary cleft rhinoplasty.1 They have very correctly identified the two major groups of these patients who have different severities of cleft nose deformities. The pathologic features of cleft nose deformity have been clearly elucidated; however, there remain certain factors that, in our opinion, exert significantly deforming influences on the function, dynamics, and aesthetics of the lower third of the nose. First, the primary repair of the cleft lip must address the nasal septum in addition to the already described operative steps. The nasal septum in this situation is always displaced, especially in its caudal part, and presents in the noncleft vestibule. The body of the septum blocks the cleft vestibule, and the dynamics of this were illustrated in our recent article.2 This deformity can be well appreciated on three-dimensional computed tomographic reconstructions in adult age groups, where the septal deviation and accompanying deformity of the vomerine groove are unmistakable (Fig. 1). In this case, the vomerine groove is significantly skewed from the midline, and a hypertrophied anterior nasal spine is also present. The septal deformity was not corrected during primary surgery, with the resultant full-blown septocolumellar and vomerine deformity becoming apparent in adult life. Clinically, this deformity manifests more on the basal view, especially in the area of the columella, which is malaligned in an oblique direction, with its base deviated to the noncleft side and the tip deviated to the cleft side (Fig. 2).Fig. 1.: A three-dimensional computed tomographic scan of a 24-year-old woman with secondary cleft lip nose deformity. The skeletal components of hypertrophied anterior nasal spine, skewed vomerine groove, and deficient pyriform fossa are noteworthy.Fig. 2.: Clinical photograph of the same patient (basal view) demonstrates the clinical consequence of the uncorrected skeletal components of the right-sided cleft lip nose deformity.Thus, the analysis of any cleft nose deformity at any age must include an inquiry regarding residual septal deformity, physical examination to specifically study the columellar deviation, and a computed tomographic scan to confirm these findings. The operative algorithm must take into account the septocolumellar influences on the tip aesthetics and plan to eliminate them to achieve consistent results. The frontal and lateral postoperative views of Byrd et al.’s patients show a good result regarding nasal cartilage sculpturing and grafting procedures, but the basal view shows deviation of the columellar base toward the noncleft side and tip deviation toward the cleft side along with a deficient cleft side nose sill, although the authors do mention a septal straightening maneuver. This indicates the presence of a residual deviated nasal septum and consequent malaligned septocolumellar infrastructure. The skeletal components of the unilateral cleft lip nose deformity thus include a deficient inferior rim of pyriform fossa, hypertrophied anterior nasal spine, and skewed vomerine groove besides the well-described feature of ipsilateral maxillary hypoplasia. In addition, the nose sill needs to be addressed regarding the muscle and skeletal deficiency and qualifies for a place in the algorithm. The nasal sill is also deficient on the postoperative photographs. Many techniques have been described for augmenting the nose sill, and we have been using a superiorly based turnover orbicularis oris muscle flap for this purpose in addition to performing the other cartilage sculpturing and grafting procedures.3 Our recommendations for cleft lip rhinoplasty would be septoplasty with relocation of the caudal part of the septum, excision of the septospinal ligament, relocation of the anterior nasal spine, and augmentation of the nose sill in addition to the standard maneuvers for reconstructing the cartilage infrastructure of the nose.4,5 Rajiv Agarwal, M.Ch. Department of Plastic Surgery Chhatrapati Shahuji Maharaj Medical University Ramesh Chandra, F.R.C.S. Doctors Clinic Lucknow, India

Alar Base Flap and Suspending Suture: A Strategy to Restore Symmetry to the Nasal Alar Contour in Primary Cleft-Lip Rhinoplasty

Patients presenting with cleft-lip deformity usually present with a characteristic nasal deformity. We describe the mechanism and contribution of different surgical techniques to restore alar symmetry in primary cleft-lip rhinoplasty. We evaluate surgical results using a retrospective, randomized, blinded surgical grading system. We describe a surgical technique designed to restore nasal symmetry in patients undergoing primary cleft-lip rhinoplasty. Patients were selected retrospectively. A series of patients were identified with nasal asymmetry associated with cleft-lip deformity. All patients underwent cleft-lip repair with concurrent primary cleft-lip rhinoplasty. Patients who underwent alar base flap suspending suture (ABF-SS) were grouped and selected consecutively after a modification in the senior author's surgical technique. A control group was matched for age, sex, and cleft characteristics. Primary rhinoplasty was carried out concurrently for both study groups while undergoing unilateral cleft-lip repair. The control group did not undergo the described ABF-SS technique. All patients were operated on by the same surgeon over a period of 5 years. Surgical outcomes were evaluated by a panel including lay people as well as trained health care workers experienced in the critical evaluation of esthetic results after cleft-lip rhinoplasty. Forty-six records were reviewed of patients undergoing complete unilateral cleft-lip repair. After applying strict inclusion/exclusion criteria, nine patients underwent the described ABF-SS technique. All patients in the preoperative group had a clinically and statistically comparable degree of deformity (P > .05). There was a clinical and statistically significant improvement in nostril size, shape, symmetry, alar base symmetry, and nasal tip/dome symmetry for patients undergoing repair with the described technique compared with the control group. No clinical or statistically significant difference was observed in the scarring scores between groups. Patients presenting with cleft-lip deformity usually present with a characteristic nasal deformity. Execution of the described surgical techniques restores nasal alar symmetry in patients undergoing concurrent primary cleft-lip rhinoplasty.

O.029 Modified forked flap for columellar length control in cleft-lip open rhinoplasty

O.029 Modified forked flap for columellar length control in cleft-lip open rhinoplasty

Secondary cleft-lip rhinoplasty utilizing porous high-density polyethylene.

Secondary nasal deformity associated with cleft lip is a difficult surgical task. For more than 100 years, numerous surgical methods have been created to address the structural changes that occur over time after the primary surgery. Although early surgical methods have relied on various rotational flaps and local tissue manipulation, the recent advent of synthetic materials has provided facial plastic surgeons with more tools to correct the structural and supportive deficiencies. In this article, we describe our 10-year experience with porous high-density polyethylene (PHDPE) implants in secondary cleft-lip rhinoplasty. PHDPE implants have been well tolerated and achieved excellent long-term aesthetic results through fibrovascular ingrowth to the surrounding tissue.

The nasal base in cleft lip rhinoplasty.

The discussion on how to correct the nasal base in cleft lip (CL) rhinoplasty focuses on timing of the surgery, the type of approach, and the technique of repositioning the ala. Little attention is paid to the nasal vestibule. We compared the results of two different techniques. Forty-two patients were operated on via an endonasal approach with total mobilization of the lateral crus and fixation after repositioning. An external approach was used in 12 patients and the lateral crus freed as a medially based chondrocutaneous flap. The defect in the lateral vestibule wall was covered with an ear composite graft. The latter group showed more stable results concerning symmetry and breathing. We conclude that in most cases of unilateral CL noses there is not only a malposition and deformity of soft tissues and skin of the ala, but also a deficiency in the surface of inner lining of the nasal vestibule that needs appropriate repair. In general, the numerous procedures for repair of the nasal base in unilateral CL patients can be attributed to three principles based on different philosophies concerning the underlying pathology.

Secondary Cleft Lip Rhinoplasty

[]Without any doubt, rhinoplasty in adults or adolescent patients born with clefts of the lip, combined with clefts of alveolus and palate, is most challenging. In unilateral clefts, the asymmetry of the nasal base is the most striking aesthetic feature. The surgeon is confronted with scars, deformed and displaced cartilages, and abnormal soft tissues, which sometimes seem to resist all attempts to move and hold them in the desired position. Residual or recurrent asymmetries are often attributed to this ``memory-effect.'' The technical procedures to overcome this tendency and correct the nasal deformity are numerous and it is difficult to evaluate their effectiveness.

Nasal Sill Augmentation in Adult Incomplete Cleft Lip Nose Deformity using Superiorly Based Turn Over Orbicularis Oris Muscle Flap: An Anatomic Approach

Adult incomplete cleft lip nose deformity is not uncommon in India. Poverty, ignorance, and parental neglect account for its late presentation. Besides the classical features of cleft lip nose deformity, the constant findings observed in this patient population have been a widened and depressed nasal sill. This is attributable to the sparse, hypoplastic, and abnormally orientated orbicularis oris muscle in the region of the sill. Failure to restore the nasal sill symmetry by suitably augmenting the sill frequently leads to unsatisfactory and asymmetric results. However, in the literature, satisfactory restoration of the nasal sill has not been given the importance it deserves while performing cleft lip rhinoplasty. We present a method of augmenting the depressed nasal sill in cases of adult incomplete nose deformity using a superiorly based orbicularis oris muscle flap, which is harvested from the soft tissues between the apex of the cleft and the nostril sill. Following de-epithelialization of the overlying skin, the exposed muscle is raised as a superiorly based flap after dissecting it from the underlying mucosa. It is folded, turned over, and tucked into the nasal sill base and anchored to the anterior nasal spine to give the desired augmentation. Satisfactory results have been obtained in 18 cases of nasal deformity associated with incomplete cleft lip. In our opinion, this technique offers a simple and effective method of augmenting the depressed sill by utilizing locally available tissues and without the need for procuring autologous tissue from distant sites.

Cleft Lip Rhinoplasty

Cleft lip rhinoplasty may be performed as an endonasal or an open rhinoplasty procedure. It is helpful for the rhinoplasty surgeon to know the type of lip closure and the extent of nasal surgery performed at the time of primary lip repair. Current methods of primary lip repair attempt to create an esthetic lip scar and leave a minimal degree of nasal tip deformity to allow the child to avoid secondary lip and nasal tip surgery at the preschool age. Single cleft lip rhinoplasty has to deal more with asymmetry than double cleft lip rhinoplasty. The double cleft lip deformity has to deal with a true deficiency in the columella and the possible need for lip augmentation. Closure of the alveolar cleft and the cleft palate in both types of cleft lip and palate often creates scar tissue that retards maxillary growth and introduces the need for cephalometric analysis and possible orthognathic surgery.

Facial Plastic and Reconstructive Surgery

I. Principles of Facial Plastic and Reconstructive Surgery: Anatomy and Physiology of the Skin Wound Healing Soft Tissue Techniques Skin Grafts and Flaps Scar Revision Synthetic Implants Biologic Tissue Implants Lasers in Facial Plastic Surgery Aesthetic Facial Proportions Computer Imaging in Facial Plastic Surgery Photography in Facial Plastic Surgery Ethics in Facial Plastic Surgery. II. Aesthetic Facial Surgery: Aesthetic Facial Analysis Anesthesia for Facial Plastic Surgery Rhytidectomy Surgical Treatment of the Forehead, Brow, and Midface Upper Eyelid Blepharoplasty Lower Eyelid Blepharoplasty Lipectomy of the Face, Head, and Neck Dermabrasion and Chemical Peel Laser Facial Resurfacing Injectable and Implantable Materials for Facial Wrinkles Aesthetic Facial Skeletal Implants Aesthetic Facial Implants Hair Replacement Techniques Otoplasty The Asian Face in Facial Plastic Surgery Aesthetic Surgery of the Lip Aesthetic Dentistry. III. Functional and Aesthetic Surgery of the Nose: Analysis in Rhinoplasty Philosophy and Principles of Rhinoplasty External Rhinoplasty Approach Management of the Bony Nasal Vault Management of the Middle Vault Surgery of the Nasal Tip: Intranasal Approach Surgery of the Nasal Tip: Vertical Dome Division Secondary Rhinoplasty Complications of Rhinoplasty Nasal Septal Surgery Management of Nasal Septal Perforations. IV. Reconstructive Surgery of the Face and Neck: Cutaneous Malignancies Grafts and Minimally Invasive Options for Cutaneous Reconstruction Local Cutaneous Flaps Tissue Expansion Musculocutaneous Flaps Microvascular Flaps Mandible Reconstruction Major Nasal Reconstruction Auricular Reconstruction and Temporoparietal Flaps Lip Reconstruction Periocular Reconstruction Management and Reanimation of the Paralyzed Face. V. Trauma: Soft Tissue Injuries of the Face Fundamentals of Bone Healing and Stabilization Bone Plating Systems Clinical Applications of Bone Plating Systems to Facial Fractures Treatment of Orbitozygomatic Fractures Nasal, Frontal Sinus, and Nasorbitoethmoid Complex Fractures Le Fort Fractures (Maxillary Fractures) Mandibular Fractures. VI. Congenital and Pediatric Facial Plastic Surgery: Embryology of the Face, Head, and Neck Craniomaxillofacial Deformities Microtia Reconstruction Cleft Lip and Palate Cleft Lip Rhinoplasty Orthognathic Surgery Hemifacial Microsomia Velopharyngeal Incompetence.

Cleft Lip Rhinoplasty: The Role of Bone and Cartilage Grafts

Correction of the cleft lip nasal deformity involves repositioning of the lower lateral cartilage on the cleft side to raise the dome, lengthening the columella and bringing it toward the midline, and correcting any asymmetries of the nasal floor. Additional structural support in the form of bone or cartilage grafts is often required in order to achieve the desired projection and angularity. Our experience with these grafts in a large number of patients over the past 20 years has shown them to produce good, predictable results that are long lasting, with minimum donor site morbidity. Long-term follow-up indicates that these grafts maintain their volume and original features, resulting in satisfaction among our patients.

Secondary cleft lip rhinoplasty: an external approach.

Secondary cleft lip rhinoplasty: an external approach.