Cleft Side Research Articles

Comparison of dental outcomes in patients with nonsyndromic complete unilateral cleft lip and palate who receive secondary alveolar bone grafting before or after emergence of the permanent maxillary canine

For patients with complete unilateralcleft lip and palate (CUCLP), secondary alveolar bone grafting (SABG) can be performed before or after the emergence of the cleft side permanent canine (pre-CE and post-CE, respectively). The controversy regarding dental outcomes related to the timing of SABG remains unsettled. The objective of this study was to evaluate dental survival and specific dental outcomes of cleft-adjacent teeth in children with CUCLP who received either pre-CE or post-CE SABG. The permanent maxillary canines and the central and lateral incisors of 21 pre-CE and 23 post-CE SABG subjects with nonsyndromic CUCLP and all cleft-related surgeries performed by the same surgeon were analyzed retrospectively. Intraoral radiographs and clinical chart notes were collected at age 7years, at the time of the SABG, and approximately 4years after the grafting. Dental survival, spontaneous canine eruption, planned prosthetic replacement, root development, and root resorption were analyzed. Dental outcomes on the noncleft side were better than those on the cleft side. On the cleft side, dental survival of the cleft-adjacent teeth was not significantly different between the pre-CE and post-CE SABG groups (P>0.05). Most teeth completed root development after grafting, and the cleft side canine root development in the pre-CE SABG group appeared to accelerate after SABG. Trends showed that the pre-CE SABG group suffered less root resorption (16.28%; post-CE: 22.73%; P>0.05) and received fewer planned prosthetic replacements (14.29%; post-CE: 26.01%; P>0.05) but required a greater number of canine exposures (33.33%; post-CE: 4.55%; P=0.02). Pre-CE SABG showed better dental outcomes in patients with CUCLP, with fewer adverse dental outcomes than post-CE SABG.

The Effect of Autologous Alveolar Bone Grafting on Nasolabial Asymmetry in Unilateral Cleft Lip and Palate.

The objective of this study was to examine whether an autologous alveolar bone graft has an effect on the nasolabial asymmetry in unilateral cleft lip, alveolus, and palate. Fifteen children (mean age 7.5 ± 2.4 years) with non-syndromic unilateral cleft lip and palate (CLP) were included. Non-ionizing three-dimensional images were acquired prior to and three months after the alveolar bone grafting procedure. A 2D and a landmark-independent 3D asymmetry assessment were used to detect changes of asymmetry in the nasolabial area. For the 2D assessment, a cleft and non-cleft side ratio for 4 linear nasal and 2 linear labial distances was expressed as a Coefficient of Asymmetry (CA). The 3D asymmetry assessment comprised a robust superimposition of the face with its mirror image, expressed as a root-mean-square-error (RSME) in mm. A significant decrease in the CA for the labial distance from the facial midline to the labial commissure was observed (P = 0.036). Also, the CA for the labial distance from the facial midline to the highest point of Cupid's bow increased significantly (P = 0.028). Non-significant changes were observed for the CA for the 2 nasal distances and the 2 other labial distances. No significant changes in 3D nasal asymmetry were detected (P = 0.820). Alveolar bone grafting completes the alveolar ridge but has only little to no clinical effect on the asymmetry of the secondary cleft lip nasal deformity.

Relationship between dental calcification of mandibular teeth and cervical vertebrae maturity in patients with unilateral complete cleft lip and palate.

The purpose of this study was to investigate the relationship between the dental calcification stage (DCS) of the mandibular teeth and the cervical vertebral maturation stage (CVMS) in patients with unilateral complete cleft lip and palate (UCLP). One hundred sixty-two UCLP patients (100 males and 62 females) between 8-16years old were included in this study. The DCS was estimated by the Demirjian method and was converted to the dental age (DA). The CVMS was evaluated by the Baccetti method. The DA of mandibular teeth on two sides of the cleft were analyzed using a t-test. Spearman correlation was used to study the association between CVMS and DCS. The correlation coefficient between the two sides of the cleft was then compared. The total DA was significantly smaller on the cleft side than on the noncleft side in males (p = 0.022). The Spearman rank correlation coefficient revealed a significant correlation between the DCS of each examined tooth and the CVMS (r = 0.627-0.793 in males and r = 0.806-0.899 in females). Additionally, the correlation of the two sides was not significantly different (p > 0.05). The DCS of the first premolar showed the strongest correlation with the CVMS. The results confirm the utility of the DCS on both sides of the mandible in male UCLP patients as a simple first-level diagnostic test to evaluate growth and development. The findings also indicate that both the DCS and the CVMS should be assessed if the maturity stage of a growing UCLP patient is relevant to clinical practice.

Force balance reconstruction of the orbicularis oris in unilateral incomplete cleft lip

PurposeTo demonstrate a maneuver for achieving optimal force balance of reconstructed orbicularis oris during primary unilateral incomplete cleft lip reconstruction. MethodsThe surgical maneuver was performed as follows: the length of the orbicularis oris on the noncleft side is first isolated and adjusted to be equal to the length of the muscle on the cleft side. The remaining muscle from the noncleft side near the midline is used to fill in the vermilion tubercle, and finally, the two orbicularis oris muscles are sutured at the midline. Finite element analysis was utilized to model the biomechanics of our novel surgical method. ResultsFinite element analysis showed that when the lengths of two orbicularis oris muscles were the same after primary cleft lip repair, the stress on this muscle system was minimized under different lip conformations. Seventeen cleft lip patients were enrolled to receive reconstruction with this new maneuver. Significant differences were found in (1) noncleft/cleft alar base width, nasal dorsum angle, columella length relationship between two sides, and columella angle under the comparison between preoperative and postoperative; (2) noncleft/cleft alar base width, nasal dorsum angle, and columella angle under the comparison between preoperative and follow-up; and (3) columella length relationship between two sides under the comparison between postoperative and follow-up. ConclusionForce balance of the orbicularis oris muscles is important during unilateral incomplete cleft lip repair. This surgical maneuver for achieving force balance of the orbicularis oris and the muscle system of the lips is easy to perform and can help avoid relapses.

Three-Dimensional Measurement of the Lateral Lip Element Sacrificed in Primary Repair of a Unilateral Cleft Lip

In most children with a unilateral cleft lip (UCL), because lateral lip tissue on the cleft side is congenitally short, the lateral lip element should be appropriately excised during primary cheiloplasty so that symmetric nasolabial features are obtained after surgery. The purpose of this study was to measure how much of the lateral lip element is removed during primary cheiloplasty and compare the amount of sacrifice between different incision designs. Preoperative 3-dimensional images of 50 infants with UCL were randomly selected. The incision designs of 3 representative techniques (Millard, Onizuka, and Fisher) were drawn on the images that were obtained before the primary repair. The lateral lip tissue excised by each technique was estimated as a percentage of the surface area of the sacrificed lateral lip to the entire lateral lip of the cleft side. In the case of incomplete UCL, the median values (range) were 3.2% (1.1%-5.9%), 11.6% (8.3%-20.1%), and 27.2% (15.1%-42.3%) for the Millard, Onizuka, and Fisher repairs, respectively. In cases of complete UCL, no sacrifice was needed for the Millard repair, whereas the median values (range) were 10.6% (5.2%-28.9%) and 22.5% (11.5%-48.6%) for the Onizuka and Fisher repairs, respectively. In Millard repair, the median values (range) of the lateral lip element that was resected before skin closure according to the "cut-as-you-go" policy were 5.8% (2.2%-11.8%) in cases with an incomplete UCL and 4.9% (2.7%-9.1%) in cases with a complete UCL. Our study demonstrated that sacrifice of the lateral lip element was minimal in the Millard repair, whereas it could exceed 20% in the Fisher repair. However, additional sacrifice of the advancement flap was needed in the Millard-type repair. The ratio of the lateral lip sacrifice varied between patients. Although UCL repair techniques should not be evaluated with the sacrifice ratio, excessive sacrifice of the lateral lip tissue can complicate the secondary lip correction. We recommend that surgeons estimate preoperatively how much lateral lip element will be sacrificed with each incision design using a 3-dimensional image for each child with a UCL.

Nasal Alar Surface Area Differences After Unilateral Cleft Lip Repair: Long-Term Effects of the Perialar Incision.

The Millard rotation-advancement cleft lip repair is the most commonly performed cleft lip repair. An extended perialar incision allows for further advancement of the lateral lip element and improved positioning of the alar base. There is a lack of data evaluating differences in nasal alar growth when the perialar incision is utilized. This study compares the long-term effects of a perialar incision on the alar surface area of unilateral cleft lip patients who underwent a Millard cleft lip repair. Thirty-seven patients with a diagnosis of unilateral cleft lip treated with a Millard primary lip repair were studied. A perialar incision was utilized in 16 patients while 21 patients underwent a standard Millard repair. 3dMD facial images were taken at least 10 years after the initial lip repair. Using the patient's non-cleft side as an internal control, the Alar Ratio (AR) was calculated, defined as the cleft alar surface area divided by the non-cleft alar surface area. The AR was significantly greater in the standard Millard repair group compared to the perialar incision group, 0.74 and 0.64 respectively (P = .02). The incomplete cleft population demonstrated a more profound difference between the treatment groups (0.82 and 0.62, respectively). This study reveals an association between a perialar incision and decreased alar surface area. Long-term follow up results suggest a perialar scar restricts alar growth leading to significant asymmetry between the cleft and non-cleft sides. Therefore, surgical technique must be carefully considered prior to utilizing a perialar incision during unilateral cleft lip repair.

Secondary Unilateral Cleft Rhinoplasty Using Natural Curvature of Rib Cartilage as Alar Rim Graft: A Three-Dimensional Evaluation of Long-Term Results

Since 2012, the senior author has incorporated the natural curvature of rib cartilage as an alar rim graft in addition to the diced cartilage technique for unilateral cleft rhinoplasty. The aim of this study is to describe this modification and evaluate its long-term results regarding nasal symmetry using three-dimensional stereophotogrammetric assessment (3dMDface system). From 2012 to 2018, 47 consecutive patients that underwent secondary unilateral cleft rhinoplasty were reviewed retrospectively. Sixteen patients with both preoperative and postoperative three-dimensional photographs taken at least 6 months after the operation were included. SimPlant O&O software was used to measure parameters on three-dimensional photographs: nostril heights, nostril widths, nasal dorsum heights, alare width, nostril areas, overlapping nostril area, nasal tip protrusion, nasal length, and nasal height before and after surgery. The ratios between cleft and noncleft sides were calculated. In addition, the overlapping nostril area ratio, tip protrusion-width index, and nasal index were compared before and after surgery. The preoperative nostril height ratio (0.79), nostril width ratio (1.24), and nasal dome height ratio (0.84) between cleft and noncleft sides were significantly improved after surgery to 0.93, 1.06, and 0.97, respectively. The preoperative overlapping nostril area ratio (72.33 percent), nasal tip protrusion-width index (0.48), and nasal index (0.81) also showed significant improvement postoperatively to 83.91 percent, 0.57, and 0.74, respectively. This preliminary study supports the use of natural curvature of rib cartilage as alar rim graft in secondary unilateral cleft rhinoplasty, with long-term improvement regarding nasal symmetry and nasal profile. Therapeutic, IV.

Beware the Alar Base Optical Illusion in Assessment of Unilateral Cleft Lip Nasal Deformity

Sir: Dr. Mulliken has once again illustrated his vast experience and expertise in a simple yet elegant study.1 Incorrectly diagnosing a lateralized cleft alar base position can lead to medial repositioning during secondary revision, thereby worsening an existing deformity. The study by Mulliken et al. demonstrates how commonly the mistake is made and provides a simple maneuver to avoid this pitfall. The article will no doubt have an important impact on cleft care. What we find interesting is the etiology of the “optical illusion.” While aberrations of form may prompt innate human perceptions that result in an “illusion,” it is also possible that bias from surgical dogma may be at play. Our literature commonly attributes the unilateral cleft lip nasal deformity to lateral displacement of the cleft alar base and considers medial repositioning as a key component of reconstruction.2–4 As such, the medical professionals who served as raters in this study may have attributed less favorable form to “undercorrection” of the cleft alar base, resulting in more frequent ratings that the alar base was too wide. We have recently analyzed three-dimensional images of infants with unrepaired cleft lip and found that, if a vertical midway through the intercanthal line is used as reference, the medial-lateral position of the cleft alar base is normal relative to control (infants without cleft) and the cleft alar base is much closer to midline than the noncleft alar base (Fig. 1).5 After repair, medial movement of the noncleft alar base and anterior movement of the cleft alar base produced nasal base positions that matched those of normal controls. Given those findings, the current dogma is wrong: the unilateral cleft lip nasal deformity does not occur because of lateral displacement of the cleft alar base. Rather, it is the columella and noncleft alar base that are displaced laterally. Therefore, the cleft alar base should not be moved medially, otherwise the distance from alare to midline would be too narrow and the underlying etiology of the nasal tip derangement would remain (Fig. 2).Fig. 1.: Current dogma dictates that the cleft alar base is laterally displaced and needs to move medial to correct the unilateral cleft lip nasal deformity. If focused on the lower nose, the collapse and resulting deformity of the cleft alar dome captures our attention, leading us to perceive that the cleft side is displaced laterally, relative to the rest of the more normal-appearing nose. Based on three-dimensional image analysis and photographs that use medial canthi to define the facial midline, it is actually the noncleft alar base and columella that are displaced laterally. The cleft alar base is retropositioned but similar in medial-lateral position relative to that of control subjects without clefts. In order to improve symmetry, the noncleft alar base needs to move medial, the columella needs to be centralized, and the cleft alar base needs to move anteriorly.Fig. 2.: The uncorrected or inadequately corrected nasal base becomes apparent when using the full face as reference. The noncleft alar base is lateral, the columella is off midline, and cleft alar base is posterior (and not lateral). While the distance from the cleft alare to subnasale (al-sn) may be wider than the noncleft side, the distance from cleft alar base to midline is less than that on the noncleft side. Medial repositioning of the cleft alar base should be avoided, as it would make the deformity worse.It would be interesting to see if the results of Mulliken et al.’s study would be reproduced with raters who are naive to existing surgical dogma. Repetition of the study utilizing a layperson rating group or crowdsourced rating system could be utilized to this end. If the same outcome is not reproduced, the phenomenon that the authors describe may be more of a bias from erroneous surgical dogma rather than a true optical illusion (i.e., an innate misperception influenced by visual cues). Regardless of optical illusion or bias, accurate assessment of alar base position is critical. The maneuver that Dr. Mulliken’s group describes and objective analysis of three-dimensional stereophotogrammetry are valuable in avoiding a cleft alar base that is too medial. Once an alar base has been placed too medially, it is very difficult to reverse. “The eye sees what the mind knows,” and by uncovering our misperceptions, we may improve the care that we provide. PATIENT CONSENT Parents or guardians provided written consent for use of the patient’s image. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding support was received for this work. Chad A. Purnell, M.D.Russell E. Ettinger, M.D.Raymond W. Tse, M.D.Division of Craniofacial and Plastic SurgerySeattle Children’s HospitalDivision of Plastic SurgeryUniversity of WashingtonSeattle, Wash.

Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction

Cleft lip and/or cleft palate are the most common congenital craniofacial anomalies. Philtral ridge morphology is an important aesthetic component of unilateral cleft lip (UCL) repair. To this end, we have developed two techniques of philtral ridge reconstruction: (1) asymmetric mattress muscle sutures, and (2) overlapping mattress muscle sutures. The objective of this retrospective cohort study was to compare their outcomes in UCL repairs. Group I patients (n=30) underwent UCL repair before August 2003, including philtral ridge reconstruction by asymmetric mattress muscle sutures. Group II patients (n=30) underwent UCL repair after August 2003, including philtral ridge reconstruction by overlapping mattress muscle sutures. Philtral morphology was evaluated by ultrasonographic and three-dimensional photographic measurements, examining cleft side philtral projection and philtral ridge symmetry. These demonstrated that group II patients had better philtral column symmetry and projection on the cleft side when compared to group I. Overlapping mattress muscle sutures produced better philtral morphology in UCL repairs than asymmetric mattress muscle sutures.

Does the Nostril Shape Change After Le Fort I Advancement in Patients With Unilateral Complete Cleft Lip?

Patients with unilateral cleft lip and palate (UCLP) may require Le Fort I advancement to correct maxillary hypoplasia after reaching skeletal maturity. The underlying cleft anatomy, previous operations, and scarring can affect nostril changes after maxillary advancement. The purpose of the present study was to determine whether Le Fort I advancement affects the nostril configuration (ie, width, axis, shape) in patients with UCLP. The specific aims were to (1) compare cleft and noncleft nostrils in patients with UCLP after maxillary advancement and (2) compare the changes in nostril configuration in patients with UCLP with those in noncleft controls after Le Fort advancement. A retrospective case-control study of nonsyndromic, skeletally mature patients with UCLP and a case-matched control group without UCLP who had undergone single-piece Le Fort I advancement with alar cinch suture from 2010 to 2014. Patients were included if they had undergone pre- and postoperative 3-dimensional photogrammetry without intervening nasal revision. Three-dimensional anthropometry was used to evaluate changes in nostril axis and width, soft triangle angle, columellar show, and nasal width after orthognathic correction. The present study included 19 patients with UCLP (11 males; mean age, 18.0years) and 19 noncleft controls (11 males; mean age, 18.7years; P=.276). The mean sagittal advancement in the patients with UCLP and noncleft controls was 7.5mm and 6.3mm, respectively (P=.143). On average, the nostrils widened, the soft triangles flattened, and the columellar show increased. No significant difference was found in the changes to the nostril configuration between the cleft and noncleft sides in the patients with UCLP. No significant differences were found in the nostril changes between patients with UCLP and noncleft controls. Baseline nostril asymmetry is not altered by Le Fort osteotomy in patients with UCLP because both nostrils respond similarly to the deforming forces of maxillary advancement. Similarly, no differences were found in the nostril changes between the cleft and noncleft controls. These findings can aid proper surgical planning for cleft nasal revisions.

3D evaluation of tooth crown size ın unilateral cleft lip and palate patients.

The aim of this retrospective study is to evaluate and compare the 3-dimensional (3D) crown sizes of the left and right sides of upper and lower dental arches in patients with unilateral cleft lip and palate (UCLP). Dental casts of 94 patients all in permanent dentition were included in this study. Dental casts were divided into three groups as 36 casts with unilateral left cleft lip and palate (ULCLP), 18 casts with unilateral right cleft lip and palate (URCLP), and 40 casts without cleft (control). Mesiodistal (MD), buccolingual (BL), and gingiva incisal (GI) values of each tooth were measured by scanning the dental models with a high-precision optical 3D scanner. Paired t-test and independent t-test were used for statistical analysis. U1 MD, U6 MD (P = 0.001) and BL (P = 0.01), L3 GI (P = 0.05) were greater in UCLP patients on the non-cleft side while U1 GI, L1 BL, L5 MD (P = 0.001), L4 MD, and BL (P = 0.01) values were found to be greater on the cleft side. Comparison of the cleft-sides and the control group showed that MD, BL, and GI dimensions of teeth on the cleft sides were generally found to be smaller, excluding the UR7 GI values for URCLP group (P = 0.05). In the measurements of teeth size, reliable and repeatable results were acquired through 3D software. Tooth size asymmetries can occur non-syndromic UCLP patients in both jaws. MD, BL, and GI dimensions of teeth are mostly found to be smaller in patients with CLP.

Effect of Cleft Types on Outcome of Unilateral Cleft Lip Repair.

Introduction:It is generally assumed that the major phenotypes of unilateral cleft lip (UCL) represent its extent of severity. There are a few studies on this, but objectivity has been lacking. It was the aim of this study to assess the effect of different phenotypes of UCL on the outcome of surgical repair.Methodology:This study was a case series of the effect of phenotypes of cleft on the outcome of repair of UCL. Fifteen subjects each were in three UCL phenotype groups. Surgical outcome was assessed quantitatively with anthropometric measurements recorded from a full frontal face photograph of subjects. The analysis was done using Student's t-test and one-way ANOVA at P = 0.05.Results:The mean values of the preoperative horizontal and vertical lip height, and nasal width on the cleft side in the cleft lip (CL) group were closest to those of the noncleft side and control. The postoperative mean values of the horizontal and vertical lip height, and nasal width on the cleft side in the CL group were closest to those of the noncleft side and control, while those of the CL, alveolus and palate group were farthest from those of the noncleft side and the control.Discussion:The different phenotypes of UCL have different degrees of tissue distortion and deficiencies. CL group had its measurements closest to that of the noncleft sides and control, suggesting that it has the least distortion.Conclusion:The comparison between the three groups did not reveal any difference, suggesting that the skill of the surgeon and the selection of a well proven technique are more important factors in the outcome of repair of unilateral cleft lip.

Presurgical orthopedic treatment of children with unilateral cleft lip and palate with a sequential splints method: indications and long-term results

To justify the use of the Sequential Splints Method of presurgical orthopedic treatment for children with unilateral cleft lip and palate depending on extent of initial deformation and to estimate long-term results. The method was applied in 17 unilateral cleft lip and palate infants who received treatment at the age from 4 days to 3 months. There was a control group of 28 cleft lip and palate patients operated with no early orthodontics. Average age in both groups at the time of research was 3.8±0.9 years. Comparative assessment was conducted before the beginning of the post-operative orthodontic treatment for the following parameters: residual width of the alveolar process cleft, presence of lateral incisor's bud, the extent of the nose deformation on the cleft side. It was found that residual width of the alveolar process cleft was, on average, 5.95 mm in the main group and 12.6 mm in the control group. The percentage of the lateral incisor adentia was 28% in the main group and 66% in the control group. The mean score of alar nose deformation was 3.9 and 3.1 points, correspondingly. According to obtained results patients who did not receive the presurgical orthopedic treatment were more likely to have residual deformations and larger residual width of the alveolar process cleft. There was higher risk of teeth germs loss in the control group. The Sequential Splints Method of presurgical orthopedic treatment is recommended as a necessary part of the treatment for the unilateral cleft lip and palate.

Three-dimensional assessment of craniofacial parameters in subjects with cleft lip and palate: A cone-beam computed tomography study

Objective: The objective of this study is to observe the differences in craniofacial parameters in subjects with cleft lip and palate and compare with normal subjects and also evaluate the association between chin deviation and asymmetry of face. Materials and Methods: Fifty cone-beam computed tomography (CBCT) scans (25 each) of the control group (Group I: normal) and study group (Group II: cleft lip and palate) subjects residing in Uttar Pradesh were obtained using care-stream CS 9300 3D system (care-stream Health, Inc. 2004). The digitizations and measurements were carried out in Dolphin Imaging software (Dolphin imaging version 11.9.07.24 premium). All subjects were within the age group of 15.1–18.9 years. Asymmetry indices (AI%) of the parameters were calculated as proposed by Habets et al. Results: Mean ± standard deviation of the differences in the variables between noncleft side (right side) and the cleft side (left) among the study group showed significant differences for Nasal width (P 3% threshold value for nasal width (5.08% ± 5.72%) and for nasal height (−4.80 ± 10.81%) in the study group. Conclusion: From the study, it was observed that asymmetry exists in the region of the defect that lies in the area of the contracture. Mandibular asymmetry has also been expressed with deviation of chin to the cleft side. The asymmetry index (AI%) values were >3% threshold value only in the region of the defect.

Three-Dimensional Evaluation of Change in Maxillary Alveolar Arch after Expansion in Unilateral Cleft Lip and Palate Patients

Narrowing of the maxillary dental arch is a major cause of occlusal abnormalities in cleft lip and palate patients. Although the dental arch may be expanded in such cases, relapse will often occur during the subsequent retention period. In this study, the stability of expansion of the maxillary arch was investigated by examining 3-dimensional change in the maxillary arch during the treatment and post-retention periods. Three-dimensional measurements was performed on maxillary plaster models obtained from 8 unilateral cleft lip and palate patients (mean age, 12.5 years) who had undergone maxillary arch expansion using an edgewise appliance and quad helix (CLP group). The controls consisted of 8 unilateral cleft lip and alveolus patients (mean age, 12.9 years). Measurements were made during the pretreatment, post-treatment, and post-retention periods. In the CLP group, horizontal relapse was observed in the alveolar and dental arches between the second premolars, together with vertical relapse on the cleft side of the central incisor, lateral incisor, and canine. The sites where relapse occurred demonstrated decreased growth before orthodontic treatment. A correlation was observed between the extents of expansion and relapse. These findings suggest that excessive horizontal or vertical tooth movement in areas showing developmental failure should be avoided in order to increase stability after orthodontic treatment.

Eustachian Tube Dysfunction in Children With Unilateral Cleft Lip and Palate: Differences Between Ipsilateral and Contralateral Ears.

To evaluate Eustachian tube dysfunction in the ipsilateral and contralateral ears, in children with unilateral cleft lip and palate (UCLP). Retrospective chart review. Tertiary care children's hospital. Seventy-four consecutive patients with UCLP born between 2005 and 2011 and treated at UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center were included. Conductive hearing loss, tympanogram type, number of middle ear effusions, tympanostomy tubes, and complications. Hypothesis was formulated prior to data collection. Conductive hearing loss was nearly twice as common in the ipsilateral ear (43.2%) compared with contralateral (23.0%; P = .001, McNemar test). There were no significant differences in the frequency of each type of tympanogram between the contralateral and ipsilateral ears. The proportions of ipsilateral (90.5%) and contralateral (91.9%) ears with effusion were not significantly different. The total number of tubes received was not significantly different between the 2 ears (median of 2 bilaterally). When combined, complications (retractions, perforations, and cholesteatomas) were significantly more common in the ipsilateral ear (29.7%) compared with the contralateral ear (18.9%; P = .039, McNemar test). In children with UCLP, there were significantly more instances of conductive hearing loss and complications on the cleft side compared to the noncleft side. This suggests that Eustachian tube dysfunction may indeed be more severe on the cleft side. Considering this information, clinicians may need to be especially observant of the ipsilateral ear.

A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip

BackgroundAdequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate lip lengthening and symmetry. MethodsThe design followed the rotation-advancement (RA) method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid's bow peak (CBP). Muscle dissection was continued to the contralateral nostril floor beneath the columellar base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the CBP. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region. ResultsAdequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory. ConclusionThe new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.

Primary Cleft Rhinoplasty: Surgical Outcomes and Complications Using Three Techniques for Unilateral Cleft Lip Nose Repair.

This study represents a single surgeon's 10 years of experience addressing unilateral cleft lip and palate nose deformity. The purpose was to compare surgical outcomes and related complications using 3 different techniques to improve nasal shape in primary unilateral cleft rhinoplasty. This retrospective study with Institutional Ethical Committee approval compares 3 groups of patients with unilateral cleft lip nose and palate who were operated on using different techniques from 2007 to 2017. Surgical outcomes were analyzed by physical examination at least 1 year after primary rhinoplasty. Anthropometric measurements were obtained for the cleft and noncleft sides of the nose. Approach with general analysis indicated differences among the 3 techniques. The author's comparative study revealed differences in nose symmetry and related complications, including increased recurrence of nose deformity using the modified McComb technique. Better short-term nose symmetry was observed using Potter technique and the V-Y-Z rhinoplasty. Potter approach and the V-Y-Z techniques achieve better short-term nose symmetry than the McComb method. Complications were less common in the group of patients operated on using the modified McComb technique. Additional studies are required to evaluate functional and long-term outcomes after primary rhinoplasty using the proposed methods.

Anthropometric Analysis of Secondary Cleft Lip Rhinoplasty Using Costal Cartilage Graft.

Despite the improvement of primary repair of nasal deformities during the management of cleft lip in infancy, this does not exclude the need for revision rhinoplasty in adulthood for complete patients' rehabilitation. The purpose of this study was to evaluate the aesthetic outcome of secondary rhinoplasty using costal cartilage grafts in patients with unilateral cleft lip nasal deformity. Twenty patients who were operated at earlier ages for correction of cleft lip and had a residual unilateral cleft lip nasal deformity were included in this study. Costal cartilage rib grafts were harvested; carved and used for maxillary augmentation, columellar strut graft, and lateral crural strut graft. Five anthropometric measurements (nostril height, width and gap area, columellar axis deviation angle and nasal base inclination angle) were used for evaluation of aesthetic results. The ratio of nostril width, height and gap area between the cleft side and the non-cleft side showed significant improvement (P <0.05). The columellar axis deviation showed significant improvement towards the midline (P = 0.004), and the alar base inclination showed improvement towards the horizontal line (P = 0.0045). In conclusion, the aesthetic outcomes of secondary cleft lip rhinoplasty using the costal cartilage are satisfactory. The costal cartilage has the required strength, is easily carved and maintains shape for considerable time.

Schneiderian Membrane Thickness Is Increased in Patients With Cleft Lip and Palate.

Patients with cleft lip and palate (CLP) are more likely to have sinusitis. The purpose of this study is to determine whether patients with CLP have thickening of the Schneiderian membrane. Specific aims were to (1) compare Schneiderian membrane thickness in patients with CLP to noncleft controls, (2) evaluate whether membrane thickening is associated with cleft side in patients with unilateral cleft lip and palate (UCLP), and (3) evaluate if age and sex are predictors of mucosal thickening. Case-control study. Tertiary care center. Patients with CLP and controls. The primary outcome variable was maximum Schneiderian membrane thickness measured on cone beam computed tomography. The primary predictor variable was the presence of a cleft. Additional variables were cleft phenotype, age, and sex. There were 225 patients with CLP and 93 controls. Median mucosal thickness was 2.4 mm in cleft group and 0.0 mm in controls (P = .006). In cleft group, 56.7% of sinuses had mucosal thickness >2.0 mm compared to 38.2% in controls (P = < .004). Pathologic membrane thickening (>4.0 mm) was significantly higher in cleft group (P = .005). No statistically significant difference in mucosal thickness between cleft and noncleft sides in patients with UCLP. Linear regression showed no association between age or sex and Schneiderian membrane thickness. Schneiderian membrane thickening is more common in patients with CLP and is not associated with the side of the cleft in patients with UCLP.