Correction Of Nasal Deformity Research Articles

Functional and aesthetic correction of secondary unilateral cleft lip nasal deformities

ABSTRACTThe treatment of patients with unilateral cleft lip has undergone significant development during the last decades. With better understanding of the anatomy of the unilateral cleft lip and nasal deformities, primary correction of the nasal deformity at the time of lip repair, critical evaluation of short and long-term results following various treatment protocols, and constant striving for perfection in both aesthetics and function, we have been able to design improved treatment strategies and more accurate surgical techniques so as to achieve overall superior and long-lasting results. In this review article, we present our protocols and experience for functional and aesthetic correction of secondary unilateral cleft lip nasal deformities and a retrospective review of 219 consecutive patients treated at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities. The protocols used in the treatment of 219 consecutive patients at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities were reviewed. In addition, analysis of the most recent 51 consecutive patients who underwent complete clinical and functional evaluation with rhinomanometry followed by correction of the cleft lip nasal deformity was performed. A variety of time-honoured techniques of rhinoplasty were applied in the correction of the residual deformities to achieve symmetry, aesthetic balance, and functional correction of the nose. Follow-up ranged from 5-11 years. Analysis of the data revealed that 39 patients (76.47%) had significant functional and aesthetic improvement; seven patients (13.07%) had significant aesthetic improvement but a modest functional improvement; and five patients (9.8%) required additional surgery to improve their appearance and had no functional improvement. Further analysis demonstrated that five out of seven patients in the second group had pharyngeal flaps in place that were primarily responsible for the airway obstruction. No attempt was made to revise the ports of these flaps because the speech was excellent. The surgical plan is based on the information gained from our extensive clinical evaluation and is tailored to the patient's specific functional and aesthetic needs.

Correction of Nasal Deformity in School Children Using Ear Cartilage for Bilateral Cleft Nasal Correction: an Alternative Method

Marked nasal deformities, in particular a flattened nasal apex with wide nostrils and a short columella, may develop with facial growth after primary cheiloplasty in patients with cleft lip and palate. This study used auricular cartilage as an augmentation material for the nasal apex to improve the shape of the nose with good results. From July 2002 to August 2006, this technique was used for cheilorhinoplasty for 10 school children (mean age, 7 years 4 months); 8 patients had bilateral cleft lip and palate and 2 had bilateral cleft lip alone. Dissection was performed only at the nasal apex to create a space for cartilage grafting. Auricular cartilage obtained from the ear concha was used as an augmentation material. In all patients, the nasal apex was elevated and the nose was elongated. The shape of the overcorrected nasal apex became natural about 6 months after surgery. Good structural characteristics were maintained, as the nose shape was improved before the growth period in children, and recurrence of deformity of the nasal apex has not been noticed at the last follow-up (mean, 31 months). This technique for the correction of nasal tip deformity using ear cartilage as an augmentation material while minimising dissection prevented the development of a bulbous nose in patients with bilateral cleft lip and palate. It has been confirmed to be useful for cheilorhinoplasty in school children.

Rhinoplasty to Correct Nasal Deformities in Postseptoplasty Patients

Although not so common, septoplasty carries the risk of inducing nasal deformity such as saddle nose and deviated nose. Surgical correction for those deformities is a formidable task to deal with, because the septal cartilage framework was already weakened due to previous procedure. This study was designed to examine various causes and effective techniques of rhinoplasty for correction of nasal deformities after septoplasty. Subjects comprised 19 patients who developed nasal deformities after septoplasty. Pre- and postoperative photographs were analyzed by two rhinoplastic surgeons. Anthropometric measurements of the external nose before and after surgery were made using frontal and lateral photographs to objectively evaluate outcomes. Intraoperative analysis showed that 5 patients had weak L-struts and 13 patients had displaced caudal septa. Septum was reconstructed using costal cartilage in 13 cases. Spreader grafting was performed in 13 patients and caudal septal extension grafts were performed in 10 patients. All but 1 patient had successful functional and esthetic outcomes. In the saddle nose group, all parameters except nasolabial angle were significantly improved. In the deviated nose group, curved deviated angles were completely corrected, whereas the linear deviated angle was not. Loss of caudal septal support appears to be a major reason for nasal deformity after septoplasty. The best surgical approach for septal cartilage framework reconstruction appears to involve the use of bilateral spreader or septal extension grafts using costal cartilage.

A Review of Intraoperative Airway Management for Midface Facial Bone Fracture Patients

In craniofacial trauma patients, oral route endotracheal intubation may thwart the accuracy of dental occlusion and nasotracheal intubation carries the risk of intracranial invasion in skull base fracture cases. Between November 2005 and June 2006, patients receiving facial bone fracture operations at Kaohsiung Medical University Hospital were enrolled in this study. Intraoperatively, the endotracheal tube was pushed to either the retromolar space or the missing tooth space and secured by two 4.0 silk stitches. Then, surgeons could perform the usual procedure to explore the fracture sites, check the occlusion and correct the deviated nose without limitation. Also, for better understanding the time needed for various intubation techniques, a time-measuring study was performed. Ninety-one patients were treated by this method. Most of them were satisfied with the result of occlusion and nasal contour. Only 2 patients received second surgery to correct nasal deformity. One hundred seventeen anesthesia procedures were checked. In average, an experienced anesthesiologist could successfully intubate a patient in less than 105 seconds. The advantages and reported complications of different intubation methods were discussed. This retromolar position and tooth fixation technique allowed surgeons to correct the dental occlusion and nasal deformity simultaneously. It has served well for zygoma fracture, maxilla fracture, and Le Fort II fracture patients. It is worthy of consideration in management of middle face trauma patients involving occlusion change and nasal deviation.

Bilateral cleft lip nasal deformity

ABSTRACTBilateral cleft lip nose deformity is a multi-factorial and complex deformity which tends to aggravate with growth of the child, if not attended surgically. The goals of primary bilateral cleft lip nose surgery are, closure of the nasal floor and sill, lengthening of the columella, repositioning of the alar base, achieving nasal tip projection, repositioning of the lower lateral cartilages, and reorienting the nares from horizontal to oblique position. The multiplicity of procedures in the literature for correction of this deformity alludes to the fact that no single procedure is entirely effective. The timing for surgical intervention and its extent varies considerably. Early surgery on cartilage may adversely affect growth and development; at the same time, allowing the cartilage to grow in an abnormal position and contributing to aggravation of deformity.Some surgeons advocate correction of deformity at an early age. However, others like the cartilages to grow and mature before going in for surgery. With peer pressure also becoming an important consideration during the teens, the current trend is towards early intervention.There is no unanimity in the extent of nasal dissection to be done at the time of primary lip repair. While many perform limited nasal dissection for the fear of growth retardation, others opt for full cartilage correction at the time of primary surgery itself. The value of naso-alveolar moulding (NAM) too is not universally accepted and has now more opponents than proponents. Also most centres in the developing world have neither the personnel nor the facilities for the same. The secondary cleft nasal deformity is variable and is affected by the extent of the original abnormality, any prior surgeries performed and alteration due to nasal growth.This article reviews the currently popular methods for correction of nasal deformity associated with bilateral cleft lip, it's management both at the time of cleft lip repair and also secondarily, at a later date. It also discusses the practices followed at our centre.

Rotation-Transposition Correction of Nasal Deformity in Tessier Number 1 and 2 Clefts

Rotation-Transposition Correction of Nasal Deformity in Tessier Number 1 and 2 Clefts

The Use of Dermicol-P35 Dermal Filler for Nonsurgical Rhinoplasty

A growing number of patients with congenital or acquired nasal defects is seeking nonsurgical procedures to correct the appearance of their nose. The use of fillers for the correction of nasal deformities is expanding because of their low risk and reversibility compared with surgery. Dermicol-P35 (Evolence; Ortho Dermatologics, Skillman, NJ) is a novel crosslinked, fibrillar type I collagen isolated from porcine tendons that has not been associated with the same degree of immunogenicity as bovine collagen. The use of Dermicol-P35 in this study of 12 subjects was associated with high tolerance, as well as a high degree of satisfaction.

Secondary correction of nasal deformity and concomitant deviated septum in the unilateral cleft lip

The aim of this study is to evaluate the effect of the operation of nasal deformity revision and simultaneous septum deviation correction in the unilateral cleft lip. During the period between July 2005 and July 2007, 15 unilateral cleft lip patients with secondary nasal deformity and septum deviation were treated in our department. The surgical methods included extensive mobilisation of all dislocated structures, straightening of the deviated septum, and correction of the deformed ala and nasal tip.

Functional and aesthetic correction of secondary unilateral cleft lip nasal deformities

The treatment of patients with unilateral cleft lip has undergone significant development during the last decades. With better understanding of the anatomy of the unilateral cleft lip and nasal deformities, primary correction of the nasal deformity at the time of lip repair, critical evaluation of short and long-term results following various treatment protocols, and constant striving for perfection in both aesthetics and function, we have been able to design improved treatment strategies and more accurate surgical techniques so as to achieve overall superior and long-lasting results. In this review article, we present our protocols and experience for functional and aesthetic correction of secondary unilateral cleft lip nasal deformities and a retrospective review of 219 consecutive patients treated at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities. The protocols used in the treatment of 219 consecutive patients at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities were reviewed. In addition, analysis of the most recent 51 consecutive patients who underwent complete clinical and functional evaluation with rhinomanometry followed by correction of the cleft lip nasal deformity was performed. A variety of time-honoured techniques of rhinoplasty were applied in the correction of the residual deformities to achieve symmetry, aesthetic balance, and functional correction of the nose. Follow-up ranged from 5-11 years. Analysis of the data revealed that 39 patients (76.47%) had significant functional and aesthetic improvement; seven patients (13.07%) had significant aesthetic improvement but a modest functional improvement; and five patients (9.8%) required additional surgery to improve their appearance and had no functional improvement. Further analysis demonstrated that five out of seven patients in the second group had pharyngeal flaps in place that were primarily responsible for the airway obstruction. No attempt was made to revise the ports of these flaps because the speech was excellent. The surgical plan is based on the information gained from our extensive clinical evaluation and is tailored to the patient's specific functional and aesthetic needs.

Bilateral cleft lip nasal deformity

Bilateral cleft lip nose deformity is a multi-factorial and complex deformity which tends to aggravate with growth of the child, if not attended surgically. The goals of primary bilateral cleft lip nose surgery are, closure of the nasal floor and sill, lengthening of the columella, repositioning of the alar base, achieving nasal tip projection, repositioning of the lower lateral cartilages, and reorienting the nares from horizontal to oblique position. The multiplicity of procedures in the literature for correction of this deformity alludes to the fact that no single procedure is entirely effective. The timing for surgical intervention and its extent varies considerably. Early surgery on cartilage may adversely affect growth and development; at the same time, allowing the cartilage to grow in an abnormal position and contributing to aggravation of deformity.Some surgeons advocate correction of deformity at an early age. However, others like the cartilages to grow and mature before going in for surgery. With peer pressure also becoming an important consideration during the teens, the current trend is towards early intervention.There is no unanimity in the extent of nasal dissection to be done at the time of primary lip repair. While many perform limited nasal dissection for the fear of growth retardation, others opt for full cartilage correction at the time of primary surgery itself. The value of naso-alveolar moulding (NAM) too is not universally accepted and has now more opponents than proponents. Also most centres in the developing world have neither the personnel nor the facilities for the same. The secondary cleft nasal deformity is variable and is affected by the extent of the original abnormality, any prior surgeries performed and alteration due to nasal growth.This article reviews the currently popular methods for correction of nasal deformity associated with bilateral cleft lip, it's management both at the time of cleft lip repair and also secondarily, at a later date. It also discusses the practices followed at our centre.

Evaluation of primary correction of unilateral cleft lip nasal deformity with open or closed rhinoplasty

Nasal deformities in cleft lip patients are caused by displacement of alar cartilage, abnormal positioning of the columella, nasal septum and lower skeleton of the nose. Previously, primary correction of nasal deformity in cleft lip was thought to cause developmental impairment of the nose. Hence, late correction was preferred. However, late rhinoplasty is more difficult and less successful in these patients. Hence, simultaneous correction of the nose is probably desirable and widely accepted now. This paper presents postoperative results of primary nasal correction in unilateral cleft lip patients treated at our centre with open or closed rhinoplasty technique (60 patients). We used Millard's rotation advancement for all patients. Either closed or open rhinoplasty was used for nasal correction. Photographic evaluations in frontal, lateral and basal views were carried out preoperatively, and postoperatively at 1st week, 3rd month and 6th month. The nasal correction achieved by closed methods is as good as by open technique. However, a larger study with a longer follow-up is probably required to comment on the superiority of one method over the other. It can be concluded that satisfactory results can be achieved by primary correction of the nose in these patients.

The use of distraction osteogenesis to correct nasal deformity

The use of distraction osteogenesis to correct nasal deformity

Entire restoration of deformities caused by naso-orbito-ethmoidal complex and adjacent craniomaxillofacial fracture

To introduce the therapy of malformation caused by naso-orbito-ethmoidal (NOE) complex and adjacent craniomaxillofacial fracture. Seventy-six cases with NOE complex and adjacent craniomaxillofacial fracture underwent surgical replacement and internal fixation, using several cosmetically favorable incisions. At the same time, nasal reconstruction was performed to correct nasal deformities and defect through the coronal access during the exposure for the treatment of the NOE fracture. If larger nasal fragments were present, they were reduced and fixed by microplates or wires. If there was lack of septal support, dorsal nasal bone grafting was used to reestablish the height and anterior projection of the nose. Synthetic material (Medpor) was chosen for restoration of the orbital defects. Transnasal reduction was used for canthopexy. After 3 - 6 months follow-up, the outcomes of these patients were satisfactory functionally and esthetically. Posttraumatic nasal malformation and enophthalmos were corrected in most cases, and residual enophthalmos occurred in 3 cases, diplopia in 2 cases, insufficient prominence in 5 cases which underwent secondary correction with good results. Transnasal reduction of canthal realignment in the type III fracture was also satisfactory. There was no complication in this group. Comprehensive pre-operative evaluation of the patient and careful examinations should be taken to workout an appropriate operation plan. Simultaneous restoration for this type of complicated fracture is critical to obtain good results.

Reconstructive Rhinoplasty

To review nasal alar support mechanisms, introduce the concept of tractional forces on the nasal ala, and describe a reconstructive technique to correct nasal tip deformities associated with weakened tractional force on the nasal ala. Photographic study and retrospective medical chart review. We noted that patients with weakened support at the dome of the lower lateral cartilage had lateral alar deformities. Strengthening the cartilaginous deficiency improved the nasal appearance and function in 90% of patients. Deformities of the nasal tip are among the most difficult to correct. Tractional forces provided by dome strength help to maintain the ala in its normal anatomical position. Structural tip grafts restore the tractional force and, thereby, help to correct the alar deformity.

Correction of the nose in patients with unilateral cleft lip with composite grafts

We used composite conchal cartilage graft for columellar lengthening in eight patients with unilateral cleft lip and a nasal deformity. In 16 patients we used a buccal mucosal graft to line the nasal vestibule. We also used corrective procedures such as alveolar bone grafting for closure of palatal fistulas, septoplasty, malar augmentation, nasal osteotomy, and Le Fort I osteotomy to deal with associated deformities. Grafts took well with no loss and no donor site morbidity. In the follow up of 8 months-3 years, corrections were found to be stable and satisfying to all the patients. Only by replacing deficient tissues with similar tissues and putting them in the proper anatomical position can long term consistent and reliable results be achieved in the correction of nasal deformities associated with unilateral cleft lip.

Primary Correction of Unilateral Cleft Lip Nasal Deformity in Asian Patients: Anthropometric Evaluation

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

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

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

Nostrilplasty: Raising, lowering, widening, and symmetry correction of the alar rim

Background: Although the alar rim has frequently been neglected in correction of nasal deformities, techniques for its improvement have been proposed and used successfully. Objective: Two techniques for correction of the deformed alar rim are described. Methods: To lower the alar rim, the internal skin of the vestibule is dissected away from the areolar tissue and brought down as a flap. A segment of cartilage is taken from the septum or upper portion of the lower lateral cartilage. The cartilage graft is placed in the rim and the vestibular mucosa is folded over the graft and sutured to hold the cartilage in place. Raising of the alar rim is accomplished through direct excision to raise the rim and to make the nostril longer or wider. This technique is applicable to correction of a dropped rim, pinched nostrils, hidden columella, sigmoid ala, small nostrils, and foreshortened nose. Results: These techniques have been used to treat primary, secondary, and traumatic nasal deformities in more than 200 patients during the past 20 years with few complications. Conclusions: Although the techniques described require a learning curve, once mastered they can be combined with other techniques used routinely in rhinoplasty to successfully treat a variety of nasal deformities. (Aesthetic Surg J 2002;22:227-237.)

口蓋床を利用した口唇形成術前の非観血的外鼻形成法

Nasal deformity associated with cleft lip and palate is already obvious at birth. Primary nasal plasty is often performed at the same time as cheiloplasty. However, the influence of surgical intervention on growing alar cartilage remains unknown. Therefore, minimally invasive techniques should be used to correct nasal deformity. Presurgical orthopedic treatment using an oral molding plate has been employed traditionally for alveolar reconstruction in infants. We describe a female infant with left cleft lip and palate who underwent nonsurgical correction of nasal deformity before cheiloplasty, using a nasal stent attached to a Hotz-type palatal molding plate. This presurgical nasoalveolar molding was successful because immature cartilage in newborn infants is malleable enough to remodel the nasal shape. The nose of the patient maintains a correct form after cheiloplasty.

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

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