Unilateral Cleft Lip Deformity Research Articles

An analysis of deformities in revision surgeries for secondary unilateral cleft lip.

To analyze the secondary cleft lip deformities and the possible causes in a cohort of cases. A case series. Services Institute of Medical Sciences and WAPDA Teaching Hospital Complex, Lahore, from September 2008 to March 2012. Consecutive cases of secondary unilateral cleft lip deformities were selected for the study. These cases were interviewed and deformities recorded. Pre and postoperative photographs were taken for comparison. Per operative photographs were taken, after marking of the incisions, to keep a record of the intervention needed to correct the deformities. These cases were then further analyzed to know the deformities and interventions needed for correction of these deformities. Study subjects comprised 114 males and 75 females. Secondary correction was the most common in second decade of life with 82 cases in this group. The most common deformity was unfavorable scar in 150 cases followed by notch at the vermilion border in 124 cases. Short lip was found in 119 cases. Complete revision of the repair was required in 158 cases and 25 cases required partial redo of the initial repair. In other 6 cases, only scar revision was carried out. Unfavorable scar followed by vermilion notch and short lip were the most common secondary cleft lip deformities. Better technique helps favorable scar. Vermilion notch and short lip can be overcome by switching from rotation advancement repair to the triangular flap repair of Noordhoff.

Second stage surgery for repair of unilateral cleft lip based on the design of nose and mouth contour

Objective To investigate the approach and clinical efficacy of second repair surgery according to the nose and mouth contour design of unilateral cleft lip.Methods Based on the characteristics of anatomy,mechanics and deformity of the cleft lip,we designed a surgical incision of nasolabial contour lines with reference to the horizontal and central vertical lines and the contour.After careful investigation of classic procedures and clinical practice,unilateral cleft lip was repaired by overall stage Ⅱ surgical procedures.Results Application of this surgical method with satisfactory clinical efficacy had been achieved.Conclusions The second stage repair personalized surgical methods of unilateral cleft lip designed according to the nose and mouth contour can achieve maximal correction of malformation and beautiful appearance. Key words: Unilateral cleft lip deformity; Second stage repair; Contour design; Comprehensive repair

Correction of secondary nasal deformity of cleft lip with autogenous costal cartilage framework

To investigate the correction of secondary nasal deformity of cleft lip with autogenous costal cartilage framework. 237 cases with secondary nasal deformity of unilateral cleft lip were treated. The rib cartilage was harvested through a mini-invasive incision, and was fabricated as a C-shaped framework, as well as some cartilage fragments. Through transcolumella incision, the C-shaped framework was implanted to support the depressed alar and the cartilage fragments were used to augment the nasal base. Satisfactory cosmetic and functional results were achieved in all the patients with primary healing. 93 patients were followed up one year after operation with good cosmetic results. Autogenous costal cartilage framework can be used for the correction of secondary nasal deformity of cleft lip with satisfactory results.

The Cleft-Columellar Angle: A Useful Variable to Describe the Unilateral Cleft Lip-Associated Nasal Deformity

Objective : To study a method for quantification of the severity of either the unilateral cleft lip deformity or the associated cleft nasal deformity. A standard method would be useful for defining surgical outcomes. Design : Using a developed rating questionnaire and patient photographs, 26 nonexpert volunteers rated 14 children with untreated unilateral cleft lip according to the severity of their overall deformity, as well as the individual lip and nose deformities. The cleft-columellar angle was measured as defined by the intersection of a line in the parasagittal plane and a line perpendicular to the columellar base along the midcolumellar line. The association between deformity ratings and the cleft-columellar angle was modeled using mixed-model regression analysis. Setting : Tertiary care academic medical center. Results : After accounting for within-rater and within-child effects, the cleft-columellar angle explained a statistically significant portion of the variance in the rated severity for lip deformity (49%, p = .0012), nasal deformity (57%, p = .0001), and overall deformity (57%, p = .0005). Conclusions : Measurement of the cleft-columellar angle in two-dimensional digital photography is simple and correlative, capturing a substantial portion of nonexpert severity ratings of the constellation of deformities seen with the unilateral cleft lip deformity. Given its ease of application, the cleft-columellar angle is a useful variable in the description of the unilateral cleft lip deformity and may find utility across institutions as cleft surgeons seek to advance surgical care through outcomes research.

Effect of primary correction of nasal septal deformity in complete unilateral cleft lip and palate on the craniofacial morphology

PurposeTo assess the long-term effect of primary correction of the nasal septum during lip repair in unilateral complete cleft lip and palate on the craniofacial morphology. Material, subjects, methodsThe study material consisted of 54 lateral cephalograms made at the ages 7–22, including 28 cephalograms of patients from a study group (aged 7–14 years) after a primary correction of the nasal septum during lip closure and 26 cephalograms of patients from a control group (aged 12–22 years) operated on without septal correction. All cephalograms have been analysed with regard to skeletal, dental and soft-tissue relationships. Data distribution has been checked using Shapiro–Wilk test (α = 0.05). Student t-test was used to compare values of normal distribution and for the latter – Mann–Whitney test. ResultsThe comparison of all cephalometric values between the study and control groups revealed a statistically significant (α = 0.05) difference only for H (p = 0.0267), 1+: NB angle (p = 0.0175) and 1+: NA (mm) (p = 0.0249). Each of the three cephalometric measurements mentioned were greater in the study than in the control group. ConclusionNo negative effect from the primary nasal septum correction on maxillary development could be found in the study group.

Early Correction of Septum JJ Deformity in Unilateral Cleft Lip–Cleft Palate

The treatment of patients affected by unilateral cleft lip-cleft palate is based on a multistage procedure of surgical and nonsurgical treatments in accordance with the different types of deformity. Over time, the surgical approach for the correction of a nasal deformity in a cleft lip-cleft palate has changed notably and the protocol of treatment has evolved continuously. Not touching the cleft lip nose in the primary repair was dogmatic in the past, even though this meant severe functional, aesthetic, and psychological problems for the child. McComb reported a new technique for placement of the alar cartilage during lip repair. The positive results of this new approach proved that the early correction of the alar cartilage anomaly is essential for harmonious facial growth with stable results and without discomfort for the child. The authors applied the same principles used for the treatment of the alar cartilage for correction of the septum deformity, introducing a primary rhinoseptoplasty during the cheiloplasty. The authors compared two groups: group A, which underwent septoplasty during cleft lip repair; and group B, which did not. After the anthropometric evaluation of the two groups, the authors observed better symmetry regarding nasal shape, correct growth of the nose, and a strong reduction of the nasal deformity in the patients who underwent primary JJ septum deformity correction. The authors can assume that, similar to the alar cartilage, the septum can be repositioned during the primary surgery, without causing growth anomaly, improving the morphologic/functional results.

Primary correction of nasal deformity in unilateral incomplete cleft lip: A comparative study between three techniques

Nasal deformities secondary to incomplete cleft lip are often underestimated in terms of their severity with resultant sub-optimal treatment. Constant refinements have led to the evolution of different surgical techniques in our institution for the treatment of these deformities. This study compared three different techniques in achieving nasal asymmetry for patients with unilateral incomplete cleft lip. Sixty-six patients who had primary correction of incomplete cleft lip nasal deformities at the age of 3 months were reviewed later at the age of 5 or 6. The patients were divided into three groups as according to the surgical treatment received: Group I (n=21) underwent a closed rhinoplasty with cartilage dissection and repositioning through lip incisions; Group II (n=25) underwent a semi-open rhinoplasty technique with cartilage dissection through bilateral rim incisions; and Group III (n=20) received a semi-open rhinoplasty technique through a Tajima incision on the cleft side and a rim incision on the contralateral side. Using photo-analysis, a total of seven measurements were obtained comparing the cleft side with the non-cleft sides, including bilateral nostril height, nostril width, height-to-width ratio, medial dome height, nasal sill height, nostril area, nasolabial angle and nostril axis. All the patients benefitted from primary correction of their incomplete cleft lip and nasal deformities. In addition, Group III patients achieved superior results over Groups I and II in terms of nostril height ratio and nostril axis (p<0.005). Primary correction of the nasal deformity is an important component of surgery at the time of lip correction. Our results indicated that a semi-open rhinoplasty technique accompanied by the Tajima incision provides the best overall nasal symmetry.

Upper Lip Asymmetry Perception Using Three-Dimensional Anthropometry in Patients With Unilateral Cleft Lip Deformity

Conventional anthropometry using photographs has been widely used, but it does not provide accurate length. For upper lip asymmetry analysis, three-dimensional photographic system (3D VECTRA; Canfield, Fairfield, NJ) was used to calculate the ratio of cleft-side and noncleft-side curvature lengths. Thirty patients with unilateral cleft lip were analyzed. Three-dimensional photographic system was used to calculate the length ratio of upper lip of cleft and noncleft sides. In addition, two-dimensional photographs were analyzed by 10 plastic surgeons, and upper lip asymmetry was scored using a visual analog scale (VAS). Pearson analysis was used to identify relations between the ratios and the VAS scores. Intrarater reliability for the VAS scores ranged from 0.653 to 0.925, and interrater reliability was 0.611. Pearson correlation coefficients for each ratio and the VAS score were 0.412 (P = 0.024) for cleft-side to noncleft-side curvature length ratio of Cupid’s bow, 0.250 (P = 0.182) for cleft-side to noncleft-side curvature length ratio from the commissure to the lowest point of the nasal ala, 0.214 (P = 0.018) for linear length ratio of Cupid’s bow, and 0.356 (P = 0.153) for linear length ratio from the commissure to the lowest point of the nasal ala. Analysis of upper lip asymmetry in unilateral cleft lip patients using the three-dimensional photographic system is more accurate than two-dimensional anthropometry. Horizontal curvature length ratio was the most strongly correlated with VAS score.

A Microcosting Approach for Isolated, Unilateral Cleft Lip Care in the First Year of Life

The concept of value-based health care underlies many new improvement initiatives in U.S. health care. To determine value, accurate measures of both outcomes and costs are essential, which may then be compared for the same provider or system over time or between providers, to foster improvement. Although outcomes measurement has received a great deal of attention since the quality movement began in the United States, costing methodologies are lacking. A basic microcosting methodology was used to obtain direct medical costs, including physician compensation, for individuals with isolated, unilateral cleft lip deformity receiving their full course of care from one surgeon. The authors analyzed costs associated with the timeline of care during the first year of life. The median cost for the first year of life was $13,013 (range, $10,426 to $16,115; n = 12). Ninety-one percent of costs were associated with the cleft lip repair, which occurred at a median age of 3.7 months. The majority of these costs stemmed from time in the operating room and the inpatient stay, which accounted for 68 and 19 percent of first-year costs, respectively. Using a microcosting approach, the authors identified specific cost drivers and outlined a distinct timeline of care for patients with isolated cleft lip in the first year of life. This approach may serve as a template for the cost side of the value equation, for which accurate methodologies are needed. When combined with key outcomes measures, it will be possible to measure and improve value at the patient and provider levels.

Classification and surgical management of secondary nasal deformity of unilateral cleft lip

To investigate the classification of alar base depression, so as to provide the reference for the surgical management of secondary nasal deformity of unilateral cleft lip. From Jul. 2008 to Feb. 2009, 26 cases with secondary deformity of unilateral cleft lip were treated. All the patients underwent 3-dimensional CT for maxillary measurement. The nasal soft tissue measurement was performed pre- and post-operatively. The relationship between the maxillary and soft tissue at alar base was analyzed. The nasal deformity was classified. The location of alar base was not related to the form of piriform aperture, but the bony defect at the alar base was correlated to the patient satisfactory. The nasal deformity was graded as I when the depression at alar base was less than 4.5 mm in depth, as II when it was 4.5-5.0 mm in depth, and as III when it was more than 5 mm in depth. The deformity could be corrected with only soft tissue plasty for grade I, with soft tissue plasty or artificial implants for grade II, with combined bone autograft or alveolar cleft repair for grade III. The depression at maxillary does not necessarily result in alar base depression. The alar base can be adjust to proper position through operation. The operation should be designed based on the preoperative nasal measurement.

110 infants with unrepaired unilateral cleft lip: An anthropometric analysis of the lip and nasal deformities

The aim of this retrospective study was to correlate the width of the cleft lip with the severity of the nasal deformity in unilateral cleft lip and palate (UCLP) patients before primary lip repair. Preoperative impression casts were made. Measurements were taken of the width of the cleft lip (CW), nose (NW), and nasal floor (NFW), alar base height (ABH), columella length (CL), nasal length (NL) and nasal tip protrusion (NTP). The ratio of the non-cleft side (NFW) to the cleft side (NFWR), the ratio of the non-cleft side (ABH) to the cleft side (ABHR), and the ratio of the cleft side (CL) to the non-cleft side (CLR) were calculated. The average NW, NL and CW were higher in the group with complete clefts. There was a negative linear relationship between CW and NFWR, and a positive linear relationship between CW and ABHR in the complete group. In the incomplete group, negative correlations were obtained between CW and NFWR and between CW and ABHR. These findings show that there are correlations between CW and the transverse and vertical imbalance of nose in both groups but not between CW and anteroposterior imbalance of nose.

Minimal Scar Repair of Unilateral Cleft Lip

Most conventional repairs for unilateral cleft lip are based on the notion that the two joined edges of skin should be the same length. To this end, they incorporate designs that include darts, cutbacks, rotation flaps, and other strategies to match the length of the two segments. As unequal skin edges are routinely joined surgically, it should be unnecessary to incorporate maneuvers in unilateral cleft lip repair to match the segment lengths. A repair that places the scar along the philtral ridge was developed. This eliminates scars that deviate from the aesthetic subunits. Since 1982, a procedure has been used for unilateral cleft lip repair that incorporates the Kernahan functional muscle repair with a vertical skin closure, a white roll flap, and a dart at the nasal sill. The results of this lip repair, which does not intentionally match the segment lengths, are reviewed. Photographs of 10 consecutive patients who had their unilateral cleft lips repaired with this technique are presented for critical analysis. The mean age at operation was 15.4 weeks (range, 8 to 30 weeks). The mean postoperative period for the presented photographs was 66 months (range, 31 to 87 months). All of the patients healed without complications, and no revisions were performed. Preoperative and postoperative photographs of 10 consecutive patients demonstrate that normal lip length can be achieved without scars outside of the aesthetic subunits of the lip. The unilateral cleft lip deformity is repairable, with excellent results, without incorporating maneuvers to match the lengths of the opposing cut edges.

Millard's repair of unilateral clefts of the lip: a retrospective review

Clefts of the lip and palate are amongst the most common congenital anomalies likely to be encountered in clinical oral and maxillofacial surgical practice. Treatment of the deformity presents a constant challenge given the plethora of treatment philosophies propounded at various times. Each philosophy has its ardent advocates, as well as equally emphatic opponents. Yet, the successful correction of the deformity is also amongst the most professionally satisfying experiences for a surgeon. The present study aims to analyse the results of protocols for the management of the unilateral cleft lip deformity at the department of Oral and Maxillofacial Surgery, Subharti Dental College, Meerut, U.P. Between April 2004 and April 2007, we performed a total of 233 surgeries for primary as well as secondary deformities associated with clefts of the lip and palate. Of these, a total of 100 patients were operated for primary repair of a unilateral cleft lip. The records of these 100 patients were retrieved for a retrospective analysis of the patient profiles, and surgical results. The Millard's rotation advancement was used for lip repair in all cases. A rhinoplasty was performed simultaneously when required. The incidence of complications and the need for revision surgeries was studied.

Two-Stage Unilateral Cleft Lip Repair

Reconstruction of the unilateral cleft lip deformity remains a challenge. The Millard repair is the most commonly employed technique of lip closure. Wide clefts with malaligned alveolar arches and very short cleft-side philtral ridges are particularly difficult to reconstruct well. These cases frequently require some degree of cleft-side alotomy with attendant scarring and potential growth disturbance. Additionally, the lip scar tends to cross the philtrum at an aesthetically unsatisfactory low level. Nasoalveolar molding is one method to address these problems, but is not always available or practical. Alternatively, a two-stage lip repair serves as a reasonable means of managing these problems as well. The first stage, performed at approximately 4 to 6 weeks of age, is a full-thickness straight-line repair with tip rhinoplasty. The second stage is a modified Millard repair done at approximately 6 months of age. An alotomy is never needed. The lip scar does not cross the philtrum until the nasolabial crease. The alveolar segments are passively brought closer together by the early lip repair facilitating anterior palate closure. This technique has been used for more than 10 years with satisfying aesthetic and functional results.

Correction of Unilateral Cleft Lip Nasal Deformity in Preschool and School-Aged Children with Refined Reverse-U Incision and V-Y Plasty: Long-Term Follow-Up Results

A total of 47 preschool and school-aged patients with cleft lip nasal deformities underwent surgery between September of 1996 and December of 2003. The age of the patients ranged from 4 to 10 years. A reverse-U incision and V-Y plasty were used in 40 patients with mild to moderate unilateral cleft lip deformities. An open rhinoplasty incision combined with a reverse-U incision and V-Y plasty was used in seven patients with severe unilateral cleft lip nasal deformities. The follow-up period ranged from 6 months to 9 years, with an average of 4 years. The final results were evaluated on the basis of the degree of symmetry of both nostrils. The length of the longitudinal axis of the nostril and width at the midcolumella level were measured with calipers. Excellent results were obtained in 28 patients in whom alar-columella web deformities were absent or minimal, and a satisfactory symmetry of the nostrils was obtained. Thirteen patients showed good results, four patients showed fair results, and two patients showed poor results. Postoperative nostril symmetry was maintained within 1 to 2 years of follow-up. However, there was a mild change of the corrected alar-columella web 4 to 5 years after the operation. These results suggest that the reverse-U incision and V-Y plasty are useful methods for creating symmetry of the nostrils in cases of cleft lip nasal deformities. In addition, they are recommended for a slight overcorrection of the cleft lip nasal deformity in preschool and school-aged children.

Management of Unilateral Cleft Lip Nose Deformity, with Retracted Ala of the Noncleft Side

Traditionally, the goal of management of unilateral cleft lip-cleft nose deformity has been nasal symmetry, with improved nasolabial and nasofacial relationships and the noncleft side as the reference point. However, symmetry does not always ensure an aesthetically desirable form. The retracted ala is characterized by an alar rim to the long axis of the nostril distance greater than 2 mm on lateral view of the nose. In the management of unilateral cleft lip nose deformity in a patient with a retracted ala of the noncleft side, a simple correction of the deformity symmetric to the noncleft side results in bilateral alar retraction, an aesthetically undesirable result. The authors present eight cases of managing unilateral cleft lip deformities with retracted alae of the noncleft side between January of 2003 and October of 2004. Correction of alar retraction of the noncleft side with or without the correction of cleft lip nose deformity yielded better aesthetic results that were maintained throughout the follow-up period. Aesthetic surgery is the natural evolution of reconstructive surgery; in the reconstruction of selected unilateral deformity, the concept of "as symmetric to the contralateral side as possible" should be changed to the pursuit of an aesthetically pleasing appearance of both sides.

Comparison of Millard Rotational Advancement Variant Incision and the Pfeifer Wavy Incision for Unilateral Cleft Lip Repair

Mulliken JB, Martinez-Perez D: The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: Technical variations and analysis of results. Plast Reconstr Surg 104: 1247, 1999 Salyer KE, Genecov ER, Genecov DG: Unilateral cleft lip-nose repair: Long-term outcome. Clin Plast Surg 31:191, 2004 (review) Lazarus DD, Hudson DA, van Zyl JE, et al: Repair of unilateral cleft lip: A comparison of five techniques Ann Plast Surg 41:587, 1998

Free dermis—fat graft to correct the whistle deformity in patients with cleft lip

Vermilion notching or ‘whistle deformity’ is a common secondary deformity of the vermilion in patients with cleft lip. The free border of the lip is a composite structure consisting of the orbicularis oris and the overlying tissues, namely subcutaneous fat, vermilion and mucosa. A deficiency of all or one of these structures is responsible for the vermilion notch. An absolute shortage of the muscle or subcutaneous tissue necessitates the use of tissue from another source to correct the deformity. Dermis fat grafts have been used to augment the free border of the lip and correct this deformity. The technique is simple and reliable. The tissue is available in plenty, easy to harvest and could be repeated if necessary, i.e. in case of resorption. From June 1996 until January 2000 the technique was used in 10 patients. Of these 10, one was a bilateral cleft and nine were unilateral cleft lip deformities. A degree of graft resorption was seen in one patient, one had a partial graft loss due to ulceration and exposure. The first patient had a further augmentation.

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.

Cleft lip: unilateral primary deformities.

The understanding and management of all aspects of unilateral cleft lip deformities continue to evolve. Just as we are entering the era of exciting advances in the understanding of the pathogenesis of craniofacial disorders, expansion of our understanding of the dynamic relationships of the structural and soft-tissue components of cleft deformities has assisted surgeons in achieving progressively improved and consistent outcomes for these patients. The anatomic and physiologic complexity of unilateral cleft lip deformities has been recognized for centuries, and generations of researchers have cumulatively contributed to our current understanding. This article examines the history, classification, anatomy, and controversies in the surgical management of unilateral cleft lip deformities, allowing surgeons to formulate a reasoned, longitudinal management plan for their patients on the basis of the available current data.