Nose Repair Research Articles

Treatment of Bilateral Complete Cleft Lip and Palate with Latham Appliance: A Case Report

Cleft lip and palate is one of the most common craniofacial deformities that have physical and psychological influences on patients’ lives. In 1950, the concept of presurgical infant orthopedics (PSIO) was introduced because surgery alone can be aggressive and less controlled treatment in patients with wide cleft or severely protruded premaxilla. Latham appliance is a kind of PSIO which can make an active forces for alignment and approximation of alveolar segments. The newborn with bilateral complete cleft lip and palate was referred from the department of Neonatology to the department of Oral & Maxillofacial Surgery (OMFS) for evaluation and further treatment. The Latham appliance was applied 10 weeks after birth and activated for 1 month. After the resting period, the operation of primary lip and nose repair was performed with removal of the Latham appliance at 6 months after birth. Through the activation of the Latham appliance, minimizing the scar tissue and reducing tension was possible, and a successful result in esthetics and function can be made.

Two Methods of Cleft Palate Repair in Patients With Complete Unilateral Cleft Lip and Palate

The objective of this study was to compare the surgical outcome between 2 patient groups with complete unilateral cleft lip and palate who underwent different types of palatoplasty. This is a cohort study between 2 groups of patients with complete unilateral cleft lip and palate who were operated using different surgical techniques from 2008 to 2011. About 28 patients were operated using a primary lip nose repair with vomer flap for hard palate single-layer closure and delayed soft palate repair (modified Oslo protocol) and 32 patients were operated using our protocol in Lima. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency and evaluation of dental arch relationships (scored using the 5-year-olds' index). Our comparative study observed statistically significant differences between the 2 groups regarding the presence of oronasal fistulas and velopharyngeal insufficiency in favor of our palatoplasty technique. A statistically significant difference was not found in functional vestibular oronasal fistula development between the studied techniques for unilateral cleft palate repair. This comparative study did not observe significant differences in dental arch relationships between the studied techniques. In this study, better surgical outcome than modified Oslo protocol regarding oronasal fistulas and velopharyngeal insufficiency on patients with complete unilateral cleft lip and palate was observed. The results arising from this study do not provide evidence that one technique is enough to obtain better functional closure of the alveolar cleft and dental arch relationship at 5 years.

Quality of life and nasal splints after primary cleft lip and nose repair: Prospective assessment of information and tolerance

Splints are commonly used after primary cleft surgery in order to secure the position of the nasal cartilages. Although the importance of splints is more and more stressed in the literature, many questions remain unanswered relative to the psychological impact of this device on children and families.Two questionnaires, Information and Tolerance, were used in order to measure the quality of life (QoL) associated with the use of nasal splints after primary cleft surgery. Information assessed the understanding of the parents the day before the procedure. Tolerance assessed their experience 3 months after splint placement. We prospectively included 41 consecutive patients from a Paris cleft center, 21 consecutive patients from a Russian center (Moscow) and 10 consecutive patients form a another French center (Nantes). In Paris and Nantes, an initial fixed splint was placed during the procedure until day 10, and then replaced by a removable splint for a period of 4 months. In the Moscow group, removable splints were used primarily for a total period of 4 months. Three types of removable splints were considered: commercial anatomical self-retentive splints (Nose-Fit™, Moscow, Russian Federation), in-house anatomical self-retentive splints and commercial Talmant-type splints requiring taping (Sebbin, Boissy-l’Aillerie, France). The data was analyzed as Likert scales and internal consistency was assessed using the Cronbach coefficient. Age at surgery, uni- or bilateral cleft, type of splint, number of splint changes and complications were tested against the scores of the questionnaires using multivariate models.We did not find correlations between the factors assessed by the multivariate analysis and the splint type. Information and Tolerance scores were high and showed satisfactory QoL associated with the use of splints. The internal consistency of the combination of the two forms was good. While the effects of splints on nasal morphology still need to be confirmed based on a controlled prospective study, we show here that this device is well tolerated by families and is not associated with specific complications.

Primary Repair of Cleft Lip and Nose in the Neonatal Period

Abstract Facial cleft malformations belong to the most common problems of the congenital facial anomalies. At the Clinic of Plastic, Aestetic and Reconstructive Surgery at the Faculty Hospital in Banská Bystrica we have been performing primary cleft lip repairs during the first week of life of a newborn since 1995. During this life period the fetal healing still persists. Modern anesthetic techniques have considerably reduced respiratory complications after the lip closure. The adequate postoperative sedation together with monitoring of the pacient remarkably reduces the occurrence of wound dehiscence. The advantages of the neonatal cleft lip repair are the scarless healing, no negative effect on the growth of the middle thirt of the face, as well as the pschychosocial effect on the family and the fact that the ortodontic aparat has not been needed.

Sort-term Result of Cutting Method for Primary Repair of the Bilateral Cleft Lip Nose

Sort-term Result of Cutting Method for Primary Repair of the Bilateral Cleft Lip Nose

Nasal Duplication Combined with Cleft Lip and Palate: Surgical Correction and Long-Term Follow-Up.

Background:Diprosopus dirrhinus, or nasal duplication, is a rare entity of partial craniofacial duplication.Methods:The case we present is the first report of diprosopus dirrhinus associated with complete cleft lip and palate. The baby was born in Cambodia at full term by normal vaginal delivery with no significant perinatal and family history. Physical examination revealed significant facial deformity due to the duplicated nose and the left complete cleft lip/palate on the right subset.Results:There were 4 nostrils; both medial apertures including the cleft site were found to be 10–15 mm deep cul-de-sac structures without communication to the nasopharynx. The upper third of the face was notable for hypertelorism with a duplication of the soft-tissue nasion and glabella. Between the 2 nasal dorsums, there was a small cutaneous depression with a lacrimal fistula in the midline. Surgical treatment included the first stage of primary lip and nose repair and the second stage of palatoplasty.Conclusions:The patient was followed up at the age of 10 years showing satisfactory results for both aesthetic and functional aspects. Further management in the future will be required for the hypertelorism and nasal deformity.

Subcutaneous C Shape Muscular Flap for Correcting the Depression of Alar Base in Affected Side in Patients With Unilateral Complete Cleft Lip/Palate During Primary Surgery.

The depression of alar base in affected side in patients with unilateral complete cleft lip/palate (CL/P) is one of common clinical features. In this study, the authors try to explore the effect of subcutaneous C shape muscular flap for correcting the depression of alar base in affected side in patients with unilateral complete CL/P during primary surgery. A total of 30 patients with unilateral complete CL/P who received primary correction of the lip nose deformity were included in this study. The C flap was used to drop and lengthen the height of upper lip in unaffected side, and the subcutaneous muscular flap was dissected from the C flap and positioned at the alar base in the affected side of upper lip to correct the depression. Then the surgical effect was evaluated based on clinical examination during follow-up. Alar base symmetry was obtained in 26 patients of this case series, and 4 patients showed slight improvement in alar base symmetry. No major complications such as flap necrosis, infection, or hypertrophic scars were observed during surgery and follow-up. No additional incisions and operative time were necessary. The subcutaneous C shape muscular flap described in this article could offer enough muscular support and markedly correct the depression of nostril and alar base in affected side in primary lip nose repair with no additional incisions and operative time for patients with unilateral complete CL/P.

Controversy and consensus for primary repair of cleft lip nose deformity

Introduction: Correction of Cleft lip nose deformity is a difficult challenge for cleft surgeons. Though, Primary repair of cleft lip nose deformity has been accepted worldwide, there are many variations amongst surgeons involved in cleft care. To demystifying the controversy of primary correction of cleft lip nose repair, we have done an internet based survey to define consensus among surgeons. Methodology: A 15 items questionnaire was framed and sent to the all plastic surgeons of India as well as oral & maxillofacial surgeons, Head & neck, ENT & Pediatric surgeons of the country involved in cleft lip surgery. The questionnaire was categorised in the form of repairing the nose deformity with cleft lip, approach to address such deformity, secondary complications & residual deformity present and satisfactory outcome in order to make a common consensus among surgeons involved in cleft surgery. Results: Of total respondents, 91.8% were plastic surgeons and 9.3 % Oral & maxillofacial surgeons. Almost all of them(100%) felt that nose deformity is a part of cleft lip, but only 81.3% agreed for nose deformity correction at the same time of cleft lip repair. Those who performed nose correction were about 58.1%, who always addressed nose deformity whereas 38.7% performed it sometimes.68.8 % address mostly flaring of ala whereas 52.1% address depressed nasal dome also while 24% address all the deformities. The maximum group, 45.3% prefer semi-open approach; whereas almost equal group 42.1% feel closed approach is sufficient enough to address all deformities. As per age of primary correction of nose deformity, 43% do it at the age of 3-4 months along with cleft lip repair whereas 33 % wait for 6 months. Regarding extent of dissection, 31.2% believe in minimum dissection, whereas for 62.7% it varies according to deformity. 89.7% feel primary correction reduces the deformities and 54.1% people feel only 25% patients may require revision before 7 years of age. However 59.6% prefer to revise the nose correction secondarily at adolescent age. About 29.3% surgeons were satisfied with their result in almost 50-75% of their patients and equal group in their 25-50% of patients' .The main complication they encounter was residual nose deformity in about 75.8%. About 87.8% believe there is no maxillary growth disturbances following nose repair and 87.52% are in favour of doing nose correction at the time of cleft lip repair. Conclusion: To conclude, nose deformity is a part of cleft lip and should be repaired at the time of cleft lip repair. The optimum age of repair is same as for cleft lip. The approach may be “semi-open” to “closed” depending on the surgeon's expertise and experiences and extent of dissection may vary according to deformities. However, a small group of patients may require secondary correction, but it is evident that primary nasal correction reduces the deformities and it should be an integral part of cleft lip repair.

Evolution of my philosophy in the treatment of unilateral cleft lip andpalate.

At the end of 50-year-long clinical activity, the evolution of my approach to the treatment of unilateral cleft of the lip and palate is discussed. I had several teachers in this field (Rusconi, Reherman, Perko, Delaire, Talmant, Sommerlad and others) and I introduced in my approach what I considered to be improvements from all of them. My current protocol is related to the anatomy of the cleft: for wide clefts a two-stage protocol is applied (1° step: soft palate and lip and nose repair; 2° step: hard palate repair with gingivoalveoloplasty); for narrow cleft (less than 1cm at the posterior border of hard palate) an "all in one" protocol is performed with or without gingivoalveoloplasty (in accordance to the presence or absence of contact between the stumps at alveolar level). The most important details regarding surgery of the lip and palate are discussed. Robust data collection on speech and skeletal growth is still needed to determine whether the "all in one" approach can be validated as the treatment of choice for unilateral complete lip and palate cleft in selected cases.

Preliminary Analysis of the 3-Dimensional Morphology of the Upper Lip Configuration at the Completion of Facial Expressions in Healthy Japanese Young Adults and Patients With Cleft Lip

To develop criteria for the analysis of upper lip configuration of patients with cleft lip while they produce various facial expressions by comparing the 3-dimensional (3D) facial morphology of healthy Japanese adults and patients with cleft lip. Twenty healthy adult Japanese volunteers (10 men, 10 women, controls) without any observed facial abnormalities and 8 patients (4 men, 4 women) with unilateral cleft lip and palate who had undergone secondary lip and nose repair were recruited for this study. Facial expressions (resting, smiling, and blowing out a candle) were recorded with 2 Artec MHT 3D scanners, and images were superimposed by aligning the T-zone of the faces. The positions of 14 specific points were set on each face, and the positional changes of specific points and symmetry of the upper lip cross-section were analyzed. Furthermore, the configuration observed in healthy controls was compared with that in patients with cleft lip before and after surgery. The mean absolute values for T-zone overlap ranged from 0.04 to 0.15mm. Positional changes of specific points in the controls showed that the nose and lip moved backward and laterally upward when smiling and the lips moved forward and downward medially when blowing out a candle; these movements were bilaterally symmetrical in men and women. In patients with cleft lip, the positional changes of the specific points were minor compared with those of the controls while smiling and blowing out a candle. The left-versus-right symmetry of the upper lip cross-section exceeded 1.0mm in patients with cleft lip, which was markedly higher than that in the controls (0.17 to 0.91mm). These left-versus-right differences during facial expressions were decreased after surgery. By comparing healthy individuals with patients with cleft lip, this study has laid the basis for determining control values for facial expressions.

Columella Lengthening with a Full-Thickness Skin Graft for Secondary Bilateral Cleft Lip and Nose Repair.

BackgroundVarious techniques for lengthening short columellae have been used for bilateral cleft nose repair. However, previous methods have not yielded satisfactory results. We performed a full-thickness skin graft to lengthen short columellae during secondary cleft nose repair in adult patients.MethodsTen bilateral cleft lip and nose patients underwent secondary cheiloplasty with open rhinoplasty between July 2008 and August 2014. The patients underwent a full-thickness skin graft on the medial crura to elongate the columella. The average age of the patients at the time of surgery was 22.2 years. Nasal profiles were evaluated before and after the operation using the photogrammetric method.ResultsThe nasal profiles were improved in all patients, and all skin grafts were well taken, with the exception of one patient. Columellar height, nostril height, and columella-lip angle increased, and nasal width decreased significantly. The ratios of columellar height to nasal height, columellar height to nasal width, and nasal height to nasal width increased to a statistically significant extent.ConclusionsColumella lengthening with a full-thickness skin graft is a simple and effective method for the repair of severely short columellae in bilateral cleft nose patients. We had satisfactory outcomes, with good color matching and aesthetically pleasing contours.

Critical choices in cleft surgery: 18-year single-surgeon retrospective review of 900 cases

Multidisciplinary management of orofacial clefts may lead to a successful treatment outcome. However, it is quite usual that lack of long-term treatment planning and collaboration among various specialists and lack of standardized surgical protocols result in poor esthetic and functional treatment outcomes. This article aims to hypothesize some critical determinants of outcome in cleft surgery. Throughout a period of 18 years, 900 patients with different clinical types of congenital cleft anomaly were subject to primary repair of cleft lip, nose, and palate by single surgeon using various procedures, including preoperative nasoalveolar molding, two-stage and one-stage repair of complete cleft lip and palate, two-flap and one-flap palatoplasty, open tip rhinoplasty, and postoperative nasal molding. Clinical results of preoperative nasoalveolar molding and surgical repair of lip, nose, and palate were satisfactory for most patients, parents, and surgeon panel. Treatment based on the individual patient’s facial assets and deficits must be the controlling factor in designing therapy. The essential key to successful management of clefts is to figure out the three-dimensional dynamics that govern the deformity and to recognize a fourth dimension for time along these dynamics in order to envision how a small difference in the position of a single suture during the first surgery can bring about a giant deformity upon completion of facial growth, hence the crucial role of the first surgery and its related concepts, techniques, and tactics in dictating the final outcome of the case. Level of Evidence: Level IV, therapeutic study.

A randomized controlled trial comparing two techniques for unilateral cleft lip and palate: Growth and speech outcomes during mixed dentition

ObjectiveTo study the growth and speech outcomes in children who were operated on for unilateral cleft lip and palate (UCLP) by a single surgeon using two different treatment protocols. Material and methodsA total of 200 consecutive patients with nonsyndromic UCLP were randomly allocated to two different treatment protocols. Of the 200 patients, 179 completed the protocol. However, only 85 patients presented for follow-up during the mixed dentition period (7–10 years of age). The following treatment protocol was followed. Protocol 1 consisted of the vomer flap (VF), whereby patients underwent primary lip nose repair and vomer flap for hard palate single-layer closure, followed by soft palate repair 6 months later; Protocol 2 consisted of the two-flap technique (TF), whereby the cleft palate (CP) was repaired by two-flap technique after primary lip and nose repair. GOSLON Yardstick scores for dental arch relation, and speech outcomes based on universal reporting parameters, were noted. ResultsA total of 40 patients in the VF group and 45 in the TF group completed the treatment protocols. The GOSLON scores showed marginally better outcomes in the VF group compared to the TF group. Statistically significant differences were found only in two speech parameters, with better outcomes in the TF group. ConclusionsOur results showed marginally better growth outcome in the VF group compared to the TF group. However, the speech outcomes were better in the TF group.

Primary rhinoplasty at the time of unilateral cleft lip repair: A review and our protocol

The cleft lip nasal deformity has been well described. However, for a long time, cleft surgeons feared that repair of the cleft lip nose at the time of primary repair would cause a growth disturbance especially of the nose. Hence the nasal deformity was not repaired until later. However, from the time of Blair and Barrett Brown, it has been shown that there are no deleterious growth effect from primary nasal interventions. At our centre the senior surgeon has performed primary nasal correction including septal respositioning from the late 1960s. There has been no deleterious growth effect and the overall appearance of the nose has actually improved. This is now well established through many objective studies. Hence it is now imperative that the deformity of the nose including the septum be addressed at the time of primary unilateral cleft lip repair.

The modified trott technique of one-stage lip and nose repair in the patient with bilateral cleft lip and palate (bclp)–a long-term follow-up

Introduction and aims: Synchronous open tip rhinoplasty at the time of lip repair in the BCLP patient introduced by J.A.Trott in 1993 was not widely accepted because of concerns about scarring, nostril stenosis, vascularity of the prolabium and growth of the nose. This paper aims to describe modifications in the Trott repair of the BCLP and present long-term results demonstrating how it addresses the core issues of the premaxilla, nose and columella, central sulcus and prolabium without the aid of devices.

Rhinoplastie de fente primaire et secondaire

Despite fifty years of statistics, congresses, publications, the cleft nose remains an enigma to the great majority of cleft specialists. Most of the published papers give recipes to camouflage the cleft deformity, very few are concerned by the functional anatomy and its relation with facial growth. The complexity of the matter, the results frequently disappointing, the lack of awareness of the necessity of early nasal breathing, and the academic condemnation of any imperfect attempt to correct the nose at the time of the first operation have led to resignation. For the last forty years, we have been involved in a careful and obstinate research about the early correction of the cleft nose deformity. We wish to present our conclusions in this chapter with at least 17 years of follow-up. They are as following: in cleft patients the nasal cartilages are only deformed. We can achieve sub periosteal and sub perichondrial dissections by 6 months of age without being harmful for facial and nasal growth. Repositioning accurately the nasal structures is enough if we are able to control the healing process and prevent endonasal wound contraction. We have not to do any compromise and favor one function with regard to the others, nasal ventilation being the most important for a good facial growth. In a word, nasal pediatric surgery is necessary at the time of the first operation from 6 months of age and should be carried on with a double demand, aesthetic and functional. To achieve this goal, we must have a sound knowledge of the cleft nose deformity, of the adequate surgical techniques and of the logic chronology to reach the best result. The nose repair cannot be limited to the nasal cartilages. The whole nasal structure is concerned especially its bony framework, the width of which at the level of the piriform orifice and the nasal floor depends on the outcomes of any surgical step that it would relate to the lip, palate or alveolar closure. Interaction of all these factors calls for an appropriate answer in adequation with the diagnosis of the deformity and a coherent answer as we know that any local action may induce an unfavorable chain reaction and should integrate a global and logic project. After the primary surgery, additional correction for aesthetic or functional purpose as well, may be useful during the period of growth. For cleft teenagers or adults, the rhinoplasty can simply be indicated for harmonization after a good primary nasal correction and optimal facial growth. On the contrary, the rhinoplasty may be more or less a complex operation for the usual and severe deformities. In the last case, the diagnosis must take into account all the residual deformities, even the labial and alveolar ones, and the treatment plan integrate all the principles and techniques of the primary surgery. What has not been done at the time of the primary surgery, should be done secondarily: all the structures are present, only deformed and embedded in scarred tissues. Primary or secondary cleft rhinoplasty must be undertaken by surgeons accustomed to cleft patients, but also trained in the other fields of nasal surgery, aesthetic and reconstructive.

An Adult Case of Unilateral Cleft Lip and Palate Treated by Primary Palatoplasty, Alveolar Bone Grafting and Secondary Repair of Cleft Lip and Nose

An Adult Case of Unilateral Cleft Lip and Palate Treated by Primary Palatoplasty, Alveolar Bone Grafting and Secondary Repair of Cleft Lip and Nose

A preliminary observation on interdomal suture through bilateral reverse-J incisions to repair cleft lip nose deformity in the setting of traveling charity programs

Background Nasal appearance is one of the most important factors in determining the success of a cleft repair. This preliminary study aimed to evaluate a simple variant of primary nose repair technique to achieve an optimal nasal esthetic outcome along with the lip repair in the setting of traveling charity programs, where time is an obvious limitation.

Integrated repair of nasal tip and columella of cleft lip/plalate using costal cartilage graft

Background and objectives: In the treatment of cleft lip and palate (CLP), it is ideal for the patients to get best results after all the treatments have been completed. We have been performing one stage repair of cleft lip and palate including primary cleft rhinoplasty. However, it is difficult to get symmetric shape of nose, so we tend to perform nose repair as the last surgery in their adulthood. Most of the cases are treated with septal cartilage graft and some of the cases, of which the bearing property is not strong enough, are treated with costal cartilage.

Normal Nasolabial Anatomy in Infants Younger Than 1 Year of Age

Normal nasolabial anatomy has received little attention in infants younger than 1 year. However, the notion of an ideal lip and nose is critical to reconstruction of this region, especially for cleft lip and nose repair. The purpose of this study was to quantitatively define the normal nasolabial anatomy in a series of infants younger than 1 year. A prospective analysis was performed of infants aged 0 to 12 months from 2011 to 2012. Plaster molds of the nasolabial region were produced from each subject. Anthropometric measurements were performed by two independent, blinded reviewers. Results were compiled and compared statistically using the two-tailed t test and analysis of variance with the post hoc Tukey honestly significant difference test. Correlation coefficients were calculated for the relationship of age and weight to nasolabial measurements. A total of 34 infants were included (mean age, 8.7 months; girls, n = 11). Ten anthropometric measurements of the nasolabial region were performed. Nasal length in boys was significantly longer than in girls (p < 0.05). With the exception of alar base width (p < 0.001), philtrum column height (p < 0.05), and cutaneous upper lip height (p < 0.01), ethnicity had no effect on nasolabial measurements. Alar thickness and nares circumference correlated positively with age and weight (p < 0.05). The normal nasolabial morphology is anthropometrically described in a population of infants younger than 1 year. Measurements were similar between boys and girls, and alar thickness and nostril circumference correlated with increasing age and weight.