Primary Cleft Rhinoplasty Research Articles

Single-Stage Posterior Vomerine Ostectomy, Premaxillary Setback, Bilateral Gingivoperiosteoplasties and Primary Bilateral Cheiloplasty in Patients with Protuberant Premaxilla.

Various patients with complete bilateral cleft lip and palate present with a protruded premaxilla. Several techniques have been described for correctional repair of the projection with a plethora of unsatisfactory outcomes. This poses a challenge not only for the cleft team providing care but also for the patients and their respective families. Multiple patients suffer from residual deformities after inadequate primary repair, which increase surgical, financial, and psychological burden. Premaxillary setback with posterior vomerine ostectomy and complete bilateral cleft lip repair can promote alignment of the premaxilla with the maxillary prominences. To effectively address this challenging deformity, we describe a single-stage surgical technique that includes vomerine ostectomy posterior to the vomero-premaxillary suture, bilateral gingivoperiosteoplasties with complete bilateral cleft lip repair, and primary cleft rhinoplasty. Careful surgical planning is essential for adequate matching between the length of the protruded premaxilla and the extent of ostectomy. The described technique offers several advantages for the management of complete bilateral cleft lip with a projected premaxilla. It can be applied anywhere around the world and is most beneficial in underprivileged areas where patients suffer from restricted access to healthcare, absence of presurgical orthodontics and lack of sufficient resources.

Mixed Dentition Period Follow-up of Primary Unilateral Cleft Nose Deformity Repair.

Recently, there has been an increased acceptance of the primary cleft rhinoplasty providing acceptable outcomes. Nose reconstruction, and specifically cleft nose deformity, should be addressed based on this philosophy. The purpose of this study was to evaluate surgical outcomes during the mixed dentition period after primary surgery to address unilateral cleft lip nose deformity based on the proposed technique. This is a retrospective cohort study. Thirty-two primary complete unilateral cleft lip patients were operated on by a single surgeon using the V-Y-Z cleft rhinoplasty. This method combines a composite V-Y advancement flap with lateral Z-plasty. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements performed under general anesthesia during primary cleft palatoplasty and alveolar bone graft. The outcomes were evaluated through anthropometric measurements of the repaired nose during the mixed dentition period of follow-up, and no type of presurgical management was performed for any of the patients. Total nasal symmetry has been observed in 34.37% of patients at 7 years or more and 40.62% at 1-year follow-up. Nonstatistically significant differences were observed during follow-up, and major revision requirement (>3 mm of asymmetry in any of the nose measurements) was observed in 9.37% of patients. The proposed primary cleft rhinoplasty is a good approach to improve nasal appearance in patients with complete unilateral cleft lip and palate.

Primary Cleft Rhinoplasty with Custom Suture Needle for Alar Cartilage Repositioning in Unilateral Cleft Lip Patients: 3D Nasal Analysis.

Primary nasal correction has been demonstrated to be a beneficial practice for patients with unilateral cleft lip and palate. However, there is currently no consensus among cleft surgeons regarding the ideal approach to addressing the malpositioned cartilages. This study aims to introduce a new surgical technique for repositioning deformed lower lateral cartilage during primary cleft rhinoplasty, which involves using a customized suture needle. Retrospective cohort study. Tertiary university-affiliated hospital. This retrospective study included 51 patients with unilateral cleft lip and palate who underwent primary rhinoplasty during the labial repair. A morphological analysis of the nose was conducted using three-dimensional (3D) photographs. The cleft-to-noncleft side ratios of various nasal parameters, including nasal tip volume, nostril width, height, and area, were calculated at three time points: preoperative (T0), 3 months postoperative (T1), and 1 year postoperative (T2). Significant improvement (p < 0.05) was observed in the cleft-to-noncleft side ratios of nasal volume and nostril parameters. The nasal volume ratio and nostril height ratio remained stable, with no significant differences between the T1 and T2 periods. The nostril width ratio increased from 0.96 ± 0.13 at T1 to 1.05 ± 0.16 at T2, indicating an appropriate degree of surgical overcorrection of nasal width during primary lip repair. Primary cleft rhinoplasty using a Chang's needle allows direct suture placement in the intercartilaginous region with minimally invasive approach, thereby preserving growth potential of the nose and restoring the nasal symmetry.

Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes.

Background: The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges. Objectives: Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair. Methods: This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models. Results: Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2-12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and -0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2-4, 5-7, 8-12, 13-24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015-0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair. Conclusions: In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

An Update on the Outcome of Primary Cleft Rhinoplasty

An Update on the Outcome of Primary Cleft Rhinoplasty

Balancing the Anteroposterior Diameters of the Nostril Lengths in Cleft Rhinoplasty.

Osteocartilaginous deformities in cleft rhinoplasties may be restored with numerous techniques. However, the anteroposterior (AP) diameter lengths of the nostrils may still be unequal and should also be addressed. A technique was designed to balance nostril AP diameter lengths and apical shapes. Balance between AP nostril diameters was accomplished by reduction of the AP diameter of the nostril at the non-cleft side by medial crural reduction and augmentation of the AP diameter of the nostril at the cleft side by three-parted mini-flap reconstruction at the soft triangle. The cleft-side AP diameter length was divided by the non-cleft-side AP diameter length of the same preoperative, per-operative and 1-year postoperative base view photographs of each patient, and "nostril balancing ratio" was obtained. The more this ratio was near to "one," the more the AP nostril diameters were equal. Seventy-eight unilateral-cleft rhinoplasty were performed between January/2019 and May/2022. Forty-two of them required nostril AP diameter equalization. Twenty-nine patients were female, thirteen were male. Thirty-three of them were operated for a primary cleft rhinoplasty. Nine of them for secondary cleft rhinoplasty. Mean age was 28years (22-39years). Mean follow-up was 25months (6-40months). The preoperative, per-operative and postoperative mean "nostril balancing ratios" were 0.714 (0.621-0.813), 0.743 (0.721-0.752) and 0.971 (0.943-0.976), respectively. Balancing AP diameter symmetry with MCO at the non-cleft side and three-parted mini skin flap reconstruction at the cleft side may provide the satisfactory results. Three mini-flaps at the soft triangle may remold the nostril apex in an oval shape, which may result in a better shape symmetry. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty.

Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty. A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models. The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone. Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

Evolving Trends in Unilateral Cleft Lip Repair Based on Continuous Certification by the American Board of Plastic Surgery.

The American Board of Plastic Surgery (ABPS) began collecting data from unilateral cleft lip (UCL) corrections in 2011 as a component of the continuous certification process. We evaluated these data to understand practice patterns in UCL repair, in the United States, and whether these practice patterns had changed over the past 9 years. Tracer data for UCL correction were reviewed from its inception in October 2011 through 2016 and compared to UCL cases between 2017 and March 2020. Trends in practice patterns were evaluated against literature reviews meant to coincide with the ABPS continuous certification data. A total of 520 cases were included from October 2011 to March 2020. Median age of UCL repair was 4 months and 66% of patients were male. Fifty-one percent of cases presented with a complete cleft lip. There was a decrease in postoperative adverse events when data from 2011 to 2016 was compared to 2017 to 2019 (P = 0.020). Revisions were the most common postoperative adverse event (2%). There was a decrease in nasoalveolar molding from 25% to 12% (P < 0.001) and 56% of total cases underwent a concurrent primary cleft rhinoplasty. The rate of gingivoperiosteoplasty at the time of primary cleft lip repair also fell (9% versus 1%; P < 0.001). This article reviews tracer data obtained by the ABPS for UCL repair. The American Board of Plastic Surgery tracer data provides a national, cleft lip-specific database with longer follow-up times than other large databases.

Primary Cleft Rhinoplasty: Long-Term Outcomes of a Single Technique Used Over 2 Decades.

Primary cleft rhinoplasty has become widely accepted owing to evidence of improved outcomes and need for fewer revisions. Several techniques have been described, but few surgeons have reported long-term outcomes of repairs performed via a single method. The present study examines long-term outcomes of a single surgeon's experience over 22 years using the same primary cleft rhinoplasty technique. All consecutive cases of primary cleft rhinoplasty performed by the senior author at the time of unilateral cleft lip repair from 1996 to 2018 were selected for retrospective review. Patients older than 3 years or lacking documented follow-up were excluded. The primary outcome was the need for secondary rhinoplasty at age 15 years or later. Fifty-six patients met inclusion criteria. Median follow-up time was 7.52 years (interquartile range, 1.38-14.82). Twelve patients required minor long-term lip revision. No school-aged patients required additional correction of the nasal deformity before beginning school. Fifteen patients had follow-up beyond 14 years of age, 5 of whom had undergone definitive rhinoplasties as adolescents (8.9% of cohort; 33.3% of patients with follow-up beyond 14 years). Of the remaining 10 patients older than 14 years at last follow-up, none were seeking additional rhinoplasty. This series represents one of the longest-running published experiences of primary cleft rhinoplasty. Using a technique that requires no nasal incisions, the senior author has had excellent long-term results, with no need for any elementary school age rhinoplasties and with the majority of patients with follow-up older than 14 years not requiring a rhinoplasty in adolescence.

Timing Is Everything: Measuring Outcomes in Primary Cleft Rhinoplasty

<h3>Purpose</h3> The timing of ideal repair of the cleft nasal deformity has been a contentious topic among craniomaxillofacial surgeons over the last several decades. Several tissues are adversely affected, from bone through the vestibule, cartilage, and external skin. While surgical techniques, paradigms and philosophies have evolved, several important considerations are factored into the clinical decision making to perform a rhinoplasty at the time of cleft repair, such as growth interruption and several craniofacial growth centers, scarring, and the predicted aesthetic result at growth maturity. To this end, we investigated the safety profile, hospitalization characteristics and costs of primary cleft lip repair with and without rhinoplasty. <h3>Methods</h3> A retrospective cohort was designed using the Kids Inpatient Database (KID), which is comprised of databases organized by the Healthcare Cost and Utilization Project. Data were collected from January 2000 to December 2011 and included infants 12 months and younger who underwent complete and incomplete cleft lip repair. Data were excluded if records did not include age at time of cleft lip repair. Predictor variables included extent of the initial cleft surgery, with or without rhinoplasty. Outcome variables included length of stay, total charges, and overall complications. Demographic characteristics included age, gender, race, insurance status, and median household income. Independent <i>t</i>-tests and chi-square tests were performed. Multiple linear regression models were used to analyze continuous variables, and a <i>P</i> value of .05 was considered statistically significant. <h3>Results</h3> The study sample included 4559 infants, of whom 1422 (31.2%) underwent primary cleft rhinoplasty. Primary cleft rhinoplasty patients had a significantly shorter length of stay (1.6 vs 2.8 days, <i>P</i> < .01) compared to the nonrhinoplasty cohort. However, the hospital charges between both groups were not significantly different, suggesting that the cost of additional rhinoplasty offset the cost savings of the shorter length of stay. There was a significant increase in the inclusion of rhinoplasty with cleft lip repair over time (<i>P</i> < .01). A greater proportion of patients with unilateral cleft lip received a rhinoplasty (33.8% vs 26.0%, <i>P</i> < .01). Likewise, patients without cardiovascular anomalies (31.6% vs 24.4%, <i>P</i> = .02), patients with a cleft palate (33.1% vs 28.6%, <i>P</i> < .01), and patients treated in urban settings (72.9% vs 69.1%, <i>P</i> < .01) were more likely to undergo primary cleft rhinoplasty. The proportion of African Americans undergoing primary cleft rhinoplasty was less than that of the other cohort (4.6% vs 7.3%, <i>P</i> < .01). Similarly, the proportion of patients from the lower income quartile was less in the rhinoplasty cohort compared to that of the nonrhinoplasty cohort (23.3% vs 28.1%, <i>P</i> < .01). Patients treated with rhinoplasty were slightly older at the time of admission (4.2 vs 4.0 months, <i>P</i> = .03). <h3>Conclusion</h3> Performing primary cleft rhinoplasty is becoming more commonplace among pediatric craniomaxillofacial surgeons. Although concomitant rhinoplasty at the time of primary cleft lip repair is more costly, the length of stay in the hospital setting was shown to be shorter. Future studies should further investigate the safety profile and risk of postoperative complications in the rhinoplasty vs non-rhinoplasty cohort in primary cleft lip repair patients.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns.

The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

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.

Primary Cleft Rhinoplasty: A 22-year Retrospective Review of a Single Technique

Primary Cleft Rhinoplasty: A 22-year Retrospective Review of a Single Technique

Outcomes of Closed Versus Open Technique of Rhinoplasty During Primary Repair of Unilateral Cleft Lip: A Systematic Review.

Primary cleft rhinoplasty has almost become the norm in cleft practice. Although various closed and open rhinoplasty techniques are in use, there is no consensus as to which technique is superior in terms of outcome. The authors hypothesized that the long-term outcomes of open rhinoplasty during primary cleft lip repair in unilateral cleft is better than that of the closed method. This systematic review has been done to evaluate the hypothesis by a review and analysis of literature. Protocol was registered on the PROSPERO register of systematic reviews. PRISMA-P guidelines for the conduct of systematic review were followed. Literature search was done in various databases. The inclusion criteria were patients with nonsyndromic unilateral cleft lip undergoing rhinoplasty with primary cleft lip repair and preference given to studies comparing the 2 procedures. Sixteen articles were selected based on inclusion criteria after screening 522 articles-1 randomized controlled trial, 2 retrospective cohorts, and 13 case series. Both closed and open techniques have achieved good symmetry of nostrils with no impairment of growth. No advantage of one technique over the other was noted. There is a paucity of randomized controlled trials and prospective studies on the subject to arrive at an evidence-based recommendation as to whether open or closed rhinoplasty during primary cleft lip repair gives better long-term outcomes. Due to insufficient evidence, the authors are not able to support or refute the hypothesis put forward in the review.

The Microsurgical Approach in Primary Cleft Rhinoplasty—An Anthropometric Analysis

Oral and maxillofacial surgeons use different approaches to repair the nasal deformity of patients with a cleft lip deformity, differing in technique and timing. The aim of this longitudinal study was to analyze a new surgical technique to treat the cleft nasal deformity at 4 to 6weeks of life using a microscope. Twenty-seven newborn patients with a cleft lip deformity were treated by primary repair of the nasal deformity using a microscope at 4 to 6weeks of life. The procedure includes a columellar incision, alar cartilage plication sutures according to Daniel (Plast Reconstr Surg 103:1491, 1999), and trans-columellar sutures. All patients were photographed at specific time points up to 1year after surgery. Established angles and distances were analyzed and compared with normal values of age-matched children by Farkas (Anthropometry of the Head and Face [ed 2]. New York: Lippincott Williams and Wilkins, 1994). All parameters improved through surgery and showed stable values at follow-up assessments. Almost ideal values concerning symmetry, as indicated by columellar deviation and nostril comparison, were obtained. Measurements of nasal morphology were similar to established norm values. The authors recommend the early treatment of cleft nasal deformity using microscopic surgery because it shows stable and symmetrical results at least up to 1year after surgery. Clinical observations up to adolescence suggest no growth disturbance or deterioration of nasal shape.

The Unilateral Cleft Lip Repair and Primary Cleft Rhinoplasty.

Supplemental Digital Content is available in the text.

Don LaRossa, M.D., 1941 to 2014.

Don LaRossa, M.D., 1941 to 2014.

Update on primary cleft lip rhinoplasty

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

Evidence-based medicine: The cleft lip nasal deformity.

After studying this article, the participant should be able to: (1) Describe the components of unilateral and bilateral secondary cleft lip nasal deformity. (2) Discuss current methods of assessing the deformity and outcomes. (3) Discuss primary treatment options including the use of preoperative orthopedics, nasal molding techniques, and the primary cleft rhinoplasty. (4) Design a treatment plan for cleft patients that will optimize the outcome of nasal appearance and function. (5) Discuss the evidence regarding outcomes of current practices, and describe areas where more research is needed. This is the third Maintenance of Certification article on the secondary cleft lip nose deformity. In the first article, Guyuron defined the deformities and described techniques for the definitive (adult) rhinoplasty. The second article, by Zbar and Canady, presented evidence regarding the assessment, surgical treatment, and outcomes from the literature published between 1999 and 2009. In this article, the authors summarize important points from the first two articles and then concentrate on the evidence for the following topics: (1) methods currently used in evaluating the severity of the deformities; (2) methods used in evaluating outcomes of different treatments; (3) benefits of rhinoplasty performed at the time of the lip repair and evidence for the effect of rhinoplasties performed after infancy but before maturity; (4) presurgical orthopedics and nasoalveolar molding; (5) common surgical techniques used in primary cleft rhinoplasties; and (6) impact of the nasal deformity on quality of life. Overall, there is little high-level evidence regarding the outcomes of cleft nasal deformity treatment, leaving much room for future study.

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.