Secondary Cleft Deformities Research Articles

Perception of aesthetic features after surgical treatment of craniofacial malformations by observers of the same age: An eye-tracking study

The aim of this study is to evaluate where exactly children and adolescents of the same group look when they interact with each other, and attempt to record and analyse the data recorded by eye-tracking technology. Materials and methods60 subjects participated in the study, evenly divided into three age categories of 20 each in pre-school/primary school age (5–9 years), early adolescence (10–14 years) and late adolescence/transition to adulthood (15–19 years). Age groups were matched and categorized to be used both for creating the picture series and testing. Photographs of patients with both unilateral and bilateral cleft lip and palate were used to create the series of images which consisted of a total of 15 photos, 5 of which were photos of patients with surgically treated cleft deformity and 10 control photos with healthy faces, that were presented in random order. Using the eye-tracking module, the data on "area of first view" (area of initial attention), "area with longest view" (area of sustained attention), "time until view in this area" (time of initial attention) and "frequency of view in each area" (time of sustained attention) were calculated. ResultsAcross all groups, there was no significant difference for the individual regions for the parameters of initial attention (area of first view), while the time until first fixation of one of the AOIs (time until view in this area) was significant for all facial regions. A predictable path of the facial scan is abandoned when secondary facial deformities are present and attention is focused more on the region of an existing deformity, which are the nose and mouth regions. ConclusionsThere are significant differences in both male and female participants' viewing of faces with and without secondary cleft deformity. While in the age group of the younger test persons it was still the mouth region that received special attention from the male viewers, this shifted in the male test persons of the middle age group to the nose region, which was fixed significantly more often and faster. In the female participants, the mouth and nose regions were each looked at for twice as long compared to the healthy faces, making both the mouth and the nose region are in the focus of observation.

Parents of Children with Cleft Lip Exhibit Heightened Visual Attention to the Perioral Area.

Twenty participants (10 control adults, 10 parents of affected children) assessed 40 colored images of children's faces while their eye movements were tracked. Twenty-four control images and 16 repaired cleft lip images were displayed to observers. Nine bilateral facial aesthetic zones were considered as regions of interest. Percentage of time visually fixating within each region, and statistical differences in fixation duration percentage between the two participant groups and across the bilateral regions of interest were analyzed. While both groups of observers directed more visual attention to the nasal and oral regions of the cleft images than control images, parents of children with cleft lip spent significantly more time fixating on these areas (25% and 24% of the time, respectively) than did unaffected adults (14.6% and 19.3%; P < 0.001). These results demonstrate that parents of cleft lip children exhibit heightened attention to this type of facial difference relative to the naive observer. These findings highlight that observer profile can meaningfully influence the perception of a facial deformity. Awareness of this information may enhance communication between surgeon and parents of an affected child by providing added insight into parental perspective.

Open rhinoplasty in secondary cleft nose deformity with suture techniques.

Correction of secondary cleft nose deformity is one of the most important portions in the management of cleft lip patients. Various techniques have been introduced to achieve adequate shape, balance, and symmetry of anatomical landmarks. None of these methods can claim to universally solve all aspects of the problems encountered in secondary cleft deformity surgery. Some authors overlook the aspect of functional rehabilitation with regard to nasal respiratory pathway problems, which is present in over 90% of the patients. This study aimed to evaluate the aesthetic and functional improvements of the authors' non-destructive technique. With over 15 years of experience, open rhinoplasty was performed, which included total remodeling of the deformed lower lateral cartilage using several suture fixation techniques without any graft or implantation with septo-turbinoplasty. A total of 150 questionnaires were sent by e-mail, but 55 completed questionnaires were returned. Surgical outcomes were evaluated using questionnaire responses, and outcomes were divided into five categories each for esthetic and functional analyses. The satisfaction rate ranged from 75 % to 98%, which means "more or less," "very much," and "absolutely yes" in the esthetic and functional viewpoints. The results of this study strongly recommend performing the suture fixation technique and functional rehabilitation simultaneously for cleft lip/nose correction.

Comparing Outcomes and Stability after Single- and Two-piece LeFort I Osteotomies in Patients with Cleft Lip and Palate

Purpose: LeFort I osteotomy is used to correct and improve the maxillary hypoplasia in secondary cleft deformities. However, surgical complex and challenge would be the risk factor of postsurgical instability. This study compared surgical and postsurgical changes in maxillary and mandibular movements and stability in patients with cleft lip and palate (CLP) who underwent single- or two-piece LeFort I osteotomies.

Aberrations in Maxillary Anatomy of Adult Patients with Cleft Maxillary Hypoplasia: A Computed Tomographic Study.

The aim of this study was to evaluate the maxillary anatomy in patients with cleft maxillary hypoplasia using computed tomogram. A cross-sectional observational study was carried out in all cleft patients reporting to our department for the correction of secondary cleft deformities. A preoperative computed tomogram of the midface (from the superior orbital rim to the maxillary occlusal plane) was recorded to assess the parameters which evaluate the maxillary and pterygomaxillary anatomy in cleft maxillary hypoplasia patients. A total of 18 adult patients (female-5; male-13) were included in the study, which includes 15 unilateral and 3 bilateral cleft lip and palate patients. All the patients had undergone palatoplasty in their early childhood. Evaluation of the circum maxillary and pterygo-maxillary anatomy on the computed tomogram revealed that the average width of maxillary tuberosity was (mean-6.91mm on cleft side, 4.51mm on noncleft side); distance between medial and lateral pterygoid plateswas (mean-6.45mm on cleft side, 5.94mm on noncleft side); distance from greater palatine foramen to posterior palatal borderwas (mean-5.6mm on cleft side, 6.1mm on noncleft side); distance from greater palatine foramen to pterygoid process was (mean-4.83mm on cleft side, 5.6mm on noncleft side); distance from pyriform rim to greater palatine foramen was (mean-30.0mm on cleft side, 31.8mm on noncleft side); inter pterygoid distance between medial pterygoid plates at the level of pterygoidhamulus was (mean-3.3cms = 33mm); inter pterygoid distance between medial pterygoid plates at skull basewas (mean-3.0 = 30mm). Maxillary hypoplasia in adult cleft patients distorts the circum maxillary and pterygomaxillary anatomy with cleft side being more hypoplastic compared to the noncleft side which needs to be evaluated prior to planning maxillary advancement.

Synchronous correction in secondary cleft deformities: a prospective cohort study.

Patients with cleft lip and palate deformities undergo multiple surgical procedures from infancy till adolescence. We hypothesized that combining these surgical procedures might offer a better quality of life without compromising on surgical outcomes. A prospective cohort study was conducted at our center including all adult patients who reported to us for the correction of secondary cleft deformities. All patients with secondary deformities associated with cleft lip palate and alveolus were enrolled in the study. Patients with medical issues who are not fit for general anesthesia, Bilateral Cleft deformities, and patients with gross skeletal deformity warranting surgical correction by Le fort I distraction were excluded from the study. All the patients who were included in the study underwent simultaneous lip revision, rhinoplasty and cleft alveolar bone grafting. The outcome lip nose profile was assessed using standardized patient photographs with Ascher Mcdade Scale and Aesthetic outcome index by 2 blinded maxillofacial surgeons and the bone grafting was assessed using Berglands grading system. Twenty-eight patients were enrolled in the study, 10 patients were excluded based on the exclusion criteria. Thus 18 patients planned for synchronous correction of unilateral secondary cleft deformities were included in the study The Ascher Mcdade Score improved from 15 (13-16), to 4 (4-5) in the post op. All the patients were totally satisfied with the surgical outcome. The aesthetic index showed excellent outcomes in all the lip-nose procedures, except for one case which showed a good outcome. The Bergland Scale showed normal bone height in all cases of alveolar bone grafting, except for one case, which showed less than 3/4th fill of bone. No complications were associated with any of the procedures. Simultaneous correction of multiple secondary cleft lip deformities should be considered when feasible, to improve the psychological benefit and reduce financial burden on these patients. However, careful planning and execution of the techniques is essential to avoid complications associated with vascular compromise.

Secondary cleft deformities: case report and review of literature

&lt;p class="abstract"&gt;The aim of this paper is to highlight the iatrogenic aspect of secondary cleft deformity, methodologies to treat them and the importance of reporting such cases. Secondary deformities are common in cleft lip and palate patients. Primary aim of treatment in cleft patients is to enhance their normal growth and development and minimize morbidity and number of operative procedures. Meticulous diagnosis, treatment planning and execution of primary surgery are of utmost importance in such cases to prevent majority of secondary deformities. Treatment of secondary deformity depends on the degree of deformity and the severity of impact on normal functions and growth. Following is a case of 16-year-old female patient who incurred secondary cleft deformities after undergoing multiple surgical interventions for congenital bilateral cleft lip alveolus and palate, last of which was conducted at the age of 6 years. Lip revision and tongue flap surgeries to close the palatal fistula were performed to address the patient’s complaint and improve quality of life. Performing a tongue flap for anterior palatal fistula was more successful than Bardach’s palatoplasty technique.&lt;strong&gt; &lt;/strong&gt;It is important that each case encountered at various congenital defect care facilities is reported in literature to make the masses aware of probably outcomes and also help maintain a database to have more accurate data of such cases.&lt;/p&gt;

Transpalatal Distraction Osteogenesis versus Hyrax Appliance for Correction of Unilateral Maxillary Hypoplasia in Cleft Palate Patients

Background: Collapsed maxilla in unilateral cleft palate patients results in unilateral cross-bite, tapered maxilla and crowding of the maxillary teeth. Distraction osteogenesis (DO) of collapsed maxilla in cleft palate patients has become the contemporary surgical management of many secondary cleft deformities. Purpose: the aim was to compare between the efficiency of using Transpalatal Distraction Osteogenesis (TPDO) and Hyrax appliance for three dimension correction of maxillary hypoplasia in unilateral cleft palate patients both clinically, radiographicaly and study cast analysis. Patients and methods: This study was comprised eight patients group1 (TPDO); (3) males and (5) females and eight patients group2 (Hyrax); (2) males and (6) females with unilateral maxillary hypoplasia after repair of unilateral cleft lip and palate. The age ranged from 13 to 27 years with a mean of 16.88 years. Patients were assessed clinically regarding: photographic, healing of the soft tissue, pain, and device loosening. Radiographically regarding: PA cephalometric, lateral cephalometric views and C.T scan. Study cast regarding: inter canine, inter premolar, and inter molar distance, palatal depth and width. Finally, the data were collected, tabulated and statistically analyzed. Results: The result of this study shows significant difference in inter canine, inter premolar and inter molar distances, palatal width and depth between the pre and post distraction in group (1) than in group (2).

Analysis of preoperative measurements in unilateral cleft lip patients toward the outcome of secondary cleft deformities

Introduction: The purpose of this study is to determine whether the severity of the initial cleft deformity has any effect on the postoperative result of primary lip and palate repair in terms of the presence or severity of secondary deformity. The anthropometric measurements of the cleft side will be measured against the noncleft side as control. Materials and Methods: This was a cross-sectional, noninterventional study conducted for 12 months from March 2017 to March 2018. All children aged 5–12 years old with unilateral cleft lip deformity who underwent cleft lip repair from the year 2005 to 2013 were included in the study with a total of 42 patients. Both preoperative and postoperative lip and nose, anthropometric measurements were taken with a ruler and caliper. Difference between cleft and noncleft sides for philtrum lateral height (PLH), lip height (LH), nostril floor width (NF), and nostril height (NH) were taken to represent asymmetry or the severity of deformity and categorized into a grading system representing initial severity (IS) and postoperative asymmetry (PA). Relationship between the IS and PA were analyzed. Results: All four indices were lesser for the postoperative measurements showing an improved outcome after surgery. There was a significant difference between the IS and PA for PLH (P < 0.001) and NF (P = 0.007), thereby inferring that IS grade is not symmetrical from PA for both indices measured. However, there was no statistically significant difference between the IS and PA for LH (P = 0.055) and NH (P = 0.410). Therefore, the IS and the PA for these two indices are symmetrical. A majority of patients are within the similar grade for both IS and PA for LH; 15 patients for IS and PA Grade 1 and 11 patients for IS and PA Grade 2 (n = 26). As for NH, there were 13 patients with IS and PA Grade 1 and eight patients with IS and PA Grade 2 (n = 21). Conclusion: This study determines a coherent connection between the preoperative and postoperative LH and NH asymmetry. Thus, the postoperative lip and nose height asymmetry was worse in more severe clefts compared to those with a less severe initial cleft deformity.

Management of Commonly Encountered Secondary Cleft Deformities of Face-A Case Series

Management of Commonly Encountered Secondary Cleft Deformities of Face-A Case Series

Postoperative Edema Resolution following Rhinoplasty: A Three-Dimensional Morphometric Assessment.

The final result of rhinoplasty may be masked for several months after surgery because of postoperative edema; however, no objective evidence supports this time estimate. The purpose of this study was to three-dimensionally quantify the decrease in postsurgical nasal edema following rhinoplasty over the first postoperative year. This was a retrospective, three-dimensional, morphometric study of primary, open rhinoplasty patients. Subjects with at least three postoperative three-dimensional images up to 1 year were included. Patients were excluded for closed or secondary procedures or cleft deformities. Images were assessed using three-dimensional stereophotogrammetry (Vectra) and volumetric analysis (Geomagic). Baseline nasal volume (time 0) occurred at the first postoperative visit at 1 to 2 weeks. All subsequent nasal volume measurements were calculated as a percentage of baseline values. Data points from all patients were pooled, and a six-point moving average was used to create an inverse function line of best fit. Forty patients were included, with 146 three-dimensional photographs quantified. The equation for the inverse function line of best fit of the six-point moving average was y = 1.484 (1/x) + 0.844 (R = 0.85, p < 0.01). According to this equation, approximately two-thirds of edema resolves within the first month, 95 percent after 6 months, and 97.5 percent after 1 year. A plateau is reached at 84.4 percent of the original postoperative volume. This study provides quantitative evidence to predict decrement of rhinoplasty edema with time. Three-dimensional morphometric assessment demonstrated a two-thirds decrease in edema at 1 month, a 95 percent decrease at 6 months, and a 97.5 percent decrease at 1 year. Therapeutic, IV.

Cosmetic Surgery in the Adolescent Patient

Individuals younger than 18 years represent an increasing number of cosmetic surgery patients. The goals of this article are to address the unique psychological aspects of teens and cosmetic surgery; to understand literature related to adolescents and cosmetic surgery; and to consider methods for evaluating adolescents who present for cosmetic surgery, specifically focusing on nasal and breast procedures. A PubMed search was performed using combinations of the keywords "cosmetic surgery," "adolescent," "psychology," "rhinoplasty," "breast augmentation/reduction," and "gynecomastia." In addition, the U.S. Food and Drug Administration and American Society of Plastic Surgeons Web sites were reviewed for related material. Thirty-three applicable articles were identified. Psychological aspects of surgery; nasal development; rhinoplasty; secondary cleft deformities; breast development, augmentation, and reduction; gynecomastia; and patient selection criteria are addressed. Because the number of adolescents seeking cosmetic surgery continues to grow, plastic surgeons must form a plan for addressing the concerns of these individuals and evaluating whether they are appropriate candidates for surgery. Further research is needed to understand the unique psychological and developmental considerations of adolescent cosmetic surgery patients.

Volume Enhancement of Upper Lip in Secondary Cleft Deformity Using Composite Mastoid Tissue

Secondary cleft lip deformity correction needs thorough assessment and planning to optimize treatment and achieve good results. Deficient volume of the upper lip, which is one of the most common secondary cleft lip deformities, has been addressed in many ways using tissues from local or distant areas. Consideration must be given to safety, easy availability of the tissues, minimum morbidity, and longevity of the results when selecting a procedure. This retrospective study included ten patients with a minimum follow-up of 1year. Composite mastoid fascia was harvested through a postauricular incision and used to augment deficient lip volume in secondary cleft lip deformities. Clinical assessment and measurement was performed by measuring the vertical height and projection of the deficient upper lip before and after surgery. At the end of 1year the average increase in the vertical height of the vermilion was 27.11% compared to the preoperative readings, with an average loss of 12.81% of increase at 1year. The lateral projection showed an increase of 23.88% compared to the reading taken before surgery, with a loss of 9.75% at the end of 1year. The donor site incision was concealed behind the ear and lip incisions were invisible in the long term. There were no major complications. This is a good way of augmenting the lip with due consideration given to longevity of the result and minimal morbidity. This method might also by used for permanent cosmetic lip enhancement for those with very thin lips.

Management of Secondary Cleft Deformities

Management of Secondary Cleft Deformities

Scar Flap for Extension of the Nasal and Lip Soft Tissue Shell in Secondary Cleft Deformities

A scar flap is formed with the pedicle at the lateral part of the columella base at the cleft side, that is, in the center of the affected region. It enables flap placement according to individual need. A prospective evaluation was performed in a group of 76 patients with cleft lip and palate, all operated on by the same plastic surgeon. The flap was used to improve the height of the columella and the extent of nasal mucosa on the frontal septum and on the nostril base in the vestibule. In the lip, the flap raised its height and improved proportionality. The average area of flap used in a unilateral deformity was 42 mm. Both flaps in a bilateral deformity were 77 mm. The average follow-up was 22.4 months. Neither local nor general complications were noted apart from a recurrence of the deformity of the nasal septum in 7.9% of patients. The nasal passage was improved in 59.9% of patients and normalized in 19.6% upon follow-up rhinomanometry, but nevertheless, only one third of patients overcame their dynamic stereotype of breathing by the mouth. Anthropometric measurements showed an absence of statistically significant differences between patients after surgery and healthy individuals in crucial parameters (nasal tip projection, length of columella, nasolabial angle, nasal angle, and lip angle). The loss of the stigmatizing deformity is based on rotation of the nasolabial angle in relation to the aesthetic axis of the face. Direct examination proved aesthetic and functional improvement as statistically significant in 92.1% of patients.

Double Unilimb Z-Plastic Repair of Microform Cleft Lip

Microform unilateral cleft lip is characterized by 1) notched mucosal margin; 2) thin medial vermilion; 3) elevated medial peak of Cupid's bow; 4) furrowed philtral column; 5) hypoplastic orbicularis oris; and 6) minor nasal deformity. The author's registry of unilateral incomplete cleft lip was culled for patients with microform cleft lip. Operative correction included: double-limb Z-plasty at the vermilion-cutaneous and vermilion-mucosal junctions; eversion of orbicularis oris; augmentation of philtral ridge with a dermal graft; medial positioning of the alar base; and elevation of the lower lateral cartilage. Microform phenotype was found in 33 of 360 infants (9.2 percent) with unilateral incomplete cleft lip. Male-to-female and left-to-right ratio were both 2:1. Median age at presentation was 11 months (range, 2 weeks to 9 years). Twenty-three patients had a double unilimb Z-plastic repair (including dermal graft and nasal correction). No revisions have been necessary at median follow-up of 5 years, however, 13 percent of children lacked prominence of the upper philtral column and one-third of children exhibited minor nostril asymmetry. Double unilimb Z-plasty corrects the vertical asymmetry in a microform cleft lip while limiting the scar to the lower one-half of the lip. The philtral ridge is formed by repair of the muscular diastasis and onlay of a dermal graft. Components of this technique are applicable to secondary cleft deformities, such as elevated peak of the Cupid's bow and inadequate philtral ridge.

The Central Lip Flap and Nasal Mucosal Rotation Advancement: Important Aspects of Composite Correction of the Bilateral Cleft Lip Nose Deformity

The columella, nasal tip, lip relationship in the secondary bilateral cleft deformity remains an enigma and a great challenge for the cleft surgeon. A subset of patients with bilateral cleft lip still require columellar lengthening and nasal correction, despite the advances in preoperative orthopedics and primary nasal corrections. An approach to correct this deformity is described. This consists of (1) lengthening the columella by a central lip advancement flap; (2) open rhinoplasty, allowing definitive repositioning of lower lateral cartilages, ear cartilage grafting to the tip and columella when necessary; (3) nasal mucosal advancement; (4) alar base narrowing; and (5) reconstruction of the orbicularis oris as required. Depending on the individual assessment of the patients, some of these steps were not performed, leaving the nasal mucosal advancement the most important aspect of the reconstruction. In a consecutive series of 72 patients with repaired bilateral cleft lip and palate, 17 patients have been treated with nasal mucosal rotation advancement and followed up for a maximum period of 10 years. With the use of this technique, the secondary bilateral cleft lip nose deformity has been successfully corrected.

Challenges in maxillofacial reconstruction on secondary cleft deformities

Cleft surgery demands much on the meticulous surgical skills and aesthetic sense in relation to craniofacial growth and functions. With the understanding of genetic interplay and peer review on the surgical outcome, cleft surgeons have made great strides in treatment concept during the past decades. It is inevitable that secondary cleft deformities may rely on the cumulative effects of functional and morphological abnormalities from the stage of primary repair. Problems could range from uncorrected defects, complicated healing from initial repair, to some exaggerated developmental facial disharmonies as the patients attain adolescent or adult age. For this reason, the Cleft Palate Team is posed an immense challenge in treating the residual cleft deformities. Some of the challenges include large oronasal fistula, severe maxillary or midfacial retrusion, and pursuit of aesthetics on lip nose complex correction. These problems demand sophisticated surgical skills and sound understanding of craniofacial bio‐physiology. The sequential treatment strategy of secondary cleft reconstruction as practiced in the United Christian Hospital is considered as the foundation in the management of those challenging maxillofacial complexities. The purpose of the present paper is to share our sequential protocol practiced in the United Christian Hospital as a foundation to accomplish those maxillofacial complexities. Treated clinical cases demonstrate the innovative application of distraction osteogenesis on severe cleft skeletal correction, the use of tongue flap for repair of large oronasal defect, and corrective radical rhinoplasty with fascial graft augmentation. The last section of the present report is concentrated on the practical application of Nasal Symmetry Index for assessing result of cleft rhinoplasty.

Challenges and recent advances in the management of secondary cleft deformities

Challenges and recent advances in the management of secondary cleft deformities

The Sliding Sulcus Procedure

During embryogenesis the clefting event unleashes a series of processes that act in concert to deform the soft tissue envelope into a "dysfunctional matrix" within which bone and cartilage subsequently form. Much of secondary cleft deformity results from failure to solve this pathologic soft tissue-bone equation at the primary repair. The sliding sulcus procedure uses the subperiosteal plane to create a centralization of the soft tissue matrix, alleviate tension, and redistribute the forces of growth in a more normal pattern. By incising at the level of the alveolus, this approach preserves the blood supply to the osteogenic cells of the buccolabial periosteum. This approach has interesting theoretical implications for the preservation of alveolar growth potential. Arch stabilization and elimination of fistula may be of long-term benefit to the orthodontist.