Secondary Cleft Rhinoplasty Research Articles

The Role of Nasal Sill Correction in Secondary Cleft Rhinoplasty.

Evaluating outcomes after cleft rhinoplasty can be challenging because of the lack of objective measures that would lead to a more desirable outcome. This study is a 10-year retrospective review of 30 consecutive patients who underwent secondary unilateral cleft rhinoplasty performed by a single surgeon. Subjective ratings were made using the Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE), which rates 4 components (nose, cupid's bow, lateral lip, and free vermillion) with a score of 0 to 2. Multiple anthropometric measurements (nostril height ratio, width ratio, medial ¼ height ratio, sill ratio, nostril area ratio, columellar angle, tip projection ratio, and nasolabial angle) were taken using a free National Institutes of Health program, ImageJ. Standardized photographs were compared at T0 (preoperatively), T1 (<6 weeks postoperatively), and T2 (>6 weeks postoperatively). There were 30 patients who met our inclusion criteria: 10 males (66.7%) and 20 females (66.7%). Of these patients, 26 (86.7%) had a complete cleft lip and 4 (13.3%) had an incomplete cleft lip. The patients' average age at time of surgery was 16.2 years with a mean follow-up of 17.9 months. Subjective scores in both nasal and overall UCL SOE ratings improved from T0 to T1, 0.7 to 1.2 (P ≤ 0.001) and 3.6 to 4.7 (P ≤ 0.001), respectively. Visual analog scores in nasal and overall UCL SOE ratings improved between T0 and T2, 0.7 to 0.9 (P = 0.023) and 3.6 to 4.8 (P = 0.002), respectively. Of all the objective measures, nasal sill ratio and cleft height to width ratio correlated with improved subjective ratings across multiple time points. Our study shows that objective measures such as nasal sill and nostril shape (cleft height to width ratio) correlate with improved subjective visual analog scale using the UCL SOE. The nasal sill is an often overlooked, yet essential, part of creating an aesthetically pleasing nose during cleft rhinoplasty.

Three-dimensional analysis of autologous costal cartilage in Asian secondary unilateral cleft rhinoplasty

This study describes a surgical technique for secondary unilateral cleft rhinoplasty using autologous costal cartilage grafts. The grafts were designed preoperatively and analysed three-dimensionally in 15 Asian patients using a photogrammetric camera. Detailed measurements of the nasal anatomy were taken both preoperatively and postoperatively; the same measurements were also taken from the pre-planned images of the anticipated result. When compared to the preoperative measurements, the postoperative three-dimensional outcome analysis revealed several statistically significant improvements in the nasal appearance: nasal dorsal length (P < 0.001), nasal column height (P = 0.001), nasal column width (P = 0.002), nasal lobule height (P = 0.008), cleft side nostril height (P < 0.001) and width (P < 0.001), columella–labial angle (P = 0.001), and nasal tip projection to nasal dorsum length ratio (NTP/NDL) (P = 0.001). Conversely, the comparison of the postoperative and preoperative design measurements showed mostly no statistically significant differences. Thus, utilizing autologous costal cartilage is a reliable approach with predictable and consistent results in secondary cleft rhinoplasty.

Quantitative analysis of aesthetic outcomes of morphofunctional septorhinoplasty for secondary cleft lip nasal deformity

The main aim of this study was to assess nasal symmetry after morphofunctional septorhinoplasty, more specifically, symmetry of the alar base and nostrils, and nasal projection, in patients with unilateral and bilateral cleft nasal deformities. Secondary cleft rhinoplasty was performed using morphofunctional septorhinoplasty techniques in 150 patients with unilateral and bilateral cleft lip and nose deformities. Nasal changes were analysed by measuring nasal tip projection, nostril height, nostril width, alar base width, and nasal gap area preoperatively and postoperatively on standard submentovertex view 2-dimensional photographs. In the unilateral cleft group there were statistically significant improvements (p<0.001) in ratios of nasal height and width (p=0.024) and nasal gap area, and in nasal tip projection and alar base width. In the bilateral cleft group there were statistically significant improvements in nasal gap area ratio (p=0.009), nasal tip projection, and alar base width. The morphofunctional septorhinoplasty technique improved aesthetic outcomes.

Three-Dimensional Analysis of Definitive Secondary Unilateral Cleft Rhinoplasty Using Cartilage Graft.

Three-dimensional assessment of nasal morphology in patients with unilateral cleft lip nose treated by cartilage graft augmentation. Retrospective study. Thirteen patients with unilateral cleft lip nose underwent definitive secondary rhinoplasty and postsurgical changes were examined using a three-dimensional (3D) laser scan. Nasal dorsum length, nasal tip, alar width, and alar base width in frontal view; nasion depth, nasal tip projection, nasal dorsal angle, and nasal tip angle in lateral view; nostril width, nostril height, and nasal tip height in basal view were measured at preoperative (T1: within 6 months), short follow-up (T2: 2-10 weeks), and long follow-up (T3: 9-14 months). A significant change in alar width, alar base width, nostril width, and nostril height at the cleft side, nasal dorsum length, nasion depth, nasal tip projection, and nasal tip height was observed from T1 to T3 follow-up after rhinoplasty (P < .05), whereas the nostril height at the noncleft side was also significantly increased at T2 follow-up but the mean change in height relapsed at T3 follow-up. Alar width, alar base width, and nostril width at the noncleft side, and nasal tip angle did not change significantly after surgery at any follow-up period. 3D imaging evaluation after secondary cleft rhinoplasty demonstrated improved functional and aesthetic outcomes using a septal or conchal graft.

Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity.

Secondary cleft rhinoplasty presents some of the most challenging cases of both cosmetic and functional nasal deformities. Understanding the anatomy and growth abnormality seen with the cleft nasal deformity helps to tailor surgical management. This article seeks to expand on the application of current concepts in secondary rhinoplasty for unilateral cleft lip nasal deformity. The authors review nasal analysis in the cleft rhinoplasty patient and provide the surgical management for each aspect in the secondary cleft rhinoplasty. The secondary rhinoplasty was divided into seven areas: piriform hypoplasia, septal reconstruction, dorsal reshaping, tip reshaping, tip projection, alar reshaping, and alar repositioning. Surgical management for each is provided. Secondary cleft rhinoplasty requires an understanding of the structural dysmorphology, and the use of cosmetic, functional, and secondary rhinoplasty techniques for its successful management.

Diced costal cartilage graft combined with muscle repositioning improves Cleft-Side Alar asymmetry in Asian secondary unilateral cleft rhinoplasty: A three-dimensional evaluation

Asymmetry in a retrusive cleft-side ala situated posterior, lateral, and/or inferior to the non-cleft ala is aggravated by ipsilateral defect of the pyriform aperture. This study assessed diced costal cartilage graft combined with muscle repositioning in enhancing structural base and alar symmetry in secondary cleft rhinoplasty. From 2016 to 2019, 20 consecutive patients who underwent pyriform aperture paranasal augmentation combined with muscle repair secondary unilateral cleft rhinoplasty were reviewed retrospectively. Clinical three-dimensional (3D) photos were analyzed pre- and postoperatively, and the augmentation method and muscle repositioning were described detailedly. Twenty cases aged 22.2 ± 3.9 years were submitted to secondary cleft rhinoplasty with diced costal cartilage graft to the pyriform rim. They were followed up for 6.2-26.2 months, with postsurgical time averaging 10.3 ± 3.4 months. After total lip takedown by anatomic muscle re-approximation, the cleft to non-cleft side showed enhanced alar symmetry (p<0.001) and heightened vertical lip length (p<0.001). Additionally, the alar base inclination was improved toward the horizontal plane (p<0.001). The cleft-side ala was anatomically ameliorated after muscle repositioning combined with diced costal cartilage graft to the pyriform rim, improving alar symmetry. Complications were minimal, indicating the safety of this method.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: A 14-Year Review of Maintenance of Certification Tracer Data From the American Board of Plastic Surgery

To evaluate evolving practice patterns in secondary cleft rhinoplasty. Retrospective review of data submitted during Maintenance of Certification (MOC). Evaluation of MOC data from the American Board of Plastic Surgery. Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns. Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period. Practice patterns were compared to EBM trends during the study period. A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007). These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: 16-Year Review of Maintenance of Certification Tracer Data from the American Board of Plastic Surgery

Journal of the American College of Surgeons 231(4):p S220, October 2020. | DOI: 10.1016/j.jamcollsurg.2020.07.324

Secondary Unilateral Cleft Rhinoplasty Using Natural Curvature of Rib Cartilage as Alar Rim Graft: A Three-Dimensional Evaluation of Long-Term Results

Since 2012, the senior author has incorporated the natural curvature of rib cartilage as an alar rim graft in addition to the diced cartilage technique for unilateral cleft rhinoplasty. The aim of this study is to describe this modification and evaluate its long-term results regarding nasal symmetry using three-dimensional stereophotogrammetric assessment (3dMDface system). From 2012 to 2018, 47 consecutive patients that underwent secondary unilateral cleft rhinoplasty were reviewed retrospectively. Sixteen patients with both preoperative and postoperative three-dimensional photographs taken at least 6 months after the operation were included. SimPlant O&O software was used to measure parameters on three-dimensional photographs: nostril heights, nostril widths, nasal dorsum heights, alare width, nostril areas, overlapping nostril area, nasal tip protrusion, nasal length, and nasal height before and after surgery. The ratios between cleft and noncleft sides were calculated. In addition, the overlapping nostril area ratio, tip protrusion-width index, and nasal index were compared before and after surgery. The preoperative nostril height ratio (0.79), nostril width ratio (1.24), and nasal dome height ratio (0.84) between cleft and noncleft sides were significantly improved after surgery to 0.93, 1.06, and 0.97, respectively. The preoperative overlapping nostril area ratio (72.33 percent), nasal tip protrusion-width index (0.48), and nasal index (0.81) also showed significant improvement postoperatively to 83.91 percent, 0.57, and 0.74, respectively. This preliminary study supports the use of natural curvature of rib cartilage as alar rim graft in secondary unilateral cleft rhinoplasty, with long-term improvement regarding nasal symmetry and nasal profile. Therapeutic, IV.

Pyriform Costal Cartilage Graft Improves Cleft-Side Alar Asymmetry in Secondary Cleft Rhinoplasty.

The asymmetry of a retrusive cleft-side ala positioned posterior, lateral, and inferior relative to the noncleft ala is exacerbated by ipsilateral deficiency of the pyriform aperture. We describe use of pyriform costal cartilage grafts for enhanced structural foundation and alar symmetry in secondary cleft rhinoplasty. Retrospective case series. All pyriform aperture paranasal augmentation secondary cleft rhinoplasty cases performed between May 2013 and February 2018 were included. Clinical photos were analyzed, and these results are provided in addition to a detailed description of the augmentation technique. Twelve total cleft patients, 10 (83.3%) unilateral cleft lip and palate, 1 (8.3%) unilateral cleft lip, and 1 cleft palate (8.3%) were included. Age averaged 18.6 ± 6.0 years with 3 (25.0%) males and 9 (75.0%) females. Costal cartilage grafting to the pyriform aperture through the gingivobuccal sulcus was used to reposition the alar base and nasal sill to a more anatomic anterior position, thereby enhancing symmetry in secondary cleft rhinoplasty. Average rib graft donor site incision was 2.5 cm. Follow-up ranged from 3.2 to 48.2 months, average 15.3 ± 14.4 months. No complications related to the pyriform cartilage graft were observed, other than one minor intraoperative breach of parietal pleura. We observed improvement in the anatomic contour of the cleft-side ala with costal cartilage grafting to the pyriform rim. This resulted in improved cleft-side alar form and thus overall alar symmetry. These results were obtained consistently, without significant complications. This technique is safe and provides a powerful tool to reposition the ala in secondary cleft rhinoplasty. Further studies will quantify the enhancement in nasal base symmetry.

Secondary Cleft Rhinoplasty in 1720 Patients: Are National Practices Consistent With Guidelines?

To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally. Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis. National Surgical Quality Improvement Program-Pediatric Database. A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair. No relevant intervention. Age, demographics, comorbidities, and associated procedures. Over 5 consecutive years, 1720 patients underwent secondary cleft lip rhinoplasty nationally. Mean patient age was 9.3 ± 5.3 years. Unilateral cleft rhinoplasty patients were older (9.0 years) than bilateral patients (7.8 years; P = .001). Rib grafting was performed in 6.3% of patients at a mean age of 10.6 years with a higher proportion of Asian and female patients. Auricular grafts were more commonly performed by otolaryngology than plastic surgery. The most common adjunct procedures included secondary cleft lip revision (33.1%) and tympanostomy tube placement (10.2%). When subdividing by type of cleft rhinoplasty, tip rhinoplasty was performed at a mean age of 7.3 years compared to rhinoplasty with osteotomies and a major septal component at 12.1 years (P < .001). This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.

An Analysis of Aesthetic Refinements in 120 Secondary Cleft Rhinoplasties.

Secondary cleft nose rhinoplasty remains a challenging procedure. Cartilage memory and scar contraction are problematic factors. The need for more detailed procedures for secondary reconstruction in this patient population has arisen. Contemporary refinements demonstrate a highly structured approach. We conducted a retrospective study evaluating the aesthetic results of cleft patients who underwent secondary rhinoplasty. In a retrospective study, a photometric analysis of cleft patients operated in the period 2003-2011 was conducted. Reconstructive methods were documented. Pre- and postoperative photographs of cleft rhinoplasty patients were evaluated using a standardized protocol. Nostril width ratio, columellar angle, tip projection ratio, and nasolabial angle served as objective instruments. The Unilateral Cleft Lip Surgical Outcomes Evaluation score was chosen for external photometric rating and rated blindly by 2 external individual plastic surgeons as independent nonbiased reviewers. The interrater and intrarater reliabilities were calculated using the Cohen kappa coefficient (κ). A total of 120 secondary rhinoplasties in 85 uni- and bilateral cleft patients could be included. Mean follow-up was 20 months. A total of 60 (71%) patients needed additional bone grafting (chin/pelvis), and 23 (27%) patients a LeFort I osteotomy. In one third of the secondary rhinoplasties, a medial and/or lateral osteotomy was performed (34%). In one fourth (24%), an external septoplasty was considered necessary. In 55% (47 patients) of the cases, a columellar strut was used. Excluding bone grafts, a total of 173 other grafts (mean of 2 grafts/patient) were applied. Postoperative measurements for nostril width ratio and columellar angle were statistically significant. A structured approach with contemporary refinements is described in detail. Intra- and interrater reliabilities for photometric assessment according to the Unilateral Cleft Lip Surgical Outcomes Evaluation score are shown. A structured approach for secondary cleft rhinoplasty yields satisfying, reproducible, and stable results.

Three Dimensional Rhinoplasty and Nasal Airway Improvement in Cleft-Nose Deformity.

Septorhinoplasty is particularly challenging among revision surgeries for cleft sequelae. The challenge of cleft septorhinoplasty is mainly due to the complex anatomy of nose, deformity of each of its components and the difficulty and lack of clarity in surgical management. From 2014 to 2017, 26 patients with cleft lip nose deformity were operated by the same cleft team. The study was conducted to assess the improvement in nasal airway and appearance following secondary rhinoplasty with extracorporeal septoplasty. Post operatively each patient was evaluated using the standard modified rhinoplasty outcome evaluation questionnaire, a validated instrument that aids in stratifying patients according to their subjective response. All patients reported great relief of nasal obstruction and improved breathing. More than 80% of our patients were satisfied with improved aesthetics and reported better self-confidence. Secondary cleft rhinoplasty with extracorporeal septoplasty surgery significantly improves the cosmesis and nasal airway opening, subsequently giving them improved self-confidence.

Columellar strut graft in unilateral cleft nasal deformity: Anthropometry and clinical outcomes

Introduction: The cleft nasal deformity is a three-dimensional asymmetry involving all layers of the nose. Columellar strut graft is an important method to provide support to the skeletal framework in an attempt to retain structural support and balance. Aims: The purpose of our study is to describe the surgical outcomes following the use of columellar strut graft when it is used in secondary cleft rhinoplasty. The study was designed to identify the changes in tip projection (Tip Proj), tip rotation (Tip Rot), and other anthropometric measurements postoperatively. Materials and Methods: A prospective study was conducted among patients presenting with secondary cleft nasal deformity and operated utilizing a columellar strut graft. The parameters considered were columellar height (CH), columellar width, Tip Proj, Tip Rot, nasofrontal angle, nasofacial angle, and nasolabial angle. All the measurements were analyzed statistically. Results: During the study, results could be evaluated for 25 patients. The Tip Proj increased in 84% of patients, and the magnitude of difference between pre- and post-operative follow-up at 9 months was found to be statistically significant (P = 0.009). The CH increased in 20 patients (80%). The Tip Rot increased in 20 patients (80%). The postoperative changes were consistently maintained at different follow-up intervals. Conclusions: Columellar strut is necessary in improving the Tip Proj, correcting the tilted tripod and lower lateral cartilage deformities. It also functions as a central scaffold on which the tip structures can be unified.

Correction of secondary unilateral cleft-lip nasal deformity using autologous costal cartilage grafts

Objective To explore the comprehensive approach and efficacy of secondary unilateral cleft rhinoplasty by using autologous costal cartilage grafts. Methods Secondary rhinoplasty was performed in 28 patients with unilateral cleft-lip nasal deformity. The costal cartilage was harvested through a mini-invasive incision. Septal deviation was corrected, and nasal tip framework was reconstructed with the autologous costal cartilage through direct transcolumellar incision. Diced cartilage fragments were used to augment the depressed alar base. Nasolabial muscles were repositioned to restore the balance of muscular tension system. Results The appearance of the nasal deformity was greatly improved in all the 28 cases postoperatively by follow-up from 3 to 12 months. Increased stability and symmetry of the nasal tip, along with the improvement of nasal breathing function was achieved and sustained effectively. Conclusions Definitive secondary unilateral cleft rhinoplasty using autologous costal cartilage grafts provides good aesthetic and functional results. Key words: Costal cartilage graft; Unilateral cleft lip; Nasal deformity

Rotational Advancement in Cleft Nose Rhinoplasty – Buccal Mucosal Grafts Serve as a Powerful Tool

Our aim was to analyze our technique of a modified rotational advancement in conjunction with buccal mucosal grafts (BMGs) in a subgroup of severe cleft cases. A retrospective clinical and photographic evaluation was conducted. Columella angle (CA) and tip projection (TPR) served as instruments in a photometric analysis. Academic university hospital and specialized craniofacial cleft center. At the time of the secondary rhinoplasty, 61 cleft patients were included, all 17 years or older. Rotational advancement with usage of BMGs was performed in selected cases by a single surgeon. Nasal symmetry and aesthetic appearance. From 2003 to 2011, 29 unilateral severe cleft cases (group I) underwent a modified alar rotational advancement with BMGs. Group II, with 32 cases, represented patients without BMGs. Technique and management of BMGs were described in detail. The complication rate of donor and recipient site presented as very low. The CA was improved significantly in both groups. Also, TPR improved (not significantly) in group I. Using our technique, we considerably enhanced the aesthetic results and symmetry in secondary cleft rhinoplast. Rotating the vestibular skin makes it possible to eliminate the traction of this skin on the repositioned alar cartilage, therefore achieving a more pleasing and stable nasal symmetry in secondary cleft rhinoplasty. Versatile BMGs close this gap, thus making them a powerful tool in the arsenal of the reconstructive cleft surgeon.

Prospective Patient-Related Outcome Evaluation of Secondary Cleft Rhinoplasty Using a Validated Questionnaire.

To evaluate patient satisfaction and quality of life following secondary cleft rhinoplasty. Prospective consecutive patient, single unit, single surgeon study. Spires Cleft Centre, Salisbury, Wilshire, United Kingdom, and private practice. 56 (27 secondary cleft rhinoplasty) patients completed evaluation forms preoperatively and 3 to 6 months postoperatively. Subjective assessment was performed using a validated Rhinoplasty Outcomes Evaluation (ROE) questionnaire. This instrument comprises six questions that capture three quality-of-life domains: physical, mental/emotional, and social. Rhinoplasty outcomes evaluation scores were calculated (range = 0 to 100) to indication satisfaction with rhinoplasty outcomes. Average age was 28 years (range = 18 to 59 years). There was a significant subjective improvement in the total ROE evaluation scores from 28 ± 10 to 80 ± 11 (P < .01) in secondary cleft rhinoplasty. Similar results were achieved in noncleft rhinoplasty 34 ± 9 to 84 ± 9 (P < .01). Specific scores for nasal aesthetic appearance improved from 0.3 ± 0.2 to 3.2 ± 0.3 (P < .01) in secondary cleft rhinoplasty. No significant change was seen in breathing capacity in secondary cleft rhinoplasty (from 2.7 ± 0.3 to 3.2 ± 0.2; P = .29). All patients said they would undergo the procedure again. Our results demonstrate high patient satisfaction after cleft rhinoplasty with particular regard to cosmetic appearance. These results are similar to those for noncleft rhinoplasty. We would recommend the use of this simple and quick validated outcome tool with all rhinoplasty patients.

Cleft Rhinoplasty: A Surgical Technique

ABSTRACTNasal deformity, a common occurrence in unilateral and bilateral cleft lip and cleft palate patients, is a formidable challenge for the cleft surgeon. The underlying abnormal anatomy, aggravated by tissue scarring and loss of facial planes after primary procedures, makes secondary rhinoplasty a difficult procedure for even the most experienced. Over the past years, numerous techniques for secondary cleft rhinoplasty have been described in literature. Regardless of the technique adopted, the fundamental goal of cleft rhinoplasty is to achieve a nose that would be esthetically accepted in society as well as functionally accepted by the patient. The correction of nasal deformity can be performed with a closed or an open technique. This article highlights the open technique used for secondary rhinoplasty for a challenging case of unilateral cleft lip nasal deformity in an adult patient.How to cite this articleMehrotra V, Natarajan S, Deshpande G, Merchant R. Cleft Rhinoplasty: A Surgical Technique. J Contemp Dent 2017;7(3):188-193.

Nasal appearance after secondary cleft rhinoplasty: comparison of professional rating with patient satisfaction.

The purpose of this study was to compare professional rating and patient satisfaction of nasal appearance after secondary cleft rhinoplasty. We used a cross-sectional study design and enrolled German adults with nonsyndromic unilateral or bilateral cleft lip and/or palate (UCLP and BCLP, respectively) undergoing secondary cleft rhinoplasty from January 2001 to December 2013. The predictor variable was professional rating. The outcome variable was patient satisfaction with postoperative nasal aesthetics. Other study variables included patient age and gender, type of surgery, and patient rating of nasal function. Appropriate descriptive and univariate statistics were computed, and a P value of <0.05 was regarded as statistically significant. Inter-rater reliability was assessed by the use of Cohen's kappa coefficient. The study sample consisted of 242 adult cleft patients of mean age of 22.1±9.2years (range 14-64), including 97 females (40%) and 176 unilateral clefts (73%). Most of the patients reported good function (82%) and good aesthetics (74%). The main professional rating was good aesthetics (65%). Analysis of inter-observer reliability revealed significant differences between patient satisfaction and professional assessment (κ=0.385; P<0.0001). Although most of the patients were satisfied with the functional and aesthetic results of secondary cleft rhinoplasty, patient self-assessment of nasal appearance differed from professional assessment.

Technique in Cleft Rhinoplasty: The Foundation Graft.

Secondary cleft rhinoplasty represents a particular surgical challenge. The authors have identified the deficit in skeletal projection of the cleft-sided piriform rim as an important contributor to the pathology. A graft is described to augment the piriform crest on the cleft side. This foundation graft is suture fixated to the piriform crest after complete release of all soft tissue attachments to the alar base. The foundation graft is articulated with a long alar strut graft, which allows for powerful projection of the cleft-sided nasal tip. An advancement flap of vestibular skin is described to correct the vestibular stenosis. A transplant of diced cartilage in fascia is added to augment maxillary soft tissue volume. Subjective and objective measures of form and function are presented in a retrospective series of five cases, illustrating the efficacy of the techniques described.