Secondary Cleft Rhinoplasty Research Articles

Factors associated with postrhinoplasty mucous cyst in cleft lip patients.

The purpose of this study was to identify risk factors associated with postrhinoplasty mucous cyst (PMC) among adult cleft patients undergoing rhinoplasty. PMC has been reported sporadically in the literature. Its aetiology is uncertain. The purpose of this study was to determine whether three factors, (1) patient age, (2) surgical trauma, and/or (3) use of a nasal septal cartilage graft (NSCG), were risk factors for PMC. We organized a retrospective, single-center study and enrolled cleft rhinoplasty patients treated between January 2003 and December 2008. The predictor variables included age at surgery, use of a NSCG, and length of surgery. The primary outcome was presence of PMC. Other study variables included demographic, surgical, and postoperative data. Appropriate descriptive and univariate statistics were calculated, and P < 0.05 was regarded as indicative of statistical significance. The sample comprised 314 cleft rhinoplasty patients (118 females; 37.6%) with a mean age of 14.9 ± 10.7years (range 0-65). Three patients had a PMC after secondary cleft rhinoplasty. Average time to disease was 26 ± 19.3months after surgery (range 12-48). There was no significant association between the presence of the PMC and the three predictor variables-patient's age, NSCG transplantation, and protracted surgery (P > 0.05). These study findings suggest that young age, use of a NSCG, and protracted surgery are not risk factors for PMC. The prevalence of PMC is greater for cleft patients after rhinosurgery than for noncleft patients.

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.

To Reduce the Secondary Revision Cleft Rhinoplasty Rate by Special Orbicularis Reconstruction

To Reduce the Secondary Revision Cleft Rhinoplasty Rate by Special Orbicularis Reconstruction

Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals

ObjectiveTo explore how improvement in facial appearance is related to patients' perception and satisfaction following cleft rhinoplasty. DesignA cross-sectional survey. Participants35 cleft rhinoplasty patients treated between 2005 and 2010. 45 observers comprised of healthcare professionals. Main outcome measuresEvaluation of patient satisfaction including Rhinoplasty Outcome Evaluation (ROE) questionnaire, Preoperative and Postoperative Semi-quantitative Ordinal Scale Rating (PPSOSR) and a specifically designed semi-structured questionnaire. Evaluation by panel of observers using Asher-McDade Aesthetic Index (AMAI) Rating and PPSOSR. ResultsPatient satisfaction was high, based on the ROE questionnaire (score 76.1). 91% of patients rated their appearance as improved, 3% remained ‘uncertain’ and 6% felt ‘different but not improved.’ Teenage females (score 94.1) showed statistically higher satisfaction, when compared to older females (score 75.5), or their male counterparts (score 69.8). The preoperative appearance ratings were not statistically different between patients and panel members but postoperatively, patients' rating of their appearance was statistically higher.All components of the AMAI were scored between ‘good’ to ‘fair’ (score 9.3). Seventy percent of the panel rated the postoperative appearance as improved. Interestingly, 10% rated the postoperative appearance as ‘unchanged’, while 3% reported a ‘worsened’ appearance. There was no correlation between panel assessment of aesthetic outcome and patient satisfaction. ConclusionsCleft rhinoplasty contributes to subjective patient satisfaction as a result of their perceived improvement in appearance and function, even though this was not correlated to objective aesthetic rating by panel members.

Secondary Cleft Rhinoplasty

The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a formidable challenge for the facial plastic surgeon. The underlying anatomic deformities combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult procedure for even the most experienced surgeons. Numerous techniques for secondary cleft rhinoplasty have been described in the literature over the past several decades, yet the lack of wide adoption of any given technique highlights the great variability seen with this problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or webbing have driven the progressive evolution of techniques developed to correct various aspects of the cleft nasal deformity. Despite the number of techniques that have been published, very few studies have looked specifically at outcomes in secondary cleft rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty.

Columellar flap for secondary cleft rhinoplasty with esthetic improvement of Millard's unilateral cheiloplasty scar

Columellar cartilage graft helps improve esthetic results in secondary cleft rhinoplasty for patients presenting with cleft lips. However, inadequate skin coverage of the cartilaginous graft can result in columellar necrosis and graft loss. Moreover, the scar after Millard's primary cheiloplasty may not be esthetic. The aim of this article was to present the columellar flap technique to cover the columellar graft and to improve the scar after unilateral Millard's cheiloplasty. The triangular flap is drawn on the edge of Millard's cheiloplasty scar. It is then moved in a V-Y fashion so as to cover the cartilaginous graft and improve the esthetic aspect of the new columella. Four hundred and twelve teenage/adult rhinoplasties were performed in our department over 10 years (October 2001 to October 2011). This flap was used in 10 patients who were followed-up for at least 1 year. There were no severe postoperative complications. Millard's unilateral cheiloplasty scar was less visible. A prospective study is ongoing.

Long-Term Effect of Primary Cleft Rhinoplasty on Secondary Cleft Rhinoplasty in Patients with Unilateral Cleft Lip–Cleft Palate

The senior author routinely performs primary nasal reconstruction with every cleft lip repair. This addresses the nasal tip asymmetry and simplifies the definitive secondary rhinoplasty in adolescence. A retrospective chart review was completed of all unilateral cleft secondary rhinoplasties performed by the senior author. The indications for secondary rhinoplasty were examined, anatomical features of the nose at the time of operation were documented, and the reconstructive techniques used were recorded. From 2001 to 2009, the senior author performed 116 secondary rhinoplasties in patients with a previously repaired unilateral cleft lip. The senior author performed 44 of the initial cleft lip repairs (group A). A Dibbell rhinoplasty was required in 26 percent, a Potter rhinoplasty was required in 5 percent, a Tajima inverted-U incision was required in 70 percent, and an alar base resection was required in 53 percent. For those patients who did not undergo cleft lip repair with primary rhinoplasty by the senior author, 60 percent required a Dibbell rhinoplasty, Potter rhinoplasty was not used, 76 percent required a Tajima inverted-U incision, and 64 percent required an alar base resection. Group A had significantly greater dome symmetry when comparing the cleft side to the noncleft side (p = 0.001). Nostril apex height was also more symmetrical in group A (p = 0.105). Primary nasal reconstruction performed with cleft lip repair as described by the senior author makes the nasal tip more symmetric and requires less complex intervention at the time of definitive secondary rhinoplasty. Therapeutic, IV.

Comparison of Suture and Graft Techniques in Secondary Unilateral Cleft Rhinoplasty

Every surgeon should master several techniques to modify the nasal tip. For secondary rhinoplasty, various techniques have been described. A modified technique of using the cephalic trim portion of lower lateral cartilage as onlay tip graft is also described. The objective of this single-blind randomized controlled trial was to compare the outcome of suture-only techniques and grafts-plus-suture techniques in terms of postoperative tip projection made measurable by the patient as excellent, good, or poor. Sixty patients with cleft nasal tip deformity who gave informed consent were included and randomly assigned to either technique. Patients requiring osteotomies and previously operated on for cleft rhinoplasty were excluded. Postoperative tip projection was assessed by the patient 6 months postoperatively. Mean age was 28.5 ± 2.1 years in suture technique (group A) and 29.1 ± 1.9 in suture-plus-graft technique (group B). There were 20 males (66.7%) and 10 females (33.3%) in group A and 22 males (73.3%) and 8 females (26.5%) in group B. Nasal deformity was moderate in 66.7% of cases in group A and 60.0% of cases in group B, whereas nasal deformity was severe in 33.3% of cases in group A and 40% of cases in group B. Postoperative tip projection was excellent in 7 patients (23.3%) in group A and 22 patients (73.3%) in group B, and good in 4 patients (13.3%) in group A and 5 patients (16.7%) in group B, whereas poor results were observed in 19 patients (63.4%) in group A and 3 patients (10.0%) in group B (P = 0.001). Graft-plus-suture technique is an effective method for improving the tip projection.

Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar grafting

Background Cleft-lip nasal deformity alters patient’s self-image, as well as posing unique challenges for the rhinoplastic surgeon. Objectives The main purpose of this study was to compare the panel perceptions of nasal aesthetics following secondary cleft rhinoplasty with versus without caudal septal extension grafting (columella grafting). We also investigated whether patient’s self-assessment and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) panel perceptions. Methods Using a cross-sectional study design, we enrolled a sample of adult laypersons and medical experts. The predictor variable was the rhinoplasty techniques (with/without columellar grafting). The outcome variable was the panel rankings of nasal aesthetics based on the photographs of 50 nonsyndromic cleft patients before and after the rhinoplasty. Other variables included the patient’s subjective assessment and satisfaction, demographic and anatomic variables. Appropriate descriptive, uni- and bivariate statistics were calculated. The significance level was set at P ≤ 0.05 and <0.05 for single- and two-tailed tests of hypothesis, respectively. Results The sample consisted of 507 laypersons and 51 professionals who gave comparative ratings ( P > 0.05). Columellar grafting was associated with higher rankings of postoperative nasal aesthetics ( P = 0.04). Most of the patients (90%) rated positive outcomes. Surgical techniques, patients’ age and gender, and panel perceptions were not individually significantly associated with subjective measures and satisfaction. Conclusions Our results suggest that caudal septal extension grafting improves the nasal aesthetics of the cleft patients, as judged by the panel. Patient’s self-assessment seems unreliable to be used as an outcome measure.

Secondary cleft rhinoplasty rejuvenates the nose: a suggestion from a panel survey

Cleft-lip nasal deformity (CLND) affects the overall facial appearance and attractiveness. The CLND nose shares some features in part with the aging nose. This questionnaire survey examined: 1) the panel perceptions of the role of secondary cleft rhinoplasty in nasal rejuvenation; and 2) the influence of a medical background in cleft care, age and gender of the panel members on the estimated age of the CLND nose. Using a cross-sectional study design, we enrolled a random sample of adult laypersons and health care providers. The predictor variables were secondary cleft rhinoplasty (before/after) and a medical background in cleft care (yes/no). The outcome variable was the estimated age of nose in photographs derived from 8 German nonsyndromic CLND patients. Other study variables included age, gender, and career of the assessors. Appropriate descriptive and univariate statistics were computed, and a P value of <.05 was considered to be statistically significant. The sample consisted of 507 lay volunteers and 51 medical experts (407 [72.9%] were female; mean age ± SD = 24.9 ± 8.2 y). The estimated age of the CLND noses was higher than their real age. The rhinoplasty decreased the estimated age to a statistically significant degree (P < .0001). A medical background, age, and gender of the participants were not individually associated with their votes (P > .05). The results of this study suggest that CLND noses lack youthful appearance. Secondary cleft rhinoplasty rejuvenates the nose and makes it come close to the actual age of the patients.

Assessment of Secondary Cleft Rhinoplasty Using Resorbable Plates at the Age of Primary School

Secondary rhinoplasty after a cleft lip repair remains a significant challenge. We have developed a technique in which resorbable plates are used to support the cleft alar cartilage to minimize relapse. There are few guidelines by which one can objectively assess the outcome of cleft rhinoplasty over time. This study attempts to demonstrate a means by which the symmetry and form of the proposed rhinoplasty technique can be evaluated. Sixteen patients with unilateral cleft lip/palate repair had a secondary rhinoplasty performed at age 6 to 8 years, using a resorbable plate (resorption time, 2-3 years) placed between the nasal lining and cleft alar cartilage to simulate the shape of the noncleft cartilage. Photographs were taken preoperatively and postoperatively. Median follow-up was 9.6 +/- 2.8 months. Various angles and ratios were measured to demonstrate outcomes, comparing preoperative to postoperative measures, and symmetry between cleft and noncleft sides. Postoperatively, the angle between the horizontal axis, drawn across the alar base and tangent to the alar rim on both sides, was significantly altered (P < 0.001); both sides were closer to 60 degrees (mean, 56.28 degrees), approximating the angle of the aesthetic norm. A measure of the angle between the horizontal axis and a line drawn from midpoint of axis to nasal tip was significantly closer to 90 degrees (P < 0.05). The shape of the affected nostril became more oval and symmetric relative to the unaffected side (P < 0.05). Angle between the horizontal axis and a line drawn through the widest point of each nostril was close to zero. (P < 0.001). The difference in nostril height between the cleft and noncleft sides was significantly decreased (P < 0.001). We have objectively evaluated the outcomes of our technique of secondary cleft rhinoplasty using resorbable plates for alar support. A careful geometric evaluation of preoperative and postoperative photographs can help determine the symmetry and overall quality of the result. These measures may help to evaluate long-term outcomes of cleft rhinoplasty over time.

Unblocking the Nose by Unplugging the Ear: The Use of Foam Ear Defenders as a Splint following Secondary Cleft Rhinoplasty

The functional and aesthetic result from secondary cleft rhinoplasty is commonly impaired by a bulge in the lateral nasal vestibule, which can relapse in the postoperative period despite careful intraoperative correction. We aim to improve our results by using a foam ear defender as a postoperative splint to prevent relapse. Case series of 10 patients with photographs of a typical clinical case. The postoperative nasal pack was exchanged with a foam ear defender on day 5. The splint was worn continuously for 3 to 4 weeks, then nightly for 3 months. The splint was changed daily by the patient. The results were assessed clinically by the senior author. The patients had little or no recurrence of the lateral vestibular bulge following nasal splintage. Foam ear defenders are a simple, cheap, and comfortable method to provide splintage to the nasal vestibule following secondary cleft rhinoplasty.

The Unrecognized Skeletal Components of the Cleft Lip Nose Deformity

Sir: We read with great interest the article entitled “Definitive Repair of the Unilateral Cleft Lip Nasal Deformity” by Dr. Byrd et al. on secondary cleft rhinoplasty.1 They have very correctly identified the two major groups of these patients who have different severities of cleft nose deformities. The pathologic features of cleft nose deformity have been clearly elucidated; however, there remain certain factors that, in our opinion, exert significantly deforming influences on the function, dynamics, and aesthetics of the lower third of the nose. First, the primary repair of the cleft lip must address the nasal septum in addition to the already described operative steps. The nasal septum in this situation is always displaced, especially in its caudal part, and presents in the noncleft vestibule. The body of the septum blocks the cleft vestibule, and the dynamics of this were illustrated in our recent article.2 This deformity can be well appreciated on three-dimensional computed tomographic reconstructions in adult age groups, where the septal deviation and accompanying deformity of the vomerine groove are unmistakable (Fig. 1). In this case, the vomerine groove is significantly skewed from the midline, and a hypertrophied anterior nasal spine is also present. The septal deformity was not corrected during primary surgery, with the resultant full-blown septocolumellar and vomerine deformity becoming apparent in adult life. Clinically, this deformity manifests more on the basal view, especially in the area of the columella, which is malaligned in an oblique direction, with its base deviated to the noncleft side and the tip deviated to the cleft side (Fig. 2).Fig. 1.: A three-dimensional computed tomographic scan of a 24-year-old woman with secondary cleft lip nose deformity. The skeletal components of hypertrophied anterior nasal spine, skewed vomerine groove, and deficient pyriform fossa are noteworthy.Fig. 2.: Clinical photograph of the same patient (basal view) demonstrates the clinical consequence of the uncorrected skeletal components of the right-sided cleft lip nose deformity.Thus, the analysis of any cleft nose deformity at any age must include an inquiry regarding residual septal deformity, physical examination to specifically study the columellar deviation, and a computed tomographic scan to confirm these findings. The operative algorithm must take into account the septocolumellar influences on the tip aesthetics and plan to eliminate them to achieve consistent results. The frontal and lateral postoperative views of Byrd et al.’s patients show a good result regarding nasal cartilage sculpturing and grafting procedures, but the basal view shows deviation of the columellar base toward the noncleft side and tip deviation toward the cleft side along with a deficient cleft side nose sill, although the authors do mention a septal straightening maneuver. This indicates the presence of a residual deviated nasal septum and consequent malaligned septocolumellar infrastructure. The skeletal components of the unilateral cleft lip nose deformity thus include a deficient inferior rim of pyriform fossa, hypertrophied anterior nasal spine, and skewed vomerine groove besides the well-described feature of ipsilateral maxillary hypoplasia. In addition, the nose sill needs to be addressed regarding the muscle and skeletal deficiency and qualifies for a place in the algorithm. The nasal sill is also deficient on the postoperative photographs. Many techniques have been described for augmenting the nose sill, and we have been using a superiorly based turnover orbicularis oris muscle flap for this purpose in addition to performing the other cartilage sculpturing and grafting procedures.3 Our recommendations for cleft lip rhinoplasty would be septoplasty with relocation of the caudal part of the septum, excision of the septospinal ligament, relocation of the anterior nasal spine, and augmentation of the nose sill in addition to the standard maneuvers for reconstructing the cartilage infrastructure of the nose.4,5 Rajiv Agarwal, M.Ch. Department of Plastic Surgery Chhatrapati Shahuji Maharaj Medical University Ramesh Chandra, F.R.C.S. Doctors Clinic Lucknow, India