Secondary Cleft Research Articles

Revisional Techniques for Secondary Cleft Lip Deformities.

Secondary deformities of repaired cleft lips are an unfortunate complication despite the meticulous approach of modern primary procedures. Most of these surgeries take place in the patient's early life and must be strategically planned to provide optimal cosmesis with minimal interventions. Depending on the level of severity, treatment of the secondary deformities ranges from noninvasive or minimally invasive techniques to complete revision cheiloplasty. Many novel topical, injectable, and laser therapies have allotted physicians more technical flexibility in treating superficial distortions. Nonetheless, surgical techniques such as diamond excision and adjacent tissue transfer remain popular and useful reconstructive modalities. Deformities involving the orbicularis oris must be completely taken down to allow full access to the muscle. Complete revision cheiloplasty requires recreation of the cleft defect and reconstruction similar to the primary repair. Due to the myriad of presentations of these secondary deformities, familiarity with the various treatments available is imperative for any cleft surgeon.

The Performance of Secondary Nasal Alar Base Revision for Unilateral Cleft Lip by Single YV-Plasty (the Importance of Overcorrection During Surgery).

Although primary surgery for cleft lip has improved over time, the degree of secondary cleft or nasal deformity reportedly varies from a minimum degree to a remarkable degree. Patients with cleft often worry about residual nose deformity, such as a displaced columella, a broad nasal floor, and a deviation of the alar base on the cleft side. Some of the factors that occur in association with secondary cleft or nasal deformity include a deviation of the anterior nasal spine, a deflected septum, a deficiency of the orbicularis muscle, and a lack of bone underlying the nose. Secondary cleft and nasal deformity can result from incomplete muscle repair at the primary cleft operation. Therefore, surgeons should manage patients individually and deal with various deformities by performing appropriate surgery on a case-by-case basis. In this report, we applied the simple method of single VY-plasty on the nasal floor to a patient with unilateral cleft to revise the alar base on the cleft side. We adopted this approach to achieve overcorrection on the cleft side during surgery, which helped maintain the appropriate position of the alar base and ultimately balanced the nose foramen at 13 months after the operation. It was also possible to complement the height of the nasal floor without a bone graft. We believe that this approach will prove useful for managing cases with a broad and low nasal floor, thereby enabling the reconstruction of a well-balanced nose.

Aesthetic Enhancement of the Vermilion Using Dermofat Graft in Patients With Cleft Lip Deformity.

There is an increasing patient expectation for better esthetics, manifesting through anatomical harmony, projection, and volume of the upper lip relative to the lower lip, in patients with cleft deformity. The aim of this study is to investigate the outcome of vermilion augmentation using autologous dermofat graft (DFG) to enhance the lip using both quantitative and qualitative assessment. Patients with secondary cleft lip deformity who received the surgical treatment in our institution from 2015 to 2018 were recruited. Panel assessment was performed on standardized preoperative and postoperative digital photographs. A patient questionnaire was used for the reported outcome. Image processing and analyses were applied to measure the lip change. Statistical analyses were performed. A total of 91 patients were included. The mean age at operation was 22.7 years, and postoperative follow-up was 3.6 years. There were no complications in the study group. The panel assessment showed significant improvement (P < .00001) on upper lip vermilion in both frontal and lateral profile views. Ninety-five percent of patients reported improvement of the upper lip projection and volume. Quantitative image analysis showed an increase in the upper lip vermilion ratio in 97% of the cases in frontal views and improvement of the vermilion projection in 87% of the cases in the superimposed lateral views. The use of DFG is an effective and reproducible method for vermilion augmentation and aesthetic enhancement in patients presenting with upper lip insufficiency relative to the lower lip.

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.

Three-dimensional creation of the peak of Cupid’s bow by muscle tension line group reconstruction in secondary cleft lip repair

The peak of Cupid’s bow is a unique three-dimensional structure. Traditional reconstructive techniques focus only on the correction of vermillion border malalignment and the vertical discrepancy between Cupid’s bow peaks from a two-dimensional perspective. The aim of this study was to introduce a novel technique – the muscle tension line group reconstruction technique – to recreate the Cupid’s bow peak three-dimensionally in secondary cleft lip repair. With this technique the orbicularis oris muscle is divided into two flaps: a lateral one composed of pars marginalis and a medial one composed of pars peripheralis. The full thickness of the medial flap is sutured to the deep layer of the lateral flap, and the end of the lateral flap is then sutured to the dermis lateral to the philtral dimple to accentuate a depression. In this way, the two muscle flaps exert opposing skin traction on each side of the peak, which improves the vertical height as well as the lateral projection of the Cupid’s bow peak. The postoperative outcomes indicate that this is a reliable technique for three-dimensional restoration of the Cupid’s bow peak, with a stable and natural reconstructive appearance.

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.

The Effects of Alar Base Augmentation in Secondary Unilateral Cleft Lip Nasal Deformity.

In unilateral cleft lip and palate patients, the alar base is displaced inferoposterolaterally due to the depression of the pyriform aperture in the cleft side, and the drooping of the nostril rim is provoked by displacement of the alar base. This study was conducted between May 1998 and December 2012. In total, 82 patients with secondary unilateral cleft lip nasal deformities were treated using alar base augmentation. The patients were divided into two groups according to the degree of their preoperative alar base asymmetry. Patients with alar base asymmetry <3 mm were treated with a soft tissue augmentation procedure. Those with alar base asymmetry >3 and <6 mm were treated with a bony augmentation procedure. Soft tissue augmentation was conducted in 42 patients, and bony augmentation was conducted in 40 patients. In the soft tissue augmentation group, the degree of alar base asymmetry was improved from 2.42 ± 0.38 mm preoperatively to 0.45 ± 0.21 mm postoperatively (P < 0.05). In the bony augmentation group, the degree of alar base asymmetry was improved from 4.33 ± 0.50 mm preoperatively to 0.81 ± 0.20 mm postoperatively (P < 0.05). In the amount of alar base augmentation, there were statistically significant differences between the soft tissue augmentation group and the bony augmentation group (P < 0.05). This clinical study shows that secondary cleft lip nasal deformities can be corrected with alar base augmentation using soft tissue and bony augmentation and that these procedures can provide reliable, satisfactory, and safe clinical outcomes.

Correction of secondary unilateral cleft lip nasal deformity in adults using lower lateral cartilage repositioning, columellar strut, and onlay cartilage graft on the nasal tip with open rhinoplasty combined with reverse-U incision

A rhinoplasty technique involving lower lateral cartilage (LLC) repositioning and grafting of ear cartilage allows for nasal lengthening and nasal tip mobility. For better esthetic outcomes in patients with cleft lip nasal deformity (CLND), we combined cosmetic nasal tip plasty with standard techniques. We performed open rhinoplasty combined with reverse-U incision and V-Y plasty in 62 patients with secondary unilateral CLND from October 2013 to June 2018. Both LLCs were isolated, repositioned, approximated medially, and advanced with a Medpor strut, followed by tip suture technique. To further project and enhance the nasal tip and columella, application of ear cartilage onlay graft was used. As adjunctive procedures, septoplasty or osteotomy was carried out for correction of septal or nasal bone deviations, respectively. Photogrammetric evaluations of patients and statistical analyses were performed. Average age at operation was 23.5 years (range: 18-42 years). Of the 62 patients, 15 underwent dorsal augmentation with silicone implant. Two-layer conchal cartilage onlay grafting was performed to manage tip height. Outcomes in 34 patients were analyzed with pre- and postoperative photography. Nasal tip projection increased, alar base width index decreased, and alar and columellar symmetry significantly improved. No Medpor implant exposure or other adverse outcomes occurred. The proposed technique is effective for correcting secondary unilateral CLND and achieving a satisfying nasal appearance in adults.

Effect of Mesenchymal Stem Cell Injection on Healing Outcome in Secondary Cleft Lip Correction

Effect of Mesenchymal Stem Cell Injection on Healing Outcome in Secondary Cleft Lip Correction

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

Strategy for Correction of the Whistling Deformity in Secondary Cleft Lip Reconstruction.

Background:Following primary repair of a cleft lip, patients present with many facial deformities. One of the commonly observed sequelae of cleft lip repair is a whistling deformity. This retrospective study was carried out to evaluate the outcomes following correction of whistling deformities in secondary cleft lip reconstruction.Methods:We retrospectively reviewed the hospital records of patients with various whistling deformities who underwent repair from April 1989 to March 2018; 2 surgeons performed the repair using either the double movable mucomuscular complex flaps technique, modified Abbe flap technique, or Abbe flap technique. The postoperative anatomical structure and aesthetic effects of the surgery were evaluated.Results:In total, 136 patients were included in this study. Among these patients, 60 (44.2%) had a grade I whistling deformity and 47 (34.5%) had a grade II deformity and repair was performed using the double movable mucomuscular complex flaps technique and modified Abbe flap transfer technique, respectively, whereas the Abbe flap transfer technique was used in 16 patients (11.8%) and 13 patients (9.5%) with a grade III and grade IV whistling deformity, respectively. All patients were found to have normal postoperative anatomical structures and aesthetic effects of the upper lip, with all patients experiencing mild to moderate postoperative edema of the upper lip, and 29 cases (21.3%) developed an inconspicuous scar.Conclusion:The repair technique should be chosen based on the type of whistling deformity.

Modified Use of Costal Cartilage in Asians for the Correction of Nostril Asymmetry in Unilateral Secondary Cleft Lip Nasal Deformity.

BackgroundWeak alar cartilage and lack of soft tissue on the cleft side are considered to be the main critical factors leading to the asymmetry of bilateral nostrils. The costal cartilage can provide strong structural support and can be used to maintain long-term stability of nostril shape after surgical correction. With the advancement in rhinoplasty techniques, the application and understanding of costal cartilage in cleft lip nasal deformity is still on going. Herein, we present our technique of applying costal cartilage to provide nostril support and correct asymmetry in Asian patients with unilateral secondary cleft lip nasal deformity.MethodsNinety-seven patients who underwent nostril asymmetry correction from January 1, 2013, to October 31, 2018, were analyzed retrospectively. Modified integrative alar cartilage strut and diced nostril augmentation with costal cartilage were implemented to improve the collapsed and flat cleft-side nostril. The release and restoration of muscle and bone were also performed when required. Surgical outcomes were analyzed based on the comparison of nostril parameters, the shape and contour, and symmetry of bilateral nostrils after surgery. During postoperative follow-up, the patients' satisfactions with the corrective outcomes were also investigated.ResultsAll patients received the corrective operations with complete survival of all implanted cartilages. The nostril width was narrower in postoperative group (P < 0.05). The nostril height and long axis angle were higher postoperatively (P < 0.05). After correction, the proportion of moderate type increased from 13.4% to 80.4%, whereas the proportion of horizontal type decreased from 86.6% to 17.5%. The symmetry score on the nostril parameters manifested the rate of high score (AS >3) in postoperative groups were 84.5%, 93.8%, and 87.6% for width, height, and angle of the long axis, respectively. They were higher compared with those of preoperative group (0%). More than 95% of the patients were satisfied with the overall aesthetic outcome of the surgery.ConclusionsThrough ameliorating its constructive technology and optimizing its filling form, the modified use of costal cartilage displayed excellent correction effects in the width, height, and long axis angle asymmetry of Asian patients' nostril. Precise and comprehensive rhinoplasty technique is the cornerstone for achieving satisfactory long-term aesthetic outcomes, especially in severe cases, such as secondary cleft lip nasal deformity.

Anthropometric Changes in the Upper Lip Between the Standing Position in the Clinic and Supine Position on the Operative Table in Secondary Cleft Lip Nasal Deformities.

We evaluated changes in lip height and length by position in cleft lip nasal deformity patients who underwent treatment with Millard technique. A retrospective review of the medical records and an anthropometric analysis of photographs were performed in 209 cases of cleft lip nasal deformity. In the photogrammetric analysis, the lip height and length were calculated with respect to the intercanthal width. To evaluate the change in the difference between the cleft- and noncleft-side measurements between the standing and supine positions, the difference between the cleft- and noncleft-side measurements (Δnc-c) was calculated. We identified which patients and surgical factors affected the difference between the cleft- and noncleft-side measurements between the standing and supine positions (Δst-sp). From a total of 120 cases, cases with missing medical charts and clinical photographs were excluded, and 89 cases were included in this study. The discrepancy between the cleft-side lip height and noncleft-side lip height was significantly different between the standing and supine positions (P = 0.007). According to the univariate regression analysis, Δst-sp (sbal-cphi) had a significant positive correlation with body mass index (P = 0.044). In the final multiple linear regression analysis, body mass index had a significant positive correlation with Δst-sp (sbal-cphi, P = 0.044). In our results, the difference in vertical lip height is easy to underestimate in the supine position during surgery. Therefore, surgeons should verify lip height with the patient in the sitting or standing position during the operation to avoid undercorrecting lips with short heights.

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.

Authors' Comments—Long-Term Postoperative Cone-Beam Computed Tomography Analysis of Secondary Bone Grafting in 79 Patients With Unrepaired Alveolar Clefts

Authors' Comments—Long-Term Postoperative Cone-Beam Computed Tomography Analysis of Secondary Bone Grafting in 79 Patients With Unrepaired Alveolar Clefts

Morpho-Functional Septorhinoplasty in Adult Patients With Unilateral Cleft Lip Nasal Deformity: A Comprehensive Approach

The aim of this study was to introduce a morpho-functional technique of rhinoplasty for correction of defective nasal morphology of the secondary unilateral cleft lip and improvement of air passage through the nose. The described comprehensive approach follows the rule of 5R's: relieve, resect, reposition, restructure, and restrengthen. The extended septal graft serves as a columellar strut on the one hand and as a spreader graft on the other hand. The described morpho-functional septorhinoplasty technique is effective for correction of the unilateral cleft lip nasal deformity because it improves the symmetry of the nose, improves the morphology of the alar cartilage, and increases the nasal tip projection. An improvement in breathing occurs as a result of restored symmetry of the ala and nasal vestibule. Morpho-functional septorhinoplasty is a practical tool to handle adult patients with secondary cleft nasal deformities.

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.

Change in Incisional Design in Primary Unilateral Cleft Lip Repair Under General Anesthesia.

Nasolabial features of infants with unilateral cleft lip (UCL) are different when they are under general anesthesia for lip repair compared to when they are awake. This study aimed to investigate changes in the incisional design of cheiloplasty according to patient position and anesthesia: upright and awake versus supine and under general anesthesia. Three-dimensional images of 20 infants with UCL were randomly selected. Two different incisional designs were drawn on the images captured while the infants were awake. Those incisional designs were anthropometrically compared to the designs drawn on the images captured while the infants were under general anesthesia. Under general anesthesia, vermillion height of both the medial and lateral sides of the cleft became significantly greater. In the rotation-advancement design, the incisional line of the rotation flap on the medial lip element became significantly shorter under general anesthesia, whereas the advancement flap on the lateral lip element was not significantly altered. In an anatomical subunit approximation, both lengths of the philtral ridge on the noncleft side and incisional line along the philtral ridge on the cleft side became significantly shorter under general anesthesia, but these alterations did not affect the calculation of the width of the small triangular flap on the lateral lip element. These changes in nasolabial features after general anesthesia may cause surgical error, which result in secondary cleft lip deformities. However, because these changes varied among infants, preoperative planning using three-dimensional facial images of infants who are awake may be able to avoid surgical error.

The use of Botulinum Toxin A in the surgical treatment of secondary cleft lip (secondary cheiloplasty): An objective and subjective evaluation of esthetic outcomes

The surgical correction of the cleft lip is a challenging one and obtaining consistently good esthetic outcomes sometimes can be elusive. Primary correction of cleft lip often results in secondary deformities requiring re intervention. Chemoimmobilsation with Botulinum Toxin A post-secondary cheiloplasty can help obtain favourable esthetic results. Aims: To evaluate the esthetic value of Botulinum Toxin A injection in secondary cleft lip surgeries and to assess the role of Botulinum toxin A in secondary cleft lip scars. Materials and Methods: 30 systemically healthy unilateral cleft lip patients reporting for secondary cheiloplasty procedure were taken up for the study. 10-12 units of Botulinum Toxin A was injected along pre-determined points on the lip. Objective (Photographic evaluation) and subjective (Patient questionnaire method) evaluation was carried out after one year post injection of Botulinum Toxin A. Results: Photographic evaluation revealed that the outcomes were mostly excellent or good. Subjective evaluation conducted showed that majority of patients were either happy or very happy with the esthetic results. Keywords: Botulinum Toxin A, cheiloplasty scars, esthetic evaluation, secondary cheiloplasty, secondary cleft lip, subjective evaluation, unilateral cleft lip.

The Effect of Autologous Alveolar Bone Grafting on Nasolabial Asymmetry in Unilateral Cleft Lip and Palate.

The objective of this study was to examine whether an autologous alveolar bone graft has an effect on the nasolabial asymmetry in unilateral cleft lip, alveolus, and palate. Fifteen children (mean age 7.5 ± 2.4 years) with non-syndromic unilateral cleft lip and palate (CLP) were included. Non-ionizing three-dimensional images were acquired prior to and three months after the alveolar bone grafting procedure. A 2D and a landmark-independent 3D asymmetry assessment were used to detect changes of asymmetry in the nasolabial area. For the 2D assessment, a cleft and non-cleft side ratio for 4 linear nasal and 2 linear labial distances was expressed as a Coefficient of Asymmetry (CA). The 3D asymmetry assessment comprised a robust superimposition of the face with its mirror image, expressed as a root-mean-square-error (RSME) in mm. A significant decrease in the CA for the labial distance from the facial midline to the labial commissure was observed (P = 0.036). Also, the CA for the labial distance from the facial midline to the highest point of Cupid's bow increased significantly (P = 0.028). Non-significant changes were observed for the CA for the 2 nasal distances and the 2 other labial distances. No significant changes in 3D nasal asymmetry were detected (P = 0.820). Alveolar bone grafting completes the alveolar ridge but has only little to no clinical effect on the asymmetry of the secondary cleft lip nasal deformity.