Unilateral Cleft Nose Deformity Research Articles

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

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

UNILATERAL CLEFT NOSE DEFORMITY

INTRODUCTION Cleft lip deformity is a complex 3-dimensional congenital facial deformity which leads to poor functional, aesthetic and social outcomes. METHODOLOGY In order to optimize the aesthetic symmetry of unilateral cleft lip nasal deformity correction, we propose an anatomic technique involving reconstruction and restoration of the cleft side alone and to fashion it akin to the normal side in teh form of a case series. SURGICAL TECHNIQUE 1. All the cases were operated by the open Rhinoplasty approach, using the standard stair step trans-columellar and infracartilaginous incision. In unilateral cleft lip nose deformity, the whole lateral wall of nose including the nasal bone, the upper lateral cartilages and the lower lateral cartilages of the cleft side appears to be imbalanced with respect to the normal side. RESULT Based on the Rhinoplasty Out come Evaluation (ROE) questionnaire, all patients experienced improved appearance of the nose and felt less stigmatization from the society Keywords: Cleft lip deformity, Rhinoplasty, open Rhinoplasty

Achieving midvault symmetry in unilateral cleft nose deformity rhinoplasty

Abstract Background The objective of the study was to provide aesthetic improvement in unilateral cleft nose deformity by reconstructing the midvault of cleft side alone with unilateral osteotomies, simulating symmetry with the normal side, together with tip reconstruction. While most of the literature emphasizes on tip reconstruction, few of them focus on techniques of repositioning the slanting nasal sidewall, which aids in achieving the desired symmetry. We describe a method of repositioning the bony nasal vault to a more lateral and symmetrical orientation by making unilateral osteotomies. Results Eighteen patients of unilateral cleft nose deformity underwent rhinoplasty between March 16 and January 20. All patients had prior primary cleft lip repair. Thirteen patients underwent primary rhinoplasty while 5 underwent secondary rhinoplasty having undergone primary rhinoplasty elsewhere. Follow-up was from 1 to 3 years. Results were evaluated using Rhinoplasty Outcome Evaluation [ROE] Questionnaire, and Asher McDade Aesthetic Index [AMAI] Rating. Pre- and post-operative scores were compared. All patients were subjectively satisfied. The ROE and AMAI scores showed statistically significant improvement from pre-operative scores. Conclusion Obtaining symmetry in cleft nose deformity is a surgical challenge even in experienced hands. Using structural grafts only on the cleft side we attempted to create a near normal symmetry and achieve a natural nasal appearance, with satisfactory improvement from both patient’s and surgeons’ perspective. Level of evidence Case series- 4

Long-Term Outcome of Primary Rhinoplasty with Overcorrection in Patients with Unilateral Cleft Lip: Avoiding Intermediate Rhinoplasty.

No consensus exists regarding the timing or technique of rhinoplasty for correction of the unilateral cleft lip nose deformity, with few studies examining the long-term effects of a single technique. This study appraised the long-term outcomes of primary rhinoplasty using the Tajima technique for overcorrection in a cohort of patients with unilateral cleft lip nose deformity after attaining skeletal maturity. Consecutive nonsyndromic patients with unilateral cleft lip nose deformity ( n = 103) who underwent primary rhinoplasty with overcorrection by a single surgeon between 2000 and 2005 were reviewed. Patients with unilateral cleft lip and nasal deformity who underwent primary rhinoplasty (but with no overcorrection) ( n = 30) and noncleft individuals ( n = 27) were recruited for comparison. Outcomes were assessed through FACE-Q scales evaluating satisfaction with appearance of nose and nostrils (two scales) and computer-based objective photogrammetric analysis of nasal symmetry (nostril height, nostril width, nostril area, alar height, and alar width parameters). Significant differences (all P < 0.001) were observed between the Tajima and non-Tajima groups for all but one photogrammetric nasal parameter (nostril area), with the Tajima group demonstrating closer mean values to the noncleft group. The Tajima and noncleft groups demonstrated no significant difference (all P > 0.05) for scores of FACE-Q nose and nostrils scales. This study indicated that the patients who underwent primary rhinoplasty with overcorrection had improved results with no necessity for intermediate rhinoplasty, emphasizing that the procedure is an effective approach to correct the unilateral cleft nose deformity. Therapeutic, III.

Surgical design and application of alar cartilage positioning and repositioning in correcting cleft lip nose deformity.

Correction of nasal deformity is integral to modern cleft lip repair, and high risk of postoperative relapse remains a technical hurdle to overcome. The authors previously presented internal fixation of alar cartilage based on Chinese nasal morphology and lateral columella tissue increment for the correction of unilateral cleft nose deformity. Through the application and review of these techniques, the authors developed a new technique named alar cartilage positioning for primary cleft nose correction, or alar cartilage repositioning for secondary cases. Here, we introduce the theoretical foundation and preliminary experience in using this new technique.

A Single Stage Composite Cleft Septorhinoplasty for Correction of the Mature Unilateral Cleft Nose Deformity - The Gujrat Technique.

To evaluate the results of a single stage composite cleft septorhinoplasty procedure ("The Gujrat Technique") to correct the exaggerated cleft nose deformity after completion of nasal growth in an adult patient cohort. Adult patients with a residual unilateral cleft nasal deformity were deemed eligible for the proposed "Gujrat Technique". Over a 10-year period (2007-2017), 96 adult patients underwent this composite cleft septorhinoplasty as a single stage operation. Post-operative nasal symmetry evaluation was undertaken using the validated computer program 'SymNose'. Functional outcome and patient satisfaction were assessed using Nasal Obstruction Symptom Evaluation scale and Rhinoplasty Outcome Evaluation (ROE) questionnaires respectively. Various statistical analysis methods were used to validate the obtained results. Due to poor compliance with follow-up, post-operative assessments were undertaken in only 32 patients. The single group study design using the non-parametric matching pairs Wilcoxon Sign test (p < 0.001) showed overall good to excellent functional and aesthetic outcomes and higher scores of the digital SymNose grading system. There was a significant improvement in ROE scores (from 26.4 ± 2.9 to 85.9 ± 4.7, p < 0.001). There were no major complications or revisions needed in our series. The individual components of "The Gujrat Technique" are not novel but their combination in this adult unilateral cleft rhinoplasty cohort has demonstrated a high patient satisfaction with its aesthetic appeal and functional versatility. In the background of limited resources and unpredictable patient follow up, the simplicity, reproducibility and cost effectiveness of this technique make it a practical reconstructive option.

A modified nasoalveolar molding technique for correction of unilateral cleft nose deformity.

Traditional Figueroa nasoalveolar molding (NAM) requires weekly or biweekly adjustments to remove acrylic from the palatal plate to narrow the alveolar gap. These frequent adjustments create a burden for patients living far from a hospital. To minimize this burden, we developed a modified NAM technique using simplified lip taping and a passive palatal plate. Herein we present our clinical experience and outcomes using the traditional and modified methods. In this blinded, retrospective study of 66 patients with complete unilateral cleft lip and palate, 33 received the traditional NAM and 33 received the modified NAM. Pretreatment and posttreatment facial photographs and clinical charts were used to compare efficacy (nostril height ratio, nostril width ratio, columellar angle, nasal base angle), efficiency (molding frequency), incidence of complications (facial irritation, mucosal ulceration), and medical cost. Traditional and modified NAM did not differ in treatment efficacy for nostril height ratio (0.88 ± 0.14 vs. 0.90 ± 0.12), nostril width ratio (2.22 ± 0.39 vs. 2.38 ± 0.50), columellar angle (73.5 ± 9.1 degrees vs. 71.3 ± 11.8 degrees), nasal base angle (5.1 ± 2.4 degrees vs. 5.9 ± 2.7 degrees), or alveolar gap width (2.0 ± 2.0 mm vs. 2.0 ± 1.7 mm) (all p > 0.05). Traditional NAM was less efficient, i.e., required more adjustments (8.6 ± 2.0 vs. 6.7 ± 1.1), and cost more (22016.4 ± 2012.7 New Taiwan dollars vs. 20137.6 ± 1173.4 New Taiwan dollars) (both p < 0.001). Both NAM techniques similarly improved nasal deformities and reduced alveolar gaps, but the modified technique was more efficient and cost less in terms of insurance reimbursement and supplies (labial tapes).

Comparative Outcomes of Two Nasoalveolar Molding Techniques for Unilateral Cleft Nose Deformity

Nasoalveolar molding is increasingly being used to treat unilateral cleft nose deformity before primary repair. The Grayson technique starts nasal molding when an alveolar gap is reduced to 5 mm, whereas the Figueroa technique performs nasal and alveolar molding at the same time. The authors investigated the comparative efficacy, efficiency, and incidence of complications of the two techniques. A blinded, retrospective study was conducted on 63 patients with complete unilateral cleft lip-cleft palate; 31 underwent the Grayson nasoalveolar molding and 32 underwent the Figueroa nasoalveolar molding. Pretreatment and posttreatment facial photographs and clinical charts were used to compare efficacy (nostril height ratio, nostril width ratio, columellar angle), efficiency (molding frequency), and incidence of complications (facial irritation, mucosal ulceration). The Grayson and Figueroa techniques did not differ in treatment efficacy for nostril height ratio (0.86 ± 0.09 versus 0.85 ± 0.09; p > 0.05) and columellar angle (84.0 ± 4.5 degrees versus 85.3 ± 2.6 degrees; p > 0.05). Although the Grayson technique was more effective for reducing nostril width ratio (1.21 ± 0.29 versus 1.27 ± 0.19, p = 0.05), it was less efficient (i.e., required more adjustments) (10.9 ± 2.5 versus 8.8 ± 1.9; p < 0.001) and had a higher incidence of mucosal ulceration (23 percent versus 3 percent; p < 0.05). The two nasoalveolar molding techniques differed in efficacy, efficiency, and incidence of complications in patients with complete unilateral cleft lip-cleft and palate. Understanding these differences may help surgeons and orthodontists improve outcome expectations and consultations with patients' families. Therapeutic, III.

NAMによる術前矯正と鼻口唇一体移動による低侵襲初回片側性唇裂外鼻修正の取り組み

Despite recent developments in cleft surgery, management of primary unilateral cleft lip nose deformity has not yet been established. In this article, our treatment of nose deformity in an infant with unilateral cleft lip and palate (UCLP) by presurgical nasoalveolar molding (NAM) followed by primary cleft lip and nose repair is described.The authors performed relatively radical treatment of unilateral cleft nose deformity by repositioning the lower lateral nasal cartilage after dissecting it from the skin and/or lining through a nostril rim incision in the 1990s. Although outcomes achieved by the above procedures were acceptable, it was difficult to handle an infant's fragile cartilage even with open dissection. Recently, we adopted NAM for successful presurgical alignment of alveolar bone and correction of nasal deformity by medial and upward advancement of the nasolabial components to reposition the nasalis muscle and orbicularis oris muscle. These procedures result in more consistent postoperative outcomes.To assess the results of our treatment for UCLP nose deformity, the nasal forms of fifteen patients with complete UCLP (correction group) who were treated and followed for more than 1 year (1-5 years) were compared to those of 15 patients who did not undergo primary rhinoplasty (no correction group). All subjects of the correction group underwent presurgical orthopedic treatment with NAM, followed by lip repair using Cronin's triangular flap method with medial-upward advancement of nasolabial components with vestibular expansion using the cleft margin flap. Postoperative nasal forms including nostril height and width ratio, ratio of the height of the top of the alar groove, and curvature of the appropriate circle of the nasal alar groove were evaluated using color photos. Comparison of postoperative nasal forms demonstrated that the nostril height and width ratio and the height of the top of the alar groove in the correction group were significantly superior compared to those in the no correction group.Our management of cleft lip nose provides a good nasal form with minimum invasion in patients with UCLP. Long-term follow-up will be necessary to clarify effects on the growth of nasal tissues reconstructed in infancy. Furthermore, additional improvements in the technique of presurgical molding of deformed facial bones will be required in order to ensure a stable postoperative result.

Isolated Nasalis Muscle Reconstruction in Secondary Unilateral Cleft Lip Nasal Reconstruction

Reconstruction of the nasalis muscle in the unilateral cleft lip nasal deformity improves surgical results. A retrospective analysis of a series of 112 consecutive procedures. Chart review and analysis of standardized preoperative and postoperative clinical photographs. Patients treated with this technique had improved contour of the alar base compared with historical controls. Nasalis muscle reconstruction should be considered in the repair of the moderate to severe unilateral cleft nose deformity.

Secondary correction of the unilateral cleft nose deformity with an endonasal technique

Malposition of the nasal bone, septum and the alar cartilage are striking features of the unilateral cleft nose deformity. An endonasal technique (the extramucosal) was used in 26 patients, aged 13–38 (median 19), to correct aesthetic and functional problems. Twenty-four patients were secondary and two were tertiary. The patients were followed from 1–9 years. The pathological anatomy of the septum varied considerably, so different types of septoplasties had to be done. In 20 patients, satisfactory aesthetic and functional results were obtained in one operation. Secondary corrections were indicated in six patients. In cases with no gross scarring in or around the alar cartilage, the form and position of this cartilage will be more normal once the alar cartilages have been undermined and the deviation of the nasal bone and the septum is corrected.

Secondary repair of flattened alae in the cleft lip deformity

A method of obtaining better nasal contour in both primary and secondary bilateral and unilateral cleft nose deformity is described. In the primary case a plea is made for alveolar repositioning as an integral part of the primary repair. In the secondary nasal correction these should be initial alveolar repositioning and later correction of the displaced lower lateral cartilages by a direct approach. This is a late follow up on the paper of Potter 1954 [12].