KEY WORDS
Cleft rhinoplasty - nose deformity - unilateral cleft lip
INTRODUCTION
Secondary nose deformity after unilateral cleft lip repair is a common problem. Loss
of nose tip projection on the affected side can be difficult to correct due to lack
of proper structural support. The nasal deformity associated with unilateral cleft
lip and palate involves skeletal and soft tissue structures [Figure 1]. Although many studies[1]
[2]
[3]
[4] have reported the use of primary rhinoplasty at the time of cleft lip repair, secondary
correction of residual unilateral cleft lip nasal deformities is often necessary for
functional and cosmetic purposes. This is primarily due to incomplete correction of
the primary nose deformity, which leaves the skeleton and nasal septum unrepaired.
Many authors[5]
[6]
[7] have reported studies on this topic; however, few studies have addressed all nasal
components and objectively evaluated patient outcomes.
Figure 1: The complete unilateral cleft lip nose and palate deformity and its basic components:
(1) Alar cartilage malposition. (2) Shortened vestibule of the nose. (3) Septal deviation.
(4) Skeletal deformity (maxillary cleft). (5) Muscular abnormal insertion (6) Retracted
appearance of the columella
Our surgical protocol addresses all five components of cleft lip deformity: alar cartilage
malposition, shortened nose vestibule, muscular abnormal insertion, skeletal deformity
(septal deviation and maxillary cleft) and foreshortened columella with retracted
appearance [Figure 1]. The main defect is the position of the ala. The alar cartilage lies caudal and
lateral to the contralateral side and is tethered by an abnormal attachment to the
pyriform aperture. This structure rests on an underdeveloped maxilla, which accounts
for alar base lowering. The nasal vestibule after primary repair is frequently smaller,
which indicates that this area should be lengthened during the primary procedure.
The tip of the nose is a combination of two factors, including incomplete projection
and a deviated columella that lies obliquely with its base oriented away from the
cleft side [Figure 1]. The septum may be displaced away from the cleft to different degrees, and dorsal
septal curvature is present [Figure 1]. In addition, their muscular pull is imbalanced, and the cheek muscles are abnormally
attached to the lateral crus. The skeleton is frequently affected, with an observable
widening at the dorsum and the frontal process of the maxilla.
The V-Y composite flap technique was first described by Potter in 1954,[8] and it is frequently used for secondary cleft rhinoplasty.[2]
[9]
[10] However, the V-Y method leaves a straight scar in the lateral segment of the closure,
which may create a lateral scar contracture of the vestibule. The utility of this
method in primary unilateral cleft lip nose repair is not well described in the literature.
A variation of this technique with extended mucosal tab was published by Cronin et al. in 2004[2] with good results. This method uses mucosa for vestibular skin repair. A comprehensive
care protocol for correction of cleft nasal deformities using the Cronin surgical
technique and post-operative outcomes is presented here. The purpose of this study
was to evaluate nose symmetry after using these protocols for primary complete unilateral
cleft lip nasal deformities.
METHODS
Patients and study design
This is a cross-sectional study of one surgeon's outcome following 32 consecutive
complete unilateral cleft lip nasal deformity repairs. All patients had a primary
cheilorhinoplasty including the following four procedures: (i) cheiloplasty using
surgical techniques based on the author's protocol;[11]
[12] (ii) medial mobilisation of the affected lateral alar crus and vestibular lengthening
using the V-Y-Z technique [Figures 2]
[3]; (iii) caudal septoplasty and (iv) labionasal muscular repair.
Figure 2: The V-Y-Z technique for complete unilateral cleft lip nose repair
Figure 3: The V-Y-Z closure using transcutaneous stitches with medial V-Y plasty and lateral
Z plasty components
Follow-up was performed at least 1 year after the surgical procedure. During follow-up,
all patients were subjected to the following three anthropometric measurements [Figure 4]: (i) nostril dome height, which was measured from the lateral border at the base
of the columella to the highest point on the nasal dome on each side; (ii) columella
length, which was measured from the lateral border at the base of the columella to
the highest point of the nostril and (iii) alar width, which was measured from the
lateral border at the base of the columella to the most lateral point of the ala in
a line perpendicular to the axis of the columella. All three measurements were performed
on both the cleft and non-cleft sides of the nose.
Figure 4: Standard anthropometric measurements. (a) Nostril dome height, (b) Columella length
and (c) Alar width
Surgical technique
We did not perform any type of pre-surgical management for any of the patients. The
surgical repair of the nose was conducted during primary cheiloplasty. The nose was
dissected before lip repair, which enables good access to the structures and facilitates
more accurate repair of all components. Alar cartilage dissection and vestibular nose
lengthening were performed using the V-Y-Z method. Therefore, the skin incision along
the marginal and intercartilaginous borders was performed to create a composite flap
(vestibular skin and alar cartilage) in a V form, and the two limbs of the lateral
Z-plasty were incised and elevated [Figure 5]. The bilateral cartilage structures of the nose tip were dissected using this incision.
Alar cartilages were then degloved at the nasal tip level. Subsequently, the flap
was displaced medially, and the lateral flaps were transposed in a Z-plasty form.
All incisions were closed using transcutaneous stitches [Figures 2]
[3]. A transcutaneous interdomal suture was placed first, then the lateral genu of the
alar cartilage was elevated using vertical transcutaneous sutures as illustrated in
[Figure 3]. We used 5-0 polyglycolic acid sutures through the skin starting inside the nose,
then coming out at the level of the supra-alar crease, returning through the same
hole and finally coming out inside the nose and tying the sutures [Figure 3]. The use of these sutures in combination with the V-Y-Z method allowed us to obtain
the following three objectives: (i) reposition the alar cartilage and lengthen the
columella at the cleft side; (ii) lengthen the nasal vestibule and prevention of scar
contracture using a lateral Z-plasty and (iii) reduce the space created by surgical
dissection, which reduces the risk of post-operative bleeding and haematoma formation.
Figure 5: Pre-operative design of the V-Y-Z technique
We did not use cartilage grafts for primary cleft rhinoplasty. A retrocolumellar incision
enabled access to the most anterior portion of the septum. The caudal septum correction
was performed through this incision. The mucoperichondrium was elevated from the septum
on both sides. The septal cartilage was released from its abnormal attachment and
fixed to the opposite side [Figure 6]. Finally, the incision was closed using transcutaneous 5-0 polyglycolic acid sutures.
The nasal floor was repaired by properly locating the ala, thereby shortening the
nasal base width. During cheiloplasty, the levator labii superioris alaeque nasi and
orbicularis oris muscles were identified and repositioned. The labial muscle reconstruction
helps us to bring support to the nasal floor. Nasal packing was used in all cases
inside the operated nostril to prevent post-operative bleeding; this packing should
be removed 1 day after surgery. Post-operative nostril stenting was not used.
Figure 6: Caudal septoplasty during primary cheilorhinoplasty in a patient with complete unilateral
cleft lip and palate. (1) Caudal septum. (2) Mucoperichondrium flap
Statistical analysis
Matched pair t-test analyses were performed when the required assumptions were met. When the normality
assumption was not met, the non-parametric Wilcoxon signed-rank test was used to assess
the statistical significance of differences between the cleft and non-cleft sides.
A value of P < 0.05 yielded 95% confidence interval. All statistical analyses were conducted using
SPSS version 15.0 (SPSS Inc., Chicago, IL, USA).
RESULTS
Thirty-two consecutive patients with complete unilateral cleft lip nose deformity
repair received the proposed surgical technique and follow-up measurements since 2012.
The mean age at the time of the surgery was 5.8 months (range, 3–7 months). The mean
time of follow-up evaluation was 1.9 years (range, 1.2–2.7 years). The patient characteristics
are summarised in [Table 1]: there were 18 male (56.25%) and 14 female (43.75%) patients; the male-to-female
ratio was 1.23 and 21 patients were affected on the left side (65.62%), whereas 11
patients were affected on the right side (34.37%). We observed slight differences
in post-operative nostril dome height and columella length between the cleft and non-cleft
sides, but these differences were not statistically significant (P = 0.49 and 0.48, respectively) [Table 2]. We did observe a statistically significant difference in alar width on the cleft
side versus the non-cleft side (P = 0.0001) [Table 2]. Nose asymmetry with respect to at least one of the measured parameters was observed
in seven of the operated cases (21.88%). These cases required minor revisions. None
of the studied cases required major revisions. Surgical outcomes are presented in
[Figures 7]
[8]
[9]
[10].
Figure 7: Case 1. A 3-month-old male patient with a right complete unilateral cleft lip nose
and palate deformity
Figure 8: Post-operative view of the patient after surgery illustrating cosmetic improvement
of the nose after 1 year
Figure 9: Case 2. A 3-month-old female patient with a right complete unilateral cleft lip nose
and palate deformity
Figure 10: Post-operative view of the patient after surgery illustrating cosmetic improvement
of the nose after 1 year
Table 1
Operative characteristics
|
Characteristic
|
Value
|
|
*Selection based on Outreach Surgical Center Lima protocol
|
|
Operative time (minutes)
|
47.5±15.2
|
|
History of cleft lip repair*
|
|
|
Modified Nakajima
|
18 (56.25%)
|
|
Triple Unilimb Z Plasty
|
14 (43.75%)
|
Table 2
Postoperative comparisons of Non-Cleft side and Cleft side using the V-Y-Z plasty
|
Nose segment
|
Non-cleft side (n=32) mean (SD)
|
Cleft side (n=32) mean (SD)
|
P
|
CL
|
|
* Paired student t-test. **Wilcoxon signed rank test
|
|
Nostril dome height*
|
9.875 (1.039541)
|
9.625 (0.975506)
|
0.0831
|
0.913842-0.408615
|
|
Columella Length*
|
5.156 (0.846601)
|
4.937 (0.800705)
|
0.1606
|
0.673190-0.370181
|
|
Alar width**
|
13.125 (0.870669)
|
14.251 (0.803219)
|
0.00001
|
-1.425255-0.824745
|
DISCUSSION
Rhinoplasty in patients with unilateral cleft lip nose deformity poses a technical
challenge for plastic surgeons. The main problems are achieving caudal nose congruity
and creating symmetric nostrils. The main objectives for correcting unilateral cleft
lip nose deformities are reorientation of the abnormal nasal anatomy and creation
of a balanced platform. Although many studies have addressed this problem,[1]
[2]
[3]
[4]
[5]
[6]
[7] most of them include pre-surgical nasal moulding and limited correction of the nose
deformity but do not include vestibular and septal repair. The anatomy of the unilateral
cleft lip nose deformity exhibits different components and degrees of severity, which
requires careful pre-operatory evaluation.
The present study proposes a surgical technique and protocol that considers the correction
of each basic component involved in unilateral cleft lip nose deformity, with the
exception of the skeleton, which is repaired at a later age. The efficacy of the proposed
technique for primary cleft nose deformity repair was confirmed by the post-operative
measurements and insignificant differences in nostril dome height and columella length
between the cleft and non-cleft side [Table 2] and [Figures 7]
[8]
[9]
[10]. Previous studies (Cutting 2003)[11]
[12]
[13] reported differences in alar width between the cleft and non-cleft sides. This unfavourable
result may be related to the development of hypertrophic scar due to tension of the
closure or facial muscle activity. This unfavourable outcome can be easily corrected
by conducting a minor revision.
Our results indicate that only 21.88% of the studied cases required minor surgical
revision, and none of the cases required a reoperation. Therefore, patient outcomes
after our surgical protocol are better than those after other procedures such as the
outcomes reported by Cohen with 76.4% improvement,[14] and 55.80% of reoperation cases observed by Haddock.[1] Considering these combined results, we propose three main conclusions: (a) the columella
does not require lengthening using the ‘c’ flap as proposed by Millard.[15] The columella can be effectively repaired by alar repositioning and vestibular lengthening.
Reshaping the nasal ala is sufficient to restore columella length. (b) Several studies
in primary and secondary cleft nose rhinoplasty indicate that vestibular lengthening
is necessary to obtain nose symmetry.[1]
[2]
[3]
[4]
[5]
[6]
[7] The nose tissues should be preserved and not resected as recently proposed by Patel
and Mulliken.[16] (c) The necessity of pre-surgical management lacks scientific support and should
be considered as an alternative strategy.
Different studies (including systematic reviews) describe the absence of scientific
evidence supporting the use of pre-surgical management for unilateral cleft nose repair.[17]
[18]
[19] Significant relapse of the deformity has been observed after using nasal mouldings,[20]
[21] and better outcomes were observed only in combination with primary rhinoplasty.[22] Good nose symmetry can be obtained as demonstrated in the current study using an
adequate surgical technique without pre-surgical treatment. Cleft segments do not
require pre-operative plate guidance; the orbicularis oris muscle is moving the segments
to proper position in a physiological form bringing support for the repaired nose.
Cartilage tip grafts are commonly used in cleft nose deformity repair; however, we
did not use them because tip projection can be achieved with the proper mobilisation
of the affected alar cartilage [as shown in [Figures 7]
[8]
[9]
[10]. A recent study of Yoshimura et al.[23] suggests that performing nasal repair at the time of primary cleft lip surgery adversely
affects nose growth. By contrast, many studies have reported normal nose growth after
primary rhinoplasty.[24]
[25] Yoshimura et al.[23] performed an observational study with a small sample size. This issue remains controversial
and requires better scientific evidence in future. Here, we did not evaluate functional
and long-term outcomes, and additional studies to address patient outcomes will be
required.
CONCLUSIONS
This study demonstrates the efficacy of the proposed surgical technique for obtaining
nose symmetry in patients with unilateral cleft lip nasal deformity. These results
suggest that the proposed protocol is a good alternative to address primary nose deformity
related to unilateral cleft lip, and the protocol may reduce secondary procedures.
Additional studies are required to evaluate functional and long-term outcomes after
primary rhinoplasty in patients with unilateral cleft lip nose deformity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
