Bilateral cleft lip nasal deformity

ABSTRACTBilateral cleft lip nose deformity is a multi-factorial and complex deformity which tends to aggravate with growth of the child, if not attended surgically. The goals of primary bilateral cleft lip nose surgery are, closure of the nasal floor and sill, lengthening of the columella, repositioning of the alar base, achieving nasal tip projection, repositioning of the lower lateral cartilages, and reorienting the nares from horizontal to oblique position. The multiplicity of procedures in the literature for correction of this deformity alludes to the fact that no single procedure is entirely effective. The timing for surgical intervention and its extent varies considerably. Early surgery on cartilage may adversely affect growth and development; at the same time, allowing the cartilage to grow in an abnormal position and contributing to aggravation of deformity.Some surgeons advocate correction of deformity at an early age. However, others like the cartilages to grow and mature before going in for surgery. With peer pressure also becoming an important consideration during the teens, the current trend is towards early intervention.There is no unanimity in the extent of nasal dissection to be done at the time of primary lip repair. While many perform limited nasal dissection for the fear of growth retardation, others opt for full cartilage correction at the time of primary surgery itself. The value of naso-alveolar moulding (NAM) too is not universally accepted and has now more opponents than proponents. Also most centres in the developing world have neither the personnel nor the facilities for the same. The secondary cleft nasal deformity is variable and is affected by the extent of the original abnormality, any prior surgeries performed and alteration due to nasal growth.This article reviews the currently popular methods for correction of nasal deformity associated with bilateral cleft lip, it's management both at the time of cleft lip repair and also secondarily, at a later date. It also discusses the practices followed at our centre.

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

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211010609 ◽

2021 ◽

pp. 105566562110106

Author(s):

Yoshitaka Matsuura ◽

Hideaki Kishimoto

Keyword(s):

Cleft Lip ◽

Minimum Degree ◽

Nasal Deformity ◽

Simple Method ◽

Primary Surgery ◽

Base Revision ◽

Alar Base ◽

Anterior Nasal Spine ◽

Nasal Floor ◽

Case Basis

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.

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The nasal cantilever technique in children undergoing primary cleft lip surgery: novel concepts and review

Innovative Surgical Sciences ◽

10.1515/iss-2020-0016 ◽

2020 ◽

Vol 5 (1-2) ◽

pp. 53-62

Author(s):

Badr M. I. Abdulrauf

Keyword(s):

Learning Curve ◽

Cleft Lip ◽

Nasal Bone ◽

Case Series ◽

Nasal Deformity ◽

Challenging Issue ◽

Primary Surgery ◽

Novel Concept ◽

Cleft Nasal Deformity

AbstractBackgroundNasal deformity associated with cleft lip deformity is a challenging issue, encompassing controversies, theories, and a diversity of techniques. Historically, esthetic outcomes have ranged from being below expectations to barely acceptable.MethodBased on the concept that the nasal cartilaginous framework in clefts is similar to that of a collapsing pyramid, a novel suspension technique has been described. The entire cartilaginous structure is lifted from the infratip segment with a loop suture and is secured in a cantilever fashion onto the periosteum overlying the nasal bone. This part of the operation is performed in a semiclosed manner. The technique is applied during primary surgery in bilateral and unilateral nasal cleft lip deformities, with changes in the orientation of the cantilever loop suture. Studies conducted by Masters S. Tajima, H. McComb, H. Thomson, D. Fisher, and J. Mulliken, which are most relevant to this article, have been reviewed and discussed throughout.ResultsThe technique was first applied over 10 years ago. A case series of nine children whose parents consented to the developing technique is presented with follow-up ranging from months to years, along with technical descriptions and illustrative drawings. None of these cases had preoperative orthopedic correction, molding, or postoperative nostril splints. The esthetic outcome was optimal enough; none of the cases requested a secondary correction.ConclusionThe nasal cantilever technique is a novel concept in cleft nasal deformity, which can be used in conjunction with an appropriate lip technique, per the surgeon’s discretion. Other than a learning curve, we believe that it provides a solid correction by securing the cartilaginous structures after they have been mobilized to a stable base, the nasion.

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Correction of the Bilateral Cleft Lip Nasal Deformity: Evolution of a Surgical Concept

The Cleft Palate-Craniofacial Journal ◽

10.1597/1545-1569_1992_029_0540_cpclnd_2.3.co_2 ◽

1992 ◽

Vol 29 (6) ◽

pp. 540-545 ◽

Cited By ~ 29

Author(s):

John B. Mulliken

Keyword(s):

Soft Tissue ◽

Cleft Lip ◽

Interim Report ◽

Nasal Deformity ◽

Bilateral Cleft Lip ◽

Cleft Nasal Deformity

The origin of the nasal deformity of a bilateral complete cleft lip is both primary (deformation/malformation) and secondary (postoperative distortion). This is an interim report of a personal evolution from staged correction of the bilateral cleft nasal deformity to synchronous repair of the nose and the lip and premaxillarymaxillary clefts. The anatomic concept is that, because of the maIpositioned alar cartilages, the columella only appears to be short in an infant with bilateral cleft lip. The technical stratagems to model the nose are: (1) alignment of the premaxilla and (2) anatomic placement of the alar cartilages with sculpturing of the overlying soft tissue.

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Dynamic Presurgical Nasal Remodeling in Patients with Unilateral and Bilateral Cleft Lip and Palate: Modification to the Original Technique

The Cleft Palate-Craniofacial Journal ◽

10.1597/05-054 ◽

2006 ◽

Vol 43 (6) ◽

pp. 639-648 ◽

Cited By ~ 21

Author(s):

Ricardo D. Bennun ◽

Alvaro A. Figueroa

Keyword(s):

Cleft Lip ◽

Cleft Lip And Palate ◽

Nasal Deformity ◽

Nasal Tip ◽

Palatal Plate ◽

Bilateral Cleft Lip ◽

Technical Modifications ◽

Cleft Lip Repair ◽

Nasal Tip Projection ◽

Cleft Nasal Deformity

Objective: To present technical modifications to the original presurgical nasal remodeling appliance introduced in 1991. The purpose of the modifications is to improve the cleft nasal deformity before unilateral and bilateral cleft lip repair. Method: The principle behind this technique, known as dynamic presurgical nasal remodeling (DPNR), is the use of the force generated during suction and swallowing. A conventional intraoral plate is built with a nasal extension added to the labial vestibular flange. The nasal extension was modified and consists of three components. The palatal plate is left loose in the mouth to generate a discontinuous but controlled impact directed to the affected nasal structures during suction and swallowing. The principle aim of the DPNR technique in unilateral cases is to improve the deformation of nasal structures by straightening the columella, elevating the nasal tip, and remodeling the depressed cleft side alar cartilages. In bilateral cases, the aims are to elongate the columella and to obtain nasal tip projection. Conclusions: The modifications introduced in the appliance enhance the original DPNR technique and are effective in ameliorating the initial cleft nasal deformity. This facilitates primary surgical cleft lip and nose correction and improves surgical outcomes in patients with complete unilateral and bilateral cleft lip and palate.

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Cleft Nasal Deformity

Operative Plastic Surgery ◽

10.1093/med/9780190499075.003.0053 ◽

2019 ◽

pp. 541-550

Author(s):

Jennifer L. McGrath ◽

Arun K. Gosain

Keyword(s):

Cleft Palate ◽

Cleft Lip ◽

Nasal Deformity ◽

Delayed Repair ◽

Complex Source ◽

Bilateral Cleft Lip ◽

Primary Focus ◽

Cleft Nasal Deformity

While the lip deformity in unilateral and bilateral cleft lip and cleft palate patients may be the primary focus of parents, most surgeons agree that it is the stigmata of the cleft nasal deformity that is most conspicuous. The cleft lip nasal deformity has been a complex source of innovation for pediatric plastic surgeons for decades. Techniques have evolved as knowledge and experience have grown. Thoughtful surgeons continue to be critical of their outcomes and modify their technique throughout their careers. Here we discuss the fundamentals of the cleft lip nasal deformity and its primary and delayed repair.

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