Addressing the Soft Tissue Element in Unilateral Cleft Lip Nasal Deformity

Correction of a cleft lip nasal deformity remains a challenging procedure in reconstructive surgery. Many different procedures have been suggested to address the problem, but few techniques have worked well and consistently. We present a case of secondary cleft nasal deformity after repair of unilateral complete cleft lip and palate on the left side. The corrective procedures carried out included closed method rhinoplasty and dorsal nasal augmentation with rib graft which was fixed to the nasal septum with needle. The patient showed satisfactory immediate post-operative result, with correction of depressed alar base and satisfying dorsal and tip projection. However, 5 months post operative result showed deviation of nasal tip to the cleft side, which we suspected was due to: warping of the rib graft, soft tissue deficiency in the cleft side which exerts pulling forces to the warping graft, and lack of rigid fixation of the graft. After appraising pitfalls encountered in augmenting nasal dorsum of cleft patients with rib graft, we concluded that some preventive measures need to be done to avoid those problems, namely: balanced cross sectional carving of rib graft, cantilever graft with plate and screw to the nasal bone, and addressing pulling force from lack of soft tissue in the cleft side by adding columellar strut graft or alar contour graft.

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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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Seven Fundamental Procedures for Definitive Correction of Unilateral Secondary Cleft Lip Nasal Deformity in Soft Tissue Aspects

Journal of Oral and Maxillofacial Surgery ◽

10.1016/j.joms.2011.04.022 ◽

2011 ◽

Vol 69 (11) ◽

pp. e420-e430 ◽

Cited By ~ 6

Author(s):

Dong Won Lee ◽

Bong-Kyoon Choi ◽

Be-Young Yun Park

Keyword(s):

Soft Tissue ◽

Cleft Lip ◽

Nasal Deformity

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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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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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Computational Analysis of Olfactory Airspace in Patients With Unilateral Cleft Lip Nasal Deformity

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665620982754 ◽

2020 ◽

pp. 105566562098275

Author(s):

Reanna Shah ◽

Jeffrey R. Marcus ◽

Dennis O. Frank-Ito

Keyword(s):

Cleft Lip ◽

Computational Analysis ◽

Normal Subjects ◽

Nasal Deformity ◽

Normal Anatomy ◽

3 Dimensional ◽

Computed Tomography Images ◽

High Prevalence ◽

Dimensional Reconstruction ◽

The Impact

Objectives: To evaluate the magnitude of olfactory recess opacity in patients with unilateral cleft lip nasal deformity (uCLND). Design: Subject-specific 3-dimensional reconstruction of the nasal airway anatomy was created from computed tomography images in 11 (4 males and 7 females) subjects with uCLND and 7 (3 males, and 4 females) normal subjects. The volume and surface area of each subject’s unilateral and bilateral olfactory airspace was quantified to assess the impact of opacification. Qualitatively speaking, patients with 75% to 100% olfactory recess opacification were classified as extreme, 50% to 75% as severe, 25% to 50% as moderate, and 0% to 25% as mild. Results: Of the 11 subjects with uCLND, 5 (45%) were classified as having extreme olfactory recess opacification, 3 (27%) subjects had severe opacification, and 3 (27%) subjects had moderate opacification. Mean (±SD) bilateral olfactory recess volume was significantly greater in normal subjects than in subjects with uCLND (0.9668 cm3 ± 0.4061 cm3 vs 0.3426 cm3 ± 0.1316 cm3; P < .001). Furthermore, unilateral olfactory airspace volumes for the cleft and non-cleft sides in subjects with uCLND were considerably less than unilateral olfactory volume in subjects with normal anatomy (uCLND cleft side = 0.1623 cm3 ± 0.0933 cm3; uCLND non-cleft side = 0.1803 cm3 ± 0.0938 cm3; normal = 0.4834 cm3 ± 0.2328 cm3; P < .001). Conclusions: Our findings indicate a high prevalence of olfactory recess opacification among subjects with uCLND when compared to subjects with normal anatomy. The majority of subjects with uCLND had extreme olfactory recess opacity, which will likely influence their sense of smell.

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Orthodontic Pre Grafting Closure of Large Alveolar Bony and Soft Tissue Gaps: A Novel Nonsurgical Protraction of the Lesser Segments in Growing Patients With Cleft Lip and Palate

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211007697 ◽

2021 ◽

pp. 105566562110076

Author(s):

Maria Costanza Meazzini ◽

Noah Cohen ◽

Valeria Marinella Augusta Battista ◽

Cristina Incorvati ◽

Federico Biglioli ◽

...

Keyword(s):

Soft Tissue ◽

Surgical Procedures ◽

Efficient Method ◽

Bone Grafting ◽

Cleft Lip ◽

Soft Tissues ◽

Cleft Lip And Palate ◽

Face Mask ◽

Younger Patients ◽

Good Healing

Background: Closure of wide alveolar clefts with large soft tissue gaps and reconstruction of the dentoalveolar defect are challenging for the surgeon. Some authors successfully used interdental segmental distraction, which requires an additional surgical procedure. Objective: This study evaluates the effectiveness of tooth borne devices utilized to orthopedically advance the lesser segments, with a complete approximation of the soft tissue of the alveolar stumps, allowing traditional simultaneous soft tissue closure and bone grafting, and avoiding the need for supplementary surgery. Methods: Eight growing patients, 2 with unilateral complete cleft lip and palate (UCLP) and 6 with bilateral complete cleft lip and palate (BCLP), with large soft tissue and bony alveolar defects prior to bone grafting were prospectively selected. A banded rapid palatal expander (RPE) in BCLP and a modified RPE in UCLP combined with protraction face mask in younger patients or a modified Alt-Ramec in patients older than 12 years were applied. Radiographic and photographic records were available at T0, at the end of protraction (T1) and at least 1 year after bone grafting (T2). Results: Patients with large gaps showed a significant reduction in the bony cleft area and approximation of the soft tissues at T1. All patients received bone grafting with good healing and ossification at T2. Conclusion: In growing patients with UCLP and BCLP with large gaps, presurgical orthodontic protraction seems to be an efficient method to reduce the cleft defect, minimizing the risk of post grafting fistulas, reducing the need for supplementary surgical procedures.

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