Cleft Rhinoplasty

Cleft rhinoplasty is one of the most difficult and challenging aesthetic surgeries to carry out and bears a significant impact on the overall nasal aesthetics and function. Two reasons understood for this are the simultaneous involvement of all the layers of the nose including the skin, cartilage, skeleton and vestibular lining (this being the principal reason) and the significant scarring that is the consequence of multiple previous surgical interventions. There is a mention of numerous techniques for ultimate correction of unilateral and bilateral cleft nasal deformities but no single technique has till date provided a definite solution for correction of all the problems that accompany these deformities. There is a revised interest in performing primary rhinoplasties at the time of lip repair with or without presurgical orthopedics but these procedures may still warrant definitive rhinoplasty at a later date. The purpose of this chapter is to provide a comprehensive review of cleft rhinoplasty in the most systematic manner beginning with the pathologic anatomy followed by surgical timing, pre-operative evaluation and surgical correction. The chapter also discusses the use of various grafts in a typical cleft rhinoplasty case as well as treatment strategy for management of both, unilateral and bilateral cleft nasal deformities. The outcomes as well as complications and a note on further revisions have also been presented.

Spontaneous Growth of the Palatal Plates in the Cleft Lip and Palate

Objective: This is a prospective study examining palatal casts from patients with unilateral cleft lip and palate (UCLP) in the first month of life, immediately before cheiloplasty, and immediately before palatoplasty. None of the patients receives presurgical orthopedics (nasoalveolar molding). Design: In this prospective study, upper arch plaster models were taken 3 times during the treatment: in the first month of life (T1), before the cheiloplasty (T2), and before the palatoplasty (T3). Anatomic landmarks were defined and linear anthropometric measurements were obtained afterward. Dimensional analysis was performed using 3D software. Two-way analysis of variance followed by Tukey test was performed for statistical analysis. Setting: Tertiary, institutional. Participants: Twelve patients with UCLP of either sex with less than 1 month of life and without any other syndrome. Intervention: No intervention was performed. Main Outcome Measure: Reduction of the cleft without using orthopedics apparatus. Results: There was a statistically significant reduction in the cleft gap comparing T1 to T3. There was also a significant reduction in the intercanine width comparing T2 and T3, and T1 and T3. There was significant increase in the posterior arch width comparing T2 and T3, and T1 and T3. The palatal plate’s width increased in all times analyzed. Conclusion: The palatal cleft narrows spontaneously as well in both midpoint and posterior point during the first 6 months of patient’s treatment. This event was enhanced by cheiloplasty. This surgery might have a greater influence on the anterior arch width than in the posterior arch region.

Presurgical Alignment of Bilateral Cleft Segments With 3D Simulation Under Special Consideration of the Vomer: A Technical Note

Background: The main goal of presurgical orthopedics (PSO) for patients with bilateral cleft lip and palate is to correct the protruded and/or twisted premaxilla. However, PSO is associated with the risk of uncontrolled development of the vomer, which has received little attention to date. Solution: We present a removable orthodontic device that can be used to keep or align the vomer and the premaxilla in the midline during preoperative molding of cleft segments independently and 3 dimensionally.

An Intercenter Comparison of Nasolabial Appearance Including a Center Using Nasoalveolar Molding

Objective: To compare nasolabial appearance outcomes of patients with complete unilateral cleft lip and palate (CUCLP) in preadolescence from 4 cleft centers including a center using nasoalveolar molding (NAM) and primary nasal reconstruction. Design: Retrospective cohort study. Setting: Four cleft centers in North America. Patients: 135 subjects with repaired CUCLP. Methods: Frontal and profile facial pictures were assessed using the Asher-McDade rating scale. Intra- and interrater reliability were tested using weighted Kappa statistics. Median scores by center were compared with Kruskal-Wallis statistics. Results: Intrarater reliability scores were moderate to good. Interrater reliability scores were moderate. Significant differences ( P < .05) among centers were found. For nasal form, center G (median = 2.83) had better scores than centers C and D (C median = 3.33, D median = 3.17). For nose symmetry, center G had better scores (median = 2.33) than all other centers (B median = 2.67, C median = 2.83, D median = 2.83). For vermillion border, center G had better scores (median = 2.58) than centers B and C (B median = 3.17, C median = 3.17). For nasolabial profile, center G (median score = 2.67) had better scores than center C (median = 3.00). For total nasolabial score, center G (median = 2.67) had better scores than all other centers (B median = 2.83, C median = 3, D median = 2.83). Conclusion: The protocol followed by center G, the only center that performed NAM and primary nasal reconstruction, produced better results in all categories when compared to center C, the only center that did not perform presurgical orthopedics or lip/nose revisions. When compared to centers that performed traditional presurgical orthopedics and surgical revisions (B and D), center G was not consistently better in all categories. As with other uncontrolled, retrospective intercenter studies, it is not possible to attribute the outcomes to a specific protocol component.

The Effect of DynaCleft® on Cleft Width in Unilateral Cleft Lip and Palate Patients

Objective: The specific aim of this retrospective cross-sectional study was to assess the efficacy of DynaCleft® as a method of presurgical orthopedics with infants with a unilateral cleft lip and cleft palate who used an oral obturator. Study design: Data was collected from 25 infants all of comparable age diagnosed with a unilateral complete cleft lip and palate. Eight patients used DynaCleft ® and an obturator (Group Alpha) and seventeen patients only had an obturator (Group Beta). Maxillary impression casts were obtained from each patient at the initial clinic visit and at the time of cleft lip repair. Differences in alveolar cleft width were compared between the two groups. Casts were measured twice by one observer using a digital caliper. Results: Group Alpha began treatment on an average age of 24.25 days and Group Beta an average of 15.35 days of age. The average cleft width of Group Alpha was 8.13 mm and after treatment it was 4.59 mm. The average cleft width of Group Beta was 8.09 mm and 6.92 mm after treatment. Results of paired t-tests and two-sample t-test showed that cleft width changes between the two groups were significant (P = .03). Conclusions: DynaCleft ® significantly decreased the size of the alveolar cleft width compared to infants who did not use it. Providers should consider using DynaCleft® for patients who may not have access to infant maxillary orthopedics.