Corrective Rhinoplasty with Combined Use of Autogenous Auricular Cartilage and Porcine Dermal Collagen in Cleft Lip Nose Deformity / 대한악안면성형재건외과학회지

Esthetic reconstruction of cleft lip nose deformity is a challenging task in surgical management of patients with orofacial cleft. The author reconstructed cleft lip nose deformity effectively using autogenous auricular cartilage and a relatively new graft material of porcine dermal collagen, Permacol(TM). After correction of the deformed lower third of the nose with patient's auricular cartilage, we applied Permacol(TM) to augment the entire nasal dorsum. Three patients were treated and followed for up to five years. All patients improved in nose aesthetics without any inflammatory or immunogenic reaction. The author suggests that the use of Permacol(TM) for nasal profile augmentation in the treatment of cleft lip nose deformity is an alternative surgical strategy with minimal surgical invasiveness. The author report long-term experience with combined use of auricular cartilage and Permacol(TM) in nasal reconstruction for cleft lip nose deformity.

Analysis of Cleft Lip Nose Deformities Correction in Adults: Detailed Techniques and Comprehensive Review

PURPOSE: Correction of cleft lip nose deformity(CLND) in adulthood is different from one in childhood. Usually correction of CLND is final surgery for adult patient who has cleft lip, so many things have to be considered for correction. Of course, it is different from common rhinoplasty, either. The adult patients can be corrected by complete rhinoplasty with various techniques. To recognize how rhinoplasty techniques was used for correction of CLND, authors analyzed detailed techniques which were selected in the adult patients for 10 years and reviewed comprehensive operation. METHODS: A retrospective review was conducted involving 64 patients with CLND who underwent surgery and aged after 14 years at operation between 2001 and 2010. Detailed techniques were investigated by medical record review and classified according to incision, septoplasty, osteotomies, correction of vault, tip plasty and etc. RESULTS: Except one, all patients were performed open rhinoplasty. 49 patients were performed septoplasty. 33 patients were performed complete rhinoplasty with osteotomies. Hump nose correction was performed for 10 patients. Dorsal augmentation was performed for 8 patients. And all patients were performed tip plasty. Tip plasty using suture technique was performed for 58 patients and graft was performed for 48 patients. CONCLUSION: Correction of CLND in adult is one of the most challenging and varied operation of plastic surgery. In this study, the majority of patients were performed complicated and delicated procedures. It seems to be because patient's demand level has been elevated and rhinoplasty procedures have been advanced. This study may help to planning of CLND correction.

Surgical Correction of Nostril Base and Nostril Sill Depression in Unilateral Secondary Cleft Lip Nose Deformity

PURPOSE: Most unilateral secondary cleft lip nose deformities have depressed nostril base and sill on the cleft side. To obtain a symmetric nose, correction of the recession on nostril is critical. The authors have worked out effective methods to elevate the nostril of the cleft side according to the extent of the depression. METHODS: A total of 115 unilateral secondary cleft lip nose deformity patients with nostril depression were evaluated. Data were acquired from patients' charts and photography with special reference to the height difference of the nostrils between the cleft side and the non-cleft side. Patients were divided into three groups based on the difference and operated with various techniques :(1) mild degree( 3mm) with graft, C-flap and suspension suture. Follow-up period averaged 21.3 months. RESULTS: Forty-six patients(40 percent) were in mild group, and forty-two(37 percent) were in moderate. In twenty-seven patients(23 percent), nostril recession was more than 3mm. The elevated nostril base and sill were maintained without height alteration during follow-up. CONCLUSION: The symmetry of the nostril base, especially projection of nostril sill influences successful correction of unilateral cleft lip nose deformity. Our tolerable techniques can be applied to most deformities with nostril depression and can present a new guideline.

Quantitative Analysis of Lower Nose and Upper Lip Asymmetry in Patient with Unilateral Cleft Lip Nose Deformity using 3D Camera

PURPOSE: Analysis of lower nose and upper lip asymmetry in patients with unilateral cleft lip nose deformity has been proceeded through direct measurement and photo analysis. But there are limitation in presenting real image because of its 2 dimensional trait. The authors analyzed such an asymmetry using 3D VECTRA system (Canfield, NJ, USA) in quantitative way. METHODS: In 25 Patients with unilateral cleft lip nose deformity (12 males, 13 females, age ranging from 4 to 19), patients with right side deformity were 10 and left were 15. Analysis of asymmetry was proceeded through 3D VECTRA system. After taking 3 dimensional photo, alar area, upper lip area, nostril perimeter, nostril area ,Cupid's bow length, nostril height and nostril width were measured. Correlation coefficient and inter data quotients were calculated. RESULTS: In nostril perimeter, maximal difference of cleft side and non-cleft side was 39.3%, asymmetric quotient Qasy = Qcl/Qncl (Qcl, value of cleft side; Qncl, value of non-cleft side) ranged from 0.84 to 1.85 and in seven cases the length of cleft side was smaller. In nostril area, maximal difference was 69.6% and in 13 cases cleft side was smaller. In lower nasal area, maximal difference was 37.2% asymmetric quotient Qasy = Qcl/Qncl was ranged from 0.47 to 2.03 and in 20 cases cleft side was smaller. The correlation coefficients of nostril perimeter and area were 0.8345. CONCLUSION: Using 3D VECTRA system, the authors measured nostril perimeter and lower nasal area that could not been measured with previous methods. Asymmetry of midface was analyzed through area comparison in quantitative way. Futhermore, post operative change can be measured in quantitative method.

Columellar Lengthening Using V-Y Advancement Flap or Central Lip Flap in Secondary Correction of Bilateral Cleft Lip Nose Deformity

Even though it is generalized to perform synchronous lip and nasal correction, there are some cases in need of secondary correction of cleft lip nose deformity. In these procedures, the lengthening of columella plays an important role. We performed eighteen cases of the secondary cleft lip nose deformity correction using two different methods from 1997 to 2003. The central lip flap was used in eight patients and V-Y advancement flap in ten patients. Additional procedures including reverse U-incision, interdomal fixation sutures and suspension sutures were used for correction of combined deformity. Silastic nasal retainers were kept in all patients for 6 months. Both of central lip flap and V-Y advancement flap seems to be a good technique for lengthening columellar soft tissue. But new columella after V-Y advancement flap appeared to be too narrow and a bit unnatural looking and central lip flap left additional scar on the upper lip although it was conspicuous. We think that central lip flap is a better technique in a case with wide philtrum and narrow columella and V-Y advancement flap can be another choice in a columella with sufficient width.

Nasal Deformity and Acoustic Airway Obstruction Profiles in Unilateral Secondary Cleft Lip Nose Deformity

Patients with secondary cleft lip nose deformity usually complain not only aesthetic problems but also functional problems such as nasal obstruction. However, there have been few studies on nasal airway problem in secondary cleft lip nose deformity patients and no reports for the correlation between degree of the deformity and nasal airway obstruction. The authors selected 34 patients with secondary cleft lip nose deformity and measured the degree of morphological deformity by photo analysis and the degree of nasal airway obstruction by VAS score and acoustic rhinometry. Almost all patients complained of more obstructive symptom on the affected side. Functional anatomic structure and volume of the nasal airway examined by acoustic rhinometry showed that narrowest point was located above the nostril and pathological obstruction was more significant in patient group in both side and the area of the narrowest point and the total nasal volume was smaller in patient group. The result that alar contour difference has correlation with total nasal volume but not with objective symptom shows that there may be other factors affecting the nasal obstruction. Therefore the authors conclude that not only the correction of the external morphologic deformity but also the consideration of nasal airway obstruction is essential when performing operation on the secondary cleft lip nose deformity patients.

Objective Evaluation of Secondary Cleft Lip Nose Deformity by Analysis of Nostril Shape

Cleft lip is one of the most common congenital deformities in craniofacial region. However, despite many reports on the outcome of various surgical techniques from individual medical centers, the evaluation of the outcome has been based on the subjective observation. Therefore, developing a new technique of objective and scientific evaluation for the nasal deformity of secondary cleft lip and nasal deformity is important to improve the management of the cleft lip patients. The authors have proposed a new scoring model to evaluate objectively the nasal deformity. The authors put 'x' axis on the nostril sill of noncleft side and 'y' axis on nasal tip at a right angle to x axis. The nostril of noncleft side was turned around the y axis to form the mirror image on the cleft side, and following four parameters were recorded: (1) angle difference between two nostril axis, (2) center of the nostril and distance between two centers, (3) the overlapped area of two nostrils and (4) the overlapped area ratio of two nostrils. The post-surgery images were evaluated by the three plastic surgeons, using the scale of 5 percentiles. The four parameters of each image were measured using a newly developed software and correlation coefficients of each parameter and the evaluation scale by the surgeons were obtained. Among the scores from scoring model, errors greater than 10 percents were found only in 2 of 14 cases (2/14=14%), but among the scores from examiners, errors of greater than 10 percents were 4 from 14 cases (4/14=29%). Based on the results, deviation among the individual examiners can be reduced using the objective evaluation program developed in this study. The correlation coefficients between the normalized overlap area (0.78) and the distance between the centers of two nostrils (-0.82) with the evaluated scale by surgeons were high. However, the relative area and the degree difference of two nostril axis were found to be not such a good parameters in the evaluation of the nasal deformity. We developed scoring model from analysis of nostril shape and neural network which is able to evaluate cleft lip nasal deformity objectively after selection of proper parameters.

A Correction Of Unilateral Cleft Lip Nose Deformity using Porous High-density Polyethylene Columellar Strut

Even though many surgical techniques have been reported to correct the unilateral cleft lip nose deformity, it is very difficult to achieve optimal results. The authors used the porous high-density polyethylene(Medpor(R)) sheet as a columellar strut for alar cartilage repositioning and the triangular transposition flap based on the superior columella for correction of excess skin of alar web. A silicone implant was used for nasal dorsal augmentation. Additional techniques including segmental resection of the excessive alar cartilage on the normal side, freeing of the septal cartilage from the vomer, the nasal osteotomies, a Z-plasty on the afftected plica vestibularis, alar advancement of denuded alar base flap or an interalar cinch, and subcutaneous reduction of the external lateral triangle were also used to repair individual differences of the nasal deformities. Twenty-four patients (11 females and 13 males; mean age, 24 years) were included in this study. From six to thirty-four months(mean fifteen months) postoperatively, the patients were evaluated by the ordinary scale method and the anthropometric analysis using preoperative and postoperative nasal cast models. The analysis of the result was conducted by Paired samples T test. All the patients showed uneventful healing except three cases of columellar strut protrusion. By the ordinary scale method, "good" aesthetic results were noted. By the postoperative anthropometric analysis, the alar length of the normal side, the columellar length and the tip projection of both normal and affected sides were significantly increased. The nostril floor width of the affected side and the nose width were significantly decreased. In conclusion, this technique is valuable in the correction of unilateral cleft lip nasal deformity. But in cases of severe deformity, residual septal deviation, those who have received the operation several times, the porous high-density polyethylene sheet must be used carefully because of the protrusion.

A Correction of Hypoplastic Alar Nasi in Cleft Lip Nose Deformity : Using A Subcutaneous Reduction of Ala and External Lateral Triangle of the Non-Cleft Side

One of the problems in the correction of the cleft lip nose deformity is the hypoplastic alar nasi on the affected side, even after secondary rhinoplasty. This deformity was managed with various cartilage grafts for augmentation of the cleft side, but that procedures have been complicated by inadequate cartilage augmentation, complex procedure, unpredictable results. To overcome the problem of the hypoplastic alar nasi, the authors used subcutaneous reduction of the upper part of the ala and external lateral triangle on the non-cleft side through the intranasal approach. Additional techniques including partial-thickness incisions of the septal cartilage, freeing of the septal cartilage from the vomer, the nasal osteotomy, a z-plasty on the affected plica vestibularis and cinching of denuded alar base of the affected side or an interalar cinch were also used to repair individual differences of the nasal deformities. The authors performed 20 cases (11 women and 9 men) of the correction of the unilateral cleft lip nose deformity between 1997 and 1999. The patient, ranged in age from 19 years to 51 years at the time of surgery, with a mean age of 24 years. Eight to twenty (mean twelve) months postoperatively, the patients were evaluated by the ordinary scale method and the photogrammetric measurements using preoperative and postoperative photos. All the patients showed uneventful healing except two cases of superficial skin necrosis. By the ordinary scale method, "good" aesthetic results were noted. By the photogrammetric measurement, the alar height of non-cleft were significantly decreased. The results showed a relatively symmetrical alar height index of both cleft and non-cleft sides. In conclusion, the procedure is very simple and fast to perform, and it is easy to achive nasal symmetry. It is possible to use the procedure with additional techniques in the various deformities for the better results.

AUGMENTATION OF ALAR BASE USING PURIFIED BOVINE CANCELLOUS BONE XENOGRAFT

It Is generally accepted that autografts of bone are superior to any other types of bone graft. But this technique may be hampered by the size of the bone defect and requires additional surgical procedure, therefore results in increased risk of infection and morbidity. Recently, there is increasing interest in autogenous bone substitute and biomaterials which being extensively investigated: coral, ceramic implants and xenograft can be used as bone substitutes. Some authors have reported successful results using bovine cancellous bone graft in experimental and clinical studies. Authors experienced 15 cases augmentation of cleft lip nose deformity of hypoplastic pyriform rim and maxillary alveolus by using Lubboc(R)(purified bovine cancellous bone matrix) including 3 failure cases of autogenous bone graft. The patient's follow-up period ranged from 4 months to 30 months. In our series, we found no adverse immune reaction and experienced favorable aesthetic results in augmentation of alar base with maintenence of considerable volume and stability. Through long term follow-up, this new purified bovine cancellous bone can be a reliable bone substitute in the treatment of minor bone defect.