Application of thin-ribbed cartilage with the perichondrium in correction of secondary cleft lip nasal deformity as lateral crural onlay graft / 中国修复重建外科杂志

Objective: To explore the application and effectiveness of thin-ribbed cartilage with the perichondrium in the correction of secondary cleft lip nasal deformity as the lateral crural onlay graft. Methods: A retrospective study was performed based on the data of 28 patients with secondary nasal deformity of cleft lip between October 2015 and April 2017. There were 16 males and 12 females with an average age of 24 years (range, 18-31 years). There were 11 cases with secondary nasal deformities on the left side, 13 cases on the right side, and 4 cases on both sides. Three-dimensional stereotaxy of the nasolabial muscles was used to correct the deformity. The costal cartilage as the support was used to perform nasal columella and nasal dorsum while the thin-ribbed cartilage with the perichondrium was used as wing cartilage support. The photography of nasal position was taken before operation and at 6-8 months after operation. The midpoint of the junction between the nasal columella and the upper lip was marked point O; the lateral horizontal line passing through the point O was marked as X-line, and the longitudinal line (the midline) as Y-line. The distance of the highest point of the affected nostril to the X-line, the distance of the nostril's outermost point to the Y-line, the symmetries of both the most lateral and the highest point of the bilateral nostrils, and the distance of the highest point of the nasal tip to the X-line were measured. Results: All incisions healed by first intention. All patients were followed up 6 to 24 months with an average of 12 months. The size and shape of the noses were stable, and no compli cation, such as cartilage exposure, hematoma, or infection occurred during the postoperative follow-up. There were 4 cases with obvious incision scars, 3 cases with nostril and alar asymmetry, and 1 case of lateral side of the nose without well positioned. The symmetry of the highest points of bilateral nostrils was 57.643%±27.491% before operation and 90.246%±18.769% after operation. The symmetry of the most lateral points of the bilateral nostrils was 77.391%±30.628% before operation and 92.373%±21.662% after operation. And there were significant differences between pre- and post-operation ( P<0.05). There were also significant differences in the distance of highest point of the affected nostril to the X-line, the distance of the nostril's outermost point to the Y-line, and the distance of the highest point of the nasal tip to the X-line ( P<0.05). No thoracic contour change occurred at the costal cartilage donor site. Conclusion: The thin-ribbed cartilage with the perichondrium has good support and long-term stability, and it can be used as one of the ideal materials for nasal alar cartilage transplantation for nasal deformity secondary to cleft lip.

Clinical efficacy of autologous fat grafting in secondary cleft lipoperations / 中华医学美学美容杂志

Objective To evaluate the therapeutic effect of autologous fat grafting in secondary cleft lip.Methods Grafting of autologous fat granules was applied to correct lip under-capacity.The technique was used in 40 patients with secondary cleft lip from June 2011 to December 2015.The ratios between the point of upper lip peak to vermilion height and to white lip height on the affected side were measured by Photoshop CS6.Results Satisfactory results were achieved with all 40 patients;the lip contour and morphology improved.The preoperative ratio was 0.417±0.190 and the postoperative ratio was 0.499±0.197, which increased average 26.02%, with statistically significant (P<0.05).Conclusions Autologous fat grafting to correct lip under-capacity with secondary cleft lip is a safe, effective and micro-invasive method which can be sustained over a lengthy period.

Retrospective subjective evaluation of aesthetic outcome in secondary cleft lip deformities operated with Abbe’s flap.

Background: The Abbe’s flap is most commonly used to repair the full thickness defects of the lip that do not involve the commissure. The Abbe flap was first introduced to correct the secondary deformity of bilateral cleft lip. By this pedicled flap, we are able to equalize the disparity which existed between the tight upper lip and excessive lower lip. Aims to study retrospective subjective evaluation of aesthetic outcome in secondary cleft lip deformities operated with Abbe’s flap. Methods: 29 patients operated during the period of January 2007 - December 2011 for correction of secondary cleft lip and nasal deformity with Abbe’s flap with or without rhinoplasty were included in our retrospective study. The secondary corrective surgeries were performed by a single surgeon. The photographs of the patients were retrospectively assessed by two plastic surgeons and one oral and maxillofacial surgeon, other than the one who performed the surgery. 29 patients operated during the period of January 2007 - December 2011 for correction of secondary cleft lip and nasal deformity with Abbe’s flap with or without rhinoplasty were included in our retrospective study. The secondary corrective surgeries were performed by a single surgeon. The photographs of the patients were retrospectively assessed by two plastic surgeons and one oral and maxillofacial surgeon, other than the one who performed the surgery. Results: Out of 29 patients with secondary cleft deformities 12 were male and 17 were female. Average follow up period was 3 years. Multiple variables of the nose and the lips were used to assess the aesthetic outcome of Abbe’s flap. Conclusion: As per the subjective retrospective analysis of our study we have come to the conclusion that Abbe’s flap is a work horse for correction of shortage of tissue for the secondary cleft lip deformities. Uniform satisfactory outcome was obtained with a more natural contour and more satisfactory proportion of both lips.

One Stage Correction of the Severe Secondary Cleft Lip Nasal Deformities in Foreigners

PURPOSE: It is accepted universally that correction of the cleft lip nasal deformity requires multiple stages of surgery. Following primary lip repair in infancy or early childhood, secondary surgery to improve the deformity of the lip and nose is frequently necessary. A suitable surgical procedure to correct the accompanying deformity, such as cleft palate and alveolus, must be carried out at an appropriate age. In developing countries, it is common for patients with cleft lip nasal deformity to present severe secondary deformities in adolescence, because of poor follow-up and inappropriate surgery. METHODS: The first patient was a 12 year old Mongolian boy. He presented prominent lip scar, short lip, wide columella, asymmetric nostril, palatal fistula, cleft alveolus, and velopharyngeal incompetence. He underwent cheilorhinoplasty, transpositional flap, alveoloplasty by iliac bone graft, and sphincter pharyngoplasty. On follow-up, a bilateral maxillary hypoplasia and a class III malocclusion developed. He underwent LeFort I osteotomy and maxillary advancement at the age of 16 years. The second patient was an 18 year old Eastern Russian girl. She presented with a deviated nose, right alar base depression, short lip, protrusion on vermilion, large palatal fistula, and severe VPI due to short palate. She underwent the combined procedure of cheilorhinoplasty, corrective rhinoplasty, tongue flap for palatal fistula, and superiorly based pharyngeal flap. And the tongue flap was detached at postoperative 3 weeks. RESULTS: The overall results have been extremely pleasing and satisfactory to patients. There were no postoperative complications. CONCLUSION: We discovered the one stage operation for radical correction was sufficient procedure to provide excellent clinical outcomes in patients with severe cleft lip nose deformity.

Correction of Retracted Ala Using Spacer Graft in Secondary Cleft Lip and Nose Deformity

PURPOSE: In patients with unilateral cleft lip and nose deformity, alar retraction is commonly seen on the non-cleft side after cleft side is corrected. Spacer graft was used to drag down the inferior border of the alar cartilage of the non-cleft side so as to match the cleft side. By performing spacer graft and septal extension graft together, symmetry and cosmetic improvements were achieved. METHODS: Seven unilateral cleft lip and nose deformity patients underwent surgery for alar retraction correction. The median age was 24 years (ranged from 15 to 34 years), and the median follow-up period was 7.4 months (ranged from 6 to 12 months). The perpendicular length from the longitudinal axis of the nostril to the alar rim, the nasolabial angle and the ala-labial angle were measured in the lateral view photo. The longest perpendicular length from the cephalic border of the alar rim to the parallel line of the alar base was measured in the frontal view photo. RESULTS: Improvement in alar retraction was seen after the surgery. There were no specific complications during the follow-up and the symmetry of both nostrils was satisfactory. No increase in the nasolabial angle or exposure of the nostrils was seen after the tip projection via tip plasty. CONCLUSION: The fundamental factor in correcting alar retraction with secondary cleft lip and nose deformity is repositioning the alar rim with spacer graft, which seems to be more physiologic than other methods. The method combining spacer graft with septal extension graft will bring symmetry as well as more cosmetic improvement in correction of alar retraction with secondary cleft lip and nose deformity.

Reconstruction of Philtral Column with Overlapping of Orbicularis Oris Muscle Flap in Secondary Cleft Lip Nose Deformity

PURPOSE: Philtral deformity is a stigma of secondary cleft lip nose. It occurs from the false arrangement of orbicularis oris muscle and the scar of previous operation. Various methods have been used to correct this deformity. We successfully corrected philtral deformity using overlapping of orbicularis oris muscle flap. METHODS: From November 2000 to August 2007, we performed 39 cases of correction of philtral deformity in secondary cleft lip nose with overlapping of orbicularis oris muscle flap. Their age ranged from 5 to 53 years old. Existing scar tissue of previous operation was deepithelialized and preserved as scar flap. Lateral orbicularis oris muscle flap was elevated, advanced and overlapped upon medial muscle flap after dissection of orbicularis oris muscle of both sides. Reconstruction of philtral column was made from overlapping area by fixation of end part of lateral muscle flap to the point between philtral dimple and column. The degree of muscle flap advancement was decided by correction state of lateral muscle bulging. Correction of nostril floor depression or whistle deformity was also performed with preserved scar flap, if necessary. RESULTS: Realignments of orbicularis oris muscle were possible in the majority of the patients and final results of philtral reconstruction were satisfactory mostly. Correction of nostril floor depression and whistle deformity was also achieved. Additional correction was performed later to 4 patients in whom insufficient reconstruction was noted. No significant complication was observed. CONCLUSION: More natural and symmetric philtrum was acquired with overlapping of orbicularis oris muscle flap. To the authors' knowledge, it is an easy and effective method for correction of philtral deformity through anatomical rearrangement of distorted orbicularis oris muscle with relatively simple procedure.

Medial and Lateral Crus Elevation to Correct the Secondary Unilateral Cleft Lip-Nasal Deformities

The characteristics of the cleft lip nasal deformity is defined in this article in three planes. The alar flaring is explained in X axis, the lower positioning of the alar free margin is imagined in Y axis and the short hemicolumella is in Z axis. Most cleft surgeons have focused on the malposition of the lateral crus of alar cartilage while the author defined it in X and Y axises and tried to correct that deformity of short hemicolumella in Z axis. For the last 13 years the author applied that method in 818 cases of secondary cleft lip nose deformity. Through the columellar splitting incision extended to free margin of the alar not beyond the nasal dorsum, the skin and soft tissue of the webbing deformed the nasal tip was excised in crescent fashion. The dissected short hemicolumella including the medial crus was thus elevated and advanced into the space of the deformed nasal tip after the crescent excision. This procedure should be followed by the correction of the deformities in X and Y axis. The medial crus elevation is more effective and critical way to have the constant and nice outcome than the lateral crus reposition in secondary cleft lip nasal deformity.

Philtrum Formation in Secondary Unilateral Cleft Lip and Microform Cleft Lip Using Vertical Interdigitation of the Orbicularis Oris Muscle

For patients who have undergone cleft lip surgery, the construction of the philtrum is crucial for restoring a normal appearance of the upper lip. Thirteen patients with unilateral secondary cleft lip deformity and 12 patients with microform cleft lip were treated for the creation of a philtral column between January of 1998 and October of 2002. Fifteen patients were male and 10 patients were female with an age ranges from 6 months to 43 years old. In patients with the depressed philtral column in secondary cleft lip deformity, external approach was used. The scar on the philtral column is excised and a full-thickness incision is made down to the orbicularis oris muscle and mucosa. The medial and lateral muscle flaps are exposed and split into two leaves. The two leaves of each muscle flap are sutured together to create a vertical interdigitation. Any excess skin is not excised but rather closed with 6-0 nylon. In patients with microform cleft lip, vertical interdigitation of the orbicularis oris was performed through the intraoral incision to avoid external scarring. The follow-up period ranged from 6 months to three years, with an average of 14 months. Among the 13 patients with secondary cleft lip deformity, 10 patients were satisfied with their surgical results. Two had fair results. One patient experienced a widening of the scar and no improvement in the philtral column. A possible cause for the lack of improvement in one patient was a partial disruption of the interdigitated muscle before wound healing. On the other hand, all patients with microform cleft lip were satisfied with their surgical results. In conclusion, the advantage of this procedure includes the creation of an anatomically natural philtrum through preserving the continuity and function of the muscle, sufficient augmentation of the philtral column by the vertical interdigitation of the muscle, relief of skin tension, and no donor-site morbidity. In addition, in microform cleft lip, the external visible scar was avoidable through the intraoral incision.

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.