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.

Comparison of therapeutic effects between auto nasal septal cartilage and Medpor nasal implants in repair of unilateral cleft lip complicated with nasal deformity / 中华医学美学美容杂志

Objective To explore the clinical methodology and comparative analysis of both autogenous septum cartilagineum nasi or Medpor surgical implant in secondary unilateral cleft lip rhinoplasty.Methods Thirty-six patients with varied secondary nasal deformities of unilateral cleft lip were treated,autogenous septum cartilagineum nasi or Medpor surgical implant were implanted to supply the powerful supporting strength for nasal constructions.An anthropometry method based on the quantitative analysis of the characteristics of nasal deformity was used to evaluate and compare the preoperative and postoperative measure of the patients.Results After 6 to 24 months follow-up,all 36 cases received satisfactory results.20 of them used autologous septum cartilagineum nasi to supply the powerful supporting strength for nasal construcions,and other used Medpor surgical implant.No rejection and exposure of implants were found.The postoperative quantitative measurement results supported that both of the implants could effectively correct nasal deformities.Conclusions Both of the implants could effectively correct nasal deformities of unilateral cleft lip in secondary rhinoplasties.The quantitative measurement is a scientific approach to evaluate the outcome.

Complete Septal Extension Graft using Porous High-Density Polyethylene Sheet or Septal Cartilage in Unilateral Cleft Lip Nasal Deformities: Photogrammetric Analysis

PURPOSE: Complete septal extension grafts have been widely used in rhinoplasty for effective projection of the short retruded columella in Asian patients. Autologous septal cartilages and porous high-density polyethylene sheets are frequently used as septal extension grafts. This study was conducted to compare the postoperative results of porous polyethylene sheets and septal cartilages used for correction of unilateral cleft lip nasal deformities by using photogrammetric analysis. METHODS: This study investigated a total of 49 patients with cleft lip nasal deformities who underwent corrective surgery, and were followed up for at least 6 months. Septal cartilages were used in 39 patients, and porous polyethylene sheets were used in 10 patients. In all patients, through the open rhinoplasty, complete septal extension grafts were sutured to the caudal margin of the septal cartilage, and the alar cartilage was sutured with suspension. The cleft side alar cartilage was overcorrected by approximately 3 - 5 mm. Postoperative outcomes were evaluated by using photogrammetric analysis. Five indices and 4 angles were measured on their photographs taken before and after the surgery. In patients with unilateral cleft lip nasal deformities, symmetry was also evaluated by means of columellar length index. RESULTS: The postoperative values obtained in photogrammetric analysis showed improvements in comparison with the preoperative ones. The polyethylene group produced more improved outcomes than the septal cartilage group but also resulted in more complications at the same time. CONCLUSION: The results of this study indicates that complete septal extension grafts are efficient for the correction of unilateral cleft lip nasal deformities. However, since postoperative complications occur more frequently in the polyethylene group than in the septal cartilage group, caution is advised in using porous high-density polyethylene sheets in patients with cleft lip nasal deformities.

Usefulness of Bardach's Technique for Secondary Correction of Cleft Lip Nasal Deformity

Augmentation of Pyriform Margin Using Porous High-Density Polyethylene Sheet In Unilateral Cleft Lip Nasal Deformity

PURPOSE: The common deformity after the correction of unilateral cleft lip nasal deformity is nasal asymmetry, and it is caused by the hypoplasia of the pyriform aperture. To correct this, many procedures have been applied, but still many problems are present. Authors performed the inlay and onlay insertion of porous high density polyethylene sheet(1mm thickness Medpor(R) sheet) in the hypoplastic pyriform margin of cleft side and obtained satisfactory results. METHODS: 11 cases were performed and the mean follow up period was 15.1 months. Their mean age was 23.6 years. Under general anesthesia, bilateral pyriform margin was exposed. Medpor(R) sheets in "match stick" like shaped were inlay inserted, and kidney shaped were onlay inserted fixating with two 6mm titanium screws. After the surgery, the results was evaluated by photogrammetric analysis. On the basal view, the distance from the subalare and labiale superius' to the transverse baseline connecting the both cheilions was measured from the cleft side and the non-cleft side. Then, the postoperative symmetry was assessed by obtaining the cleft side against the non-cleft side as proportion index, defined as lateral and medial upper lip contour index. RESULTS: There were 2 infections. The cause was because the inserted implant was too long and thus protruded to the base of nasal cavity. The lateral upper lip contour index was from 95.49 to 103.27, and medial upper lip contour index was from 90.92 to 100.49, it was statistically increased, and thus the symmetry was improved. However clinically mild depression remained at nostril floor. CONCLUSION: Authors performed porous high density polyethylene sheet inlay and onlay insertion for the hypoplasia of the pyriform margin in unilateral cleft lip nasal deformity. It was found that depressed pyriform margin and upper lip were corrected effectively except for the nostril floor, for which an additional soft tissue augmentation would be necessary. The inlay insertion has risk of protrusion, thus the guideline of the use of artificial prosthesis should be observed strictly.

Correction of secondary cleft-lip nasal deformity by using Abbe flap: Report of 4 cases

Comparative Analysis in Social Development of Children with Cleft Lip Nasal Deformity According to Timing of Correction: School Age and Preschool Age

PURPOSE: Correction of cleft lip nasal deformity has been performed from March, 1995 to June, 2006 at Donga-A University. The goal of this study is to evaluate children's psychosocial development and to determine the optimal timing of repair. METHODS: This is the retrospective study of patients operated at pre-school and school age. The patients could be divided into two groups, corrected at pre-school age(n=30), and school age(n=30). To evaluate the social development, we used 4 parameters, Children individualism-collectivism scale, Pictorial scale perceived competence social acceptance for young children, Matson's children social adaptability scale, Academic performance rating scale. RESULTS: Operated group at pre-school age had better social adaptation, social acceptance, self-image, self- esteem and academic performance than operated group at school age. CONCLUSION: It is better that correction of secondary lip nasal deformity at pre-school age than at school age in social development.

Indirect Anthropometry on Cast Model of Cleft Lip Nose: Comparison with Direct Anthropometry

PURPOSE: Anthropometry can be divided into two methods, direct anthropometry and indirect anthropometry. The most ideal and accurate method is a direct anthropometry. However, it is difficult to measure in the case of children because of poor cooperation, and it lacks re-productivity. Cast model has advantages of three dimensional featuring, inexpensive and easy fabrication. This study is conducted to find out an accuracy of indirect anthropometry on cast model by comparing it with direct anthropometry. METHODS: Total 48 cleft lip nasal deformity patients (unilateral, 40; bilateral, 8) were included in this study. Cast models were made before surgery under general anesthesia with alginate impression material and model plaster. Eleven linear measurements among 7 landmarks were taken as direct anthropometry before surgery with Castroviejo spreading caliper. At the same time, indirect anthropometry on cast model was done at the same linear distances as well. RESULTS: Of the total 11 linear measurements, both ala lengths, both columella lengths, nose width, projective distance between facial insertion points of the ala, projective distance between the alar base points, right nostril floor width, and columella width were statistically correlated between indirect anthropometry on cast model and direct anthropometry. However, the nasal tip protrusion and the left nostril floor width were not statistically correlated. CONCLUSION: Accuracy of indirect anthropometry on cast model can be influenced by cast model fabrication techniques and correct identification of landmarks. Nasal tip protrusion could be reduced by compression of the nasal tip in the process of cast model fabrication and nostril floor width can be varied by muscle relaxation of anesthetics and incorrect identification of subalare in cleft lip nasal deformity. If sufficient care is taken to make cast model and to define landmarks exactly, indirect anthropometry on cast model can be a reliable method as direct anthropometry.

Indirect Anthropometry on Cast Model of Cleft Lip Nose: Comparison with Direct Anthropometry

PURPOSE: Anthropometry can be divided into two methods, direct anthropometry and indirect anthropometry. The most ideal and accurate method is a direct anthropometry. However, it is difficult to measure in the case of children because of poor cooperation, and it lacks re-productivity. Cast model has advantages of three dimensional featuring, inexpensive and easy fabrication. This study is conducted to find out an accuracy of indirect anthropometry on cast model by comparing it with direct anthropometry. METHODS: Total 48 cleft lip nasal deformity patients (unilateral, 40; bilateral, 8) were included in this study. Cast models were made before surgery under general anesthesia with alginate impression material and model plaster. Eleven linear measurements among 7 landmarks were taken as direct anthropometry before surgery with Castroviejo spreading caliper. At the same time, indirect anthropometry on cast model was done at the same linear distances as well. RESULTS: Of the total 11 linear measurements, both ala lengths, both columella lengths, nose width, projective distance between facial insertion points of the ala, projective distance between the alar base points, right nostril floor width, and columella width were statistically correlated between indirect anthropometry on cast model and direct anthropometry. However, the nasal tip protrusion and the left nostril floor width were not statistically correlated. CONCLUSION: Accuracy of indirect anthropometry on cast model can be influenced by cast model fabrication techniques and correct identification of landmarks. Nasal tip protrusion could be reduced by compression of the nasal tip in the process of cast model fabrication and nostril floor width can be varied by muscle relaxation of anesthetics and incorrect identification of subalare in cleft lip nasal deformity. If sufficient care is taken to make cast model and to define landmarks exactly, indirect anthropometry on cast model can be a reliable method as direct anthropometry.

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.

Correction of unilateral cleft lip nasal deformity with double V-Y open tip rhinoplasty.

The correction of unilateral cleft lip nasal deformity is a challenging task. Many different technique to correct this deformity. The V shape incision was made at the columella and alar web. Lower lateral cartilage on cleft site was sutured to the upper cartilage and lower cartilage on non-cleft site. The incision was closed in V-Y fashion. Thirty-two patients (20 females, 12 males) were operated on during 1997-2000. All the patients were satisfied with the results. Five patients needed more correction. No complication was founded. All scars were un-noticeable.

Correction of Severe Cleft Lip Nasal Deformity Using Composite Graft

Correction of the severe cleft lip nasal deformity is challenging and we used the composite graft to correct the cleft lip nasal deformity with severe tissue deficiency or severe nostril asymmetry. A total of 19 patients, who were born with complete cleft type, was operated between 1995 and 1999. Among them, 10 patients were men and nine were women. Age distribution was seven to 35 years old. In nine patients with unilateral cleft lip nasal deformity and six patients with bilateral cleft lip nasal deformity, columella lengthening was performed using composite graft taken from the helix in 14 cases and contralateral alar rim in one case. In four patients with severe asymmetric nostrils due to a short alar rim in unilateral cleft lip nasal deformity, the ear helix was used in two cases. while in the other two cases the alar rim of the unaffected side was transferred to the affected side to make symmetric nostril by reducing the length of the alar on the affected side. Follow up periods ranged from one to three years, and results were as follows: 1. Four days after the graft, the composite tissue exhibited a pinkish color. Complete survival was confirmed after seven days. The absorption rate observed was about 10 percent and color mismatch became minimal with time. 2. Composite tissue taken from the ear was found to be useful for a full layer reconstruction of the alar and columella due to its stiffness, thin nature, and similarity. Composite tissue from the alar rim of the contralateral side was also determined as good material for a full layer reconstruction of the deficient alar.

Total En Bloc Reconstruction of Alar Cartilage with Conchal Cartilage in Seconday Cleft Lip Nasal Deformity

The cleft lip nasal deformity includes not only distorted lower lateral cartilage but generally also an abnormal deficient maxillary bony platform as well as distorted anterior nasal spine and deviated nasal septum. The main defect in the nose is in the position and shape of lower lateral cartilage. There were many literatures for modification of alar cartilage for nasal symmetry in the past several decades, that is, relocation, suture fixation and graft augmentation with deformed alar cartilage itself. But the various corrective techniques were unsatisfactory for both surgeons and patients. The purpose of this article is to present new concepts and surgical techniques. Author's basic concept is total replacement of deformed alar cartilage with new sources of contoured alar cartilage. The grafts were taken from conchal cartilage en bloc. The medial crus, dome, and lateral crus were replaced by the lamina tragi, isthmus and cavum conchae, respectively. The unilateral secondary cleft lip and nose deformity patients were reviewed with charts and photographs from 1991 to 1998. The surgical procedures were open rhinoplasty incision technique with reversed U-incision of nostril web and wide undermining of cartilaginous vault. The total en bloc reconstruction technique has been performed for 125 patients, aged from 5 to 40 years, and they were followed up for 6 months to 8 years. There were no surgical complications and donor site morbidities. There were no relapse and growth disturbance over time. The postoperative results showed symmetry of alar unit, alar dome projection, tip-defining points and nostrils. CONCLUSION: A new technique is described for sensational improvement of the nasal esthetics in secondary cleft lip nasal deformity by using an en bloc autogenous conchal cartilage graft. But further observation is needed for evaluating its effect on the long-term growth potentials.