Secondary correction of bilateral cleft lip nose deformity

For correction of the bilateral cleft lip nasal deformity, a modified bilateral reverse U incision is used in combination with a short, forked flap; by using this combination, satisfactory lengthening of the columella, preserving the natural pout of the lip, can be obtained. We have applied this method to 12 cases undergoing secondary repair of bilateral cleft lip in the past 3 years, and the results of this treatment, along with representative photographs of some of our patients, are presented herein.     

Reconstruction of bilateral cleft lip and nose deformity

Bilateral cleft lip and nose deformity can be divided into several types according to the extent of the cleft, protruding premaxilla, size of prolabium and nose deformity. Many repair techniques introduced in the literatures were not perfect because of the change of facial profile under the influence of facial growth.The author uses 1-stage cheiloplasty with nose correction for bilateral cleft lip and nose deformity. Early lip adhesion is used before definitive corrections in wide-cleft patients. The lateral mucosal flaps are used for the lining of alveolar cleft. The lateral orbicularis oris peripheralis flaps with the mucosa approximate in front of premaxilla with creation of a buccal alveolar sulcus and continuity of an orbicularis oris muscle. The lateral orbicularis marginalis muscle flaps with white skin roll and vermillion are used for reconstruction of the Cupid's bow. To enhance the median tubercle, prolabial vermilliomucosal flap is inserted into the gap between an approximated orbicularis peripheralis flap and an approximated orbicularis marginalis flap. Z-plasty of the vestibular ridge and the fixation of lower lateral cartilages to dissect through alar rim excision achieve columella lengthening and tip projection. Lip scar revision is rare, but secondary nose correction using triple V-Y flap is frequent.     

双侧唇裂术后唇鼻畸形的美容整形术

目的 :探讨双侧唇裂继发畸形美容整形术的技术改进。方法 :采用两侧红唇上缘的小三角瓣插入到原人中的下方来延长上唇 ,及利用 2种方案修复鼻畸形。结果 :双侧唇裂术后唇鼻畸形Ⅱ期美容整形术12例均取得了比较明显的手术效果。结论 :此方法在唇峰重建、唇珠再造、人中凹形成及唇鼻畸形的矫正方面有比较独特的效果     

Comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using conchal composite grafts.

INTRODUCTION: Anatomical abnormalities and heterogeneous tissue deficiencies of the bilateral cleft lip nasal deformity challenges the cranio-maxillofacial plastic surgeon to create a functional, yet aesthetically pleasing nose. The authors propose a comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using composite conchal grafts. PATIENTS: Five children with bilateral cleft lip nasal deformities had nasal reconstruction using conchal composite grafts, averaging 5 years in age at time of surgery. Patient follow-up averaged 21 months. METHODS: An open tip rhinoplasty was performed using a 'V' shaped columellar incision. The conchal composite graft was obtained from the lateral aspect of the ear and was used to reconstruct the lateral alar mucosal defects. Conchal cartilage was used as a columellar strut. The columellar skin was closed in a 'V-Y' fashion, giving greater columellar length. RESULTS: Visual inspection confirmed that the cleft lip nasal deformity was improved in all patients. There were no postoperative complications. All patients had complete composite graft take with minimal donor site morbidity and deformity. CONCLUSIONS: This comprehensive rhinoplasty technique improves the abnormalities found in bilateral cleft lip nasal deformity by using the successful aspects of other methods and introducing the composite conchal graft.     

Secondary correction of the cleft lip and nose deformity: a new technique for revision of whistling deformity

Reconstruction of the continuity of the orbicularis oris is the main component in correction of the whistling deformity. However, many of the cases are associated with other deformities, such as conspicuous lip scars, an unnaturally wide central lip, flaring alae with wide nostril floors, and a short columella with a flat nasal tip. We report a technique that combines correction of such deformities with reconstruction of the orbicularis oris in a single operation.     

单侧重度唇裂鼻畸形整复的临床研究

目的:探讨单侧重度唇裂鼻畸形的整复方法。方法:对单侧重度唇裂患者,采用鼻内切口、整改畸形组织、调整定位、整复鼻外形,以达到一期修复鼻部畸形、关闭裂隙的目的。结果:唇裂伴鼻畸形整复手术85例,经13年随访,取得满意效果。结论:鼻内切口整改畸形组织是一种值得推荐的一期修复鼻部畸形关闭裂隙的手术方法。     

膨体聚四氟乙烯补片在唇裂术后鼻畸形矫正术中的应用

目的:探索理想的唇裂术后鼻畸形矫正方法.方法:用膨体聚四氟乙烯补片加强患侧鼻翼软骨强度的方法对120例唇裂术后鼻畸形患者行鼻畸形矫正术.结果:120 例患者鼻翼塌陷畸形均得到明显改善,76例随访患者伤口愈合良好,无一例发生排异反应.结论:膨体聚四氟乙烯补片是一种理想的植入材料,运用这种材料可以使唇裂术后鼻畸形矫正达到满意的效果.     

Three-dimensional Z-plasty in the correction of the unilateral cleft lip nasal deformity.

OBJECTIVE: Numerous methods have been introduced for correction of the cleft lip nasal deformities, but no single procedure has given sufficiently satisfactory results to provide a surgical standard. Much effort has been put on restoring cartilaginous structures using alar cartilage modification and suspension. But even after the cartilage framework is repositioned well, redundant alar webbing is still unsightly and frequently conspicuous. This paper presents a procedure combining the usual open rhinoplasty technique and three-dimensional Z-plasty in an external approach to remove the alar web and to lengthen the columella at the same time. METHODS: Open rhinoplasty was performed in 26 consecutive patients with unilateral cleft lip nasal deformity from 1991 to 1996. We used an open rhinoplasty approach, which is a combination of the usual infracartilaginous incision on the noncleft side and a small triangular flap on the cleft side. RESULTS AND CONCLUSIONS: This external rhinoplasty incision can provide a wide surgical field for the handling of the whole cartilage framework. The three-dimensional Z-plasty utilizing redundant alar skin not only removes the alar web but also helps lengthen the columella and provides soft tissue to the nasal vestibule. This technique is easy, and the postoperative result is very consistent. Our open rhinoplasty approach has several advantages and can be a useful approach in the correction of the unilateral cleft lip nasal deformity.     

Simultaneous reconstruction of columella and philtrum using prolabial flap combined with Abbe flap in secondary bilateral cleft lip and nasal deformity

Open rhinoplasty and Abbe flap techniques are traditionally useful tools for the reconstruction of secondary bilateral cleft lip nasal (BCLN) deformity. We aimed to investigate the long-term outcomes of simultaneous columella and philtrum reconstruction using prolabial flap combined with Abbe flap in secondary BCLN deformity.From January 2009 to July 2014, 26 patients (17 males and 9 females; mean age 21 years) with secondary BCLN deformity were recruited. All patients had severe short columella and philtrum deficiency. The whole superiorly based prolabial flap was harvested and trimmed for columella reconstruction. An Abbe flap from the central lower lip was elevated to reconstruct the esthetic philtral unit. No flap necrosis occurred postoperatively. The average follow-up was 2.7 years. The columella length was 4.7 ± 1.3 mm preoperatively and 10.4 ± 2.1 mm postoperatively. The philtrum length increased to 14.4 ± 2.6 mm postoperatively from a preoperative 8.9 ± 2.4 mm. Regarding the overall impression of the reconstruction, 22 patients ranked it as very good or good.In secondary BCLN deformity, the prolabial flap combined with Abbe flap technique is an effective alternative for the treatment of severe short columella complicated with severe philtrum deficiency.     

Correction of the bilateral cleft lip nasal deformity: evolution of a surgical concept.

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 premaxillary-maxillary clefts. The anatomic concept is that, because of the malpositioned 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.     

Secondary repair of the bilateral cleft lip deformity

A wide prolabial segment with a "whistling" defect used to be a common deformity following bilateral cleft lip surgery when the muscle repair was ignored. Simply revising scars often will be followed by recurrence of the deformity. An adequate muscle repair is the basis for a successful and permanent correction. The operation described in this paper includes elevation of the prolabial skin and reconstruction of the orbicularis oris muscle.     

Treatment of the unilateral cleft lip nasal deformity

The lack of tip projection on the affected side of a unilateral cleft lip nasal deformity can be difficult to correct due to lack of adequate structural support. A new technique for the correction of the unilateral cleft lip nasal deformity is described. The key components of the technique involve the use of a dorsally angulated unilateral spreader graft on the cleft side and the use of an L-shaped septal graft to provide support to the cleft nasal tip.     

中国人唇裂鼻畸形整复的思路与术式设计

唇裂鼻畸形的整复是唇腭裂序列治疗的难点之一,其矫治原理与技术方法多源于西方学者的观点和技术。本文通过对中国人和西方人的典型鼻形态进行观察,寻找二者的差异,在此基础上提出了对中国唇裂鼻畸形患者有针对性的整复理论与方法,希望以此加深对唇裂鼻畸形特点的认识,促进我国唇裂鼻畸形整复方法的改进。     

Secondary unilateral cleft lip nasal deformity: functional and esthetic reconstruction

Secondary correction of residual unilateral cleft lip nasal deformities is necessary in a number of patients for functional and cosmetic purposes. Myriads of techniques and modifications have been reported. Most of these publications, however, deal with the correction of the esthetic aspects of the deformity, and little attention has been given to the functional problems associated with the deformity and to the functional outcome of these procedures. A comprehensive protocol of care for correction of residual nasal deformities describing our preoperative anatomical and physiological evaluation, our surgical techniques, and postoperative outcome is presented here. The first 30 consecutive patients managed with this protocol were evaluated clinically and physiologically with rhinomanometry. Significant functional improvement was identified in 73.3% of our patients. It is recommended that airway obstruction be evaluated and addressed in all patients with residual cleft nasal deformities. Component rhinomanometry provides objective information about airway obstruction, and postoperative testing and comparison with preoperative data provide for an objective evaluation of results and assist the surgeon to evaluate the outcome of all procedures critically and to modify or improve them appropriately.     

A new modified forked flap with subcutaneous pedicles for adult cases of bilateral cleft lip nasal deformity: from normalization to aesthetic improvement

In adult cases of bilateral cleft lip nasal deformity, an esthetically satisfying result can not be obtained only by manipulation inside the nose with the nasal tip pointing upward. The nasal tip should be made in a more anterior direction for nasal esthetic improvement. Additional tissue beyond the nose is needed, and the forked flap is a useful method in such cases. However, the blood circulation of long and narrow flaps containing the scar, especially after open rhinoplasty, is unstable. We have developed a new long and narrow forked flap that has a more stable blood circulation. The forked flap was made using two subcutaneous pedicles attached to the periphery of the each flap. We applied this flap to five adult cases of bilateral cleft lip nasal deformity. Four of the cases had the scar associated with the flying bird incision, and one case required no treatment after the primary repair. All the flaps took without signs of partial necrosis. In all cases, the nasal tip was projected forward with adequate columella elongation, and the profile was esthetically improved. In the final stage of correction for adult cases of bilateral cleft lip nasal deformity, this method, making maximum use of the tissue containing the scar in not only the white lip but also the vermilion, is very effective. It is very important to obtain nasal esthetic improvement for the adult patient with bilateral cleft lip nasal deformity.     

Improved nasal tip projection in the treatment of bilateral cleft nasal deformity

The cleft nose deformity in bilateral cleft lip and palate patients with severely flattened alar cartilages, a short, scarred columella, and thickened skin is a reconstructive challenge. The Wolfe double-arch tip rhinoplasty technique was compared with a cartilage release and tip grafting technique to determine the optimal modality for tip projection and columella lengthening. Patients with significant bilateral cleft nasal deformities and previous bilateral cleft lip repairs were divided into two groups (n = 22). Group 1 (double-arch) patients underwent an open rhinoplasty using conchal cartilage grafts to create a columellar strut and new lower lateral arches placed over the existing arches (n = 12). In group 2 (release and tip graft), the lower lateral cartilages were released, and nasal tip grafting was performed (n = 10). Preoperative and 6-month postoperative measurements, including (1) columellar length, (2) alar base-nasal tip-columellar base (ATC) angle, and (3) lateral tip projection, were compared. The lateral tip projection is the perpendicular distance between the nasal tip and a line created from the connection of points at the nasion to the subnasale. In group 1 (double arch), the mean columella length increased 47.2%, whereas in group 2 (release and tip graft), it only increased 14.1%. The ATC angle had a mean decrease or narrowing of 26.7 degrees in group 1, compared with a 12.5 degrees decrease in group 2. Lateral tip projection improvement was greater in group 1 (52.2% increase) compared with group 2 (19.9% increase). The authors' data showed that for the difficult bilateral cleft nasal deformity with significant tip flattening, the double-arch tip rhinoplasty provides improved nasal tip projection.     

唇腭裂成年患者鼻唇外形评价方法的比较研究

目的 本研究针对不同面部畸形程度的唇腭裂成年患者，应用全面相、眼部以下裁剪相和鼻唇区剪相评价鼻唇外形；比较三种评价方法的区别。方法 随机选取北京大学口腔医院唇腭裂治疗中心既往住院治疗患者30名，有不同面部畸形程度，取其正侧位标准相片，并裁剪成眼部以下的面相相片和仅有鼻唇面相的相片。评价者为口腔系本科学生，不熟悉唇腭裂治疗和此研究目的，共18名，三组面相由三组不同的评价者评价。患者和评价者的性别比例为1。将每一个患者三种正侧位面相的鼻对称度、鼻外形、鼻突度、唇外形、红白唇缘、唇突度共6个变量进行5分评价，并分别将每个变量分和变量分总和进行统计比较。结果 应用三种方法评价时，6项评价指标总和在统计学意义上没有差别，但全面相对于鼻突度和鼻评价变量总和的评价与另外两种方法统计学意义上差别显著，后两种方法问无明显差别。结论 对唇腭裂患者的面相评价中，若要单独评价鼻唇区畸形程度，尽量选用眼部以下或鼻唇区裁剪相，以排除眼睛和其他面部特征对评价结果的影响。     

Application of nasal clip in the one-stage repair of unilateral cleft lip nasal deformity

目的 探讨鼻夹在单侧唇裂鼻畸形一期整复术后的应用效果。方法 选取2017年1月—2018年6月在四川大学华西口腔医院唇腭裂外科行单侧唇裂鼻畸形一期整复术的患者60例,分为鼻夹组、鼻模组和对照组。3组患者均在术后6~12个月复诊,并对鼻外形进行评价。结果 鼻夹组患者的鼻外形发育及美学效果较对照组有明显改善,差异有统计学意义（P<0.05）。结论 鼻夹对于唇裂鼻畸形患者矫正术后鼻外形的改善有良好的效果,而且鼻夹操作简单,患者依从性较好,值得临床推广使用。     

Three-dimensional facial morphology, following primary cleft lip repair using the triangular flap with or without rotation advancement

INTRODUCTION: There are numerous methods of repairing a cleft lip. In our institution, two methods have been used for primary lip repair, the triangular flap method, and the rotation-advancement plus small triangular flap method. The purpose of this study was to compare postsurgical anthropometric results following these two surgical methods. PATIENTS: Twenty children with a unilateral complete cleft lip, alveolus and palate (UCLAP) were selected for this study. Ten underwent primary lip repair by the triangular flap method (Triangular Group), and the other 10 underwent repair by the rotation-advancement plus small triangular flap method (Rotation Group). METHOD: They were documented with a three-dimensional optical scanner, and analysed with computer-aided anthropometric method reported previously (Comput. Methods Programs 58: 159-173, 1999a; J. Cranio-Maxillofac Surg 27: 345-353, 1999b). RESULTS: The shapes of the nose and nostril were a little better in the Rotation Group. However, in the Rotation Group, differences between good and poor cases were more extreme than in the Triangular Group. The shape of Cupid's bow was good shortly after surgery in the Triangular Group. A good shape of Cupid's bow was also obtained in the Rotation Group, but the improvement was more delayed. On the non-cleft side, the length of Cupid's bow was more extended in the Triangular Group. Certain deformities were common to both groups, such as deviation of the columella and a flattened ala on the cleft side. CONCLUSION: Rotation-advancement plus the small triangular flap method was thought to produce somewhat better results, however, further improvements in the technique are needed.     

单侧唇腭裂外鼻软骨的外科解剖

为探讨单侧唇腭裂外鼻软骨的解剖异常与鼻畸形的关系，对６例单侧唇腭裂死婴的外鼻部进行解剖，发现患侧鼻翼软骨及鼻中隔软骨发生了组织错位，与鼻畸形的产生有明确的对应关系；统计学处理结果显示，健、患侧鼻翼软骨的大小差异无显著性。说明组织错位是单侧唇腭裂鼻畸形的病理解剖的基础之一。