1 Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 27e33 Evaluation of the outcome of secondary rhinoplasty in cleft lip and palate patients * N. Chaithanyaa a, *, K.K. Rai b, H.R. Shivakumar b, Amarnath Upasi b a Department of Oral Maxillofacial and Reconstructive Surgery, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India b Department of Oral Maxillofacial and Reconstructive Surgery, Bapuji Dental College and Hospital, Davangere, Karnataka, India Received 18 February 2010; accepted 16 March 2010 KEYWORDS Cleft nose; Nasal deformities; Open rhinoplasty; Conchal graft; Aesthetic and functional evaluation Summary Purpose: A definitive correction of nasal deformity is best performed by creating symmetry and addressing the nostril/tip/columella complex, which is more easily handled by direct vision. The main objective is to evaluate the nasal changes along with function and also to evaluate the satisfaction outcome of the patients following secondary rhinoplasty. Methods: Ten patients who were admitted to our unit for secondary rhinoplasty procedure involving the cleft lipepalate defects associated with nasal deformities were considered for the study. All the patients were evaluated pre- and postoperatively for aesthetics and function along with patient satisfaction and perception. Results: All the operated cases of cleft nasal deformity had a significant improvement in the facial aesthetics and function postoperatively. Clinical evaluation revealed that the post-nasal changes were significant with no nasal obstruction. Statistically, the results were significant (p < 0.05). Conclusion: Although our sample is small, this study would assist in some preliminary conclusions. From our present study, in the view of a distinct deformity of the internal and external nose associated with cleft lip/nose/palate in adolescents or adults, septal rhinoplasty or rhinoplasty alone provides good aesthetics and functional results. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Nasal deformity associated with cleft lip has been viewed as one of the most challenging reconstructive s in rhinoplasty. The characteristic cleft lip nose represents a stigma of the cleft lip patient. This complexity results from a combination of altered anatomy, surgical scarring from previous reconstructive attempts and the inevitable * Work attributed to Bapuji Dental College and Hospital, Davangere, Karnataka, India. * Corresponding author. address: (N. Chaithanyaa) /$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps
2 28 N. Chaithanyaa et al. effects of growth, 1,2 and includes deformities of the septum, nasal pyramid, malformation of the nasal tip and malposition of ala on the cleft side. 3 The severity of the deformity varies with each case and is directly related to the extent of the lip deformity and particularly the alveolar cleft. 4 The maxillary cleft along with hypoplasia and malpositioning of the maxillary segments also contribute significantly to the facial asymmetry. The anatomic and functional deformity of the orbicularis muscle also contributes to the nasal deformity. 4 It is a fact that a significant number of patients who suffer from cleft lip and palate also suffer from airway obstruction, which might have significant implication on nasal physiology as well as the patients quality of life. Septal curvature and associated soft-tissue deviations are important components of the cleft lip nasal deformity. Deviated columella and nasal tip are as a result of a defective septum that would result in an aesthetic and functional deformity of the nose. 5,6 Definitive nasal correction is planned after completion of the nasal growth, typically after the age of 14e15 years. 7,8 The cleft lip nasal deformity is often retained during primary lip repair due to interference with nose growth, ineffective repair and resulting scars that make secondary correction difficult. 9 The main objective is to evaluate the nasal changes along with function and also to evaluate the satisfaction outcome of the patients following secondary rhinoplasty. Figure 2 Measurement in sagittal plane. Methods and methodology Patients reporting to the Department of Oral Maxillofacial and Reconstructive surgery, Bapuji Dental College and Hospital, Davangere, were selected for the study. Sample included three men and seven women, aged between 15 and 40 years with their mean age being 20.4 years. These patients were born with non-syndromic cleft lip palate (CLP) and were operated earlier for the cleft lip, alveolus and palate. Six patients had left defect, one patient had right and three patients had bilateral defects. Those who were operated for corrective rhinoplasty earlier were excluded from the study. On initial presentation, the patients were clinically and radiographically evaluated and photographs were taken using 8 megapixels, 3.5 x optical zoom camera. Pre- and post-operative photographs (Figures 4e9) were used for the evaluation of aesthetics in the vertical and horizontal planes (Figures 1,2) before and after the surgery. The mean results were calculated and confirmed by cephalometric values to avoid discrepancies following photographic evaluation. Cephalometrics values were calculated from the pre-operative (Figure 13) and post-operative (Figure 14) lateral cephalograms that were used to evaluate aesthetics in the sagittal plane (Figure 3). Extra-nasal clinical examination included (1) deviation of the dorsum from the midline; (2) presence of any irregularities along the dorsum; (3) examination of the tip; (4) position of the columella; (5) alar base width; (6) width of individual nostrils; and (7) skin. Intranasal examination included (1) position of the nasal septum; (2) vomers; (3) nasal valve; (4) turbinates; (5) upper lateral cartilages; (6) nasal spine; and (7) nasal floor. Six of the ten patients underwent orthognathic procedures for improvement of the facial profile prior to the rhinoplasty procedure as determined by the cephalometric analysis and clinical examination. Figure 1 Measurement in vertical plane. (a) Nasal axis deviation (b) Evaluation of the vertical position of the alar bases. Figure 3 Measurement in horizontal plane.
3 Evaluation of the outcome of secondary rhinoplasty in cleft lip and palate patients 29 Figure 6 Pre-operative left lateral profile. Figure 4 Figure 5 Pre-operative frontal profile. Post-operative frontal profile. Aesthetically, the nose was evaluated in the vertical, horizontal and sagittal planes. In the vertical plane, nasal deviations from the mid-sagittal plane were measured. The position of the alar bases relative to the interpupillary line was measured for vertical alar dystopia (Figure 1(A) and (B)). The nasolabial angle was measured in the sagittal plane and was considered excellent if it was between 95 and 105 (Figure 2). Horizontally, the distance from the mid-columella to the bucco alar groove on each side was measured. The alar tip angle on each side was measured. This way, the ala, the columella and the nasal tip were evaluated separately and as a complex (Figure 3). Table 3 gives a list of abbreviations used in the line figures. All these measurements were made on the cleft side; therefore, in the group with bilateral CLP, they were measured bilaterally. Nasal function was evaluated, both subjectively and objectively, for obstructed nasal passage using a nasal obstructive symptom evaluation scale (NOSE; Table 1). The parameters considered for nasal evaluation were nasal congestion or stuffiness, nasal blockage or obstructiveness, troublesome breathing through nose, troublesome sleeping and while inhaling air through nose while exercising and exertion. The overall trouble in breathing was evaluated pre- and postoperatively using a linear symptom evaluation scale. Qualitative analysis was performed to get the results. All the surgeries were carried out under general anaesthesia. Standard surgical procedures ( Figures 10e12) were carried out using open structure rhinoplasty and, in few cases, grafting was done using conchal and costochondral grafts as per the requirements. The patients were initially reviewed following the first week of surgery and then were reviewed regularly with 1-month intervals, followed by 3 and 6 months, for a total period of 1 year. Patients were examined for pain, any discomfort following the procedure and for function.
4 30 N. Chaithanyaa et al. Figure 7 Post-operative left lateral profile. Figure 9 Post-operative left lateral profile. Results The significance of the differences in the vertical, horizontal and sagittal planes with their pre- and postoperative data was analysed qualitatively. The patients studied completed the nasal obstructive symptoms evaluation scale and the linear symptom evaluation scale pre- and postoperatively, with a baseline of 0 indicating no existing, up to a score of 4 indicating very severe. Out of the 10 patients in the present study, eight were evaluated as having medium/moderate difficulty in breathing with two patients having severe difficulty while Figure 8 Pre-operative right lateral profile. Figure 10 Exposure of lower lateral cartilage.
5 Evaluation of the outcome of secondary rhinoplasty in cleft lip and palate patients 31 Figure 11 Shield and Strut graft. breathing. Postoperatively, one patient, whose difficulty in breathing was severe as recorded preoperatively, had a considerable relief following a surgical intervention although the postoperative evaluation of the same parameter was considered moderate, while the remaining nine patients manifested with no breathing difficulty. Preoperatively, the patients perceived that their unequal alar positions were the most deformed part of their nasal anatomy, followed by their nasal tip, nostrils and finally their dorsum. Following surgical procedure, the alar base and nostril were the most improved site, followed by the nasal tip and finally the dorsum. The patients satisfaction with the postoperative outcome revealed highest visual analogue scale (VAS) scores at the nasal tip in most of the patients, followed by the dorsum, unequal alar bases and nostril. All patients were satisfied with the outcome of the surgery and even expressed they would undergo such a procedure a second time if necessary. Although the postoperative results were satisfactory, few patients required secondary surgical procedures (Table 2). Figure 13 Pre-operative cephalograpm. These patients present with a wide range of nasal deformities. Along with these abnormalities, this group of patients also frequently presents with alveolar arch malalignments and anterior fistulae. 12 Four of our patients in the Discussion It is universally acknowledged that the correction of a cleft lip nasal deformity continues to be a difficult. Figure 12 Closure. Figure 14 Post-operative cephalograpm.
6 32 N. Chaithanyaa et al. Table 1 NOSE scale 17 Sl. no. Conditions Not a Very mild Moderate Fairly 1 Nasal congestion or stiffness Nasal blockage or obstruction Trouble breathing through my nose Trouble sleeping Unable to get enough air through my nose while exercising or exertion Severe present study have presented with anterior fistulae, which was surgically corrected. Nasal surgery is the end result of an overall treatment programme for secondary cleft lip. These patients have associated facial skeletal deformities. Along with the clinical examination, radiographic and imaging modalities help us to know the severity of the deformity. Subperiosteal or subperichondrial correction of the perioral and perinasal muscle has to be done to maintain symmetry. One of the most important aspects of the cleft lip rhinoplasty is the creation of a symmetric and ideally positioned maxilla, without which the outcome of rhinoplasty will not be optimal. Six out of ten patients underwent orthognathic procedures for the improvement of the facial profile prior to the rhinoplasty procedure. All the orthognathic procedures were performed in our unit. Residual deformities exist in sagittal, horizontal and vertical planes that require correction. The operation may be performed by an endonasal or an open technique. Majority of the nasal deformities are corrected by an open technique and all our patients underwent open rhinoplasty. Few patients require augmentation of the radix and dorsum. Lateral osteotomies were done in two patients to correct the dorsal asymmetry. The alar basal width was reduced by the Weir wedge excision procedure. Reenforcement of the left ala with conchal cartilage was done in one of the patients. Columella strut for the tip projection, shield graft/tip graft for tip definition and dorsal graft for dorsal height were used to correct the asymmetries. Nasal obstruction is one of the most common complaints in the patient with cleft nasal deformity, and has been attributed to the altered nasal anatomy as well as physiology and to the reduced size of the nasal airway caused by the significant external nasal deformity, septal deviation, vomerine spurs and the deficit in maxillary growth. In the present study, six out of 10 patients underwent septorhinoplasty with correction of the hypertrophied inferior turbinates. Following the surgical procedure, two patients manifested with mild nasal obstruction. The symptoms of nasal blockage, nasal congestion or stuffiness had significantly improved following surgery. The evaluation of the outcome of rhinoplasty to treat secondary residual cleft lip nasal deformities has been the subject of numerous reports. 1,4,10e16 Patient satisfaction was evaluated at a 1-year follow-up visit. The data presented in this patient satisfaction survey indicate that the unilateral and bilateral cleft nasal deformities can be improved in the eyes of the patient using a combination of the external rhinoplasty approach, alar base relocation where necessary and augmentation of the nasal tip using an auricular cartilage graft. 10 The patients were satisfied with the postoperative outcome in terms of both aesthetics and function. Although our sample is small, this study would assist in some preliminary conclusions. Management of some of the important features seen in the case of cleft rhinoplasty has been emphasised here as follows: 1. The way in which the unilateral cases the alar cartilages are oriented as well as reduced to attain the required shape and form as observed on the opposite normal alar cartilage. 2. The downturned nasal tip, which is caudally moved by lengthening the foot end of the medial crura as well as reducing the caudal edge of alar cartilage on the cleft side. 3. Reinforcing of the medial crura with strut conchal cartilage graft. 4. Shield graft to be used in cases of deficient tip projection as well as in cases where debulking of thickskinned nasal lobule has been carried out. Table 2 Secondary surgical procedures Sl. no. Residual defects Number of patients Surgical correction performed 1 Extended columellar strut graft at the region 1 Trimming of the extruded graft of the septum 2 Increased alar width 1 Reduction of the alar base width by wier -wich excision 3 Notching of the alar bilaterally 1 Z-plasty 4 Stitch abscess at the base of the columella 1 Incision and drainage and removal the extruded suture material 5 Hypoplastic defect over the left perinasal area 1 Augmentation of the hypoplastic defect
7 Evaluation of the outcome of secondary rhinoplasty in cleft lip and palate patients 33 Table 3 List of abbrevations used A(Figure 2) Nasal tip projection A(Figure 3) Distance from right ala to mid columella IPL Interpupillary line AB-IPL Position of the alar base-relative to the inter pupillary line ABL Left alar base ABR Right alar base a (Figure 2) Ala-columella to FHP a (Figure 3) Angle formed between a tangent drawn to the right ala & the mid nasal tip line B Distance from left ala to mid columella b Same as angle alpha on the left side FHP Frankfurt horizontal plane NLA Naso-labial angle MSP Mid-sagittal plane NA Nasal axis NT Nasal tip HPA Highest point on the alar margin SS Stomion superior NTP Nasal tip projection The correction whistle deformity seen in the patient studied was reserved for the next surgical procedure. The soft triangle (towards the dome of the lateral crura) and the weak triangle (towards the intermediate crura) that is created on the cleft side can be eliminated with interdomal suture as well as a Tagima procedure, respectively, so that the cleft side of the nasal lobule can match with the noncleft side. Cleft rhinoplasty is a challenge because these are cases with high expectations and frustrations both, for having undergone multiple surgical procedures. To achieve near-normal architecture both with respect to form and function in cleft rhinoplasty cases is challenging but a daunting task. Conflict of interest The authors declare there is no conflict of interests or funding provided for the study. References 1. Wang TD, Madorsky SJ. Secondary rhinoplasty in nasal deformity associated with the unilateral cleft lip. Arch Facial Plast Surg 1999;1:40e5. 2. Shih Charles W, Sykes Jonathan M. Correction of the cleft-lip nasal deformity. Facial Plast Surg 2002;18:253e Hade DV, Peter JFML, editors. Textbook of Facial and Plastic Surgery; p McCarthy, editor. Textbook of Plastic Surgery 1990;4. p Gubisch Wolfgang, Reichert Heinz, Widmaier Werner. Six years experience with free septum replantation in cleft nasal correction. J Craniomaxillofac Surg 1989;17:31e3. 6. Blackwell Steven J, Parry Samuel W, Roberg Bradford C, et al. Onlay cartilage graft of the alar lateral crus for cleft lip nasal deformities. Plast Reconstr Surg 1985;76:395e Matukas VJ, Louis PJ. Secondary management of the nose in the cleft patient. Int J Oral Maxillofac Surg 1993;22:195e9. 8. Coghlan BA, Boorman JG. Objective evaluation of the Tajima secondary cleft lip nose correction. Br J Plast Surg 1996;49: 457e Ray Broadbent T, Woolf Robert M. Cleft lip nasal deformity. Ann Plast Surg 1984;12:216e Sandor GKB, Ylikontiola LP. Patient evaluation of outcomes of external rhinoplasty for unilateral cleft lip and palate. Int J Oral Maxillofac Surg 2006;35:407e Beyoung YP, Chung Seum, Young HL. Three- layer corrections of secondary cleft lip nasal deformities. Cleft Palate Craniofac J 1996;33:169e Ahuja Rajeev B. Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late. Plast Reconstr Surg 2001;108:1127e Stal Samuel, Hollier Larry. Correction of secondary deformities of the cleft lip nose. Plast Reconstr Surg 2002;109:1386e Cohen Mimis, Smith Bonnie E, Daw Joseph L. Secondary unilateral cleft lip nasal deformity: functional and esthetic reconstruction. Plast Reconstr Surg 2003;14:584e Guyuron Bahman. Late cleft lip nasal deformity. Plast Reconstr Surg 2008;121:1e Anastassov GE, Joos U, Zollner B. The evaluation of the results of the delayed rhinoplasty in cleft lip and palate patient: functional and aesthetic implications and factors that affect successful nasal repair. Br J Oral Maxillofac Surg 1998;36:416e Sam PM. Analysis of outcome after functional rhinoplasty using a disease specific quality of life instrument. Arch Facial Plast Surg 2006;8:306e9.