Dynamic presurgical nasal remodeling in patients with unilateral and bilateral cleft lip and palate: modification to the original technique.

OBJECTIVE: To present technical modifications to the original presurgical nasal remodeling appliance introduced in 1991. The purpose of the modifications is to improve the cleft nasal deformity before unilateral and bilateral cleft lip repair. METHOD: The principle behind this technique, known as dynamic presurgical nasal remodeling (DPNR), is the use of the force generated during suction and swallowing. A conventional intraoral plate is built with a nasal extension added to the labial vestibular flange. The nasal extension was modified and consists of three components. The palatal plate is left loose in the mouth to generate a discontinuous but controlled impact directed to the affected nasal structures during suction and swallowing. The principle aim of the DPNR technique in unilateral cases is to improve the deformation of nasal structures by straightening the columella, elevating the nasal tip, and remodeling the depressed cleft side alar cartilages. In bilateral cases, the aims are to elongate the columella and to obtain nasal tip projection. CONCLUSIONS: The modifications introduced in the appliance enhance the original DPNR technique and are effective in ameliorating the initial cleft nasal deformity. This facilitates primary surgical cleft lip and nose correction and improves surgical outcomes in patients with complete unilateral and bilateral cleft lip and palate.     

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.     

The central lip flap and nasal mucosal rotation advancement: important aspects of composite correction of the bilateral cleft lip nose deformity

The columella, nasal tip, lip relationship in the secondary bilateral cleft deformity remains an enigma and a great challenge for the cleft surgeon. A subset of patients with bilateral cleft lip still require columellar lengthening and nasal correction, despite the advances in preoperative orthopedics and primary nasal corrections. An approach to correct this deformity is described. This consists of (1) lengthening the columella by a central lip advancement flap; (2) open rhinoplasty, allowing definitive repositioning of lower lateral cartilages, ear cartilage grafting to the tip and columella when necessary; (3) nasal mucosal advancement; (4) alar base narrowing; and (5) reconstruction of the orbicularis oris as required. Depending on the individual assessment of the patients, some of these steps were not performed, leaving the nasal mucosal advancement the most important aspect of the reconstruction. In a consecutive series of 72 patients with repaired bilateral cleft lip and palate, 17 patients have been treated with nasal mucosal rotation advancement and followed up for a maximum period of 10 years. With the use of this technique, the secondary bilateral cleft lip nose deformity has been successfully corrected.     

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.     

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.     

Secondary correction of nasal abnormalities associated with cleft lip.

Approximately 30% of patients will require a second operation for correction of nasal abnormalities associated with unilateral cleft lip. In a single second operation, the following steps seem to give the most satisfactory correction: repositioning the nasal septum in the midline; altering the contour of the alar cartilage on the cleft side; and rotation of the axis of the external naris on the cleft side. The usual result following this combination of procedures is moderate but not complete correction of the abnormality. About 50% of the patients will need a second operation for correction of nasal abnormalities associated with bilateral cleft lip. Satisfactory correction of the bilateral cleft lip nasal deformity is usually obtained by lengthening the columella (which secondarily corrects a flat nasal tip) and narrowing the width of the nose at the level of the alae. Satisfactory restoration to normal is usually obtained by the aforementioned procedure.     

66例双侧唇裂功能性整复的临床疗效观察

目的 探讨改良Mulliken法功能性修复双侧唇裂的临床效果。方法 选取66例双侧唇裂患者,应用改良Mulliken法进行唇裂整复,术中在前唇设计窄的“领带”型人中结构;解剖复位侧唇口轮匝肌,重建口轮匝肌环;利用侧唇唇红组织重建唇珠。同期初步矫正鼻畸形,延长鼻小柱。结果 术后经0.5~2 a随访,所有患者无“三等份上唇”不良外观,超过80%（54/66）的患者上唇唇弓形态恢复自然,左右对称,人中宽度与正常相似。唇红丰满,唇珠大小适度,无口哨畸形,动静态外形良好。鼻底宽度正常、鼻孔形态对称,鼻小柱高度较术前延长,鼻尖形态基本满意。结论 利用改良Mulliken法功能性修复双侧唇裂,能有效纠正鼻唇畸形,临床效果良好,值得推广使用。     

单侧唇裂鼻翼软骨定位术与再定位术的设计及应用

鼻畸形矫正日益成为唇裂治疗关注的重点,其术后高复发问题是亟需解决的技术难点.笔者前期提出了依据中国人群鼻翼形态特点建立的鼻翼软骨二焦点固定技术(鼻翼软骨内固定术),之后在单侧唇裂整复中又建立了鼻小柱侧方软组织增量的理论与技术.基于对这两种技术的应用和总结,笔者将其进一步相结合从而发展出新的鼻畸形整复方法,称之为鼻翼软骨...     

Bilateral cleft lip and nose repair

Over the last three decades bilateral cleft lip and nose repair has been characterised by a trend towards more detailed reconstruction of the nasolabial muscles together with simultaneous correction of the deformity. An understanding of the true nature of the nasal deformity in bilateral cleft lip and palate (BCLP) has gradually emerged, and has inspired new approaches to their repair. This article discusses recent trends and controversies in primary cheilorhinoplasty for BCLP.     

个体化双侧唇裂修复术式的设计

目的：探讨能使双侧唇裂修复术后唇及唇弓形态对称的个体化裂修复术式。方法;以双侧唇裂术前鼻小柱基部两侧至前唇唇峰点,以及两侧鼻翼基部至侧唇唇峰的距离是否对称作标准。将术前双侧唇裂的畸形特点分为５种类型,并针对每一种类型的畸形特点设计手术术式。结果;共设计出５种双侧唇裂修复术式,每一种术式仅适用一种双侧唇裂术前畸形的手术修复。     

Repairing the cleft lip nasal deformity.

OBJECTIVE: The repair of the cleft lip nose and nasal deformity remains a challenging endeavor for reconstructive surgeons. Psychosocially, this complex, multifaceted deformity significantly stigmatizes the patient. Numerous techniques have been advocated by multiple authors for the treatment and reconstruction of these deformities, usually requiring serial staged reconstructions. METHOD: Described is our technique for early primary repair of the cleft lip nasal deformity. The use of multiple suspension sutures to repair the nasal defect facilitates the repair of even very wide cleft lips. CONCLUSIONS: These maneuvers provide an aesthetic and functional repair of the nasal defect in conjunction with the lip repair. Long-term results have minimized the need for surgical revision.     

Simplifying cleft surgery by presurgical nasoalveolar molding (PNAM) for infant born with unilateral cleft lip,alveolus, and palate: A clinical report

PatientA 2-day-old female infant with complete unilateral cleft lip, alveolus, and palate (left side) was presented to the Department of Prosthodontics, Government Dental College and Hospital, Nagpur for evaluation and treatment with presurgical nasoalveolar molding (PNAM) prior to surgical intervention.DiscussionThe alignment of the alveolar segments creates the foundation upon which excellent results of primary lip and nasal surgery are dependent in the repair of the cleft lip, alveolus, and palate patient. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. One of the problems that the traditional approach failed to address was the deformity of the nasal cartilages and the deficiency of columella tissue in infants with unilateral and bilateral cleft lip and palate. The purpose of this article is to illustrate the step-by-step fabrication process of the PNAM prosthesis used to direct growth of the alveolar segments, lips, and nose in the presurgical treatment of cleft lip and palate.ConclusionAs a result, the primary surgical repair of the lip and nose heals under minimal tension, thereby reducing scar formation and improving the esthetic result. Frequent surgical intervention to achieve the desired esthetic results can be avoided by PNAM.     

双侧唇裂术后鼻唇畸形的修复

目的 报道双侧唇裂术后鼻唇畸形修复的一种新方法。方法 在双侧鼻孔的内侧沿鼻小柱皮肤粘膜交界缘向下达鼻小柱基部并经鼻底向外达外侧脚外侧并绕鼻翼外侧脚弧形向上;在上唇正中上部画出叉形瓣切口线;再在双侧鼻孔底部上唇瘤痕两侧画垂线至唇红缘。然后切开鼻底及鼻翼外侧脚皮肤,在鼻翼内侧脚上端缝合。将叉形瓣向上推形成鼻小柱下端。切除上唇瘢痕组织,必要时可设 Abbe瓣经旋转180°后按粘膜、肌层及皮肤层缝合。10～14天行Abbe瓣断蒂。结果 用该术式对34位患者进行了手术,术后鼻唇外形、鼻小柱长度及鼻孔大小趋于正常。上唇过紧得到了松驰。结论 该术式对双侧唇裂术后鼻唇畸形矫正有用。     

Presurgical nasoalveolar molding in infants with cleft lip and palate.

Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. In this paper, we present a paradigm shift from the traditional methods of presurgical infant orthopedics. Some of the problems that the traditional approach failed to address include the deformity of the nasal cartilages in unilateral as well as bilateral clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The nasoalveolar molding (NAM) technique we describe uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period. This technique takes advantage of the malleability of immature cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically construct the columella through the application of tissue expansion principles. This construction is performed by gradual elongation of the nasal stents and the application of tissue-expanding elastic forces that are applied to the prolabium. Use of the NAM technique has eliminated surgical columella reconstruction and the resultant scar tissue from the standard of care in this cleft palate center.     

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.     

Single-stage repair of secondary unilateral cleft lip-nose deformity in adults

Correction of cleft lip-nose deformity in adult patients is different from that in children. One-stage correction has proved to be a suitable technique for patients with cleft-lip nose deformity. This study aimed to explore a particular single-stage method and evaluate the effect of simultaneous reparation of secondary unilateral cleft lip-nose deformities.Cleft lip patients who had previously undergone nasolabial surgery with residual poor nasal/lip appearance were included. The alveolar bone defect was repaired with granular costal cortical bone. Lip revision and rhinoplasty were performed using diced costal cartilage. The lip, nose, and alveolar deformities were corrected in one stage.From 2011 to 2017, 53 cases were treated. The vermilion discrepancy was corrected in all cases. Fifty-one patients were successfully treated, with primary healing in the bony recipient area. Cancellous bone exposure occurred in two cases. The wounds were healed after debridement and drainage. Appearances were improved in all patients. The mean change in columella–labial angle ranged from 82.50 to 92.78° (p < 0.001).This one-stage correction appears to have led to a distinct improvement in the nasal tip projection and lip. The method is considered to be effective and reliable in patients with secondary unilateral cleft lip-nose deformities.     

Early and late treatment of unilateral cleft nasal deformity.

Surgical techniques have been developed to correct nasal deformity associated with unilateral cleft lip, alveolus, and palate. This deformity can be significantly corrected during the primary cleft lip repair, as performed by the technique described by the author. Secondary corrective procedures focus mostly on skeletal support and lining distortions as well as on rearrangements of lower lateral cartilages. At the final stage, esthetic appearance can be significantly improved by contour remodeling with the addition of cartilage and/or bony implants. Choice of surgical technique depends upon the severity of the deformity and the experience and proficiency of the surgeon. At the present time, correction of the nasal deformity associated with a unilateral cleft is an integral part of primary cleft lip repair and part of multidisciplinary management of cleft deformities.     

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     

Analysis of nasal and labial deformities in cleft lip, alveolus and palate patients by a new rating scale: preliminary report.

INTRODUCTION: In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analysed and the relevant role of the perinasal-perioral muscular balance, and the inborn dislocation of the alar cartilages is presented. PATIENTS AND METHODS: 50 CLAP patients were analysed in whom 29 primary cheiloplasties, 12 lip revisions and 9 rhinoplasties were performed. The lip repair was done by a modification of Millard's technique, the nose by either a closed or open-sky rhinoplasty. The severity of the cleft appearance was evaluated pre- and postoperatively, according to a pre-agreed visual rating scale. There were 4 degrees of severity of the deformity preoperatively (mild, moderate, severe and very severe), and postoperatively 5 categories of outcome (excellent, very good, good, satisfactory and poor) depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts. RESULTS: 17 excellent, 4 very good, 2 good, 5 satisfactory and 1 poor result were obtained in the group of primary cheiloplasty. Eight excellent, 4 very good results were obtained by the lip revisions. Seven excellent and 2 satisfactory results were obtained following rhinoplasty. CONCLUSIONS: During the primary lip repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. When correct insertion of m. transversus nasi to the nasal spine is achieved and a good repair of m. orbicularis oris, symmetry of the alae and normal growth of lip and columella was obtained even in most severe bilateral cases. In cases of diastasis of the orbicularis and transversus nasi muscles, in combination with other soft tissue deformities or scars, a secondary musculo-periosteal revision is recommended. The defect of the soft tissue triangle of the nose is best corrected via an open rhinoplasty.     

两类单侧不全唇裂鼻畸形临床特点的初步研究

目的：研究单侧不全唇裂伴有／和不伴有牙槽突裂患儿的唇、鼻部畸形特征。方法：对68例患者进行唇鼻部相关数据的测量研究,采用改良Mohler术式修复唇裂并同期矫正鼻畸形。结果：术前测量显示伴有牙槽突裂患儿的唇峰～鼻翼,唇峰～鼻小柱基底的距离,鼻孔高,鼻孔宽和鼻小柱高度与不伴有牙槽突裂的患儿相同指标有显著性差异。结论：通过测量数据的分析显示：单侧不完全性唇裂伴有牙槽突裂是一种畸形更为严重的不全唇裂。