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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 84-92

Columellar strut graft in unilateral cleft nasal deformity: Anthropometry and clinical outcomes


1 Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication7-Aug-2019

Correspondence Address:
Dr. Kumar Prasad Preetha Rani
Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_2_19

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  Abstract 

Introduction: The cleft nasal deformity is a three-dimensional asymmetry involving all layers of the nose. Columellar strut graft is an important method to provide support to the skeletal framework in an attempt to retain structural support and balance. Aims: The purpose of our study is to describe the surgical outcomes following the use of columellar strut graft when it is used in secondary cleft rhinoplasty. The study was designed to identify the changes in tip projection (Tip Proj), tip rotation (Tip Rot), and other anthropometric measurements postoperatively. Materials and Methods: A prospective study was conducted among patients presenting with secondary cleft nasal deformity and operated utilizing a columellar strut graft. The parameters considered were columellar height (CH), columellar width, Tip Proj, Tip Rot, nasofrontal angle, nasofacial angle, and nasolabial angle. All the measurements were analyzed statistically. Results: During the study, results could be evaluated for 25 patients. The Tip Proj increased in 84% of patients, and the magnitude of difference between pre- and post-operative follow-up at 9 months was found to be statistically significant (P = 0.009). The CH increased in 20 patients (80%). The Tip Rot increased in 20 patients (80%). The postoperative changes were consistently maintained at different follow-up intervals. Conclusions: Columellar strut is necessary in improving the Tip Proj, correcting the tilted tripod and lower lateral cartilage deformities. It also functions as a central scaffold on which the tip structures can be unified.

Keywords: Columellar strut graft, tip projection, unilateral cleft nasal deformity


How to cite this article:
Preetha Rani KP, Parashar A, Sharma RK. Columellar strut graft in unilateral cleft nasal deformity: Anthropometry and clinical outcomes. J Cleft Lip Palate Craniofac Anomal 2019;6:84-92

How to cite this URL:
Preetha Rani KP, Parashar A, Sharma RK. Columellar strut graft in unilateral cleft nasal deformity: Anthropometry and clinical outcomes. J Cleft Lip Palate Craniofac Anomal [serial online] 2019 [cited 2019 Dec 8];6:84-92. Available from: http://www.jclpca.org/text.asp?2019/6/2/84/264093


  Introduction Top


The nose is a complexly contoured, multilayered three-dimensional structure which occupies a central position on the face. The nasal deformity associated with congenital cleft lip may vary from mild to severe and is related both to the extent of original cleft severity and to the primary repair technique.[1] The cleft nasal deformity involves all the layers of the nose, beginning with skeletal platform and extending into the vestibular lining, cartilaginous infrastructure, and external nasal skin.[2] The fact that cleft noses have abnormality in all tissue layers separates them in kind from most cosmetic rhinoplasties. Skin and soft-tissue alterations alone do not usually provide long-term correction against the relentless resistance of deformed skeletal and cartilaginous structures associated with clefts. Early intervention, strong columellar support for nasal tip projection (Tip Proj), and construction of a nasal framework that mimics the appearance, symmetry, and position of a normal lower lateral cartilage are essential. After a strong framework is reconstructed, skin cover can be adjusted so that it contours around the new lower lateral cartilage framework. This produces improved results in the appearance of the reconstructed cleft nasal deformity. Columellar strut graft is one of the most important in adding supports to the skeletal framework. In addition to the esthetic contribution, the columellar strut potentially provides a central scaffold on which the adjacent structures retain support and balance.[3] The purpose of our study is to describe the outcomes following the use of columellar strut in secondary cleft rhinoplasty. The study was designed to identify the changes in tip position, tip rotation (Tip Rot), and other anthropometric measurements postoperatively. The longevity of the alterations over a period of 9 months was also studied.


  Materials and Methods Top


The study was conducted over a period of 18 months in the Department of Plastic Surgery at tertiary level teaching Centre. All patients of unilateral cleft reporting with secondary cleft nasal deformity were included in the study. Patients with syndromic clefts, craniofacial malformation were excluded from the study. A written informed consent was taken from the patients, and patients were detailed about the study. The study recruitment period was 7 months with a minimum follow-up of 9 months following the surgical intervention.

Preoperative assessment

The patient's history was recorded in detail. Data including gender, age, type of cleft, and previous surgeries were recorded. The findings of the local examination were recorded. Photographic records were made to document the extent of cleft deformity and included standard frontal, lateral, oblique, and basal views. Both linear and angular measurements were taken. These included columellar height (CH), columellar width (CW), Tip Proj, Tip Rot, nasofrontal angle (NFR), nasolabial angle (NLA), and nasofacial angle (NFA). All linear measurements were made with a Vernier calipers. The angular measurements were recorded on standardized photographs using “Image J software.” The photography was done under uniform lighting, at a fixed distance, with the same standard background. All photos were taken by the same person using the same high definition camera [Figure 1],[Figure 2],[Figure 3],[Figure 4].
Figure 1: Nasofrontal angle

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Figure 2: Nasofacial angle

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Figure 3: Nasolabial angle

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Figure 4: Tip rotation angle

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Operative technique

Open rhinoplasty approach was used using a V-shaped incision extending on to the upper part of the lip. The cartilaginous and skeletal framework of the nose was exposed. Deviated nasal septum if any was corrected. Simultaneously, cartilage graft was harvested from the septum leaving L-strut of 1 cm or more. The lateral alar cartilages were freed laterally so as to permit its rotation into the correct position. The alar domes on both sides were held in the desired position, and a columellar strut graft was placed between the two medial crura with lower end extending up to the maxillary crest. This was fixed to the medial crura using interrupted nylon sutures. The source of cartilage graft was from the septum. All the patients were followed up at 1 month, 3 months, 6, and 9 months [Figure 5], [Figure 6], [Figure 7].
Figure 5: Operative technique ‘a’

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Figure 6: Operative technique ‘b’

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Figure 7: Operative technique ‘c’

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Postoperative follow-up

During each follow-up visit, photographic documentation was done, and both angular and linear measurements were repeated and recorded.

Statistical analysis

At the end of the 9 months' follow-up, all data were collected, and statistical data analysis was carried out mean and standard deviation were compared for all anthropometric measurements. Normality of quantitative data was checked by measures of Kolmogorov–Smirnov tests of normality. Since our data were normally distributed continuous variables between different timings were analyzed. Repeated measure ANOVA followed by one-way ANOVA and post hoc multiple comparisons tests were conducted. The Pearson product-moment was computed to quantify the extent of the interrelationship between different nasal dimensions. The interrelationship between each nasal dimension was analyzed preoperatively, at 1 month, 3 months, 6 months, and 9 months. Qualitative or categorical variables were described as frequencies and proportions. P < 0.05 was considered to indicate statistical significance. All tests were two-sided. All calculations were performed using SPSS® version 17 (Statistical Packages for the Social Sciences, Chicago, IL, USA).


  Observation and Results Top


During the study, 27 patients were enrolled in the study. Among these 2 were lost to follow-up. Thus, finally, data were evaluated for 25 patients.

Age

The age range was 16–35 years. The average age was 20.48 years.

Gender

Total number of female patients was 12 and total number of male patients was 13 in our study.

Anthropometric measurements of the nose

Mean and standard deviation of different anthropometric measurements taken for the patients preoperatively as well as at 1 month, 3 months, 6 months, and 9 months of postoperative phases of the study are shown.

Linear measurements

Columellar height

The preoperative mean CH was 0.49 ± 0.13 cm. It increased to 0.59 ± 0.15 cm at 1 month and was retained at 0.59 ± 0.16 cm and 0.59 ± 0.15 cm at 3 and 6 months' follow-up. The final mean CH at 9 months' follow-up was 0.59 ± 0.16 cm. The magnitude of difference between pre- and post-operative follow-up at 9 months was, however, not statistically significant (P = 0.24) [Figure 8].
Figure 8: Columellar height

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Columellar width

The preoperative mean of CW was 0.47 ± 0.07 cm. The mean CW at 1-month follow-up was 0.43 ± 0.06 cm, which further decreased to 0.42 ± 0.06 cm at 3 months' follow-up and was further sustained at 0.42 ± 0.07 cm at 6 months. The final mean CW at 9 months' follow-up was 0.42 ± 0.07 cm. The mean decrease was 0.04 cm. The magnitude of difference between pre- and post-operative follow-up at 9 months was not statistically significant (P = 0.11) [Figure 9].
Figure 9: Columellar width

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Tip projection

The preoperative mean Tip Proj was 0.58° ± 0.13°. It increased to 0.67° ± 0.1° at 1-month follow and 0.68° ± 0.1° at 3 months' follow-up. The mean Tip Proj at 6 months' follow-up was 0.67 ± 0.1 and at 9 months was 0.67° ± 0.1°. The mean increase was 0.09. The magnitude of difference between pre- and post-operative follow-up at 9 months was statistically significant (P = 0.009) [Figure 10].
Figure 10: Tip projection

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Tip rotation

The preoperative mean of Tip Rot was 15.48° ± 6.3°. It increased to 17.12° ± 5.05° at 1 month follow and 17.16° ± 5.16° at 3 months' follow-up. The mean Tip Rot at 6 months' and 9 months' follow-up was 17.16° ± 5.18°. The mean increase was 1.64°. The magnitude of difference between pre- and post-operative follow-up at 9 months was not statistically significant (P = 1) [Figure 11].
Figure 11: Tip rotation

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Nasofrontal angle

The preoperative mean of NFR was 133.8 ± 12. It remained stable at 133.8 ± 9.7 at 1-month follow-up and 133.6 ± 9.3 at 3 months' follow-up. The mean NFR at 6 months' follow-up 133.5 ± 9.4 and 133.4 ± 9.4 at 9 months' follow-up. The magnitude of difference between pre- and post-operative follow-up at 9 months was not statistically significant (P = 1) [Figure 12].
Figure 12: Nasofrontal angle chart

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Nasofacial angle

The preoperative mean of NFR was 30° ± 5°. It increased to 31.8° ± 3.6° at 1 month and 31.7° ± 3.7° at 3-month follow-up. The mean NFA at 6-month follow-up was 31.7 ± 3.8 and 31.7° ± 3.6° at 9-month follow-up. The mean increase was 1.6°. The magnitude of difference between pre- and post-operative follow-up at 9 months was not statistically significant (P = 1) [Figure 13].
Figure 13: Nasofacial angle chart

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Nasolabial angle

The preoperative mean of NLA was 89.04 ± 18.4. It increased to 98.16° ± 14.1° at 1-month follow-up. Thereafter, it was sustained at 97.72° ± 13.72° at 3, 6, and 9 months' follow-up. The mean increase was 8.68°. The magnitude of difference between pre- and post-operative follow-up at 9 months was not statistically significant (P = 1) [Figure 14].
Figure 14: Nasolabial angle chart

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Comparison of preoperative and postoperative measurements

Post hoc test

Statistical significance of the nose anthropometric measurements made preoperatively was analyzed with the postoperative values measured at 1 month, 3 months, 6 months, and 9 months. The parameters considered were CH, CW, NFR, NFA, NLA, Tip Proj, Tip Rot.

The analysis showed that there was no statistical significance between all the measurements made in the operated nose preoperatively and postoperatively except for Tip Proj in which the P value was significant for 1, 3, 6, and 9 months.

Correlation

To evaluate the interrelationship among all the seven anthropometric dimensions of the operated nose of the patients, values computed in terms of Pearson product-moment coefficient(r). CH, NFA, NLA, Tip Proj, and Tip Rot did not have a significant correlation with any other parameter. Only CW had a significant correlation with CH postoperatively, which was maintained from 1st month to 9th month (0.418–0.411).


  Discussion Top


Rhinoplasty is among the most demanding esthetic surgeries. It is undeniably challenging to achieve a precise and predictable change in a cleft nasal deformity.[4] The skeletal support of the nose is best described by the tripod concept, in which nasal support is provided centrally by the septum and laterally by the nasal side walls and lower lateral cartilages.[5] Compromise of any these structures will result in deviation of the tripod. In the unilateral deformity, the cleft maxilla is laterally displaced and hypoplastic resulting in altered platform for cleft side ala. Consequently, the cleft side ala splays laterally, with associated loss of nasal tip definition, obliquity of alar facial angle, and septal deviation. Shortening the two lateral crus legs will cause the tripod to fall in that direction, thereby “rotating and deprojecting” the tripod. The lower lateral cartilage in a cleft nose is deformed with shorter medial crus and longer lateral crus. Thus, the cleft nose has a shorter nasal length, poor Tip Proj, and altered columellar show.[6]

There has been an evolving consensus in the management of cleft rhinoplasty.[7] The ability to gain and maintain Tip Proj in an under-projected nose is the key to a successful correction of cleft nasal deformity.[8] The concepts now applied are early intervention, strong columellar support for nasal Tip Proj, and construction of nasal framework.[9] Adjusting the skin cover around a strong framework results in improved appearance of the reconstructed cleft nasal deformity. Many techniques have been described for attaching the lower lateral cartilage to each other or to the upper lateral cartilages. Supporting the lower lateral cartilage by suturing them to the upper lateral cartilages has shown to have only short-term benefit. It also does not result in adequate projection. The common denominator is tip definition, and lower lateral cartilage collapse is the lack of persistent tip support.[10] The columellar strut, by nature of its relationship to the medial crura and the lateral crura (i.e., tip-defining points), plays a significant role in defining nasal esthetics. In addition to the esthetic contribution, the columella can help to provide a central scaffold on which the adjacent structures retain support and balance, including the much needed skeletal support for lower lateral cartilage.[11] A columellar strut will strengthen the “medial crural” leg of the tripod. A strut graft can also be used to increase columellar show and improve columellar retraction. The use of a columellar strut to correct buckled medial or intermediate crura may increase Tip Proj and rotation.[12]

An ideal nose is one that is in harmony with the rest of the face. Various angles and proportions that signify the esthetic ideal can simply act as a goal or a frame of reference that could be modified to reflect the realities of a particular patient's features.[13] However, there is no consensus on how to define or analyze the changes that occur after surgery. The evaluation of nasal form and symmetry is simple, as it requires mere inspection. Nevertheless, it is difficult to describe this impression objectively. Various evaluation methods have been described, such as direct and indirect anthropometric analysis, panel evaluation, and linear, area and three-dimensional computerized measurements.[14],[15] Anthropometric measurements of the nose provide objective data about the shape and size of the external nose. It plays a vital role in research by acting as an instrument to measure surgical outcomes. There are studies on anthropometric analysis of cleft nose deformity using highly sophisticated computerized analytical methods.[16],[17] These are usually very complex methods, requiring expensive hardware and software backgrounds. These special analytical methods are not usually available outside the center that has developed it. This hinders the comparison of surgical results in various centers. There are very few studies in literature in which the nose anthropometric measurements have been studied after the use of columellar strut in secondary cleft lip nasal deformity. Kuran et al.[18] in their study on tip surgery in rhinoplasty have used dorsal length, Tip Proj, columellar length, lobular angle, crural length, and intercanthal tip angle as parameters in measuring the outcome. In their study, there was no significant difference in the crural length in the tip-binding suture group, whereas there was statistically significant change in the crural length in the cartilaginous graft group. The insertion of columellar strut helps in increasing the columella height. In our series, CH increased in 20 of 25 patients, and the increase maintained throughout the follow-up. In our series, CW decreased in 19 of 25 patients, even though the magnitude of the difference was not statistically significant. CW had a correlation with CH postoperatively which maintained throughout the follow-up.

The angles which were measured in our study were NFR, NLA, and NFA. The angles were measured using Image J software which is a Java-based image processing program.[19] In our study, NFA increased in 18 out of 25 patients and decreased in 7 out of 25 patients even though the difference was not statistically significant. Jang et al.[20] in their study have compared preoperative NFA with postoperative values after using Medpor implant as columellar strut. Even though they have used implant, while we have used autologous material in our study, this is one of the few studies which measures changes in NFA after the use of columellar strut. In our study, the NFR decreased in 12 out of 25 patients (48%). The NFR increased in 13 out of 25 patients (52%). The NFR can be affected by dorsal hump reduction in addition to columellar strut. No dorsal hump reduction was done in our study, and the results were secondary to the use of columellar strut. The NLA has traditionally been accepted as a parameter for Tip Rot. In some cases, it is difficult to precisely define the subnasale and the most anterior point on the columella. Correcting the tilted tripod helps in bringing the NLA toward normal. In our series, the NLA increased in 18 out of 25 patients, decreased in 7 out of 25 patients. Tip management is among the most challenging arts in rhinoplasty. It is very important to understand the anatomic variations of soft tissues and cartilaginous framework on the tip, factors that influence tip support and their interrelation and final effect of each surgical procedure on the final surgical result.[21],[22] There are various techniques to restore Tip Proj and rotation, and the choice is dependent on the surgeon. Various techniques include columellar struts, lateral crural steal techniques, medial crural-caudal septal imbrications, and medialization of the medial crural footplates, premaxillary grafting, suture techniques, and tip onlay grafts.[23],[24] Columellar strut plays an important role in the correction of nasal tip deformities. Rohrich et al.[25] mentions that a lack of Tip Proj can be remedied by the placement of a long strut whereas adequate projection in the presence of weak or asymmetric lower cartilages requires shorter strut to strengthen and unify the tip elements. In his study, 34% was used to maintain adequate Tip Proj, 26% for tip asymmetry, and 12% for the combination of tip asymmetry and Tip Proj. Kuran et al.[18] have mentioned in their study that cartilaginous grafts should be considered if the dimensional changes have priority in preoperative plan. The columellar strut gives satisfactory tip support and dimensional changes in crural length. If minor dimensional changes with more rotational alterations are planned, tip suture techniques should be preferred. In our series, Tip Proj increased in 21 out of 25 patients. The mean increase was 0.09. The magnitude of difference between pre- and post-operative follow-up was statistically significant (P = 0.009), and it maintained in the follow-up from 3 to 9 months. There was no regression in the Tip Proj from 3 to 9 months. The use of the columellar strut cartilage graft does not necessarily imply an increase in Tip Proj, but rather serves as a means of unifying the nasal tip and helping to control final tip position.[26] The Tip Rot angle has been used as an alternative parameter for Tip Rot in our study. The Tip Rot angle defined by the line between the long axis of the nostril and the Frankfurt horizontal plane has been described as being more accurate.[27] In our series, Tip Rot increased in 20 out of 25 patients and decreased in 5 out of 25 patients. The magnitude of difference between the pre- and post-operative follow-up was not statistically significant. In our study, the follow-up was for 9 months. The improvements in anthropometric parameters as measured during 1-month follow-up were consistently maintained over time. There were no significant changes in these throughout the follow-up 9 months.


  Conclusions Top


The specific role of the columellar strut in cleft nasal surgery has been largely overlooked in the literature despite the fact that its use is almost universal in the management of nasal tip asymmetries. Although many studies have elaborated the role of columellar strut in primary rhinoplasty, very few of this nature exist to discuss its role in unilateral secondary cleft rhinoplasty. In this aspect, our study has a distinct role to play in the forthcoming literature. From our study, we conclude that columellar strut is necessary in improving the Tip Proj, correcting the tilted tripod and lower lateral cartilage deformities. The columellar strut has a role not only in supporting weak lower lateral cartilages but also functions as a central scaffold on which the corrected tip structures can be unified. The goal of this study was also to objectively analyze the effect of the columellar strut graft on nasal tip position. We conclude that the columellar strut actually helps control and/or maintains tip position. In addition, it serves as a means of unifying the nasal tip and helps to control final tip position. This conclusion is supported by our patient series in which columellar strut helped in improving the Tip Proj and correcting the cleft nasal deformity. Further studies are needed with longer duration of follow-up to know the long-term effects of the columellar strut and the statistical significance of the improvements achieved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sykes JM, Jang YJ. Cleft lip rhinoplasty. Facial Plast Surg Clin North Am 2009;17:133-44, vii.  Back to cited text no. 1
    
2.
Sykes JM, Senders CW. Pathologic anatomy of cleft lip, palate and nasal deformity. In: Meyers AD, editor. Biological Basis of Facial Plastic Surgery. New York: Thieme; 1993. p. 57-71.  Back to cited text no. 2
    
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Adams WP Jr., Rohrich RJ, Hollier LH, Minoli J, Thornton LK, Gyimesi I, et al. Anatomic basis and clinical implications for nasal tip support in open versus closed rhinoplasty. Plast Reconstr Surg 1999;103:255-61.  Back to cited text no. 3
    
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Bendre DV, Ofadile FA. Rhinoplasty in adolescent cleft patients. Oral Maxillofac Surg Clin North Am 2002;14:453-61.  Back to cited text no. 4
    
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Rohrich RJ, Griffin JR. Correction of intrinsic nasal tip asymmetries in primary rhinoplasty. Plast Reconstr Surg 2003;112:1699-712.  Back to cited text no. 5
    
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Sykes JM, Senders CW. Surgery of the cleft lip and nasal deformity. Oper Tech Otolaryngol Head Neck Surg 1990;1:219-24.  Back to cited text no. 6
    
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Kane AA, Pilgram TK, Moshiri M, Marsh JL. Long-term outcome of cleft lip nasal reconstruction in childhood. Plast Reconstr Surg 2000;105:1600-8.  Back to cited text no. 7
    
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Sadeghi M, Saedi B, Arvin Sazegar A, Amiri M. The role of columellar struts to gain and maintain tip projection and rotation: A randomized blinded trial. Am J Rhinol Allergy 2009;23:e47-50.  Back to cited text no. 8
    
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Doddi NM, Eccles R. The role of anthropometric measurements in nasal surgery and research: A systematic review. Clin Otolaryngol 2010;35:277-83.  Back to cited text no. 13
    
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Nagy K, Mommaerts MY. Analysis of the cleft-lip nose in submental-vertical view, part I – Reliability of a new measurement instrument. J Craniomaxillofac Surg 2007;35:265-77.  Back to cited text no. 14
    
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Farkas LG, Hreczko TA, Deutsch CK. Objective assessment of standard nostril types – A morphometric study. Ann Plast Surg 1983;11:381-9.  Back to cited text no. 15
    
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Okawachi T, Nozoe E, Nishihara K, Nakamura N. 3-dimensional analyses of outcomes following secondary treatment of unilateral cleft lip nose deformity. J Oral Maxillofac Surg 2011;69:322-32.  Back to cited text no. 16
    
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Lee DW, Choi BK, Park BY. Seven fundamental procedures for definitive correction of unilateral secondary cleft lip nasal deformity in soft tissue aspects. J Oral Maxillofac Surg 2011;69:e420-30.  Back to cited text no. 17
    
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Kuran I, Tümerdem B, Tosun U, Yildiz K. Evaluation of the effects of tip-binding sutures and cartilaginous grafts on tip projection and rotation. Plast Reconstr Surg 2005;116:282-8.  Back to cited text no. 18
    
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Schneider CA, Rasband WS, Eliceiri KW. NIH image to ImageJ: 25 years of image analysis. Nat Methods 2012;9:671-5.  Back to cited text no. 19
    
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Jang D, Yu L, Wang Y, Cao D, Yu Z, Mu X, et al. Nasal measurements in Asians and high-density porous polyethylene implants in rhinoplasty. Arch Facial Plast Surg 2012;14:181-7.  Back to cited text no. 20
    
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Gunter JP, Haclney FL. Basic nasal tip surgery: Anatomy and technique. Dallas Rhinoplasty: Nasal Surgery by the Masters. 2nd ed. St Louis, MO: Quality Medical Publishing, 2007. p. 477-99.  Back to cited text no. 22
    
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25.
Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in rhinoplasty: Indications and rationale. Plast Reconstr Surg 2012;129:118e-25e.  Back to cited text no. 25
    
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Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, Mojallal A. The effect of the columellar strut graft on nasal tip position in primary rhinoplasty. Plast Reconstr Surg 2012;130:926-32.  Back to cited text no. 26
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]



 

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