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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 43-49

Controversy and consensus for primary repair of cleft lip nose deformity


Department of Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication21-Nov-2017

Correspondence Address:
Raj Kumar Manas
Department of Plastic, Reconstructive and Burns Surgery, 5th Floor, 5014C, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_84_17

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  Abstract 

Introduction: Correction of Cleft lip nose deformity is a difficult challenge for cleft surgeons. Though, Primary repair of cleft lip nose deformity has been accepted worldwide, there are many variations amongst surgeons involved in cleft care. To demystifying the controversy of primary correction of cleft lip nose repair, we have done an internet based survey to define consensus among surgeons. Methodology: A 15 items questionnaire was framed and sent to the all plastic surgeons of India as well as oral & maxillofacial surgeons, Head & neck, ENT & Pediatric surgeons of the country involved in cleft lip surgery. The questionnaire was categorised in the form of repairing the nose deformity with cleft lip, approach to address such deformity, secondary complications & residual deformity present and satisfactory outcome in order to make a common consensus among surgeons involved in cleft surgery. Results: Of total respondents, 91.8% were plastic surgeons and 9.3 % Oral & maxillofacial surgeons. Almost all of them(100%) felt that nose deformity is a part of cleft lip, but only 81.3% agreed for nose deformity correction at the same time of cleft lip repair. Those who performed nose correction were about 58.1%, who always addressed nose deformity whereas 38.7% performed it sometimes.68.8 % address mostly flaring of ala whereas 52.1% address depressed nasal dome also while 24% address all the deformities. The maximum group, 45.3% prefer semi-open approach; whereas almost equal group 42.1% feel closed approach is sufficient enough to address all deformities. As per age of primary correction of nose deformity, 43% do it at the age of 3-4 months along with cleft lip repair whereas 33 % wait for 6 months. Regarding extent of dissection, 31.2% believe in minimum dissection, whereas for 62.7% it varies according to deformity. 89.7% feel primary correction reduces the deformities and 54.1% people feel only 25% patients may require revision before 7 years of age. However 59.6% prefer to revise the nose correction secondarily at adolescent age. About 29.3% surgeons were satisfied with their result in almost 50-75% of their patients and equal group in their 25-50% of patients' .The main complication they encounter was residual nose deformity in about 75.8%. About 87.8% believe there is no maxillary growth disturbances following nose repair and 87.52% are in favour of doing nose correction at the time of cleft lip repair. Conclusion: To conclude, nose deformity is a part of cleft lip and should be repaired at the time of cleft lip repair. The optimum age of repair is same as for cleft lip. The approach may be “semi-open” to “closed” depending on the surgeon's expertise and experiences and extent of dissection may vary according to deformities. However, a small group of patients may require secondary correction, but it is evident that primary nasal correction reduces the deformities and it should be an integral part of cleft lip repair.

Keywords: Cleft lip nose deformity, Cleft lip rhinoplasty, Primary Cleft lip rhinoplasty, Primary repair of cleft lip nasal deformity


How to cite this article:
Manas RK, Sahu SA. Controversy and consensus for primary repair of cleft lip nose deformity. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:43-9

How to cite this URL:
Manas RK, Sahu SA. Controversy and consensus for primary repair of cleft lip nose deformity. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:43-9. Available from: https://www.jclpca.org/text.asp?2017/4/3/43/218897


  Introduction Top


Primary repair of cleft lip nose deformity has been one of the most controversial topics to the cleft surgeons, and still, surgeons involved in cleft surgery have a divergent opinion while addressing such deformities.

Conventionally, cleft lip nose deformity has received step-motherly treatment than primary cleft lip repair or has been ignored altogether.[1] Traditionally, cleft lip nose deformities have not been corrected during repair of cleft lip with the fear of causing more trauma to the nose and subsequent maxillary growth disturbance.[2] McComb and Coghlan and Salyer et al. popularized the concept of addressing the nose deformity along with cleft lip, and gradually it got accepted worldwide, and now, it has become the integral part of cleft lip repair in many centers.[3],[4]

However, in developing countries like India, where with the large population outnumber the surgeons involved in cleft care, and there is great diversity geographically, ethnically so does the approach involved in cleft care too as depends on patient's profile and the age of presentation for surgery. Correction of nose deformity is still one of the controversies that exist among cleft surgeons because of lack of uniform guidelines and protocol and there is no common consensus that everyone can follow. Although, individual surgeons have been tried to give their best result in their individual hands. Therefore the authors believe that there should be a common protocol to address such nasal deformity and which can be accepted by the majority of surgeons.

To demystify the concept, an internet-based survey was done to recognize the nasal deformities to be addressed along with cleft lip and to classify the severity of the problems, the approaches to correct it and probable outcome with complications that may require secondary correction. The survey was aimed to bring a consensus that can be accepted by the majority of surgeons. A 15-items questionnaire was framed and sent to all plastic surgeons, maxillofacial surgeons, ear, nose, and throat (ENT) surgeons, and pediatric surgeons by E-mail who have been involved in cleft care. The data were collected and analyzed with aim to formulate a guideline that is to be followed by all surgeons involved in cleft care while addressing nasal deformity along with cleft lip.


  Materials and Methods Top


The internet-based survey was started from May 15, 2016 and was closed on February 15, 2017. A 15-point questionnaire format was created using “Google form application” [Table 1], and the form was mailed as a link to all plastic surgeons, maxillofacial surgeons, ENT surgeons, head and neck surgeons, and pediatric surgeons of India by E-mail for their response. The trainees were not included as a respondent in the study.
Table 1: Questionnaire form filled by the respondent

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During the study, reminder mail was sent to all nonrespondents at 3rd week, 6th week, 3rd month, and 6th month. The questionnaire was categorized into recognizing and classifying the nasal deformities, the approach involved to address the deformities, probable outcomes, complications encountered, and the current trend to follow their correction [Table 1].

On submission, the response from each respondent was automatically updated in the Google excel sheet. The data from excel sheet were then collected and analyzed.


  Results Top


Of the total respondents were almost 91.8% plastic surgeons and 9.3% oral and maxillofacial surgeons doing cleft surgery [Figure 1]; however, majority (61.9%) come under the group whose cleft work was <20% of their total work, Only significant group whose cleft work was 20%-50% of their total work was 19.5% [Figure 2].
Figure 1: Percentage of surgeons from different specialties involved in cleft care

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Figure 2: Percentage of cleft work done by the respondent out of total surgeries

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Almost all of them (100%) felt that nose deformity is a part of cleft lip, but only 81.3% agreed for correction of nose deformities at the same time of cleft lip repair [Figure 3]. Of those who do nose correction are those about 53.6% who always address nose deformity whereas 45.4% does it sometimes and 4.1% never repair nose deformity [Figure 4].
Figure 3: Percentage of cleft surgeons who feel that nose deformity is part of cleft lip

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Figure 4: Percentage of cleft surgeons who address nose deformity at the time of cleft lip repair

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Almost 68.8 % cleft surgeons address flaring of ala most of the time whereas 52.1% address depressed nasal dome also. About 30.2% address deviated nasal septum too whereas columella shortening has been addressed by 32.3% of surgeons. Lower lateral cartilage (LLC) hypoplasia is addressed by 17.7%, and 24% of surgeons correct all the deformities [Figure 5].
Figure 5: Type of deformity to be addressed at the time of cleft lip repair as per cleft surgeons

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Most of the surgeons about 45% prefers closed approach, whereas almost similar number of groups, 42.1%, feel that semi-open approach is required to address all deformities whereas 21.1% prefer open approach [Figure 3].

As per age of primary correction of nose deformity, 43.3% of the surgeons do it at the age of 3–4 months along with cleft lip repair whereas 33.3% wait for 6 months and few groups, 23.3%, do it between 6 months and 1 year.

Regarding extent of dissection, 31.2% believe in minimum dissection, whereas, for 55.9%, it varies according to deformities present; however, 12.9% do extensive dissection. Almost 87% of respondents feel that primary correction reduces the deformities whereas 13% were against it.

Almost 54.1% of surgeons feel that only 25% patients may require revision before 7 years of age, whereas 21.2% think 25%–50% of their patients require secondary revision before 7 years of age, about 15.3% think 50%–75% of patients need revision, whereas 7.1% feel >75% of their patients do require any revision surgery at the age of 7 years of age [Figure 6].
Figure 6: Percentage of patients requiring secondary nose correction before 7 years of age who have undergone primary cleft lip nose correction

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About 59.6% prefer to revise the nose correction secondarily at adolescent age, whereas 33% do it at late secondary school age group and 11.7% do it at the age of 5 years only.

However, 8.7% surgeons are satisfied with their result of primary repair of their <25% of patients, 29.3% with their 25%–50% patients and almost equal number with 50%–75% of their patients, and only 14.1% of their >75% of patients.

The main complication they encounter is residual nose deformity about 75.8% whereas 27.5% complain that, over a period of time, the lower lateral cartilage gets slump and nostril stenosis occurs in about 13.2% [Figure 7].
Figure 7: Type of complication following primary cleft lip nose correction

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Nearly 87.8% believe that there is no maxillary growth disturbances following nose repair and 87.2% are in favor of doing nose correction at the time of cleft lip repair [Figure 8].
Figure 8: Percentage of cleft surgeons who believe nose correction should be a part of cleft lip repair

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  Discussion Top


Correction of cleft lip nose deformities has been debatable for many years. In pre-Columbian figurines, cleft lip was sculpted accurately, but nasal appearance was depicted incorrectly as normal. Rhinoplasty for cleft lip was not introduced until the turn of 20th century.

The two plastic surgeons McComb and Coghlan and Salyer et al. popularized the concept of primary correction of nasal deformity at the same stage of cleft lip repair, and now, this concept has gradually gained wide acceptance.[3],[4] However, still as many variations exist in timing of repair, approaches and lack of uniform guidelines to address this deformity.[5]

In our survey, we have found almost 100% respondents feel that nose deformity is a part of cleft lip, but only 81.3% feel to correct it primarily; however, it is only 53.6% of total respondents who address the nose deformity correction always. The major difference and variations exist among surgeons because of various reasons such as (a)clinical presentation of cleft lip nose deformities varies widely, requiring a host of surgical techniques; (b) deformities may be quite asymmetric, making surgical correction difficult; (c) lack of presurgical orthopedics treatment in many parts of country like India, to get symmetry; (d) age of presentations, as in countries like India due to lack of awareness, many people do not come at ideal age of repair of cleft lip nose; (e) nasal deformities affect the pediatric population and the patient's growth affect surgical results; (f) lack of uniform guidelines to repair the nose deformities; (g) multidisciplinary approach is essential to get desired result; and (h) an unrecognized fear that nose surgery might affect midface growth.

However, many cleft centers in India and other parts of the world devoted to cleft work have been doing primary correction of nasal deformities primarily with best result and have set their protocol to address nasal deformity.[6] Cusson et al. also supported early nasal correction in his panel-based assessment of “early” versus “no nasal correction” of the cleft lip nose.[7] Anderl et al. described the techniques of synchronous repair of cleft lip and nose for developing countries where frequent surgery is not possible.[8] Salyer et al. in his 33 years of experiences of primary repair of cleft lip and nose emphasized that nose repair should be an integral part of cleft lip repair.[4]

Regarding the age of repair, many surgeons (43.3%) voted to repair it at the age of 3–4 months along with cleft lip repair; however, 33.3% wait it till 6 months depending on the age of presentation. Dutton and Bumsted[9] in his three-tiered approach advocated repairing the nose at the time of 3–4 months along with cleft lip repair whereas Talamant recommends the nasal pediatric surgery at the time of the first operation at 6 months of age.[9],[10]

To classify the deformities to be corrected, its 68.8% are in favor to correct alar flaring that is mostly responsible for asymmetry, whereas 52.1% demand for nasal dome correction also. About 32.3% felt to heighten the columella shortening, whereas 30.2% do the septoplasty and 24% address all the deformities.

In all literature, primary alar flaring correction by alar cartilage dissection and repositioning has got wide acceptance as documented by McComb and Coghlan, Salyer et al., and Adenwalla and Narayanan.[3],[4],[11] Lo aims to restore symmetry by lifting the alar cartilage and lengthening the columella.[12] Anderal et al. in his 35 years of experiences advocate for permanent stability and shape of nose, and freeing airway deviated nasal septum should be placed in anatomical position.[8] However, the septal correction has still not gained wide acceptance in the literature and (has based on individual surgeon's experiences) despite no valid reason.[6]

While discussing the approach required to correct the deformity, in our survey, many surgeons preferred semi-open approach (42.1%) and almost equal closed approach (45.3%) and few went for open approach (21.1%). Lu et al.[13] in their comparative study of primary correction of nasal deformity in unilateral incomplete cleft lip found semi-open rhinoplasty with Tajima incision (Group III) achieved superior result over Group I (closed) and Group II (semi-open) in terms of nostril height ratio and nostril axis (P < 0.005).[13] In study by Marimuthu et al., the comparison between open versus closed rhinoplasty with primary cheiloplasty, there was no statistically significant difference except alar base width.[14] Many authors used closed approach,[3],[4],[6] whereas open approach has been advocated by some authors.[15],[16]

Thomas and Mishra routinely doing open tip rhinoplasty with some modifications of techniques described by Trott and Mohan with excellent postoperative result without causing any trauma to cartilage complex than any conventional method of closed rhinoplasty.[15],[16] Comparing the data, the approaches can vary according to training and experiences of surgeons.

Most of the surgeons believed that to obtain nasal symmetry, one should dissect the nose according to deformity and almost 55.9% do the variable dissection, whereas 31.2% limited to minimum dissection, only 12.9% are in favor of extensive dissection.

Gelbke was very radical in primary repair, but his techniques were abandoned because of unsatisfactory result;[5] however, the concept of conservative or minimum dissection was also abandoned during mid-seventy, and a more radical and comprehensive approach was grown according to deformity exists.[8]

Almost 87.2% surgeons feel that primary correction of cleft lip nose reduces the deformity. Lo has concluded that primary correction of cleft nasal deformities significantly improves nasal appearance and achieves excellence.[12] Anderl et al. in his 500 cases of primary simultaneous cleft lip and nose study found that 80% of children show satisfactory result.[8] Both the authors support our data.

Only 7.1% surgeons feel that in their >75% children may require additional nose surgery by the age of 7 years. However, 54.1% surgeons thought that in <25% children, additional secondary revision may require because of changes occur during growth of face. Dutton and Bumsted describe after the primary surgery, additional correction for esthetic or functional purpose may be useful during the period of growth so that he advocates “Intermediate rhinoplasty” after primary correction.[9]

More than 59.6% surgeons prefer to wait till adolescence period to do definitive rhinoplasty; however, 33% could revise the nose secondarily by 12–15 years of age. To support the data, many authors recommend delayed rhinoplasty in late teenager years to correct bony dorsal deformity and various causes of nasal obstruction.[9] Based on data, we can say if the deformities are significant, it is better to revise it early otherwise one can wait till adolescent age for definitive rhinoplasty. In our survey, 8.7% surgeons are satisfied with their result of primary correction in <25% of children and almost equal group, 29.3%, happy with 25%–50% of their patients and almost equal group in more than - 75% children after primary correction.

However, 18.3% are not happy with their result probably because of changes during facial growth, lack of follow-up, and postoperative care of unavailability of nasal conformers. Lonic et al. also say that primary correction cannot guarantee an excellent result and it is not definitive rhinoplasty, but with a combination of techniques can achieve promising result.[17]

The common complications encountered by the surgeons are residual nasal deformity which was about 75.8% followed by slumping of lower lateral cartilage 27.5% and nostril stenosis 13.2%. This may be because of lack of availability of nasal conformers that is useful in postoperative care in most of the places in India and tendency of lower lateral cartilage to slump over time because of inherent elasticity,[18] so many authors recommend the overcorrection of lower lateral cartilage. Thomas and Mishra[15] in his earlier series (1994) found nostril stenosis being the most common complication that he corrected by placing the C-flap in nostril sill.[15]

A significant group, 87.8%, believe that nose surgery does not cause a maxillary growth disturbance that is well supported by many authors in their long-term follow-up.[4],[19],[20]

Almost 87.2% are in favor of incorporating primary correction of cleft lip nose along with cleft lip repair. This has been well documented by many authors in their long-term result.[4],[15],[12]


  Conclusion Top


Based on our survey, we demystify the controversy and conclude that nose deformity is a part of cleft lip and its correction should be an integral protocol during cleft lip repair. The ideal age of addressing these deformities is at the same age of cleft lip repair that is 3–6 months depending on the age of presentation. The approach requires may be open, closed, or semi-open depending on surgeons expertise and experiences and extent of dissection varies according to deformities. Primary nose correction does not affect maxillary growth and should be incorporated in cleft lip repair. However, residual nasal deformity, slumping of lower lateral cartilage, and nostril stenosis are the complications that affect postoperative result, but with a combination of techniques, proper postoperative care, multidisciplinary approach and follow-up can reduce these complications. If the deformities are significant, a two-tier approach may require to revise it secondarily to obtain the best result.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Randall P. History of cleft lip nasal repair. Cleft Palate Craniofac J 1992;29:527-30.  Back to cited text no. 1
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2.
McComb HK. Primary correction of unilateral cleft lip nose. Plast Reconstr Surg 1992;70:64-73.  Back to cited text no. 2
    
3.
McComb HK, Coghlan BA. Primary repair of the unilateral cleft lip nose: Completion of a longitudinal study. Cleft Palate Craniofac J 1996;33:23-30.  Back to cited text no. 3
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4.
Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose repair: A 33-year experience. J Craniofac Surg 2003;14:549-58.  Back to cited text no. 4
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5.
Gelbke H. The nostril problem in unilateral harelips and its surgical management. Plast Reconstr Surg (1946) 1956;18:65-75.  Back to cited text no. 5
    
6.
Narayanan PV, Adenwalla HS. Primary rhinoplasty at the time of unilateral cleft lip repair: A review and our protocol. J Cleft Lip Palate Craniofacial Anomalies 2015;2:92-7.  Back to cited text no. 6
    
7.
Cussons PD, Murison MS, Fernandez AE, Pigott RW. A panel based assessment of early versus no nasal correction of the cleft lip nose. Br J Plast Surg 1993;46:7-12.  Back to cited text no. 7
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8.
Anderl H, Hussl H, Ninkovic M. Primary simultaneous lip and nose repair in the unilateral cleft lip and palate. Plast Reconstr Surg 2008;121:959-70.  Back to cited text no. 8
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Dutton JM, Bumsted RM. Management of the cleft lip nasal deformity. Facial Plast Surg Clin North Am 2001;9:51-8.  Back to cited text no. 9
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Talmant JC, Talmant JC. Cleft rhinoplasty, from primary to secondary surgery. Ann Chir Plast Esthet 2014;59:555-84.  Back to cited text no. 10
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11.
Adenwalla HS, Narayanan PC. Unilateral cleft lip. In: Mani V, editor. Surgical Correction of Facial Deformities. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2010. p. 144-52.  Back to cited text no. 11
    
12.
Lo LJ. Primary correction of the unilateral cleft lip nasal deformity: Achieving the excellence. Chang Gung Med J 2006;29:262-7.  Back to cited text no. 12
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13.
Lu TC, Lam WL, Chang CS, Kuo-Ting Chen P. Primary correction of nasal deformity in unilateral incomplete cleft lip: A comparative study between three techniques. J Plast Reconstr Aesthet Surg 2012;65:456-63.  Back to cited text no. 13
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14.
Marimuthu M, Bonanthaya K, Shetty P, Wahab A. Open versus closed rhinoplasty with primary cheiloplasty: A comparative study. J Maxillofac Oral Surg 2013;12:289-96.  Back to cited text no. 14
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15.
Thomas C, Mishra P. Open tip rhinoplasty along with the repair of cleft lip in cleft lip and palate cases. Br J Plast Surg 2000;53:1-6.  Back to cited text no. 15
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16.
Trott JA, Mohan N. A preliminary report on open tip rhinoplasty at the time of lip repair in unilateral cleft lip and palate: The Alor Setar experience. Br J Plast Surg 1993;46:363-70.  Back to cited text no. 16
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17.
Lonic D, Morris DE, Lo LJ. Primary overcorrection of the unilateral cleft nasal deformity: Quantifying the results. Ann Plast Surg 2016;77 Suppl 1:S25-9.  Back to cited text no. 17
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Yeow VK, Chen PK, Chen YR, Noordhoff SM. The use of nasal splints in the primary management of unilateral cleft nasal deformity. Plast Reconstr Surg 1999;103:1347-54.  Back to cited text no. 18
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Kim SK, Cha BH, Lee KC, Park JM. Primary correction of unilateral cleft lip nasal deformity in Asian patients: Anthropometric evaluation. Plast Reconstr Surg 2004;114:1373-81.  Back to cited text no. 19
    
20.
Park BY, Lew DH, Lee YH. A comparative study of the lateral crus of alar cartilages in unilateral cleft lip nasal deformity. Plast Reconstr Surg 1998;101:915-20.  Back to cited text no. 20
    


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