CLINICAL STUDY
The ‘‘Anatomical Balance Correction’’ for Secondary Cleft Lip Nasal Deformities Dario Bertossi, MD, Claudia Corega, MD, DDS,y Armando Boccieri, MD,z Pasquale Procacci, MD, Carmen Mortellaro, MD, DDS,§ and Pierfrancesco Nocini, MD Secondary cleft lip nasal deformities corrective procedures are still a major concern for the maxillofacial surgeons. Objective: The aim of this study was twofold, to present a new ‘‘anatomical balance’’ correction for the correction of secondary cleft nose deformities and to evaluate it through a long-term followup study. Participants: One hundred twenty patients with cleft lip and palate and secondary nasal tip deformities were recruited for this study. The age ranged from 22 to 39 years (mean: 25.9 years old). Main Outcome Measurements: The stability of the functional aesthetic result has been evaluated by means of an aesthetic protocol completed with a set of 10 photographs. Results: The 3 years follow-up study of 120 patients supports the results of the newly introduced technique that guarantees a better shaping of the nasal tip without further need of another correction procedure. Conclusions: Results indicate that the treatment of secondary cleft nose defects with the ‘‘anatomical balance’’ method gives an improvement of the tip projection by means of various techniques, thus avoiding further surgical procedures. Key Words: Anatomic balance correction, long-term follow-up study, secondary cleft nose tip deformities, surgical treatment of cleft nose (J Craniofac Surg 2016;27: 2130–2133)
S
econdary cleft lip and palate (CLP) nasal deformities are still a major concern for the maxillofacial surgeons. Contemporary cleft surgery includes the treatment of CLP nasal deformities in order to obtain symmetry and adequate projection of the nasal tip and nostrils during primary lip closure by means of a noninvasive procedure. Since cartilage growth disturbance has not yet been reported, various authors tend to perform a simultaneous repositioning and closure of the cleft and of the displaced muscle fibers of the lip and nose.1–6 Secondary surgical corrections of hard and soft From the Maxillofacial Surgery, Department of Surgery, University of Verona, Verona, Italy; yUniversity of Paris V, Paris, France; zHospital San Camillo, Rome; and §Department of Health Sciences, ‘‘A. Avogadro’’ University of Eastern Piedmont, Novara, Italy. Received January 17, 2016. Accepted for publication August 21, 2016. Address correspondence and reprint requests to Prof Dario Bertossi, MD, Associate Professor in the Maxillofacial Department, University of Verona, Policlininico G.B. Rossi, Piazzale L. Scuro 37134, Verona, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003193
tissue defects caused by scars occurring after previous surgery are almost always necessary. The aim of this article is to introduce a new surgical method, namely the ‘‘Anatomical Balance Correction’’ (ABC). This method is indicated for the correction of all secondary CLP nasal deformities where the original anatomy is altered in order to rebuild a new structure moving one part to another. The follow-up study of 120 treated patients over a period of 6 years reveals reproducible esthetic results and eliminates the need of any further surgical procedure. The sequence of the ABC protocol is the correction of the tip, then the nasal septum and finally the remaining nasal architecture, according to the existing anatomical features. With the ABC technique, we perform a progressive nasal dismounting and reconstruction taking away some anatomic parts to graft them in some other area to maximize function, achieve symmetry, and good esthetic outcomes. This is always done through an open approach to improve exposure, diagnosing, surgical outcomes, and to facilitate the insertion of autologous cartilage grafts, which are the elective material for structural and aesthetic corrections7 –11: tip and spreader grafts, alar battens, dorsal grafts (all fixed with 6-0 monofilament absorbable suture). The septal cartilage has been always resected in the posterior area and if necessary, exteriorized and reinserted. The deviated septum is corrected by means of multiple incisions. The morphological shape and position alterations of the alar cartilages were corrected by means of reshaping with 6-0 monofilament suture or graft positioning.12 The BCRCC technique similar to the one used by Peled13 is sometimes used (together with the ABC) with the main difference that the 2 ‘‘pedicled’’ cephalic segments of the lateral crura were rotated contralaterally with various degrees and thereafter fixed on the external portion of the lateral crura with PDS 6-0 sutures (see Scheme 1). This rotation of the pedicled cephalic segments provides a good projection of the nasal tip, especially if the segments are fixed in a medial position. In bilateral CLP patients, this technique can be used to support the nasal tip where the 2 segments are sutured as it was done with the batten grafts. It is recommended especially in secondary unilateral CLP deformities, where the nasal tip appears to be less supported and the tip defining points are less visible. In the secondary stage, the dorsum and then the bony vault is reshaped with single or multiple osteotomies. In some patients, the Gubisch technique to correct nostril apex asymmetries is used14 and the nostrils are packed with a plastic material stent made of polyvinyl siloxane impression material. The nasal stent is used to maintain the surgical results by opposing healing contraction15–17 and is worn 24 hours a day for the first month postoperatively and at night for the next 4 months. The nasal stent has been adapted every 15 days so that it could be adjusted to the decreasing nasal edema.
MATERIALS AND METHODS One hundred twenty patients of both genders (81 females and 39 males), ages 22 to 39 years (mean age of 24.3 years), with cleft lip, alveolus, and palate, either unilateral (89 patients) or bilateral (31) participated in the study. All have been diagnosed with nasal tip deformities due to the primary surgical treatment of the cleft and
2130 The Journal of Craniofacial Surgery Volume 27, Number 8, November 2016 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
TABLE 1. CLP Patient Features
Retropositioned nasal ala Deviated tip Short columella Deviated septum Severe scars of the nasolabial angle Nasal hump Asymmetric nostrils Altered dome cartilage
TABLE 2. CLP Patient Evaluation Unilateral Cleft (89)
Bilateral Cleft (35)
72 72 (48 left) 48 89 36 39 89 (cleft site) 37
12 4 25 2 22 2 1 3
underwent the same 1 stage surgical procedure, where the ‘‘Anatomical Balance’’ method has been used for the correction of the secondary nasal deformity (this was the main inclusion criteria). All patients underwent surgery at the Department of Maxillofacial Surgery of Verona University from 1997 to 2001. Exclusion criteria comprised the presence of a systemic disorder. The following clinical parameters were evaluated by means of an aesthetic protocol which included a clinical examination, a set of 10 pictures, and a computed tomography (CT) scan with 3D reconstuction. All individuals signed a written informed consent and the study was approved by the ethic committee of the university. Clinical examinations were performed by the same 2 surgeons at the first appointment, 2 weeks before the surgical procedure and after 1 year. Of the 120 patients, 60 were reexamined. Agreement between examiners was higher than 92% (K test). In 84 CLP patients, a retropositioned ala attachment (72 unilateral and 12 bilateral CLP) was found. A deviated tip was present in 72 unilateral CLP patients most frequently in left side clefts (48 patients). The same defect (nasal tip deviation) was detected in 24 bilateral CLP patients. A short columella was found in 25 bilateral CLP patients and in 48 unilateral CLP patients due to accompanying severe scars. Among the investigated individuals, a deviated septum was found in 89 unilateral and 2 bilateral CLP patients, severe scarring was noticed in 36 unilateral and 22 bilateral CLP patients, a nasal hump was detected in 39 unilateral and 2 bilateral CLP patients, and asymmetric nostrils appeared in 89 unilateral and 1 bilateral CLP patients. Altered dome cartilage was found in 37 unilateral and 3 bilateral CLP patients (Table 1). Nose function was evaluated and it was found as severely altered in 72 CLP patients with a reduction of 35% in the airway flow) and slightly impaired in the rest of the patients. The evaluation was made through the Mirror test, rhinomanometry, and acoustic manometry. The surgical procedures were performed under general anesthesia. At the beginning, tip surgery was done reorienting and resecting the alar cartilages with conventional techniques or BCRCC technique. The septum was addressed in most of the unilateral CLP patients (97%). The nasal septum was straightened in all CLP patients, in 56 patients was also exteriorized and reinserted. The bony part of the septum was deviated and removed in 103 patients. In bilateral CLP patients, none of the septum was treated except for cartilage harvesting. In 2 bilateral CLP patients, a CT scan was indicated, thus a partial atresia of the upper airways has been diagnosed and treated simultaneously endoscopically (Table 2). In all CLP patients, 1 to 2 cm of posterior septal cartilage has been harvested and used as autologous graft. The nasal tip is remodeled beginning from the alar cartilages. All the alar cartilages have been freed from the other nasal structures and reshaped. The cartilage excess was used for autologous grafts. The tip was grafted with autologous septal grafts (shield grafts) in 86 patients. The nasal dorsum (hump) was found prominent in 75% of the unilateral CLP #
The ‘‘Anatomical Balance Correction’’
Septal exteriorization Cephalic crura resection BCRCC Hump resection Bone osteotomies Weir incisions
Unilateral Cleft
Bilateral Cleft
20 64 25 66 89 76
2 31 0 4 31 3
patients and in 15% of the bilateral ones and it was corrected with bone osteotomies and smooth rasps. Of the bilateral CLP patients, 10% presented a depressed nasal dorsum, treated with septal grafts and in some patients with auricular concha cartilage grafts. Nasal bones osteotomies were performed on all of our patients (100%). The nasal ala attachments were retropositioned in 85 of the unilateral CLP patients, respectively; they have been sectioned and reattached. The columella was elongated by means of Potter incisions (slight defects) or composite grafts. The nostril correction was made in order to correct the residual nostril asymmetries. Patients’ nostrils were packed with polyvinyl siloxane dental impression material in order to manufacture a splint. These splints were changed every 15 days over a period of 5 months and worn 24 hours a day for the first month postoperatively and at night for the next 4 months. The hypertrophic scars were treated with ER-YAG Laser in 2 or 3 sessions as necessary. Nasal medication was administered together with the thermoplastic protection of the nasal dorsum for 7 days, transeptal PDS 4-0 suture. The nylon 7-0 skin sutures were removed after 6 days. Follow-up examinations of all patients were scheduled on day 7, 10, 21, 30, and 12 months after surgery. The advantages of the ‘‘ABC’’ method are highlighted through 2 clinical patients where the aesthetic protocol was used for the diagnosis and evaluation of the final result.
Patient 1 A 22-year-old male with a unilateral left CLP was referred to the Department of Maxillofacial Surgery of the University of Verona for surgical evaluation and treatment. When referred to our department, he had a history of lip closure done at age of 6 months and of an alveolar bone graft at age of 13. The aesthetic analysis protocol revealed the followings: On frontal view: nasal tip deviated to the left, the left nasal ala flat, and a dependent nasal tip. On lateral view: a short columella, an altered nasolabial angle, a slight hump, and the alar–columellar relationship out of proportion (Fig. 1A-B). The surgical plan was an open approach with a Sercer incision, the exteriorization and reinsertion of the nasal septum after multiple parallel partial incision on the concave side, multiple dome incisions on the medial portion and dome repositioning on the septum, fixation
FIGURE 1. (A) Frontal view: left nasal tip deviation, flattened left nasal ala, and dependent tip. (B) Lateral view: short columella, altered nasolabial angle, and slight hump. (C) Frontal view: symmetric tip, improvement of the aesthetic brow-tip lines. (D) Lateral view: better profile and uprotation of the tip.
2131 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery
Bertossi et al
Volume 27, Number 8, November 2016
DISCUSSION
avoid dramatic alterations of the nasal base anatomy resulting in aesthetic and functional problems. The aim of our protocol is first the correction of the tip and then the remaining nasal architecture, according to the own anatomical features. This is the ‘‘Anatomical Balance’’ method in which a progressive nasal dismounting and reconstruction taking away some anatomic parts to graft them in some other area to achieve symmetry and good esthetic outcome was performed. An open approach was used in almost all patients to better control the results and to facilitate the insertion of autologous cartilage grafts, considered to be the elective material for structural and aesthetic corrections7 –11: tip and spreader grafts, alar battens, and dorsal grafts (all fixed with PDS 6.0). The septal cartilage in the posterior area was always resected and if necessary, exteriorized and reinserted. Septum deviations were corrected by means of multiple incisions. The morphological shape and position alterations of the alar cartilages were corrected by means of reshaping with 6-0 PDS suture or graft positioning.12 The BCRCC technique similar to the 1 used by Peled13 was used (together with the new method) with the main difference that the 2 ‘‘pedicled’’ cephalic segments of the lateral crura were rotated contralaterally with various degrees and thereafter fixed on the external portion of the lateral crura with PDS 6-0 sutures (X). This kind of rotation of the pedicled cephalic segments provides a good projection of the nasal tip, especially if the segments are fixed in a medial position. In bilateral CLP patients, this technique can be used to support the nasal tip where the 2 segments are sutured as it was done with the batten grafts. It is mainly recommended in secondary unilateral CLP patients, where the nasal tip appears to be less supported and the tip defining points are less visible. In the secondary stage the dorsum and after that the bony vault was reshaped with single or multiple osteotomies. In some patients additionally to our method, the Gubisch technique to correct nostril apex asymmetries was used14 and the nostrils were packed with a plastic material stent made of polyvinyl siloxane impression material. The nasal stent was used to maintain the surgical results by opposing healing contraction15–17 for 30 days postoperatively and for 4 months during the night. The nasal stent dressing has been changed every 15 days so that it could be adjusted to the decreasing nasal edema. The columellar grafts had a good outcome and the severe scars were further treated with ER-YAG Laser as well as all other residual scars. The evolution of technology will probably lead to a new ‘‘Change in Technique.’’ A lot of residual anatomical imbalances due to old protocols and to the primary treatments are noticed. The tip is the most involved nasal structure in secondary CLP nasal deformities. If an improvement in the aesthetic and function is aimed, the tip must be given an adequate support and definition through an increase in the strength of the alar cartilages. We can conclude that our method seems to be a good way for a progressive approach and correction of a secondary CLP nasal deformity due to its simplicity and to the natural preservation of the existing structures. The ‘‘Anatomical Balance’’ concept was useful in almost all patients treated according to this philosophy. The follow-up study supports the good results and guarantees a better shape of the nasal tip without the need of other surgical procedures as nostril symmetry was achieved in all patients with a single-stage surgery. Further long-term follow-up studies are needed in order to improve and validate the method and the results.
Normal nasal growth depends on the absence of inhibitional factors.18 Thus the best final result of the new method can be achieved with the rebuilding of the entire nasal structure. Although the results are promising, further surgical corrections might not be avoided. Secondary corrective procedures focus mostly on function and lining distortion.19 During primary treatment it is impossible to
1. Reichert H, Gubisch W. Various techniques of secondary nose correction in unilateral cleft lip procedure. Ann Plast Surg 1991;26:18–29 2. Mulliken JB. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg 1985;75:477–486
FIGURE 2. (A) Frontal view: wide nasal radix, asymmetric aesthetic lines, bulbosity of the tip, undefined tip-defining points. (B) Lateral view: acute nasolabial angle, obtuse nasofrontal angle, and dorsal hump. (C) Frontal view: good aesthetics of the nasal base. (D) Lateral view: improvement of nasal tip projection and facial profile of the patient.
of the septum to it with 6.0 ‘‘PDS’’ inter- and intradomal sutures; nasal hump resection together with medial and lateral osteotomies. A columella dermocutaneous graft was used. A final pleasant aesthetic result on frontal, lateral, and basal view was obtained (Fig. 1C-D).
Patient 2 A 25-year-old woman with a unilateral CLP was referred to the Department of Maxillofacial Surgery of the University of Verona in June 1999. The aesthetic analysis protocol revealed the followings: On frontal view: a wide nasal radix, asymmetric brow-tip aesthetic lines, and a depressed nasal tip together with a lack of definition. On lateral view: an open nasolabial angle, an absent nasofrontal angle, a dorsal hump, and an exposed columella (Fig. 2A-B). The surgical plan included an open approach, the excision and repositioning of the left nasal ala insertion, a medial shifting of the 2 domes, and a columellar strut from the septum. A pleasant esthetic result was obtained (Fig. 2C-D).
RESULTS All the patients treated with the ‘‘ABC’’ method had any complaint regardless of the columella scar. The 2 patients diagnosed with the partial atresia of the upper airways reported a better function after surgery, but at the 1 year follow-up examination still 40% of the upper airway flow was compromised due to scar retraction of the internal nasal valve. BCRCC technique was considered and applied to 24 CLP patients with the same degree of rotation of the lateral cephalic segments. Of the bilateral cleft nose secondary deformities patients, 6 patients had a good outcome with the cartilage positioned as alar battens. Finally the nasal tip was projected in all our 120 patients with a medium increase of 108. Good symmetry was achieved after 1 stage treatment. This was particularly visible with our protocol which includes some elements of the Asher method of clinical evaluation. All nostrils asymmetries treated with the Gubisch technique showed a good outcome except for 3 CLP patients where hypertrophic scarring was noticed and received further treatment with ER-YAG Laser (X). The clinical followup examination together with rhinomanometry revealed any further nasal airways obstructions. Apart from the 3 CLP patients where severe scarring was noticed and the 2 CLP patients with upper airway atresia no further complications at were noticed at 3 years follow-up recall. The aesthetic improvement achieved with the ‘‘Anatomical Balance’’ method remained stable in all the patients.
REFERENCES
# 2016 Mutaz B. Habal, MD 2132 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
3. McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10 year review. Plast Reconstr Surg 1985;75:791–799 4. Cutting C, Grayson B, Brecht L, et al. Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair. Plast Reconstr Surg 1998;101:630–639 5. Trott JA, Mohan N. A preliminary report on one stage open tip rhinoplasty at the time of lip repair in bilateral cleft lip and palate: the Alor Setar experience. Br J Plast Surg 1993;46:215–222 6. Enlow DH, Hans MG. Essentials of Facial Growth. Philadelphia, PA: Saunders; 1996 7. Stucker FJ, Hoasjoe D. Nasal reconstruction with conchal cartilage— correcting valve and lateral nasal collapse. Arch Otolaryngol Head Neck Surg 1994;120:653–658 8. McKinney P, Loomis MG, Wiedrich TA. Reconstruction of the nasal cap with a thin septal graft. Plast Reconstr Surg 1993;92:346–351 9. Tardy ME, Denneny J, Fritsch MH. The versatile cartilage autografts in reconstruction of the nose and face. Laryngoscope 1985;95:523–533 10. Jack HS. Tip graft: a 20 year retrospective. Plast Reconstr Surg 1993;91:48–63
#
The ‘‘Anatomical Balance Correction’’
11. Constantian MB. Distant effects of dorsal and tip grafting in rhinoplasty. Plast Reconstr Surg 1992;90:405–416 12. Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new, systematic approach. Plast Reconstr Surg 1994;94:61–77 13. Peled IJ, Ramon Y, Ullmann Y. Wrap-around cartilage flap for correction of unilateral cleft lip nose deformity. Plast Reconstr Surg 1997;99:2085–2088 14. Gubisch W. The triple swing flap technique to correct the asymmetry of unilateral cleft lip nose deformities. Scand J Plast Reconstr Surg Hand Surg 1998;32:287–294 15. Matsuo K, Hirose T. Preoperative non-surgical over-correction of cleft lip nasal deformity. Br J Plast Surg 1991;44:5–11 16. Costa P, Orlando A, di Mascio D. An expansible splint for treatment of nostril stenosis. Ann Plast Surg 1995;34:197–200 17. Cenzi R, Guarda L. A dynamic nostril splint in the surgery of the nasal tip: technical innovation. J Craniomaxillofac Surg 1996;24:88–91 18. Nolst-Trenite` GJ. Secondary rhinoplasty in the bilateral cleft. Facial Plast Surg 2002;18:179–186 19. Salyer KE. Early and late treatment of unilateral cleft nasal deformity. Cleft Palate Craniofac J 1992;29:556–569
2133 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
The ‘‘Anatomical Balance Correction’’ for Secondary Cleft Lip Nasal Deformities Dario Bertossi, MD, Claudia Corega, MD, DDS,y Armando Boccieri, MD,z Pasquale Procacci, MD, Carmen Mortellaro, MD, DDS,§ and Pierfrancesco Nocini, MD Secondary cleft lip nasal deformities corrective procedures are still a major concern for the maxillofacial surgeons. Objective: The aim of this study was twofold, to present a new ‘‘anatomical balance’’ correction for the correction of secondary cleft nose deformities and to evaluate it through a long-term followup study. Participants: One hundred twenty patients with cleft lip and palate and secondary nasal tip deformities were recruited for this study. The age ranged from 22 to 39 years (mean: 25.9 years old). Main Outcome Measurements: The stability of the functional aesthetic result has been evaluated by means of an aesthetic protocol completed with a set of 10 photographs. Results: The 3 years follow-up study of 120 patients supports the results of the newly introduced technique that guarantees a better shaping of the nasal tip without further need of another correction procedure. Conclusions: Results indicate that the treatment of secondary cleft nose defects with the ‘‘anatomical balance’’ method gives an improvement of the tip projection by means of various techniques, thus avoiding further surgical procedures. Key Words: Anatomic balance correction, long-term follow-up study, secondary cleft nose tip deformities, surgical treatment of cleft nose (J Craniofac Surg 2016;27: 2130–2133)
S
econdary cleft lip and palate (CLP) nasal deformities are still a major concern for the maxillofacial surgeons. Contemporary cleft surgery includes the treatment of CLP nasal deformities in order to obtain symmetry and adequate projection of the nasal tip and nostrils during primary lip closure by means of a noninvasive procedure. Since cartilage growth disturbance has not yet been reported, various authors tend to perform a simultaneous repositioning and closure of the cleft and of the displaced muscle fibers of the lip and nose.1–6 Secondary surgical corrections of hard and soft From the Maxillofacial Surgery, Department of Surgery, University of Verona, Verona, Italy; yUniversity of Paris V, Paris, France; zHospital San Camillo, Rome; and §Department of Health Sciences, ‘‘A. Avogadro’’ University of Eastern Piedmont, Novara, Italy. Received January 17, 2016. Accepted for publication August 21, 2016. Address correspondence and reprint requests to Prof Dario Bertossi, MD, Associate Professor in the Maxillofacial Department, University of Verona, Policlininico G.B. Rossi, Piazzale L. Scuro 37134, Verona, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003193
tissue defects caused by scars occurring after previous surgery are almost always necessary. The aim of this article is to introduce a new surgical method, namely the ‘‘Anatomical Balance Correction’’ (ABC). This method is indicated for the correction of all secondary CLP nasal deformities where the original anatomy is altered in order to rebuild a new structure moving one part to another. The follow-up study of 120 treated patients over a period of 6 years reveals reproducible esthetic results and eliminates the need of any further surgical procedure. The sequence of the ABC protocol is the correction of the tip, then the nasal septum and finally the remaining nasal architecture, according to the existing anatomical features. With the ABC technique, we perform a progressive nasal dismounting and reconstruction taking away some anatomic parts to graft them in some other area to maximize function, achieve symmetry, and good esthetic outcomes. This is always done through an open approach to improve exposure, diagnosing, surgical outcomes, and to facilitate the insertion of autologous cartilage grafts, which are the elective material for structural and aesthetic corrections7 –11: tip and spreader grafts, alar battens, dorsal grafts (all fixed with 6-0 monofilament absorbable suture). The septal cartilage has been always resected in the posterior area and if necessary, exteriorized and reinserted. The deviated septum is corrected by means of multiple incisions. The morphological shape and position alterations of the alar cartilages were corrected by means of reshaping with 6-0 monofilament suture or graft positioning.12 The BCRCC technique similar to the one used by Peled13 is sometimes used (together with the ABC) with the main difference that the 2 ‘‘pedicled’’ cephalic segments of the lateral crura were rotated contralaterally with various degrees and thereafter fixed on the external portion of the lateral crura with PDS 6-0 sutures (see Scheme 1). This rotation of the pedicled cephalic segments provides a good projection of the nasal tip, especially if the segments are fixed in a medial position. In bilateral CLP patients, this technique can be used to support the nasal tip where the 2 segments are sutured as it was done with the batten grafts. It is recommended especially in secondary unilateral CLP deformities, where the nasal tip appears to be less supported and the tip defining points are less visible. In the secondary stage, the dorsum and then the bony vault is reshaped with single or multiple osteotomies. In some patients, the Gubisch technique to correct nostril apex asymmetries is used14 and the nostrils are packed with a plastic material stent made of polyvinyl siloxane impression material. The nasal stent is used to maintain the surgical results by opposing healing contraction15–17 and is worn 24 hours a day for the first month postoperatively and at night for the next 4 months. The nasal stent has been adapted every 15 days so that it could be adjusted to the decreasing nasal edema.
MATERIALS AND METHODS One hundred twenty patients of both genders (81 females and 39 males), ages 22 to 39 years (mean age of 24.3 years), with cleft lip, alveolus, and palate, either unilateral (89 patients) or bilateral (31) participated in the study. All have been diagnosed with nasal tip deformities due to the primary surgical treatment of the cleft and
2130 The Journal of Craniofacial Surgery Volume 27, Number 8, November 2016 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
TABLE 1. CLP Patient Features
Retropositioned nasal ala Deviated tip Short columella Deviated septum Severe scars of the nasolabial angle Nasal hump Asymmetric nostrils Altered dome cartilage
TABLE 2. CLP Patient Evaluation Unilateral Cleft (89)
Bilateral Cleft (35)
72 72 (48 left) 48 89 36 39 89 (cleft site) 37
12 4 25 2 22 2 1 3
underwent the same 1 stage surgical procedure, where the ‘‘Anatomical Balance’’ method has been used for the correction of the secondary nasal deformity (this was the main inclusion criteria). All patients underwent surgery at the Department of Maxillofacial Surgery of Verona University from 1997 to 2001. Exclusion criteria comprised the presence of a systemic disorder. The following clinical parameters were evaluated by means of an aesthetic protocol which included a clinical examination, a set of 10 pictures, and a computed tomography (CT) scan with 3D reconstuction. All individuals signed a written informed consent and the study was approved by the ethic committee of the university. Clinical examinations were performed by the same 2 surgeons at the first appointment, 2 weeks before the surgical procedure and after 1 year. Of the 120 patients, 60 were reexamined. Agreement between examiners was higher than 92% (K test). In 84 CLP patients, a retropositioned ala attachment (72 unilateral and 12 bilateral CLP) was found. A deviated tip was present in 72 unilateral CLP patients most frequently in left side clefts (48 patients). The same defect (nasal tip deviation) was detected in 24 bilateral CLP patients. A short columella was found in 25 bilateral CLP patients and in 48 unilateral CLP patients due to accompanying severe scars. Among the investigated individuals, a deviated septum was found in 89 unilateral and 2 bilateral CLP patients, severe scarring was noticed in 36 unilateral and 22 bilateral CLP patients, a nasal hump was detected in 39 unilateral and 2 bilateral CLP patients, and asymmetric nostrils appeared in 89 unilateral and 1 bilateral CLP patients. Altered dome cartilage was found in 37 unilateral and 3 bilateral CLP patients (Table 1). Nose function was evaluated and it was found as severely altered in 72 CLP patients with a reduction of 35% in the airway flow) and slightly impaired in the rest of the patients. The evaluation was made through the Mirror test, rhinomanometry, and acoustic manometry. The surgical procedures were performed under general anesthesia. At the beginning, tip surgery was done reorienting and resecting the alar cartilages with conventional techniques or BCRCC technique. The septum was addressed in most of the unilateral CLP patients (97%). The nasal septum was straightened in all CLP patients, in 56 patients was also exteriorized and reinserted. The bony part of the septum was deviated and removed in 103 patients. In bilateral CLP patients, none of the septum was treated except for cartilage harvesting. In 2 bilateral CLP patients, a CT scan was indicated, thus a partial atresia of the upper airways has been diagnosed and treated simultaneously endoscopically (Table 2). In all CLP patients, 1 to 2 cm of posterior septal cartilage has been harvested and used as autologous graft. The nasal tip is remodeled beginning from the alar cartilages. All the alar cartilages have been freed from the other nasal structures and reshaped. The cartilage excess was used for autologous grafts. The tip was grafted with autologous septal grafts (shield grafts) in 86 patients. The nasal dorsum (hump) was found prominent in 75% of the unilateral CLP #
The ‘‘Anatomical Balance Correction’’
Septal exteriorization Cephalic crura resection BCRCC Hump resection Bone osteotomies Weir incisions
Unilateral Cleft
Bilateral Cleft
20 64 25 66 89 76
2 31 0 4 31 3
patients and in 15% of the bilateral ones and it was corrected with bone osteotomies and smooth rasps. Of the bilateral CLP patients, 10% presented a depressed nasal dorsum, treated with septal grafts and in some patients with auricular concha cartilage grafts. Nasal bones osteotomies were performed on all of our patients (100%). The nasal ala attachments were retropositioned in 85 of the unilateral CLP patients, respectively; they have been sectioned and reattached. The columella was elongated by means of Potter incisions (slight defects) or composite grafts. The nostril correction was made in order to correct the residual nostril asymmetries. Patients’ nostrils were packed with polyvinyl siloxane dental impression material in order to manufacture a splint. These splints were changed every 15 days over a period of 5 months and worn 24 hours a day for the first month postoperatively and at night for the next 4 months. The hypertrophic scars were treated with ER-YAG Laser in 2 or 3 sessions as necessary. Nasal medication was administered together with the thermoplastic protection of the nasal dorsum for 7 days, transeptal PDS 4-0 suture. The nylon 7-0 skin sutures were removed after 6 days. Follow-up examinations of all patients were scheduled on day 7, 10, 21, 30, and 12 months after surgery. The advantages of the ‘‘ABC’’ method are highlighted through 2 clinical patients where the aesthetic protocol was used for the diagnosis and evaluation of the final result.
Patient 1 A 22-year-old male with a unilateral left CLP was referred to the Department of Maxillofacial Surgery of the University of Verona for surgical evaluation and treatment. When referred to our department, he had a history of lip closure done at age of 6 months and of an alveolar bone graft at age of 13. The aesthetic analysis protocol revealed the followings: On frontal view: nasal tip deviated to the left, the left nasal ala flat, and a dependent nasal tip. On lateral view: a short columella, an altered nasolabial angle, a slight hump, and the alar–columellar relationship out of proportion (Fig. 1A-B). The surgical plan was an open approach with a Sercer incision, the exteriorization and reinsertion of the nasal septum after multiple parallel partial incision on the concave side, multiple dome incisions on the medial portion and dome repositioning on the septum, fixation
FIGURE 1. (A) Frontal view: left nasal tip deviation, flattened left nasal ala, and dependent tip. (B) Lateral view: short columella, altered nasolabial angle, and slight hump. (C) Frontal view: symmetric tip, improvement of the aesthetic brow-tip lines. (D) Lateral view: better profile and uprotation of the tip.
2131 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery
Bertossi et al
Volume 27, Number 8, November 2016
DISCUSSION
avoid dramatic alterations of the nasal base anatomy resulting in aesthetic and functional problems. The aim of our protocol is first the correction of the tip and then the remaining nasal architecture, according to the own anatomical features. This is the ‘‘Anatomical Balance’’ method in which a progressive nasal dismounting and reconstruction taking away some anatomic parts to graft them in some other area to achieve symmetry and good esthetic outcome was performed. An open approach was used in almost all patients to better control the results and to facilitate the insertion of autologous cartilage grafts, considered to be the elective material for structural and aesthetic corrections7 –11: tip and spreader grafts, alar battens, and dorsal grafts (all fixed with PDS 6.0). The septal cartilage in the posterior area was always resected and if necessary, exteriorized and reinserted. Septum deviations were corrected by means of multiple incisions. The morphological shape and position alterations of the alar cartilages were corrected by means of reshaping with 6-0 PDS suture or graft positioning.12 The BCRCC technique similar to the 1 used by Peled13 was used (together with the new method) with the main difference that the 2 ‘‘pedicled’’ cephalic segments of the lateral crura were rotated contralaterally with various degrees and thereafter fixed on the external portion of the lateral crura with PDS 6-0 sutures (X). This kind of rotation of the pedicled cephalic segments provides a good projection of the nasal tip, especially if the segments are fixed in a medial position. In bilateral CLP patients, this technique can be used to support the nasal tip where the 2 segments are sutured as it was done with the batten grafts. It is mainly recommended in secondary unilateral CLP patients, where the nasal tip appears to be less supported and the tip defining points are less visible. In the secondary stage the dorsum and after that the bony vault was reshaped with single or multiple osteotomies. In some patients additionally to our method, the Gubisch technique to correct nostril apex asymmetries was used14 and the nostrils were packed with a plastic material stent made of polyvinyl siloxane impression material. The nasal stent was used to maintain the surgical results by opposing healing contraction15–17 for 30 days postoperatively and for 4 months during the night. The nasal stent dressing has been changed every 15 days so that it could be adjusted to the decreasing nasal edema. The columellar grafts had a good outcome and the severe scars were further treated with ER-YAG Laser as well as all other residual scars. The evolution of technology will probably lead to a new ‘‘Change in Technique.’’ A lot of residual anatomical imbalances due to old protocols and to the primary treatments are noticed. The tip is the most involved nasal structure in secondary CLP nasal deformities. If an improvement in the aesthetic and function is aimed, the tip must be given an adequate support and definition through an increase in the strength of the alar cartilages. We can conclude that our method seems to be a good way for a progressive approach and correction of a secondary CLP nasal deformity due to its simplicity and to the natural preservation of the existing structures. The ‘‘Anatomical Balance’’ concept was useful in almost all patients treated according to this philosophy. The follow-up study supports the good results and guarantees a better shape of the nasal tip without the need of other surgical procedures as nostril symmetry was achieved in all patients with a single-stage surgery. Further long-term follow-up studies are needed in order to improve and validate the method and the results.
Normal nasal growth depends on the absence of inhibitional factors.18 Thus the best final result of the new method can be achieved with the rebuilding of the entire nasal structure. Although the results are promising, further surgical corrections might not be avoided. Secondary corrective procedures focus mostly on function and lining distortion.19 During primary treatment it is impossible to
1. Reichert H, Gubisch W. Various techniques of secondary nose correction in unilateral cleft lip procedure. Ann Plast Surg 1991;26:18–29 2. Mulliken JB. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg 1985;75:477–486
FIGURE 2. (A) Frontal view: wide nasal radix, asymmetric aesthetic lines, bulbosity of the tip, undefined tip-defining points. (B) Lateral view: acute nasolabial angle, obtuse nasofrontal angle, and dorsal hump. (C) Frontal view: good aesthetics of the nasal base. (D) Lateral view: improvement of nasal tip projection and facial profile of the patient.
of the septum to it with 6.0 ‘‘PDS’’ inter- and intradomal sutures; nasal hump resection together with medial and lateral osteotomies. A columella dermocutaneous graft was used. A final pleasant aesthetic result on frontal, lateral, and basal view was obtained (Fig. 1C-D).
Patient 2 A 25-year-old woman with a unilateral CLP was referred to the Department of Maxillofacial Surgery of the University of Verona in June 1999. The aesthetic analysis protocol revealed the followings: On frontal view: a wide nasal radix, asymmetric brow-tip aesthetic lines, and a depressed nasal tip together with a lack of definition. On lateral view: an open nasolabial angle, an absent nasofrontal angle, a dorsal hump, and an exposed columella (Fig. 2A-B). The surgical plan included an open approach, the excision and repositioning of the left nasal ala insertion, a medial shifting of the 2 domes, and a columellar strut from the septum. A pleasant esthetic result was obtained (Fig. 2C-D).
RESULTS All the patients treated with the ‘‘ABC’’ method had any complaint regardless of the columella scar. The 2 patients diagnosed with the partial atresia of the upper airways reported a better function after surgery, but at the 1 year follow-up examination still 40% of the upper airway flow was compromised due to scar retraction of the internal nasal valve. BCRCC technique was considered and applied to 24 CLP patients with the same degree of rotation of the lateral cephalic segments. Of the bilateral cleft nose secondary deformities patients, 6 patients had a good outcome with the cartilage positioned as alar battens. Finally the nasal tip was projected in all our 120 patients with a medium increase of 108. Good symmetry was achieved after 1 stage treatment. This was particularly visible with our protocol which includes some elements of the Asher method of clinical evaluation. All nostrils asymmetries treated with the Gubisch technique showed a good outcome except for 3 CLP patients where hypertrophic scarring was noticed and received further treatment with ER-YAG Laser (X). The clinical followup examination together with rhinomanometry revealed any further nasal airways obstructions. Apart from the 3 CLP patients where severe scarring was noticed and the 2 CLP patients with upper airway atresia no further complications at were noticed at 3 years follow-up recall. The aesthetic improvement achieved with the ‘‘Anatomical Balance’’ method remained stable in all the patients.
REFERENCES
# 2016 Mutaz B. Habal, MD 2132 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
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The ‘‘Anatomical Balance Correction’’
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2133 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
