Long term comparison of the results of four techniques used for bilateral cleft nose repair a single surgeons experience

The midline structure is defi-cient in patients with bilateral complete cleft lip, characterized by a small prolabium, small premax-illa with deficient columella, and deformed lower late

Bilateral cleft lip nose reconstruction is more

challenging than unilateral cleft lip nose

reconstruction The midline structure is

defi-cient in patients with bilateral complete cleft lip,

characterized by a small prolabium, small

premax-illa with deficient columella, and deformed lower

lateral cartilage.1 In our previous study,

overcorrec-tion on the cleft side nostril in patients with

unilat-eral complete cleft lip produced the best surgical

results.2 The effect of overcorrection of both nos-trils in patients with bilateral complete cleft lip has not previously been addressed in the literature Two-stage reconstructions with the banked forked flap were once popular in our institution for the management of bilateral cleft lip nose deformity Elongation of the columella was per-formed at age 1 to 6 years by advancing nasal floor tissue onto the columella and repositioning the alar cartilage When the nasal floor tissues were inadequate, the elongation was performed using

a composite auricular graft In our experience, regardless of which methods were used, the scars were unsightly (compounded by the effect of scar contracture at this age) and the nostrils appeared unnatural (Fig 1)

Disclosure: The authors have no financial interest in

any of the products or devices mentioned in this article.

Copyright © 2014 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000000715

Chun-Shin Chang, M.D.,

M.S

Yu-Fang Liao, D.D.S., Ph.D

Christopher Glenn Wallace,

M.D., M.S

Fuan-Chiang Chan, M.D

Eric Jein-Wein Liou, D.D.S.,

M.S

Philip Kuo-Ting Chen, M.D

M Samuel Noordhoff, M.D

Taoyuan, Taiwan

Background: The purpose of this study was to evaluate progressive changes in

surgical techniques and results, aiming for improved nasal shape in primary bilateral cleft rhinoplasty

Methods: This is an institutional review board–approved retrospective study

Ninety-one consecutive patients with bilateral complete cleft lip underwent pri-mary cheiloplasty with four different techniques of nasal reconstruction from

1992 to 2007 as follows: group I, primary rhinoplasty alone; group II, nasoalve-olar molding alone; group III, nasoalvenasoalve-olar molding plus primary rhinoplasty; group IV, nasoalveolar molding plus primary rhinoplasty with overcorrection; and group V, patients without cleft lip The surgical results were analyzed using photographic records obtained at age 3 years Four measurements and one angle measurement were obtained A panel assessment was obtained to grade the appearance of the surgical results

Results: The results are expressed in order from groups I through V The

nos-tril height-to-width ratio was 0.49, 0.59, 0.62, 0.78, and 0.82, respectively The nasal tip height–to–nasal width ratio was 0.29, 0.39, 0.49, 0.57, and 0.60 The columella height–to–nasal width ratio was 0.11, 0.18, 0.22, 0.27, and 0.28 The dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.10 The nostril area ra-tio was 1.2, 1.17, 1.13, 1.11, and 1.07 The nasolabial angle was 144.95, 143.98, 121.98, 120.99, and 100.88 Finally, group IV had the best panel assessment

Conclusions: The results revealed that group IV had the best overall result

Presurgical nasoalveolar molding followed by primary rhinoplasty with overcor-rection resulted in a nasal appearance that was closer to the patients without

cleft lip (Plast Reconstr Surg 134: 926e, 2014.)

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

From the Department of Chemical and Materials

Engineer-ing, College of EngineerEngineer-ing, Chang Gung University; and

the Craniofacial Research Center, Departments of Medical

Research, Plastic and Reconstructive Surgery, and

Ortho-dontics, Craniofacial Dentistry and the Craniofacial Center,

Chang Gung Memorial Hospital.

Received for publication February 17, 2014; accepted May

28, 2014.

Long-Term Comparison of the Results of

Four Techniques Used for Bilateral Cleft Nose Repair: A Single Surgeon’s Experience

During the late 1980s and early 1990s, the

senior author (P.K.T.C.) performed closed

rhino-plasty in conjunction with primary cheilorhino-plasty

The cartilage dissection was performed through

the columella The advent of presurgical

nasoal-veolar molding enabled elongation of the

colu-mella and molding of the protruded premaxilla

preoperatively After the introduction of

nasoal-veolar molding, from 1996 to 2001, the senior

author did not perform primary cleft

rhino-plasty in conjunction with primary cheilorhino-plasty

for bilateral cleft lip patients who had

under-gone presurgical nasoalveolar molding This was

because a satisfactory nasal shape was obtained

immediately after primary cheiloplasty

How-ever, the senior author observed a progressive

deterioration in the cleft nasal appearance with

time; therefore, after 2001, primary open

rhino-plasty with bilateral rim incisions was added at

the time of bilateral cheiloplasty This improved

the elongation of the columella Unfortunately,

a reduction in columella length within the first

and second years postoperatively was noticed.3 In

2003, overcorrection of the cleft nose was added

in an attempt to address this less than

satisfac-tory clinical outcome We added the bilateral

Tajima incision to lengthen the columella and to

prevent webbing in the nasal soft triangle

Fur-thermore, silicone sheets were added to the nasal

stent to maintain the nose in an overcorrected

fashion The objective of the present study was to

compare the long-term columella stability,

nos-tril shape, the nasal tip projection and nasolabial

angle of these four techniques of primary

bilat-eral cleft rhinoplasty

PATIENTS AND METHODS

This retrospective study, designed to investigate the long-term effect of nasoalveolar molding and primary rhinoplasty with or without overcorrection

in bilateral cleft lip patients, was approved by the Institutional Review Board of Chang Gung Memo-rial Hospital Ninety-one complete bilateral cleft lip patients were selected from four groups of children who underwent four different treatment protocols They were treated at the Craniofacial Center of Chang Gung Memorial Hospital from 1992 to 2007 The groups were numbered from I to IV to represent the progression of technical modifi-cations over this period as follows: group I (23 patients), primary rhinoplasty alone; group II (19 patients), nasoalveolar molding alone; group III (24 patients), nasoalveolar molding plus primary rhinoplasty; and group IV (25 patients), nasoalve-olar molding plus primary rhinoplasty with over-correction The inclusion criteria were as follows: (1) complete bilateral cleft lip–cleft palate, (2) no other craniofacial malformations, (3) preopera-tive nasoalveolar molding for groups II through IV, (4) primary cheiloplasty performed by the same surgeon (P.K.T.C.) at approximately 3 months of age, (5) postoperative nasal stent used for more than 6 months, and (6) available basilar view pho-tograph at approximately 3 years of age We also included a group V with 23 consecutive cleft pal-ate patients who underwent palatoplasty between

2006 to 2008 for comparison The inclusion crite-ria for group V were as follows: (1) patients with incomplete cleft palate, (2) patients without cleft lip, (3) patients with no other craniofacial malfor-mation, and (4) available basilar view photograph

at approximately 3 years of age A summary of groups I through V is listed in Figure 2

Presurgical Nasoalveolar Molding

The nasoalveolar molding device was com-posed of a dental plate and two nasal components, which enabled alveolar and nasal molding to be performed at the same time The nasal component was composed of two soft resin bulbs attached to the acrylic plate by stainless steel wires Denture adhesive was used to stick the dental plate onto the palate and dental arches We used Micropore tapes (3M, St Paul, Minn.) to approximate the cleft lip and to retract the prolabium The nasal molding bulb was adjusted every 1 to 2 weeks and the premaxilla was retracted into a position where the discrepancy between the roof of the columella and the lower lateral crus of the nasal cartilage was less than 4 mm, and the columella was at least

3 mm in length.3

Fig 1 A long-term result of two-stage rhinoplasty using a

banked forked flap There is a noticeable scar contracture over

the columella, and the nostril shape appears unnatural.

Primary Cheiloplasty and Rhinoplasty

The markings of bilateral cheiloplasty were as

described before The width of the central lip at

the bottom was maintained at 4 mm The central

segment was narrowed gradually down to 3 mm

at the base of columella The philtral flap and

forked flap were elevated In group I, with closed

blunt dissection through the columella, fibrofatty

tissue was dissected off the lower lateral cartilage

For group II, there was no primary rhinoplasty

In group III, as for traditional open rhinoplasty,

there was an extension behind the columella up

to the lower border of the lower lateral cartilage

The central segment, forked flap, and columella

together with the bilateral rim incision were raised

together to expose the lower lateral cartilages For

group IV, the senior author (P.K.T.C.) made

sev-eral modifications First, the forked flap incision

was extended behind the columella up to just

one-third of the columella Bilateral Tajima incisions

were made on both alar rims to expose the lower lateral cartilages The Tajima incisions did not connect to the incisions behind the columella For groups I, III, and IV, the separated lower lateral cartilages were approximated by mattress sutures using 5-0 polydioxanone (transdomal suture) By approximating the lower lateral cartilages, the skin of the inverted-U incision was turned inward, elongating the columella The skin excess at the rim of the nostril was excised Two through-and-through sutures using 5-0 polydioxanone were placed on the septum and an additional two alar-transfixion sutures were placed in the alar-facial groove on each side to provide further support

to the lower lateral cartilages.4 In groups I and

II, there were no specific strategies for nasolabial angle reconstruction In group III, the lateral part

of the central segment of skin flap between the columella and philtrum (forked flap) was sutured

in a cephalic-posterior fashion to the nasal septum

Fig 2 Summary of the five groups Group I, no presurgical nasoalveolar molding This

group underwent closed rhinoplasty, and the dissection of fibrofatty tissue from the lower lateral cartilages was performed through the columella Group II, presurgical nasoalveolar molding; no primary rhinoplasty was performed There was no dissection

of the fibrofatty tissue from the lower lateral cartilages Group III, presurgical nasoalveo-lar molding; open rhinoplasty, the philtral flap and forked flap were elevated with exten-sion behind the columella The inciexten-sion was continuous with the bilateral rim inciexten-sions

Group IV, presurgical nasoalveolar molding; semiopen rhinoplasty, the philtral flap and forked flap were elevated with extension of just one-third behind the columella The columella was not separated completely from the underlying medial crura of the lower lateral cartilages Other inverse-U incisions were made over the nostril dome There was

no connection between the incision behind the columella and the inverse-U incisions

NAM, nasoalveolar molding.

to create a more acute nasolabial angle In group

IV, unlike traditional open rhinoplasty, the

attach-ment of the columella-labial junction was not

com-pletely freed The lateral segment development,

nasal floor reconstruction, muscle reconstruction,

and Cupid’s bow reconstruction were performed

as described previously.5

Postoperative Nasal Stent

A silicone nasal conformer (Koken Co., Tokyo,

Japan) of appropriate size was used on

postopera-tive day 6 when sutures were removed, and used

for at least 6 months In group IV, overcorrection

of the nostrils was maintained with silicone sheets

(cut from 1-mm-thick silicone tubing); these were

added during the first-, second-, and third-month

visits and used for a total of 6 months (Fig 3)

The nasal conformer was fixed with half-inch 3M

Micropore tapes approximately 5 cm in length;

two holes were created with a hole puncher to

match to the position of each nostril

Records and Measurements

All measurements were performed by the

first author (C.S.C.) The first author was blinded

regarding the treatment group to which the

patient belonged The standard basilar view and

lateral photographs of each patient at age 3 years

were used in this study For the basilar photograph,

a horizontal reference line was constructed by

con-necting the most inward point at the outer lateral

borders of the cleft and noncleft nostrils The

mea-surements were obtained using Photoshop CS5

Extended Version 12.0 (Adobe Systems, Inc., San

Jose, Calif.) The measurements were as follows:

• Nasal width: The horizontal distance between the most outward point of the outer lateral border of the nostril aperture

• Nasal tip height: The vertical distance between the horizontal reference line to the highest point of the nasal tip

• Columella height: The vertical distance between the most superomedial point of the nostril aperture to the horizontal refer-ence line

• Dome height: The vertical distance between the most superomedial point of the nostril aperture to the highest point of the nasal tip

• Nostril height: The vertical distance between the lowest point to the highest point of the nostril aperture

• Nostril width: The widest horizontal dis-tance between the inner medial and lateral border of the nostril aperture

• Nostril area: The area presented by the nos-tril aperture

The following five ratios were calculated and one angle was measured (Figs 4 and 5):

• Nostril height-to-width ratio of both nostrils

• Nasal tip height–to–nasal width ratio

• Columella height–to–nasal width ratio

• Dome height–to–columella height of both nostrils When the nostril heights were differ-ent on each side, the midpoint of both high-est points of the nostril apertures was taken

to measure the dome and columella length

• Nostril symmetry: Larger nostril area/ smaller nostril area

• Nasolabial angle: The angle formed by the inferior border of the columella and the labial surface of the upper lip This angle is measured on the lateral photograph

Panel Assessment

A five-point visual analogue scale was used to assess the patient’s nasal shape The nasal shape

in groups I through IV was graded by six examin-ers (three expert cleft physicians and three layper-sons) The normal patient’s photographs were first shown to each examiner, and then the independent examiners were blinded with regard to the groups to which the patients belonged The results were classi-fied as follows: 1, very poor (flat nose, wide nasal tip, horizontal displaced tear shape nostril, obvious nasal webbing, and obvious cleft ala deformity); 2, poor; 3, fair (oval nostril with indentation); 4, good; and 5, very good (good nasal tip projection, rounded nos-tril, no indentation, resembling a normal nostril)

Fig 3 For group IV, one silicone sheet was added to both sides

of the nasal conformer each month A total of three silicone

sheets were added at the end of 3 months The nasal stent for

group IV was used for at least 6 months.

Statistical Analysis

After the data points were measured in units

of pixels, the ratios were determined and the data

collected from five groups were analyzed and

compared The measurements were analyzed with

analysis of variance For the visual analogue scale

assessment, the interrater reliability was tested

with the kappa test

Method of Errors

The method of errors was assessed for

pho-tograph variance, and the ratios of nostril height

and nostril width were measured and calculated

in photographs of five different randomly selected

patients The two photographs of the same patient

were taken 1 day apart The ratios were analyzed with correlation analysis (Pearson’s analysis) for photograph reliability

RESULTS

The method of errors showed a highly signifi-cant correlation for the nostril height-to-width ratio

(r = 0.940, p = 0.017) between the photographs.

Severity of Cleft on Initial Visit

The severity of nasal deformity was assessed at the time of initial visit using the ratio of nasal tip height and nasal width, calculated from standard photographs The ratio of nasal tip height and

Fig 4 Ratios and measurements (Above, left) Ratio of nostril height and width (Above, right) Ratio

of nasal tip height and nasal width (Below, left) Ratio of columella height and nasal width (Below,

right) Dome-to-columella ratio (A, dome height; B, columella height).

Fig 5 Nostril symmetry and nasolabial angle (Left) The nasolabial angle is the angle formed by the inferior

border of the columella and labial surface of the upper lip on lateral photography (Right) nostril symmetry was

calculated with the larger nostril area (black) and the smaller nostril area (red).

nasal width on initial visit was 0.36, 0.39, 0.37, and

0.38 in groups I, II, II, and IV, respectively There

was no statistically significant difference between

the four groups (p = 0.616, analysis of variance),

indicating that groups I through IV had similar

severity of nasal deformity on initial presentation

Ratio of Nostril Height and Width

The ratio of nostril height and width was 0.49,

0.59, 0.62, 0.78, and 0.82 for groups I through V,

respectively Group IV had a nostril height-to-width

ratio that was almost comparable to the patients

with-out cleft lip, and group I had the lowest ratio of

nos-tril height and width The difference between group

IV compared with groups I through III was

statisti-cally significant (Tables 1 and 2) This indicated that

overcorrection was necessary to maintain a better

nostril height-to-width ratio over the long term

Ratio of Nasal Tip Height and Nasal Width

If an aesthetic basal nasal shape is an

equi-lateral triangle in the adult, this ratio would be

0.86 In patients without cleft lip, the nasal tip

height is lower The ratio of nasal tip height and

nasal width was 0.29, 0.39, 0.49, 0.57, and 0.60 for

groups I through V, respectively Group IV had a

nasal tip height-to-width ratio that was closest to

that of group V, and the difference between group

IV compared with groups I through III was

statisti-cally significant (Tables 3 and 4)

Ratio of Columella Height and Nasal Width

The ratio of columella height and nasal width

was 0.11, 0.18, 0.22, 0.27, and 0.28 for groups I

through V, respectively The ratio for group IV

was closest to that for group V Group IV showed

a statistically significant difference from the other three groups (Tables 5 and 6) This showed that the bilateral Tajima incision after nasoalveolar molding could achieve a columella comparable to group V and was able to correct nasal webbing

Dome-to-Columella Ratio

The dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.1 for groups I through V, respectively Group I had the highest dome-to-columella ratio compared with the other groups (Tables 7 and 8) This indicates that group I had the shortest columella in relation to nasal tip height Accordingly, nasoalveolar molding had a

Table 1 Ratio of Nostril Height and Width

Group No Mean SD p*

*Analysis of variance.

Table 2 Intergroup Comparison, Mean

Ratio Difference: p Value Calculated by the

Bonferroni Method

Group

Group

I II III IV

Table 3 Ratio of Nasal Tip Height and Nasal Width

Group No Mean SD p

*Analysis of variance.

Table 4 Intergroup Comparison, Mean Ratio

Difference: p Value Calculated by the Bonferroni

Method

Group

Group

Table 5 Ratio of Columella Height and Nasal Width

Group No Mean SD p

*Analysis of variance.

Table 6 Intergroup Comparison, Mean

Ratio Difference: p Value Calculated by the

Bonferroni Method

Group

Group

direct impact on increasing columella height in

relation to nasal tip height

Nostril Symmetry

The ratio of nostril area was 1.2, 1.17, 1.13,

1.11, and 1.07 for groups I through V, respectively

Groups III and IV had different nostril symmetry

than groups I and II (Tables 9 and10) Thus, rim

and Tajima incisions did not produce particular

differences in this aspect

Nasolabial Angle

The nasolabial angle was 144.95, 143.98,

121.98, 120.99, and 100.88 for groups I through

group V, respectively Groups I through IV showed

a statistically significant increase of nasolabial angle compared with group V Nasoalveolar mold-ing and primary rhinoplasty (either rim incision

or Tajima incision) showed a statistically signifi-cant less increase of nasolabial angle compared with the rhinoplasty-alone and nasoalveolar mold-ing–alone groups (Tables 11 and 12)

Panel Assessment

For panel assessment, the interobserver reli-ability was assessed This was analyzed with the kappa test, and showed good interobserver reli-ability (kappa = 0.88, 0.87, 0.90, and 0.84 for groups I through IV, respectively) Group IV had the best panel assessment score compared with groups III, II, and I (Tables 13 through 15)

DISCUSSION

The reconstruction of bilateral cleft lip–cleft nose deformity is difficult and demanding The principles of bilateral cleft nose reconstruction are as follows: (1) release and reposition the lower lateral cartilages; (2) produce adequate columella length; (3) prevent soft triangle nasal webbing; (4) provide adequate nasal tip projection; (5) provide adequate nostril shape with good nostril height while limiting nostril width; and (6) main-tain a good nasolabial angle.6 In many instances, a two-stage correction with columella elongation as

a secondary procedure was necessary to produce

an adequate bilateral cleft nose reconstruction.7–16 Millard suggested preserving the prolabial tissue lateral to the central segment as forked flaps that were banked on the nasal floor.8,17 There was a

Table 7 Dome-to-Columella Ratio

Group No Mean SD p

*Analysis of variance.

Table 8 Intergroup Comparison, Mean

Ratio Difference: p Value Calculated by the

Bonferroni Method

Group

Group

Table 10 Intergroup Comparison, Mean

Ratio Difference: p Value Calculated by the

Bonferroni Method

Group

Group

Table 9 Nostril Area Ratio

Group No Mean SD p

*Analysis of variance.

Table 11 Nasolabial Angle

Group No Mean SD p

*Analysis of variance.

Table 12 Intergroup Comparison, Mean

Ratio Difference: p Value Calculated by the

Bonferroni Method

Group

Group

Table 13 Panel Assessment

Group Average Scores p*

*Analysis of variance.

period of almost one decade where we used

mus-cle repositioning and banked forked flap

cheilo-plasty for bilateral cleft lip reconstruction The

elongation of the premaxilla was performed at

1 to 6 years of age by advancing nasal floor

tis-sue onto the columella and lower lateral

carti-lage repositioning with transfixion sutures The

columella was elongated and the nostril shape

appeared improved.5 This was abandoned later

because it was technically highly complicated.6

Moreover, because of the increased rate of

unfa-vorable scarring in Asians compared with

Cau-casians, many of our patients complained of the

permanent unsightly scar over the lower part of

the columella (Fig 1)

One-stage bilateral cleft nose reconstruction

was then proposed The primary closed

rhino-plasty technique was used Fibrofatty tissues were

released from the lower lateral cartilages through

the columella The lower lateral cartilages were

then fixed medially and superiorly through

sev-eral transfixion sutures

With the introduction of modern techniques

of presurgical orthopedics and nasoalveolar

mold-ing, a better skeletal foundation and nasal shape

for repair of the bilateral cleft lip–cleft nose

defor-mity were achieved.18–20 These techniques were

instituted in the late 1990s The senior author

(P.K.T.C.), working together with our

orthodon-tists (mainly E.J.W.L.), went through a journey of

investigation and adaptation of the surgical tech-nique of primary bilateral cleft nasal repair to the use of nasoalveolar molding Initially, we were content with the results of presurgical nasoalveo-lar molding and did not perform primary cleft rhi-noplasty Unfortunately, the relapse of the stigma

of the bilateral cleft nose deformity was evident at

1 year of age Thus, we adopted traditional open rhinoplasty.21 The philtral flap and forked flap were elevated together The incision was extended behind the columella and connected to bilateral rim incisions; we dissected fibrofatty tissues from the lower lateral cartilages The lower lateral car-tilage repositioning was performed with trans-fixion sutures With this method, the forked flap was sutured back to the junction of the columella-philtrum area in a cephalic and posterior fashion The nasolabial angle was improved compared with the previous two groups With this method, the columella remained the same length for the first

3 years, whereas the nasal tip height kept increas-ing year by year We found that the nasal tip kept increasing in its upper part and the lower part (columella) remained the same The columella is still short compared with nasal tip height.3

The final changes added the concept of over-correction with exposure of the lower lateral cartilage through bilateral Tajima incisions, the other modification being that we extend the inci-sion behind the columella to only one-third of the columella The fibrofatty tissue was released from the lower lateral cartilages through the inverted-U incisions After transfixion sutures, the reverse-U flap was reflected.22 In almost all cases, some excess of the reverse-U flap was noticed and trimmed off To maintain the columella length, a nasal conformer was used during the first clinic visit One silicone sheet was added to the nasal conformer per month up to a total of three layers

of silicone sheets to each side of the nasal con-former (Fig 3)

Group I underwent only primary closed rhi-noplasty, without presurgical lengthening of the columella, resulting in an inadequate columella length and nasal tip height even with the use of

a nasal conformer for more than 6 months The typical bilateral cleft nose deformity was observed soon after the children stopped wearing the nasal conformer Group II underwent only nasoalveo-lar molding From this study, it would appear that without the fibrofatty tissue release and without lower lateral suspension, nasoalveolar molding alone would obtain a result similar to that of primary closed rhinoplasty alone In group III, the traditional open rhinoplasty technique, as

Table 14 Intergroup Comparison, Mean

Ratio Difference: p Value Calculated by the

Bonferroni Method

Group

Group

Table 15 Reliability Analysis*

Group I Group II Group III Group IV

*The reliability test is calculated using the kappa test.

described by Trott and Mohan, was added after

nasoalveolar molding.21 After the columella was

sufficiently elongated with nasoalveolar molding,

the columella was further improved with primary

open rhinoplasty However, the columella length

remained the same up to 3 years after surgery,

whereas the nostril height, nostril width, and

nasal tip height grew significantly.3 The relative

shortness of the columella gave the impression of

a reduction of columella length In group IV, the

lower lateral cartilage was approached with Tajima

incisions With overcorrection, this group had the

nostril height-to-width ratio closest to the patients

without cleft lip It had the columella length and

nasal tip height in relation to nasal width closest

to the patients without cleft lip This group also

had the best panel assessment score

In the present study, all of the groups have

an increased nasolabial angle, with groups III

and IV having the least increase Our

orthodon-tists always emphasize that the nasal component

of nasoalveolar molding should push the nasal

dome forward, instead of pushing the nasal dome

up With rhinoplasty, we could further increase

the length of the columella and further improve

the nasal shape In group III, the forked flap is

sutured back to the columella-philtrum junction

in a cephalic-posterior direction to create a better

nasolabial fold In group IV, the columella is not

completely separated from the medial crura as

in group III; the attached upper two-thirds of the columella would give a better nasolabial angle comparable to group III Thus, with this study, we hypothesize that presurgical nasoalveolar mold-ing plus primary rhinoplasty (either traditional open rhinoplasty or semiopen rhinoplasty with Tajima incision) could decrease the nasolabial angle to a lesser degree than nasoalveolar mold-ing alone or surgery alone

Presurgical nasoalveolar molding can improve nasal symmetry before surgical cor-rection.23 However, without surgical reposition-ing of the lower lateral cartilages, some relapse might result from the less than satisfactory nos-tril symmetry in our group II Presurgical naso-alveolar molding followed by open or semiopen rhinoplasty could improve nostril area symmetry between both nostrils

There are some limitations to this study First,

it is retrospective This limitation was minimized

by the selection of consecutive patients and the blinding of the investigator involved in perform-ing the measurements Further randomized trials might be needed to confirm our findings More-over, the present study relied on two-dimensional measurements, which were our preferred method because standard craniofacial photographs are noninvasive, acceptable by both the patient and

Fig 6 (Above, left) Typical photograph of a group I patient at age 3 years (Above, right) Typical

photograph of a group II patient at age 3 years (Below, left) Typical photograph of a group III

patient at age 3 years (Below, right) Typical photograph of a group IV patient at age 3 years.

the parents, and cost-effective To minimize errors

with this technique, all the photographs were

taken by the same photographer, and the

mea-surements were evaluated as ratios Other

tech-niques such as three-dimensional photographs,

nasal impressions, or direct measurements over

the patient’s face might be used in the future to

obtain more accurate measurements

In this study, we concluded that the addition

of overcorrection after nasoalveolar molding

achieved the best overall result with a nasal

appear-ance that was closer to that of patients without

cleft lip (Figs 6 and 7) This is the method that is

currently recommended to our bilateral cleft lip

patients However, further technical modifications

are necessary to reduce the nasolabial angle

Philip Kuo-Ting Chen, M.D.

Plastic and Reconstructive Surgery Chang Gung Memorial Hospital at Taoyuan

5, Fu-Hsin Street Guei-Shan 333, Taoyuan, Taiwan philip@adm.cgmh.org.tw

PATIENT CONSENT

Parents or guardians provided written consent for

the use of patients’ images.

REFERENCES

1 Monson LA, Kirschner RE, Losee JE Primary repair

of cleft lip and nasal deformity Plast Reconstr Surg

2013;132:1040e–1053e.

2 Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: A single

sur-geon’s experience Plast Reconstr Surg 2010;126:1276–1284.

3 Liou EJ, Subramanian M, Chen PK Progressive changes of columella length and nasal growth after nasoalveolar

mold-ing in bilateral cleft patients: A 3-year follow-up study Plast

Reconstr Surg 2007;119:642–648.

4 Chen PKT, Noordhoff MS Bilateral cleft lip and nose repair

In: Losee JE, Kirschner RE, eds Comprehensive Cleft Care New

York: McGraw Hill Medical; 2009:331–342.

5 Noordhoff MS Bilateral cleft lip reconstruction Plast

Reconstr Surg 1986;78:45–54.

6 Chen PKT, Noordhoff MS, Liou EJW Treatment of

com-plete bilateral cleft lip-nasal deformity Semin Plast Surg

2005;19:329–341.

7 Cronin TD, Upton J Lengthening of the short columella

associated with bilateral cleft lip Ann Plast Surg 1978;1:75–95.

8 Millard DR, Cassisi A, Wheeler JJ Designs for correction

and camouflage of bilateral clefts of the lip and palate Plast

Reconstr Surg 2000;105:1609–1623.

9 Xu H, Salyer KE, Genecov ER Primary bilateral

two-stage cleft lip/nose repair: Part II J Craniofac Surg

2009;20(Suppl 2):1927–1933.

10 Cheon YW, Park BY Long-term evaluation of elongating colu-mella using conchal composite graft in bilateral secondary cleft

lip and nose deformity Plast Reconstr Surg 2010;126:543–553.

11 Elshahat A, Safe I A modification of the transverse forked

flap to allow three-dimensional columella reconstruction J

Craniofac Surg 2006;17:692–695.

12 Jung DH, Lansangan LJ, Choi JM, Jang TY, Lee JJ Subnasale

flap for correction of columellar deformity Plast Reconstr

Surg 2007;119:885–890.

13 Rikimaru H, Kiyokawa K, Koga N, Takahashi N, Morinaga K, Ino K A new modified forked flap with subcutaneous pedi-cles for adult cases of bilateral cleft lip nasal deformity: From

normalization to aesthetic improvement J Craniofac Surg

2008;19:1374–1380.

Fig 7 Photographs of one of the patients from group IV with the longest follow-up shown (above, left) at first visit; (center) after

nasoalveolar molding, just before surgery; and (right) after surgery Photographs obtained at (below, left) 1 year, (center) 3 years, and (right) 7 years.