Postoperative nasal forms after presurgical nasoalveolar molding followed by medial upward advancement of nasolabial components with vestibular expansion for children with unilater

Postoperative Nasal Forms After Presurgical Nasoalveolar Molding Followed by Medial-Upward Advancement of Nasolabial Components With Vestibular Expansion for Children With Unilateral Com

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Postoperative Nasal Forms After Presurgical Nasoalveolar Molding

Followed by Medial-Upward Advancement

of Nasolabial Components With Vestibular Expansion for Children With Unilateral Complete Cleft Lip and Palate

Norifumi Nakamura, DDS, PhD,* Masaaki Sasaguri, DDS,†

Etsuro Nozoe, DDS, PhD,‡ Kazuhide Nishihara, DDS, PhD,§

Hiroko Hasegawa, DDS, PhD, 储 and Seiji Nakamura, DDS, PhD¶

Purpose: The management for primary unilateral cleft lip nose deformities has not yet been estab-lished In this study, short-term postoperative nasal forms after presurgical nasoalveolar molding (NAM) followed by primary lip repair for children with complete unilateral cleft lip and palate (UCLP) were evaluated and compared with the nasal forms achieved by treatment without nose correction

Patients and Methods: Fifteen patients with complete UCLP who were treated in our department and followed up for more than 1 year (range 1 to 5 yrs) were enrolled All subjects underwent presurgical orthopedic treatment with NAM, followed by lip repair using Cronin’s triangular flap method with medial-upward advancement of nasolabial components with vestibular expansion Postoperative nasal forms including nostril height and width ratio, ratio of the height of the top of the alar groove, and curvature of the appropriate circle of the nasal ala were evaluated using color photographs Fifteen patients with complete UCLP who underwent presurgical orthopedic treatment using a Hotz plate followed by lip repair without nose correction served as controls

Results: The comparison of postoperative nasal forms demonstrated that the nostril height and width ratio and the height of the top of the alar groove in the correction group were significantly superior compared with those of the controls

Conclusions: Our management of cleft lip nose will provide good nasal forms with minimum invasion

in patients with UCLP Long-term follow-up will be necessary to clarify effects on the growth of nasal tissues reconstructed in infancy

J Oral Maxillofac Surg 67:2222-2231, 2009

*Professor, Department of Oral and Maxillofacial Surgery, Field of

Maxillofacial Rehabilitation, Kagoshima University Graduate School

of Medical and Dental Sciences, Kagoshima, Japan.

†Assistant Professor, Division of Oral and Maxillofacial

Diagnos-tic and Surgical Sciences, Kyushu University, Graduate School of

Dental Science, Kyushu, Japan.

‡Associate Professor, Department of Oral and Maxillofacial

Sur-gery, Field of Maxillofacial Rehabilitation, Kagoshima University,

Graduate School of Medical and Dental Sciences, Kagoshima, Japan.

§Senior Assistant Professor, Department of Oral and Maxillofacial

Surgery, Kagoshima University, Medical and Dental Hospital,

Kagoshima, Japan.

储Assistant Professor, Department of Pediatric Dentistry, Field of

Developmental Medicine, Kagoshima University, Graduate School

of Medical and Dental Sciences, Kagoshima, Japan.

¶Professor, Division of Oral and Maxillofacial Diagnostic and Surgical Sciences, Kyushu University, Graduate School of Dental Science, Kyushu, Japan.

Address correspondence and reprint requests to Dr Nakamura: Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima 88908544, Japan; e-mail: nakamura@denta.hal.kagoshima-u.ac.jp

doi:10.1016/j.joms.2009.04.098

2222

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lages interfered with nasal growth, but there is little

evidence to support this theory.1,3,4Because clefts of

the lip and nose are not individual pathologic

condi-tions, primary nasal correction has become the

stan-dard of care.5The optimal method of achieving such

primary correction while minimizing the surgical

in-tervention and causing less interference with nasal

growth remains controversial

Numerous surgical procedures for early correction

of the lip and nose have been introduced during the

past 2 or 3 decades.1-3,5-10Anderl et al,11McComb and

Coghlan,12 and Salyer4 all noted that good primary

correction of the nose is critical for growth and

long-term esthetics However, early primary rhinoplasty

initially produced good results, but the original

defor-mity soon returned There remain some questions

regarding whether the infant’s fragile cartilage is free

of damage after wide blind dissection, and whether

these results and future nasal growth can be achieved

universally even if the procedure is performed by less

skillful surgeons

However, Grayson et al13 introduced nasoalveolar

molding (NAM) for the successful presurgical

align-ment and correction of deformity in the nasal

carti-lages, minimizing the extent of primary nasal surgery

required and thereby also minimizing the formation

of scar tissue and producing more consistent

postop-erative results These investigators reported

signifi-cant improvement of symmetry of unilateral cleft

nose in children who underwent presurgical NAM,14

and successful columella lengthening of the bilateral

cleft nose.15Many institutions currently perform

pre-such as depressed and deviated nasal tip, small and inferiorly dislocated nasal ala, and flat and V-shaped nostril on the cleft side often persist (Figs 1A,B) In the uncorrected noses of patients with complete UCLP, in addition to the splayed-out deformity, the lower lateral nasal cartilage is also rotated distally downwardly, so the dome is retroposed and the nose

is lengthened on the cleft side.17 The nasalis muscle attaching the lateral surface of the upper lateral car-tilage and the lateral crura of the major alar carcar-tilage dislocates because of the distal and downward dis-placement of the anterior maxillary wall If the lip and nose are repaired with cartilage in this displaced po-sition, the nostril rim droops on the cleft side, and the distal border of the alar cartilage pushes up, forming

a tight nasal vestibular fold in the nostril.1 Our treatment strategy for unilateral cleft lip nose

was characterized as follows: 1) presurgical orthope-dics using NAM to minimize surgical intervention; 2)

simultaneous medial-upward advancement of nasola-bial components, which provides repositioning of both the lower lateral cartilage and the muscles of the

nasolabial region on the affected side; and 3)

vestib-ular expansion using a cleft margin flap to provide vertical height of the nasal ala and nostril In this study, short-term postoperative nasal forms after pre-surgical orthopedics using NAM followed by primary lip repair for children with complete UCLP were evaluated The outcomes of these procedures were then compared with the nasal forms achieved by treatment without nasal correction during primary lip repair

FIGURE 1 Postoperative deformities of patients with complete UCLP A, Inferiorly displaced and small nasal ala in the frontal view, and B,

deviated nasal tip and flat V-shaped nostril are persistent problems.

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Patients and Methods

Data were obtained from the records of Kyushu

University Hospital and Kagoshima University

Hospi-tal for cases treated between 2004 and 2008, because

the first author moved from Kyushu University to

Kagoshima University in 2005 The samples in this

study included 15 infants with complete UCLP who

underwent presurgical orthopedics using NAM

fol-lowed by primary lip repair at approximately 3

months of age (correction group) All subjects were

followed for more than 1 year (range 1 to 5 yrs)

postoperatively All patients underwent labioplasty by

Cronin’s triangular-flap method18with anatomical

re-construction of the orbicular oris muscle19 by the

same surgeon Serial pictures of frontal and basal

views taken preoperatively and 6 months, 1 year, and

over 2 years postoperatively were used for

2-dimen-sional analyses of nasal forms

As controls, serial pictures of 15 patients with

com-plete unilateral cleft lip and palate, who underwent

lip repair without nose correction, were used

(con-trol group) All patients received orthopedic

treat-ment by Hotz plate20without nasal molding and they

underwent lip repair by modified Randal’s

triangular-flap method21 with reconstruction of the orbicular

oris muscle at around 3 months of age All procedures

were performed by the same senior surgeon All

sub-jects were followed for more than 1 year (range 1 to 5

yrs) postoperatively The age distribution of subjects in

the control group did not differ from that in the

correc-tion group The Institucorrec-tional Review Board at the

Grad-uate School of Medical and Dental Sciences, Kagoshima

University, approved the protocol of this study

PRESURGICAL ORTHOPEDICS USING NAM

Presurgical orthopedics using NAM was performed

by pediatric dentists in both Kyushu and Kagoshima

University Hospitals An oral impression was taken at

the first examination, within 2 weeks after birth in

most patients, and an alveolar molding plate was set

approximately 1 week later After checking the fit of the plate and the feeding condition, a nasal stent was added at the anterior part of the alveolar molding appliance The appliance was retained by elastic and tape in accordance with Grayson’s method,13and the tape was placed across the upper lip (Figs 2A,B) Every 2 weeks, the tip of the stent was molded grad-ually using self-curing soft acrylic

SURGICAL PROCEDURES FOR PRIMARY LIP AND NOSE CORRECTION

Details of step-by-step surgical procedures for cleft lip and nose correction were as follows (Figs 3,4): 1) The skin incision was made by Cronin’s triangu-lar method, and a triangutriangu-lar skin flap was de-signed 1 mm above the peak of Cupid’s bow (Fig 4A) When a difference in the length be-tween the lateral and medial lips was larger than

4 mm, triangular skin flaps were divided into 2 parts: a 1-mm flap located at the upper part at the white lip and a 3-mm flap at the original position The hinged margin flap using cleft mar-gin tissue with a pedicle of the mucous mem-brane of the labial sulcus was made at the edge

of the medial lip (Fig 3A)

2) The vestibular incision reached the top of the nasal dome and freed the lateral crura of the lower lateral cartilage (Figs 3A, 4B) Through the vestibular incision, nasal undermining sur-rounding the piriform margin and the lower border of the upper lateral cartilage on the cleft side was performed These dissections achieved repositioning of the nasalis muscle and facili-tated the 3-dimensional advancement of the na-sal alar base (Fig 4C)

3) Deviation of the columella base was corrected

by undermining around the anterior nasal spine with/without septoplasty The nasal and labial components on the cleft side including the

FIGURE 2 Presurgical orthopedic treatment using NAM A, appliance for NAM B, Stent approaching the top of the medial crura of the

major alar cartilage.

Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009.

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lower lateral cartilage, the nasalis muscle, the

orbicularis oris muscles, and lining mucosa

were then advanced medially and upwardly as a

single body

4) During this step, temporary suturing of the lip

was made (Fig 4E), and 2 or 3 mattress sutures

of absorbable thread (6-0 polydioxanone suture)

were placed to hold the lateral crura of the

lower lateral cartilage in a slightly overlapped

position on the upper lateral cartilage (Figs 3C,

4D) A transcartilage suture was not made, but

the stay suture to fix the highest point of the

nasal alar was made by through-and-through

su-turing using absorbable thread

5) The defect of the lining of the nasal vestibule

caused by advancement of the nasal

compo-nents was covered using hinged cleft margin

flaps and/or free mucosal graft donated from the

buccal mucosa, depending on the extent of the

raw area (Figs 3B,4D)

6) For reconstruction of the orbicularis oris

mus-cle, pars peripheralis and pars marginalis were

connected individually in different manners,

overlapping, interdigitation, and edge-to-edge

suturing, as shown inFigure 3C The edge of the

nasalis muscle was connected at the bottom of

the nostril floor

7) Subcutaneous and cutaneous suturing were

made carefully (Fig 4F), and a nasal stent made

from a sponge tube was applied for 1 week

postoperatively, and a silicon nostril retainer

(Koken Co, Tokyo, Japan) was used for at least

3 months in both groups

Comparison of Pre- and Postoperative Nasal Forms Between Patients With and Without Rhinoplasty

Pre- and postoperative nasal forms were compared between the 2 groups using color photographs taken serially during the postoperative period The items evaluated were the nostril height and width ratio, the ratio of the alar groove height, and the curvature of the appropriate circle of the nasal ala

1) The nostril height and width ratio: To assess

the correction of lateral cartilages, the ratio be-tween height and width of the nostril was cal-culated based on the basal view using the for-mula shown inFigure 5A The ratios were then compared between the cleft and noncleft side

2) The ratio of the height of the top of the alar

groove:To assess the upward reposition of the nasalis muscle, the vertical height of the top of the alar groove (distance between the baseline, the line containing both medial ocular angles, and the top of the alar groove) was compared with the distance between the baseline and the bottom of the alar groove on both sides (Fig 5B)

3) The curvature of the appropriate circle of the

nasal ala: The outline of the alar groove was traced on pictures and scanned into a personal computer The curvature of the appropriate circle

of ala was then calculated using 3D-Rugle IV

soft-FIGURE 3 Schematic demonstration of correction of unilateral cleft lip and nose A, Oral and nasal vestibular incision along the piriform

margin and the posterior edge of the nasal vestibule B, Medial-upward advancement of nasolabial components for repositioning the major alar cartilage, and closure in raw area in the nasal vestibule using the hinged cleft margin flap (pink) C, Before (left) and after (right)

reconstruction of the nasalis muscle and orbicularis oris muscle Pars peripheralis and pars marginalis of the orbicular oris muscle were individually reconstructed by different techniques: overlapping, interdigitation, and edge-to-edge suturing The shadow shows the supra-periosteal dissection field The major alar cartilage was fixed by overlapping on the lateral cartilage.

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ware (Medic Engineering Inc, Kyoto, Japan)

Be-cause the craniofacial size differed between the

subjects, the distance between both medial ocular

angles was standardized at the same distance

(Fig 5C)

For statistical analyses, the Mann-Whitney U test was

used to compare mean values of the measurements of

the nasal forms between the nose correction group

and controls The significance of differences was

ac-cepted when the P value was less than 01.

Results

PRE- AND POSTOPERATIVE VIEWS OF PATIENTS

WHO UNDERWENT PRIMARY NOSE CORRECTION

Pre- and postoperative views of representative

patients with complete UCLP who underwent

cor-rection of cleft lip nose are shown inFigures 6and

7 In case 1, the patient whose surgical procedures

are depicted in Figure 4, NAM was applied for presurgical orthopedics for 3 months and the short columella on the cleft side was extended suffi-ciently Postoperative nasal form showed the satis-factory forms of nasal tip and nasal ala on the frontal view, and the almost symmetric nostril on the basal view at 4.5 years of age (Figs 6A-D) The patient designated as case 2 had quite a severe deformity of the nose at birth, and presurgical or-thopedic treatment was performed for 4 months

On postoperative view, the nostril on the cleft side was a little flatter and the small webbing of the nostril rim and small ala remained (Figs 7A-D) The shape of the nasal tip and a distal and backward dislocation of the nasal ala were improved in most cases in the correction group None of the patients developed serious sequelae such as infection or ste-nosis of the nose Furthermore, to date there has not been any additional correction required because of persistent deformities of the lip and nose

FIGURE 4 Step-by-step procedures for simultaneous correction of unilateral cleft lip and nose A, Design of skin incision by Cronin’s method.

B, Cleft margin flap with the pedicle of the mucous membrane of the labial sulcus and the design of the vestibular incision C, Dissection

surrounding the piriform margin for repositioning the nasalis muscle (picture from another case) D, Medial-upward advancement of nasolabial components and hinged cleft margin flap E, Frontal view of the nose at temporary suturing to confirm the height of the nostril rim.

F, Postoperative basal view.

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COMPARISON OF PRE- AND POSTOPERATIVE

NASAL FORMS BETWEEN PATIENTS TREATED WITH

OR WITHOUT NOSE CORRECTION

Comparison of the nostril height and width ratio

be-tween the correction and control groups was 0.46⫾

0.07 in the control group and 0.42⫾ 0.09 in the

con-trols The preoperative ratio of the correction group

seemed to be higher, but there were no significant

differences between the 2 groups (P⫽ 19) At 1 year

postoperatively, the ratio of the correction group was

improved to 0.76⫾0.12, and it was significantly larger

than that (0.61⫾ 0.14) of the control group (P ⬍ 01).

On analysis of the serial alterations in nostril height and

width ratio in the correction group, the ratio was highest

at 6 months postoperatively (0.80), then tended to de-crease at 1 year postoperatively Postoperative alteration of ratio then seemed to increase slightly after 2 years Comparison of-the ratio of the height of the top of the alar groove between patients treated with or without correction demonstrated that the preoperative ratio in each group was almost 1.2, and there were no signifi-cant differences between the 2 groups (Fig 8B) Postop-eratively, the ratio of the height of the alar groove was improved to 1.03⫾ 0.06 in the correction group, and it was significantly larger than that (1.13 ⫾ 0.08) of the

control group (P⬍ 01)

Regarding the curvature of the appropriate circle of the nasal ala, preoperative ratios were 0.86 ⫾ 0.10

FIGURE 5 Assessment of the nasal forms using color photos A, The nostril height and width ratios were compared between the cleft and

noncleft sides The nostril height and width ratio ⫽ the nostril height and width ratio on the cleft side (A=/B=)/the nostril height and width ratio

on the noncleft side (A/B) B, The height of the top of the alar groove (the distance between the baseline, line containing the medial ocular

angles, and the top of the alar groove) was compared with the distance between the baseline and the bottom of the alar groove on both sides The ratio of the height of the alar groove ⫽ the ratio of the height of the top of the alar groove on the cleft side (D=/C=)/the ratio of the height

of the top of the alar groove on the noncleft side (D/C) C, The curvature of the appropriate circle of ala was calculated using 3D-Rugle IV

software The curvature of the appropriate circle of the nasal ala ⫽ the curvature of the appropriate circle of the nasal ala on the cleft side

(r)/the curvature of the appropriate circle of the nasal ala on the noncleft side (r=) The distance between both medial ocular angles was

standardized at the same distance.

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and 0.92⫾ 0.05 in the nose correction and control

groups, respectively Postoperatively, the ratio was

improved to 1.00⫾ 0.05 in the correction group The

postoperative ratio of the control group was slightly

larger, but there was no significant difference

be-tween the 2 groups (Fig 8C)

Discussion

The authors performed simultaneous correction of the cleft lip and nasal deformity at primary surgery on cleft patients for nearly 15 years In the early period,

we were eager to reposition the lower lateral nasal

FIGURE 6 A, Preoperative basal view of a patient with complete UCLP C, D, 4.5-years postoperative views of this patient The surgical

procedure for the patient is shown in Figure 4 B, NAM was applied for 3 months before primary lip repair.

FIGURE 7 A, B, Preoperative views of a patient with serious deformity of the nose C, D, 1.5-year postoperative views Webbing at the rim

still persisted postoperatively.

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cartilage by dissecting it from both the skin and lining

through a nostril rim incision Although the results

were thought to be acceptable, it was difficult to

handle an infant’s fragile cartilage even with open

dissection Consequently, to establish a universally

acceptable correction of cleft lip nose, we started to

perform a less invasive management using presurgical

NAM and primary repair without wide dissection of

the surrounding lateral cartilages The concept

under-lying this procedure is to obtain anatomical

reposi-tioning of all structure of the cleft lip and nose except

the underlying anterior maxillary bone and to

mini-mize the surgical intervention

The NAM is designed to align the alveolar segment,

restore the lower lateral cartilage position, and

in-crease the columella length.15 Grayson et al13

indi-cated that nasal molding alone is not sufficient to

correct deformity of the nasal tip Although NAM

stretches the columella skin into a more normal

con-figuration and normalizes the shape and position of

the lower lateral cartilages, coordinated primary nasal

surgical correction is still required after NAM These

investigators combined a surgical technique similar to

that described by McComb, Salyer, and Anderl et al

for primary correction, but excluded the use of

ex-ternal bolsters.14 MacComb1 and Anderl et al11 dis-sected the skin widely from the alar cartilage using columella base and alar base incisions, extending the skin dissection to the contralateral alar cartilage and

up to the nasion Salyer8undermined the alar cartilage from both the skin and lining from the lateral ala incision, and the alar cartilage was repositioned and secured using temporary stent sutures Grayson et al13 also reported that with the advent of presurgical NAM, these surgical procedures have become much less extensive, because lateral dissection of the lower lateral cartilage is no longer necessary Although the effects of NAM can reduce the amount of dissection

of the cartilages, surgical intervention in the cartilages

is still necessary for correction of unilateral cleft lip nose at present

The present analyses of postoperative nasal forms

of patients managed by presurgical orthopedics using NAM followed by our surgical procedures for lip repair demonstrated the benefits and limitations The height of the top of the alar groove and the curvature

of the appropriate circle of the nasal ala on the af-fected side were almost completely corrected in the correction group This means that medial-upward ad-vancement of nasolabial components through the

ves-FIGURE 8 Results of comparing the nasal forms between the nose correction and control groups A, Pre- and postoperative height and width ratios

of the nostril B, Pre- and postoperative ratios of the height of the top of the alar groove C, Pre- and postoperative circle of the nasal ala.

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tibular incision and expansion of the nasal vestibule

provides successful reconstruction of nasal alar

com-ponents including the nasalis muscle

As part of his original procedure for cleft lip repair,

Millard22described the nasal vestibular incision with

subsequent placement of a lateral edge mucosal flap

into the lateral vestibular defect to maintain nasal ala

advancement against contracture For primary nasal

correction, Millard exposed the major alar cartilage

through the total vestibular incision and freed the alar

cartilage from the overlying skin, and bilateral alar

cartilages were sutured directly at the time of lip

repair.9,22The concept of advancing both ala and the

lower lateral cartilage and placement of the mucosal

flap is basically the same as ours, but we handle the

cartilage as a single body with the overlying skin and

lining mucosa without dissecting the surface of the

cartilage Therefore, our procedures are less invasive

than those reported by Millard,22MacComb,1Sayler,8

and Anderl et al.11Tajima23reported nasal correction

by an internasal incision along the area just inside the

piriform margin to free the lateral cartilage and

em-phasized the importance of transposition of the

peri-osteum attached to the nasalis muscles and covering

the defect of the nasal vestibule using bilobed cleft

margin flaps For correction of nose, Tajima23

com-bined the reverse-U skin incision to produce a

symmet-rical ala Except for limited undermining of the lower

edge of the upper lateral cartilage to overlap the alar

cartilage, we do not make any skin incision on the

nostril rim or any dissection of the periosteum because

of concern regarding growth disturbance In our

expe-rience, to achieve successful repositioning of the nasal

ala, nasal undermining along a single plane beyond the

lower part of the lateral cartilage, piriform margin, and

the anterior maxillary wall and placement of the lateral

crura of lower lateral cartilage in an overlapped position

on the upper lateral cartilage are essential techniques

during the primary correction The effects of presurgical

orthopedics and the completeness of the above

proce-dures during lip repair may contribute to the need for

additional surgical nasal correction

The present analyses further demonstrated that the

ratio of nostril height and width in the correction

group was much better than that of the controls

However, the ratio in the correction group reached

approximately 0.8 postoperatively Although the

sub-jects in this study had serious nasal deformity before

treatment, this postoperative ratio suggested that our

procedures for correcting the major alar cartilage are

not yet complete Furthermore, when analyzing serial

alterations in the corrected nose, the nostril height and

width ratio was highest at 6 months postoperatively,

and then tended to gradually decrease until 2 years

postoperatively To prevent relapse of the nasal forms,

an improvement of our presurgical orthopedics and surgical modality is thought to be necessary

Several factors affecting insufficient recovery of the

nostril forms can be listed as follows: 1) insufficient nasal molding before surgery, 2) insufficient nasal undermining, 3) insufficient overcorrection of the lower lateral cartilage, and 4) postoperative

contrac-ture of the subsequent tissue in the vestibule When considering the patients with persistent deformity as shown inFigure 7, most patients had a wide cleft and markedly depressed anterior maxillary before treat-ment After presurgical orthopedics, the nasal ala was adequately repositioned at the primary repair; how-ever, the nasal ala gradually subsided postoperatively into the retroposed position The loss of bony support may cause a collapse of the distal end of the lateral crura, resulting in a relapse of the nostril shape Therefore, presurgical orthopedics providing more symmetric bone support as well as a symmetric shape

of the nasal cartilages will be required for the man-agement of nose deformity in complete UCLP.24 The influence of our procedures on nasal growth is

an important issue that has not yet been clarified Although subjects in our series have not shown any apparent growth disturbance to date, long-term fol-low up will be necessary to clarify effects on the growth of nasal tissues reconstructed in infancy

In conclusion, our management of the cleft lip nose will provide good nasal forms with minimum invasion

in patients with complete UCLP Long-term follow-up will be necessary to clarify the effects on the growth

of nasal tissues reconstructed in infancy

Acknowledgments

The main contents of this study have been presented and re-ceived “the Best International Basic Scientific Poster Award” at the 89th Annual Meeting, Scientific Sessions and Exhibition of the American Association of Oral and Maxillofacial Surgeons, held in conjunction with the Japanese Society of Oral and Maxillofacial Surgeons and the Korean Association of Oral and Maxillofacial Surgeons in Honolulu in October 2007 We express great thanks to

Dr Masamichi Ohishi, Emeritus Professor of Kyushu University, who instructed us on the surgical management of cleft lip and nose.

We also express great thanks to our colleagues in the Department

of Pediatric Dentistry at Kyushu University and Kagoshima Univer-sity Hospital for managing the orthopedic appliances and for their cooperation in this study.

References

1 MacComb H: Primary correction of unilateral cleft lip nasal deformity: 10 Year review Plast Reconstr Surg 75:791, 1985

2 Sugihara T, Yoshida T, Igawa H, et al: Primary correction of the unilateral cleft lip nose Cleft Palate Craniofac J 30:231, 1991

3 Berkeley WT: The cleft-lip nose Plast Reconstr Ssurg 23:567, 1959

4 Salyer KE: Primary correction of the unilateral cleft lip nose: A 15-year experience Plast Reconstr Surg 77:558, 1986

5 Byrd HS, Salomon J: Primary correction of the unilateral cleft nasal deformity Plast Reconstr Surg 106:1276, 2000

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11 Anderl H, Hussl H, Ninkovic MN: Primary simultaneous lip and

nose repair in the unilateral cleft lip and palate Plast Reconstr

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12 McComb HK, Coghlan BA: Primary repair of the unilateral cleft

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14 Maull DJ, Grayson BH, Cutting CB, et al: Long-term effects of

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uni-lateral cleft Cleft Palate Craniofac J 36:391, 1999

20 Hotz M, Gnoinski W: Comprehensive care of the cleft lip and palate children at Zurich University: A preliminary report Am J Orthod 70:481, 1976

21 Millard DR, Jr: Cleft craft: The evolution of its surgery, in Vol I: The Unilateral Deformity Boston, Little, Brown, 1976, p 146

22 Millard DR, Jr: Cleft craft: How to rotate and advance in a complete cleft, in Vol I: The Unilateral Deformity Boston, Little, Brown, 1976, p 449

23 Tajima S: The importance of the musculus nasalis and the use

of the cleft margin flap in the repair of complete unilateral cleft lip J Maxillofac Surg 11:64, 1983

24 Millard DR, Jr, Latham RA: Improved primary surgical and dental treatment of clefts Plast Reconstr Surg 86:856, 1990

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