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Follow-up of unilateral cleft-lip nose deformity after secondary repair with a modified reverse-U method
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 747e753
Follow-up of unilateral cleft-lip nose deformity after secondary repair with a modified reverse-U method* Takuya Fujimoto, Keisuke Imai *, Takaharu Hatano, Makoto Takahashi, Motoki Tamai Department of Plastic & Reconstructive Surgery, Osaka City General Hospital, Osaka, Japan Received 12 July 2010; accepted 28 October 2010
KEYWORDS Reverse-U incision; Cleft-lip; Secondary repair; Rhinoplasty; Modification
Summary Emphasis of secondary repair for unilateral cleft-lip has been placed on correction of the cleft-lip nasal deformity by translocation of the alar cartilage with its attached vestibular lining into a normal position, thereby establishing the normal vault and shape of the cartilage. We have managed cleft-lip deformities employing a modified reverse-U method. We present our modified technique and the obtained results. Eighty-nine patients with unilateral cleft-lip nasal deformity underwent surgical repair between 1998 and 2007 by one surgeon. These patients were divided into two groups based on their previous operative histories. Group A comprised 52 patients who underwent primary cheiloplasty using a modified Tajima technique. No other surgery had been performed prior to our modified reverse-U method in these cases. Group B consisted of 37 patients receiving the primary operation and/or more than one rhinoplasty at another hospital before our method was employed. The ages of our patients at the time of the secondary operation ranged from 4 to 40 years (average, 8.1 years; 4.2 years in group A and 13.4 years in group B). The follow-up period ranged from 2 to 11 years (average 7.2 years). For objective evaluation, points on the nasal dome and alar crease were measured on patient photographs. The results were retrospectively distinguished to three levels by total point score: Excellent, Good and Fair. Excellent or Good results were obtained in 74 cases, while 15 had Fair results. Eighty-one percent of all cases maintained acceptable results without relapse. Fair results were attributed to an unclear alar crease or relapse.
* Part of this work was presented at the 76th annual meeting of American Society of Plastic Surgeons in Baltimore, Maryland, USA in October 2007. * Corresponding author. Department of Plastic & Reconstructive Surgery, Osaka City General Hospital, 2-13-22, Miyakojimahondori, Miyakojima-ku, Osaka 5340021, Japan. Tel.: þ81 6 6929 1221; fax: þ81 6 6929 1090. E-mail address: [email protected] (K. Imai).
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.10.019
748
T. Fujimoto et al. In conclusion, rigid fixation and release of nasal cartilage are very important. We believe our modified reverse-U method to be very useful for achieving symmetry of the unilateral cleft-lip nose in the long term. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The focus of secondary correction of unilateral cleft-lip nose deformity has been nasal symmetry. Importance has been placed on correction of the cleft-lip nasal deformity by translocation of the alar cartilage with its attached vestibular lining into a normal position, thereby establishing the normal vault and shape of the cartilage. We have managed cases with cleft-lip deformities using our modified reverse-U method.1 We report our technique and the results obtained, as assessed retrospectively.
Patients and methods Eighty-nine patients with unilateral cleft-lip nose deformity underwent surgical repair between 1998 and 2007 by one surgeon. These cases were divided into two groups based on their previous operative histories. Group A comprised 52 patients who underwent cheiloplasty using a modified Tajima technique2 without a reverse-U incision as the primary surgery. No other surgery had been performed prior
Figure 1 while ala base is pinched, the design can be engraved outside of the nostril (a). By raising up nostrils and checking symmetry (b), it is confirmed that the design is correct. The ala is found to be rather symmetrical in shape after their only abruption (c). Two skin hooks are used to hook the lateral cartilage so that it can be seen (d), this is then sutured to alar cartilage. In practice this is much easier than expected. The nasal cartilages are fixed with 4 sutures. The reverse-U incision is closed. They are repositioned in the normal position with an overcorrection done after suturing (e). Four to six through-and-through mattress sutures of absorbable string being done over a roll of gauze as bolster suture (f).
Secondary unilateral cleft-lip nose repair with a modified reverse-U method to our modified reverse-U method in these cases. Group B consisted of 37 patients receiving the primary operation and/or more than one rhinoplasty at another hospital before our method was employed. Patient ages at the time of the secondary operation ranged from 4 to 40 years (average, 8.1 years; 4.2 years in group A and 13.4 years in group B). Our technique employing the reverse-U incision has been improved since its initial use in 1998 by modifications that have led to better symmetry and balance.
Our operative procedure (Figure 1) The displaced alar base is pushed slightly upwards and medially by the surgeon’s fingers, and the incision line is marked in the same way as in the original method.1 This design makes a semilunar mark on the dorsum of the nostril so that the plotted line looks identical in shape to the nostril of the non-cleft side. Good exposure is obtained by this incision, and wide subcutaneous undermining is carried out all over the lower two-thirds of the nose. Both sides of the alar cartilage are completely separated from alar base. The right and left alar cartilages are completely separated to reach the columellar base. The ala is found to be rather symmetrical in shape after their abruption. Two skin hooks are used to hook the lateral cartilage so that it can be seen; this is then sutured to alar cartilage. At first, the alar cartilage is sutured to the lateral cartilage on the same side; next the alar cartilage is sutured to the contralateral
749
cartilage and, finally, the alar cartilage is sutured to the opposite one with two threads. In practice, this is much easier than expected. The alar cartilage on the affected side receives four sutures. They are repositioned in the normal position with an overcorrection done after the plication of the nasal fascia in four directions. The reverseU incision is closed. A single suture with nylon thread is made through the columella as a trans-columellar suture. Four to six through-and-through mattress sutures of absorbable string being done over a roll of gauze as bolster suture are placed to hold the ala in a slightly overcorrected position. With the original Tajima method, release of the alar cartilage from the alar base is to be avoided (Figure 2(a)). With our modified method, the bilateral alar cartilages are released from the alar base and completely separated (Figure 2(b)). With the original technique, three sutures are placed which overcorrect these cartilages (Figure 2(c)). With the modified method, there is even greater cartilage overcorrection, which is achieved with four sutures (Figure 2(d)). The original method involves subcutaneous undermining in the alar area only on the bilateral alar cartilages. With the modified method, subcutaneous undermining is much more extensive, reaching the bilateral alar bases and the lower part of the columella. After repositioning and correction, the nasal cartilages are fixed with bolster sutures for about 2 weeks. Then, in all patients, a nasal retainer is applied for over 3 months to maintain the nose’s corrected contour.
Figure 2 Our modified procedure employing a reverse-U incision. a, b: absorptions with the original method (a, slash lines)1 and our method (b) subcutaneous undermining should reach the alar base and the lower part of the columellar (red area). c, d: fixation of nasal cartilages with the original method1 (c) and our modification (d). Much greater overcorrection, employing 4 sutures adding alarealar thread (arrow), is achieved with our method.
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T. Fujimoto et al.
Discussion
Figure 3 Measurement of points for evaluation on photographs. A) Height of Nostril, B) Width of Nostril, C) Length between Medial Canthus and Alar base. Each ratio was assessed as a point on a scale of 1e3, with 3 being the most favourable.
The follow-up period in this retrospective study ranged from 2 to 11 years (average, 7.2 years). To evaluate the surgical results, three elevated points on the nasal dome and alar crease were measured on patient photographs. Evaluation was based on the degree of symmetry of the nasal dome and alar crease contour as a ratio of the affected side to the non-affected side. Each ratio was assessed as a point on a scale of 1e3, with 3 being the most favourable (Figure 3). Secondary corrections were then compared. Symmetry was assessed based on the total point score: 8 or 9 points, Excellent; 6 or 7, Good; and 5 or less, Fair.
Results Excellent (44.2%) and Good (42.3%) results were obtained in 45 group A cases. Excellent (18.9%) and Good (62.2%) results were obtained in 29 group B cases (Table 1). Excellent and Good results were achieved in 74 cases (81%) with satisfactory nasal dome symmetry and no relapse (Figures 4 and 5). Fifteen patients (19%) had only Fair results, with these outcomes being attributable to an unclear alar crease or relapse (Figure 6). Table 1 Results: ‘Group A’ underwent cheiloplasty with a modified Tajima technique without a reverse-U incision as the primary surgery and no other surgeries were performed prior to our modified reverse-U method. ‘Group B’ underwent the primary operation and/or more than one rhinoplasty at other hospitals before our method was applied. Group A Excellent Good Fair
52 23 22 7
cases (44.2%) (42.3%) (13.5%)
Group B Excellent Good Fair
37 7 22 8
cases (18.9%) (62.2%) (18.9%)
Secondary deformity after the primary operation is a significant problem encountered in cleft-lip repair. It is very difficult to achieve the objective of nose and lip symmetry through anatomical reconstruction with complete cosmetic satisfaction.3e5 This is especially true for nasal structures, due to the complexity and threedimensionality of the cartilage of the nose. Cleft nasal deformity is caused by malposition and hypoplasia of the alar cartilage, interruption of the muscle ring across the nasal sill, fixation of the accessory chain of the lateral crus through fibrous connections to the piriform margin, soft-tissue deficiency at the nasal floor, septal deviation and abnormal muscle insertions at the alar base to the cheek and lip.6 These abnormalities make such deformities very difficult to repair. Numerous published reports have described application of Tajima’s reverse-U method and many surgeons regard this approach as being very useful focorrecting such deformities.7,8 A few descriptions of postoperative relapse have led to reports suggesting modifications or improvements to the Tajima procedure.3,9e12 The basic procedure1,2 we follow was developed by Tajima’s group between 1983 and 1994. Tajima et al. reported that subcutaneous undermining was broadly carried out over the entire lower two-thirds of the nose, including the upper part of the columella, and the alar cartilage on the affected side was sutured to the alar cartilage of the normal side and to the lateral cartilages on both the cleft and the non-cleft side with three sutures. In the few postoperative cases in this period that tended to relapse, based on our own experience and other reports, such postoperative deformities appeared to be related to the alar cartilage relapsing into its former position. Modifications suggested in subsequent reports that sought to rectify the shortcomings of the reverse-U method included replacement of the alar cartilage or repair of the plica in the nasal cavity.3,10,11 All of these procedures prevented postoperative relapse through restitution of soft tissues. In the original procedure, bilateral alar cartilages were not separated completely and the undermining did not reach the lower part of the columella. Subcutaneous undermining of the bilateral alar bases was not carried out.1 Our modified technique focusses on procedures to prevent relapse of the alar cartilages. Specifically, this technique has three important modifications: the bilateral alar cartilages are sufficiently released from the alar base and the columellar base, they are strongly fixed to each other and the skin is completely elevated from all nasal cartilages. Much wider elevation prevents relapse caused by skin tension. Our modified procedures eliminate tissue distortion and malposition, which are among the primary factors causing deformity. The results of the reverse-U method depend on the number of surgeries and its procedure patients have been performed, with no touching of the nasal cartilages and thus minimal resection of unnecessary tissue. Rhinoplasty as part of the primary Tajima method without a reverse-U incision is carried out as follows2: the columella is centralised by freeing it from the anterior nasal spine, the nasalis muscles are transferred and advanced to a normal
Secondary unilateral cleft-lip nose repair with a modified reverse-U method
751
Figure 4 Excellent case in group A: a; 3-month-old girl. Preoperative view of the primary operation. b; Preoperative view of the secondary operation at 4 years of age. c; 3 years after the secondary operation. Excellent in group B: d; Preoperative view of the secondary operation at 36 years of age (left), and 3 years after second operation (right).
anatomical position and the lateral cartilage is freed by a pyriform margin incision.2 It was not possible to ascertain the details of the primary operative method in group B. Although the primary method and/or whether more than one rhinoplasty procedure had been performed could not always be confirmed, alar hypoplasia and tissue deficiencies are known to be related to operations on nasal cartilages. The results of previous operations had a major impact on the outcomes of secondary corrections employing the reverse-U method only in the excellent group. The final results may therefore depend on scarring, the amount of soft-tissue and the
growth of nasal cartilages. These results suggest that a series of procedures be recommended for primary and secondary cleft-lip repair, and that subsequent correction of problems related to any previous operations is very difficult. However, in group B, 81.1% of cases had Excellent or Good results. Therefore, the modified reverse-U method appears to be useful even for cases with multiple previous operations. Overall, 81% of our patients had satisfactory nasal-dome symmetry results (Excellent or Good), while 19% had Fair results. Retina insertion had been neglected in about half of the Fair group. Further, these cases rubbed their noses
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Figure 5 Good case in group A: a; Preoperative view of the secondary operation at 4 years of age. b; 5 years after the secondary operation. Good result in group B: c; Preoperative view of the secondary operation at 6 years of age. d; 10 years after the secondary operation.
frequently and were not able to leave the surgical area untouched postoperatively. This suggests that lack of follow-up could also be related to an increased probability of relapse. An advantage of the reverse-U method is that a short incision is made on just one side, such that scar tissue can be hidden in the nasal cavity. On the other hand, some experts are of the opinion that the procedure requires mastery of complex skills because the operation has a narrow field of view.9,12 However, it is relatively easy to cover the alar and lateral cartilages with sutures by sufficiently elevating the skin. To avoid the problem of insufficient detachment, it is very important to separate the nasal skin from the bilateral alar and lateral cartilages. Rigid fixation and release of the nasal cartilages, individually, is also very important. Our technique reduces soft-tissue traction through extended elevation and strong fixation with four sutures (one stitch added over an original method) and transcolumellar suture. Thus, we believe that our modified reverse-U method reduces the chance of relapse and is a promising approach to achieving long-term symmetry in patients with unilateral cleft-lip nose deformity.
Ethical approval This study was approved by the Ethical Committee of Osaka City General Hospital, Osaka City.
Acknowledgement Figure 6 Fair result in group B: a; Preoperative view of the secondary operation at 4 years of age. b; 11 years after the secondary operation.
The authors declare there is no conflict of interests or funding provided for the study.
Secondary unilateral cleft-lip nose repair with a modified reverse-U method
References 1. Tajima S, Maruyama M. Reverse-U incision for secondary repair of cleft lip nose. Plast Reconstr Surg 1977;60:256e61. 2. 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 1983;11:64e70. 3. Coghlan BA, Boorman JG. Objective evaluation of the Tajima secondary cleft lip nose correction. Br J Plast Surg 1996;49: 457e61. 4. Coghlan BA, Boorman JG. Outcome analysis of a modified Tajima procedure. Br J Plast Surg 1997;50:590e4. 5. Flores RL, Sailon AM, Cutting CB. A novel cleft rhinoplasty procedure combining an open rhinoplasty with the Dibbell and Tajima techniques: a 10-year review. Plast Reconstr Surg 2009; 124:2041e7. 6. Kim SK, Cha BH, Lee KC, et al. Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation. Plast Reconstr Surg 2004;114:1373e81.
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7. Cho BC, Baik BS. Correction of cleft lip nasal deformity in Orientals using a refined reverse-U incision and VeY plasty. Br J Plast Surg 2001;54:588e96. 8. Cho BC. Correction of unilateral cleft lip nasal deformity in preschool and school-aged children with refined reverse-U incision and V-Y plasty: long-term follow-up results. Plast Reconstr Surg 2007;119:267e75. 9. Grayson BH, Cutting CB. Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J 2001;38:193e8. 10. Byrd HS, El-Musa KA, Yazdani A. Definitive repair of the unilateral cleft lip nasal deformity. Plast Reconstr Surg 2007; 120:1348e56. 11. McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Plast Reconstr Surg 1985;75: 791e9. 12. Wolfe SA. A pastiche for the cleft lip nose. Plast Reconstr Surg 2004;114:1e9.
Follow-up of unilateral cleft-lip nose deformity after secondary repair with a modified reverse-U method* Takuya Fujimoto, Keisuke Imai *, Takaharu Hatano, Makoto Takahashi, Motoki Tamai Department of Plastic & Reconstructive Surgery, Osaka City General Hospital, Osaka, Japan Received 12 July 2010; accepted 28 October 2010
KEYWORDS Reverse-U incision; Cleft-lip; Secondary repair; Rhinoplasty; Modification
Summary Emphasis of secondary repair for unilateral cleft-lip has been placed on correction of the cleft-lip nasal deformity by translocation of the alar cartilage with its attached vestibular lining into a normal position, thereby establishing the normal vault and shape of the cartilage. We have managed cleft-lip deformities employing a modified reverse-U method. We present our modified technique and the obtained results. Eighty-nine patients with unilateral cleft-lip nasal deformity underwent surgical repair between 1998 and 2007 by one surgeon. These patients were divided into two groups based on their previous operative histories. Group A comprised 52 patients who underwent primary cheiloplasty using a modified Tajima technique. No other surgery had been performed prior to our modified reverse-U method in these cases. Group B consisted of 37 patients receiving the primary operation and/or more than one rhinoplasty at another hospital before our method was employed. The ages of our patients at the time of the secondary operation ranged from 4 to 40 years (average, 8.1 years; 4.2 years in group A and 13.4 years in group B). The follow-up period ranged from 2 to 11 years (average 7.2 years). For objective evaluation, points on the nasal dome and alar crease were measured on patient photographs. The results were retrospectively distinguished to three levels by total point score: Excellent, Good and Fair. Excellent or Good results were obtained in 74 cases, while 15 had Fair results. Eighty-one percent of all cases maintained acceptable results without relapse. Fair results were attributed to an unclear alar crease or relapse.
* Part of this work was presented at the 76th annual meeting of American Society of Plastic Surgeons in Baltimore, Maryland, USA in October 2007. * Corresponding author. Department of Plastic & Reconstructive Surgery, Osaka City General Hospital, 2-13-22, Miyakojimahondori, Miyakojima-ku, Osaka 5340021, Japan. Tel.: þ81 6 6929 1221; fax: þ81 6 6929 1090. E-mail address: [email protected] (K. Imai).
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.10.019
748
T. Fujimoto et al. In conclusion, rigid fixation and release of nasal cartilage are very important. We believe our modified reverse-U method to be very useful for achieving symmetry of the unilateral cleft-lip nose in the long term. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The focus of secondary correction of unilateral cleft-lip nose deformity has been nasal symmetry. Importance has been placed on correction of the cleft-lip nasal deformity by translocation of the alar cartilage with its attached vestibular lining into a normal position, thereby establishing the normal vault and shape of the cartilage. We have managed cases with cleft-lip deformities using our modified reverse-U method.1 We report our technique and the results obtained, as assessed retrospectively.
Patients and methods Eighty-nine patients with unilateral cleft-lip nose deformity underwent surgical repair between 1998 and 2007 by one surgeon. These cases were divided into two groups based on their previous operative histories. Group A comprised 52 patients who underwent cheiloplasty using a modified Tajima technique2 without a reverse-U incision as the primary surgery. No other surgery had been performed prior
Figure 1 while ala base is pinched, the design can be engraved outside of the nostril (a). By raising up nostrils and checking symmetry (b), it is confirmed that the design is correct. The ala is found to be rather symmetrical in shape after their only abruption (c). Two skin hooks are used to hook the lateral cartilage so that it can be seen (d), this is then sutured to alar cartilage. In practice this is much easier than expected. The nasal cartilages are fixed with 4 sutures. The reverse-U incision is closed. They are repositioned in the normal position with an overcorrection done after suturing (e). Four to six through-and-through mattress sutures of absorbable string being done over a roll of gauze as bolster suture (f).
Secondary unilateral cleft-lip nose repair with a modified reverse-U method to our modified reverse-U method in these cases. Group B consisted of 37 patients receiving the primary operation and/or more than one rhinoplasty at another hospital before our method was employed. Patient ages at the time of the secondary operation ranged from 4 to 40 years (average, 8.1 years; 4.2 years in group A and 13.4 years in group B). Our technique employing the reverse-U incision has been improved since its initial use in 1998 by modifications that have led to better symmetry and balance.
Our operative procedure (Figure 1) The displaced alar base is pushed slightly upwards and medially by the surgeon’s fingers, and the incision line is marked in the same way as in the original method.1 This design makes a semilunar mark on the dorsum of the nostril so that the plotted line looks identical in shape to the nostril of the non-cleft side. Good exposure is obtained by this incision, and wide subcutaneous undermining is carried out all over the lower two-thirds of the nose. Both sides of the alar cartilage are completely separated from alar base. The right and left alar cartilages are completely separated to reach the columellar base. The ala is found to be rather symmetrical in shape after their abruption. Two skin hooks are used to hook the lateral cartilage so that it can be seen; this is then sutured to alar cartilage. At first, the alar cartilage is sutured to the lateral cartilage on the same side; next the alar cartilage is sutured to the contralateral
749
cartilage and, finally, the alar cartilage is sutured to the opposite one with two threads. In practice, this is much easier than expected. The alar cartilage on the affected side receives four sutures. They are repositioned in the normal position with an overcorrection done after the plication of the nasal fascia in four directions. The reverseU incision is closed. A single suture with nylon thread is made through the columella as a trans-columellar suture. Four to six through-and-through mattress sutures of absorbable string being done over a roll of gauze as bolster suture are placed to hold the ala in a slightly overcorrected position. With the original Tajima method, release of the alar cartilage from the alar base is to be avoided (Figure 2(a)). With our modified method, the bilateral alar cartilages are released from the alar base and completely separated (Figure 2(b)). With the original technique, three sutures are placed which overcorrect these cartilages (Figure 2(c)). With the modified method, there is even greater cartilage overcorrection, which is achieved with four sutures (Figure 2(d)). The original method involves subcutaneous undermining in the alar area only on the bilateral alar cartilages. With the modified method, subcutaneous undermining is much more extensive, reaching the bilateral alar bases and the lower part of the columella. After repositioning and correction, the nasal cartilages are fixed with bolster sutures for about 2 weeks. Then, in all patients, a nasal retainer is applied for over 3 months to maintain the nose’s corrected contour.
Figure 2 Our modified procedure employing a reverse-U incision. a, b: absorptions with the original method (a, slash lines)1 and our method (b) subcutaneous undermining should reach the alar base and the lower part of the columellar (red area). c, d: fixation of nasal cartilages with the original method1 (c) and our modification (d). Much greater overcorrection, employing 4 sutures adding alarealar thread (arrow), is achieved with our method.
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T. Fujimoto et al.
Discussion
Figure 3 Measurement of points for evaluation on photographs. A) Height of Nostril, B) Width of Nostril, C) Length between Medial Canthus and Alar base. Each ratio was assessed as a point on a scale of 1e3, with 3 being the most favourable.
The follow-up period in this retrospective study ranged from 2 to 11 years (average, 7.2 years). To evaluate the surgical results, three elevated points on the nasal dome and alar crease were measured on patient photographs. Evaluation was based on the degree of symmetry of the nasal dome and alar crease contour as a ratio of the affected side to the non-affected side. Each ratio was assessed as a point on a scale of 1e3, with 3 being the most favourable (Figure 3). Secondary corrections were then compared. Symmetry was assessed based on the total point score: 8 or 9 points, Excellent; 6 or 7, Good; and 5 or less, Fair.
Results Excellent (44.2%) and Good (42.3%) results were obtained in 45 group A cases. Excellent (18.9%) and Good (62.2%) results were obtained in 29 group B cases (Table 1). Excellent and Good results were achieved in 74 cases (81%) with satisfactory nasal dome symmetry and no relapse (Figures 4 and 5). Fifteen patients (19%) had only Fair results, with these outcomes being attributable to an unclear alar crease or relapse (Figure 6). Table 1 Results: ‘Group A’ underwent cheiloplasty with a modified Tajima technique without a reverse-U incision as the primary surgery and no other surgeries were performed prior to our modified reverse-U method. ‘Group B’ underwent the primary operation and/or more than one rhinoplasty at other hospitals before our method was applied. Group A Excellent Good Fair
52 23 22 7
cases (44.2%) (42.3%) (13.5%)
Group B Excellent Good Fair
37 7 22 8
cases (18.9%) (62.2%) (18.9%)
Secondary deformity after the primary operation is a significant problem encountered in cleft-lip repair. It is very difficult to achieve the objective of nose and lip symmetry through anatomical reconstruction with complete cosmetic satisfaction.3e5 This is especially true for nasal structures, due to the complexity and threedimensionality of the cartilage of the nose. Cleft nasal deformity is caused by malposition and hypoplasia of the alar cartilage, interruption of the muscle ring across the nasal sill, fixation of the accessory chain of the lateral crus through fibrous connections to the piriform margin, soft-tissue deficiency at the nasal floor, septal deviation and abnormal muscle insertions at the alar base to the cheek and lip.6 These abnormalities make such deformities very difficult to repair. Numerous published reports have described application of Tajima’s reverse-U method and many surgeons regard this approach as being very useful focorrecting such deformities.7,8 A few descriptions of postoperative relapse have led to reports suggesting modifications or improvements to the Tajima procedure.3,9e12 The basic procedure1,2 we follow was developed by Tajima’s group between 1983 and 1994. Tajima et al. reported that subcutaneous undermining was broadly carried out over the entire lower two-thirds of the nose, including the upper part of the columella, and the alar cartilage on the affected side was sutured to the alar cartilage of the normal side and to the lateral cartilages on both the cleft and the non-cleft side with three sutures. In the few postoperative cases in this period that tended to relapse, based on our own experience and other reports, such postoperative deformities appeared to be related to the alar cartilage relapsing into its former position. Modifications suggested in subsequent reports that sought to rectify the shortcomings of the reverse-U method included replacement of the alar cartilage or repair of the plica in the nasal cavity.3,10,11 All of these procedures prevented postoperative relapse through restitution of soft tissues. In the original procedure, bilateral alar cartilages were not separated completely and the undermining did not reach the lower part of the columella. Subcutaneous undermining of the bilateral alar bases was not carried out.1 Our modified technique focusses on procedures to prevent relapse of the alar cartilages. Specifically, this technique has three important modifications: the bilateral alar cartilages are sufficiently released from the alar base and the columellar base, they are strongly fixed to each other and the skin is completely elevated from all nasal cartilages. Much wider elevation prevents relapse caused by skin tension. Our modified procedures eliminate tissue distortion and malposition, which are among the primary factors causing deformity. The results of the reverse-U method depend on the number of surgeries and its procedure patients have been performed, with no touching of the nasal cartilages and thus minimal resection of unnecessary tissue. Rhinoplasty as part of the primary Tajima method without a reverse-U incision is carried out as follows2: the columella is centralised by freeing it from the anterior nasal spine, the nasalis muscles are transferred and advanced to a normal
Secondary unilateral cleft-lip nose repair with a modified reverse-U method
751
Figure 4 Excellent case in group A: a; 3-month-old girl. Preoperative view of the primary operation. b; Preoperative view of the secondary operation at 4 years of age. c; 3 years after the secondary operation. Excellent in group B: d; Preoperative view of the secondary operation at 36 years of age (left), and 3 years after second operation (right).
anatomical position and the lateral cartilage is freed by a pyriform margin incision.2 It was not possible to ascertain the details of the primary operative method in group B. Although the primary method and/or whether more than one rhinoplasty procedure had been performed could not always be confirmed, alar hypoplasia and tissue deficiencies are known to be related to operations on nasal cartilages. The results of previous operations had a major impact on the outcomes of secondary corrections employing the reverse-U method only in the excellent group. The final results may therefore depend on scarring, the amount of soft-tissue and the
growth of nasal cartilages. These results suggest that a series of procedures be recommended for primary and secondary cleft-lip repair, and that subsequent correction of problems related to any previous operations is very difficult. However, in group B, 81.1% of cases had Excellent or Good results. Therefore, the modified reverse-U method appears to be useful even for cases with multiple previous operations. Overall, 81% of our patients had satisfactory nasal-dome symmetry results (Excellent or Good), while 19% had Fair results. Retina insertion had been neglected in about half of the Fair group. Further, these cases rubbed their noses
752
T. Fujimoto et al.
Figure 5 Good case in group A: a; Preoperative view of the secondary operation at 4 years of age. b; 5 years after the secondary operation. Good result in group B: c; Preoperative view of the secondary operation at 6 years of age. d; 10 years after the secondary operation.
frequently and were not able to leave the surgical area untouched postoperatively. This suggests that lack of follow-up could also be related to an increased probability of relapse. An advantage of the reverse-U method is that a short incision is made on just one side, such that scar tissue can be hidden in the nasal cavity. On the other hand, some experts are of the opinion that the procedure requires mastery of complex skills because the operation has a narrow field of view.9,12 However, it is relatively easy to cover the alar and lateral cartilages with sutures by sufficiently elevating the skin. To avoid the problem of insufficient detachment, it is very important to separate the nasal skin from the bilateral alar and lateral cartilages. Rigid fixation and release of the nasal cartilages, individually, is also very important. Our technique reduces soft-tissue traction through extended elevation and strong fixation with four sutures (one stitch added over an original method) and transcolumellar suture. Thus, we believe that our modified reverse-U method reduces the chance of relapse and is a promising approach to achieving long-term symmetry in patients with unilateral cleft-lip nose deformity.
Ethical approval This study was approved by the Ethical Committee of Osaka City General Hospital, Osaka City.
Acknowledgement Figure 6 Fair result in group B: a; Preoperative view of the secondary operation at 4 years of age. b; 11 years after the secondary operation.
The authors declare there is no conflict of interests or funding provided for the study.
Secondary unilateral cleft-lip nose repair with a modified reverse-U method
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