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Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar grafting
Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 319e325
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Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar graftingq Poramate Pitak-Arnnop a, b, *, Alexander Hemprich a, Kittipong Dhanuthai a, c, Vedat Yildirim a, Niels Christian Pausch a a
Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, Scientific Unit for Clinical and Psychosocial Research, Evidence-Based Surgery and Ethics in Oral and Maxillofacial Surgery, Faculty of Medicine, University Hospital of Leipzig, Leipzig, Germany Laboratory of Medical Ethics and Legal Medicine, Faculty of Medicine, University Paris 5 (René Descartes), Paris, France c Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 18 December 2009 Accepted 30 July 2010
Background: Cleft-lip nasal deformity alters patient’s self-image, as well as posing unique challenges for the rhinoplastic surgeon. Objectives: The main purpose of this study was to compare the panel perceptions of nasal aesthetics following secondary cleft rhinoplasty with versus without caudal septal extension grafting (columella grafting). We also investigated whether patient’s self-assessment and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) panel perceptions. Methods: Using a cross-sectional study design, we enrolled a sample of adult laypersons and medical experts. The predictor variable was the rhinoplasty techniques (with/without columellar grafting). The outcome variable was the panel rankings of nasal aesthetics based on the photographs of 50 nonsyndromic cleft patients before and after the rhinoplasty. Other variables included the patient’s subjective assessment and satisfaction, demographic and anatomic variables. Appropriate descriptive, uni- and bivariate statistics were calculated. The significance level was set at P 0.05 and <0.05 for single- and two-tailed tests of hypothesis, respectively. Results: The sample consisted of 507 laypersons and 51 professionals who gave comparative ratings (P > 0.05). Columellar grafting was associated with higher rankings of postoperative nasal aesthetics (P ¼ 0.04). Most of the patients (90%) rated positive outcomes. Surgical techniques, patients’ age and gender, and panel perceptions were not individually significantly associated with subjective measures and satisfaction. Conclusions: Our results suggest that caudal septal extension grafting improves the nasal aesthetics of the cleft patients, as judged by the panel. Patient’s self-assessment seems unreliable to be used as an outcome measure. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Aesthetic perception Cleft-lip nasal deformity Columellar grafting Rhinoplasty
1. Introduction ‘Un grand nez ne gâte jamais un beau visage.’ (Literally, a big nose never spoils a pretty face.) French proverb q Presented at the 70th Anniversary Celebration 2010, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand, Aug. 12e14, 2010; and at the 23rd Symposium of the German Interdisciplinary Workshop on Cleft Lip/Palate and Craniofacial Anomalies under the cooperation of the German Associations of Oral and Maxillofacial Surgery, Orthodontics, Speech Therapy, Paediatric Audiology and OtolaryngologyeHead and Neck Surgery, Mainz, Germany, Oct. 1e2, 2010. * Corresponding author. Klinik und Poliklinik für Mund-, Kiefer- und Plastische Gesichtschirurgie, Universitätsklinikum Leipzig AöR, Nürnberger Str. 57, 04103 Leipzig, Germany. Tel.: þ49 341 97 21 100; fax: þ49 341 97 21 109. E-mail address: [email protected] (P. Pitak-Arnnop).
As a central and prominent landmark of the face the nose is the focal point of attention, as well as representing the individual identity. Hence, the nose, despite being a tiny organ, affects the overall facial appearance (Rees, 1978; Sinko et al., 2005; Andretto Amodeo, 2007; Moolenburgh et al., 2008a; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). A good-looking and harmonic nose implies positive personality characteristics in the eye of the public: honest, trustful, successful and loyal (Dion
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et al., 1972). Any operation changing the shape and size of the nose has an effect on body image and psychological stability until the patient has a new self-sense or self-concept (Andretto Amodeo, 2007). In 1949, Huffmann and Lierle first described cleft-lip nasal deformity (CLND) that consists of 22 typical features occurring independently or in combination. Unlike a ‘big’ nose, CLND is not a variation, but a deformity. It is difficult to camouflage and degrades the overall appearance of the face. Most cleft patients possess a flattened nasal tip, flattened nostrils, and a wide nasal base with a short columella. With visible facial impairment and low self-esteem, cleft patients may develop psychosocial maladjustment, speech difficulties, unrealistic perceptions about facial appearance, and physiognomic rejection (Marcusson et al., 2002; Al-Omari et al., 2005; Andretto Amodeo, 2007; Noor and Musa, 2007; Oosterkamp et al., 2007; Meyer-Marcotty and StellzigEisenhauer, 2009). Table 1 summarises the characteristic features of CLND. Although nasoalveolar moulding and initial lip surgery in early infancy minimise the CLND deformity, many patients require secondary rhinoplasty to correct alar-columellar disproportion in their teenage years once growth is complete (Stal and Hollier, 2002). In definitive cleft rhinoplasty, Guyuron (2008) recommended supporting the nasal tip with an intercrural columellar strut in order to (1) increase tip projection, (2) elongate the columella on the cleft side, (3) augment the deficient subnasale, (4) correct an acute nasolabial angle, and (5) prevent the tip from shifting caudally. With the strut, the columellar show is increased by up to 2 mm (Toriumi, 1995). However, caudal septal extension grafting can be used in cases with severe deficiency in the columellar show and nasal septum. This graft will increase the nasal length and columellar show, lessen the nasal index, and improve the tip support (Toriumi, 1995, 1996; Byrd et al., 1997).
One important goal of cleft care is to eradicate all visible stigmata of the facial deformities (Marcusson et al., 2002; Russell et al., 2009). However, aesthetic outcomes of the nasolabial complex after cleft surgery present a challenge for the rhinoplastic surgeon. Most studies concentrate on the surgical outcomes with regard to different techniques or different centres, but the effect of columellar grafting on nasal aesthetics has received limited attention (Sharp and Rowe-Jones, 2003; Al-Omari et al., 2005). Outcome assessment offers evidence to improve clinical decision making (Moolenburgh et al., 2008b). Standardised, valid and reliable methods for evaluating success in facial cosmetic procedures including rhinoplasty are still lacking (Moolenburgh et al., 2008b; Kosowski et al., 2009). Subjective patient reporting and clinicians’ opinions on treatment outcomes, albeit controversial, seem to be biased (Eliason et al., 1991; Marcusson et al., 2002; Sharp and Rowe-Jones, 2003; Al-Omari et al., 2005; Sàndor and Ylikontiola, 2006; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). The primary purpose of this study was to examine the relationship between secondary cleft rhinoplasty (with versus without a caudal septal extension graft) and panel perceptions of nasal aesthetics in CLND patients. The null hypothesis was that there was no diference in the panel perceptions of nasal aesthetics after secondary cleft rhinoplasty between the 2 groups (with or without columellar grafting). The alternative, 1-tail hypothesis was that panel perceptions of nasal beauty in the columellar grafting group were far superior to those in the non-grafting group. If this null hypothesis was rejected, it would suggest grafting the columella in every nasal cleft revision. The secondary aim was to investigate whether patient’s subjective measures and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) the perceptions of the third-party observers. Technical refinements of our columellar extension grafting are presented, and relevant issues on nasal cleft aesthetics are also reviewed.
Table 1 The specific characteristics of cleft-lip nasal deformity (CLND)a. Locations
Unilateral CLND
Bilateral CLND
Columella
- Shorter on the cleft side (sometimes) - Deviated columellar base towards the noncleft side (secondary to contraction of orbicularis-oris muscle) - Longer lateral crus and shorter medial crus on the cleft side (the same length with the noncleft side, but the position and shape are different) - Caudally displaced lateral crus (frequent) - Introversion (posterior and inferior rotation of the cephalic edge of the lower lateral cartilage on the cleft side), causing thickening of the ala and hooding of the nostril rim - Displaced in both frontal and horizontal planes - Asymmetric - Loss of nasal tip definition - Tendency for bifidity - Flattened, causing in horizontal orientation of the nostril - Laterally and/or posteriorly (and sometimes inferiorly) displaced alar base - Obliquity of the alar facial angle - Asymmetric (horizontally orientation on the cleft side) - Retropositioned because of deficiency in the underlying frame - Deviated, causing nasal obstruction and external nasal deviation - Perpendicular plate deviating towards the cleft side and anterior nasal spine towards the noncleft vestibule - Deviated nasal spine towards the noncleft side
- Relatively short with a wide base - Prolabium attached to the nasal tip (sometimes)
Lower lateral cartilage
Nasal tip
Alae of nose
Nostrils Nasal septum and spine
Skeletal platform
a
- Hypotrophic maxilla on the cleft side - Displaced premaxilla and maxillary segments
After Nolst Trenité (1993), Shih and Sykes (2002), Stal and Hollier (2002), and Guyuron (2008).
-
Severely deformed Short medial crus bilaterally Long lateral crus bilaterally with caudal displacement Downward rotation of the alar cartilage Buckling of the lateral crura
- Flat and board - Asymmetric (if the cleft is incomplete) - Loss of tip projection - Bifidity - Flat and sometimes S-shaped - Laterally and posteriorly (and sometimes inferiorly) displaced alar base on the both sides - Horizontally orientation on the both sides - Asymmetric (usually) - Inferior displacement of caudal cartilaginous septum (relative to the alar base level) - Displaced and short nasal spine - Board nasal septum - Deviated septum and vomer towards the less affected side (if the cleft is incomplete) - Bilateral maxillary hypoplasia - Protuding premaxilla (sometimes), causing distortion of the columella
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2. Materials and methods 2.1. Study design/sample This study was partially based on our previous research design and sample (Pausch et al., in press). To address the research question, we used a cross-sectional study design, approved by the institutional ethics committee (Registration No. 221-2006), with the questionnaire and the CLND patients’ photographs administered in a double-blinded, randomised fashion. The study participants, who were unknown to the data evaluators (PP and KD), did not know the patients or the treatments they had received. A random sample of the general public and medical professionals in Leipzig and Dresden, Germany, was taken; all were German. One of the senior investigators (NCP) screened the subjects for study eligibility and initiated the consent process, including a review of the study rationale and protocol. Informed consent was received from all participants, including the use of the patients’ photographs in the study. The recommendations of the Helsinki declaration were adhered to during this study. To be considered for study inclusion, the subjects whom we interviewed were not involved in the treatments for the patients involved in this study. All non-medical laypersons were unfamiliar with facial plastic surgery, cleft care or any related fields. The healthcare professionals included maxillofacial surgeons, oral surgeons, otolaryngologists, and orthodontists; all confirmed that they regularly had contact with cleft patients. The broad inclusion criteria provided the opportunity to enrol a diverse, heterogeneous study sample with results that may be more generally applicable (Tunis et al., 2003). There was no exclusion criterion for this study.
Fig. 1. Schematic diagrams of the incisions by (a) Bardach et al. (1987) for unilateral clefts; (b) Millard (1967) for bilateral clefts.
2.2. Variables and data collection The same experienced assessment instructor chaired every rating procedure that was not time-limited. All instructions were standardised and read from a paper to ensure the similar information given to the voters. The predictor variable was the rhinoplasty techniques. This was a binary variable: with or without caudal septal extension grafting. We used photographs of 50 consecutive German nonsyndromic cleft patients treated by the last author (NCP) at the Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, University Hospital of Leipzig, for CLND between January 2002 and December 2007. Twenty-four patients (48%) received columellar grafting, but the others did not. As per standard practice, the surgeon performed a secondary cleft rhinoplasty via an open approach as described by Bardach et al. (1987) for unilateral clefts or by Millard (1967) for bilateral clefts (Fig. 1). The external approach allows for complete visualisation of all nasal structures. In the grafted group, the L-shaped cartilage graft harvested from the nasal septum was placed between the medial crura as an extension graft onto the caudal nasal septum, as demonstrated by Toriumi (1995; 1996) and Byrd et al. (1997) (Fig. 2: details are discussed below). All patients received treatment according to our functionally-based strategy for cleft patients (Hemprich et al., 2006). Because no difference exists between judgements on facial appearance made from live subjects (adult cleft patients) and those made from colour photographs (Glass, 1978; Johnson and Sandy, 2003), we decided to use a sample of patients’ photographs. As described by Galdino et al. (2001), 6 preoperative and postoperative standardised photographs of each patient’s whole face were utilised: 2 lateral views, 1 frontal view, 2 oblique views and 1 basal view.
Fig. 2. Schematic diagrams of caudal septal extension grafting: (1) dorsal hump reduction; (2) the septal cartilage is harvested and cut into 2e3 pieces; (3) the upper part serves as dorsal or spreader grafts, the strong lower part is placed at the columella, and the small middle chip is sometimes used for nasal tip augmentation; the columellar graft is placed and secured at the caudal edge of the septum; (4) The lateral crura of the lower lateral cartilages are advanced supero-interiorly before the placement of interdomal and transdomal surtures.
The outcome variable was the panel’s rankings of nasal aesthetics of each patient’s photographs before and after the rhinoplasty. The preoperative photographs were rated on a 3-point ordinal scale: like/dislike/uncertain. We used a rating scale with 5 categories on postoperative results: improved/worsened/different but not improved/unchanged/uncertain. Other study variables were categorised as patient’s selfperceptions and satisfaction, demographic and anatomic variables. Demographic variables were age, gender and career of the participants, and patients’ age (teenage years or older) and gender. The anatomic variable was patients’ cleft defect (unilateral or bilateral). For subjective measures; patients were asked to rank their level of postoperative results as improved, worsened, different but not improved, unchanged, or uncertain. Patient satisfaction was
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assessed using a 4-point semi-quantitative ordinal scale: 1, dissatisfied; 2, moderately satisfied; 3, satisfied; 4, very satisfied. 2.3. Data analysis The results collected were entered into a statistical database (SPSS Version 10.0; SPSS, Inc, Chicago, IL). Descriptive, uni- and bivariate statistics were computed as indicated. Spearman rank correlation tests were performed to determine interobserver reliability. P values 0.05 for single-tailed tests of hypothesis, and <0.05 for 2-tailed analyses (e.g. of age, gender) were considered statistically significant. 3. Results The study sample consisted of 507 non-medical adult laypersons and 51 medical staff with a mean age of 24.8 8.2 years. They were 151 women (27.1%) and 407 men (72.9%) (Table 2). The laypersons were 5 athletes (1.0%), 15 businessmen (3.0%), 9 cooks (1.8%), 18 craftsmen (3.6%), 4 engineers (0.8%), 132 ergonomists (26.0%), 64 hairdressers (12.6%), 31 nurses (6.1%), 5 painters (1.0%), 64 paramedics (12.6%), 44 speech therapists (8.7%), 69 students (13.6%), 7 teachers (1.4%), 10 unemployed (2%), and 30 others (5.9%). The medical professionals included 15 maxillofacial surgeons (29.4%),12 oral surgeons (23.5%), 16 otolaryngologists (31.4%), and 8 orthodontists (15.7%). We used photographs of 50 cleft patients, 24 of whom (48%) were females and 28 cases (56%) had unilateral clefts. Their ages ranged from 15 to 48 years with the mean SD ¼ 19.8 5.3 years. Eighteen patients (36%) were teenagers. Symmetry of nostril, nasal dome projection and the correction rate of buckling deformity of the alar cartilage and flaring deformity of the alar base were corrected in all patients. Forty-five patients (90%) revealed their improved nasal aesthetics postoperatively and expressed satisfaction (scale 3 or 4). Columellar elongation techniques, and patients’ age and gender did not individually affect subjective assessment and satisfaction of the patients to a statistically significant degree. Perceptions of the independent evaluators did not correlate with patient’s self-assessment and satisfaction. Spearman rank correlation analyses indicated a high degree of agreement between the laypersons and the medical experts (P > 0.05). The raters disliked the preoperative noses (r ¼ 0.92, P < 0.0001), and they liked the postoperative noses more than the preoperative noses (r ¼ 0.86, P < 0.0001). Overall, columellar grafting was associated with higher rankings of nasal aesthetics by the panel (P ¼ 0.04). Postoperative nasal appearance was improved in 11 of 24 (or 45.8%) and 18 of 26 (or 69.2%) patients without and with the columellar graft, respectively. Complete data are not shown, but available upon request. 4. Discussion The study’s first aim was to gain insight into the relationship between 2 rhinoplastic techniques (with versus without caudal septal extension grafting) and panel evaluation of nasal aesthetics.
Table 2 The study samples. Study variables
Patients
Laypersons
Medical professionals
P value
Sample size Age (mean SD) Sex: male
50 19.8 5.3 26 (52.0%)
507 23.9 7.6 124 (24.5%)
51 34.9 7.2 27 (52.9%)
Not applicable <0.0001a <0.0001b
a b
ANOVA, analysis of variance. Chi-squared test.
We hypothesised that columellar grafting would increase nasal aesthetics after secondary cleft rhinoplasty, as judged by a panel of independent assessors. The data from this study highlighted that postoperative nasal aesthetics ratings in the grafted group were higher than those in the non-grafted group (P ¼ 0.04). Our secondary purpose was to investigate whether patient’s subjective assessment of aesthetics and satisfaction correlated with 4 variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) panel perceptions. It was statistically determined that surgical techniques, patient’s age and gender, and panel opinions were not associated with patient’s subjective measures and satisfaction. Patient’s self-perceptions and satisfaction after the revision rhinoplasty were relatively high. CLND is three-dimensional because it involves skin envelope, nasal bone and cartilage, nasal vestibular lining and skeletal platform (Table 1). Each of these components requires particular attention during planning the surgery. Secondary cleft rhinoplasty usually attempts to improve the nasal tip, dorsum, alar position, and symmetry of the nostrils (Sàndor and Ylikontiola, 2006). The columella is an important subunit of the face. In the profile view, the columella is generally shown 2e4 mm below the alar rim. The ratio of the columella length (the subnasale to the columella breakpoint) to the infratip lobule’s length (the columella breakpoint to the tip-defining point) should be 2:1. In the basal view, the lobule (the pronasale to the arch or height of the alar rim) is onethird of the nasal triangle, and the collumela occupies the remaining two-thirds. The columella forms a nasolabial angle of 90e95 in males and 95e110 in females with the upper lip (Toriumi, 1995; Sharp and Rowe-Jones, 2003; Bouguila et al., 2008). The nostril-alar relationship combines a hanging or normal or retracted alar rim with a hanging or normal or retracted columella (Gunter and Rohrich, 1989). The CLND nose and the ageing nose are similar. Many cleft patients have a hanging alar rim (or both rims in bilateral cleft cases) with a shortened and retracted columella, a convex nasal profile and deformed nasal frameworks. Our previous study revealed that the CLND nose looked older than the actual age of the patients. Secondary cleft rhinoplasty rejuvenated the nose (Pausch et al., in press). The major support of the nasal tip includes size, strength and shape of lateral and medial crura of the lower lateral cartilages, the attachments between the upper and lower lateral cartilages, the medial crural-septal fibrous union, and the interdomal ligamentous sling. Grafting onto the columella is aimed to strengthen the tip support and correct the buckled and malpositioned alar cartilages. The postero-inferior septal cartilage where the septum joins the maxillary crest is the gold standard grafting material (Toriumi, 1995; Quatela and Pearson, 2009). We cut out the lower part from the remaining segments of the graft into a size that allows it to overlap with the caudal margin of the septum. The upper cartilaginous portion of the graft serves as dorsal or spreader grafts, whilst the small middle chip is used to augment the nasal tip when indicated (Fig. 2). Once in place, the L-shaped caudal septal extension graft becomes a new caudal margin of the septum. The thickness of the overlying skin/soft-tissue envelope and the expected nasal anthropological measurements dictate the distance the graft extends beyond the septum. Excessive projection or rotation of the lower third of the nose may result in overprojection of the infratip lobule, and dehiscence of the transcolumellar incision if used. The graft will increase the columella show, a nasolabial angle, the nasal projection, and the structural integrity of the tip support and nasal base (Toriumi, 1995, 1996; Byrd et al., 1997; Ha and Byrd, 2003).
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We modified the ‘lateral crural steal technique’: the lateral crura are advanced onto the medial crura and the columellar graft (Kridel et al., 1989; Toriumi, 1995, 1996). According to the ‘tripod/pedestal concept’ by Anderson (1984), superior and anterior advancement of the lateral crura shortens the upper tripod limbs, increasing tip rotation and projection (Toriumi, 1995, 1996). Spreader grafts, albeit rarely used in our practice, strengthen and stabilise a weakened or deviated septum (Cochran et al., 2007). The remaining of the harvested cartilage can be milled before being reunited with the aid of fibrin glue and replanted into the donor site. Both nasal tip refinement and preservation of tip rotation are best corrected using interdomal and transdomal surtures (Byrd et al., 1997; Rohrich et al., 2004; Cochran et al., 2007). Transdermal suspension that anchors the alar cartilage to the external skin helps secure the desired position of the lateral crus of the cleft side (or both crura in bilateral clefts) (Stal and Hollier, 2002). Taken together, it may explain in part why caudal nasal extension grafting provides a more favourable cosmetic result than rhinoplasty without a columellar graft (Fig. 3). This technique has now become our method of choice for correcting late CLND. However, its main disadvantage is a rigid or stiff nasal tip without normal tip recoil. This technique is contraindicated in cases with a septal perforation or inadequate septal support, and/or lack of nasal vestibular skin available to allow caudal advancement. The caudal margin of the septum that is severely deviated can be excised and replaced by the graft (Toriumi, 1995, 1996). It should be borne in mind that open rhinoplasty can damage the supporting structures of the nose and the external value competency, as it frees the entire skin/soft-tissue envelope from the underlying nasal frameworks. Meticulous tissue handling is therefore mandatory during rhinoplasty, and radical operations on the nasal infrastructures should be avoided (Lam and Williams, 2002; Cochran et al., 2007). In general, patient’s subjective assessment and satisfaction is essential in determining success in aesthetic surgery (Moolenburgh et al., 2008b; Kosowski et al., 2009). Previous studies indicated that cleft patients were less satisfied with the outcomes, whilst medical professionals usually judged the outcomes more optimistically (Marcusson et al., 2002; Sinko et al., 2005; Oosterkamp et al., 2007; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). Springer et al. (2008) found that the judgement on nasal shape is based on each individual subject’s evaluation of their ‘own’ nose. Nonetheless, our findings suggest that patients’ self-assessment and satisfaction are positive, regardless of the treatments given. This supports the study results by Moolenburgh et al. (2008b). There are conflicting data surrounding gender differences in satisfaction of cleft patients with postoperative facial appearance (Turner et al., 1998; Marcusson et al., 2002; Sinko et al., 2005; Landsberger et al., 2006). In our study, there was no statistical significance in the patient’s subjective ratings of nasal aesthetics between the sexes. Comparison between studies is difficult due to heterogeneity of sampling, panel compositions and measures used. Moreover, it is of concern that postoperative anthropometric changes are not linked to the patient’s subjective assessment (Russell et al., 2009). Clinicians who are familiar with the patients in the study and/or cleft care usually assess the degree of CLND impairment better (Willams, 1968; Eliason et al., 1991). and their judgments are therefore at risk of bias (Marcusson et al., 2002; Al-Omari et al., 2005; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). Public perceptions closely resemble social interactions in daily life (Al-Omari et al., 2005; Moolenburgh et al., 2008b), but laypersons may judge the patients empathetically and thus raise their ratings of patients’ facial appearance (Eliason et al., 1991; Al-Omari et al., 2005; Moolenburgh et al., 2008b). In our study, there was no difference between the familiar and non-familiar ratings, as was also found by
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Fig. 3. Photographs of 2 patients underwent secondary cleft rhinoplasty (a) with, and (b) without a caudal septal extension graft (Left: preoperative; Right: postoperative). Postoperatively, the columella show and tip projection differ greatly between the 2 patients.
other authors (Coghlan et al., 1987; Roberts-Harry and Stephens, 1991; Cussons et al., 1993; Kane et al., 2000). This agreement between the laypersons and experts is helpful in deciding the type of surgical intervention needed for the treatment of the CLND. Noor and Musa (2007) showed that cleft patients and their family considered teeth and the nose as the most important organs. MeyerMarcotty and Stellzig-Eisenhauer (2009) found, however, that nasolabial morphology and aesthetics was critical to the patients whereas correction of malocclusion came later. Marcusson et al. (2002) reported that over half of the cleft patients (38 out of 68; or 59%) still needed further surgical correction, including a rhinoplasty. The findings on cleft patient’s dissatisfaction with their nasal appearance concurs with other studies (Semb et al., 2005; Sinko et al., 2005; Noor and Musa, 2007; Oosterkamp et al., 2007; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). A recent survey of laypersons pointed out that a nasal defect alone deteriorated facial attractiveness (Moolenburgh et al., 2008a). Nevertheless, little is known about the influence of nasal aesthetics on the overall quality of life of this patient population, requiring additional investigations. The present study suffers from many limitations. Firstly, the statistically significant differences in the sample characteristics
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(age and sex) may skew our results, reflecting only a catchment area of subjects. There are different judgements on nasal aesthetics between the sexes and between different sexual orientations (Springer et al., 2009). It is also difficult to compare the current panel outcomes with previously published data because of different panel compositions and methods used (Moolenburgh et al., 2008b). However, a large number of samples seem to have increased external validity of this study. Secondly, multiple factors affect nasal aesthetic perceptions. This study was not designed to identify whether and how columellar grafting plays a critical role over the corrections of other components of the CLND. Thirdly, the ordinal data scales in our assessment are difficult to handle and analyse, compared with a visual analogue scale (Al-Omari et al., 2005). Fourthly, we used a 2-dimensional static imaging technique because it is simple, cheap, valid, reproducible and non-invasive. Although we routinely use this technique to record 3-dimensional anatomy of the craniofacial region, the major drawback is the distortion error in translation from a 3- to a 2-dimensional object. The surrounding facial features, lighting, head orientation and subject-camera distance also affect the measurements (Al-Omari et al., 2005). To cope with these known shortcomings, we used standardised fullface photographs as described by Galdino et al. (2001). The wholeface assessment simulates social interaction in daily life (Al-Omari et al., 2005; Russell et al., 2009). It is unknown if any factors (e.g. culture, socially desirable response) constitute positive selfperceptions of our patients. Retrospective studies asking for opinions on past treatments may be subject to recall and memory bias. The interviewer’s experience and enthusiasm also affect the responses (Turner et al., 1998). Finally, the responses to interview questions preclude any test-retest analysis as they were only asked once (Marcusson et al., 2002). 5. Conclusion Our findings show a statistically significant association between panel perceptions of nasal aesthetics, and columellar lengthening with anterior nasal septum grafting. Laypersons and medical experts share similar overall judgements. No statistically significant association exists between subjective assessment, and panel perceptions or patients’ gender or age or rhinoplasty techniques. Given the results of this study, our advice is that in secondary cleft rhinoplasty, the columella be augmented with a caudal nasal extension graft. Patient’s self-perception is relatively high so that it seems unreliable to be used as an outcome measure. Because this study was cross-sectional, longitudinal studies would be needed to investigate whether intra-individual self-perception changes with age. Investigative links between the anthropometric changes after secondary cleft rhinoplasty and perceptions of the panel and patients should also be addressed. Disclosure of potential conflicts of interest The authors indicate full freedom of investigation and no potential conflicts of interest. Financial disclosure There was no grant support for this study. Acknowledgement We thank Ms. Evelyn Kuhnt, Coordination Centre for Clinical Trials, Faculty of Medicine, University Hospital of Leipzig, for her help with statistic analyses.
This article was completed in partial fulfilment of the requirements for the postdoctoral degree (‘Doctor habilitatus’: Dr. habil.) at the University of Leipzig by the last author (NCP); and for the ‘Doctorat en sciences’ (PhD/DSc) degree at the University Paris 5 (René Descartes) and the ‘Doktor der Zahnheilkunde’ (Dr. med. dent.) degree at the University of Leipzig by the first author (PP). References Al-Omari I, Millett DT, Ayoub AF: Methods of assessment of cleft-related facial deformity: a review. Cleft Palate Craniofac J 42: 145e156, 2005 Anderson JR: A reasoned approach to nasal base surgery. Arch Otolaryngol 110: 349e358, 1984 Andretto Amodeo C: The central role of the nose in the face and the psyche: review of the nose and the psyche. Aesthetic Plast Surg 31: 406e410, 2007 Bardach J, Salyer K, Jackson I: Correction of nasal deformity associated with unilateral cleft lip. In: Bardach J, Salyer K (eds)Surgical techniques in cleft lip and palate, vol. 68. 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J Pers Soc Psychol 24: 285e290, 1972 Eliason MJ, Hardin MA, Olin WH: Factors that influence ratings of facial appearance for children with cleft lip and palate. Cleft Palate Craniofac J 28: 190e193, 1991 Galdino GM, Vogel JE, Vander Kolk CA: Standardizing digital photography: it’s not all in the eye of the beholder. Plast Reconstr Surg 108: 1334e1344, 2001 Glass L: The effects of cosmetic appearance and speech on patients with oro-facial anomalies. Minneapolis: University of Minnesota, 1978 [Dissertation] Gunter JP, Rohrich RJ: Lengthening the aesthetically short nose. Plast Reconstr Surg 83: 793e800, 1989 Guyuron B: MOC-PS(SM) CME article: late cleft lip nasal deformity. Plast Reconstr Surg 121(4 Suppl): 1e11, 2008 Ha RY, Byrd HS: Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape. Plast Reconstr Surg 112: 1929e1935, 2003 Hemprich A, Frerich B, Hierl T, Dannhauer KH: The functionally based Leipzig concept for the treatment of patients with cleft lip, alveolus and palate. J Craniomaxillofac Surg 34(Suppl. 2): 22e25, 2006 Huffmann WC, Lierle DM: Studies on the pathologic anatomy of the unilateral hare-lip nose. Plast Reconstr Surg 4: 225e234, 1949 Johnson N, Sandy J: An aesthetic index for evaluation of cleft repair. Eur J Orthod 25: 243e249, 2003 Kane AA, Pilgram TK, Moshiri M, Marsh JL: Long-term outcome of cleft lip nasal reconstruction in childhood. Plast Reconstr Surg 105: 1600e1608, 2000 Kosowski TR, McCarthy C, Reavey PL, Scott AM, Wilkins EG, Cano SJ, Klassen AF, Carr N, Cordeiro PG, Pusic AL: A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg 123: 1819e1827, 2009 Kridel RW, Konior RJ, Shumrick KA, Wright WK: Advances in nasal tip surgery. The lateral crural steal. Arch Otolaryngol Head Neck Surg 115: 1206e1212, 1989 Lam SM, Williams 3rd EF: Anatomic considerations in aesthetic rhinoplasty. Facial Plast Surg 18: 209e214, 2002 Landsberger P, Proff P, Dietze S, Hoffmann A, Kaduk W, Meyer FU, Mack F: Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate. J Craniomaxillofac Surg 34(Suppl. 2): 31e33, 2006 Marcusson A, Paulin G, Östrup L: Facial appearance in adults who had cleft lip and palate treated in childhood. Scand J Plast Reconstr Surg Hand Surg 36: 16e23, 2002 Meyer-Marcotty P, Stellzig-Eisenhauer A: Dentofacial self-perception and social perception of adults with unilateral cleft lip and palate. J Orofac Orthop 70: 224e236, 2009 Millard DR: Bilateral cleft lip and a primary forked flap: a preliminary report. Plast Reconstr Surg 39: 59e65, 1967 Moolenburgh SE, Mureau MA, Hofer SO: Facial attractiveness and abnormality of nasal reconstruction patients and controls assessed by laypersons. J Plast Reconstr Aesthet Surg 61: 676e680, 2008a Moolenburgh SE, Mureau MA, Hofer SO: Aesthetic outcome after nasal reconstruction: patient versus panel perception. J Plast Reconstr Aesthet Surg 61: 1459e1464, 2008b Nolst Trenité GJ: Secondary surgery of the cleft-lip nose. In: Nolst Trenité GJ (ed.), Rhinoplasty. Amsterdam: Kugler Publications, 105e116, 1993 Noor SN, Musa S: Assessment of patients’ level of satisfaction with cleft treatment using the Cleft Evaluation Profile. Cleft Palate Craniofac J 44: 292e303, 2007
P. Pitak-Arnnop et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 319e325 Oosterkamp BCM, Dijkstra PU, Remmelink HJ, van Oort RP, Goorhuis-Brouwer SM, Sandham A, de Bont LGM: Satisfaction with treatment outcome in bilateral cleft lip and palate patients. Int J Oral Maxillofac Surg 36: 890e895, 2007 Pausch NC, Pitak-Arnnop P, Herzberg PY, Dhanuthai K, Hemprich A: Secondary cleft rhinoplasty rejuvenates the nose: a suggestion from a panel survey. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, in press, doi:10.1016/j.tripleo.2010.04.010. Quatela VC, Pearson JM: Management of the aging nose. Facial Plast Surg 25: 215e221, 2009 Rees TD: Rhinoplasty in the older adult. Ann Plast Surg 1: 27e29, 1978 Roberts-Harry D, Stephens CD: Panel perception of facial attractiveness. Br J Orthod 18: 152e153, 1991 Rohrich RJ, Hollier Jr LH, Janis JE, Kim J: Rhinoplasty with advancing age. Plast Reconstr Surg 114: 1936e1944, 2004 Russell KA, Orthod D, Tompson B, Orthod D, Paedo D: Correlation between facial morphology and esthetics in patients with repaired complete unilateral cleft lip and palate. Cleft Palate Craniofac J 46: 319e325, 2009 Sàndor GK, Ylikontiola LP: Patient evaluation of outcomes of external rhinoplasty for unilateral cleft lip and palate. Int J Oral Maxillofac Surg 35: 407e411, 2006 Semb G, Brattström V, Mølsted K, Prahl-Andersen B, Zuurbier P, Rumsey N, Shaw WC: The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 4: relationship among treatment outcome, patient/parent satisfaction, and the burden of care. Cleft Palate Craniofac J 42: 83e92, 2005 Sharp HR, Rowe-Jones JM: Assessing outcome in aesthetic rhinoplasty. Clin Otolaryngol Allied Sci 28: 430e435, 2003
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Shih CW, Sykes JM: Correction of the cleft-lip nasal deformity. Facial Plast Surg 18: 253e262, 2002 Sinko K, Jagsch R, Prechtl V, Watzinger F, Hollmann K, Baumann A: Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients. Cleft Palate Craniofac J 42: 355e361, 2005 Springer IN, Zernial O, Nölke F, Warnke PH, Wiltfang J, Russo PA, Terheyden H, Wolfart S: Gender and nasal shape: measures for rhinoplasty. Plast Reconstr Surg 121: 629e637, 2008 Springer IN, Zernial O, Warnke PH, Wiltfang J, Russo PA, Wolfart S: Nasal shape and gender of the observer: implications for rhinoplasty. J Craniomaxillofac Surg 37: 3e7, 2009 Stal S, Hollier L: Correction of secondary deformities of the cleft lip nose. Plast Reconstr Surg 109: 1386e1392, 2002 Toriumi DM: Caudal septal extension graft for correction of the retracted columella. Operat Tech Otolaryngol Head Neck Surg 6: 311e318, 1995 Toriumi DM: Surgical correction of the aging nose. Facial Plast Surg 12: 205e214, 1996 Tunis SR, Stryer DB, Clancy CM: Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA 290: 1624e1632, 2003 Turner SR, Rumsey N, Sandy JR: Psychological aspects of cleft lip and palate. Eur J Orthod 20: 407e415, 1998 Willams HB: A method of assessing cleft lip repairs: comparison of LeMesurier and Millard techniques. Plast Reconstr Surg 41: 103e107, 1968
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Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar graftingq Poramate Pitak-Arnnop a, b, *, Alexander Hemprich a, Kittipong Dhanuthai a, c, Vedat Yildirim a, Niels Christian Pausch a a
Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, Scientific Unit for Clinical and Psychosocial Research, Evidence-Based Surgery and Ethics in Oral and Maxillofacial Surgery, Faculty of Medicine, University Hospital of Leipzig, Leipzig, Germany Laboratory of Medical Ethics and Legal Medicine, Faculty of Medicine, University Paris 5 (René Descartes), Paris, France c Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 18 December 2009 Accepted 30 July 2010
Background: Cleft-lip nasal deformity alters patient’s self-image, as well as posing unique challenges for the rhinoplastic surgeon. Objectives: The main purpose of this study was to compare the panel perceptions of nasal aesthetics following secondary cleft rhinoplasty with versus without caudal septal extension grafting (columella grafting). We also investigated whether patient’s self-assessment and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) panel perceptions. Methods: Using a cross-sectional study design, we enrolled a sample of adult laypersons and medical experts. The predictor variable was the rhinoplasty techniques (with/without columellar grafting). The outcome variable was the panel rankings of nasal aesthetics based on the photographs of 50 nonsyndromic cleft patients before and after the rhinoplasty. Other variables included the patient’s subjective assessment and satisfaction, demographic and anatomic variables. Appropriate descriptive, uni- and bivariate statistics were calculated. The significance level was set at P 0.05 and <0.05 for single- and two-tailed tests of hypothesis, respectively. Results: The sample consisted of 507 laypersons and 51 professionals who gave comparative ratings (P > 0.05). Columellar grafting was associated with higher rankings of postoperative nasal aesthetics (P ¼ 0.04). Most of the patients (90%) rated positive outcomes. Surgical techniques, patients’ age and gender, and panel perceptions were not individually significantly associated with subjective measures and satisfaction. Conclusions: Our results suggest that caudal septal extension grafting improves the nasal aesthetics of the cleft patients, as judged by the panel. Patient’s self-assessment seems unreliable to be used as an outcome measure. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Aesthetic perception Cleft-lip nasal deformity Columellar grafting Rhinoplasty
1. Introduction ‘Un grand nez ne gâte jamais un beau visage.’ (Literally, a big nose never spoils a pretty face.) French proverb q Presented at the 70th Anniversary Celebration 2010, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand, Aug. 12e14, 2010; and at the 23rd Symposium of the German Interdisciplinary Workshop on Cleft Lip/Palate and Craniofacial Anomalies under the cooperation of the German Associations of Oral and Maxillofacial Surgery, Orthodontics, Speech Therapy, Paediatric Audiology and OtolaryngologyeHead and Neck Surgery, Mainz, Germany, Oct. 1e2, 2010. * Corresponding author. Klinik und Poliklinik für Mund-, Kiefer- und Plastische Gesichtschirurgie, Universitätsklinikum Leipzig AöR, Nürnberger Str. 57, 04103 Leipzig, Germany. Tel.: þ49 341 97 21 100; fax: þ49 341 97 21 109. E-mail address: [email protected] (P. Pitak-Arnnop).
As a central and prominent landmark of the face the nose is the focal point of attention, as well as representing the individual identity. Hence, the nose, despite being a tiny organ, affects the overall facial appearance (Rees, 1978; Sinko et al., 2005; Andretto Amodeo, 2007; Moolenburgh et al., 2008a; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). A good-looking and harmonic nose implies positive personality characteristics in the eye of the public: honest, trustful, successful and loyal (Dion
1010-5182/$ e see front matter Ó 2010 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2010.07.007
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et al., 1972). Any operation changing the shape and size of the nose has an effect on body image and psychological stability until the patient has a new self-sense or self-concept (Andretto Amodeo, 2007). In 1949, Huffmann and Lierle first described cleft-lip nasal deformity (CLND) that consists of 22 typical features occurring independently or in combination. Unlike a ‘big’ nose, CLND is not a variation, but a deformity. It is difficult to camouflage and degrades the overall appearance of the face. Most cleft patients possess a flattened nasal tip, flattened nostrils, and a wide nasal base with a short columella. With visible facial impairment and low self-esteem, cleft patients may develop psychosocial maladjustment, speech difficulties, unrealistic perceptions about facial appearance, and physiognomic rejection (Marcusson et al., 2002; Al-Omari et al., 2005; Andretto Amodeo, 2007; Noor and Musa, 2007; Oosterkamp et al., 2007; Meyer-Marcotty and StellzigEisenhauer, 2009). Table 1 summarises the characteristic features of CLND. Although nasoalveolar moulding and initial lip surgery in early infancy minimise the CLND deformity, many patients require secondary rhinoplasty to correct alar-columellar disproportion in their teenage years once growth is complete (Stal and Hollier, 2002). In definitive cleft rhinoplasty, Guyuron (2008) recommended supporting the nasal tip with an intercrural columellar strut in order to (1) increase tip projection, (2) elongate the columella on the cleft side, (3) augment the deficient subnasale, (4) correct an acute nasolabial angle, and (5) prevent the tip from shifting caudally. With the strut, the columellar show is increased by up to 2 mm (Toriumi, 1995). However, caudal septal extension grafting can be used in cases with severe deficiency in the columellar show and nasal septum. This graft will increase the nasal length and columellar show, lessen the nasal index, and improve the tip support (Toriumi, 1995, 1996; Byrd et al., 1997).
One important goal of cleft care is to eradicate all visible stigmata of the facial deformities (Marcusson et al., 2002; Russell et al., 2009). However, aesthetic outcomes of the nasolabial complex after cleft surgery present a challenge for the rhinoplastic surgeon. Most studies concentrate on the surgical outcomes with regard to different techniques or different centres, but the effect of columellar grafting on nasal aesthetics has received limited attention (Sharp and Rowe-Jones, 2003; Al-Omari et al., 2005). Outcome assessment offers evidence to improve clinical decision making (Moolenburgh et al., 2008b). Standardised, valid and reliable methods for evaluating success in facial cosmetic procedures including rhinoplasty are still lacking (Moolenburgh et al., 2008b; Kosowski et al., 2009). Subjective patient reporting and clinicians’ opinions on treatment outcomes, albeit controversial, seem to be biased (Eliason et al., 1991; Marcusson et al., 2002; Sharp and Rowe-Jones, 2003; Al-Omari et al., 2005; Sàndor and Ylikontiola, 2006; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). The primary purpose of this study was to examine the relationship between secondary cleft rhinoplasty (with versus without a caudal septal extension graft) and panel perceptions of nasal aesthetics in CLND patients. The null hypothesis was that there was no diference in the panel perceptions of nasal aesthetics after secondary cleft rhinoplasty between the 2 groups (with or without columellar grafting). The alternative, 1-tail hypothesis was that panel perceptions of nasal beauty in the columellar grafting group were far superior to those in the non-grafting group. If this null hypothesis was rejected, it would suggest grafting the columella in every nasal cleft revision. The secondary aim was to investigate whether patient’s subjective measures and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) the perceptions of the third-party observers. Technical refinements of our columellar extension grafting are presented, and relevant issues on nasal cleft aesthetics are also reviewed.
Table 1 The specific characteristics of cleft-lip nasal deformity (CLND)a. Locations
Unilateral CLND
Bilateral CLND
Columella
- Shorter on the cleft side (sometimes) - Deviated columellar base towards the noncleft side (secondary to contraction of orbicularis-oris muscle) - Longer lateral crus and shorter medial crus on the cleft side (the same length with the noncleft side, but the position and shape are different) - Caudally displaced lateral crus (frequent) - Introversion (posterior and inferior rotation of the cephalic edge of the lower lateral cartilage on the cleft side), causing thickening of the ala and hooding of the nostril rim - Displaced in both frontal and horizontal planes - Asymmetric - Loss of nasal tip definition - Tendency for bifidity - Flattened, causing in horizontal orientation of the nostril - Laterally and/or posteriorly (and sometimes inferiorly) displaced alar base - Obliquity of the alar facial angle - Asymmetric (horizontally orientation on the cleft side) - Retropositioned because of deficiency in the underlying frame - Deviated, causing nasal obstruction and external nasal deviation - Perpendicular plate deviating towards the cleft side and anterior nasal spine towards the noncleft vestibule - Deviated nasal spine towards the noncleft side
- Relatively short with a wide base - Prolabium attached to the nasal tip (sometimes)
Lower lateral cartilage
Nasal tip
Alae of nose
Nostrils Nasal septum and spine
Skeletal platform
a
- Hypotrophic maxilla on the cleft side - Displaced premaxilla and maxillary segments
After Nolst Trenité (1993), Shih and Sykes (2002), Stal and Hollier (2002), and Guyuron (2008).
-
Severely deformed Short medial crus bilaterally Long lateral crus bilaterally with caudal displacement Downward rotation of the alar cartilage Buckling of the lateral crura
- Flat and board - Asymmetric (if the cleft is incomplete) - Loss of tip projection - Bifidity - Flat and sometimes S-shaped - Laterally and posteriorly (and sometimes inferiorly) displaced alar base on the both sides - Horizontally orientation on the both sides - Asymmetric (usually) - Inferior displacement of caudal cartilaginous septum (relative to the alar base level) - Displaced and short nasal spine - Board nasal septum - Deviated septum and vomer towards the less affected side (if the cleft is incomplete) - Bilateral maxillary hypoplasia - Protuding premaxilla (sometimes), causing distortion of the columella
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2. Materials and methods 2.1. Study design/sample This study was partially based on our previous research design and sample (Pausch et al., in press). To address the research question, we used a cross-sectional study design, approved by the institutional ethics committee (Registration No. 221-2006), with the questionnaire and the CLND patients’ photographs administered in a double-blinded, randomised fashion. The study participants, who were unknown to the data evaluators (PP and KD), did not know the patients or the treatments they had received. A random sample of the general public and medical professionals in Leipzig and Dresden, Germany, was taken; all were German. One of the senior investigators (NCP) screened the subjects for study eligibility and initiated the consent process, including a review of the study rationale and protocol. Informed consent was received from all participants, including the use of the patients’ photographs in the study. The recommendations of the Helsinki declaration were adhered to during this study. To be considered for study inclusion, the subjects whom we interviewed were not involved in the treatments for the patients involved in this study. All non-medical laypersons were unfamiliar with facial plastic surgery, cleft care or any related fields. The healthcare professionals included maxillofacial surgeons, oral surgeons, otolaryngologists, and orthodontists; all confirmed that they regularly had contact with cleft patients. The broad inclusion criteria provided the opportunity to enrol a diverse, heterogeneous study sample with results that may be more generally applicable (Tunis et al., 2003). There was no exclusion criterion for this study.
Fig. 1. Schematic diagrams of the incisions by (a) Bardach et al. (1987) for unilateral clefts; (b) Millard (1967) for bilateral clefts.
2.2. Variables and data collection The same experienced assessment instructor chaired every rating procedure that was not time-limited. All instructions were standardised and read from a paper to ensure the similar information given to the voters. The predictor variable was the rhinoplasty techniques. This was a binary variable: with or without caudal septal extension grafting. We used photographs of 50 consecutive German nonsyndromic cleft patients treated by the last author (NCP) at the Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, University Hospital of Leipzig, for CLND between January 2002 and December 2007. Twenty-four patients (48%) received columellar grafting, but the others did not. As per standard practice, the surgeon performed a secondary cleft rhinoplasty via an open approach as described by Bardach et al. (1987) for unilateral clefts or by Millard (1967) for bilateral clefts (Fig. 1). The external approach allows for complete visualisation of all nasal structures. In the grafted group, the L-shaped cartilage graft harvested from the nasal septum was placed between the medial crura as an extension graft onto the caudal nasal septum, as demonstrated by Toriumi (1995; 1996) and Byrd et al. (1997) (Fig. 2: details are discussed below). All patients received treatment according to our functionally-based strategy for cleft patients (Hemprich et al., 2006). Because no difference exists between judgements on facial appearance made from live subjects (adult cleft patients) and those made from colour photographs (Glass, 1978; Johnson and Sandy, 2003), we decided to use a sample of patients’ photographs. As described by Galdino et al. (2001), 6 preoperative and postoperative standardised photographs of each patient’s whole face were utilised: 2 lateral views, 1 frontal view, 2 oblique views and 1 basal view.
Fig. 2. Schematic diagrams of caudal septal extension grafting: (1) dorsal hump reduction; (2) the septal cartilage is harvested and cut into 2e3 pieces; (3) the upper part serves as dorsal or spreader grafts, the strong lower part is placed at the columella, and the small middle chip is sometimes used for nasal tip augmentation; the columellar graft is placed and secured at the caudal edge of the septum; (4) The lateral crura of the lower lateral cartilages are advanced supero-interiorly before the placement of interdomal and transdomal surtures.
The outcome variable was the panel’s rankings of nasal aesthetics of each patient’s photographs before and after the rhinoplasty. The preoperative photographs were rated on a 3-point ordinal scale: like/dislike/uncertain. We used a rating scale with 5 categories on postoperative results: improved/worsened/different but not improved/unchanged/uncertain. Other study variables were categorised as patient’s selfperceptions and satisfaction, demographic and anatomic variables. Demographic variables were age, gender and career of the participants, and patients’ age (teenage years or older) and gender. The anatomic variable was patients’ cleft defect (unilateral or bilateral). For subjective measures; patients were asked to rank their level of postoperative results as improved, worsened, different but not improved, unchanged, or uncertain. Patient satisfaction was
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assessed using a 4-point semi-quantitative ordinal scale: 1, dissatisfied; 2, moderately satisfied; 3, satisfied; 4, very satisfied. 2.3. Data analysis The results collected were entered into a statistical database (SPSS Version 10.0; SPSS, Inc, Chicago, IL). Descriptive, uni- and bivariate statistics were computed as indicated. Spearman rank correlation tests were performed to determine interobserver reliability. P values 0.05 for single-tailed tests of hypothesis, and <0.05 for 2-tailed analyses (e.g. of age, gender) were considered statistically significant. 3. Results The study sample consisted of 507 non-medical adult laypersons and 51 medical staff with a mean age of 24.8 8.2 years. They were 151 women (27.1%) and 407 men (72.9%) (Table 2). The laypersons were 5 athletes (1.0%), 15 businessmen (3.0%), 9 cooks (1.8%), 18 craftsmen (3.6%), 4 engineers (0.8%), 132 ergonomists (26.0%), 64 hairdressers (12.6%), 31 nurses (6.1%), 5 painters (1.0%), 64 paramedics (12.6%), 44 speech therapists (8.7%), 69 students (13.6%), 7 teachers (1.4%), 10 unemployed (2%), and 30 others (5.9%). The medical professionals included 15 maxillofacial surgeons (29.4%),12 oral surgeons (23.5%), 16 otolaryngologists (31.4%), and 8 orthodontists (15.7%). We used photographs of 50 cleft patients, 24 of whom (48%) were females and 28 cases (56%) had unilateral clefts. Their ages ranged from 15 to 48 years with the mean SD ¼ 19.8 5.3 years. Eighteen patients (36%) were teenagers. Symmetry of nostril, nasal dome projection and the correction rate of buckling deformity of the alar cartilage and flaring deformity of the alar base were corrected in all patients. Forty-five patients (90%) revealed their improved nasal aesthetics postoperatively and expressed satisfaction (scale 3 or 4). Columellar elongation techniques, and patients’ age and gender did not individually affect subjective assessment and satisfaction of the patients to a statistically significant degree. Perceptions of the independent evaluators did not correlate with patient’s self-assessment and satisfaction. Spearman rank correlation analyses indicated a high degree of agreement between the laypersons and the medical experts (P > 0.05). The raters disliked the preoperative noses (r ¼ 0.92, P < 0.0001), and they liked the postoperative noses more than the preoperative noses (r ¼ 0.86, P < 0.0001). Overall, columellar grafting was associated with higher rankings of nasal aesthetics by the panel (P ¼ 0.04). Postoperative nasal appearance was improved in 11 of 24 (or 45.8%) and 18 of 26 (or 69.2%) patients without and with the columellar graft, respectively. Complete data are not shown, but available upon request. 4. Discussion The study’s first aim was to gain insight into the relationship between 2 rhinoplastic techniques (with versus without caudal septal extension grafting) and panel evaluation of nasal aesthetics.
Table 2 The study samples. Study variables
Patients
Laypersons
Medical professionals
P value
Sample size Age (mean SD) Sex: male
50 19.8 5.3 26 (52.0%)
507 23.9 7.6 124 (24.5%)
51 34.9 7.2 27 (52.9%)
Not applicable <0.0001a <0.0001b
a b
ANOVA, analysis of variance. Chi-squared test.
We hypothesised that columellar grafting would increase nasal aesthetics after secondary cleft rhinoplasty, as judged by a panel of independent assessors. The data from this study highlighted that postoperative nasal aesthetics ratings in the grafted group were higher than those in the non-grafted group (P ¼ 0.04). Our secondary purpose was to investigate whether patient’s subjective assessment of aesthetics and satisfaction correlated with 4 variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) panel perceptions. It was statistically determined that surgical techniques, patient’s age and gender, and panel opinions were not associated with patient’s subjective measures and satisfaction. Patient’s self-perceptions and satisfaction after the revision rhinoplasty were relatively high. CLND is three-dimensional because it involves skin envelope, nasal bone and cartilage, nasal vestibular lining and skeletal platform (Table 1). Each of these components requires particular attention during planning the surgery. Secondary cleft rhinoplasty usually attempts to improve the nasal tip, dorsum, alar position, and symmetry of the nostrils (Sàndor and Ylikontiola, 2006). The columella is an important subunit of the face. In the profile view, the columella is generally shown 2e4 mm below the alar rim. The ratio of the columella length (the subnasale to the columella breakpoint) to the infratip lobule’s length (the columella breakpoint to the tip-defining point) should be 2:1. In the basal view, the lobule (the pronasale to the arch or height of the alar rim) is onethird of the nasal triangle, and the collumela occupies the remaining two-thirds. The columella forms a nasolabial angle of 90e95 in males and 95e110 in females with the upper lip (Toriumi, 1995; Sharp and Rowe-Jones, 2003; Bouguila et al., 2008). The nostril-alar relationship combines a hanging or normal or retracted alar rim with a hanging or normal or retracted columella (Gunter and Rohrich, 1989). The CLND nose and the ageing nose are similar. Many cleft patients have a hanging alar rim (or both rims in bilateral cleft cases) with a shortened and retracted columella, a convex nasal profile and deformed nasal frameworks. Our previous study revealed that the CLND nose looked older than the actual age of the patients. Secondary cleft rhinoplasty rejuvenated the nose (Pausch et al., in press). The major support of the nasal tip includes size, strength and shape of lateral and medial crura of the lower lateral cartilages, the attachments between the upper and lower lateral cartilages, the medial crural-septal fibrous union, and the interdomal ligamentous sling. Grafting onto the columella is aimed to strengthen the tip support and correct the buckled and malpositioned alar cartilages. The postero-inferior septal cartilage where the septum joins the maxillary crest is the gold standard grafting material (Toriumi, 1995; Quatela and Pearson, 2009). We cut out the lower part from the remaining segments of the graft into a size that allows it to overlap with the caudal margin of the septum. The upper cartilaginous portion of the graft serves as dorsal or spreader grafts, whilst the small middle chip is used to augment the nasal tip when indicated (Fig. 2). Once in place, the L-shaped caudal septal extension graft becomes a new caudal margin of the septum. The thickness of the overlying skin/soft-tissue envelope and the expected nasal anthropological measurements dictate the distance the graft extends beyond the septum. Excessive projection or rotation of the lower third of the nose may result in overprojection of the infratip lobule, and dehiscence of the transcolumellar incision if used. The graft will increase the columella show, a nasolabial angle, the nasal projection, and the structural integrity of the tip support and nasal base (Toriumi, 1995, 1996; Byrd et al., 1997; Ha and Byrd, 2003).
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We modified the ‘lateral crural steal technique’: the lateral crura are advanced onto the medial crura and the columellar graft (Kridel et al., 1989; Toriumi, 1995, 1996). According to the ‘tripod/pedestal concept’ by Anderson (1984), superior and anterior advancement of the lateral crura shortens the upper tripod limbs, increasing tip rotation and projection (Toriumi, 1995, 1996). Spreader grafts, albeit rarely used in our practice, strengthen and stabilise a weakened or deviated septum (Cochran et al., 2007). The remaining of the harvested cartilage can be milled before being reunited with the aid of fibrin glue and replanted into the donor site. Both nasal tip refinement and preservation of tip rotation are best corrected using interdomal and transdomal surtures (Byrd et al., 1997; Rohrich et al., 2004; Cochran et al., 2007). Transdermal suspension that anchors the alar cartilage to the external skin helps secure the desired position of the lateral crus of the cleft side (or both crura in bilateral clefts) (Stal and Hollier, 2002). Taken together, it may explain in part why caudal nasal extension grafting provides a more favourable cosmetic result than rhinoplasty without a columellar graft (Fig. 3). This technique has now become our method of choice for correcting late CLND. However, its main disadvantage is a rigid or stiff nasal tip without normal tip recoil. This technique is contraindicated in cases with a septal perforation or inadequate septal support, and/or lack of nasal vestibular skin available to allow caudal advancement. The caudal margin of the septum that is severely deviated can be excised and replaced by the graft (Toriumi, 1995, 1996). It should be borne in mind that open rhinoplasty can damage the supporting structures of the nose and the external value competency, as it frees the entire skin/soft-tissue envelope from the underlying nasal frameworks. Meticulous tissue handling is therefore mandatory during rhinoplasty, and radical operations on the nasal infrastructures should be avoided (Lam and Williams, 2002; Cochran et al., 2007). In general, patient’s subjective assessment and satisfaction is essential in determining success in aesthetic surgery (Moolenburgh et al., 2008b; Kosowski et al., 2009). Previous studies indicated that cleft patients were less satisfied with the outcomes, whilst medical professionals usually judged the outcomes more optimistically (Marcusson et al., 2002; Sinko et al., 2005; Oosterkamp et al., 2007; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). Springer et al. (2008) found that the judgement on nasal shape is based on each individual subject’s evaluation of their ‘own’ nose. Nonetheless, our findings suggest that patients’ self-assessment and satisfaction are positive, regardless of the treatments given. This supports the study results by Moolenburgh et al. (2008b). There are conflicting data surrounding gender differences in satisfaction of cleft patients with postoperative facial appearance (Turner et al., 1998; Marcusson et al., 2002; Sinko et al., 2005; Landsberger et al., 2006). In our study, there was no statistical significance in the patient’s subjective ratings of nasal aesthetics between the sexes. Comparison between studies is difficult due to heterogeneity of sampling, panel compositions and measures used. Moreover, it is of concern that postoperative anthropometric changes are not linked to the patient’s subjective assessment (Russell et al., 2009). Clinicians who are familiar with the patients in the study and/or cleft care usually assess the degree of CLND impairment better (Willams, 1968; Eliason et al., 1991). and their judgments are therefore at risk of bias (Marcusson et al., 2002; Al-Omari et al., 2005; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). Public perceptions closely resemble social interactions in daily life (Al-Omari et al., 2005; Moolenburgh et al., 2008b), but laypersons may judge the patients empathetically and thus raise their ratings of patients’ facial appearance (Eliason et al., 1991; Al-Omari et al., 2005; Moolenburgh et al., 2008b). In our study, there was no difference between the familiar and non-familiar ratings, as was also found by
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Fig. 3. Photographs of 2 patients underwent secondary cleft rhinoplasty (a) with, and (b) without a caudal septal extension graft (Left: preoperative; Right: postoperative). Postoperatively, the columella show and tip projection differ greatly between the 2 patients.
other authors (Coghlan et al., 1987; Roberts-Harry and Stephens, 1991; Cussons et al., 1993; Kane et al., 2000). This agreement between the laypersons and experts is helpful in deciding the type of surgical intervention needed for the treatment of the CLND. Noor and Musa (2007) showed that cleft patients and their family considered teeth and the nose as the most important organs. MeyerMarcotty and Stellzig-Eisenhauer (2009) found, however, that nasolabial morphology and aesthetics was critical to the patients whereas correction of malocclusion came later. Marcusson et al. (2002) reported that over half of the cleft patients (38 out of 68; or 59%) still needed further surgical correction, including a rhinoplasty. The findings on cleft patient’s dissatisfaction with their nasal appearance concurs with other studies (Semb et al., 2005; Sinko et al., 2005; Noor and Musa, 2007; Oosterkamp et al., 2007; Meyer-Marcotty and Stellzig-Eisenhauer, 2009). A recent survey of laypersons pointed out that a nasal defect alone deteriorated facial attractiveness (Moolenburgh et al., 2008a). Nevertheless, little is known about the influence of nasal aesthetics on the overall quality of life of this patient population, requiring additional investigations. The present study suffers from many limitations. Firstly, the statistically significant differences in the sample characteristics
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(age and sex) may skew our results, reflecting only a catchment area of subjects. There are different judgements on nasal aesthetics between the sexes and between different sexual orientations (Springer et al., 2009). It is also difficult to compare the current panel outcomes with previously published data because of different panel compositions and methods used (Moolenburgh et al., 2008b). However, a large number of samples seem to have increased external validity of this study. Secondly, multiple factors affect nasal aesthetic perceptions. This study was not designed to identify whether and how columellar grafting plays a critical role over the corrections of other components of the CLND. Thirdly, the ordinal data scales in our assessment are difficult to handle and analyse, compared with a visual analogue scale (Al-Omari et al., 2005). Fourthly, we used a 2-dimensional static imaging technique because it is simple, cheap, valid, reproducible and non-invasive. Although we routinely use this technique to record 3-dimensional anatomy of the craniofacial region, the major drawback is the distortion error in translation from a 3- to a 2-dimensional object. The surrounding facial features, lighting, head orientation and subject-camera distance also affect the measurements (Al-Omari et al., 2005). To cope with these known shortcomings, we used standardised fullface photographs as described by Galdino et al. (2001). The wholeface assessment simulates social interaction in daily life (Al-Omari et al., 2005; Russell et al., 2009). It is unknown if any factors (e.g. culture, socially desirable response) constitute positive selfperceptions of our patients. Retrospective studies asking for opinions on past treatments may be subject to recall and memory bias. The interviewer’s experience and enthusiasm also affect the responses (Turner et al., 1998). Finally, the responses to interview questions preclude any test-retest analysis as they were only asked once (Marcusson et al., 2002). 5. Conclusion Our findings show a statistically significant association between panel perceptions of nasal aesthetics, and columellar lengthening with anterior nasal septum grafting. Laypersons and medical experts share similar overall judgements. No statistically significant association exists between subjective assessment, and panel perceptions or patients’ gender or age or rhinoplasty techniques. Given the results of this study, our advice is that in secondary cleft rhinoplasty, the columella be augmented with a caudal nasal extension graft. Patient’s self-perception is relatively high so that it seems unreliable to be used as an outcome measure. Because this study was cross-sectional, longitudinal studies would be needed to investigate whether intra-individual self-perception changes with age. Investigative links between the anthropometric changes after secondary cleft rhinoplasty and perceptions of the panel and patients should also be addressed. Disclosure of potential conflicts of interest The authors indicate full freedom of investigation and no potential conflicts of interest. Financial disclosure There was no grant support for this study. Acknowledgement We thank Ms. Evelyn Kuhnt, Coordination Centre for Clinical Trials, Faculty of Medicine, University Hospital of Leipzig, for her help with statistic analyses.
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