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Seven Fundamental Procedures for Definitive Correction of Unilateral Secondary Cleft Lip Nasal Deformity in Soft Tissue Aspects
J Oral Maxillofac Surg 69:e420-e430, 2011
Seven Fundamental Procedures for Definitive Correction of Unilateral Secondary Cleft Lip Nasal Deformity in Soft Tissue Aspects Dong Won Lee, MD,* Bong-Kyoon Choi, MD,† and Be-Young Yun Park, MD, PhD‡ Purpose: It is accepted that patients who undergo appropriate primary repair for cleft lip will have
secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category. Patients and Methods: Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients. Results: Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes. Conclusions: These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes. © 2011 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:e420-e430, 2011 Secondary cleft lip nasal deformity (CLND) is not as much an unsatisfactory result of primary surgery, as an unavoidable fate. For the correction of secondary CLND, various procedures have been developed and successful treatment outcomes have been reported.1-31 However, the continuous development
of new procedures represents a lack of standardization among the methods used to correct complex deformities. It is not easy to accurately describe the anatomic pathology of secondary CLND. Small defects that are left after the primary repair are amplified with the growth process and affect adjacent structures. These eventually cause complex and diverse patterns of secondary deformity, such as nasal asymmetry and muscular discontinuity. To make an accurate diagnosis, therefore, a 3-dimensional understanding of the skin, soft tissue, cartilage, vestibular lining, and underlying bony structure is needed. Simple categorization of these complex deformities would contribute to the elucidation of an anatomic pathology and allow surgeons to perform the most effective correction procedures. The purpose of the present study was to clarify the cardinal deformities in the context of unilateral secondary CLND. Based on the authors’ experience with intensive correction of these deformities, this report proposes guidelines that can be commonly applied to various types of unilateral secondary CLND.
*Clinical Research Assistant Professor, Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Republic of Korea. †Director of Maxillofacial Center, Jeong Won Aesthetic Clinic, Seoul, Republic of Korea. ‡Professor, Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Republic of Korea. Address correspondence and reprint requests to Dr Park: Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, 134 Shinchon-dong, Seodaemun-gu, 120-752 Seoul, Republic of Korea; e-mail: [email protected] © 2011 Published by Elsevier Inc on behalf of the American Association of
Oral and Maxillofacial Surgeons 0278-2391/11/6911-0043$36.00/0 doi:10.1016/j.joms.2011.04.022
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ally acknowledged.1,33,34 The cleft-side medial crus is set to be lower than the noncleft side, which results in a lower position of the alar dome and short columella on the cleft side. Even if nasal correction is performed during a primary repair, the medial crus frequently returns to a low setting in cases of incomplete correction. Tethering Deformity of Lateral Crus The cleft-side lateral crus is attached to the piriform aperture in a lower position, and the alar cartilage is lateralized and flattened.2 In addition to a low setting of the medial crus, tethering deformity of the lateral crus plays a role in lowering the alar dome. Moreover, because there is a lack of nasal vestibule along the lower border of the lateral crus, the plica vestibularis is markedly deformed. This may have a tethering effect, leading to lateralization of the alar cartilage.3 SECONDARY CLEFT LIP FIGURE 1. Seven cardinal deformities: A, caudal deflection of the nasal septum to the noncleft side; B, deviation of the nasal dorsum; C, low setting of the medical crus; D, tethering deformity of the lateral crus; E, discontinuity of the orbicularis oris muscle; F, long or short lip deformity; and G, absence of a philtral column. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
Anatomic Defects Secondary deformities of the corrected unilateral cleft lip are classified as secondary nasal deformity or secondary cleft lip, excluding those involving the maxilla, alveolus, and dentition. These deformities can be subclassified into several types of cardinal deformities. Although there is a difference in the severity of secondary CLND, most patients have the following 7 features (Fig 1). SECONDARY NASAL DEFORMITY
Caudal Deflection of Nasal Septum to Noncleft Side The caudal edge of the septum is deviated from the anterior nasal spine and vomerine groove and flexed to the noncleft side.1,32 Septal deviation plays a role in twisting the nasal tip, thus greatly affecting the impairment of nasal symmetry. This deformity is always observed, even in the microform cleft lip. Deviation of Nasal Dorsum The cartilaginous dorsal septum is deviated to the noncleft side and pathologically fused with the upper lateral cartilage.1,32 This contributes to bending of the nasal tip and nasal dorsum to the noncleft side. Low Setting of Medial Crus Whether or not the cleft side alar cartilage is hypoplastic, malpositioning of the alar cartilage is gener-
Discontinuity of Orbicularis Oris Muscle Before the primary repair, the orbicularis oris muscle (OOM) runs parallel to the cleft margin and is inserted into the nasal base and piriform aperture. During muscular contraction, a typical pattern denoted as orbicularis bulge is observed on the cleft side.35 Although the discontinuity of the OOM is definitively corrected during the primary lip repair, a relapse commonly occurs. Therefore, an assessment of muscle continuity in patients with secondary cleft lip should not be overlooked.36 Such relapse occurs because lip elevators, such as the levator labii superioris, transversalis nasalis, and levator labii superioris alaeque nasi muscles on the cleft side, forcefully advance into the OOM more medially than on the noncleft side, unless they have been detached during primary surgery. Repeated action of the lip elevators could aggravate separation of the OOM. Long or Short Lip Deformity When a preoperative design is inappropriate in primary lip repair, the cleft-side philtral length will be too long or too short.37 In wide cleft lip, it is difficult to design the cleft-side philtral length identical to the noncleft-side length, which easily induces a short lip. In mild cleft lip, inexperienced surgeons tend to design a long lip. Furthermore, inappropriate correction of the OOM can affect the vertical length of the lip. Absence of Philtral Column The OOM plays a pivotal role in the formation of the philtral column. The short fiber of the superficial portion of the OOM extends to the ipsilateral column, and the long fiber to the contralateral column. The short fiber is interdigitated with the long fiber and eventually forms the philtrum.38,39 In general, a more natural-looking philtral column can be achieved dur-
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ing secondary lip repair than during primary correction.
Patients and Methods In total, 1,170 patients with unilateral secondary CLND underwent surgical correction from January 1992 through August 2009. The patient population consisted of 714 male and 456 female patients. There were 583 preschool patients (1 year to 6 years old), 223 prepubertal patients (6 to 10 years old), 247 pubertal patients (10 to 18 years old), and 117 adult patients (⬎18 years old). To correct the cardinal defects in patients with unilateral secondary CLND, the following 7 fundamental procedures were performed. The institutional review board waived informed consent and approved the design of this retrospective study. TRANSPOSITION OF CAUDAL SEPTUM
The caudal margin of the septum can be accessed through a midcolumella splitting incision. The septum, caudally dislocated to the noncleft side, was isolated from the anterior nasal spine and displaced to the cleft side with a scoring incision on the noncleft-side septum. The displaced caudal septum was fixed to the periosteum of the anterior nasal spine on the cleft side by a nonabsorbable suture (Fig 2). When relapse is a concern because of a short caudal septum or an underdeveloped nasal spine, cartilage should be inserted between the anterior nasal spine and the transposed septum. If the septal correction is effectively achieved, nasal obstruction of the cleft side is relieved and functional improvement can be expected. RELEASE OF SEPTAL-CARTILAGINOUS JUNCTION
For complete correction of septal deflection, the pathologically attached dorsal septum should be separated from the medial aspect of the upper lateral cartilage on the noncleft side and directed to the cleft side, as performed for deflection of the caudal septum. An incision was performed with a scalpel on the noncleft-side junction between the septum and upper lateral cartilage to free the dorsal septum (Fig 2). Insertion of the adjacent superficial fascia, which came from the superficial musculoaponeurotic system, into the separated septal-cartilaginous junction would prevent a relapse because of fusion of the separated junction. MEDIAL CRUS ELEVATION
Medial crus elevation plays an essential role in the correction of the deformed alar cartilage. The midcolumella splitting incision was extended horizontally to the cleft-side membranous septum, 2 mm superior from the nasolabial angle, until reaching the upper lip incision. A crescent excision was performed from the
FIGURE 2. Transposition of the caudal septum and release of the septal-cartilaginous junction. In a patient with left-side secondary cleft lip nasal deformity, the caudally dislocated septum is isolated from the anterior nasal spine and displaced to the cleft side using a nonabsorbable suture. To correct the dorsal septum, an incision is performed on the noncleft-side junction between the septum and the upper lateral cartilage together with a scoring incision on the noncleft-side septum to free the cartilaginous dorsal septum. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
webbing tissues over the nostril on the cleft side to allow the apex of the nostril to be drawn up level with the noncleft side. The depressor septi nasi was isolated from the footplate of the low-set medical crus, and the interdomal suture was symmetrically performed (Fig 3). The medial crus elevation was completed using several pillow sutures. However, tissue defects usually occur at the base of an effectively elevated hemicolumella. The defects were covered with a rotated cicatricle flap, which was developed during scar revision of the upper lip or with a composite graft of the crescent-shaped excised tissue placed over the nostril. LATERAL CRUS ELEVATION
Although the nasal tip projection is greatly improved with medial crus elevation, release of the tethered lateral crus is essential to render a more natural look to the alar dome and nasal groove. A longitudinal incision was performed on the plica vestibularis. The lateral crus was dissected free from the skin and piriform aperture, and the caudally displaced lateral crus was moved to the correct position using pillow sutures. One large Zplasty was performed on the lower end of the plica
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ANCHORING THE OOM TO THE ANTERIOR NASAL SPINE
Another way to minimize a relapse of OOM discontinuity is to suspend the muscle to a fixed structure, namely the anterior nasal spine. The tip of the deep half of the dissected cleft-side muscle was medially advanced to reach the noncleft-side philtrum and fixed to the periosteum of the anterior nasal spine using a nonabsorbable suture, and the tip of the superficial half was fixed to the contralateral muscles at the base of the noncleft-side philtral column. The vertical length of the upper lip was adjusted depending on the suture site of the OOM. Thus, a long or short lip deformity can be rectified. PHILTRAL COLUMN FORMATION
FIGURE 3. Medial crus elevation and lateral crus elevation. A, Preoperative view. The cleft-side alar cartilage is positioned inferiorly and laterally. For medial crus elevation, a midcolumella splitting incision with horizontal extension on the cleft-side membranous septum and a crescent excision from the nostril apex are performed. The lateral crus elevation is approached through a large Z-plasty on the plica vestibularis. B, Postoperative view. The crescent excision allows medial crus elevation, and the interdomal suture is performed for alar symmetry. The lateral crus is dissected free from the piriform aperture, and Z-plasty is performed for vertical lengthening of the plica vestibularis. By controlling the length of the lower triangular flap (asterisk) in the Z-plasty, the height of a drooping alar base can be corrected.
Most methods designed for philtral formation have imitated the physiologic anatomy of OOM insertion into the dermis.4-8 The full layer of the noncleft-side OOM and the deep two-thirds of the cleft-side OOM were sutured together, and the superficial one-third of the cleft-side OOM was fixed to the dermis of the philtral dimple, creating a more natural-looking philtral column (Fig 4). PATIENT SATISFACTION SURVEY
Since 2001, the level of patient satisfaction with overall outcomes for these procedures has been assessed by the senior author in the outpatient
Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
vestibularis for vertical lengthening. By controlling the length of a lower triangular flap in the Z-plasty, the height of a drooping alar base can be easily corrected (Fig 3). RELEASE OF OOM FROM LIP ELEVATORS
Despite successful primary surgery, most patients with secondary CLND display OOM discontinuity. Through the previous lip scar, the OOM was sufficiently dissected from the external subcutaneous tissue and internal oral mucosa and the anterior wall of the maxilla and piriform aperture. The noncleft-side muscle was sufficiently released from the anterior nasal spine and the base of the contralateral philtral column to rotate downward and the cleft-side muscle to advance medially. Importantly, it is necessary to release the OOM from the cleft-side lip elevators, which could cause a relapse of OOM discontinuity and worsen distortion of the lateral lip.
FIGURE 4. Philtral column formation. A, Preoperative view. The full layer of the noncleft-side muscle (NC) is sutured to the deep part of cleft-side muscle (CD), and the remaining superficial part of the cleft-side muscle (CS) is sutured to the dermis of the philtral dimple. B, Postoperative view. The philtral dimple and column are formed by traction of these sutures. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
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FIGURE 5. Anthropometric analysis by digital photographs. A, Septal deviation. B, Difference in nostril angle. C, Difference in philtral length. D, Difference in alar width. Anthropometric measurements are defined in Table 1. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
clinic using the visual analog scale,40 with a range from 0 to 10, where 0 denotes “unsatisfied” and 10 denotes “most satisfied.” Although the visual analog scale was generally applied to all patients, when the patient was of preschool age or a patient’s decision making was ambiguous, the written agreement of the closest guardian of the patient was included in the present data. The satisfaction scores were separately obtained for the nose and upper lip during the preoperative period, short-term postoperative period, and long-term postoperative period. Shortterm postoperative scoring was performed 6 months after the surgery, and long-term scoring was performed on the last day that the patient visited the outpatient clinic. Visual analog scale results were compared using the linear mixed model of SPSS 15.0 (SPSS, Inc, Chicago, IL). ANTHROPOMETRIC ANALYSIS
Anthropometric analysis was performed using preoperative and postoperative digital photographs from worm’s-eye and frontal views. The anthropometric analysis was evaluated in 4 aspects to objectively reflect the outcome of fundamental procedures. In
the worm’s-eye view, septal deviation and difference of nostril angles were evaluated; in the frontal view, differences in philtral length and alar width were measured on digital photographs (Fig 5). The anthropometric measurements are defined in Table 1. Preoperative and postoperative measurements for each analysis were compared using paired Student t tests (SPSS 15.0).
Results PATIENT SATISFACTION SURVEY
Of the 1,170 patients who underwent these 7 fundamental procedures, patient satisfaction scores were obtained from 171 patients. The patient population included 108 male and 63 female patients consisting of 57 preschool patients (1 year to 6 years old), 39 prepubertal patients (6 to 10 years old), 37 pubertal patients (10 to 18 years old), and 38 adult patients (⬎18 years old). The mean postoperative long-term follow-up of 171 patients was 60 months (range, 20 to 115 months). The satisfaction scores (mean ⫾ standard deviation) for the nose were 3.3 ⫾ 1.6 during the
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Table 1. ANTHROPOMETRIC MEASUREMENTS
Measurements Septal deviation (a) Line SD Line H Difference in nostril angle (b) Nostril angle (b1 or b2) Line NA Line H Difference in philtral length (c) Philtral length (P1 or P2) Difference in alar width (d) Alar width (W1 or W2)
Definition Angle between line SD and line H Line between midpoint of most medial points of bilateral nostrils and midpoint of Most inferior points of bilateral nostrils Horizontal reference line drawn between bilateral medial canthal points Difference of bilateral nostril angle Angle between line NA and line H Line between nostril apex and midpoint of alar base Horizontal reference line between bilateral medial canthal points Ratio of difference of philtral length to noncleft-side philtral length Length between columella base and ipsilateral peak of Cupid’s bow Ratio of difference of alar width to noncleft-side alar width Length between midpoint of columella base and midpoint of alar base
NOTE. Anthropometric measurements are depicted in Figure 5. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
preoperative period, 7.2 ⫾ 1.3 during the short-term postoperative period, and 7.0 ⫾ 1.4 during the longterm postoperative period. The preoperative score was significantly different from the short-term (P ⬍ .05) and long-term (P ⬍ .05) postoperative scores, but there was no significant difference between the shortand long-term postoperative scores. The satisfaction scores for the upper lip were 3.3 ⫾ 1.7 during the preoperative period, 7.5 ⫾ 1.4 during the short-term postoperative period, and 7.2 ⫾ 1.4 during the longterm postoperative period. As observed with cases involving the nose, the preoperative score was significantly different from the short-term (P ⬍ .05) and
long-term (P ⬍ .05) postoperative scores, but there was no significant difference between the short- and long-term postoperative scores (Fig 6). In addition, age at the time of operation did not correlate with the satisfaction score. ANTHROPOMETRIC ANALYSIS
Anthropometric analysis was performed in 38 patients (18 male and 20 female) with unilateral secondary CLND. Patients’ ages ranged from 4 to 38 years (mean age, 20.6 years). The follow-up period ranged from 12 to 144 months (mean, 40 months). The preoperative and postoperative values for septal deviation, difference in nostril angle, difference in philtral length, and difference of alar width are presented in Table 2. All preoperative values were significantly different from postoperative values (P ⬍ .05). The final results are shown in Figures 7 through 9.
Discussion There has been controversy as to whether concomitant correction of the nasal deformity in pri-
Table 2. RESULTS OF ANTHROPOMETRIC ANALYSIS
Preoperative Value Septal deviation (°) Difference in nostril angle (°) Difference in philtral length (%) Difference in alar width (%)
Postoperative P Value Value
12.0 ⫾ 7.9 18.1 ⫾ 9.6
3.9 ⫾ 4.7 5.1 ⫾ 4.0
⬍.05 ⬍.05
12.2 ⫾ 7.3
2.3 ⫾ 2.2
⬍.05
26.1 ⫾ 19.6
8.2 ⫾ 6.2
⬍.05
FIGURE 6. Patient satisfaction for nose and upper lip. The difference between the preoperative score and the short- and long-term postoperative scores was statistically significant (*P ⬍ .05), but there was no difference between the short- and long-term postoperative scores.
NOTE. Values are presented as mean ⫾ standard deviation.
Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
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FIGURE 7. A 12-year-old girl with right secondary cleft lip nasal deformity: A, preoperative and C, 1-year postoperative frontal views; B, preoperative and D, 1-year postoperative worm’s-eye views. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
mary cleft lip surgery has an effect on long-term outcomes. Despite concerns that early correction of a nasal deformity might have a detrimental effect on facial growth, many plastic surgeons have concluded that it produces satisfactory outcomes.9-11 However, it is not easy to definitively correct CLND through primary correction alone. Moreover, the expectation of patients and their parents is increasing. Therefore, the correction of secondary CLND is becoming more important.
NASAL REPAIR
Through trial and error, the senior author (B.Y.P.) obtained better outcomes for secondary nasal correction. In 1977, Tajima and Maruyama12 introduced an operation in which the deformed alar cartilage was fixed to the upper lateral cartilage through a reverse-U incision, and the insufficient area within the nostril was filled with the overhanging alar web tissues. Until recently, this method has been popular for the correction of asymmetric nostrils.13-15 The senior author
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FIGURE 8. A 27-year-old man with left secondary cleft lip nasal deformity: A, preoperative and C, 6-year postoperative frontal views; B, preoperative and D, 6-year postoperative worm’s-eye views. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
modified the method of Tajima and Maruyama to a 3-layer (skin, cartilage, and mucosa) correction technique through the use of reverse-W incision.16 Using this modified method, secondary correction was performed in 213 patients from 1981 through 1993. Nevertheless, the shape of the nostril was still not natural enough and the nasal projection was insufficient. Thus, the necessity for radical transpositioning of the alar cartilage to correct secondary nasal deformities has been recognized. In 1925, Blair17 first attempted to reposition the medial crus. He split the columella in the midline
and rotated the cleft-side nostril from the horizontal direction to the vertical direction. Joseph18 performed an elliptical excision of tissues over the cleft-side alar dome to allow for easy elevation of the alar cartilage. Thereafter, Gillies and Kilner19 and Wilkie20 developed an operation that allowed alar cartilage repositioning through a vertical split of the columella. However, this technique has not been extensively used because it leaves an ugly scar on the nasal tip. In 1982, Dibbell21 performed a crescent excision right above the nostril to conceal the operative scar.
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FIGURE 9. A 33-year-old man with right secondary cleft lip nasal deformity: A, preoperative and C, 12-year postoperative frontal views; B, preoperative and D, 12-year postoperative worm’s-eye views. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
Potter22 and Rees et al23 reported repositioning of the lateral crus. They advanced the lateral crus as a chondromucosal flap into the anatomic position. The method of Tajima and Maruyama12 focused on the lateral crus rather than the medial crus; the dissection consisted primarily of the lateral component of the alar cartilage. Uchida3 introduced a surgical technique that isolated the lateral crus from the upper lateral cartilage and the piriform aperture and released the plica vestibularis. Nakajima et al24 combined the methods of Tajima and Maruyama and of Uchida, a combination that effectively corrected the deformed lateral crus.
The authors insist that, for the correction of an abnormally shaped nostril and an underprojected nasal tip, the medial and lateral crura of the alar cartilage should be repositioned. Although many surgeons tend to consider repositioning the lateral crus to correct secondary nasal deformities, a concomitant correction of the medial and lateral crura is essential to obtain satisfactory long-term outcomes. According to the theory that the cartilaginous framework of the nasal tip can be considered a tripod, proposed by Anderson,41 lateral crus elevation leads to downward displacement of the nasal tip and its forward projection, but vector medial crus elevation achieves mainly
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tip projection. That is, from the viewpoint of nasal tip projection, medial crus elevation is more effective than lateral crus elevation. Lateral crus elevation plays a more essential role in the correction of alar flaring and alar base drooping. The fact that the cleft-side alar cartilage is not more hypoplastic than the noncleftside alar cartilage could be a theoretical basis for the sufficiency of secondary nasal correction by cartilage repositioning alone, ie, without an additional cartilage graft.33,34 Another important factor for secondary nasal correction is the deformation of septal cartilage. Deviation of the nasal tip to the noncleft side is affected by the deformed septum rather than the alar cartilage. In previous experiences, the authors found that a surgical procedure dealing only with the caudal portion of the septum could cause a relapse. The reason was that the upper lateral cartilage on the noncleft side pathologically grasped the dorsal portion of the septum and impeded septal repositioning. Therefore, synchronous manipulation of the caudal and dorsal portions of the septum is necessary for effective correction. Surgeons should be concerned that partial obstruction of the airway within the nasal cavity could develop after nasal correction, because the airway has been compensated for long periods. LIP REPAIR
The OOM is most important in the correction of secondary cleft lip. Although attention has been previously focused on the design of the skin incision, the rearrangement of the OOM has recently been emphasized.25-28,42 By Delaire’s theory, the anterior face is arranged in 3 circles—the superior rings, such as lip elevators; the middle rings, such as the OOM; and the inferior rings—and that all 3 circles of the cleft side are inferiorly displaced compared with the noncleft side.43,44 Malpositioning of the cleft-side muscles is responsible for septal deviation and premaxillary maldevelopment and influences normal facial growth.45 Functional cheiloplasty has been suggested to restore the malpositioned periosteal musculoaponeurotic system, and it has been completed successfully by several cleft surgeons.46-48 The authors basically agree with the concept that correction of an oronasal muscle malposition is essential and that, especially in this study, inappropriate positioning between the superior rings and middle rings should be cause for concern. Because abnormal insertion to the OOM of lip elevators can cause separation of the OOM, it is necessary to relocate the relation between these 2 muscle groups. After a wide dissection of the OOM from the surrounding tissues, the advancing deep layer of cleftside muscles should be sutured to the periosteum of the anterior nasal spine. There are 3 important con-
siderations. First, the site of the OOM suture determines the height of the upper lip and the width of the alar base. Second, depression of the nostril floor is prevented even in patients who did not undergo alveolar bone grafting because the advancing OOM crosses over the alveolar gap. Third, a relapse can be prevented by securely suspending the OOM to a fixed structure. In addition, to produce a more natural look for the upper lip, tension in the soft tissues of the upper lip should be considered. Even if the muscles are ideally rearranged, insufficient soft tissues can distort the upper lip. In conclusion, a myriad of methods for secondary CLND has been introduced over recent decades, but these methods lack standardization. Therefore, 7 fundamental procedures are proposed as guidelines for the correction of secondary CLND: transposition of the caudal septum, release of the septal-cartilaginous junction, medial crus elevation, lateral crus elevation, release of the OOM from lip elevators, anchoring of the OOM to the anterior nasal spine, and philtral column formation. These methods can be applied as standard surgical techniques for various types of secondary CLND to achieve ideal treatment outcomes. Acknowledgments The authors are grateful to Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the figures.
References 1. Byrd HS, El-Musa KA, Yazdani A: Definitive repair of the unilateral cleft lip nasal deformity. Plast Reconstr Surg 120:1348, 2007 2. Stenstrom SJ, Oberg TR: The nasal deformity in unilateral cleft lip. Some notes on its anatomic bases and secondary operative treatment. Plast Reconstr Surg Transplant Bull 28:295, 1961 3. Uchida JI: A new approach to the correction of cleft lip nasal deformities. Plast Reconstr Surg 47:454, 1971 4. Nicolau PJ: The orbicularis oris muscle: A functional approach to its repair in the cleft lip. Br J Plast Surg 36:141, 1983 5. Furlow LT Jr: Flaps for cleft lip and palate surgery. Clin Plast Surg 17:633, 1990 6. Cho BC, Baik BS: Formation of philtral column using vertical interdigitation of orbicularis oris muscle flaps in secondary cleft lip. Plast Reconstr Surg 106:980, 2000 7. Kim SW, Oh M, Park JL, et al: Functional reconstruction of the philtral ridge and dimple in the repaired cleft lip. J Craniofac Surg 18:1343, 2007 8. Cakir B, Gideroglu K, Akan M, et al: Jack-like eversion by splitting the orbicularis oris muscle for reconstruction of the philtral column in secondary cleft lip. Scand J Plast Reconstr Surg Hand Surg 43:8, 2009 9. McComb H: Primary correction of unilateral cleft lip nasal deformity: A 10-year review. Plast Reconstr Surg 75:791, 1985 10. Salyer KE: Primary correction of the unilateral cleft lip nose: A 15-year experience. Plast Reconstr Surg 77:558, 1986 11. Byrd HS, Salomon J: Primary correction of the unilateral cleft nasal deformity. Plast Reconstr Surg 106:1276, 2000 12. Tajima S, Maruyama M: Reverse-U incision for secondary repair of cleft lip nose. Plast Reconstr Surg 60:256, 1977 13. Harashina T: Open reverse-U incision technique for secondary correction of unilateral cleft lip nose deformity. Br J Plast Surg 43:557, 1990
e430 14. Nakajima T, Yoshimura Y: Secondary repair of unilateral cleft lip nose deformity with bilateral reverse-U access incision. Br J Plast Surg 51:176, 1998 15. 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 119:267, 2007 16. Park BY, Chung S, Lee YH: Three-layer corrections of secondary cleft-lip/nasal deformities. Cleft Palate Craniofac J 33:169, 1996 17. Blair VP: Nasal deformities associated with congenital cleft of lip. JAMA 84:185, 1925 18. Joseph J: Nasenplastik und Sonstige Gesichts Plastik. Leipzig, Curt Kabitzsch, 1931, p 114 19. Gillies HD, Kilner TP: Hare-lip: Operations for the correction of secondary deformities. Lancet 2:1369, 1932 20. Wilkie TF. The “alar shift” revisited. Br J Plast Surg 22:70, 1969 21. Dibbell DG: Cleft lip nasal reconstruction: Correcting the classic unilateral defect. Plast Reconstr Surg 69:264, 1982 22. Potter J: Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg 13:358, 1954 23. Rees TD, Guy CL, Converse JM: Repair of the cleft lip-nose: Addendum to the synchronous technique with full-thickness skin grafting of the nasal vestibule. Plast Reconstr Surg 37:47, 1966 24. Nakajima T, Yoshimura Y, Kami T: Refinement of the “reverse-U” incision for the repair of cleft lip nose deformity. Br J Plast Surg 39:345, 1986 25. Randall P, Whitaker LA, LaRossa D: The importance of muscle reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg 54:316, 1974 26. Kernahan DA, Bauer BS: Functional cleft lip repair: A sequential, layered closure with orbicularis muscle realignment. Plast Reconstr Surg 72:459, 1983 27. Park CG, Ha B: The importance of accurate repair of the orbicularis oris muscle in the correction of unilateral cleft lip. Plast Reconstr Surg 96:780, 1995 28. Seagle MB, Furlow LT Jr: Muscle reconstruction in cleft lip repair. Plast Reconstr Surg 113:1537, 2004 29. Onizuka T, Akagawa T, Tokunaga S: A new method to create a philtrum in secondary cleft lip repairs. Plast Reconstr Surg 62:842, 1978 30. Müller W: Differentiated reconstruction of the orbicularis oris muscle in unilateral labioplasty. J Craniomaxillofac Surg 17(suppl 1):11, 1989 31. Wijayaweera CJ, Amaratunga NA, Angunawela P: Arrangement of the orbicularis oris muscle in different types of cleft lips. J Craniofac Surg 11:232, 2000
SECONDARY CLEFT LIP NASAL DEFORMITY 32. Cutting CB: Secondary cleft lip nasal reconstruction: State of the art. Cleft Palate Craniofac J 37:538, 2000 33. Park BY, Lew DH, Lee YH: A comparative study of the lateral crus of alar cartilages in unilateral cleft lip nasal deformity. Plast Reconstr Surg 101:915, 1998 34. Kim YS, Cho HW, Park BY, et al: A comparative study of the medial crura of alar cartilages in unilateral secondary cleft nasal deformity: The validity of medial crus elevation. Ann Plast Surg 61:404, 2008 35. Fára M: Anatomy and arteriography of cleft lips in stillborn children. Plast Reconstr Surg 42:29, 1968 36. Climo MS: Diastasis of the orbicularis oris muscle in repaired unilateral clefts of the lip. Cleft Palate J 6:316, 1969 37. Stal S, Hollier L: Correction of secondary cleft lip deformities. Plast Reconstr Surg 15:1672, 2002 38. Latham RA, Deaton TG: The structural basis of the philtrum and the contour of the vermilion border: A study of the musculature of the upper lip. J Anat 121:151, 1976 39. Briedis J, Jackson IT: The anatomy of the philtrum: Observations made on dissections in the normal lip. Br J Plast Surg 34:128, 1981 40. Takemura Y, Liu J, Atsumi R, et al: Development of a questionnaire to evaluate patient satisfaction with medical encounters. Tohoku J Exp Med 210:373, 2006 41. Anderson JR: A personal technique of rhinoplasty. Otolaryngol Clin North Am 8:559, 1975 42. Kim SW, Jeong YW, Cheon JE, et al: Orbicularis oris muscle defects in philtral deformities in the repaired cleft lip. J Korean Soc Plast Reconstr Surg 37:427, 2010 43. Delaire J: Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg 6:109, 1978 44. Schendel SA, Delaire J: Functional musculoskeletal correction of secondary unilateral cleft lip deformities: Combined lip-nose correction and Le Fort I osteotomy. J Maxillofac Surg 9:108, 1981 45. Markus AF, Delaire J: Functional primary closure of cleft lip. Br J Oral Maxillofac Surg 31:281, 1993 46. Precious DS: Primary bilateral cleft lip/nose repair using the “Delaire” technique. Atlas Oral Maxillofac Surg Clin North Am 17:137, 2009 47. Joos U: The importance of muscular reconstruction in the treatment of cleft lip and palate. Scand J Plast Reconstr Surg Hand Surg 21:109, 1987 48. Horswell BB, Pospisil OA: Nasal symmetry after primary cleft lip repair: Comparison between Delaire cheilorhinoplasty and modified rotation-advancement. J Oral Maxillofac Surg 53: 1025, 1995
Seven Fundamental Procedures for Definitive Correction of Unilateral Secondary Cleft Lip Nasal Deformity in Soft Tissue Aspects Dong Won Lee, MD,* Bong-Kyoon Choi, MD,† and Be-Young Yun Park, MD, PhD‡ Purpose: It is accepted that patients who undergo appropriate primary repair for cleft lip will have
secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category. Patients and Methods: Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients. Results: Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes. Conclusions: These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes. © 2011 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:e420-e430, 2011 Secondary cleft lip nasal deformity (CLND) is not as much an unsatisfactory result of primary surgery, as an unavoidable fate. For the correction of secondary CLND, various procedures have been developed and successful treatment outcomes have been reported.1-31 However, the continuous development
of new procedures represents a lack of standardization among the methods used to correct complex deformities. It is not easy to accurately describe the anatomic pathology of secondary CLND. Small defects that are left after the primary repair are amplified with the growth process and affect adjacent structures. These eventually cause complex and diverse patterns of secondary deformity, such as nasal asymmetry and muscular discontinuity. To make an accurate diagnosis, therefore, a 3-dimensional understanding of the skin, soft tissue, cartilage, vestibular lining, and underlying bony structure is needed. Simple categorization of these complex deformities would contribute to the elucidation of an anatomic pathology and allow surgeons to perform the most effective correction procedures. The purpose of the present study was to clarify the cardinal deformities in the context of unilateral secondary CLND. Based on the authors’ experience with intensive correction of these deformities, this report proposes guidelines that can be commonly applied to various types of unilateral secondary CLND.
*Clinical Research Assistant Professor, Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Republic of Korea. †Director of Maxillofacial Center, Jeong Won Aesthetic Clinic, Seoul, Republic of Korea. ‡Professor, Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Republic of Korea. Address correspondence and reprint requests to Dr Park: Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, 134 Shinchon-dong, Seodaemun-gu, 120-752 Seoul, Republic of Korea; e-mail: [email protected] © 2011 Published by Elsevier Inc on behalf of the American Association of
Oral and Maxillofacial Surgeons 0278-2391/11/6911-0043$36.00/0 doi:10.1016/j.joms.2011.04.022
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ally acknowledged.1,33,34 The cleft-side medial crus is set to be lower than the noncleft side, which results in a lower position of the alar dome and short columella on the cleft side. Even if nasal correction is performed during a primary repair, the medial crus frequently returns to a low setting in cases of incomplete correction. Tethering Deformity of Lateral Crus The cleft-side lateral crus is attached to the piriform aperture in a lower position, and the alar cartilage is lateralized and flattened.2 In addition to a low setting of the medial crus, tethering deformity of the lateral crus plays a role in lowering the alar dome. Moreover, because there is a lack of nasal vestibule along the lower border of the lateral crus, the plica vestibularis is markedly deformed. This may have a tethering effect, leading to lateralization of the alar cartilage.3 SECONDARY CLEFT LIP FIGURE 1. Seven cardinal deformities: A, caudal deflection of the nasal septum to the noncleft side; B, deviation of the nasal dorsum; C, low setting of the medical crus; D, tethering deformity of the lateral crus; E, discontinuity of the orbicularis oris muscle; F, long or short lip deformity; and G, absence of a philtral column. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
Anatomic Defects Secondary deformities of the corrected unilateral cleft lip are classified as secondary nasal deformity or secondary cleft lip, excluding those involving the maxilla, alveolus, and dentition. These deformities can be subclassified into several types of cardinal deformities. Although there is a difference in the severity of secondary CLND, most patients have the following 7 features (Fig 1). SECONDARY NASAL DEFORMITY
Caudal Deflection of Nasal Septum to Noncleft Side The caudal edge of the septum is deviated from the anterior nasal spine and vomerine groove and flexed to the noncleft side.1,32 Septal deviation plays a role in twisting the nasal tip, thus greatly affecting the impairment of nasal symmetry. This deformity is always observed, even in the microform cleft lip. Deviation of Nasal Dorsum The cartilaginous dorsal septum is deviated to the noncleft side and pathologically fused with the upper lateral cartilage.1,32 This contributes to bending of the nasal tip and nasal dorsum to the noncleft side. Low Setting of Medial Crus Whether or not the cleft side alar cartilage is hypoplastic, malpositioning of the alar cartilage is gener-
Discontinuity of Orbicularis Oris Muscle Before the primary repair, the orbicularis oris muscle (OOM) runs parallel to the cleft margin and is inserted into the nasal base and piriform aperture. During muscular contraction, a typical pattern denoted as orbicularis bulge is observed on the cleft side.35 Although the discontinuity of the OOM is definitively corrected during the primary lip repair, a relapse commonly occurs. Therefore, an assessment of muscle continuity in patients with secondary cleft lip should not be overlooked.36 Such relapse occurs because lip elevators, such as the levator labii superioris, transversalis nasalis, and levator labii superioris alaeque nasi muscles on the cleft side, forcefully advance into the OOM more medially than on the noncleft side, unless they have been detached during primary surgery. Repeated action of the lip elevators could aggravate separation of the OOM. Long or Short Lip Deformity When a preoperative design is inappropriate in primary lip repair, the cleft-side philtral length will be too long or too short.37 In wide cleft lip, it is difficult to design the cleft-side philtral length identical to the noncleft-side length, which easily induces a short lip. In mild cleft lip, inexperienced surgeons tend to design a long lip. Furthermore, inappropriate correction of the OOM can affect the vertical length of the lip. Absence of Philtral Column The OOM plays a pivotal role in the formation of the philtral column. The short fiber of the superficial portion of the OOM extends to the ipsilateral column, and the long fiber to the contralateral column. The short fiber is interdigitated with the long fiber and eventually forms the philtrum.38,39 In general, a more natural-looking philtral column can be achieved dur-
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ing secondary lip repair than during primary correction.
Patients and Methods In total, 1,170 patients with unilateral secondary CLND underwent surgical correction from January 1992 through August 2009. The patient population consisted of 714 male and 456 female patients. There were 583 preschool patients (1 year to 6 years old), 223 prepubertal patients (6 to 10 years old), 247 pubertal patients (10 to 18 years old), and 117 adult patients (⬎18 years old). To correct the cardinal defects in patients with unilateral secondary CLND, the following 7 fundamental procedures were performed. The institutional review board waived informed consent and approved the design of this retrospective study. TRANSPOSITION OF CAUDAL SEPTUM
The caudal margin of the septum can be accessed through a midcolumella splitting incision. The septum, caudally dislocated to the noncleft side, was isolated from the anterior nasal spine and displaced to the cleft side with a scoring incision on the noncleft-side septum. The displaced caudal septum was fixed to the periosteum of the anterior nasal spine on the cleft side by a nonabsorbable suture (Fig 2). When relapse is a concern because of a short caudal septum or an underdeveloped nasal spine, cartilage should be inserted between the anterior nasal spine and the transposed septum. If the septal correction is effectively achieved, nasal obstruction of the cleft side is relieved and functional improvement can be expected. RELEASE OF SEPTAL-CARTILAGINOUS JUNCTION
For complete correction of septal deflection, the pathologically attached dorsal septum should be separated from the medial aspect of the upper lateral cartilage on the noncleft side and directed to the cleft side, as performed for deflection of the caudal septum. An incision was performed with a scalpel on the noncleft-side junction between the septum and upper lateral cartilage to free the dorsal septum (Fig 2). Insertion of the adjacent superficial fascia, which came from the superficial musculoaponeurotic system, into the separated septal-cartilaginous junction would prevent a relapse because of fusion of the separated junction. MEDIAL CRUS ELEVATION
Medial crus elevation plays an essential role in the correction of the deformed alar cartilage. The midcolumella splitting incision was extended horizontally to the cleft-side membranous septum, 2 mm superior from the nasolabial angle, until reaching the upper lip incision. A crescent excision was performed from the
FIGURE 2. Transposition of the caudal septum and release of the septal-cartilaginous junction. In a patient with left-side secondary cleft lip nasal deformity, the caudally dislocated septum is isolated from the anterior nasal spine and displaced to the cleft side using a nonabsorbable suture. To correct the dorsal septum, an incision is performed on the noncleft-side junction between the septum and the upper lateral cartilage together with a scoring incision on the noncleft-side septum to free the cartilaginous dorsal septum. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
webbing tissues over the nostril on the cleft side to allow the apex of the nostril to be drawn up level with the noncleft side. The depressor septi nasi was isolated from the footplate of the low-set medical crus, and the interdomal suture was symmetrically performed (Fig 3). The medial crus elevation was completed using several pillow sutures. However, tissue defects usually occur at the base of an effectively elevated hemicolumella. The defects were covered with a rotated cicatricle flap, which was developed during scar revision of the upper lip or with a composite graft of the crescent-shaped excised tissue placed over the nostril. LATERAL CRUS ELEVATION
Although the nasal tip projection is greatly improved with medial crus elevation, release of the tethered lateral crus is essential to render a more natural look to the alar dome and nasal groove. A longitudinal incision was performed on the plica vestibularis. The lateral crus was dissected free from the skin and piriform aperture, and the caudally displaced lateral crus was moved to the correct position using pillow sutures. One large Zplasty was performed on the lower end of the plica
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ANCHORING THE OOM TO THE ANTERIOR NASAL SPINE
Another way to minimize a relapse of OOM discontinuity is to suspend the muscle to a fixed structure, namely the anterior nasal spine. The tip of the deep half of the dissected cleft-side muscle was medially advanced to reach the noncleft-side philtrum and fixed to the periosteum of the anterior nasal spine using a nonabsorbable suture, and the tip of the superficial half was fixed to the contralateral muscles at the base of the noncleft-side philtral column. The vertical length of the upper lip was adjusted depending on the suture site of the OOM. Thus, a long or short lip deformity can be rectified. PHILTRAL COLUMN FORMATION
FIGURE 3. Medial crus elevation and lateral crus elevation. A, Preoperative view. The cleft-side alar cartilage is positioned inferiorly and laterally. For medial crus elevation, a midcolumella splitting incision with horizontal extension on the cleft-side membranous septum and a crescent excision from the nostril apex are performed. The lateral crus elevation is approached through a large Z-plasty on the plica vestibularis. B, Postoperative view. The crescent excision allows medial crus elevation, and the interdomal suture is performed for alar symmetry. The lateral crus is dissected free from the piriform aperture, and Z-plasty is performed for vertical lengthening of the plica vestibularis. By controlling the length of the lower triangular flap (asterisk) in the Z-plasty, the height of a drooping alar base can be corrected.
Most methods designed for philtral formation have imitated the physiologic anatomy of OOM insertion into the dermis.4-8 The full layer of the noncleft-side OOM and the deep two-thirds of the cleft-side OOM were sutured together, and the superficial one-third of the cleft-side OOM was fixed to the dermis of the philtral dimple, creating a more natural-looking philtral column (Fig 4). PATIENT SATISFACTION SURVEY
Since 2001, the level of patient satisfaction with overall outcomes for these procedures has been assessed by the senior author in the outpatient
Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
vestibularis for vertical lengthening. By controlling the length of a lower triangular flap in the Z-plasty, the height of a drooping alar base can be easily corrected (Fig 3). RELEASE OF OOM FROM LIP ELEVATORS
Despite successful primary surgery, most patients with secondary CLND display OOM discontinuity. Through the previous lip scar, the OOM was sufficiently dissected from the external subcutaneous tissue and internal oral mucosa and the anterior wall of the maxilla and piriform aperture. The noncleft-side muscle was sufficiently released from the anterior nasal spine and the base of the contralateral philtral column to rotate downward and the cleft-side muscle to advance medially. Importantly, it is necessary to release the OOM from the cleft-side lip elevators, which could cause a relapse of OOM discontinuity and worsen distortion of the lateral lip.
FIGURE 4. Philtral column formation. A, Preoperative view. The full layer of the noncleft-side muscle (NC) is sutured to the deep part of cleft-side muscle (CD), and the remaining superficial part of the cleft-side muscle (CS) is sutured to the dermis of the philtral dimple. B, Postoperative view. The philtral dimple and column are formed by traction of these sutures. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
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FIGURE 5. Anthropometric analysis by digital photographs. A, Septal deviation. B, Difference in nostril angle. C, Difference in philtral length. D, Difference in alar width. Anthropometric measurements are defined in Table 1. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
clinic using the visual analog scale,40 with a range from 0 to 10, where 0 denotes “unsatisfied” and 10 denotes “most satisfied.” Although the visual analog scale was generally applied to all patients, when the patient was of preschool age or a patient’s decision making was ambiguous, the written agreement of the closest guardian of the patient was included in the present data. The satisfaction scores were separately obtained for the nose and upper lip during the preoperative period, short-term postoperative period, and long-term postoperative period. Shortterm postoperative scoring was performed 6 months after the surgery, and long-term scoring was performed on the last day that the patient visited the outpatient clinic. Visual analog scale results were compared using the linear mixed model of SPSS 15.0 (SPSS, Inc, Chicago, IL). ANTHROPOMETRIC ANALYSIS
Anthropometric analysis was performed using preoperative and postoperative digital photographs from worm’s-eye and frontal views. The anthropometric analysis was evaluated in 4 aspects to objectively reflect the outcome of fundamental procedures. In
the worm’s-eye view, septal deviation and difference of nostril angles were evaluated; in the frontal view, differences in philtral length and alar width were measured on digital photographs (Fig 5). The anthropometric measurements are defined in Table 1. Preoperative and postoperative measurements for each analysis were compared using paired Student t tests (SPSS 15.0).
Results PATIENT SATISFACTION SURVEY
Of the 1,170 patients who underwent these 7 fundamental procedures, patient satisfaction scores were obtained from 171 patients. The patient population included 108 male and 63 female patients consisting of 57 preschool patients (1 year to 6 years old), 39 prepubertal patients (6 to 10 years old), 37 pubertal patients (10 to 18 years old), and 38 adult patients (⬎18 years old). The mean postoperative long-term follow-up of 171 patients was 60 months (range, 20 to 115 months). The satisfaction scores (mean ⫾ standard deviation) for the nose were 3.3 ⫾ 1.6 during the
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Table 1. ANTHROPOMETRIC MEASUREMENTS
Measurements Septal deviation (a) Line SD Line H Difference in nostril angle (b) Nostril angle (b1 or b2) Line NA Line H Difference in philtral length (c) Philtral length (P1 or P2) Difference in alar width (d) Alar width (W1 or W2)
Definition Angle between line SD and line H Line between midpoint of most medial points of bilateral nostrils and midpoint of Most inferior points of bilateral nostrils Horizontal reference line drawn between bilateral medial canthal points Difference of bilateral nostril angle Angle between line NA and line H Line between nostril apex and midpoint of alar base Horizontal reference line between bilateral medial canthal points Ratio of difference of philtral length to noncleft-side philtral length Length between columella base and ipsilateral peak of Cupid’s bow Ratio of difference of alar width to noncleft-side alar width Length between midpoint of columella base and midpoint of alar base
NOTE. Anthropometric measurements are depicted in Figure 5. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
preoperative period, 7.2 ⫾ 1.3 during the short-term postoperative period, and 7.0 ⫾ 1.4 during the longterm postoperative period. The preoperative score was significantly different from the short-term (P ⬍ .05) and long-term (P ⬍ .05) postoperative scores, but there was no significant difference between the shortand long-term postoperative scores. The satisfaction scores for the upper lip were 3.3 ⫾ 1.7 during the preoperative period, 7.5 ⫾ 1.4 during the short-term postoperative period, and 7.2 ⫾ 1.4 during the longterm postoperative period. As observed with cases involving the nose, the preoperative score was significantly different from the short-term (P ⬍ .05) and
long-term (P ⬍ .05) postoperative scores, but there was no significant difference between the short- and long-term postoperative scores (Fig 6). In addition, age at the time of operation did not correlate with the satisfaction score. ANTHROPOMETRIC ANALYSIS
Anthropometric analysis was performed in 38 patients (18 male and 20 female) with unilateral secondary CLND. Patients’ ages ranged from 4 to 38 years (mean age, 20.6 years). The follow-up period ranged from 12 to 144 months (mean, 40 months). The preoperative and postoperative values for septal deviation, difference in nostril angle, difference in philtral length, and difference of alar width are presented in Table 2. All preoperative values were significantly different from postoperative values (P ⬍ .05). The final results are shown in Figures 7 through 9.
Discussion There has been controversy as to whether concomitant correction of the nasal deformity in pri-
Table 2. RESULTS OF ANTHROPOMETRIC ANALYSIS
Preoperative Value Septal deviation (°) Difference in nostril angle (°) Difference in philtral length (%) Difference in alar width (%)
Postoperative P Value Value
12.0 ⫾ 7.9 18.1 ⫾ 9.6
3.9 ⫾ 4.7 5.1 ⫾ 4.0
⬍.05 ⬍.05
12.2 ⫾ 7.3
2.3 ⫾ 2.2
⬍.05
26.1 ⫾ 19.6
8.2 ⫾ 6.2
⬍.05
FIGURE 6. Patient satisfaction for nose and upper lip. The difference between the preoperative score and the short- and long-term postoperative scores was statistically significant (*P ⬍ .05), but there was no difference between the short- and long-term postoperative scores.
NOTE. Values are presented as mean ⫾ standard deviation.
Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
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FIGURE 7. A 12-year-old girl with right secondary cleft lip nasal deformity: A, preoperative and C, 1-year postoperative frontal views; B, preoperative and D, 1-year postoperative worm’s-eye views. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
mary cleft lip surgery has an effect on long-term outcomes. Despite concerns that early correction of a nasal deformity might have a detrimental effect on facial growth, many plastic surgeons have concluded that it produces satisfactory outcomes.9-11 However, it is not easy to definitively correct CLND through primary correction alone. Moreover, the expectation of patients and their parents is increasing. Therefore, the correction of secondary CLND is becoming more important.
NASAL REPAIR
Through trial and error, the senior author (B.Y.P.) obtained better outcomes for secondary nasal correction. In 1977, Tajima and Maruyama12 introduced an operation in which the deformed alar cartilage was fixed to the upper lateral cartilage through a reverse-U incision, and the insufficient area within the nostril was filled with the overhanging alar web tissues. Until recently, this method has been popular for the correction of asymmetric nostrils.13-15 The senior author
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FIGURE 8. A 27-year-old man with left secondary cleft lip nasal deformity: A, preoperative and C, 6-year postoperative frontal views; B, preoperative and D, 6-year postoperative worm’s-eye views. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
modified the method of Tajima and Maruyama to a 3-layer (skin, cartilage, and mucosa) correction technique through the use of reverse-W incision.16 Using this modified method, secondary correction was performed in 213 patients from 1981 through 1993. Nevertheless, the shape of the nostril was still not natural enough and the nasal projection was insufficient. Thus, the necessity for radical transpositioning of the alar cartilage to correct secondary nasal deformities has been recognized. In 1925, Blair17 first attempted to reposition the medial crus. He split the columella in the midline
and rotated the cleft-side nostril from the horizontal direction to the vertical direction. Joseph18 performed an elliptical excision of tissues over the cleft-side alar dome to allow for easy elevation of the alar cartilage. Thereafter, Gillies and Kilner19 and Wilkie20 developed an operation that allowed alar cartilage repositioning through a vertical split of the columella. However, this technique has not been extensively used because it leaves an ugly scar on the nasal tip. In 1982, Dibbell21 performed a crescent excision right above the nostril to conceal the operative scar.
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FIGURE 9. A 33-year-old man with right secondary cleft lip nasal deformity: A, preoperative and C, 12-year postoperative frontal views; B, preoperative and D, 12-year postoperative worm’s-eye views. Lee, Choi, and Park. Secondary Cleft Lip Nasal Deformity. J Oral Maxillofac Surg 2011.
Potter22 and Rees et al23 reported repositioning of the lateral crus. They advanced the lateral crus as a chondromucosal flap into the anatomic position. The method of Tajima and Maruyama12 focused on the lateral crus rather than the medial crus; the dissection consisted primarily of the lateral component of the alar cartilage. Uchida3 introduced a surgical technique that isolated the lateral crus from the upper lateral cartilage and the piriform aperture and released the plica vestibularis. Nakajima et al24 combined the methods of Tajima and Maruyama and of Uchida, a combination that effectively corrected the deformed lateral crus.
The authors insist that, for the correction of an abnormally shaped nostril and an underprojected nasal tip, the medial and lateral crura of the alar cartilage should be repositioned. Although many surgeons tend to consider repositioning the lateral crus to correct secondary nasal deformities, a concomitant correction of the medial and lateral crura is essential to obtain satisfactory long-term outcomes. According to the theory that the cartilaginous framework of the nasal tip can be considered a tripod, proposed by Anderson,41 lateral crus elevation leads to downward displacement of the nasal tip and its forward projection, but vector medial crus elevation achieves mainly
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tip projection. That is, from the viewpoint of nasal tip projection, medial crus elevation is more effective than lateral crus elevation. Lateral crus elevation plays a more essential role in the correction of alar flaring and alar base drooping. The fact that the cleft-side alar cartilage is not more hypoplastic than the noncleftside alar cartilage could be a theoretical basis for the sufficiency of secondary nasal correction by cartilage repositioning alone, ie, without an additional cartilage graft.33,34 Another important factor for secondary nasal correction is the deformation of septal cartilage. Deviation of the nasal tip to the noncleft side is affected by the deformed septum rather than the alar cartilage. In previous experiences, the authors found that a surgical procedure dealing only with the caudal portion of the septum could cause a relapse. The reason was that the upper lateral cartilage on the noncleft side pathologically grasped the dorsal portion of the septum and impeded septal repositioning. Therefore, synchronous manipulation of the caudal and dorsal portions of the septum is necessary for effective correction. Surgeons should be concerned that partial obstruction of the airway within the nasal cavity could develop after nasal correction, because the airway has been compensated for long periods. LIP REPAIR
The OOM is most important in the correction of secondary cleft lip. Although attention has been previously focused on the design of the skin incision, the rearrangement of the OOM has recently been emphasized.25-28,42 By Delaire’s theory, the anterior face is arranged in 3 circles—the superior rings, such as lip elevators; the middle rings, such as the OOM; and the inferior rings—and that all 3 circles of the cleft side are inferiorly displaced compared with the noncleft side.43,44 Malpositioning of the cleft-side muscles is responsible for septal deviation and premaxillary maldevelopment and influences normal facial growth.45 Functional cheiloplasty has been suggested to restore the malpositioned periosteal musculoaponeurotic system, and it has been completed successfully by several cleft surgeons.46-48 The authors basically agree with the concept that correction of an oronasal muscle malposition is essential and that, especially in this study, inappropriate positioning between the superior rings and middle rings should be cause for concern. Because abnormal insertion to the OOM of lip elevators can cause separation of the OOM, it is necessary to relocate the relation between these 2 muscle groups. After a wide dissection of the OOM from the surrounding tissues, the advancing deep layer of cleftside muscles should be sutured to the periosteum of the anterior nasal spine. There are 3 important con-
siderations. First, the site of the OOM suture determines the height of the upper lip and the width of the alar base. Second, depression of the nostril floor is prevented even in patients who did not undergo alveolar bone grafting because the advancing OOM crosses over the alveolar gap. Third, a relapse can be prevented by securely suspending the OOM to a fixed structure. In addition, to produce a more natural look for the upper lip, tension in the soft tissues of the upper lip should be considered. Even if the muscles are ideally rearranged, insufficient soft tissues can distort the upper lip. In conclusion, a myriad of methods for secondary CLND has been introduced over recent decades, but these methods lack standardization. Therefore, 7 fundamental procedures are proposed as guidelines for the correction of secondary CLND: transposition of the caudal septum, release of the septal-cartilaginous junction, medial crus elevation, lateral crus elevation, release of the OOM from lip elevators, anchoring of the OOM to the anterior nasal spine, and philtral column formation. These methods can be applied as standard surgical techniques for various types of secondary CLND to achieve ideal treatment outcomes. Acknowledgments The authors are grateful to Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the figures.
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