Improving Nasal Symmetry after Primary Cleft Rhinoplasty Kayva Crawford1, Matthew C Freeman PhD2 and Andrew R Scott MD FACS3

1Tufts University School of Medicine – Boston, MA 2Rollins School of Public Health, Emory University – Atlanta, GA

3Department of Otolaryngology & Pediatric Facial Plastic Surgery Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine – Boston MA

INTRODUCTION ABSTRACT

REFERENCES

CONTACT

1.  LuTC, Lam WL, Chang CS, Kuo-Ting Chen P. Primary correction of nasal deformity in unilateral incomplete cleft lip: A comparative study between three techniques. J Plast Reconstr Aesthet Surg. 2012 Apr;65(4):456-63. Epub 2011 Nov 29.

2.  Meltzer NE, Vaidya D, Capone RB. The cleft columellar angle: a useful variable to describe the unilateral cleft lip-associated nasal deformity. Cleft Palate Craniofacial J. 2013 Jan;50(1):82-27.

3.  Asher-McDade C, Roberts C, Shaw WC, Gallager C. Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J. 1991 Oct;28(4):385-90; discussion 390-1.

4.  Tajima S, Maruyama M. Reverse-U incision for secondary repair of cleft lip nose. Plast Reconstr Surg. 1977 Aug;60(2):256-61.

Andrew R. Scott, MD Division of Pediatric Otolaryngology and Facial Plastic Surgery Floating Hospital for Children at Tufts Medical Center Boston, MA 02111 Email: ascott@tuftsmedicalcenter.org

Suspension of the lower lateral nasal cartilage during

primary cleft rhinoplasty has been described as a means

of improving nasal symmetry outcomes following

unilateral cleft lip repair. The purpose of this study is to

compare the perceived nasal symmetry outcomes in

patients who have undergone endonasal primary cleft

rhinoplasty with double suspension suture, single

suspension suture, and sutureless techniques.

FIGURE 2: A: An image from the online survery. B: A summary of nasal landmarks examined for this study

Zero Sutures One Suture Two Sutures

Objectives: To compare perceived nasal symmetry outcomes in patients who have undergone endonasal pr imary clef t rhinoplasty with placement of zero, one, or two suspension sutures to reposition the lower lateral cartilage. Methods: The charts of 20 patients with unilateral cleft lip with or without cleft palate were reviewed for subject inclusion based on cleft-columellar angle, and an electronic survey was created to assess perceived nasal symmetry using a modified Asher-McDade aesthet ic index. F ive pediatric facial plastic surgeons, six otolaryngology residents, and seven medical students were surveyed, representing variable levels of surgical experience. Results: Of the 20 patients who underwent primary cleft rhinoplasty, 15 had complete or wide incomplete cleft lip (as defined as a cleft-columellar angle >40 degrees), and 5 had incomplete cleft lip. In both categories, double suture placement appeared to create consistently s u p e r i o r a e s t h e t i c o u t c o m e s compared to placement of one suture or sutureless cartilage repositioning. The average aesthetic score also increased wi th leve l o f ra te r experience. Discussion: Placement of two suspension sutures produced the best aesthetic outcomes in patients with complete or wide incomplete unilateral cleft lip. Aesthetic scores in the two-suture group were similar to those seen following repair of more minor unilateral incomplete clefts. Less experienced raters were more critical of results. Conclusion: Using two lower lateral cartilage suspension sutures may improve nasal aesthetic outcomes following primary cleft rhinoplasty in patients with unilateral complete and wide incomplete cleft lip.

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Nasal Form Symmetry Nostril base Nostril height

Average Rating Score Increases with Rater Experience

METHODS Operations were performed by one of two cleft

surgeons, who regularly perform cleft lip and palate

surgery. At the time of repair (3-4 months of age)

primary rhinoplasty was performed. The lower lateral

cartilage was freed from the skin and soft tissue

envelope through the incisions for the lip repair allowing

for independent positioning of the nasal cartilages free

of the skin. If sutures were utilized, 5-0 PDS was used to

place one suspension suture between the cephalic edge

of the lower lateral cartilage and the ipsilateral upper

lateral cartilage. In the two suture group, a stitch was

also placed between the cephalic edge of the dome and

the contralateral upper lateral cartilage (Figure 1). Institutional review board approval was obtained. The

charts of 20 patients with unilateral cleft lip with or without

cleft palate were reviewed for subject inclusion based on

cleft-columellar angle, and an electronic survey was

created to assess perceived nasal symmetry using a

modified Asher-McDade aesthetic index with raters

blinded to the severity of the pre-operative cleft deformity

as well as the technique used to repair the nose (Figure 2).

Five pediatric facial plastic surgeons, six otolaryngology

residents, and seven medical students were surveyed in

an effort to represent variable levels of surgical

experience.

Complete  and  Wide  Incomplete  Unilateral  Cle2  Lip  (n  =  15)           No  sutures  (n  =  4)  One  suture  (n  =  3)   Two  sutures  (n  =  8)   Average  

Nasal  Form  

Med  Student   1.9821   2.4286   3.4821   2.6310  Resident   2.1458   2.3889   3.9368   2.8239  ADending   2.6563   3.0833   4.4688   3.4028  Average   2.2614   2.6336   3.9626   2.9525  

Symmetry  

Med  Student   1.9464   2.1905   3.2703   2.4691  Resident   2.2292   2.2857   3.8316   2.7822  ADending   2.5625   2.6250   4.2813   3.1563  Average   2.2460   2.3671   3.7944   2.8025  

Nostril  base  

Med  Student   2.2500   2.2381   3.4196   2.6359  Resident   2.4167   2.1111   3.8125   2.7801  ADending   2.5625   2.4583   4.0625   3.0278  Average   2.4097   2.2692   3.7649   2.8146  

Nostril  height  

Med  Student   2.1964   2.5476   3.2321   2.6587  Resident   2.3750   2.7222   3.7813   2.9595  ADending   2.4375   2.5833   4.0625   3.0278  Average   2.3363   2.6177   3.6920   2.8820  

Incomplete  Unilateral  Cle2  Lip  (n  =  5)           No  sutures  n  =  4   Two  sutures  n  =  1   Average  

Nasal  Form  

Med  Student   3.3214   3.5714   3.4464  Resident   3.7292   4.0833   3.9062  ADending   4.0000   4.6250   4.3125  Average   3.6835   4.0933   3.8884  

Symmetry  

Med  Student   3.2143   3.4286   3.3214  Resident   3.6042   3.8333   3.7187  ADending   3.7333   4.3750   4.0542  Average   3.5173   3.8790   3.6981  

Nostril  base  

Med  Student   3.0536   3.2857   3.1696  Resident   3.3958   4.0833   3.7396  ADending   3.7333   4.6250   4.1792  Average   3.3942   3.9980   3.6961  

Nostril  height  

Med  Student   2.7857   2.7857   2.7857  Resident   3.4468   3.2500   3.3484  ADending   3.4000   4.3750   3.8875  Average   3.2108   3.4702   3.3405  

FIGURE 3: Examples of nasal appearance after placement of zero, one, or two suspension sutures during primary cleft rhinoplasty in three children with complete / wide incomplete right unilateral cleft lip.

FIGURE 1: The senior author’s technique of endonasal primary rhinoplasty. Through a medial intercartilagenous incision, a 5-0 PDS suture passes through

cephalic edge of dome and out mucosa. A 25g spinal needle inserted through the skin is used to capture the contralateral upper lateral cartilage before the needle is

inserted to the point of delivery into the endonasal field. The free end of suture is then passed up needle. The needle is backed out of the cartilage without withdrawing it from the skin envelope and then reinserted into cartilage and then pushed back into endonasal field. The free end of the suture is pulled back out of the needle and tied.

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Tables I and II: Composite ratings of nasal aesthetics for unilateral complete / wide incomplete cleft lip and

incomplete cleft lip

FIGURE 2: A: An image from the online survey. B: A summary of nasal landmarks examined for this study

RESULTS Of the 20 patients who underwent primary cleft

rhinoplasty, 15 had complete or wide incomplete cleft lip

(as defined as a cleft-columellar angle >40 degrees), and 5

had incomplete cleft lip. Controlling for clustered nature of

the data, medical students rated lowest (mean rating = 2.9,

SD 0.9), compared to residents (mean rating = 3.3, SD 1.2,

p<0.001) and attending surgeons (mean rating = 3.6, SD

1.0, p<0.001). Attending surgeons rated the outcomes

significantly higher than residents (p<0.001). Double

suture placement resulted in aesthetic outcomes that were

rated 35%-44% higher than those with 0 or 1 suture (β =

1.3; 95%CI 0.46, 2.12; p=0.002).

DISCUSSION Placement of two suspension sutures produced the best

aesthetic outcomes in patients with complete or wide

incomplete unilateral cleft lip. Aesthetic scores in the two-

suture group were similar to those seen following repairs

of more minor nasal deformities associated with narrow,

unilateral incomplete clefts. Even though the two suture

technique differs only in the elevation of the dome of the

lower lateral cartilage, raters of all experiences

consistently gave better scores of alar base width as well

as symmetry, form, and nostril height.

CONCLUSION Using two lower lateral cartilage suspension sutures

appears to improve nasal aesthetic outcomes following

primary cleft rhinoplasty in patients with unilateral

complete and wide incomplete cleft lip

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No sutures (n=4) One suture (n=3) Two sutures (n=8) incomplete cleft results (n=5)

Average Ratings Combining all Training Levels

Nasal form Symmetry Nostril Base Nostril Height

ACKNOWLEDGEMENT Dr. Arnold S. Lee performed several of the surgeries included in this series