Analysis of nasal and labial deformities in cleft lip, alveolus and palate patients by a new rating scale: preliminary report

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Abstract

Introduction: In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analysed and the relevant role of the perinasal-perioral muscular balance, and the inborn dislocation of the alar cartilages is presented.

Patients and methods: 50 CLAP patients were analysed in whom 29 primary cheiloplasties, 12 lip revisions and 9 rhinoplasties were performed. The lip repair was done by a modification of Millard's technique, the nose by either a closed or open-sky rhinoplasty. The severity of the cleft appearance was evaluated pre- and postoperatively, according to a pre-agreed visual rating scale. There were 4 degrees of severity of the deformity preoperatively (mild, moderate, severe and very severe), and postoperatively 5 categories of outcome (excellent, very good, good, satisfactory and poor) depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts.

Results: 17 excellent, 4 very good, 2 good, 5 satisfactory and 1 poor result were obtained in the group of primary cheiloplasty. Eight excellent, 4 very good results were obtained by the lip revisions. Seven excellent and 2 satisfactory results were obtained following rhinoplasty.

Conclusions: During the primary lip repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. When correct insertion of m. transversus nasi to the nasal spine is achieved and a good repair of m. orbicularis oris, symmetry of the alae and normal growth of lip and columella was obtained even in most severe bilateral cases. In cases of diastasis of the orbicularis and transversus nasi muscles, in combination with other soft tissue deformities or scars, a secondary musculo-periosteal revision is recommended. The defect of the soft tissue triangle of the nose is best corrected via an open rhinoplasty.

Section snippets

INTRODUCTION

Nasal deformities have always been a fundamental problem in the treatment of cleft lip, alveolus and palate patients. Some authors (McComb, 1985; Pigott, 1985; Trott and Mohan, 1993a,b) prefer primary, i.e. early correction of these deformities during the initial operation (cheilo-rhinoplasty), whilst others (Delaire, 1978; Cronin and Denkler, 1988; Pellerin and Louis, 1993) concerned with growth retardation reserve these corrections for a later date (secondary rhinoplasty). In our opinion, the

MATERIAL AND METHODS

Application of this method helps to obtain the following data for every patient:

  • initial assessment of the severity before operation;

  • postoperative assessment at different stages of treatment and reassessment after each operation.

Classification of the severity of the cleft before surgery is based on the principle of dividing the cleft into thirds, i.e. nose and lip, hard palate as well as soft palate, similar to the classification of the American Cleft Palate Association. The rating system is

SURGICAL METHODS AND PATIENTS

Fifty patients with cleft lip, alveolus and palate who underwent different surgical procedures were analysed (Table 4).

  • 1.

    Primary cheiloplasty: a modified Millard primary cheiloplasty was performed on 29 children aged from 5 days to 18 months (mostly at age of 3 months). Thirteen of those were unilateral clefts of lip, alveolus and palate scored as “moderate” and 16 were bilateral CLAP, 11 of them classified as “very severe”, 4 “severe” and 1 “mild”. A modification of Millard's procedure was used

RESULTS

All results were analysed at least 6 months postoperatively by clinical examination.

In the 13 primary unilateral cheiloplasties: 10 “excellent”, 2 “good” and 1 “satisfactory” results were obtained. The most common deformities after primary cheiloplasty were the defect of the soft tissue triangle (10 out of 13 cases; Fig. 4) and insufficient wrapping of the ala (4 out of 13 cases).

In the 16 primary bilateral cheiloplasties: 7 “excellent”, 4 “very good”, 4 “satisfactory” and 1 “poor” result were

DISCUSSION

From the results presented in the pictures it is obvious, that the defect of the soft tissue triangle of the nose was the most common problem found pre- and postoperatively in both uni- and bilateral clefts. The lack of insertion of the transverse nasal muscle to the anterior nasal spine leads to dislocation of the medial alar cartilages and insertion into the skin, which takes place in utero. Correction of this deformity might be achieved following primary cheiloplasty, but our observations

CONCLUSION

Detailed analysis of the preoperative state compared with the postoperative results using the described scoring system has its benefits. It enables comparisons between the results obtained in cases of equally severe clefts, i.e. a more precise assessment of the therapeutic benefits. It makes it possible to define every single defect of any nasal deformity, and to determine its frequency and aetiology; it will reveal errors and show whether the aim of the operation has been achieved.

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