BackgroundThe aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing the postoperative complications. This study aimed to compare the long-term outcome of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center.MethodsA retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included.ResultsA total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were eligible in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% versus 4.6%, p =0.01), and the VPI prevalence was not significantly different (9.2% versus 7.9%, p =0.62). Patients who developed fistula had significantly higher likelihood of having VPI than patients without oronasal fistula (50.0% versus 7.1%, respectively; p < 0.01), with an odds ratio of 13.0.ConclusionBoth modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension facilitated to lower the risk of oronasal fistula.

BACKGROUND:Secondary rhinoplasty in patients with bilateral cleft lip poses ongoing challenges and requires a reliable method for achieving optimal outcomes. OBJECTIVES:The purpose of this study was to establish a safe and effective method for secondary bilateral cleft rhinoplasty. METHODS:A consecutive series of 92 skeletally matured patients with bilateral cleft lip and nasal deformity were included. All had undergone secondary open rhinoplasty, performed by a single surgeon with a bilateral reverse-U flap and septal extension graft, between 2013 and 2021. Medical records of these 92 patients were reviewed to assess the clinical course. A 3-dimensional (3D) anthropometric analysis and panel assessment of 32 patients were performed to evaluate the aesthetic improvement, with an age-, sex-, and ethnicity-matched normal control group for comparisons. RESULTS:The methods showed statistically significant improvement in addressing a short columella (columellar height), short nasal bridge (nasal bridge length), de-projected nasal tip (nasal tip projection, nasal dorsum angle), poorly defined nasal tip (nasal tip angle, dome height, and panel assessment), and transversely oriented nostrils (columellar height, alar width, nostril type). Importantly, these improvements were accompanied by a low complication rate of 4%. However, upper lip deficiency over the upper lip angle and labial-columellar angle remained without significant improvement. CONCLUSIONS:In this study we described effective secondary rhinoplasty, which was composed of a bilateral reverse-U flap and septal extension graft, with acceptable outcome. The 3D anthropometric analysis and panel assessment clarified that our rhinoplasty procedure could bring the nasal morphology in these patients closer to the normal data. LEVEL OF EVIDENCE: 3:

Patients with class III malocclusion often exhibit mandibular prognathism and complain of "prognathic appearance". The overall positive effects of orthognathic surgery on facial appearance have been demonstrated using patient-reported outcome measures (PROMs), but studies investigating the correlation between subjective PROMs results and objective measurements of imaging studies are sparse in the literature. This study recruited consecutive patients with skeletal class III malocclusion who underwent two-jaw orthognathic surgery between January 2016 and January 2021. The PROMs survey was conducted focusing on subjective perception of mandibular appearance. Lateral cephalometric images were measured to examine the correlation with the PROMs results. A total of 96 patients were eligible for this study. Of these, 74 patients (77.1%) reported complete correction of prognathic appearance postoperatively, whereas 22 patients (22.9%) perceived residual prognathic appearance. In a comparison of postoperative measurements between completely and incompletely satisfied patients, there were significant differences in SNB, ANB, convexity, facial angle, Nv-B, Nv-Pog, SN'B', soft tissue facial angle, lip-chin-throat angle, N'v-B', and N'v-Pog'. The PROM results were significantly associated with the objective measurements of imaging studies. Investigating the correlation between PROMs and objective measurements enables integration of patients' perception of the outcomes into future therapeutic strategy and surgical planning, contributing to the enhancement of patient satisfaction.

Background: Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty. Methods: Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed. Results: In the comparative analysis at preschool age, semi-open rhinoplasty significantly im- proved the typical nasal deformities, including transversely oriented wide nostrils, short co- lumella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age. Conclusion: This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.

BACKGROUND:Patients with cleft have functional and aesthetic impairment, and typically require several interventions as they grow. Long-term evaluation following a treatment protocol is essential, but such reports on patients with complete cleft lip and alveolus (CLA) are sparse in the literature. METHODS:A retrospective review was conducted of all patients with complete CLA born between January of 1995 and August of 2002 and treated at our center. Patients who received continuous multidisciplinary team care until 20 years of age were included, and patients with cleft palate and syndromic abnormalities were excluded. Facial bone growth was evaluated using cephalometric analysis. RESULTS:Eighty-seven and 11 patients with unilateral and bilateral CLA, respectively, were included. All patients underwent one-stage cheiloplasty with primary rhinoplasty. Revision lip/nose surgery was performed in 21.8% and 27.3% during growing age, and in 51.7% and 72.7% after skeletal maturity, respectively. Orthognathic surgery was performed in 20.7% and 27.3%, respectively. Compared with unilateral CLA patients, bilateral CLA patients had more operations (3.0 versus 3.7; P = 0.03) and a higher chance of undergoing alveolar bone grafting twice (1.1% versus 36.4%; P < 0.01). Patients with complete CLA had less hypoplastic maxilla, and underwent fewer operations than those with complete cleft lip and palate. CONCLUSIONS:Complete CLA is a less severe form of cleft, but the patients still require multiple interventions. This review revealed certain suboptimal results, and modifications have been made in the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Summary: Columellar base deviation is a common and challenging deformity in patients with unilateral cleft lip. Debate continues on its surgical correction without sufficient studies to establish effective management. This article presents the authors’ experience in correcting the columellar base deviation with the muscle-driven method in primary lip repair. The key is to perform extensive muscle dissection and reconstruction. In the medial lip segment, muscle dissection is performed subcutaneously up to the contralateral nostril floor for effective lengthening and rotation. In the lateral lip segment, muscle dissection is executed in both submucosal and subcutaneous planes, and muscle component is extensively separated from the lip skin and buccal mucosa. The lateral muscle flap is advanced and reattached to the contralateral nostril floor and columellar base using a subcutaneous sustaining suture. Cinching suture between columellar base and alar base is performed. These 2 sutures help centralize and overcorrect the columellar base. Bilateral muscle components are reoriented and approximated in a Z-plasty format for lengthening of the lip. The patients were followed up for at least 3 years. Quantitative measurements of deviation in columellar base angulation were taken and revealed 55.8 ± 2.6 degrees (before nasoalveolar molding), 29.6 ± 1.7 degrees (after nasoalveolar molding), and 2.8 ± 0.4 degrees (postoperative follow-up), respectively. The muscle-driven method represents a safe and effective technique to correct columellar base deviation in patients with unilateral cleft lip.

Background: Tip refinement procedures are still controversial in secondary unilateral cleft rhinoplasty. The aim of this study was to assess whether the septal extension graft improved nasal and tip deformity and achieved a normal profile with clinical and three-dimensional morphometric analyses. Methods: A consecutive series of 194 skeletally mature patients with unilateral cleft were included and analyzed. All had undergone secondary open rhinoplasty, performed by a single surgeon, with the use of the septal extension graft between 2013 and 2021. Clinical data were collected, and three-dimensional morphometric measurements were performed. An age-, sex-, and ethnicity-matched normal group was included for comparisons. Results: The authors’ standard procedures included open approach combining reverse-U incision, septal extension graft, dorsal augmentation, lip revision, and vermilion augmentation. The postoperative outcome showed significantly increased numerical values (nasal bridge length, nasal height, nasal tip projection, nasal dorsum angle, columellar angle, columellar-lobule angle, nostril height ratio, nasal surface area, nasal volume) and decreased numerical values (alar width, tip/middle deviation, nasal tip angle, labial-columellar angle) compared with the preoperative morphology. The postoperative measurement showed significantly higher numerical values (nasal protrusion, tip/middle deviation, nasal dorsum angle) and lower numerical values (columellar-lobule angle, nostril height ratio, alar width ratio) compared with the control group. Conclusions: This study revealed that the authors’ secondary cleft rhinoplasty significantly improved the underprojected, up-rotated, deviated, and poorly defined tip and short nasal bridge deformities. The technique could result in the nose of the patients with cleft lip nasal deformity being closer to that of the normative profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND:Postpalatoplasty velopharyngeal function needs to be evaluated through long-term follow-up, but such reports are limited in the literature, and there has been no consensus as to which surgical technique yields optimal velopharyngeal function with minimum complication rate. This study aimed to evaluate the long-term outcome of the modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ). METHODS:A retrospective review was conducted of consecutive patients who underwent palatoplasty performed by the senior author (L.J.L.) between January of 2000 and March of 2014. Nonsyndromic patients who underwent palatoplasty before the age of 18 months and followed up until at least 9 years of age were included. Comparisons between the small-DOZ and 2-flap methods for soft palate repair were made. RESULTS:A total of 196 small-DOZ and 167 2-flap palatoplasty patients were eligible in the study. Among the small-DOZ palatoplasty patients, 1 patient (0.5%) developed oronasal fistula and 18 patients (9.2%) developed velopharyngeal insufficiency (VPI) surgery (10 patients at preschool age, and 8 at 9 years of age). Compared with the small-DOZ palatoplasty, the oronasal fistula rate, VPI surgery rate, and the need for myringotomy tube insertion were significantly higher in the 2-flap group (P = 0.01, P < 0.01, and P < 0.01, respectively). Patients who developed oronasal fistula had significantly higher likelihood of having VPI (P < 0.01). CONCLUSIONS:The small-DOZ provided successful palatal repair with low rates of oronasal fistula and VPI in the long term. Wound closure under minimal tension facilitated avoiding oronasal fistula. Reconstruction of the functional muscle sling enabled the authors to achieve normal velopharyngeal function with favorable speech outcome and middle ear function. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

Background:Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature. Patients and methods:A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis. Results:A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient. Conclusion:Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.