Improving Nasal Symmetry after Primary Cleft Rhinoplasty Kayva Crawford 1 , Matthew C Freeman PhD 2 and Andrew R Scott MD FACS 3 1 Tufts University School of Medicine – Boston, MA 2 Rollins School of Public Health, Emory University – Atlanta, GA 3 Department 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: [email protected] 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. Zero Sutures One Suture Two Sutures Objectives: To compare perceived nasal symmetry outcomes in patients who have undergone endonasal primary cleft 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 aesthetic index. Five 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 superior aesthetic outcomes compared to placement of one suture or sutureless cartilage repositioning. The average aesthetic score also increased with level of rater 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. 0.0000 0.5000 1.0000 1.5000 2.0000 2.5000 3.0000 3.5000 4.0000 Med Student Resident Attending Average Med Student Resident Attending Average Med Student Resident Attending Average Med Student Resident Attending Average 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. A B 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 1.0000 1.5000 2.0000 2.5000 3.0000 3.5000 4.0000 4.5000 5.0000 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