xRead - Treatment of Cleft Lip and Cleft Palate (May 2025)

Jayarajan et al

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term effect of primary rhinoplasty on secondary cleft rhino plasty (Haddock et al., 2012), it was found that the nasal tip was more symmetric and required less complex intervention during the definitive secondary procedure. A review on pri mary cleft rhinoplasty (Gudis and Patel, 2014) has concluded that this procedure reduces the frequency and magnitude of intermediate and definitive operations. A recent study from Japan (Yoshimura et al., 2015) where nasal growth evaluation using lateral cephalograms has been done to assess cases with and without primary rhinoplasty, growth of the nose was found to be adversely affected in the primary rhinoplasty cases. Although this study had a follow-up duration of 5 and 10 years, the sample size was very small—only 14 patients with and 12 without primary rhinoplasty. Narayanan and Adenwalla (2015) have not found any detrimental effect on growth with primary rhinoplasty, the senior author having performed thousands of unilateral cleft lips where he has been doing an aggressive correction of the cleft lip nose since 1960s. They have found that the overall shape and symmetry is better and extend of secondary deformity is much less. Primary rhinoplasty, which is addressing the nasal deformities at the time of initial cleft lip repair, is aimed at achieving better contour, symmetry, and projection of the nose. Various tech niques have been described to correct the cleft nose deformity (Salyer et al., 2004; Sykes and Jang, 2009; Haddock et al., 2012). Closed technique involves dissection of the skin overlying the lower lateral cartilages from either side through the incisions used for cleft lip repair (Shih and Sykes, 2002). Once the cartilage has been dissected free of the skin, they are resuspended using trans nasal sutures. Bolsters (McComb, 1975) were used initially, which have later been replaced by internal knots (Cutting, 1994). Radical nasal correction with an external incision on the columella and septal correction was advocated by Berkeley (Millard, 1976). Tajima (Tajima and Maruyama, 1977; Tajima, 1990) devised the reverse-U incision originally for use in second ary repairs of the cleft nasal deformity and was subsequently adapted for primary cleft nose. Combination of open reverse-U and alar rim incisions (Harashina, 1990) gives a wider exposure for open dissection of the cartilages. Open tip rhinoplasty incor porating an incision along the columella philtrum junction allows easy access to the tip for further refinements according to the study by Thomas (Thomas and Mishra, 2000; Thomas, 2009). Various modifications (Cutting, 1994; Mulliken and Martinez Perez, 1999; Wong et al., 2002) in primary rhinoplasty have resulted in significant improvement in the technique. The advan tages of primary rhinoplasty have been suggested by numerous investigators (Brusse et al., 1999; Haddock et al., 2012). Both open and closed techniques have evolved extensively. Proponents of either technique stand by their personal conviction. There is no evidence-based consensus so far as to which technique is superior in terms of outcome so as to be recommended. Methods Protocol was registered on the PROSPERO register of systema tic reviews (CRD42018086370). PRISMA-P guidelines for the

conduct of systematic review and meta-analysis protocol were followed.

Search Strategy The following electronic databases were searched:

Cochrane, PubMed, Embase, and LILACS BIREME (Latin American and Caribbean Health Science Information database) Ongoing trials: The Meta-Register of Controlled Trials. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov. The Australian New Zealand Clinical Trials Registry. The World Health Organization International Clinical Trials Registry Platform. The EU Clinical Trials Register. There were no restrictions in the search with regard to lan guage, study setting, or date of publication. Study Selection Studies were selected based on the following inclusion criteria: human study of rhinoplasty with primary repair of unilateral cleft lip. Open versus closed rhinoplasty technique comparisons as randomized controlled trials (RCTs) preferably, if not avail able prospective or retrospective cohorts, are to be included. Assessment of outcome should be ideally long term (5-14 years). As there are several techniques and modifications described for both open and closed primary cleft rhinoplasty varying from closed, semiopen, and open, no concrete definition is being given as such for either. Due to this ambiguity, all incisions resulting in exposure of alar cartilages have been taken as open and nonexposure with dissection of cartilage from dorsal skin as closed. Maneuvers of the alar base and sill are not included as part of the technique. Studies that did not meet the inclusion criteria, review articles, case reports, editorials, and letters were excluded. The population of interest is patients with nonsyndromic uni lateral cleft lip undergoing rhinoplasty along with primary cleft lip repair. The intervention is use of open rhinoplasty and the control is use of closed rhinoplasty technique. Outcome assess ment method is definitive anatomical measurements of the nose parameters during follow-up, which are reliable and reproduci ble. A 3-stage review process was followed. During the initial stage, the titles were reviewed by 2 reviewers, and the articles not relevant to the reviews were excluded. In the second stage, the abstracts of the selected articles were reviewed against the inclusion criteria. The final stage consisted of detailed review of the full texts selected by both reviewers. Discrepancies that arose were dealt with by discussion. Data Extraction We designed data extraction forms to record authorship, year of publication, and details of study based on inclusion criteria.