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The Cleft Palate-Craniofacial Journal 56(1)

to correct. The longest follow-up reported is 14 years (Thomas, 2009) and has mentioned that there has been no trauma to the nasal cartilage complex. Overcorrection of the cleft nostril at the time of primary rhinocheiloplasty has been used in few studies with good results. Kim et al. (2004), as mentioned above, has used Tajima with overcorrection of cleft nostril and obtained good correc tion and symmetry with no significant difference from the nor mal children on 3-year follow-up. Lo (2006) has obtained better symmetry compensating for relapse during the post operative period by using the Tajima technique. The compara tive studies by Chang et al. (2010), Lu et al. (2012), and Lonic et al. (2016) have also confirmed this. The study by Chang et al used a progressively overcorrecting splint postoperatively. The last 4 studies are from the same institution. Long-term follow up on these cases regarding need for, and extend of, secondary surgery is unavailable. We came across 2 studies on use of internal resorbable splint (polyglycolic acid/polylactic acid) over the corrected alar car tilages. Wong et al. (2002) has used the splint during primary rhinoplasty on 15 patients, average age of 5 months. After a mean follow-up period of 20.4 months, photogrammetry anal ysis of the alar contour was used for assessment and they found a definitive improvement in symmetry compared to controls and has concluded that an internal splint protects alar cartilage longer than external splint. The second study by Linden et al. (2017) on 20 patients with and 18 without the internal splint on 3-D photogrammetry showed no improvement in nasal sym metry with use of the splint. Due to the heterogeneity of the methods of study and scarcity of standardized outcome assess ment, we were not able to do a meta-analysis or compare the data from the available studies. Conclusion This systematic review was an attempt to arrive at a consensus based on the trials and studies available so far as to whether open technique or closed technique of rhinoplasty at the time of primary lip repair gives superior results consistently on follow up. Best possible evidence based on a meta-analysis of multiple RCTs is not available due to the lack of such trials. There is insufficient evidence to support or refute the hypothesis put forward in the review. A unified research strat egy in clefts is required to conduct high-quality multicenter RCTs in centers with heavy caseloads. There is no concur rence on methods of assessment of outcomes at present. Stan dardization of photo capturing techniques, establishment of specific landmarks, and use of definitive anatomical measure ments using 2-D or 3-D digital photogrammetry will be essen tial to make the outcome measurement reliable and reproducible.

Available from http://www.crd.york.ac.uk/PROSPERO/display_ record.php?ID ¼ CRD42018086370. Acknowledgments The review team would like to thank Education Library Team, Uni versity Hospitals of Leicester for their support with the search and material for this review. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, author ship, and/or publication of this article. ORCID iD Rajshree Jayarajan, MCh, FEBOPRAS http://orcid.org/0000-0002 4002-3894 References Ahmed MK, Bui AH, Taioli E. Epidemiology of cleft lip and palate. In: Amasri MA, eds. Designing Strategies for Cleft Lip and Palate Care . Rijeka, Croatia: Intech Open; 2017. doi:10.5772/67165. https://www.intechopen.com/books/designing-strategies-for-cleft lip-and-palate-care/epidemiology-of-cleft-lip-and-palate. Accessed Februaury 8, 2018. Ahuja RB. Primary rhinoplasty in unilateral cleft patients: the “limited open” approach and other technical considerations. Cleft Palate Craniofac J . 2006;43(4):492-498. Brusse CA, Van der Werff JF, Stevens HP, Vermeij-Keers C, Prahl Andersen B, Van der Meulen JC, Vaandrager JM. Symmetry and morbidity assessment of unilateral complete cleft lip nose cor rected with or without primary nasal correction. Cleft Palate Cra niofac. J . 1999;36(4):361-366. Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS. Long-term comparison of four techniques for obtaining nasal sym metry in unilateral complete cleft lip patients: a single surgeon’s experience. Plast Reconstr Surg . 2010;126(4):1276-1284. Chowchuen B, Keinprasit C, Pradubwong S. Primary unilateral cleft lip-nose repair: the Tawanchai cleft center’s integrated and func tional reconstruction. J Med Assoc Thai . 2010;93(4):34-44. Cutting C. Cleft lip nasal reconstruction. In: Rees T, La Trenta G, eds. Aesthetic Plastic Surgery . Philadelphia, PA: WB Saunders; 1994: 497-532. Gudis DA, Patel KG. Update on primary cleft lip rhinoplasty. Curr Opin Otolaryngol Head Neck Surg . 2014;22(4):260-266. Haddock NT, McRae MH, Cutting CB. Long-term effect of primary cleft rhinoplasty on secondary cleft rhinoplasty in patients with unilateral cleft lip-cleft palate. Plast Reconstr Surg . 2012;129(3): 740-748. Harashina T. Open reverse-U incision technique for secondary cor rection of unilateral cleft lip nose deformity. Br J Plast Surg . 1990; 43(5):557-564. Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane

Authors’ Note Protocol registered with PROSPERO (International prospective reg ister of systematic reviews) Registration number: CRD42018086370.

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