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

Plastic and Reconstructive Surgery • March 2023

Objective Outcomes Eighteen publications measured results objectively, 10,22–25 as demonstrated in Table 3. Objective assessment included measures of sep tal deviation, 22 two-dimensional (2D) indirect anthropometric measurements, 11,17,18,23,24,26–30 three-dimensional (3D) indirect anthropometric measurements, 10,13,31 direct anthropometric mea surements, 25,32,33 and nasal endoscopy. 16 The following comparison groups were applied in objective studies: unilateral cleft lip repair without septoplasty, 22,23 unilateral cleft lip repair without rhinoplasty, 11,16,24,25,27,29 age-matched norms, 10,11,13,24,27–30 and noncleft volunteers from the same population 31 ; two studies did not use a comparison group. 32,33 Three studies compared different rhinoplasty techniques. These included comparing lip repair and PR with cartilage graft placement versus lip repair and PR without car tilage graft placement, 18 lip repair and PR with versus without overcorrection, 26 and closed rhino plasty versus bilateral nostril rim incision versus Tajima incision on the cleft side and rim incision on noncleft side. 17 Fifteen of the 16 publications (94%) able to make a determination with objective evaluation supported PR during cleft lip repair. No septal deviation was found in 83% of those who under went septoplasty. 22 Of the nine articles that used 2D indirect anthropometric measurements, one identified concerns with PR. 24 Three-dimensional indirect anthropometric measurements using age-matched normal controls found a decreased subnasale and alar base difference between cleft and noncleft sides with PR 10 and no significant dif ferences were observed for most measurements between study participants and age-matched nor mal controls. 13 Direct anthropometric measure ments revealed a significant increase in nostril thickness symmetry and no difference in nostril diameter with PR compared with those who had cleft repair without rhinoplasty 25 and no signifi cant difference in nostril dome height or columel lar length when compared with the noncleft side. 32 Nasal endoscopy showed that 85% of patients who underwent rhinoseptoplasty had no significant septal deviation and a mean Friedman turbinate hypertrophy grade of 0.45 compared with 100% septal deviation and a turbinate grade of 2.8 in those who underwent cheiloplasty without rhino septoplasty. 16 Two studies had designs that could not evaluate whether PR had positive or negative results per se, but showed that PR does not result in complete facial symmetry 31 and results in some relapse after 9 months. 33

Of the 25 selected articles, eight were single surgeon case series, 16 were case–control stud ies, and one was a retrospective cohort study. In total, a population of 3354 patients with unilateral cleft lip were included. Study size ranged from 10 patients 11 to 1200. 12 Studies were published between 1986 7 and 2020. 10,13 There was signifi cant variation in the PR technique used, as can be seen in Table 1. Risk of bias in the selected articles overall was high using the ROBINS-I tool, with a majority of articles with high or critical risk (Fig. 2). Subjective Outcomes The results of PR during cleft lip repair were assessed subjectively in 10 publications. 7,12,14–21 Outcomes were assessed in multiple ways, includ ing five-point visual assessment scores, 17–19 the author or surgical team, 7,12,14,15,20,21 or the Nasal Obstructive Symptom Evaluation (NOSE) ques tionnaire, 16 as shown in Table 2. For many of the studies, a comparison group was not used. 7,12,19,20 Some studies compared patients with age-matched norms 15,21 or patients who underwent unilateral cleft lip repair without PR. 15,16 Two studies 17,18 compared different surgi cal techniques: unilateral cleft repair and rhino plasty with septal cartilage graft versus unilateral cleft repair and rhinoplasty without graft place ment 18 and closed rhinoplasty versus bilateral rim incisions versus cleft side Tajima incision and non cleft side rim incision. 17 All of the articles that measured subjective results (10/10) supported cleft lip repair with PR. Results that were assessed by means of a five-point visual analogue scale (VAS) revealed a mean score of 3.7 (based on highest VAS technique in comparative articles). 17–19 Author or surgical team assessment demonstrated positive results, with the following noteworthy examples: 80% of patients had a satisfactory result without need for revision at 14 years or variable, 7,21 94.3% had good to excellent result, 14 and although ranked behind normal controls, the cleft repair with rhinoplasty group was consistently ranked higher than those who had cleft repair without rhinoplasty based on symmetry and aesthetic outcomes. 15 The NOSE questionnaire revealed that those who under went repair with septorhinoplasty had a NOSE score of 21.4 versus 70.8 for the cheiloplasty without septorhinoplasty group, indicating that nasal obstruction was of less concern in the sep torhinoplasty group. 16

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