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

Plastic and Reconstructive Surgery • March 2023

restriction, or if there would be catch-up growth in the PR group during puberty. In any case, our review only identified five studies that evaluated nasal growth objectively in patients with cleft lip or palate. Whereas the overall picture sug gests that nasal growth restriction is minimal after PR, this is an area where larger, prospec tive, long-term studies are needed. In particu lar, as surgeons continue to be more aggressive with septoplasty and septal dissection in PR, they should continue to follow their outcomes with growth measurements as well. This also does not answer the larger question of maxillary growth restriction after primary rhinoplasty, which would introduce more confounding because of other cleft procedures. Avoidance of Secondary Rhinoplasty Another longstanding question in cranio facial surgery is whether a primary rhinoplasty can decrease the need for definitive rhinoplasty at maturity. Five included studies evaluated 620 patients followed until a mean age of 15 years, with 81% of them not requiring a secondary rhi noplasty. The largest study by Salyer 7 included 400 patients, 20% of whom required a secondary procedure by age 15. However, this aspect of the literature is difficult to assess as opposed to stud ies showing objective measures. The decision to perform a secondary rhinoplasty is a complicated one, and includes surgeon bias, patient prefer ences, and practice pattern differences. However, the available literature does serve as a proof of concept that in experienced hands, a PR can be the final rhinoplasty in select patients. However, it also seems unlikely that secondary rhinoplasty will ever be completely or even mostly eliminated given the heterogeneity of clefting, prevalence of nasal airway obstruction in this population, and differences in patients’ aesthetic goals. Variability in Technique It is also clear from this study that “primary rhi noplasty” does not mean the same thing to all sur geons. A wide range of techniques were employed in the articles reviewed. In general, repairs can be categorized as the presence or absence of sep toplasty, open nasal incisions, and nasal tip dis section. These general groupings are noted in Table 1. These differences are impossible to con trol for in this type of review and are a significant weakness of this study methodology. Our systematic review is in a way limited to compare doing some thing to the nose primarily versus doing nothing.

Table 5. Avoidance of Secondary Rhinoplasty

Follow Up, Years

Percent Avoiding Secondary Rhinoplasty

Patients, n

Article

Anderl et al. 21 (2008) 130

>14

80 80

Salyer 7 (1986)

400 Up to 15

Seo et al. 13 (2020) McComb and Coghlan 11 (1996)

52 10

>17

43

18

100

Brusse et al. 29 (1999) 28

9

100

behind the creation of this study. To analyze this adequately, follow-up into puberty is necessary. Three studies evaluated patients from ages 14 to 19 years. 13,21,22 None of these studies discov ered growth impairment and one documented bone growth under the alar base. 21 Gawrych and Janiszewska-Olszowska 22 focused on sep tal deviation and found that septal position was maintained in 83% of patients with only 2% expe riencing severe deviation compared with the 48% severely deviated septums in those who did not have septoplasty. Albeit with shorter follow-up (6.5 years), Kim et al. 27 also support the notion that PR does not inhibit nasal growth, tip projection, or columel lar growth. Between 6 months postoperatively and 3 years, they found a 24.8% increase in nasal tip projection, 28.8% increase in columellar growth, and 12.3% increase in nasal width. No statisti cally significant differences between age-matched normal controls and those undergoing PR were found among these values. It is important to highlight the one study that found evidence of growth restriction after PR. Yoshimura et al. 24 found by means of 2D indirect anthropometric measurements that patients who underwent PR had a significantly worsened nasal height:dorsum ratio and colu mellar angle compared with both age-matched norms and patients undergoing cleft repair with out PR. The examiners then compared the three separate groups at ages 5 and 10 years. They discovered that patients with cleft lip or palate who underwent PR had a significant increase in nasal height ratio, decrease in nasal tip:height ratio, and an increase in columellar angle com pared with controls. This study was small, with 14 patients, and used ratios because of difficulty with exact measurements in 2D photographs, but was well-designed, with long-term follow-up. The surgical technique used was atypical in that children were operated on within 2 weeks of life. It is not clear if this study is underpowered, if the author’s technique timing resulted in growth

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