Long term comparison of the results of four techniques used for bilateral cleft nose repair a single surgeons experience

PEDIATRIC/CRANIOFACIAL
Long-Term Comparison of the Results of
Four Techniques Used for Bilateral Cleft Nose
Repair: A Single Surgeon’s Experience
Chun-Shin Chang, M.D.,
M.S.
Yu-Fang Liao, D.D.S., Ph.D.
Christopher Glenn Wallace,
M.D., M.S.
Fuan-Chiang Chan, M.D.
Eric Jein-Wein Liou, D.D.S.,
M.S.
Philip Kuo-Ting Chen, M.D.
M. Samuel Noordhoff, M.D.
Taoyuan, Taiwan

Background: The purpose of this study was to evaluate progressive changes in
surgical techniques and results, aiming for improved nasal shape in primary
bilateral cleft rhinoplasty.
Methods: This is an institutional review board–approved retrospective study.
Ninety-one consecutive patients with bilateral complete cleft lip underwent primary cheiloplasty with four different techniques of nasal reconstruction from
1992 to 2007 as follows: group I, primary rhinoplasty alone; group II, nasoalveolar molding alone; group III, nasoalveolar molding plus primary rhinoplasty;
group IV, nasoalveolar molding plus primary rhinoplasty with overcorrection;
and group V, patients without cleft lip. The surgical results were analyzed using
photographic records obtained at age 3 years. Four measurements and one
angle measurement were obtained. A panel assessment was obtained to grade
the appearance of the surgical results.
Results: The results are expressed in order from groups I through V. The nostril height-to-width ratio was 0.49, 0.59, 0.62, 0.78, and 0.82, respectively. The
nasal tip height–to–nasal width ratio was 0.29, 0.39, 0.49, 0.57, and 0.60. The
columella height–to–nasal width ratio was 0.11, 0.18, 0.22, 0.27, and 0.28. The
dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.10. The nostril area ratio was 1.2, 1.17, 1.13, 1.11, and 1.07. The nasolabial angle was 144.95, 143.98,

121.98, 120.99, and 100.88. Finally, group IV had the best panel assessment.
Conclusions: The results revealed that group IV had the best overall result.
Presurgical nasoalveolar molding followed by primary rhinoplasty with overcorrection resulted in a nasal appearance that was closer to the patients without
cleft lip.  (Plast. Reconstr. Surg. 134: 926e, 2014.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

B

ilateral cleft lip nose reconstruction is more
challenging than unilateral cleft lip nose
reconstruction. The midline structure is deficient in patients with bilateral complete cleft lip,
characterized by a small prolabium, small premaxilla with deficient columella, and deformed lower
lateral cartilage.1 In our previous study, overcorrection on the cleft side nostril in patients with unilateral complete cleft lip produced the best surgical
From the Department of Chemical and Materials Engineering, College of Engineering, Chang Gung University; and
the Craniofacial Research Center, Departments of Medical
Research, Plastic and Reconstructive Surgery, and Orthodontics, Craniofacial Dentistry and the Craniofacial Center,
Chang Gung Memorial Hospital.
Received for publication February 17, 2014; accepted May
28, 2014.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000715

926e

results.2 The effect of overcorrection of both nostrils in patients with bilateral complete cleft lip has
not previously been addressed in the literature.
Two-stage reconstructions with the banked
forked flap were once popular in our institution
for the management of bilateral cleft lip nose
deformity. Elongation of the columella was performed at age 1 to 6 years by advancing nasal floor

tissue onto the columella and repositioning the
alar cartilage. When the nasal floor tissues were
inadequate, the elongation was performed using
a composite auricular graft. In our experience,
regardless of which methods were used, the scars
were unsightly (compounded by the effect of scar
contracture at this age) and the nostrils appeared
unnatural (Fig. 1).
Disclosure: The authors have no financial interest in
any of the products or devices mentioned in this article.

www.PRSJournal.com


Volume 134, Number 6 • Bilateral Cleft Nose Repair
PATIENTS AND METHODS

Fig. 1. A long-term result of two-stage rhinoplasty using a
banked forked flap. There is a noticeable scar contracture over
the columella, and the nostril shape appears unnatural.

During the late 1980s and early 1990s, the
senior author (P.K.T.C.) performed closed rhinoplasty in conjunction with primary cheiloplasty.
The cartilage dissection was performed through
the columella. The advent of presurgical nasoalveolar molding enabled elongation of the columella and molding of the protruded premaxilla
preoperatively. After the introduction of nasoalveolar molding, from 1996 to 2001, the senior
author did not perform primary cleft rhinoplasty in conjunction with primary cheiloplasty
for bilateral cleft lip patients who had undergone presurgical nasoalveolar molding. This was
because a satisfactory nasal shape was obtained
immediately after primary cheiloplasty. However, the senior author observed a progressive

deterioration in the cleft nasal appearance with
time; therefore, after 2001, primary open rhinoplasty with bilateral rim incisions was added at
the time of bilateral cheiloplasty. This improved
the elongation of the columella. Unfortunately,
a reduction in columella length within the first
and second years postoperatively was noticed.3 In
2003, overcorrection of the cleft nose was added
in an attempt to address this less than satisfactory clinical outcome. We added the bilateral
Tajima incision to lengthen the columella and to
prevent webbing in the nasal soft triangle. Furthermore, silicone sheets were added to the nasal
stent to maintain the nose in an overcorrected
fashion. The objective of the present study was to
compare the long-term columella stability, nostril shape, the nasal tip projection and nasolabial
angle of these four techniques of primary bilateral cleft rhinoplasty.

This retrospective study, designed to investigate
the long-term effect of nasoalveolar molding and
primary rhinoplasty with or without overcorrection
in bilateral cleft lip patients, was approved by the
Institutional Review Board of Chang Gung Memorial Hospital. Ninety-one complete bilateral cleft lip
patients were selected from four groups of children
who underwent four different treatment protocols.
They were treated at the Craniofacial Center of
Chang Gung Memorial Hospital from 1992 to 2007.
The groups were numbered from I to IV to
represent the progression of technical modifications over this period as follows: group I (23
patients), primary rhinoplasty alone; group II (19
patients), nasoalveolar molding alone; group III
(24 patients), nasoalveolar molding plus primary
rhinoplasty; and group IV (25 patients), nasoalveolar molding plus primary rhinoplasty with overcorrection. The inclusion criteria were as follows:

(1) complete bilateral cleft lip–cleft palate, (2) no
other craniofacial malformations, (3) preoperative nasoalveolar molding for groups II through IV,
(4) primary cheiloplasty performed by the same
surgeon (P.K.T.C.) at approximately 3 months of
age, (5) postoperative nasal stent used for more
than 6 months, and (6) available basilar view photograph at approximately 3 years of age. We also
included a group V with 23 consecutive cleft palate patients who underwent palatoplasty between
2006 to 2008 for comparison. The inclusion criteria for group V were as follows: (1) patients with
incomplete cleft palate, (2) patients without cleft
lip, (3) patients with no other craniofacial malformation, and (4) available basilar view photograph
at approximately 3 years of age. A summary of
groups I through V is listed in Figure 2.
Presurgical Nasoalveolar Molding
The nasoalveolar molding device was composed of a dental plate and two nasal components,
which enabled alveolar and nasal molding to be
performed at the same time. The nasal component
was composed of two soft resin bulbs attached to
the acrylic plate by stainless steel wires. Denture
adhesive was used to stick the dental plate onto
the palate and dental arches. We used Micropore
tapes (3M, St. Paul, Minn.) to approximate the
cleft lip and to retract the prolabium. The nasal
molding bulb was adjusted every 1 to 2 weeks and
the premaxilla was retracted into a position where
the discrepancy between the roof of the columella
and the lower lateral crus of the nasal cartilage
was less than 4 mm, and the columella was at least
3 mm in length.3

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Plastic and Reconstructive Surgery • December 2014

Fig. 2. Summary of the five groups. Group I, no presurgical nasoalveolar molding. This
group underwent closed rhinoplasty, and the dissection of fibrofatty tissue from the
lower lateral cartilages was performed through the columella. Group II, presurgical
nasoalveolar molding; no primary rhinoplasty was performed. There was no dissection
of the fibrofatty tissue from the lower lateral cartilages. Group III, presurgical nasoalveolar molding; open rhinoplasty, the philtral flap and forked flap were elevated with extension behind the columella. The incision was continuous with the bilateral rim incisions.
Group IV, presurgical nasoalveolar molding; semiopen rhinoplasty, the philtral flap and
forked flap were elevated with extension of just one-third behind the columella. The
columella was not separated completely from the underlying medial crura of the lower
lateral cartilages. Other inverse-U incisions were made over the nostril dome. There was
no connection between the incision behind the columella and the inverse-U incisions.
NAM, nasoalveolar molding.

Primary Cheiloplasty and Rhinoplasty
The markings of bilateral cheiloplasty were as
described before. The width of the central lip at
the bottom was maintained at 4 mm. The central
segment was narrowed gradually down to 3 mm
at the base of columella. The philtral flap and
forked flap were elevated. In group I, with closed
blunt dissection through the columella, fibrofatty
tissue was dissected off the lower lateral cartilage.
For group II, there was no primary rhinoplasty.
In group III, as for traditional open rhinoplasty,
there was an extension behind the columella up
to the lower border of the lower lateral cartilage.
The central segment, forked flap, and columella

together with the bilateral rim incision were raised
together to expose the lower lateral cartilages. For
group IV, the senior author (P.K.T.C.) made several modifications. First, the forked flap incision
was extended behind the columella up to just onethird of the columella. Bilateral Tajima incisions

928e

were made on both alar rims to expose the lower
lateral cartilages. The Tajima incisions did not
connect to the incisions behind the columella. For
groups I, III, and IV, the separated lower lateral
cartilages were approximated by mattress sutures
using 5-0 polydioxanone (transdomal suture). By
approximating the lower lateral cartilages, the
skin of the inverted-U incision was turned inward,
elongating the columella. The skin excess at the
rim of the nostril was excised. Two through-andthrough sutures using 5-0 polydioxanone were
placed on the septum and an additional two alartransfixion sutures were placed in the alar-facial
groove on each side to provide further support
to the lower lateral cartilages.4 In groups I and
II, there were no specific strategies for nasolabial
angle reconstruction. In group III, the lateral part
of the central segment of skin flap between the
columella and philtrum (forked flap) was sutured
in a cephalic-posterior fashion to the nasal septum


Volume 134, Number 6 • Bilateral Cleft Nose Repair
to create a more acute nasolabial angle. In group
IV, unlike traditional open rhinoplasty, the attachment of the columella-labial junction was not completely freed. The lateral segment development,

nasal floor reconstruction, muscle reconstruction,
and Cupid’s bow reconstruction were performed
as described previously.5
Postoperative Nasal Stent
A silicone nasal conformer (Koken Co., Tokyo,
Japan) of appropriate size was used on postoperative day 6 when sutures were removed, and used
for at least 6 months. In group IV, overcorrection
of the nostrils was maintained with silicone sheets
(cut from 1-mm-thick silicone tubing); these were
added during the first-, second-, and third-month
visits and used for a total of 6 months (Fig. 3).
The nasal conformer was fixed with half-inch 3M
Micropore tapes approximately 5 cm in length;
two holes were created with a hole puncher to
match to the position of each nostril.
Records and Measurements
All measurements were performed by the
first author (C.S.C.). The first author was blinded
regarding the treatment group to which the
patient belonged. The standard basilar view and
lateral photographs of each patient at age 3 years
were used in this study. For the basilar photograph,
a horizontal reference line was constructed by connecting the most inward point at the outer lateral
borders of the cleft and noncleft nostrils. The measurements were obtained using Photoshop CS5
Extended Version 12.0 (Adobe Systems, Inc., San
Jose, Calif.). The measurements were as follows:

Fig. 3. For group IV, one silicone sheet was added to both sides
of the nasal conformer each month. A total of three silicone
sheets were added at the end of 3 months. The nasal stent for

group IV was used for at least 6 months.

• Nasal width: The horizontal distance
between the most outward point of the
outer lateral border of the nostril aperture.
• Nasal tip height: The vertical distance
between the horizontal reference line to
the highest point of the nasal tip.
• Columella height: The vertical distance
between the most superomedial point of
the nostril aperture to the horizontal reference line.
• Dome height: The vertical distance between
the most superomedial point of the nostril
aperture to the highest point of the nasal tip.
• Nostril height: The vertical distance
between the lowest point to the highest
point of the nostril aperture.
• Nostril width: The widest horizontal distance between the inner medial and lateral
border of the nostril aperture.
• Nostril area: The area presented by the nostril aperture.
The following five ratios were calculated and
one angle was measured (Figs. 4 and 5):
•
•
•
•

Nostril height-to-width ratio of both nostrils.
Nasal tip height–to–nasal width ratio.
Columella height–to–nasal width ratio.

Dome height–to–columella height of both
nostrils. When the nostril heights were different on each side, the midpoint of both highest points of the nostril apertures was taken
to measure the dome and columella length.
• Nostril symmetry: Larger nostril area/
smaller nostril area.
• Nasolabial angle: The angle formed by the
inferior border of the columella and the
labial surface of the upper lip. This angle is
measured on the lateral photograph.
Panel Assessment
A five-point visual analogue scale was used to
assess the patient’s nasal shape. The nasal shape
in groups I through IV was graded by six examiners (three expert cleft physicians and three laypersons). The normal patient’s photographs were first
shown to each examiner, and then the independent
examiners were blinded with regard to the groups to
which the patients belonged. The results were classified as follows: 1, very poor (flat nose, wide nasal tip,
horizontal displaced tear shape nostril, obvious nasal
webbing, and obvious cleft ala deformity); 2, poor; 3,
fair (oval nostril with indentation); 4, good; and 5,
very good (good nasal tip projection, rounded nostril, no indentation, resembling a normal nostril).

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Plastic and Reconstructive Surgery • December 2014

Fig. 4. Ratios and measurements. (Above, left) Ratio of nostril height and width. (Above, right) Ratio
of nasal tip height and nasal width. (Below, left) Ratio of columella height and nasal width. (Below,
right) Dome-to-columella ratio (A, dome height; B, columella height).

Fig. 5. Nostril symmetry and nasolabial angle. (Left) The nasolabial angle is the angle formed by the inferior
border of the columella and labial surface of the upper lip on lateral photography. (Right) nostril symmetry was
calculated with the larger nostril area (black) and the smaller nostril area (red).

Statistical Analysis
After the data points were measured in units
of pixels, the ratios were determined and the data
collected from five groups were analyzed and
compared. The measurements were analyzed with
analysis of variance. For the visual analogue scale
assessment, the interrater reliability was tested
with the kappa test.
Method of Errors
The method of errors was assessed for photograph variance, and the ratios of nostril height
and nostril width were measured and calculated
in photographs of five different randomly selected
patients. The two photographs of the same patient

930e

were taken 1 day apart. The ratios were analyzed
with correlation analysis (Pearson’s analysis) for
photograph reliability.

RESULTS
The method of errors showed a highly significant correlation for the nostril height-to-width ratio
(r = 0.940, p = 0.017) between the photographs.
Severity of Cleft on Initial Visit
The severity of nasal deformity was assessed at
the time of initial visit using the ratio of nasal tip

height and nasal width, calculated from standard
photographs. The ratio of nasal tip height and


Volume 134, Number 6 • Bilateral Cleft Nose Repair
nasal width on initial visit was 0.36, 0.39, 0.37, and
0.38 in groups I, II, II, and IV, respectively. There
was no statistically significant difference between
the four groups (p = 0.616, analysis of variance),
indicating that groups I through IV had similar
severity of nasal deformity on initial presentation.
Ratio of Nostril Height and Width
The ratio of nostril height and width was 0.49,
0.59, 0.62, 0.78, and 0.82 for groups I through V,
respectively. Group IV had a nostril height-to-width
ratio that was almost comparable to the patients without cleft lip, and group I had the lowest ratio of nostril height and width. The difference between group
IV compared with groups I through III was statistically significant (Tables 1 and 2). This indicated that
overcorrection was necessary to maintain a better
nostril height-to-width ratio over the long term.
Ratio of Nasal Tip Height and Nasal Width
If an aesthetic basal nasal shape is an equilateral triangle in the adult, this ratio would be
0.86. In patients without cleft lip, the nasal tip
height is lower. The ratio of nasal tip height and
nasal width was 0.29, 0.39, 0.49, 0.57, and 0.60 for
groups I through V, respectively. Group IV had a
nasal tip height-to-width ratio that was closest to
that of group V, and the difference between group
IV compared with groups I through III was statistically significant (Tables 3 and 4).

Table 3.  Ratio of Nasal Tip Height and Nasal Width

Group

No.

Mean

SD

p*

I
II
III
IV
V

23
19
24
25
23

0.29
0.39
0.49
0.57
0.60

0.07
0.1

0.08
0.05
0.07

0.000

*Analysis of variance.

Table 4.  Intergroup Comparison, Mean Ratio
Difference: p Value Calculated by the Bonferroni
Method
Group
Group
II
III
IV
V

I

II

III

IV

0.000
0.000
0.000
0.000

0.000
0.000
0.000

0.001
0.000

0.153

was closest to that for group V. Group IV showed
a statistically significant difference from the other
three groups (Tables 5 and 6). This showed that
the bilateral Tajima incision after nasoalveolar
molding could achieve a columella comparable to
group V and was able to correct nasal webbing.

Ratio of Columella Height and Nasal Width
The ratio of columella height and nasal width
was 0.11, 0.18, 0.22, 0.27, and 0.28 for groups I
through V, respectively. The ratio for group IV

Dome-to-Columella Ratio
The dome-to-columella ratio was 1.88,
1.25, 1.26, 1.14, and 1.1 for groups I through V,
respectively. Group I had the highest dome-tocolumella ratio compared with the other groups
(Tables 7 and 8). This indicates that group I had
the shortest columella in relation to nasal tip
height. Accordingly, nasoalveolar molding had a

Table 1.  Ratio of Nostril Height and Width

Table 5.  Ratio of Columella Height and Nasal Width

Group

No.

Mean

SD

I
II
III
IV
V

23
19
24
25
23

0.49
0.59
0.62
0.78
0.82

0.35
0.08
0.09
0.13
0.16

p*

0.000

Group

No.

Mean

SD

p*

I
II
III
IV
V

23
19
24
25

23

0.11
0.18
0.22
0.27
0.28

0.05
0.04
0.04
0.03
0.03

0.000

*Analysis of variance.

*Analysis of variance.

Table 2.  Intergroup Comparison, Mean
Ratio Difference: p Value Calculated by the
Bonferroni Method

Table 6.  Intergroup Comparison, Mean
Ratio Difference: p Value Calculated by the
Bonferroni Method

Group
Group

II
III
IV
V

I
0.067
0.014
0.000
0.000

II
0.612
0.005
0.000

Group
III
0.005
0.001

IV

0.481

Group
II
III
IV
V

I

II

III

IV

0.000
0.000
0.000
0.000

0.003
0.000
0.000

0.000
0.000

0.107

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Plastic and Reconstructive Surgery • December 2014
Table 7.  Dome-to-Columella Ratio
Group

No.

Mean

SD

p*

I
II
III
IV
V

23
19
24
25
23

1.88
1.25
1.26
1.14
1.1

0.78
0.5
0.4
0.28

0.19

0.000

*Analysis of variance.

Table 8.  Intergroup Comparison, Mean
Ratio Difference: p Value Calculated by the
Bonferroni Method
Group
Group
II
III
IV
V

I

II

III

IV

0.000
0.000
0.000
0.000

0.954

0.460
0.324

0.396
0.268

0.779

a statistically significant increase of nasolabial
angle compared with group V. Nasoalveolar molding and primary rhinoplasty (either rim incision
or Tajima incision) showed a statistically significant less increase of nasolabial angle compared
with the rhinoplasty-alone and nasoalveolar molding–alone groups (Tables 11 and 12).
Panel Assessment
For panel assessment, the interobserver reliability was assessed. This was analyzed with the
kappa test, and showed good interobserver reliability (kappa = 0.88, 0.87, 0.90, and 0.84 for
groups I through IV, respectively). Group IV had
the best panel assessment score compared with
groups III, II, and I (Tables 13 through 15).

DISCUSSION

Nasolabial Angle
The nasolabial angle was 144.95, 143.98,
121.98, 120.99, and 100.88 for groups I through
group V, respectively. Groups I through IV showed

The reconstruction of bilateral cleft lip–cleft
nose deformity is difficult and demanding. The
principles of bilateral cleft nose reconstruction
are as follows: (1) release and reposition the lower

lateral cartilages; (2) produce adequate columella
length; (3) prevent soft triangle nasal webbing;
(4) provide adequate nasal tip projection; (5)
provide adequate nostril shape with good nostril
height while limiting nostril width; and (6) maintain a good nasolabial angle.6 In many instances, a
two-stage correction with columella elongation as
a secondary procedure was necessary to produce
an adequate bilateral cleft nose reconstruction.7–16
Millard suggested preserving the prolabial tissue
lateral to the central segment as forked flaps that
were banked on the nasal floor.8,17 There was a

Table 9.  Nostril Area Ratio

Table 11.  Nasolabial Angle

direct impact on increasing columella height in
relation to nasal tip height.
Nostril Symmetry
The ratio of nostril area was 1.2, 1.17, 1.13,
1.11, and 1.07 for groups I through V, respectively.
Groups III and IV had different nostril symmetry
than groups I and II (Tables 9 and10). Thus, rim
and Tajima incisions did not produce particular
differences in this aspect.

Group

No.

Mean

SD

I
II
III
IV
V

23
19
24
25
23

1.2
1.17
1.13
1.11
1.07

0.19
0.09
0.1
0.07
0.07

p*

0.002

Group

No.

Mean

SD

p*

I
II
III
IV
V

23
19
24
25
23

144.95
143.98
121.98
120.99
100.88

6.95
11.45
15.98
17.83
9.54

0.000

*Analysis of variance.

*Analysis of variance.

Table 10.  Intergroup Comparison, Mean
Ratio Difference: p Value Calculated by the
Bonferroni Method

Table 12.  Intergroup Comparison, Mean
Ratio Difference: p Value Calculated by the
Bonferroni Method

Group
Group
II
III
IV
V

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I

0.526
0.059
0.008
0.000

II
0.245
0.060
0.004

Group
III
0.446
0.064

IV

0.259

Group
II
III
IV
V

I

II

III

IV

0.814
0.000
0.000
0.000

0.000
0.000
0.000

0.792
0.000

0.000


Volume 134, Number 6 • Bilateral Cleft Nose Repair
Table 13.  Panel Assessment
Group

Average Scores

p*

1.95
3.17
4.15
4.59

0.000

I
II
III
IV
*Analysis of variance.

Table 14.  Intergroup Comparison, Mean
Ratio Difference: p Value Calculated by the
Bonferroni Method
Group
Group
II
III
IV

I

II

III

0.000
0.000
0.000

0.000
0.000

0.005

Table 15.  Reliability Analysis*
Kappa

Group I
0.88

Group II
0.87

Group III
0.90

Group IV
0.84

*The reliability test is calculated using the kappa test.

period of almost one decade where we used muscle repositioning and banked forked flap cheiloplasty for bilateral cleft lip reconstruction. The
elongation of the premaxilla was performed at
1 to 6 years of age by advancing nasal floor tissue onto the columella and lower lateral cartilage repositioning with transfixion sutures. The
columella was elongated and the nostril shape
appeared improved.5 This was abandoned later
because it was technically highly complicated.6
Moreover, because of the increased rate of unfavorable scarring in Asians compared with Caucasians, many of our patients complained of the
permanent unsightly scar over the lower part of
the columella (Fig. 1).
One-stage bilateral cleft nose reconstruction

was then proposed. The primary closed rhinoplasty technique was used. Fibrofatty tissues were
released from the lower lateral cartilages through
the columella. The lower lateral cartilages were
then fixed medially and superiorly through several transfixion sutures.
With the introduction of modern techniques
of presurgical orthopedics and nasoalveolar molding, a better skeletal foundation and nasal shape
for repair of the bilateral cleft lip–cleft nose deformity were achieved.18–20 These techniques were
instituted in the late 1990s. The senior author
(P.K.T.C.), working together with our orthodontists (mainly E.J.W.L.), went through a journey of

investigation and adaptation of the surgical technique of primary bilateral cleft nasal repair to the
use of nasoalveolar molding. Initially, we were
content with the results of presurgical nasoalveolar molding and did not perform primary cleft rhinoplasty. Unfortunately, the relapse of the stigma
of the bilateral cleft nose deformity was evident at
1 year of age. Thus, we adopted traditional open
rhinoplasty.21 The philtral flap and forked flap
were elevated together. The incision was extended
behind the columella and connected to bilateral
rim incisions; we dissected fibrofatty tissues from
the lower lateral cartilages. The lower lateral cartilage repositioning was performed with transfixion sutures. With this method, the forked flap
was sutured back to the junction of the columellaphiltrum area in a cephalic and posterior fashion.
The nasolabial angle was improved compared with
the previous two groups. With this method, the
columella remained the same length for the first
3 years, whereas the nasal tip height kept increasing year by year. We found that the nasal tip kept
increasing in its upper part and the lower part
(columella) remained the same. The columella is
still short compared with nasal tip height.3
The final changes added the concept of overcorrection with exposure of the lower lateral
cartilage through bilateral Tajima incisions, the

other modification being that we extend the incision behind the columella to only one-third of
the columella. The fibrofatty tissue was released
from the lower lateral cartilages through the
inverted-U incisions. After transfixion sutures, the
reverse-U flap was reflected.22 In almost all cases,
some excess of the reverse-U flap was noticed and
trimmed off. To maintain the columella length, a
nasal conformer was used during the first clinic
visit. One silicone sheet was added to the nasal
conformer per month up to a total of three layers
of silicone sheets to each side of the nasal conformer (Fig. 3).
Group I underwent only primary closed rhinoplasty, without presurgical lengthening of the
columella, resulting in an inadequate columella
length and nasal tip height even with the use of
a nasal conformer for more than 6 months. The
typical bilateral cleft nose deformity was observed
soon after the children stopped wearing the nasal
conformer. Group II underwent only nasoalveolar molding. From this study, it would appear that
without the fibrofatty tissue release and without
lower lateral suspension, nasoalveolar molding
alone would obtain a result similar to that of
primary closed rhinoplasty alone. In group III,
the traditional open rhinoplasty technique, as

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Plastic and Reconstructive Surgery • December 2014
described by Trott and Mohan, was added after
nasoalveolar molding.21 After the columella was

sufficiently elongated with nasoalveolar molding,
the columella was further improved with primary
open rhinoplasty. However, the columella length
remained the same up to 3 years after surgery,
whereas the nostril height, nostril width, and
nasal tip height grew significantly.3 The relative
shortness of the columella gave the impression of
a reduction of columella length. In group IV, the
lower lateral cartilage was approached with Tajima
incisions. With overcorrection, this group had the
nostril height-to-width ratio closest to the patients
without cleft lip. It had the columella length and
nasal tip height in relation to nasal width closest
to the patients without cleft lip. This group also
had the best panel assessment score.
In the present study, all of the groups have
an increased nasolabial angle, with groups III
and IV having the least increase. Our orthodontists always emphasize that the nasal component
of nasoalveolar molding should push the nasal
dome forward, instead of pushing the nasal dome
up. With rhinoplasty, we could further increase
the length of the columella and further improve
the nasal shape. In group III, the forked flap is
sutured back to the columella-philtrum junction
in a cephalic-posterior direction to create a better
nasolabial fold. In group IV, the columella is not

completely separated from the medial crura as
in group III; the attached upper two-thirds of the
columella would give a better nasolabial angle

comparable to group III. Thus, with this study, we
hypothesize that presurgical nasoalveolar molding plus primary rhinoplasty (either traditional
open rhinoplasty or semiopen rhinoplasty with
Tajima incision) could decrease the nasolabial
angle to a lesser degree than nasoalveolar molding alone or surgery alone.
Presurgical nasoalveolar molding can
improve nasal symmetry before surgical correction.23 However, without surgical repositioning of the lower lateral cartilages, some relapse
might result from the less than satisfactory nostril symmetry in our group II. Presurgical nasoalveolar molding followed by open or semiopen
rhinoplasty could improve nostril area symmetry
between both nostrils.
There are some limitations to this study. First,
it is retrospective. This limitation was minimized
by the selection of consecutive patients and the
blinding of the investigator involved in performing the measurements. Further randomized trials
might be needed to confirm our findings. Moreover, the present study relied on two-dimensional
measurements, which were our preferred method
because standard craniofacial photographs are
noninvasive, acceptable by both the patient and

Fig. 6. (Above, left) Typical photograph of a group I patient at age 3 years. (Above, right) Typical
photograph of a group II patient at age 3 years. (Below, left) Typical photograph of a group III
patient at age 3 years. (Below, right) Typical photograph of a group IV patient at age 3 years.

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Volume 134, Number 6 • Bilateral Cleft Nose Repair

Fig. 7. Photographs of one of the patients from group IV with the longest follow-up shown (above, left) at first visit; (center) after
nasoalveolar molding, just before surgery; and (right) after surgery. Photographs obtained at (below, left) 1 year, (center) 3 years,

and (right) 7 years.

the parents, and cost-effective. To minimize errors
with this technique, all the photographs were
taken by the same photographer, and the measurements were evaluated as ratios. Other techniques such as three-dimensional photographs,
nasal impressions, or direct measurements over
the patient’s face might be used in the future to
obtain more accurate measurements.
In this study, we concluded that the addition
of overcorrection after nasoalveolar molding
achieved the best overall result with a nasal appearance that was closer to that of patients without
cleft lip (Figs. 6 and 7). This is the method that is
currently recommended to our bilateral cleft lip
patients. However, further technical modifications
are necessary to reduce the nasolabial angle.
Philip Kuo-Ting Chen, M.D.
Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital at Taoyuan
5, Fu-Hsin Street
Guei-Shan 333, Taoyuan, Taiwan


PATIENT CONSENT

Parents or guardians provided written consent for
the use of patients’ images.
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