Sir:
We read with great interest the recent article by Mercan et al. entitled “Objective Assessment of the Unilateral Cleft Lip Nasal Deformity Using Three-Dimensional Stereophotogrammetry: Severity and Outcome.”1 The study has been well planned, and we appreciate the effort made by the authors to shed light on this topic.
We agree with the authors that correction of nasal deformity remains a challenge because of the complexity of the operation and because of its effect on facial growth. Asymmetry and relapse are common, and one of the main aspects is that residual or recurrent deformity can be accentuated with further time and growth, especially when endonasal anomalies are not properly corrected at the right time.2
High-quality aesthetic outcomes are of paramount importance for children growing up after cleft lip–cleft palate surgery, and defining objective and measurable endpoints is important in all health care, including cleft care. These objective endpoints are essential for the evaluation of care and are an important tool when comparing different treatment protocols. Identification of objective measurements would support the physicians in their decision-making and provide objective information on treatment effect progress over time. The article by Mercan et al. definitely provides an added value to the literature on this topic.
Nevertheless, we should keep in mind that it is essential to systemically analyze the functional implications of the aesthetic correction of the nasal deformities commonly associated with unilateral cleft lip–cleft palate. Although cleft lip nasal deformity has long been a recognized aspect of cleft lip and/or cleft palate, most attention has been paid to the aesthetic aspect of this deformity and to the means with which to improve appearance. A relatively neglected aspect is represented by endonasal deformities (septal deviation, compensatory hypertrophy of the inferior turbinate, and consequent nasal cavity narrowing, contributing to nasal obstruction) and the effect of these anomalies on the functional airway. The impaired nasal patency may exert a negative effect on other systems and organs that play a role in the somatic and psychic development of small patients, and this can be of particular relevance for children with special medical needs such as cleft lip–cleft palate patients.
In addition, nasal airway obstruction in patients with clefts might also affect the growth of the maxillofacial skeleton and result in various deformities, including class II malocclusion, open bite, and retrognathic mandible, that could compromise long-term aesthetic outcomes.3 In conclusion, we agree with the authors that anthropometric measurements could be used to quantify severity and outcome, not forgetting that the severity and the evaluation of the aesthetic results cannot be separated from the functional aspect that represents an important indicator of the long-term success of the operations performed to correct the nasal deformities of unilateral cleft lip–cleft palate patients.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this communication.
Valentina Pinto, M.D.
Department of Plastic and Reconstructive Surgery
Ottavio Piccin, M.D., M.Sc.
Department of Otolaryngology
Paolo G. Morselli, M.D.
Department of Plastic and Reconstructive Surgery
S. Orsola-Malpighi University Hospital
Bologna, Italy
REFERENCES
1. Mercan E, Oestreich M, Fisher DM, et al. Objective assessment of the unilateral cleft lip nasal deformity using three-dimensional stereophotogrammetry: Severity and outcome. Plast Reconstr Surg. 2018;141:547e558e.
2. Morselli PG, Pinto V, Negosanti L, Firinu A, Fabbri E. Early correction of septum JJ deformity in unilateral cleft lip-cleft palate. Plast Reconstr Surg. 2012;3:434441.
3. Zemann W, Kärcher H, Drevenšek M, Koželj V. Sagittal maxillary growth in children with unilateral cleft of the lip, alveolus and palate at the age of 10 years: An intercentre comparison. J Craniomaxillofac Surg. 2011;39:469474.
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