Long-Term Outcome of Primary Rhinoplasty with Overcorrection in Patients with Unilateral Cleft Lip: Avoiding Intermediate Rhinoplasty

Abstract

Background: 

No consensus exists regarding the timing or technique of rhinoplasty for correction of the unilateral cleft lip nose deformity, with few studies examining the long-term effects of a single technique. This study appraised the long-term outcomes of primary rhinoplasty using the Tajima technique for overcorrection in a cohort of patients with unilateral cleft lip nose deformity after attaining skeletal maturity.

Methods: 

Consecutive nonsyndromic patients with unilateral cleft lip nose deformity (n = 103) who underwent primary rhinoplasty with overcorrection by a single surgeon between 2000 and 2005 were reviewed. Patients with unilateral cleft lip and nasal deformity who underwent primary rhinoplasty (but with no overcorrection) (n = 30) and noncleft individuals (n = 27) were recruited for comparison. Outcomes were assessed through FACE-Q scales evaluating satisfaction with appearance of nose and nostrils (two scales) and computer-based objective photogrammetric analysis of nasal symmetry (nostril height, nostril width, nostril area, alar height, and alar width parameters).

Results: 

Significant differences (all P < 0.001) were observed between the Tajima and non-Tajima groups for all but one photogrammetric nasal parameter (nostril area), with the Tajima group demonstrating closer mean values to the noncleft group. The Tajima and noncleft groups demonstrated no significant difference (all P > 0.05) for scores of FACE-Q nose and nostrils scales.

Conclusion: 

This study indicated that the patients who underwent primary rhinoplasty with overcorrection had improved results with no necessity for intermediate rhinoplasty, emphasizing that the procedure is an effective approach to correct the unilateral cleft nose deformity.

CLINICAL QUESTION/LEVEL OF EVIDENCE: 

Therapeutic, III.

Surgical cleft care has progressed considerably over the past decades, but the management of the unilateral cleft nose deformity remains a challenging task.^1,2 The timing of cleft rhinoplasty has always been a highly disputed subject, with advocates and opponents of reconstruction of the cleft nose deformities (primary rhinoplasty) concurrent with the cleft lip repair.^3,4 Some surgeons do not address the nose at the time of the primary repair because of potential growth disturbance and possible scarring that would further complicate a future surgical intervention.⁵ Although there is a growing body of evidence showing that primary rhinoplasty does not have a detrimental effect on nasal growth,^6,7 other surgeons routinely perform it to improve the nasal symmetry and contour and minimize the nasal deformity-related psychosocial issues, especially during school age.^8,9 Outstanding results have been reported by surgeons performing different techniques of primary rhinoplasty.^10–15 However, no consensus regarding the ideal technique for cleft nose repair has been established.

Primary rhinoplasty has been adopted at the Chang Gung Craniofacial Center since the 1980s, with technical modifications introduced to enhance outcome, including reduction of the need for intermediate rhinoplasty at preschool age. A long-term evaluation of the closed primary rhinoplasty technique originally applied in our center revealed less than satisfactory results, with a high rate of revision rhinoplasty during the growing age.¹⁶ Rhinoplasty with nostril rim incision has been described by Millard¹⁷ and Tajima and Maruyama¹⁸ for primary and secondary nasal correction, respectively. Since the year 2000, we have adopted a modified semiopen rhinoplasty with primary overcorrection to achieve a higher nostril height on the cleft side compared with the noncleft side. This rhinoplasty approach is focused on three components: (1) intraoral component (composite turbinate and nasal mucosal flap to resurface the dissected pyriform margin, avoiding collapse of the repositioned alar base), (2) muscle component (orbicularis oris muscle to contralateral columella base suture), and (3) nasal component (cinching suture and Tajima reverse-U incision).^18–20 Previous investigations have demonstrated the positive outcome of this technique during the early postoperative follow-up,^20,21 but no long-term data were provided to date. Only recently, after the treated patients reached skeletal maturity, could long-term outcomes be formally assessed.

The purpose of this study was to evaluate the long-term outcomes of primary rhinoplasty with overcorrection in a cohort of patients with unilateral cleft lip nose deformity by using patient-reported and photogrammetric analysis-based outcome measures. These outcomes were compared against the data derived from healthy individuals with no cleft deformity and patients with unilateral cleft lip nose deformity who underwent primary rhinoplasty with no overcorrection. This study (201701131B0) was approved by the Ethics Committee for Human Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

PATIENTS AND METHODS

This retrospective comparative study (Fig. 1) included consecutive nonsyndromic patients with unilateral cleft lip nose deformity with or without cleft palate who underwent primary rhinoplasty with overcorrection using the Tajima technique (Tajima group) performed by a single surgeon (L.J.L.) between 2000 and 2005. Data from patients with similar diagnoses who underwent primary closed rhinoplasty with no overcorrection according to the Noordhoff technical description²² (non-Tajima group) performed by the same surgeon (L.J.L.) before the year 2000 were retrieved from the Chang Gung electronic medical records database and included for comparison. Data from healthy individuals with no history of facial trauma, facial surgery, or craniofacial deformity were also included for comparison (noncleft group). Included patients and healthy individuals had reached skeletal maturity (15 and 17 years for girls and boys, respectively).^23,24 Patient demographic and clinical data were collected from the Chang Gung Craniofacial Research Center database.

Fig. 1.: Flowchart illustrating the selection process of the patients with unilateral cleft lip with or without cleft palate (UCL/P) and nose deformity, and healthy individuals recruited for the study.

The exclusion criteria were patients who underwent lip adhesion followed by cleft lip repair, primary cleft lip repair later than 6 months, intermediate or secondary rhinoplasty, and orthognathic surgery. Patients who had microform cleft lip, presence of median facial dysplasia or any associated syndrome, any mental disabilities that would prevent them from completing the patient-reported outcome measure questionnaires, or inadequate photographic data and/or incomplete follow-up were also excluded from the study.

Primary Rhinoplasty with Overcorrection

A typical unilateral cleft lip nasal deformity has been characterized by the following features: posteriorly, inferiorly, and laterally displaced alar base; short columella base deviated toward the noncleft side; and depressed ala on the cleft side.¹ These features are secondary to the aberrant muscle insertion, displaced lower lateral cartilages (LLCs), and lack of skeletal support.¹ To correct these abnormal features, a combination of maneuvers was adopted.

Presurgical nasoalveolar molding was performed in all patients with complete unilateral cleft lip and palate.^25,26 The anatomical marking followed the modified Millard rotation advancement technique but with no skin measurements.²⁷ After skin incision, the C-flap mucosal flap was raised, creating the medial element for nasal floor reconstruction.¹⁹ The lateral pyriform margin region was incised and dissected in the supraperiosteal plane to elevate the alar base, allowing for adequate medial, superior, and anterior mobilization.¹⁹ The raw surface area in the pyriform margin was covered with the inferior turbinate mucosal flap, to reduce scarring of the exposed raw area that might lead to contracture and inferior retraction of the alar base during the wound healing process. The nasal mucosal flap was raised at the anatomical division between the nasal and buccal mucosa. The turbinate plus nasal mucosal flaps formed a composite mucosal flap, creating the lateral element for nasal floor reconstruction.¹⁹ Reconstruction of the nasal floor is not required in patients with incomplete cleft lip.

The medial and lateral portions of the orbicularis oris muscle were dissected.^22,27 After ensuring that the medial and lateral lip elements were sufficiently mobilized without tension, the muscle sutures (5-0 polydioxanone) were placed using the four-suture method. The first three muscle sutures approximate the muscle fibers and re-create the philtrum by simulating the lateral elevation and the median dimpling. The fourth suture catches the upper part of the orbicularis oris muscle on the cleft side and affixes it to the columella base on the noncleft side, correcting the columella deviation (Fig. 2). [See Video 1 (online), which demonstrates muscle reconstruction and alar cinching during the primary rhinoplasty.] It also fills the space that was previously occupied by the muscle of the medial lip element, which was rotated downward. A fifth suture (alar cinching suture) was adopted for repositioning the displaced alar base (Fig. 3 and Video 1). This suture helps change the abnormal position of the depressed LLC from a horizontal to a vertical position. After the muscle and cinching sutures were tied, the lip skin was adjusted and sutured.

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Fig. 2.: Illustration describing the subcutaneous sustaining suture technique of muscle approximation: (1) bite taken through the muscle and out through skin at contralateral columella base point; (2) subcutaneous pass; and (3) bite taken through the muscle, completing the subcutaneous sustaining suture.

Fig. 3.: Illustration describing the technique of alar cinching: (1) bite taken through the skin at alar base point; (2) subcutaneous pass; (3) bite taken through skin at contralateral columellar base point; and (4) subcutaneous pass (subcutaneous sustaining suture).

The cleft side nasal dome was then treated through reverse-U incision that was designed approximately 2 mm over the height of the nostril on the noncleft side. [See Video 2 (online), which demonstrates primary rhinoplasty using the Tajima technique for nasal overcorrection.] The dissected LLCs were repositioned superiorly (30% higher than the nostril height on the noncleft side) and held in position using transdomal fixing sutures (5-0 polydioxanone). This results in elevation of the depressed alar dome and creation of the nasal tip definition (Fig. 4). The skin incision turns and becomes concealed inside the nostril cavity, and excess skin, if any, can be trimmed before closure. All patients used silicone nasal conformers postoperatively for 6 months.¹³

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Fig. 4.: Illustration showing the change in position and shape of the depressed lower lateral cartilage after primary rhinoplasty with overcorrection. (Left) Inferiorly and laterally displaced lower lateral cartilage. (Right) Repositioning of the lower lateral cartilage and fixation using transdomal sutures. Note the nasal tip projection.

Outcome Assessment

The patient’s satisfaction with the appearance of their nose and nostrils was assessed using the validated Mandarin version of the FACE-Q (permission was obtained).^28,29 The items contained several characteristics, such as how their nose appears in photographs, among others. Individuals in the Tajima and noncleft groups completed the nose and nostril questionnaire unaided and independently. Higher scores (ranging from 0 to 100) represented greater patient satisfaction.^28,29

Two sets (at preschool age and at maturity) of standardized photographs (basal views) were used for quantitative photogrammetric nasal symmetry analysis using ImageJ software (National Institutes of Health, Bethesda, MD).³⁰ All anatomical landmarks, reference lines, and measurements were standardized based on previous nasal photogrammetric studies.^21,31,32 [See Figure, Supplemental Digital Content 1, which shows photogrammetric nose parameters on the cleft and noncleft sides. (Left) Nostril height (NH) (the maximum vertical distance of a nostril aperture) and nostril width (NW) (the widest horizontal distance of a nostril aperture). (Center) Nostril area (the area represented by each nostril aperture). (Right) Alar height (AH) (the vertical distance between the alar-base line, along the perpendicular bisecting line of the nostril width) and alar width (AW) (the horizontal distance between the subnasale and the alar curvature point), https://links.lww.com/PRS/F645.]

These photogrammetric parameters were calculated on both the cleft and noncleft sides, and the data were presented as a ratio. For patients with cleft, the ratio was calculated by dividing the values obtained on the cleft side by the noncleft side, and for healthy patients, by dividing the values obtained on the left side by the right side. A ratio of 1 indicated perfect symmetry, whereas any deviation from a ratio of 1 denoted nasal asymmetry.^21,29,32 All nasal measurements were performed by a single investigator who was blinded for group allocation. Ten percent of images were randomly selected for reliability test, and all measurements were made in duplicate for these images. The intraclass correlation coefficients ranged from 0.80 to 0.99, with a mean of 0.93, indicating good/excellent reliability for all five photogrammetric parameters.

Statistical Analysis

The distribution of data was verified using the Kolmogorov-Smirnov test. Chi-square test and one-way analysis of variance were performed to evaluate difference in age, sex, side, and type of cleft parameters. Paired and independent t tests were adopted for intragroup (preschool age versus maturity) and intergroup (noncleft, Tajima, and non-Tajima groups) comparisons. A Bonferroni correction was applied for multiple comparisons. Two-sided values of P < 0.05 were considered statistically significant. All analyses were performed using SPSS Version 23.0 (IBM Corp., Armonk, NY).

RESULTS

From a total of 151 patients who underwent primary rhinoplasty with overcorrection (Tajima group), 48 patients were excluded, with two of them (1.3 percent) presenting with a history of intermediate rhinoplasty at preschool age. A total of 103 patients in the Tajima group were included for outcome analysis, of whom 45 patients had appropriate photographs at skeletal maturity. No significant difference was observed between Tajima, non-Tajima, and noncleft groups for age, sex, side, and type of cleft parameters. (See Table, Supplemental Digital Content 2, which shows the characteristics of cohorts included for photogrammetric analysis at preschool age and after reaching skeletal maturity, https://links.lww.com/PRS/F646.)

Patient-Reported Outcome

No significant difference (P > 0.05) was observed between Tajima and noncleft groups for the mean scores of FACE-Q satisfaction with appearance of nose and nostrils scales (Table 1).

Table 1. - FACE-Q Scores for Satisfaction with Appearance of Nose and Nostrils^a

	FACE-Q Scores
	Nose	Nostrils
Noncleft group (n = 58)	60.6 ± 20.0	68.1 ± 24.9
Tajima group (n = 71)	61.1 ± 20.7	56.2 ± 26.4
P	0.912	0.481

^aData shown as mean ± standard deviation.

Photogrammetry-Based Outcome

Significant (Bonferroni corrected P < 0.005) differences were observed between the Tajima and noncleft groups for all photogrammetric parameters, with the exceptions of nostril area and nostril width at preschool age and skeletal maturity, respectively. Comparisons by sex showed similar results, except for nostril area (no statistical difference for male and female subjects) and alar width (no statistical difference for male subjects) at skeletal maturity (Table 2).

Table 2. - Photogrammetric Comparative Analysis between Noncleft and Tajima Groups^a

Parameter	Total			Male			Female
	Noncleft Group	Tajima Groupb	P	Noncleft Group	Tajima Groupc	P	Noncleft Group	Tajima Groupd	P
No.	27			10			17
Nostril height
Preschool age	0.99 ± 0.09	0.82 ± 0.13	<0.001	0.97 ± 0.06	0.82 ± 0.13	<0.001	1.00 ± 0.10	0.81 ± 0.13	<0.001
Skeletal maturity	1.01 ± 0.09	0.84 ± 0.08	<0.001	1.01 ± 0.08	0.81 ± 0.09	<0.001	1.00 ± 0.09	0.85 ± 0.07	<0.001
Nostril width
Preschool age	0.98 ± 0.17	1.10 ± 0.08	<0.001	1.00 ± 0.19	1.12 ± 0.10	<0.001	0.96 ± 0.16	1.08 ± 0.06	<0.001
Skeletal maturity	1.08 ± 0.12	1.13 ± 0.09	0.039	1.07 ± 0.06	1.14 ± 0.10	0.102	1.07 ± 0.15	1.12 ± 0.09	0.158
Nostril area
Preschool age	1.01 ± 0.21	0.91 ± 0.16	0.012	1.01 ± 0.22	0.93 ± 0.15	0.159	0.99 ± 0.21	0.88 ± 0.16	0.030
Skeletal maturity	1.09 ± 0.23	0.95 ± 0.12	0.001	1.07 ± 0.10	0.93 ± 0.13	0.011	1.10 ± 0.29	0.96 ± 0.12	0.022
Alar height
Preschool age	1.02 ± 0.04	0.89 ± 0.12	<0.001	1.00 ± 0.03	0.90 ± 0.14	<0.001	1.02 ± 0.04	0.87 ± 0.10	<0.001
Skeletal maturity	1.08 ± 0.18	0.94 ± 0.06	<0.001	1.06 ± 0.03	0.94 ± 0.04	<0.001	1.08 ± 0.22	0.93 ± 0.06	<0.001
Alar width
Preschool age	0.98 ± 0.17	1.10 ± 0.08	<0.001	1.00 ± 0.20	1.11 ± 0.09	<0.001	0.96 ± 0.16	1.08 ± 0.07	<0.001
Skeletal maturity	1.06 ± 0.06	1.15 ± 0.12	<0.001	1.07 ± 0.06	1.16 ± 0.14	0.078	1.04 ± 0.06	1.13 ± 0.11	0.002

^aData shown as mean ± SD; values of P < 0.005 (Bonferroni corrected) were considered statistically significant.

^bn = 103 at preschool age and n = 45 at skeletal maturity.

^cn = 47 at preschool age and n = 15 at skeletal maturity.

^dn = 56 at preschool age and n = 30 at skeletal maturity.

Significant (Bonferroni corrected P < 0.005) differences were observed between the Tajima and non-Tajima groups for all photogrammetric parameters, with exception for nostril area. [See Figure, Supplemental Digital Content 3, which shows box plots of dispersion of the values of nostril height (ratio calculated by dividing the values obtained on the cleft side by the noncleft side, with a ratio of 1 indicating perfect symmetry) at preschool age and skeletal maturity for Tajima and non-Tajima groups (yellow and gray, respectively); red asterisks indicate maximum and minimum outliers’ values, https://links.lww.com/PRS/F647.] Comparisons by sex showed similar results, except for alar width at skeletal maturity, with no statistical difference for male and female patients (Table 3). This indicated that the group that underwent primary rhinoplasty with overcorrection obtained superior results compared to the group that did not.

Table 3. - Photogrammetric Comparative Analysis between Tajima and Non-Tajima Groups^a

Parameter	Total			Male			Female
	Tajima Groupb	Non-Tajima Group	P	Tajima Groupc	Non-Tajima Group	P	Tajima Groupd	Non-Tajima Group	P
No.		30			12			18
Nostril height
Preschool age	0.82 ± 0.13	0.73 ± 0.1	<0.001	0.82 ± 0.13	0.74 ± 0.12	<0.001	0.81 ± 0.13	0.71 ± 0.09	<0.001
Skeletal  maturity	0.84 ± 0.08	0.74 ± 0.09	<0.001	0.81 ± 0.09	0.74 ± 0.10	<0.001	0.85 ± 0.076	0.72 ± 0.09	<0.001
Nostril width
Preschool age	1.10 ± 0.08	1.31 ± 0.18	<0.001	1.12 ± 0.10	1.34 ± 0.17	<0.001	1.08 ± 0.06	1.29 ± 0.19	<0.001
Skeletal  maturity	1.13 ± 0.09	1.33 ± 0.18	<0.001	1.14 ± 0.10	1.37 ± 0.19	<0.001	1.12 ± 0.09	1.30 ± 0.18	<0.001
Nostril area
Preschool age	0.91 ± 0.16	0.91 ± 0.21	0.999	0.93 ± 0.15	0.96 ± 0.27	0.664	0.88 ± 0.16	0.87 ± 0.15	0.766
Skeletal  maturity	0.95 ± 0.12	0.96 ± 0.17	0.951	0.93 ± 0.13	0.98 ± 0.15	0.329	0.96 ± 0.12	0.93 ± 0.18	0.507
Alar height
Preschool age	0.89 ± 0.12	0.73 ± 0.10	<0.001	0.90 ± 0.14	0.74 ± 0.12	<0.001	0.87 ± 0.10	0.71 ± 0.09	<0.001
Skeletal  maturity	0.94 ± 0.06	0.74 ± 0.09	<0.001	0.94 ± 0.04	0.74 ± 0.10	<0.001	0.93 ± 0.06	0.72 ± 0.09	<0.001
Alar width
Preschool age	1.10 ± 0.08	1.29 ± 0.18	<0.001	1.11 ± 0.09	1.32 ± 0.18	<0.001	1.08 ± 0.07	1.27 ± 0.19	<0.001
Skeletal  maturity	1.15 ± 0.12	1.30 ± 0.15	<0.001	1.07 ± 0.06	1.16 ± 0.14	0.078	0.81 ± 0.09	0.74 ± 0.10	0.072

^aData shown as mean ± SD; values of P < 0.005 (Bonferroni corrected) were considered statistically significant.

^bn = 103 at preschool age and n = 45 at skeletal maturity.

^cn = 47 at preschool age and n = 15 at skeletal maturity.

^dn = 56 at preschool age and n = 30 at skeletal maturity.

Intragroup comparisons between the preschool age and skeletal maturity revealed no significant difference (Bonferroni corrected p > 0.01) in the Tajima and noncleft groups (Table 4).

Table 4. - Photogrammetric Comparative Analysis between Preschool Age and Skeletal Maturity^a

Parameter	Tajima Group		Non-Tajima Group		Noncleft Group
	Preschool Age	Skeletal Maturity	Preschool Age	Skeletal Maturity	Preschool Age	Skeletal Maturity
No.	45		30		27
Nostril height	0.79 ± 0.14	0.84 ± 0.08	0.73 ± 0.10	0.74 ± 0.09	0.99 ± 0.09	1.01 ± 0.09
P	0.02		0.73		0.31
Nostril width	1.11 ± 0.07	1.13 ± 0.09	1.31 ± 0.18	1.33 ± 0.18	0.98 ± 0.17	1.08 ± 0.12
P	0.16		0.66		0.03
Nostril area	0.89 ± 0.17	0.95 ± 0.12	0.91 ± 0.21	0.96 ± 0.17	1.01 ± 0.21	1.09 ± 0.23
P	0.05		0.30		0.11
Alar height	0.90 ± 0.07	0.94 ± 0.06	0.73 ± 0.1	0.74 ± 0.09	1.02 ± 0.04	1.08 ± 0.18
P	0.01		0.73		0.09
Alar width	1.10 ± 0.07	1.15 ± 0.12	1.29 ± 0.18	1.30 ± 0.15	0.98 ± 0.17	1.06 ± 0.06
P	0.05		0.80		0.04

^aData shown as mean ± SD; values of P < 0.01 (Bonferroni corrected) were considered statistically significant.

DISCUSSION

The premise that performing a primary rhinoplasty could impair normal nasal growth and development has been negated, and the literature is supplied with evidence demonstrating the advantages of primary intervention and an absence of growth interference.^6,7,9,33 A recent survey indicated that 57% of surgeons routinely perform primary cleft rhinoplasty.³⁴ Cleft care is constantly undergoing improvements and innovations to provide optimal care for patients. For the past 20 years, the primary nasal overcorrection has been routinely performed at the time of initial cleft lip repair, targeting reduction of surgical and psychological burden by eliminating further intervention during the growing age. During our initial transition to the overcorrection technique, we performed two intermediate rhinoplasty procedures. As our technique evolved over the years, we have been able to completely avoid the need for intermediate rhinoplasty.

Overall, our long-term photogrammetric findings supplement previous investigations with shorter follow-up periods,^20,21,35 indicating that a semi–open rhinoplasty with overcorrection using the Tajima technique provides better results compared to the closed rhinoplasty using the inferior approach. Our appraisal of patients treated with primary nasal overcorrection indicated a residual nasal asymmetry compared with the healthy individuals. However, the results for height and width of the nostril and ala were significantly superior when the Tajima group was compared with the non-Tajima group, which is consistent with previous findings from our center.^20,21 This could be attributed to two main reasons: (1) the reverse-U incision procedure provides direct access for effective release and repositioning of the displaced LLC, in combination with (2) the alar cinching method that helps elevate the depressed LLC, improving the shape and height of the nostril and alar dome.

The importance of patient-reported outcome measures in cleft care has been emphasized in many publications.^36,37 The FACE-Q tool provides comprehensive information regarding patient satisfaction for specific anatomical regions of the face.²⁸ Previous long-term outcome study of patients with unilateral cleft lip nose deformity who underwent closed primary rhinoplasty with no overcorrection showed a significant difference between the cleft and the noncleft groups for mean scores of FACE-Q satisfaction with appearance of nose.¹⁶ Despite the presence of residual nasal asymmetry, the patients who underwent the primary nasal overcorrection rated their satisfaction with the appearance of their nose and nostrils similar to healthy individuals with no cleft. This reflects a marked improvement in outcomes as evidenced by the FACE-Q tool.

Previous investigations have evaluated the long-term effects of intermediate rhinoplasty in comparison to control groups, and have indicated that their results were sustained for greater than 3 years after surgery.³⁸ Our study has evaluated long-term outcomes of the primary rhinoplasty by assessing outcomes at the preschool age, and after attaining skeletal maturity. We noted that there was no significant change in the photogrammetric parameters in both the cleft groups. With the exception of nostril and alar width, the results obtained for the Tajima group show values closer to 1, indicating almost symmetric results, which are consistent with growth.

This long-term study is unique in that it combines both patient-reported and photogrammetry-based outcome measure, validating the results twofold. Previous investigations have demonstrated the importance of combining patient-reported and clinician-derived outcome measures to compose a set of metrics for outcome-based research; incorporating a patient-reported outcome measure tool could provide additional outcome-related evidence beyond that delivered by computer-assisted data (and vice versa).³⁹ We have evaluated outcomes over a follow-up period of over 17 years, which to our knowledge is the longest study comparing outcomes of primary rhinoplasty techniques including a healthy group. Our findings evidenced that the use of the primary nasal overcorrection with the Tajima technique provides significantly better results than without. Although concerns with using nasal incisions include scar contracture and nostril stenosis,⁴⁰ no such complications were observed in our study. In addition, only two of 151 patients (1.3 percent) treated with primary nasal overcorrection required an intermediate rhinoplasty. This marks a notable improvement compared to our previous outcome study reporting a rate of intermediate rhinoplasty of 56.9 percent after closed rhinoplasty.¹⁶ Variable rates of intermediate rhinoplasty have been described by surgeons using different techniques of nasal reconstruction.^16,41–44 This further strengthens our claim that an interim rhinoplasty can be avoided if the nasal deformity is effectively corrected at the time of lip repair. [See Figure, Supplemental Digital Content 4, which displays serial photographs of a patient who underwent primary rhinoplasty without overcorrection and received intermediate rhinoplasty. Above and below, from left to right: before lip repair, before intermediate rhinoplasty (note the prominent alar groove and asymmetric shape and size of the nostril apertures), after intermediate rhinoplasty, and at skeletal maturity, https://links.lww.com/PRS/F648.] With regard to primary rhinoplasty and growth, our study further proves that there are no detrimental effects to the growth of the nose.

This study is not without limitations. Apart from the inherent bias associated with being a retrospective study, it relied on two-dimensional photogrammetric analysis, which is dependent on the image quality and fails to provide additional information that could be obtained using three-dimensional image analysis.^45,46 We have assessed the basal view, with no computer-based objective photogrammetric analysis for profile or frontal views. The nasal width discrepancy is less noticeable by patients on the frontal view²¹; therefore, the clinical results can be considered as acceptable, despite the residual asymmetry on the basal view (Fig. 5). (See Figure, Supplemental Digital Content 5, which shows a case of left complete cleft lip and palate before surgical treatment. Serial and long-term follow-up photographs are shown in Fig. 5, https://links.lww.com/PRS/F649.) Some patterns of nasal asymmetry may not be noticeably detected from the frontal view, but the selected parameters measured from the basal view can easily detect and objectively quantify the degree of nasal asymmetry, mainly the nasal and nostril height– and nostril width–related problems. Previous studies have also emphasized the relevance of the basal view^47–51; the basal view could not represent a real-life social interaction, but critical nasal elements, such as the columella and ala, have suitably been visualized and appraised on the basal view. Further outcome investigation could assess the impact of different primary rhinoplasty procedures on nasal form and symmetry by using frontal and profile views. Future nasal analysis encompassing objective and subjective functional tests such as rhinomanometry, acoustic rhinometry, and patient-reported outcome measure tools could enhance the evolving body of evidence^{12,13,16,19–21,27,35} concentrating on the adopted approach for primary nasal overcorrection.

Fig. 5.: Serial photographs of a patient with left complete cleft lip and palate who underwent primary rhinoplasty with overcorrection. Preoperative frontal and basal views are shown in Figure, Supplemental Digital Content 5, https://links.lww.com/PRS/F649. (Above, left) Following preoperative nasoalveolar molding. (Above, right) Immediate postoperative view with nasal overcorrection. Frontal and basal views at preschool age (center) and at skeletal maturity (below), before a scheduled orthognathic operation.

In addition, our control groups (non-Tajima and healthy cohorts), although matched for age span and sex, included only patients of Asian descent, requiring additional studies in populations with different ethnic origins. All included patients were operated on by the same surgeon using a similar protocol and technique (presurgical nasoalveolar molding for complete cleft lip, cleft lip repair, and postoperative nasal stent), with the exception for the type of primary rhinoplasty. The level of expertise of the senior surgeon would have increased for the Tajima cohort, deserving additional investigation encompassing surgeons with different levels of expertise in repairing cleft lip and nasal deformities to address the learning curve–related issue. Moreover, obtaining long-term data from patients treated with no presurgical nasal molding or no primary rhinoplasty for comparison is beyond the therapeutic objectives of this center.⁶ Further comparative study could define the long-term outcome of other modalities of primary rhinoplasty with different combinations of maneuvers such as bilateral alar rim incisions, septal manipulation, and/or symmetric correction with no overcorrection on the cleft side. The impact of different strategies for closure of the nasal floor and piriform aperture^15,52,53 on nasal form and symmetry could also be addressed. Future investigation can also consider a changing paradigm in position of the alar base on the cleft and noncleft sides when defining the methodologic design to compute the primary rhinoplasty-derived results.⁵²

Despite the limitations, our study provides additional information regarding the long-term growth effects of a primary rhinoplasty procedure in a unilateral cleft nose deformity. Based on our current FACE-Q– and photogrammetry-based outcomes and previous results,^12,20,21 primary nasal overcorrection could be recommended as a routine procedure for the surgical approach of patients with unilateral cleft lip and nose deformities, attenuating the need for intermediate rhinoplasty at preschool age. Residual nasal deformities can be addressed with secondary rhinoplasty after patients attain skeletal maturity and the need for orthognathic surgery is defined. It has been shown that the procedures required for definitive secondary rhinoplasty are less complex if primary nasal repair has been performed effectively, strengthening the premise for performing an effective primary rhinoplasty.⁴¹ Future investigation could appraise the level of complexity to perform a definitive secondary rhinoplasty on patients who were treated with the primary nasal overcorrection protocol.

CONCLUSION

This study shows that patients with unilateral cleft lip nose deformity treated with primary nasal overcorrection achieved superior early- and long-term nasal symmetry compared with patients treated with no overcorrection, and they reported satisfaction scores similar to healthy individuals.

ACKNOWLEDGMENTS

The authors would like to thank M. Samuel Noordhoff, MD, for teaching and supervision in cleft care in this center. The authors also thank Pei-Chun Tang for help in data collection and Yi-Tan Hung for assistance in statistical analysis.

PATIENT CONSENT

The patients or parents or guardians provided written informed consent for use of patients’ images.