Aesthetic and Functional Outcomes in Early Columellar Lengthening for Bilateral Cleft Lip and Palate
Nina L. DeBenedictis, MD, MPH1, Martha Matthews, MD, FACS2.
1Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA, 2Cooper University Hospital, Camden, NJ, USA.
Nasal deformity is an expected result after bilateral cleft lip and palate repair due to columellar tissue limitations, with tension placed on nasal cartilage following repair. Various pre-surgical orthopedic and surgical techniques have been utilized in attempt to minimize deformation, and while these techniques have displayed positive aesthetic outcomes in the early pre-op period, less is known about long-term function, aesthetics, and operative revision requirements. The current work hypothesizes that early columellar lengthening performed simultaneously with palate repair in patients with bilateral cleft lip and palate will have beneficial functional and aesthetic outcomes when compared with traditional repair without early lengthening. We also posit a lower surgical burden for further rhinoplasty and follow-up procedures.
Subjects included for the study were those patients with bilateral cleft lip and palate treated and followed by a single surgeon at a regional cleft-craniofacial program between 2002 and 2016. Aesthetic, functional, surgical, and dental outcomes were compared between patients who received early lengthening (ECL) and those who did not (No-ECL). Aesthetic outcomes included nasal-alveolar angle, alveolar and nasal symmetry, philtrum proportionality, labial fissure to philtrum width ratio, and cheilion-subnasale angle and laterality, measured using subject photographs. Functional outcomes included total and sub-scores on the Pittsburgh Weighted Speech Scale. Surgical revision outcomes included rhinoplasty, complex and simple lip revisions, fistulae, Le Fort fracture, and tooth extraction. Dental outcome was assessed as presence or absence of malocclusion, with associated classification. Aesthetic outcomes were assessed using Independent-samples T test while functional outcomes were compared via Mann-Whitney U, and surgical outcomes were compared using Pearson's chi-squared test.
Of 43 patients treated for bilateral cleft lip and palate, a total of 24 subjects, consisting of 16 ECL and 8 non-ECL subjects, were included for assessment after exclusion criteria were applied. Mean age at assessment was 15 years, and gender distribution included 11 female (7 ECL and 4 non-ECL) and 13 male (9 ECL and 4 non-ECL) subjects. Those with ECL were significantly less likely to receive rhinoplasty later in childhood c2(1, N=24) = 9, p= 0.003. ECL groups were also less likely to require simple lip revision via dermabrasion later in childhood c2(1, N=24) = 6.189, p= 0.013. On aesthetic assessment, nasolabial angle was found to be significantly greater in those with ECL t(22)= 2.907, p=0.008. No other anthropometric, functional, or surgical measures were found to be different between the two groups.
ECL was associated with fewer subsequent rhinoplasty and simple lip revisions, suggesting better aesthetic outcome and lower surgical burden. ECL was also found to be associated with greater nasolabial angle, suggesting greater nasal
tip projection versus the non-ECL group. Given these noted differences between groups, future work may aim to correlate these differences with more subjective aesthetic measures, such as that performed via the Asher-McDade rating scale, or equivalent.
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