Inverted V-Y and fibrofatty Flap technique for columellar lengthening and tip augmentation in adults post bilateral cleft lip nasal deformity

INTRODUCTION

Bilateral cleft lip nasal deformity is a complex presentation that interferes with the child respiration, feeding, growth and speech. Early surgery is required to minimize the post cleft lip nasal deformity complications.¹ However, with best hands usually, there are somewhat of nasal deformities presented after puberty² that affects patient social integration and may limit nasal function. Short columella and the short depressed nasal tip are the common features in post cleft lip nasal deformities.³ Moreover, many associated deformities could be present like flared wide ala, disturbed external nasal valve, disturbed nasal facial aesthetic angles of the nose e.g., columello-labial, and nasolabial angles.⁴ Lower lateral cartilage shows lateral displacement of the domes on both sides with diversion away from the middle septum.⁵

Although, the literature shows many different techniques to overcome these unpleasant presentations, but tissue deficiencies and scars' contractions are usually challenging problems are facing the surgeons during design for reconstruction.⁶

This study proposes Inverted v-y incision and fibrofatty Flap technique for columellar lengthening and tip augmentation in post bilateral cleft lip nasal deformity. Study also evaluates the safety and outcome of this technique.

MATERIALS AND METHODS

This is a case series preliminary study that includes 8 patients (2 female, and 6 male) were presented with post bilateral cleft lip nasal deformity. This study was conducted as a university-based practice in a period from January 2017 to 2020. The age of the patients ranged from 16 to 27 years old. The functional and aesthetic outcomes were evaluated by an objective assessment.

Postoperative complications such as wound dehiscence, infection, hematoma, partial or total flap loss were reported during the follow up.

A nasal obstructive symptom rating scale was used to measure nasal function both subjectively and objectively (NOSE).⁷ Analyzed factors included difficulty breathing via the nose and difficulty sleeping, as well as difficulties in inhaling air through the nose during exercising and effort. A linear symptom rating scale was used to assess overall breathing difficulties both before and after surgery.

Objective aesthetic assessments included two independent board-certified plastic surgeons and digital photography. The analysis included frontal, lateral, oblique, and basal profiles. (Table1) The aesthetic analysis of the nasal profile was performed with the following angles and landmarks (Figure1A, B)

Nasofrontal angle, the dorsal aesthetic line, nasal facial angle, naso-mental angle, nose to chin angle, pre-nasale, columella peak, sub-nasale, and alar curvature points. Basal nasal profiles were evaluated with the columellar height in term of the ratio of columellar height to nasal height, the ratio of columellar height to alar base width. Columellar height is (columellar peak to the subnasale), the ratio of columellar height to nasal height (the pronasale to the subnasale), the ratio of columellar height to alar base (distance between alar curvature points).

The measurements were achieved with the aid of digital photography of the different nasal profile views, pre-operative, intra operative, 3 weeks postoperative and at 6^th months follow up.

Subjective questionnaire for degrees of the improvement of the air entry and overall satisfaction of the patients was also reported in terms of mild moderate and marked improvement/ satisfaction (Table 2). Statistical analysis of the data was used to determine the confidence interval and the probability of the proposed alternative technique hypothesis and P-value significance using SSS package system. In this study the degree of statistical significance depends on the level of significance. If p-value is more than 0.05 is considered statistically significant while less than 0.01 is a highly statistically significant.

The paired Student's t-test was used to compare preoperative and postoperative continuous variables. (Measurements and angles).

Informed patients’ consents and institutional ethical approval were obtained.

Surgical techniques

Five patients underwent local anesthesia with sedation and three patients underwent general anesthesia. 2% lidocaine in a 1:100,000 epinephrine solution was frequently injected into the dorsum of the nose, the nasal tip, and along the columellar tissue to ensure appropriate hemostasis. The nasal tamponade is then inserted into the nose.

Fig. 1 a: Angles and landmarks which used as pre-operative basics in the objective assessment: Nasofrontal angle, the dorsal aesthetic line, nasal facial angle, naso-mental angle (nose to chin angle), pre-nasale, columella peak, sub-nasale and alar curvature points.

Fig. 1 b: Same angles and landmarks in post-operative objective assessment.

Incision: Open rhinoplasty with inverted V- columellar incision started in infra lobular area to steel skin from the tip towards the deficient Columella (Figure 2). The incisions in the infra-lobule area are continued till fuse with rim incisions to complete open approach (Figure 3). Then subcutaneous dissection of the skin of the tip is continued laterality and cephalic till complete exposure of the tip. Gentle dissection and caution are practiced preserving fibrofatty tissue.  Fibrofatty tissue is randomly elevated, and the flap remains attached and based caudally to preserve blood supply (Figure 4).

Fig. 2: shows an inverted V- columellar incision started in infra lobular area.

Fig. 3: shows the incisions in the infra-lobule area that were continued till fused with the rim incisions to complete the open approach.

Figure 4: shows a fibrofatty tissue was elevated and the flap remained attached randomly and based caudally to preserve blood supply. Also, it shows the medial crura suture that were carried on as usual. Then the fibrofatty flap was ready to be turned on towards the columellar base.

Figure 5: shows that the incised V was closed in Y manner to address the final shape of the nose after tip definition and columellar lengthening.

Sliding, suturing, and reshaping of the medial crura of lower lateral cartilage in both sides achieved to give a cartilaginous columellar length. Inter-domal suture was carried on as usual. Then the fibrofatty flap is turned over towards the columellar base, giving a bulge that enhances the infra tip lobule and gives the sloping shape of infra tip area as well as it modulates up the depressed tip. Then closure of the V in Y manner to address the final shape of the nose after tip definition and columellar lengthening (Figure 5). Lastly alar reduction, then the skin is finally closed by proline 6-0 and the internal nasal mucosa is closed by Vicryl 5/0. No nasal back is usually needed but splint for one week to minimize oedema and for protection.

Post-operative antibiotic Augmentin (825 amoxicillin,125 mg clavulanic acid) twice daily, anti-edematous ( Chymotrypsin) and  nonsteroidal anti-inflammatory drug (NSAID)  as analgesic  used for one week.

Later, CO2 laser was done after three weeks of operations and continuous every month for 2-4 sessions for more improvement of the scar A fractional CO2, laser was done after three weeks of operations and continuous every month for 2-4 sessions was used with irradiation parameters set as follows: output power 10 W, pulse width 600 μs, dot spacing 800 μm, and stack 2 (irradiation output power 0.91 J/cm(2) ) for more improvement of the scar.

RESULTS

During the 6-month follow up, there were no problems such as wound dehiscence or infection, hematoma, partial or entire flap loss in any of the patients. A two-day hospital stay was the average.

The scars were inconspicuous at 6^th months follow up, and no scar contracture was seen in the late postoperative period. (Figures 6-9)

In accordance with this study's results, functionally all patients have completed the nasal obstructive symptoms evaluation scale and the linear symptom evaluation scale pre- and post-operative showed improvement of the respiration (Table 3). Objective aesthetic assessments of Facial angles and nasal facial landmarks (Figure1A, B) showed marked improvement of the columellar height in relation to the nasal height in all cases. The dropped nasal tip has been improved in all cases with near normal projection.  Confidence interval showed that more than 98% improvement in both functional and aesthetic outcomes. Most patients were most satisfied with their postoperative results when measured by the visual analogue scale (VAS), with the dorsum, uneven alar bases, and the nostril coming in close behind. Each of the patients was happy with the results of the procedure, and several even said they would have it done again in the future if required.

Fig. 6: 26 years old male patient presented by post bilateral cleft nasal deformity. Pre and 12 months post-operative submission to the proposed technique. Front views.

Fig. 7: 26 years old male patient presented by post bilateral cleft nasal deformity. Pre and 12 months post-operative submission to the proposed technique. Basal views.

Fig. 8: 18 years old female patient presented by post bilateral cleft nasal deformity. Pre and 6 months post-operative submission to the proposed technique. Frontal views.

Fig. 9: 18 years old female patient presented by post bilateral cleft nasal deformity. Pre and 6 months post-operative submission to the proposed technique. Lateral views.

Table 1: Objective aesthetic assessments included two independent board-certified plastic surgeons and digital photography.

Table 2:  Patients and parents’ satisfaction were good in 7 out of 8 cases.

Table 3: Functional analysis of outcome after proposed technique that includes rhinoplasty nasal congestion or stuffiness, nasal blockage or obstructiveness, troublesome breathing through nose, troublesome sleeping and problem while inhaling air through nose while exercising and exertion.