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 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 to 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 • Bilateral Cleft Nose Repair PATIENTS AND METHODS Fig 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 months of age, (5) postoperative nasal stent used for more than months, and (6) available basilar view photograph at approximately 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 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 to 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 927e Plastic and Reconstructive Surgery • December 2014 Fig 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 • 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 when sutures were removed, and used for at least 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 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 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 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 months The nasal stent for group IV was used for at least 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) 929e Plastic and Reconstructive Surgery • December 2014 Fig 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 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 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 • 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 931e 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 932e 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 • 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 to 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 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 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 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 933e 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 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 (Above, left) Typical photograph of a group I patient at age years (Above, right) Typical photograph of a group II patient at age years (Below, left) Typical photograph of a group III patient at age years (Below, right) Typical photograph of a group IV patient at age years 934e Volume 134, Number • Bilateral Cleft Nose Repair Fig 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) year, (center) years, and (right) 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 philip@adm.cgmh.org.tw PATIENT CONSENT Parents or guardians provided written consent for the use of patients’ images references Monson LA, Kirschner RE, Losee JE Primary repair of cleft lip and nasal deformity Plast Reconstr Surg 2013;132:1040e–1053e Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: A single surgeon’s experience Plast Reconstr Surg 2010;126:1276–1284 Liou EJ, Subramanian M, Chen PK Progressive changes of columella length and nasal growth after nasoalveolar molding in bilateral cleft patients: A 3-year follow-up study Plast Reconstr Surg 2007;119:642–648 Chen PKT, Noordhoff MS Bilateral cleft lip and nose repair In: Losee JE, Kirschner RE, eds Comprehensive Cleft Care New York: McGraw Hill Medical; 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