J Oral Maxillofac Surg 67:2222-2231, 2009 Postoperative Nasal Forms After Presurgical Nasoalveolar Molding Followed by Medial-Upward Advancement of Nasolabial Components With Vestibular Expansion for Children With Unilateral Complete Cleft Lip and Palate Norifumi Nakamura, DDS, PhD,* Masaaki Sasaguri, DDS,† Etsuro Nozoe, DDS, PhD,‡ Kazuhide Nishihara, DDS, PhD,§ Hiroko Hasegawa, DDS, PhD,ʈ and Seiji Nakamura, DDS, PhD¶ Purpose: The management for primary unilateral cleft lip nose deformities has not yet been estab- lished In this study, short-term postoperative nasal forms after presurgical nasoalveolar molding (NAM) followed by primary lip repair for children with complete unilateral cleft lip and palate (UCLP) were evaluated and compared with the nasal forms achieved by treatment without nose correction Patients and Methods: Fifteen patients with complete UCLP who were treated in our department and followed up for more than year (range to yrs) were enrolled All subjects underwent presurgical orthopedic treatment with NAM, followed by lip repair using Cronin’s triangular flap method with medial-upward advancement of nasolabial components with vestibular expansion Postoperative nasal forms including nostril height and width ratio, ratio of the height of the top of the alar groove, and curvature of the appropriate circle of the nasal ala were evaluated using color photographs Fifteen patients with complete UCLP who underwent presurgical orthopedic treatment using a Hotz plate followed by lip repair without nose correction served as controls Results: The comparison of postoperative nasal forms demonstrated that the nostril height and width ratio and the height of the top of the alar groove in the correction group were significantly superior compared with those of the controls Conclusions: Our management of cleft lip nose will provide good nasal forms with minimum invasion in patients with UCLP Long-term follow-up will be necessary to clarify effects on the growth of nasal tissues reconstructed in infancy © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:2222-2231, 2009 *Professor, Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan †Assistant Professor, Division of Oral and Maxillofacial Diagnostic and Surgical Sciences, Kyushu University, Graduate School of Dental Science, Kyushu, Japan ‡Associate Professor, Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University, Graduate School of Medical and Dental Sciences, Kagoshima, Japan §Senior Assistant Professor, Department of Oral and Maxillofacial Surgery, Kagoshima University, Medical and Dental Hospital, Kagoshima, Japan ʈAssistant Professor, Department of Pediatric Dentistry, Field of Developmental Medicine, Kagoshima University, Graduate School of Medical and Dental Sciences, Kagoshima, Japan ¶Professor, Division of Oral and Maxillofacial Diagnostic and Surgical Sciences, Kyushu University, Graduate School of Dental Science, Kyushu, Japan Address correspondence and reprint requests to Dr Nakamura: Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima 88908544, Japan; e-mail: nakamura@denta.hal.kagoshima-u.ac.jp © 2009 American Association of Oral and Maxillofacial Surgeons 0278-2391/09/6710-0022$36.00/0 doi:10.1016/j.joms.2009.04.098 2222 2223 NAKAMURA ET AL Despite recent developments in cleft surgery, the surgical modality for primary correction of unilateral cleft lip nose has not yet been established It was previously thought that correction of the nose should be postponed until nasal development is complete Consequently, these children suffer a good deal of embarrassment regarding their appearance during childhood and puberty.1 Sugihara et al2 warned that early dissection and manipulation of the nasal cartilages interfered with nasal growth, but there is little evidence to support this theory.1,3,4 Because clefts of the lip and nose are not individual pathologic conditions, primary nasal correction has become the standard of care.5 The optimal method of achieving such primary correction while minimizing the surgical intervention and causing less interference with nasal growth remains controversial Numerous surgical procedures for early correction of the lip and nose have been introduced during the past or decades.1-3,5-10 Anderl et al,11 McComb and Coghlan,12 and Salyer4 all noted that good primary correction of the nose is critical for growth and longterm esthetics However, early primary rhinoplasty initially produced good results, but the original deformity soon returned There remain some questions regarding whether the infant’s fragile cartilage is free of damage after wide blind dissection, and whether these results and future nasal growth can be achieved universally even if the procedure is performed by less skillful surgeons However, Grayson et al13 introduced nasoalveolar molding (NAM) for the successful presurgical alignment and correction of deformity in the nasal cartilages, minimizing the extent of primary nasal surgery required and thereby also minimizing the formation of scar tissue and producing more consistent postoperative results These investigators reported significant improvement of symmetry of unilateral cleft nose in children who underwent presurgical NAM,14 and successful columella lengthening of the bilateral cleft nose.15 Many institutions currently perform pre- surgical orthopedics using NAM or a modification of that procedure.16 The successful outcomes of NAM promote the expectation that the need for primary cleft nasal surgery may eventually be eliminated, but the surgical procedures for lip repair after NAM have not yet been well debated When considering the characteristics of postoperative nasal deformities, of patients with complete unilateral cleft lip and palate (UCLP), nasal deformities, such as depressed and deviated nasal tip, small and inferiorly dislocated nasal ala, and flat and V-shaped nostril on the cleft side often persist (Figs 1A,B) In the uncorrected noses of patients with complete UCLP, in addition to the splayed-out deformity, the lower lateral nasal cartilage is also rotated distally downwardly, so the dome is retroposed and the nose is lengthened on the cleft side.17 The nasalis muscle attaching the lateral surface of the upper lateral cartilage and the lateral crura of the major alar cartilage dislocates because of the distal and downward displacement of the anterior maxillary wall If the lip and nose are repaired with cartilage in this displaced position, the nostril rim droops on the cleft side, and the distal border of the alar cartilage pushes up, forming a tight nasal vestibular fold in the nostril.1 Our treatment strategy for unilateral cleft lip nose was characterized as follows: 1) presurgical orthopedics using NAM to minimize surgical intervention; 2) simultaneous medial-upward advancement of nasolabial components, which provides repositioning of both the lower lateral cartilage and the muscles of the nasolabial region on the affected side; and 3) vestibular expansion using a cleft margin flap to provide vertical height of the nasal ala and nostril In this study, short-term postoperative nasal forms after presurgical orthopedics using NAM followed by primary lip repair for children with complete UCLP were evaluated The outcomes of these procedures were then compared with the nasal forms achieved by treatment without nasal correction during primary lip repair FIGURE Postoperative deformities of patients with complete UCLP A, Inferiorly displaced and small nasal ala in the frontal view, and B, deviated nasal tip and flat V-shaped nostril are persistent problems Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 2224 TREATMENT OF CHILDREN WITH UNILATERAL COMPLETE CLEFT LIP AND PALATE FIGURE Presurgical orthopedic treatment using NAM A, appliance for NAM B, Stent approaching the top of the medial crura of the major alar cartilage Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 Patients and Methods Data were obtained from the records of Kyushu University Hospital and Kagoshima University Hospital for cases treated between 2004 and 2008, because the first author moved from Kyushu University to Kagoshima University in 2005 The samples in this study included 15 infants with complete UCLP who underwent presurgical orthopedics using NAM followed by primary lip repair at approximately months of age (correction group) All subjects were followed for more than year (range to yrs) postoperatively All patients underwent labioplasty by Cronin’s triangular-flap method18 with anatomical reconstruction of the orbicular oris muscle19 by the same surgeon Serial pictures of frontal and basal views taken preoperatively and months, year, and over years postoperatively were used for 2-dimensional analyses of nasal forms As controls, serial pictures of 15 patients with complete unilateral cleft lip and palate, who underwent lip repair without nose correction, were used (control group) All patients received orthopedic treatment by Hotz plate20 without nasal molding and they underwent lip repair by modified Randal’s triangularflap method21 with reconstruction of the orbicular oris muscle at around months of age All procedures were performed by the same senior surgeon All subjects were followed for more than year (range to yrs) postoperatively The age distribution of subjects in the control group did not differ from that in the correction group The Institutional Review Board at the Graduate School of Medical and Dental Sciences, Kagoshima University, approved the protocol of this study PRESURGICAL ORTHOPEDICS USING NAM Presurgical orthopedics using NAM was performed by pediatric dentists in both Kyushu and Kagoshima University Hospitals An oral impression was taken at the first examination, within weeks after birth in most patients, and an alveolar molding plate was set approximately week later After checking the fit of the plate and the feeding condition, a nasal stent was added at the anterior part of the alveolar molding appliance The appliance was retained by elastic and tape in accordance with Grayson’s method,13 and the tape was placed across the upper lip (Figs 2A,B) Every weeks, the tip of the stent was molded gradually using self-curing soft acrylic SURGICAL PROCEDURES FOR PRIMARY LIP AND NOSE CORRECTION Details of step-by-step surgical procedures for cleft lip and nose correction were as follows (Figs 3, 4): 1) The skin incision was made by Cronin’s triangular method, and a triangular skin flap was designed mm above the peak of Cupid’s bow (Fig 4A) When a difference in the length between the lateral and medial lips was larger than mm, triangular skin flaps were divided into parts: a 1-mm flap located at the upper part at the white lip and a 3-mm flap at the original position The hinged margin flap using cleft margin tissue with a pedicle of the mucous membrane of the labial sulcus was made at the edge of the medial lip (Fig 3A) 2) The vestibular incision reached the top of the nasal dome and freed the lateral crura of the lower lateral cartilage (Figs 3A, 4B) Through the vestibular incision, nasal undermining surrounding the piriform margin and the lower border of the upper lateral cartilage on the cleft side was performed These dissections achieved repositioning of the nasalis muscle and facilitated the 3-dimensional advancement of the nasal alar base (Fig 4C) 3) Deviation of the columella base was corrected by undermining around the anterior nasal spine with/without septoplasty The nasal and labial components on the cleft side including the 2225 NAKAMURA ET AL FIGURE Schematic demonstration of correction of unilateral cleft lip and nose A, Oral and nasal vestibular incision along the piriform margin and the posterior edge of the nasal vestibule B, Medial-upward advancement of nasolabial components for repositioning the major alar cartilage, and closure in raw area in the nasal vestibule using the hinged cleft margin flap (pink) C, Before (left) and after (right) reconstruction of the nasalis muscle and orbicularis oris muscle Pars peripheralis and pars marginalis of the orbicular oris muscle were individually reconstructed by different techniques: overlapping, interdigitation, and edge-to-edge suturing The shadow shows the supraperiosteal dissection field The major alar cartilage was fixed by overlapping on the lateral cartilage Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 4) 5) 6) 7) lower lateral cartilage, the nasalis muscle, the orbicularis oris muscles, and lining mucosa were then advanced medially and upwardly as a single body During this step, temporary suturing of the lip was made (Fig 4E), and or mattress sutures of absorbable thread (6-0 polydioxanone suture) were placed to hold the lateral crura of the lower lateral cartilage in a slightly overlapped position on the upper lateral cartilage (Figs 3C, 4D) A transcartilage suture was not made, but the stay suture to fix the highest point of the nasal alar was made by through-and-through suturing using absorbable thread The defect of the lining of the nasal vestibule caused by advancement of the nasal components was covered using hinged cleft margin flaps and/or free mucosal graft donated from the buccal mucosa, depending on the extent of the raw area (Figs 3B, 4D) For reconstruction of the orbicularis oris muscle, pars peripheralis and pars marginalis were connected individually in different manners, overlapping, interdigitation, and edge-to-edge suturing, as shown in Figure 3C The edge of the nasalis muscle was connected at the bottom of the nostril floor Subcutaneous and cutaneous suturing were made carefully (Fig 4F), and a nasal stent made from a sponge tube was applied for week postoperatively, and a silicon nostril retainer (Koken Co, Tokyo, Japan) was used for at least months in both groups Comparison of Pre- and Postoperative Nasal Forms Between Patients With and Without Rhinoplasty Pre- and postoperative nasal forms were compared between the groups using color photographs taken serially during the postoperative period The items evaluated were the nostril height and width ratio, the ratio of the alar groove height, and the curvature of the appropriate circle of the nasal ala 1) The nostril height and width ratio: To assess the correction of lateral cartilages, the ratio between height and width of the nostril was calculated based on the basal view using the formula shown in Figure 5A The ratios were then compared between the cleft and noncleft side 2) The ratio of the height of the top of the alar groove: To assess the upward reposition of the nasalis muscle, the vertical height of the top of the alar groove (distance between the baseline, the line containing both medial ocular angles, and the top of the alar groove) was compared with the distance between the baseline and the bottom of the alar groove on both sides (Fig 5B) 3) The curvature of the appropriate circle of the nasal ala: The outline of the alar groove was traced on pictures and scanned into a personal computer The curvature of the appropriate circle of ala was then calculated using 3D-Rugle IV soft- 2226 TREATMENT OF CHILDREN WITH UNILATERAL COMPLETE CLEFT LIP AND PALATE FIGURE Step-by-step procedures for simultaneous correction of unilateral cleft lip and nose A, Design of skin incision by Cronin’s method B, Cleft margin flap with the pedicle of the mucous membrane of the labial sulcus and the design of the vestibular incision C, Dissection surrounding the piriform margin for repositioning the nasalis muscle (picture from another case) D, Medial-upward advancement of nasolabial components and hinged cleft margin flap E, Frontal view of the nose at temporary suturing to confirm the height of the nostril rim F, Postoperative basal view Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 ware (Medic Engineering Inc, Kyoto, Japan) Because the craniofacial size differed between the subjects, the distance between both medial ocular angles was standardized at the same distance (Fig 5C) For statistical analyses, the Mann-Whitney U test was used to compare mean values of the measurements of the nasal forms between the nose correction group and controls The significance of differences was accepted when the P value was less than 01 Results PRE- AND POSTOPERATIVE VIEWS OF PATIENTS WHO UNDERWENT PRIMARY NOSE CORRECTION Pre- and postoperative views of representative patients with complete UCLP who underwent correction of cleft lip nose are shown in Figures and In case 1, the patient whose surgical procedures are depicted in Figure 4, NAM was applied for presurgical orthopedics for months and the short columella on the cleft side was extended sufficiently Postoperative nasal form showed the satisfactory forms of nasal tip and nasal ala on the frontal view, and the almost symmetric nostril on the basal view at 4.5 years of age (Figs 6A-D) The patient designated as case had quite a severe deformity of the nose at birth, and presurgical orthopedic treatment was performed for months On postoperative view, the nostril on the cleft side was a little flatter and the small webbing of the nostril rim and small ala remained (Figs 7A-D) The shape of the nasal tip and a distal and backward dislocation of the nasal ala were improved in most cases in the correction group None of the patients developed serious sequelae such as infection or stenosis of the nose Furthermore, to date there has not been any additional correction required because of persistent deformities of the lip and nose 2227 NAKAMURA ET AL FIGURE Assessment of the nasal forms using color photos A, The nostril height and width ratios were compared between the cleft and noncleft sides The nostril height and width ratio ϭ the nostril height and width ratio on the cleft side (A=/B=)/the nostril height and width ratio on the noncleft side (A/B) B, The height of the top of the alar groove (the distance between the baseline, line containing the medial ocular angles, and the top of the alar groove) was compared with the distance between the baseline and the bottom of the alar groove on both sides The ratio of the height of the alar groove ϭ the ratio of the height of the top of the alar groove on the cleft side (D=/C=)/the ratio of the height of the top of the alar groove on the noncleft side (D/C) C, The curvature of the appropriate circle of ala was calculated using 3D-Rugle IV software The curvature of the appropriate circle of the nasal ala ϭ the curvature of the appropriate circle of the nasal ala on the cleft side (r)/the curvature of the appropriate circle of the nasal ala on the noncleft side (r=) The distance between both medial ocular angles was standardized at the same distance Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 COMPARISON OF PRE- AND POSTOPERATIVE NASAL FORMS BETWEEN PATIENTS TREATED WITH OR WITHOUT NOSE CORRECTION Comparison of the nostril height and width ratio between the correction and control groups was 0.46 Ϯ 0.07 in the control group and 0.42 Ϯ 0.09 in the controls The preoperative ratio of the correction group seemed to be higher, but there were no significant differences between the groups (P ϭ 19) At year postoperatively, the ratio of the correction group was improved to 0.76 Ϯ0.12, and it was significantly larger than that (0.61 Ϯ 0.14) of the control group (P Ͻ 01) On analysis of the serial alterations in nostril height and width ratio in the correction group, the ratio was highest at months postoperatively (0.80), then tended to decrease at year postoperatively Postoperative alteration of ratio then seemed to increase slightly after years Comparison of-the ratio of the height of the top of the alar groove between patients treated with or without correction demonstrated that the preoperative ratio in each group was almost 1.2, and there were no significant differences between the groups (Fig 8B) Postoperatively, the ratio of the height of the alar groove was improved to 1.03 Ϯ 0.06 in the correction group, and it was significantly larger than that (1.13 Ϯ 0.08) of the control group (P Ͻ 01) Regarding the curvature of the appropriate circle of the nasal ala, preoperative ratios were 0.86 Ϯ 0.10 2228 TREATMENT OF CHILDREN WITH UNILATERAL COMPLETE CLEFT LIP AND PALATE FIGURE A, Preoperative basal view of a patient with complete UCLP C, D, 4.5-years postoperative views of this patient The surgical procedure for the patient is shown in Figure B, NAM was applied for months before primary lip repair Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 and 0.92 Ϯ 0.05 in the nose correction and control groups, respectively Postoperatively, the ratio was improved to 1.00 Ϯ 0.05 in the correction group The postoperative ratio of the control group was slightly larger, but there was no significant difference between the groups (Fig 8C) Discussion The authors performed simultaneous correction of the cleft lip and nasal deformity at primary surgery on cleft patients for nearly 15 years In the early period, we were eager to reposition the lower lateral nasal FIGURE A, B, Preoperative views of a patient with serious deformity of the nose C, D, 1.5-year postoperative views Webbing at the rim still persisted postoperatively Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 2229 NAKAMURA ET AL FIGURE Results of comparing the nasal forms between the nose correction and control groups A, Pre- and postoperative height and width ratios of the nostril B, Pre- and postoperative ratios of the height of the top of the alar groove C, Pre- and postoperative circle of the nasal ala Nakamura et al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 cartilage by dissecting it from both the skin and lining through a nostril rim incision Although the results were thought to be acceptable, it was difficult to handle an infant’s fragile cartilage even with open dissection Consequently, to establish a universally acceptable correction of cleft lip nose, we started to perform a less invasive management using presurgical NAM and primary repair without wide dissection of the surrounding lateral cartilages The concept underlying this procedure is to obtain anatomical repositioning of all structure of the cleft lip and nose except the underlying anterior maxillary bone and to minimize the surgical intervention The NAM is designed to align the alveolar segment, restore the lower lateral cartilage position, and increase the columella length.15 Grayson et al13 indicated that nasal molding alone is not sufficient to correct deformity of the nasal tip Although NAM stretches the columella skin into a more normal configuration and normalizes the shape and position of the lower lateral cartilages, coordinated primary nasal surgical correction is still required after NAM These investigators combined a surgical technique similar to that described by McComb, Salyer, and Anderl et al for primary correction, but excluded the use of ex- ternal bolsters.14 MacComb1 and Anderl et al11 dissected the skin widely from the alar cartilage using columella base and alar base incisions, extending the skin dissection to the contralateral alar cartilage and up to the nasion Salyer8 undermined the alar cartilage from both the skin and lining from the lateral ala incision, and the alar cartilage was repositioned and secured using temporary stent sutures Grayson et al13 also reported that with the advent of presurgical NAM, these surgical procedures have become much less extensive, because lateral dissection of the lower lateral cartilage is no longer necessary Although the effects of NAM can reduce the amount of dissection of the cartilages, surgical intervention in the cartilages is still necessary for correction of unilateral cleft lip nose at present The present analyses of postoperative nasal forms of patients managed by presurgical orthopedics using NAM followed by our surgical procedures for lip repair demonstrated the benefits and limitations The height of the top of the alar groove and the curvature of the appropriate circle of the nasal ala on the affected side were almost completely corrected in the correction group This means that medial-upward advancement of nasolabial components through the ves- 2230 TREATMENT OF CHILDREN WITH UNILATERAL COMPLETE CLEFT LIP AND PALATE tibular incision and expansion of the nasal vestibule provides successful reconstruction of nasal alar components including the nasalis muscle As part of his original procedure for cleft lip repair, Millard22 described the nasal vestibular incision with subsequent placement of a lateral edge mucosal flap into the lateral vestibular defect to maintain nasal ala advancement against contracture For primary nasal correction, Millard exposed the major alar cartilage through the total vestibular incision and freed the alar cartilage from the overlying skin, and bilateral alar cartilages were sutured directly at the time of lip repair.9,22 The concept of advancing both ala and the lower lateral cartilage and placement of the mucosal flap is basically the same as ours, but we handle the cartilage as a single body with the overlying skin and lining mucosa without dissecting the surface of the cartilage Therefore, our procedures are less invasive than those reported by Millard,22 MacComb,1 Sayler,8 and Anderl et al.11 Tajima23 reported nasal correction by an internasal incision along the area just inside the piriform margin to free the lateral cartilage and emphasized the importance of transposition of the periosteum attached to the nasalis muscles and covering the defect of the nasal vestibule using bilobed cleft margin flaps For correction of nose, Tajima23 combined the reverse-U skin incision to produce a symmetrical ala Except for limited undermining of the lower edge of the upper lateral cartilage to overlap the alar cartilage, we not make any skin incision on the nostril rim or any dissection of the periosteum because of concern regarding growth disturbance In our experience, to achieve successful repositioning of the nasal ala, nasal undermining along a single plane beyond the lower part of the lateral cartilage, piriform margin, and the anterior maxillary wall and placement of the lateral crura of lower lateral cartilage in an overlapped position on the upper lateral cartilage are essential techniques during the primary correction The effects of presurgical orthopedics and the completeness of the above procedures during lip repair may contribute to the need for additional surgical nasal correction The present analyses further demonstrated that the ratio of nostril height and width in the correction group was much better than that of the controls However, the ratio in the correction group reached approximately 0.8 postoperatively Although the subjects in this study had serious nasal deformity before treatment, this postoperative ratio suggested that our procedures for correcting the major alar cartilage are not yet complete Furthermore, when analyzing serial alterations in the corrected nose, the nostril height and width ratio was highest at months postoperatively, and then tended to gradually decrease until years postoperatively To prevent relapse of the nasal forms, an improvement of our presurgical orthopedics and surgical modality is thought to be necessary Several factors affecting insufficient recovery of the nostril forms can be listed as follows: 1) insufficient nasal molding before surgery, 2) insufficient nasal undermining, 3) insufficient overcorrection of the lower lateral cartilage, and 4) postoperative contracture of the subsequent tissue in the vestibule When considering the patients with persistent deformity as shown in Figure 7, most patients had a wide cleft and markedly depressed anterior maxillary before treatment After presurgical orthopedics, the nasal ala was adequately repositioned at the primary repair; however, the nasal ala gradually subsided postoperatively into the retroposed position The loss of bony support may cause a collapse of the distal end of the lateral crura, resulting in a relapse of the nostril shape Therefore, presurgical orthopedics providing more symmetric bone support as well as a symmetric shape of the nasal cartilages will be required for the management of nose deformity in complete UCLP.24 The influence of our procedures on nasal growth is an important issue that has not yet been clarified Although subjects in our series have not shown any apparent growth disturbance to date, long-term follow up will be necessary to clarify effects on the growth of nasal tissues reconstructed in infancy In conclusion, our management of the cleft lip nose will provide good nasal forms with minimum invasion in patients with complete UCLP Long-term follow-up will be necessary to clarify the effects on the growth of nasal tissues reconstructed in infancy Acknowledgments The main contents of this study have been presented and received “the Best International Basic Scientific Poster Award” at the 89th Annual Meeting, Scientific Sessions and Exhibition of the American Association of Oral and Maxillofacial Surgeons, held in conjunction with the Japanese Society of Oral and Maxillofacial Surgeons and the Korean Association of Oral and Maxillofacial Surgeons in Honolulu in October 2007 We express great thanks to Dr Masamichi Ohishi, Emeritus Professor of Kyushu University, who instructed us on the surgical management of cleft lip and nose We also express great thanks to our colleagues in the Department of Pediatric Dentistry at Kyushu University and Kagoshima University Hospital for managing the orthopedic appliances and for their cooperation in this study References MacComb H: Primary correction of unilateral cleft lip nasal deformity: 10 Year review Plast Reconstr Surg 75:791, 1985 Sugihara T, Yoshida T, Igawa H, et al: Primary correction of the unilateral cleft lip nose Cleft Palate Craniofac J 30:231, 1991 Berkeley WT: The cleft-lip nose Plast Reconstr Ssurg 23:567, 1959 Salyer KE: Primary correction of the unilateral cleft lip nose: A 15-year experience Plast Reconstr Surg 77:558, 1986 Byrd HS, Salomon J: Primary correction of the unilateral cleft nasal deformity Plast Reconstr Surg 106:1276, 2000 NAKAMURA ET AL Millard DR, Jr: Cleft craft: The evolution of its surgery, in Vol I: The Unilateral Deformity Boston, Little, Brown, 1976, p 19, 251 Pigott RW: Alar leapfrog—A technique for repositioning the total alar cartilage at primary cleft lip repair Clin Plast Surg 12:643, 1985 Salyer KE: Early and late treatment of unilateral cleft nasal deformity Cleft Palate Craniofac J 29:557, 1992 Millard DR, Jr, Morovic CG: Primary unilateral cleft nose correction: A 10-year follow-up Plast Reconstr Surg 102:1331, 1998 10 Wolfe SA: A pastiche for the cleft lip nose Plast Reconstr Surg 114:1, 2004 11 Anderl H, Hussl H, Ninkovic MN: Primary simultaneous lip and nose repair in the unilateral cleft lip and palate Plast Reconstr Surg 121:959, 2008 12 McComb HK, Coghlan BA: Primary repair of the unilateral cleft lip nose: Completion of a longitudinal study Cleft Palate Craniofac J 33:23, 1996 13 Grayson BH, Santiago PE, Brecht LE, et al: Presurgical nasoalveolar molding infants with cleft lip and palate Cleft Palate Craniofac J 36:486, 1999 14 Maull DJ, Grayson BH, Cutting CB, et al: Long-term effects of nasolalveolar molding on three-dimensional nasal shape in unilateral cleft Cleft Palate Craniofac J 36:391, 1999 2231 15 Lee CTH, Garfinkle JS, Warren SM, et al: Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate Plast Reconstr Surg 122:1131, 2008 16 Da Silveira AC, Oliveira N, Gonzalez S, et al: Modified nasal alveolar molding appliance for management of cleft lip defect J Craniofac Surg 14:700, 2003 17 Smith HW: The Atlas of Cleft Lip and Cleft Palate Surgery New York, Grune & Stratton, 1983, p 131, 155 18 Cronin TD: A modification of the Tennison-type lip repair Cleft Palate J 3:376, 1966 19 Ohishi M, Nakamura N, Honda Y, et al: Lip scar of the cleft lip patient J Craniomax-fac Surg 22:31, 1994 20 Hotz M, Gnoinski W: Comprehensive care of the cleft lip and palate children at Zurich University: A preliminary report Am J Orthod 70:481, 1976 21 Millard DR, Jr: Cleft craft: The evolution of its surgery, in Vol I: The Unilateral Deformity Boston, Little, Brown, 1976, p 146 22 Millard DR, Jr: Cleft craft: How to rotate and advance in a complete cleft, in Vol I: The Unilateral Deformity Boston, Little, Brown, 1976, p 449 23 Tajima S: The importance of the musculus nasalis and the use of the cleft margin flap in the repair of complete unilateral cleft lip J Maxillofac Surg 11:64, 1983 24 Millard DR, Jr, Latham RA: Improved primary surgical and dental treatment of clefts Plast Reconstr Surg 86:856, 1990 ... followed by primary lip repair for children with complete UCLP were evaluated The outcomes of these procedures were then compared with the nasal forms achieved by treatment without nasal correction... correction of unilateral cleft lip and nose A, Oral and nasal vestibular incision along the piriform margin and the posterior edge of the nasal vestibule B, Medial-upward advancement of nasolabial components. .. al Treatment of Children With Unilateral Complete Cleft Lip and Palate J Oral Maxillofac Surg 2009 COMPARISON OF PRE- AND POSTOPERATIVE NASAL FORMS BETWEEN PATIENTS TREATED WITH OR WITHOUT NOSE