|ORIGINAL ARTICLE – RETROSPECTIVE STUDY
|Year : 2016 | Volume
| Issue : 1 | Page : 63-67
Cleft Rhinoplasty- Columellar lengthening prolabial reconstruction with Abbe flap
Director and Consultant Maxillofacial Surgeon, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||12-Jul-2016|
Dr. S M Balaji
Balaji Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai - 600 018, Tamil Nadu
Introduction: A single center's experience of correction of cleft lip/palate associated rhinoplasty using Abbe flap is relatively rare in literature. The outcome and perception of the Abbe flap for cleft rhinoplasty at patient, surgeons, and patient's caregiver level have not been found in literature. This manuscript aims to address this lacuna through the use of rhinoplasty outcomes evaluation questionnaire (ROEQ). Materials and Methods: A retrospective analysis of preoperative satisfaction and prospective analysis of postoperative satisfaction of patients who underwent cleft rhinoplasty were carried out using ROEQ. This was used twice measuring the pre- and post-operative periods. Results: Twenty-one cases of bilateral cleft lip and palate who had earlier undergone (0.5–3 years back) cleft rhinoplasty and lip revision with Abbe's flap formed the study group. The mean age of the 21 subjects was 22.87 ± 4.23 years. There were 13 males and 8 females forming the study group. The mean presurgical ROEQ score was 19.8 ± 11.2, while the postsurgical score was 78.5 ± 21.2. This difference was statistically significant (P = 0.001). The difference in score between the time period was 58.7%. Discussion: From the ROEQ and other qualitative parameters, it is possible to demonstrate the impact of Abbe flap for cleft rhinoplasty and its impact on the quality of life of patients. Most of the patients and caregivers believed that this approach achieved a good or excellent postoperative result. The biological and operators factors behind such a success are discussed in light of previously published literature.
Keywords: Abbe flap, cleft lip, cleft palate, India, quality of life, revision rhinoplasty
|How to cite this article:|
Balaji S M. Cleft Rhinoplasty- Columellar lengthening prolabial reconstruction with Abbe flap. Ann Maxillofac Surg 2016;6:63-7
| Introduction|| |
In cases of patients with cleft lip and palate (CLP), often the columella, owing to deficiency of columella height, the nasal tip is depressed, alar bases flared and altered nasolabial angle in the profile. The degree of deformity is different between unilateral and bilateral cases. In most instances of the complete unilateral CLP cases, the deformity is often tilted to the involved side while in the complete bilateral CLP (BCLP) cases the entire columella is deformed. In complete CLP rehabilitation, such a deformed, “crooked nose” poses a significant challenge. In cases of deficiency, the columellar lengthening procedure (CoLP) is the most viable treatment procedure. However, the type of CoLP needs to be chosen on the degree of nasolabial deformity. It has been always a challenge to recreate an ideal and a natural columella. This could be due to the reconstructed columella which often becomes thick and retracted. Addition of autogenous cartilage would solve the issue in most of the instances. Moreover, it would help to design proper nasal tip, contour.,
The “Abbe flap” introduced by Robbert Abbe as “lip switch” flap in 1898 for the secondary correction of a cleft lip deformity is still most widely used flap. Still this pedicled flap is used to recreate the philtral subunit which is usually deficient in BCLP.,, The experience of cleft center's with respect to the use of Abbe's flap in correcting the BCLP rhinoplasties using cartilaginous grafts is very little in literature emanating from this part of the world. The primary aim of this manuscript is to present a single center's experience of correction of BCLP rhinoplasties.
| Materials and Methods|| |
The present study is a longitudinal, retrospective, cohort who had undergone rhinoplasties with BCLP correction with the center during 2012–2014. The study included a retrospective analysis of preoperative satisfaction and a prospective one concerning the postoperative satisfaction. The patients who were turning up for clinical review and/or orthodontic reviews were invited to be a part of this study in the phase of June 2015–December 2015. A specifically formulated rhinoplasty outcome evaluation questionnaire (ROEQ) based on previous publication was used for this specific purpose.
The ROEQ contained the following questions:
- How much do you like the appearance of your nose?
- How much can you breathe through your nose?
- How much do you think your friends and those close to you like your nose?
- Do you think the appearance of your nose limits your social or professional activities?
- How safe are you that your nose has the best possible appearance?
- Would you like to surgically change the appearance or function of your nose?
Each question in the questionnaire was answered with a score between 0 and 4. Zero was used for the least score and 4 for the most positive score. The total score was then added, divided by 24 (maximum possible score) and multiplied by 100 to be expressed as a percentage as described previously.
The ROEQ was administered twice during the visit and the patient's satisfaction was measured pre- and post-surgery. To aid the patients, their profile photographs from the records were shown. The postsurgical experience did not require any aid.
Beside the 2 ROEQ scores, age and gender of the patients were noted down. The qualitative assessment of the postrhinoplasty success as perceived by the patient was also taken down. Postrhinoplasty, the deforming malposition, distortion, asymmetry or scar of the lip vermillion, columellar lengthening, the axis of the nose, and its deviation from the midline, tip projection, and dorsal augmentation of the nose were asked for. The choices were categorized as unnoticeable (to be recognized by patients), obvious (noticed by patients but not by attendants), and deforming (noticed both by patients and attendants). This procedure was also followed in a previous, pertinent literature.
The preoperative assessment of patients was those that are used for a standard BCLP and rhinoplasty, the factors that were given specific reconsideration for reconstruction included symmetry of the alar bases and nostril shape, length of the columella, any deformations or deficiencies of the nasal lining, associated lip deformity due to a lack of correct muscle realignment at primary surgery. All patients had undergone various degrees of presurgical orthodontics and would require further postsurgical orthodontics for refinement of the technique.,,,,,
Presurgical counseling about the procedure was done. Informed consent was obtained from patients as well as their attendants. They were detailed about the two staged procedure, especially the need to raise the flap from the central (mental) part of the lower lip. The need to temporarily join the upper and lower lip for a limited period and its potential, brief impact on quality of life was explained with the help of diagrams. The need for procuring grafts for rhinoplasty was explained.,,,,,
The first stage of the procedure was performed under general anesthesia with orotracheal intubation. Local epinephrine injection was avoided in the labial region to prevent possible immediate swelling and thus distortions. The surgical margins were outlined and marked. Fistulas, if any were eliminated and the lateral lip segments were mobilized by incisions onto the nostril floor. The release incision of the oral mucosa and muscle from the premaxilla and pyriform margin allowed the medial advancement of the lateral lip segments without tension.,,,,,
The standard open rhinoplasty was performed with incision being placed along the lower border of alar cartilages. The nasal columella was slightly raised from its nasal base through a small, strategically placed lateral incisions, just behind the columella that was extended upward and into the nostrils. To perform nasal tip modifications, subcutaneous dissection of the nasal skin envelope was performed. In this process, hemostasis was achieved at every stage. Previously harvested, preshaped (to prevent warping) cartilage grafts were employed for supporting the medical crus of the lower nasal lateral cartilage while ensuring sufficient columellar elongation. At this stage, nasal tip morphology was also corrected if needed. The nasal skin was checked and lateral margins of the lip flap were approximated to the columella base. Alar cinch sutures were placed to keep the redesigned nostril width and height.
As per previous work up, the Abbe flap design was marked. Care was taken to rise only minimal, narrow portion of graft and utilized to stimulate the missing philtrum. The flap at its end was forked to a classic W shape to match the columellar base incision. While raising an Abbe flap by blood pressure blade 11, a full thickness graft with a cuff of tissue on one side was allowed back to facilitate donor site closure. It was ensured that the flap contained sufficient amount of mucosa, muscle, and arterial supply (from an inferior labial branch of facial artery). The flap was then carefully rotated upward to the recipient site without any vascular distortion. The flap was then closed with approximation at the recipient site. The edges were trimmed and donor site carefully closed in layers to prevent scar formation. Standard postoperative medicines and care instructions were given. The Abbe flap was dissected under local anesthesia on postoperative 10–14 days. During the postoperative period or the perioperative circumstances, no complications such as airway obstruction, bleeding, infection, wound disruption, or flap necrosis were encountered as observed in the case records. No instance of warping was encountered.
Statistics: Data were entered and analyzed using Statistical Package for Social Services (version 20, IBM, IL, USA). Comparison of the pre- and post-rhinoplasty ROEQ score was performed by using unpaired t-test. For qualitative questionnaire, descriptive statistics and Chi-square tests were performed. A P ≤ 0.05 was taken as significant.
| Results|| |
During the study period, 21 cases of BCLP approached the center again for various dental issues ranging from interventional dental care such as extractions and root canal therapies, orthodontic care to regular dental visits. With voluntary consents, the ROEQ and qualitative assessments were performed as outlined above.
The mean age of the 21 subjects was 22.87 ± 4.23 years. There were 13 males and 8 females forming the study group. Several of the subjects had previous treatment for BCLP but the ones with repeat rhinoplasties were excluded from this study. They had undergone presurgical orthodontics, osteotomies, and two cases of distraction osteogenesis as a part of correction of their BCLP. The mean follow-up period ranged from 0.5 to 3 years. The mean latency period was 14 ± 5 months.
The representative preoperative and postoperative pictures of the nose are given in [Figure 1] and [Figure 2].
|Figure 1: (a) Preoperative frontal view. (b) Surgical outline marked. (c) Open rhinoplasty and graft employed to lengthen the columella. (d) Lateral margins of the lip flap are approximated to the columella base. (e-g) The width of deficiency measured and Abbe flap design marked. (h) Abbe flap with mucosa, muscle, and arterial supply raised and rotated, donor site closed. (i) Flap fixed to reconstruct deficient philtrum. (j) Postoperative frontal view|
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|Figure 2: (a and b) Preoperative views showing lip and nose defect. (c) Incision marked. (d) Open rhinoplasty using graft. (e) Columella lengthened, Abbe flap margins marked to be fixed in the recipient site. (f) Flap fixed to reconstruct deficient philtrum, donor site closed, and care taken to include hair follicles in the raised flap to ensure normal mustache growth in the male patient. (g and h) Postoperative views|
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The mean presurgical ROEQ score was 19.8 ± 11.2, while the postsurgical score was 78.5 ± 21.2. This difference was statistically significant (P = 0.001). The difference between score was 58.7%.
In the qualitative approach [Table 1], on comparing the different states of rhinoplasty result perception between the patients and the parameters, it was identified that χ2 was 10.5 and P = 0.0147.
|Table 1: Qualitative difference in perception of postoperative rhinoplasty outcome measures|
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None of the patients required surgical revision of the scar or any functional compromise.
| Discussion|| |
The BCLP intrinsically involves an alteration in the formation and bulk of the premaxillary structures, noticeably the philtral areas. This results in the deficiency of the tissues along the philtral column and partly nasal structures. In addition, this deficiency reflects on the nasal width, prominence, malformed nasolabial fold. These, in addition to deformed nasal structures, compromise the nasal form, function, and esthetics. Surgical correction of BCLP, which at certain instances, requires correction of the nasal architecture too.,,
The versatility of Abbe flap to correct the BCLP, especially the philtral area has been carried out successfully. Combining this with cosmetic cleft rhinoplasty offers a simple solution to midfacial deformity. The flap is based on the principle that it employs the extra local tissue, namely the lower labial tissues to correct the deformity in the upper lip. Moreover, the dimensional variations between the lips help the transfer of tissue. As the flap is a local flap, ideal color, tissue type matching is possible as accurate as possible.,,,
The timing of revision of BCLP and nasal deformities has often been deferred till functional growth ceases for the following reasons as cited by various authors including Bardach and Salyer:,,,
- To facilitate the orthodontic intervention
- To permit the maturation of the lower nasal cartilage maturation – strong, stable, support for redesigned nasal tip
- To facilitate completion of cleft palate correction.
The current technique is often reserved for a patient who shows a nasal and upper labial deformity in spite of early intervention. The results of the simultaneous correction show the effectiveness of this technique. However, in well-executed cases of early cleft lip repairs, this approach may not be required.
As in this modified method, the entire philtral subunit is redesigned; it gives a well desired esthetic appeal. The patient or their immediate attendants often do not observe the residual deformities or scar. This is evident from the results given in [Table 1]. The patients perception of their deformity before the surgery as reflected by the ROEQ score, indicate the psychological, social, and physiological impact of nasal deformity. The postsurgical ROEQ score indicates that nearly all patients were completely satisfied to the highest order. Similar reports have been produced earlier from Brazil.
This approach for understanding the success of rhinoplasty has been previously studied, published, and accepted., To the best of our knowledge, this study is the first of its kind, which appreciates the outcome of rhinoplasty of BCLP patients. Few other studies have been in this approach,,, but none of them employed the ROEQ kind of approach. The effective lengthening of columella with Abbe flap serves many purposes:,,
- Helps to correct the redundant lower lip
- Helps to correct the deficient upper lip, particularly the philtral area
- Corrects the nasal base, tip, columella length, and tissue deformities in the area
- In case of males, facial hair is found in both the donor and recipient site. In this regard, with the Abbe flap, the issue of facial hair is negated.
Lo et al., Mokal and Juneja, and Kumar et al. have shown that the Abbe flap with simultaneous reconstructive rhinoplasty is a safe and effective procedure without any significant surgical morbidity and airway obstruction. Similar to Mokal et al. authors did not encounter any airway obstruction, but Kumar et al. reported two such instances in their cohort. Probably, the nature of study, patient factors, and difference in approaches contributed to this effect.
The late labial correction often aggravates nasal deformity owing to complex muscle and loco-regional interactions of the peri-oral and peri-nasal musculatures. In this regard, the simultaneous correction of the base of nose, columella, and the upper lip yields a better result than the separately reconstructed ones. In addition, the patient's perceptions of their postoperative results, the attendant's version are crucial as they have living with the stigma over the years. In this, it was identified that the scar was a major problem. At least 9 of the 21 patients (42.85%) patients reported that they were conscious of the resultant scars in the lips, while none of the patient's attendants noted the same. Malpositioning of nose, distortion of tip, and asymmetry of nares were not noticeable in at least 86% of the study subjects, postoperatively. This part of the study could carry an inherent time-related bias. However, to compensate for this bias, we did show the archival images that probably helped them to revive their memories. This type of study approach has been used previously.
| Conclusion|| |
Abbe flap with reconstruction rhinoplasty is a reliable, safe procedure, and much effective in corrective of secondary or residual deformities that are especially found at the time after cessation of growth with no complications. The present study presently evaluated the outcome of the procedures and found to have a high degree of satisfaction, postoperatively. This helps to instill confidence in this subgroup of patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]