Primary rhinocheiloplasty: Comparison of open and closed methods of alar cartilage reposition.

AIMS: To establish which rhinoplasty method for primary repairing of unilateral cleft lip (UCL) is better. SETTINGS AND
DESIGN: Two patient groups with cleft lip were compared. Each group was operated on either by McComb's technique as closed rhinoplasty method or by Vissarionov-Kosin technique as an open method. SUBJECTS AND METHODS: First group included 29 patients and the second consisted of 31. All patients were operated on by single surgeon over 10 years. Randomization was based on wishes and intention of surgeon to use one of two methods. Evaluation of results was based on impartial data, and subjective information collected from respondents with different levels of knowledge about UCL. The objective scale was based on the evaluation of five noticeable residual deformations of nose that usually appear after primary lip-nose surgery: Alar flattening, low position of alar, widening or narrowing of nostril, and deformation of the upper part of nostril rim. Subjective evaluation was based on the opinion of respondents who were ranged every case depending on own judgment. STATISTICAL ANALYSIS: Was performed using Fisher method and Chi-square by Statistica 10.0, StatSoft Inc.
RESULTS: Approach with general analysis indicated no difference between two methods. Despite of absence of clear differences between two groups we consider the closed rhinoplasty more favorable due to less damage to alar cartilages and no scars inside nostrils.
CONCLUSIONS: We think that mentioned scarring may complicate secondary rhinoplasty, which is often needed to correct nose deformation.

INTRODUCTION

Usually, deformation of the midface is quite visible in patients with operated cleft face. The deformation often takes shape of nose asymmetry. At present, the majority of surgeons consider that rhinoplasty should be performed together with cheiloplasty. However, no common method of rhinoplasty exists. Both closed[123] and open[45] methods of alar cartilage reposition are widely used. This is why there is a lot of argument over which method is the best. To answer this question, we present this research study about two groups of patients who were operated on using open and closed methods of rhinoplasty which are rather popular in Russia.

SUBJECTS AND METHODS

To evaluate the efficiency of open and closed methods of rhinoplasty we compared two groups of patients. One group was operated on with McComb and Coghlan[2] method (the most frequent method), and the second group was operated on with sliding flap method of Vissarionov[67] (the most widely spread method of open rhinoplasty). First group included 29 patients, and second – 31. None of the cases included orthodontic reposition of mandibular parts and septum nasi centralization before to the surgery. We selected only patient who had frontal and half axial projection photos before and after the surgery (taken not earlier than 1 year after). All the patients were operated on by one surgeon over the last 10 years. The surgery method was random and depended only on surgeon's willingness to perform certain method of rhinocheiloplasty in every case.

The valuation of the surgery result was based both on objective and subjective data. The data were collected from survey among respondents with different degree of awareness about unilateral cleft lip (UCL). Objective criteria included five most visible residual nose deformations such as flattening and retraction of ala nasi, narrowing, widening, and unnatural shape of nostril [Figure 1a–e]. Evaluation scale was based on complications. The result was considered “good” if patient had no more than one complication [Figure 2a–d], “satisfactory” if patient had two complications [Figure 3a–d]. The result was rated as “bad” in case of three or more complications [Figure 4a–d]. Three groups of respondents were surveyed to conduct subjective analysis of nose deformation. First group of respondents included plastic surgeons who continuously operated on patients with cleft lip and palate. We called this group “experts.” Second group of respondents consisted of doctors with a notion of cleft lip and palate treatment methods but by condition these doctors did not deal with UCL directly. We named this group “related” since their opinion was highly influenced by frequent contact with patients with cleft lip and palate. Third group included parents of children who had facial deformations but not cleft lip or palate. We called this group “unrelated” because they have never dealt with cleft lip and palate. Each group included five respondents. The surgery result was evaluated only on post-surgery photos. This condition was introduced with intention to avoid “sudden change effect” which is likely to take place if pre- and post-surgery images are compared. This effect is especially big in cases where deformation is significant. Subconsciously, we generally notice drastic changes in patients’ image and cannot evaluate minimal defects which, after all, contribute greatly to the residual deformation. Moreover, respondents did not know to which group the patient belonged. All the respondents were asked to rate treatment result as good, satisfactory, or bad based on personal opinion.

Figure 1

Types of secondary deformation alar nose: (a) flattening, (b) narrowing, (c) widening, (d) retraction, (e) unnatural shape of nostril

Figure 2

Patients with “good” result (subjective analysis): (a and c) open rhinoplasty, (b and d) closed rhinoplasty

Figure 3

Patients with “satisfactory” result (subjective analysis): (a and c) open rhinoplasty, (b and d) closed rhinoplasty

Figure 4

Patients with “bad” result (subjective analysis): (a and c) open rhinoplasty, (b and d) closed rhinoplasty

RESULTS

Statistical analysis was performed using Fisher method and Chi-square. Good result was achieved for 13 patients which underwent closed rhinoplasty, and for 15 patients with open rhinoplasty (P = 0.8). Satisfactory result was manifested for 13 patients with closed rhinoplasty and for 8 patients with open rhinoplasty (P = 0.17). Bad result was mentioned for three patients with closed rhinoplasty and for nine patients with open rhinoplasty (P = 0.1). Simple analysis showed no difference between open and closed rhinoplasty [Table 1].

Table 1

Evaluation of surgery result depending on method (general analysis)

Detailed analysis of complications revealed that flattening of ala nasi was most frequent 23 in closed rhinoplasty group and 17 in case of open rhinoplasty (P = 0.05). Narrowing of ala nasi was the second most frequent complication: Seven and ten patients had this complication in closed and open rhinoplasty group correspondingly (P = 0.6). Unnatural shape of ala nasi was more frequently observed among patients with open rhinoplasty compared to another group (14 vs one, P = 0.006). Widening of ala nasi and retraction had identical frequency in both groups: Seven and four cases in first group, six and three cases in second group correspondingly (P =0.75 and P =0.7). Consequently, the only conclusion which is statistically significant is that shape of ala nasi was more frequently changed in case of open rhinoplasty, whereas widening of ala nasi was more frequent in case of closed rhinoplasty. Apparent worse performance of closed rhinoplasty was not statistically proven [Table 2].

Table 2

Frequency of deformations depending on method (detailed analysis 1)

However, if we range residual deformation based on complexity of consequent treatment, unnatural shape and narrowing of ala nasi are harder to correct compared to widening and retraction of it. This is why we classified all deformations in two groups: “Easy-to-correct” and “difficult-to-correct” and analyzed treatment results in the context of these groups. Analysis of easy-to-correct complication cases revealed higher frequency in closed rhinoplasty group (23) compared to open rhinoplasty group (18). This difference is statistically significant (P = 0.05). Analysis of difficult-to-correct complications showed worse results in open rhinoplasty group (18) compared to another group (eight), which is also statistically significant (P = 0.04). We also noted that number of complications was higher among patients in open rhinoplasty group [Table 3].

Table 3

Evaluation of complications from surgery point of view “what is easier to correct”

Subjective evaluation

For the analysis, we used mode indicator Moda (Mo) both for combined data across three groups of respondents and separately within each group.

Treatment results in 26 cases (43%) in first group and 14 (40%) in the second group were rated as “good” in subjective evaluation. Surgeons rated as “good” 26 (43%) cases in first group and 12 (40%) cases in the second group (P = 0.4). “Related” respondents noted good results in 20 cases (33%), more frequently in second group – 11 cases (37%) compared to first group – 9 (31%), P = 0.2. “Unrelated” respondents, parents, marked 32 cases (52%) as good. Both experts and parents scored “good” more frequently among patients who underwent closed rhinoplasty – 17 patients (59%), whereas in group of open rhinoplasty only 15 cases (50%) were evaluated “good”(P = 0.4) [Table 4].

Table 4

Distribution of evaluation “good results” among groups of experts

Subjectively, all types of respondents evaluated result as “bad” in 13 cases (22%), 6 (21%) of which belonged to first group, and seven (23%) – to the second group (P = 1). Surgeons marked 16 (27%) cases as “bad” result, 6 (21%) from the first group, and ten (33%) from the second (P = 0, 3). Doctors, unrelated respondents, labeled 12 (20%) cases as bad, six cases from each group (20% from first group and 21% from the second group, P = 1). Regretfully, all the results are statistically insignificant. This means that subjective evaluation did not reveal any statistically significant differences between open and closed methods [Table 5].

Table 5

Distribution of evaluation “bad results” among groups of experts

DISCUSSION

Deformation of ala nasi is one of the major challenges in cleft lip and palate surgery. Rotation advancement method which is widely spread nowadays solves most of the problems caused by cleft lip and palate. However, there is no universal method of treatment which to a maximum extent allows to reducing all the deformations of cartilaginous skeleton of the nose cased by the cleft. Some authors offer one-moment correction of nose and lip deformations,[8] whereas others see value in delayed rhinoplasty.[910] There is much argument on better method of surgical access – open[45] or closed[123] rhinoplasty. The absence of defined evaluation criteria of cleft surgery results sets fruitful ground for this argument. It is conventional to detail the deformation by splitting it to small features[11] or to evaluate separate area of the face,[12] nasolabial area in our case. This approach is rather valuable since it enables surgeon to analyze surgery results in details. However, in real life, we evaluate appearance as aggregation of all facial features. This method is called “subjective” because it does not fall under any rules and strict definitions, but it is particularly socially important for the patient. This is why we consider subjective evaluation to be useful for surgeries of this kind.

The second challenge in treatment result evaluation is impartiality when comparing surgical methods. It is peculiar that majority of researches aim to prove superiority of one method out of two. Naturally, this approach leaves certain features out of discussion. As a result, we end up with a number of methods which are brilliant in hands of the author but hardly applicable by other surgeons. Unfortunately, we encountered only one prospective, randomized controlled research study which did not advertise new surgery methods.[13]

This study compared the results of open and closed rhinoplasty performed by one surgeon using Millard method. The point of the research was to compare two traditional approaches in standard conditions but not to promote one of the methods. The result was evaluated based on quantitative analysis of certain linear dimensions of nasal cartilage. The authors have completed study highly valuable to evidence-based medicine, despite all the difficulties with results interpretation coming from different age of patients and short period of postoperation observation.

Our study is the first in its class to integrate the evaluation of quantitative (objective) and qualitative (subjective) criteria which give a better understanding of treatment result. Besides, this study has included independent distribution of patients across treatment methods. This means that it could be considered as a retrospective randomized, single-blind study.

We did not reveal any statistically significant difference between two methods of rhinoplasty such as other investigators. However, when we evaluated the difficulty of deformation correction we saw that closed rhinoplasty is rather mild procedure. The degree of difficulty of deformation correction may be useful for future research in this area.

CONCLUSION

Based on the conducted analysis, we concluded the following. Subjective and objective analysis did not reveal statistical difference between open and closed method of rhinoplasty. However, when dividing nose deformations into “easy-to-correct” and “difficult-to-correct,” we have found statistical difference between open and closed rhinoplasty. Open rhinoplasty seems to be less effective compared to closed reposition of alar cartilage. We consider reasonable conducting cheilorhinoplasty with reposition of alar cartilage as primary surgery. Open rhinoplasty is more suitable for correction of residual deformation in increased age 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

Nil.

Conflicts of interest

There are no conflicts of interest.