The valuation of the residual and secondary deformation of the medium face zone in patients with unilateral cleft lip

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Background

Among patients with congenital malformations of the face, congenital cleft lip and palate (CCLP) accounts for up to 90% of cases [1]. Full completion of medical rehabilitation for patients with CCLP is one of the most important problems in health care.

Incomplete medical rehabilitation of patients in this category is not limited to children with CCLP. Despite the significant successes of integrated surgical and orthodontic treatment and medical rehabilitation of patients with unilateral CCLP, a number of treatment problems remain for adults [2–4]. According to some authors, approximately 80% of adult patients with CCLP require remedial facial surgery [5–7].

The natural shape and symmetry of the upper lip and nose, their aesthetic appeal, the contribution of the facial muscles, and a number of functions are primarily due to the anatomically regular position of the nasal cartilage and muscles of the nasolabial region. Deformity of the nasal passage boundary, flattening of the tip and wings of the nose, cicatricial deformity of the upper lip and the arch of the oral vestibule, and a slit-like defect of the alveolar process are typical signs of residual and secondary deformities of the midface after surgical treatment for CCLP [1].

The aim of this study was to assess the severity of residual and secondary deformities of the midface (nose, upper lip, oral vestibule) in adult patients after surgical treatment of unilateral CCLP in childhood. Specifically, we aimed to identify the most significant typical signs of residual and secondary (postoperative) deformities of the midface in adulthood; to assess the severity of typical facial deformities using a developed point system; and to justify the suitability of remedial surgeries for medical reasons, based on the results of an objective assessment of the degree of deformity severity as well as the possibility of performing surgeries only to improve facial aesthetics.

Materials and methods

Deformities of the midface were studied in 42 patients with CCLP, aged 25 to 40 years, after their medical rehabilitation had been completed in childhood.

To assess the deformity of the nasolabial zone, we developed a three-point assessment system, in accordance with which the degree of severity was determined, from 0 to 2 points, for each deformity of the nose, upper lip, and oral vestibule. Criteria for assessing the degree of deformity severity were as follows: 0, no deformity after complete recovery; 1, deformity is slightly pronounced, with no dysfunction; 2, severe deformity, dysfunction.

Results and discussion

In our patient group, we found that primary cheilorhinoplasty was performed according to the Miro-Limberg-Obukhova method in 96% of cases. In 4% of cases, it was not possible to establish the technique of the primary surgery.

Flattening of the nasal tip on the side of the cleft was noted in 24% of cases. No pronounced deformity was found in this zone. Flattening of the nasal wing with preservation of the contour of the nose was observed in 40% of cases, although this type of deformity did not cause patient complaints. No asymmetry of the position of the base of the nasal wing was found in more than half of the patients. However, 4% had a pronounced asymmetry of the nasal wing position, about which the patients complained. No pronounced deformities of the nasal boundary and nasal opening were observed. The curvature of the nasal dorsum with gross deformity was found in 4% of cases; however, even with a slight curvature of the dorsum in 32% of patients, this defect was noted by them as significant. One of the patients’ complaints was of nasal breathing impairment (according to a subjective assessment). Some 9% of the examined patients reported breathing difficulty in the two nasal passages, and 40% had this symptom in CCLP (Table 1).

In terms of upper lip deformity, the number of patients with pronounced signs of this localization exceeded the number of patients with severe nose deformities. A pronounced deformity of the vermilion surface was observed in 16%; in 36% of patients, this symptom was less pronounced. Hypertrophic scars, deforming the shape of the upper lip, were noted in 8% of patients, which led to facial disharmony. The impairment of the philtral column height with a subtle scar was registered in 68% of the patients examined, and was due to the characteristics of the Miro-Limberg-Obukhova method. Patients with a significant disorder of the philtral column height comprised 8% of cases, and were classified as a severe deformity of the upper lip. Discontinuity of the orbicularis oris muscle was found only in 4% of the patients examined (Table 2).

Cicatricial cords and folds of the oral vestibule were observed in 36% of the patients examined, and they did not disturb the depth of the oral vestibule. The so-called “slit” of the upper jaw’s alveolar process was noted in 32% of patients, and 12% had a defect in the palate (Table 3).

A score of 2 points for at least one of the signs presented, in our opinion, relegated the patient to the group with mandatory indications for surgical treatment. In the case of existing but unpronounced deformity (1 point), the patient could undergo surgical treatment for aesthetic reasons. However, despite a 2-point indicator, a number of patients were completely satisfied with their appearance, which was ground for refusing remedial surgery.

Case studies. Figure 1 shows an example of a good long-term result from surgical treatment: Patient M., 26 years of age, with a diagnosis of residual deformity of the nose and upper lip after unilateral CCLP. A slight flattening of the wing of the nose is noted, as well as narrowing of the nasal cavity boundary (up to 2 mm) on the side of the cleft; nasal breathing is free; there is a subtle normotrophic scar on the skin of the upper lip; vermilion surface shows no alteration in size or shape. There are no pathological changes in the oral vestibule. Nose score is 1 point, upper lip score is 0 points. The patient has no complaints. Quality of life is high according to all the scales. Complete rehabilitation of the patient.

 

Fig. 1. Patient M., 26 years of age. Residual deformity of the nose and upper lip after unilateral congenital cleft of the upper lip and palate

 

Clinical cases. Figure 2 shows a clinical case demonstrating a satisfactory result of long-term surgical treatment. Patient A., 31 years of age, had a diagnosis of residual deformity of the nose and upper lip after unilateral CCLP. Clinician-observed signs were as follows: a slight flattening of the nasal wing; narrowing of the nose boundary (up to 2 mm) on the side of the cleft; nasal breathing is free; insignificant narrowing of the upper lip across the width, the normotrophic scar on the dermal part of the lip, and defect in the shape and size of the vermilion surface. The alveolar process is slit (food enters into the nose). Assessment of the nose: 1 point; assessment of the upper lip: 1 point. The patient has no complaints. Quality of life on the “social functioning” and “psychological health” scales is reduced. Remedial surgery on the nose and upper lip is recommended.

 

Fig. 2. Patient A., 31 years of age. Residual deformity of the nose and upper lip after unilateral congenital cleft of the upper lip and palate

 

Figure 3 shows a clinical example with a poor result from surgical treatment. Patient A., 38 years of age, had a diagnosis of residual deformity of the nose and upper lip after unilateral CCLP. There is a slight flattening of the tip and wing of the nose on the side of the cleft; nasal breathing is free; normotrophic scar on the cutaneous part of the upper lip; severe deformity of the vermilion surface with interposition into the cutaneous part of the lip; and disruption of discontinuity of the orbicularis oris muscle. Assessment of the nose: 1 point; assessment of the upper lip: 2 points. The patient has no complaints. Quality of life is high according to all assessment scales; however, remedial surgery of the lip and nose is recommended.

 

Fig. 3. Patient A., 38 years of age. Residual deformity of the nose and upper lip after unilateral congenital cleft of the upper lip and palate

 

Additional information

Funding. The study was conducted as a part of research and development project supported by Mechnikov North Western State Medical University.

Conflicts of interest. The authors declare no obvious or potential conflicts of interest related to the publication of this article.

Ethical review. All patients gave voluntary consent to participate and for us to process and publish personal data. Permission was obtained from the local ethics committee.

About the authors

Mikhail G. Semyonov

North-Western State Medical University n.a. I.I. Mechnikov

Author for correspondence.
Email: mikhail.semenov@szgmu.ru

MD, PhD, Professor, Head of the Department of Maxillofacial Surgery and Surgical Dentistry n.a. A.A. Limberg

Russian Federation, 41, Kirochnaya street, Saint-Petersburg, 191015

Svetlana S. Mushkovskaya

North-Western State Medical University n.a. I.I. Mechnikov

Email: mushkovskii@gmail.com

MD, PhD of the Department of Maxillofacial Surgery and Surgical Dentistry n.a. A.A. Limberg

Russian Federation, 41, Kirochnaya street, Saint-Petersburg, 191015

Kseniya U. Kovalenko

North-Western State Medical University n.a. I.I. Mechnikov

Email: ksenia7-12@mail.ru
ORCID iD: 0000-0002-2051-1567

Сandidate of the Department of Maxillofacial Surgery and Surgical Dentistry n.a. A.A. Limberg

Russian Federation, 41, Kirochnaya street, Saint-Petersburg, 191015

References

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