Original Article

The Cleft Palate-Craniofacial Journal

2019, Vol. 56(1) 74-83
Outcomes of Closed Versus Open Technique ª 2018, American Cleft Palate-
Craniofacial Association

of Rhinoplasty During Primary Repair Article reuse guidelines:

sagepub.com/journals-permissions
DOI: 10.1177/1055665618787689
of Unilateral Cleft Lip: A Systematic Review journals.sagepub.com/home/cpc

Rajshree Jayarajan, MCh, FEBOPRAS1 ,

Anantharajan Natarajan, MRCS, MCh2, and
Ravindranathan Nagamuttu, MBBS, FRCS2

Abstract
Objective: Primary cleft rhinoplasty has almost become the norm in cleft practice. Although various closed and open rhinoplasty
techniques are in use, there is no consensus as to which technique is superior in terms of outcome. The authors hypothesized that
the long-term outcomes of open rhinoplasty during primary cleft lip repair in unilateral cleft is better than that of the closed
method. This systematic review has been done to evaluate the hypothesis by a review and analysis of literature.
Methods: Protocol was registered on the PROSPERO register of systematic reviews. PRISMA-P guidelines for the conduct of
systematic review were followed. Literature search was done in various databases. The inclusion criteria were patients with
nonsyndromic unilateral cleft lip undergoing rhinoplasty with primary cleft lip repair and preference given to studies comparing
the 2 procedures.
Results: Sixteen articles were selected based on inclusion criteria after screening 522 articles—1 randomized controlled trial, 2
retrospective cohorts, and 13 case series. Both closed and open techniques have achieved good symmetry of nostrils with no
impairment of growth. No advantage of one technique over the other was noted.
Conclusions: There is a paucity of randomized controlled trials and prospective studies on the subject to arrive at an evidence-
based recommendation as to whether open or closed rhinoplasty during primary cleft lip repair gives better long-term outcomes.
Due to insufficient evidence, the authors are not able to support or refute the hypothesis put forward in the review.

Keywords
rhinoplasty, surgical technique, nose, nonsyndromic clefting

Introduction interference with nasal growth and the correction of alar carti-
lages and nasal tip was maintained. Anthropometric measure-
Cleft lip and palate is one of the most common congenital
ment showed no difference between patients who had
defects with an overall prevalence of 1 in 700 live births world-
undergone primary rhinoplasty and normal children at 3 years
wide (Ahmed et al., 2017). Correction of the cleft nasal defor-
in a series by Kim et al. (2004). This study also showed better
mity is almost an integral part of primary repair of the cleft lip
symmetry of nostril and nasal dome projection in children who
since it has been proved that early surgery on the cartilage does
had primary rhinoplasty. In a retrospective assessment of long-
not have a detrimental effect on growth (Salyer, 1986;
McComb and Coghlan, 1996). Blair and Brown were the initia-
tors of primary nasal correction with lip surgery (Millard, 1
Department of Plastic Surgery, University Hospitals of Leicester, Leicester,
1976). This concept was popularized by McComb (1985) and United Kingdom
2
Salyer (1986). As Millard and Morovic (1998) had noted, uni- Maxillofacial, Facial Plastic and Reconstructive Surgery, Pantai Jerudong
lateral cleft lip repair without nasal correction condemns the Medical Centre, Brunei Darussalam
child to a childhood burdened by this deformity. A 10-year
Corresponding Author:
follow-up of children who had undergone primary cleft rhino- Rajshree Jayarajan, MCh, FEBOPRAS, Department of Plastic Surgery,
plasty by McComb (1985) and after completion of this study 18 University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom.
years later (McComb and Coghlan, 1996) demonstrated no Email: [email protected]
Jayarajan et al 75

term effect of primary rhinoplasty on secondary cleft rhino- conduct of systematic review and meta-analysis protocol were
plasty (Haddock et al., 2012), it was found that the nasal tip followed.
was more symmetric and required less complex intervention
during the definitive secondary procedure. A review on pri-
Search Strategy
mary cleft rhinoplasty (Gudis and Patel, 2014) has concluded
that this procedure reduces the frequency and magnitude of The following electronic databases were searched:
intermediate and definitive operations. A recent study from Cochrane, PubMed, Embase, and LILACS BIREME (Latin
Japan (Yoshimura et al., 2015) where nasal growth evaluation American and Caribbean Health Science Information database)
using lateral cephalograms has been done to assess cases with Ongoing trials:
and without primary rhinoplasty, growth of the nose was found
to be adversely affected in the primary rhinoplasty cases.  The Meta-Register of Controlled Trials.
Although this study had a follow-up duration of 5 and 10 years,  The US National Institutes of Health Ongoing Trials
Register ClinicalTrials.gov.
the sample size was very small—only 14 patients with and 12
without primary rhinoplasty. Narayanan and Adenwalla (2015)  The Australian New Zealand Clinical Trials Registry.
have not found any detrimental effect on growth with primary  The World Health Organization International Clinical
Trials Registry Platform.
rhinoplasty, the senior author having performed thousands of
unilateral cleft lips where he has been doing an aggressive  The EU Clinical Trials Register.
correction of the cleft lip nose since 1960s. They have found There were no restrictions in the search with regard to lan-
that the overall shape and symmetry is better and extend of guage, study setting, or date of publication.
secondary deformity is much less.
Primary rhinoplasty, which is addressing the nasal deformities
at the time of initial cleft lip repair, is aimed at achieving better Study Selection
contour, symmetry, and projection of the nose. Various tech- Studies were selected based on the following inclusion criteria:
niques have been described to correct the cleft nose deformity human study of rhinoplasty with primary repair of unilateral
(Salyer et al., 2004; Sykes and Jang, 2009; Haddock et al., 2012). cleft lip. Open versus closed rhinoplasty technique comparisons
Closed technique involves dissection of the skin overlying the as randomized controlled trials (RCTs) preferably, if not avail-
lower lateral cartilages from either side through the incisions used able prospective or retrospective cohorts, are to be included.
for cleft lip repair (Shih and Sykes, 2002). Once the cartilage has Assessment of outcome should be ideally long term (5-14 years).
been dissected free of the skin, they are resuspended using trans- As there are several techniques and modifications described for
nasal sutures. Bolsters (McComb, 1975) were used initially, both open and closed primary cleft rhinoplasty varying from
which have later been replaced by internal knots (Cutting, closed, semiopen, and open, no concrete definition is being
1994). Radical nasal correction with an external incision on given as such for either. Due to this ambiguity, all incisions
the columella and septal correction was advocated by Berkeley resulting in exposure of alar cartilages have been taken as open
(Millard, 1976). Tajima (Tajima and Maruyama, 1977; Tajima, and nonexposure with dissection of cartilage from dorsal skin as
1990) devised the reverse-U incision originally for use in second- closed. Maneuvers of the alar base and sill are not included as
ary repairs of the cleft nasal deformity and was subsequently part of the technique. Studies that did not meet the inclusion
adapted for primary cleft nose. Combination of open reverse-U criteria, review articles, case reports, editorials, and letters were
and alar rim incisions (Harashina, 1990) gives a wider exposure excluded.
for open dissection of the cartilages. Open tip rhinoplasty incor- The population of interest is patients with nonsyndromic uni-
porating an incision along the columella philtrum junction allows lateral cleft lip undergoing rhinoplasty along with primary cleft
easy access to the tip for further refinements according to the lip repair. The intervention is use of open rhinoplasty and the
study by Thomas (Thomas and Mishra, 2000; Thomas, 2009). control is use of closed rhinoplasty technique. Outcome assess-
Various modifications (Cutting, 1994; Mulliken and Martinez- ment method is definitive anatomical measurements of the nose
Perez, 1999; Wong et al., 2002) in primary rhinoplasty have parameters during follow-up, which are reliable and reproduci-
resulted in significant improvement in the technique. The advan- ble. A 3-stage review process was followed. During the initial
tages of primary rhinoplasty have been suggested by numerous stage, the titles were reviewed by 2 reviewers, and the articles
investigators (Brusse et al., 1999; Haddock et al., 2012). not relevant to the reviews were excluded. In the second stage,
Both open and closed techniques have evolved extensively. the abstracts of the selected articles were reviewed against the
Proponents of either technique stand by their personal conviction. inclusion criteria. The final stage consisted of detailed review of
There is no evidence-based consensus so far as to which technique the full texts selected by both reviewers. Discrepancies that arose
is superior in terms of outcome so as to be recommended. were dealt with by discussion.

Methods Data Extraction

Protocol was registered on the PROSPERO register of systema- We designed data extraction forms to record authorship, year of
tic reviews (CRD42018086370). PRISMA-P guidelines for the publication, and details of study based on inclusion criteria.
76 The Cleft Palate-Craniofacial Journal 56(1)

Two review authors extracted data independently. The follow- new techniques, modifications, or personal protocols and expe-
ing details were recorded when available: rience. Some of the papers reported on combined cohorts of
unilateral and bilateral and primary and secondary rhinoplasty,
1. Trial methods: method of randomization, allocation, and it was not possible to extract data separately in these cases.
sample size, blinding methods, and losses at follow-up. Although long-term follow-up was one of the inclusion criter-
2. Participants: country of origin, year of study, setting ion, due to lack of adequate studies, we had to include studies
sample size, age, and inclusion and exclusion criteria. with short-term follow-up also.
3. Intervention: technique used, details of the method, Quality assessment of the included studies is presented in
time of follow-up. Table 1. We identified 5 case series on open rhinoplasty
4. Control: surgical technique used and details of method. (Table 2) and 8 on closed technique (Table 3), 2 retrospective
5. Outcomes: Method of assessment of the outcomes, sta- cohorts comparing open and closed techniques (Table 4), and a
tistical analysis. single RCT.
Presence of multiple cointerventions in addition to the inter-
vention of interest like presurgical orthopedics, postoperative
Dealing With Missing Data splinting, and variations in techniques used for rhinoplasty and
In studies where data were unclear or missing, we contacted the assessment of outcome makes attempts at comparing the data
principle investigator by e-mail. of questionable validity.
There was only 1 RCT comparing open and closed tech-
niques. This study has concluded that both techniques give
Data Synthesis similar results after a short follow-up evaluation at 6 months.
Assessment of risk of bias. The assessment of the risks of bias was The retrospective comparative studies had done assess-
done using Cochrane’s tool for assessing risk of bias as described ments subjectively and objectively using definite parameters,
in section 8.5 of the Cochrane Handbook for Systematic Reviews though there is no uniformity between the studies on these
of Interventions (Higgins and Green, 2011). Two reviewers inde- parameters. The first one has concluded that there is no dif-
pendently carried out the assessment and any disagreements were ference between the 2 techniques but is in favor of the closed
resolved through discussion with the third reviewer. technique as they found more “difficult to correct
Assessment of risk of bias carried out for the RCT is as follows: complications” following their open approach. The second
comparative study has demonstrated better results with the
Sequence generation. Randomization has been carried out
semiopen technique using Tajima incision.
using the sealed envelope technique. This has been evaluated
The closed technique series have all shown improved sym-
as low risk of bias.
metry of nostrils with follow-up, so that secondary surgery will
Allocation. Allocation concealment was not reported in the be less extensive. No interference with growth has been found.
article. E-mail communication with the corresponding author The completely open technique is being done by fewer sur-
confirmed it was carried out—low risk of bias. geons. The studies included have shown good long-term results
and have reported reduced number of secondary surgeries, and
Blinding. Blinding of personnel to the intervention is probably
when required the intervention to be of much smaller
not completely feasible in this study. E-mail communications
magnitude.
revealed that patients and assessor were blinded—there is low
All the reports demonstrate the advantages of a primary cleft
risk of detection bias, but overall evaluated as unclear risk of bias.
rhinoplasty. It is interesting to note that nasal overcorrection
Incomplete outcomes data. The study reports 20 cases lost with Tajima, which has been carried out in many of the studies,
to follow-up. Hence, the study is evaluated to have a high appears to maintain nostril height long term.
risk of bias.
Selective outcome reporting. There is no study protocol avail- Discussion
able in the publication. E-mail communication confirmed that
This systematic review of published outcomes of closed and
there is designed protocol regarding parameters and follow-up.
open rhinoplasty techniques yielded 3 comparative studies, of
Hence, the study is considered to have unclear risk of bias.
which 1 was an RCT and other 2 retrospective cohort studies,
Other bias. As a study protocol is not published, it is difficult and 13 case series, of which 5 were open and 8 closed methods.
to assess other potential bias in the study. Hence, judged as Marimuthu et al. (2013) conducted a single-center RCT
unclear risk of bias. comparing closed to open technique of rhinoplasty with pri-
mary cleft lip repair in unilateral cleft cases involving 36
patients. The age range of patients was 2 to 45 years and
Results follow-up assessment could be done only in 16, with 8 in each
The study selection PRISMA flow diagram is given in Figure 1. group. A statistically significant outcome was found only in
There is a paucity of controlled trials on this procedure. Most of one of the 3 measurements used for quantitative analysis—the
the publications on cleft rhinoplasty are narrative regarding alar base width in favor of open technique (Table 5). This study
Jayarajan et al 77

Figure 1. Study selection PRISMA-P flow diagram.

Table 1. Quality Assessment of Included Studies.

Level of Statistical
Study Study Design Evidencea Technique Randomization Blinding Analysis
Marimuthu et al. (2013) RCT II Open versus closed Yes Patients and assessor Yes
Yasonov et al. (2016) Retrospective cohort III Open versus closed No Assessors Yes
Lu et al. (2012) Retrospective cohort III Open versus closed No Assessors Yes
Chang et al. (2010) Case series IV Open Yes Assessors Yes
Chowchuen et al. (2010) Case series IV Open No No No
Thomas (2009) Case series IV Open No No No
Ahuja (2006) Case series IV Open No No No
Trott and Mohan (1993) Case series IV Open No No No
Spencer and Buzzo (2017) Case series IV Closed No No Yes
Tang et al. (2016) Case series IV Closed No No Yes
Lonic et al. (2016) Retrospective III Closed versus No No Yes
cohort overcorrection
with Tajima
Kluba et al. (2015) Case series IV Closed No No Yes
Margulis et al. (2014) Case series IV Closed No No Yes
Rottgers and Jiang (2010) Case series IV Closed No No No
Kim et al. (2004) Case series IV Closed Yes No Yes
McComb and Coghlan (1996) Case series IV Closed No No Yes
Abbreviation: RCT, randomized controlled trial.
a
Oxford Center for Evidence-Based Medicine—level of evidence for the included studies.
78
Table 2. Open Rhinoplasty Case Series.
Study Number of Age During Follow-Up
Study Study Location Period Patients Intervention Period Details of Procedure Assessment Method Outcome Conclusion

Chang et al. Chang Gung 1992-2003 76 (all complete) 3 months 5 years Group I—Rim incision and no Photographic (2-D) evaluation by Best outcome for group IV based Overcorrection of 20% maintains
(2010) Memorial NAM blinded independent observer on measurements and panel nostril height long term
Hospital, Gr II—NAM. No rhinoplasty on measurement of nostrils assessment. Group IV had the
Taiwan Gr III—NAM þ B/L rim height, width, area, sill most symmetrical nose in
incisions heightened fourth medial part terms of height, width, nasal
Gr IV—NAM þTajima on cleft nostril height, height to width web, nasal sill, nostril area, and
side, rim incision noncleft ratio, and panel assessment by nostril shape.
sideþ overcorrection (splint Visual Analog Scale
overcorrection also)
Chowchuen Tawanchai 2002-2010 122 (72 3-4 months, – Bilateral alar rim incisions— Patient direct evaluation by surgeon Score for nasal symmetry was Minor variations and secondary
et al. Center, Khon complete, 50 4-6 months slightly higher on cleft side. and peer. 6 parameters—1 for 0.72 with standard deviation of deformities are less difficult to
(2010) Kaen incomplete) (if presurgical Absorbable transfixing nostril symmetry. 4 scales based 0.42. Less satisfactory score correct during secondary
University, orthopedics) sutures to realign on noncleft as 0. Mild, moderate, surgery if indicated
Thailand and severe deviations as 1, 2, and 3
Thomas Khoula Hospital, 1994-2007 255 (complete) 3 months 14 years Harashina’s open rhinoplasty. Evaluation with photographs Better projection of nostril tip as Excellent postoperative results
(2009) Muscat Rim incisions; septum— closed technique does not and does not entail any more
dislocation done allow intercrural soft tissue trauma to nasal cartilage
dissection complex
Ahuja (2006) Lok Nayak 1999-2004 35 (29 complete Mean 6 months Mean 18 months Limited open rhinoplasty— Analysis by colleagues on—alar Excellent 20%; very good 48.5%; Very good results with limited
Hospital, and 6 (4-36 months) (4 months to Tajima on cleft and rim on elevation, tip reconstitution, good 25.8%; fair 5.7% open approach. No
Maulana Azad incomplete 4.5 years) noncleft. Realign alar nostril shape and symmetry, intermediate rhinoplasty
Medical cleft of lip) cartilage with single stitch; columellar height, and web in required. 40% do not require
College, New septum—not done vestibule/soft triangle definitive rhinoplasty
Delhi, India
Trott and Hospital Besar, 1991-1993 15 cases 6 months to 16 6 months Harashina open rhinoplasty Photographic documentation and Anatomical repositioning of alar Early results superior to closed
Mohan Alor Setar, years (8 cases technique; septum—not evaluation cartilages maintained technique; Need for secondary
(1993) Malaysia before 1 year) done surgery will be reduced in
number and magnitude of
intervention

Abbreviation: NAM, nasoalveolar molding.

 Table 3. Closed Rhinoplasty Case Series.
Number of Age During Follow-Up
Study Study Location Study Period Patients Intervention Period Details of Procedure Assessment Technique Outcome Conclusion

Spencer and Buzzo Professor Heriberto July 2008 to 26 3-12 months 6 months Goteborg/McComb Photographic evaluation by Cleft severity is an important
Aesthetic results of all cases were
(2017) Bezerra Pediatric October to 2 rhinoplasty 5 plastic surgeons optimal or factor contributing to
Hospital, Brazil 2013 years satisfactory aesthetics results; the greater
the severity, the worse the
results
Tang et al. (2016) Queen Elizabeth 2009-2013 29 (all complete 3 months 9 months Tajima incision, transalar Intraoperative direct Significant relapse in nasal Study validates the rationale for
Hospital and United cleft) stitches anthropometric measurements deformity at 9-month follow-up overcorrection of nasal
Christian Hospital, of 2 components—nostril configuration during primary
Kowloon, Hong height and nostril floor width repair
Kong
Lonic et al. (2016) Chang Gung Memorial 38 (all complete) 3-4 months 12 months Closed dissection versus Photo evaluation of 6 parameters Overcorrection with Tajima Primary nasal overcorrection
Hospital, Taiwan overcorrection with for the nose incision showed statistically gives long-term symmetric alar
Tajima incision on cleft significant better results in and nostril height compared to
side terms of nostril and ala height non-overcorrected noses
Kluba et al. (2015) University Hospital – 79 8 months 4 years Primary rhinoplasty with Indirect 2-D photogrammetry—5 Nostril asymmetry could almost be Most symmetry scores improved
Tuebingen, Tennison-Randall (no parameters for nose. eliminated. Nostril axis with surgery. Problem area
Germany description on Comparison between cleft and inclination-flatter compared was nostril axis inclination
rhinoplasty) noncleft side and also normal with normal values more on cleft
population side, but also on unaffected side
Margulis et al. Hadassah University 2003-2008 23 3 months 1 year Kernahan and Bauer Measurements with digital caliper. Minimal difference between Surgical technique described is
(2014) Medical Center, technique with primary Assessment of 5 anatomical healthy and corrected sides largely successful in achieving
Israel rhinoplasty (undermining parameters—one for nose (less than 10%) overall symmetry of the upper
skin from lower lateral. (nose sill width) lip and nostril regions
cartilageþ Tajima sutures)
Rottgers and Jiang University of Pittsburgh 13 6.6 months 9 months Tajima with rim incision on Reviewed to assess nasal symmetry All exhibited adequate cartilage Early results demonstrate
(2010) Medical Center and cleft side and overall aesthetics repositioning and improvement adequate repositioning of
Children’s Mercy in nasal symmetry. Also slight cartilage and improved tip
Hospital, Kansas overcorrection of the defect symmetry
City
Kim et al. (2004) Dong-a University 1992-2001 217 3 months 78 months Alar rim incision on cleft side, Photography and More symmetry of nostril and nasal Rhinoplasty with primary cleft lip
Hospital, Korea average dissection and Tajima anthropometric—nasal tip dome projection than without repair helps to promote more
suture. Septoplasty done projection, columellar length, rhinoplasty. No significant symmetrical and natural nasal
nasal width difference in anthropometric growth and better appearance
measurements between at an early age
children with primary
rhinoplasty and normal children
McComb and Princess Margaret 1975-1993 10 18 years Undermining of nasal skin Photographs and computer-based No recurrence of drooping of Adolescent growth spurt did not
Coghlan (1996) Hospital for from rim to nasion. measurement analysis—4 nostril rims. Nasal tips alter overall nasal symmetry
Children, Perth Sutures to lift alar cartilage parameters reasonably symmetrical. No and growth is unaffected
nostril flare

79
80 The Cleft Palate-Craniofacial Journal 56(1)

Table 4. Comparative Retrospective Studies.

Criteria Yasonov et al. (2016) Lu et al. (2012)

Number of patients 60 (closed 29, open 31) 66 (closed 21, semiopen 1-25, semiopen 2-20)
Mean age of patients 3 months
Closed rhinoplasty technique Mc Comb and Coghlan Limited nasal dissection through lip incision
Open rhinoplasty technique Vissarionov Semiopen 1: cartilage dissection and repositioning through
bilateral rim incisions. Semiopen 2: cartilage dissection
and repositioning through Tajima incision on cleft side
and rim incision on noncleft side
Mean follow-up period 10 years (retrospective) 5-6 years (retrospective)
Analysis of outcome 1. Subjective information from respondents 1.Measurements by single observer using digital analysis
2. Objective scales based on evaluation of 5 software—6 parameters
parameters 2.Panel assessment using Visual Analog Scale
Statistical analysis Applied (Fisher method and w2) Applied (ANOVA test)
Conclusions Subjective and objective analysis did not reveal Open method especially using the Tajima incision showed
statistical difference between open and closed better results in terms of nostril height and nostril axis
method of rhinoplasty which were statistically significant
Abbreviation: ANOVA, analysis of variance.

Table 5. Randomized Controlled Trial Analysis.a

Parameters Assessed Closed Rhinoplasty Open Rhinoplasty P Value Comments

Nostril height deference between 2.48 + 1.29 2.1 + 1.53 .593 Statistically not significant
cleft and noncleft side (mm)
Alar base width difference between 5.56 + 2.47 2.7 + 2.72 .046 Statistically significant difference between the
cleft and noncleft (mm) closed and open rhinoplasty group in favor of
open rhinoplasty
Columella length difference between 2.07 + 1.16 1.47 + 0.9 .271 Statistically not significant
cleft and noncleft (mm)
Nostril orientation—symmetrical 62.5% 50%
Nostril orientation—asymmetrical 37.5% 50%
Columella deviation—present 62.5% 37.5%
Columella deviation—absent 37.5% 62.5%
a
Marimuthu et al. (2013): Patient or population: Nonsyndromic unilateral cleft lip patients; Setting: Bhagwan Mahaveer Jain Hospital, Smile Train Unit, Bangalore,
India; Study Period: January 1, 2007 to January 31, 2008; Age of patients: 2 to 45 years; Follow-up period: 6 months; Intervention: Open rhinoplasty with primary
lip repair; Comparison: Closed rhinoplasty with primary lip repair.

has concluded that both techniques give similar results. The with rim incision and overcorrection on cleft side. This 5- to
deficiencies in this study such as small sample size, wide 6-year retrospective study on patients with incomplete cleft lip
age-group of samples, loss to follow-up, short follow-up dura- has reported statistically better outcomes for the overcorrected
tion (6 months), and classification as unclear risk of bias make group in terms of nostril height and axis compared with the
this conclusion unreliable evidence to guide clinical decision- closed method and also with the rim incision-only group. All
making. the patients benefitted from primary rhinoplasty.
Of the 2 retrospective cohort studies, Yasonov et al. (2016) A retrospective series of 26 cases of McComb rhinoplasty
conducted a 10-year period retrospective study of 60 patients on 3- to 12-month old primary lip repair with a follow-up of
and subjective and objective assessment showed no statisti- 6 months to 2 years by Spencer and Buzzo (2017) reports
cally significant difference between the 2 methods. In their results as optimal or satisfactory regarding symmetry between
evaluation of complications, they found the number of nostrils and columella position on being assessed by 5 plastic
“difficult to correct” complications to be more in the open surgeons using photographs.
rhinoplasty group and anticipate that this would complicate Tang et al. (2016) have used preoperative nasoalveolar mold-
secondary rhinoplasty. In view of this, they consider closed ing (NAM) and Tajima incision for correction of nasal deformity
rhinoplasty better as there is less damage to alar cartilages and in 29 patients. Intraoperative direct anthropometric measure-
no scars. ments of nostril height and nostril floor and comparison with
Lu et al. (2012) have done a comparative study in 66 patients the normal side were done. They have reported significant
between closed and 2 types of open incisions—one with bilateral relapse of the nasal deformity during the 9-month follow-up and
rim incisions and other with rim incision on noncleft and Tajima recommend primary overcorrection as a solution.
Jayarajan et al 81

Lonic et al. (2016) is a retrospective comparative study of which has reported that the symmetry achieved is not altered
closed technique with overcorrected technique using a Tajima by adolescent growth and growth as such is unaffected.
on the cleft side. On a follow-up assessment of the results at The retrospective study by Chang et al. (2010) on 76 cases is
12 months, a statistically significant difference favoring the 4 different approaches to the management of unilateral cleft lip
overcorrected group has been reported in terms of nostril and nose which the senior author has evolved over time. All groups
ala height. had postoperative nasal splints for 6 months. Except group I,
Kluba et al. (2015) in a prospective study of 79 cases using which underwent rhinoplasty with bilateral rim incisions, all
Tennison-Randall repair with primary rhinoplasty (details of other groups have NAM. Group II had only NAM and no
the rhinoplasty not reported; e-mail query regarding this was rhinoplasty. The difference between group III and IV is that
unanswered) evaluated the results after 4 years using indirect 2- IV had Tajima incision and overcorrection of the nostril
D photogrammetry. They managed to almost eliminate nasal (increased height and narrow width) on the cleft side. The post-
asymmetry. The problematic area reported was nostril axis. operative splinting in this group was also augmented during
A retrospective study of 23 cases by Margulis et al. (2014) subsequent visits to maintain the overcorrection. Follow-up
on cleft lip repair with primary nose repair by closed technique assessment done 5 years after the intervention using photo-
with Tajima suture is mainly an assessment of upper lip with graphic records and measurement of 6 parameters for the nose
only 1 of the 5 anatomical parameters used for the nose-nasal and a panel assessment showed statistically significant results
sill width. Minimal difference (less than 10%) between the in favor of group IV in 5 of the 6 parameters and the panel
healthy and corrected sides was seen on quantitative analysis assessment score also scored group IV the best. Overcorrection
after 1-year follow-up. of the cleft nostril by 20% through a Tajima incision has given
In the series by Rottgers and Jiang (2010), Tajima incision the best results long term.
with semipermanent buried suture on the cleft side followed up Primary nose correction described as a part of their center’s
after 9 months has been reviewed with images. They have integrated concepts for reconstruction by Chowchuen et al.
commented that adequate cartilage repositioning was achieved (2010) is carried out using bilateral rim incisions, slightly higher
and there is improvement in nasal symmetry with slight over- on cleft side. Assessment of the results on 122 patients carried
correction noted at follow-up. out by 2 plastic surgeons on nasal symmetry is given as a less
Kim et al. (2004) have done a comparison between cleft lip satisfactory score compared to other 5 parameters for the lip.
repair with no rhinoplasty and lip repair and rhinoplasty using The case series by Thomas (2009) is a 14-year follow-up of
alar rim incision and Tajima suture on cleft nostril. Of the 412 255 cases of unilateral complete cleft lip repaired by Harashina
patients in this series, 195 had no rhinoplasty (1992-1997) and technique. This is a completely open technique with rim inci-
217 underwent rhinoplasty (1997-2001). Follow-up was done sions and a columella incision which on closure leaves a scar at
at 6 months and 3 years of age. Analysis was performed using the philtrum–columella junction. Evaluation of the follow-up
photographs and anthropometric measurements of 3 para- results is with photographs and reported as excellent with no
meters in 30 random children from each group and 60 random trauma to the nasal cartilage complex. The earlier follow-up
normal children. The author concludes that in Asian patients series from the same author (Thomas and Mishra, 2000) of 69
repair of nose with cleft lip provided more symmetry of nostril cases included both unilateral and bilateral cases.
and nasal dome projection in comparison to children who have The series by Ahuja (2006) consisted of 35 cases which
not undergone primary rhinoplasty. In their series, the differ- underwent a limited open rhinoplasty with Tajima incision with
ence in postoperative anthropometric measurement between rim incision on cleft side and rim incision on noncleft side with
patients receiving primary nasal correction and normal children a mean follow-up of 18 months. Assessment was done by col-
was not significant. leagues based on 5 parameters for the nose and results rated as
McComb has done a 10-year (McComb, 1985) and later excellent in 20% and very good in 48.5%. No intermediate
18-year follow-up (McComb and Coghlan, 1996) on his first rhinoplasty was required in his series and 40% did not require
10 cases of closed technique. These patients at 18 years of age definitive rhinoplasty.
had photographs taken and computer-based measurement and Trott and Mohan (1993) in their study on 15 complete cases
analysis of nasal asymmetry done. The final long-term of cleft lip using open rhinoplasty with Harashina’s technique
follow-up showed no recurrence of drooping of nostril rims evaluated by photographic documentation after 6 months
or nostril flare and adolescent growth spurt had not altered the reports that the technique has the potential to maintain perma-
overall nasal symmetry. nent anatomical repositioning of alar cartilage. The senior
The techniques used for closed rhinoplasty in the studies author found the early results with this method were consis-
included, varies considerably. This is probably due to a multi- tently better than that obtained previously when he had used
tude of techniques and modifications available and is a matter primary closed rhinoplasty.
of surgeon preference rather than proven eminence of tech- Open rhinoplasty is technically more demanding during pri-
nique. All the procedures have succeeded in achieving mary cleft lip repair in an infant. A complete open method has
improvement in appearance and symmetry, some more than been followed only in 2 of the above studies. All have achieved
others. But long-term follow-up is lacking except for the good results with fewer cases requiring a secondary procedure,
McComb publication with 18-year follow-up assessment, and when required, the residual deformities being much easier
82 The Cleft Palate-Craniofacial Journal 56(1)

to correct. The longest follow-up reported is 14 years (Thomas, Available from http://www.crd.york.ac.uk/PROSPERO/display_
2009) and has mentioned that there has been no trauma to the record.php?ID¼CRD42018086370.
nasal cartilage complex.
Overcorrection of the cleft nostril at the time of primary Acknowledgments
rhinocheiloplasty has been used in few studies with good The review team would like to thank Education Library Team, Uni-
results. Kim et al. (2004), as mentioned above, has used Tajima versity Hospitals of Leicester for their support with the search and
with overcorrection of cleft nostril and obtained good correc- material for this review.
tion and symmetry with no significant difference from the nor-
mal children on 3-year follow-up. Lo (2006) has obtained Declaration of Conflicting Interests
better symmetry compensating for relapse during the post- The author(s) declared no potential conflicts of interest with respect to
operative period by using the Tajima technique. The compara- the research, authorship, and/or publication of this article.
tive studies by Chang et al. (2010), Lu et al. (2012), and Lonic
et al. (2016) have also confirmed this. The study by Chang et al Funding
used a progressively overcorrecting splint postoperatively. The The author(s) received no financial support for the research, author-
last 4 studies are from the same institution. Long-term follow- ship, and/or publication of this article.
up on these cases regarding need for, and extend of, secondary
surgery is unavailable. ORCID iD
We came across 2 studies on use of internal resorbable splint Rajshree Jayarajan, MCh, FEBOPRAS http://orcid.org/0000-0002-
(polyglycolic acid/polylactic acid) over the corrected alar car- 4002-3894
tilages. Wong et al. (2002) has used the splint during primary
rhinoplasty on 15 patients, average age of 5 months. After a References
mean follow-up period of 20.4 months, photogrammetry anal- Ahmed MK, Bui AH, Taioli E. Epidemiology of cleft lip and palate.
ysis of the alar contour was used for assessment and they found In: Amasri MA, eds. Designing Strategies for Cleft Lip and Palate
a definitive improvement in symmetry compared to controls Care. Rijeka, Croatia: Intech Open; 2017. doi:10.5772/67165.
and has concluded that an internal splint protects alar cartilage https://www.intechopen.com/books/designing-strategies-for-cleft-
longer than external splint. The second study by Linden et al. lip-and-palate-care/epidemiology-of-cleft-lip-and-palate.
(2017) on 20 patients with and 18 without the internal splint on Accessed Februaury 8, 2018.
3-D photogrammetry showed no improvement in nasal sym- Ahuja RB. Primary rhinoplasty in unilateral cleft patients: the “limited
metry with use of the splint. Due to the heterogeneity of the open” approach and other technical considerations. Cleft Palate
methods of study and scarcity of standardized outcome assess- Craniofac J. 2006;43(4):492-498.
ment, we were not able to do a meta-analysis or compare the Brusse CA, Van der Werff JF, Stevens HP, Vermeij-Keers C, Prahl-
data from the available studies. Andersen B, Van der Meulen JC, Vaandrager JM. Symmetry and
morbidity assessment of unilateral complete cleft lip nose cor-
rected with or without primary nasal correction. Cleft Palate Cra-
Conclusion niofac. J. 1999;36(4):361-366.
Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS.
This systematic review was an attempt to arrive at a consensus
Long-term comparison of four techniques for obtaining nasal sym-
based on the trials and studies available so far as to whether
metry in unilateral complete cleft lip patients: a single surgeon’s
open technique or closed technique of rhinoplasty at the time of
experience. Plast Reconstr Surg. 2010;126(4):1276-1284.
primary lip repair gives superior results consistently on follow-
Chowchuen B, Keinprasit C, Pradubwong S. Primary unilateral cleft
up. Best possible evidence based on a meta-analysis of multiple
lip-nose repair: the Tawanchai cleft center’s integrated and func-
RCTs is not available due to the lack of such trials.
tional reconstruction. J Med Assoc Thai. 2010;93(4):34-44.
There is insufficient evidence to support or refute the
Cutting C. Cleft lip nasal reconstruction. In: Rees T, La Trenta G, eds.
hypothesis put forward in the review. A unified research strat-
Aesthetic Plastic Surgery. Philadelphia, PA: WB Saunders; 1994:
egy in clefts is required to conduct high-quality multicenter
497-532.
RCTs in centers with heavy caseloads. There is no concur-
Gudis DA, Patel KG. Update on primary cleft lip rhinoplasty. Curr
rence on methods of assessment of outcomes at present. Stan-
Opin Otolaryngol Head Neck Surg. 2014;22(4):260-266.
dardization of photo capturing techniques, establishment of
Haddock NT, McRae MH, Cutting CB. Long-term effect of primary
specific landmarks, and use of definitive anatomical measure-
cleft rhinoplasty on secondary cleft rhinoplasty in patients with
ments using 2-D or 3-D digital photogrammetry will be essen-
unilateral cleft lip-cleft palate. Plast Reconstr Surg. 2012;129(3):
tial to make the outcome measurement reliable and
740-748.
reproducible.
Harashina T. Open reverse-U incision technique for secondary cor-
rection of unilateral cleft lip nose deformity. Br J Plast Surg. 1990;
Authors’ Note 43(5):557-564.
Protocol registered with PROSPERO (International prospective reg- Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews
ister of systematic reviews) Registration number: CRD42018086370. of interventions version 5.1.0 [updated March 2011]. The Cochrane
Jayarajan et al 83

Collaboration. 2011. http://handbook.cochrane.org. Accessed Janu- technical variations and analysis of results. Plast Reconstr Surg.
ary 4, 2018. 1999;104(5):1247-1260.
Kim SK, Cha BH, Lee KC, Park JM. Primary correction of unilateral Narayanan PV, Adenwalla HS. Primary rhinoplasty at the time of
cleft lip nasal deformity in Asian patients: anthropometric evalua- unilateral cleft lip repair: a review and our protocol. J Cleft Lip
tion. Plast Reconstr Surg. 2004;114(6):1373-1381. doi:10.1097/ Palate Craniofac Anom. 2015;2(2):92-97.
01.PRS.0000138592.37419.FD Rottgers SA, Jiang S. Repositioning of the lower lateral cartilage in
Kluba S, Bopp C, Bacher M, Reinert S, Krimmel M. Morphological primary cleft nasoplasty: utilization of a modified Tajima tech-
analysis of the lip and nose following cleft lip repair with simulta- nique. Ann Plast Surg. 2010;64(5): 691-695.
neous partial primary rhinoplasty: a prospective study over 4 years. Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year
J Craniomaxillofac Surg. 2015;43(5):599-605. experience. Plast Reconstr Surg. 1986;77(4):558-568.
Linden OE, Taylor HO, Vasudavan S, Byrne ME, Deutsch CK, Mul- Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose
liken JB, Sullivan SR. Three-dimensional analysis of nasal sym- repair—long-term outcome. Clin Plast Surg. 2004;31(2):191-208.
metry following primary correction of unilateral cleft lip nasal Shih CW, Sykes JM. Correction of the cleft-lip nasal deformity.
deformity. Cleft Palate Craniofac J. 2017;54(6):715-719. Facial Plast Surg. 2002;18(4):253-226.
Lo LJ. Primary correction of the unilateral cleft lip nasal deformity: Spencer LSB, Buzzo CL. Primary treatment of lip and nasal defor-
achieving the excellence. Chang Gung Med J. 2006;29(3): mity in unilateral cleft lip and palate. Rev Bras Cir Plast. 2017;
262-267. 32(1):37-45.
Lonic D, Morris DE, Lo LJ. Primary overcorrection of the unilateral Sykes JM, Jang YJ. Cleft lip rhinoplasty. Facial Plast Surg Clin North
cleft nasal deformity: quantifying the results. Ann Plast Surg. Am. 2009;17(1):133-144.
2016;(77 suppl 1):25-29. doi:10.1097/SAP.0000000000000708 Tajima S. Follow-up results of the unilateral primary cleft lip opera-
Lu TC, Lam WL, Chang CS, Chen PKT. Primary correction of nasal tion with special reference to primary nasal correction by the
deformity in unilateral incomplete cleft lip: a comparative study author’s method. Facial Plast Surg. 1990;7(2):97-104.
between three techniques. J Plast Reconstr Aesthet Surg. 2012; Tajima S, Maruyama M. Reverse-U incision for secondary repair of
65(4):456-463. cleft lip nose. Plast Reconstr Surg. 1977;60(2):256-261.
Margulis A, Aperson E, Billig A. A Cephalometric evaluation of Tang PM, Chao NS, Leung MW, Liu KW. Changes in nasal config-
upper lip symmetry after functional unilateral cleft lip repair with uration following primary rhinoplasty: direct anthropometric mea-
the Kernahan and Bauer technique and primary cleft rhinoplasty. surement in patients with complete unilateral cleft lip and palate.
Isr Med Assoc J. 2014;16(11):693-696. Cleft Palate Craniofac J. 2016;53(5):557-561. doi:10.1597/15-
Marimuthu M, Bonanthaya K, Shetty P, Wahab A. Open versus closed 125. Epub 2015 Sep 25.
rhinoplasty with primary cheiloplasty: a comparative study. J Max- Thomas C. Primary rhinoplasty by open approach with repair of uni-
illofac Oral Surg. 2013;12(3):289-296. doi:10.1007/s12663-012- lateral complete cleft lip. J Craniofac Surg. 2009;20(suppl 2):
0436-9 1711-1714. doi:10.1097/SCS.0b013e3181b3eee4.
McComb H. Treatment of the unilateral cleft lip nose. Plast Reconstr Thomas C, Mishra P. Open tip rhinoplasty along with the repair of cleft
Surg. 1975;55(5):596-601. lip in cleft lip and palate cases. Br J Plast Surg. 2000;53(1):1-6.
McComb H. Primary correction of unilateral cleft lip nasal deformity: Trott JA, Mohan N. A preliminary report on open tip rhinoplasty at the
a 10-year review. Plast Reconstr Surg. 1985;75(6):791-779. time of lip repair in unilateral cleft lip and palate: the Alor Setar
McComb H, Coghlan B. Primary repair of the unilateral cleft lip nose: experience. Br J Plast Surg. 1993;46(5):363-373.
completion of longitudinal study. Cleft Palate Craniofac J. 1996; Wong GB, Burvin R, Mulliken JB. Resorbable internal splint: an
33(1):23-31. adjunct to primary correction of unilateral cleft lip-nasal defor-
Millard DRJr. Cleft Craft: Primary Nasal Correction, in the Uni- mity. Plast Reconstr Surg. 2002;110(2):385-391.
lateral Deformity. Boston, MA: Little Brown and Co; 1976: Yasonov SA, Lopatin AV, Kugushev AY. Primary rhinocheiloplasty:
251-267. comparison of open and closed methods of alar cartilage reposi-
Millard DR Jr, Morovic CG. Primary unilateral cleft nose correc- tion. Ann Maxillofac Surg. 2016;6(1):21-24. doi:10.4103/2231-
tion: a 10-year follow-up. Plast Reconstr Surg. 1998;102(5): 0746.186139.
1331-1338. Yoshimura Y, Okumoto T, Lijima Y, Inoue Y. Reduced nasal growth
Mulliken JB, Martinez-Perez D. The principle of rotation advance- after primary nasal repair combined with cleft lip surgery. J Plast
ment for repair of unilateral complete cleft lip and nasal deformity: Reconstr Aesthet Surg. 2015;68(11):e159-e166.