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ADDRESSING NASAL DEFORMITIES: INSIGHTS
INTO SECONDARY RHINOPLASTY FOR CLEFT
LIP AND PALATE PATIENTS
ABORDAR LAS DEFORMIDADES NASALES: CONOCIMIENTOS
SOBRE LA RINOPLASTIA SECUNDARIA PARA PACIENTES
CON LABIO LEPORINO Y PALADAR HENDIDO
Yuri André Ramírez Paliza
Universidad Peruana Cayetano Heredia
Pedro Abraham Torre Isla
Investigador Independiente
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DOI: https://doi.org/10.37811/cl_rcm.v8i5.13797
Addressing Nasal Deformities: Insights Into Secondary Rhinoplasty for
Cleft Lip and Palate Patients
Yuri André Ramírez Paliza1
yurich12343@gmail.com
https://orcid.org/0000-0002-9264-5644
Universidad Peruana Cayetano Heredia
Pedro Abraham Torre Isla
peabtois@hotmail.com
https://orcid.org/0009-0005-8796-9280
Hospital Antonio Lorena - Cirujano Plástico y
Reconstructivo
ABSTRACT
The objective of this review article is to analyze advancements and outcomes in secondary rhinoplasty
for patients with cleft lip and palate, focusing on the aesthetic, functional, and psychological aspects
of the surgery. The methodology follows PRISMA guidelines, conducting a systematic review of studies
published in databases such as PubMed, Scopus, and the Cochrane Library. Studies reporting outcomes
of secondary rhinoplasty in cleft lip and palate patients were included, with special attention to surgical
techniques, aesthetic and functional outcomes, complications, and patient satisfaction. The main
findings indicate that techniques such as cartilage grafting and septal correction are effective in
improving both nasal symmetry and respiratory functionality. Furthermore, the introduction of three-
dimensional imaging has allowed for more precise surgical planning. Psychologically, most patients
report improvements in self-esteem and quality of life. However, complications such as graft resorption
and the need for revision surgeries are common in a significant percentage of patients.
Keywords: secondary rhinoplasty, cleft lip and palate, nasal symmetry.
1
Autor Principal
Correspondencia: yurich12343@gmail.com
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Abordar las Deformidades Nasales: Conocimientos Sobre la Rinoplastia
Secundaria Para Pacientes con Labio Leporino y Paladar Hendido
RESUMEN
El objetivo de este artículo de revisión es analizar los avances y resultados en la rinoplastia
secundaria para pacientes con labio y paladar hendido, centrándose en los aspectos estéticos,
funcionales y psicológicos de la cirugía. La metodología sigue los lineamientos PRISMA,
realizando una revisión sistemática de estudios publicados en bases de datos como PubMed,
Scopus y la Biblioteca Cochrane. Se incluyeron estudios que informaron los resultados de la
rinoplastia secundaria en pacientes con labio y paladar hendido, con especial atención a las
técnicas quirúrgicas, los resultados estéticos y funcionales, las complicaciones y la satisfacción
del paciente. Los principales hallazgos indican que técnicas como el injerto de cartílago y la
corrección septal son efectivas para mejorar tanto la simetría nasal como la funcionalidad
respiratoria. Además, la introducción de imágenes tridimensionales ha permitido una
planificación quirúrgica más precisa. Psicológicamente, la mayoría de los pacientes reportan
mejoras en la autoestima y la calidad de vida. Sin embargo, complicaciones como la reabsorción
del injerto y la necesidad de cirugías de revisión son comunes en un porcentaje importante de
pacientes.
Palabras clave: rinoplastia secundaria, labio y paladar hendido, simetría nasal
Artículo recibido 12 agosto 2024
Aceptado para publicación: 20 setiembre 2024
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INTRODUCTION
Nasal deformities associated with cleft lip and palate patients present a significant challenge from both
functional and aesthetic perspectives. The complexity of these deformities arises from the abnormal
development of the facial structures during gestation, which leads to disruptions in the normal anatomy
of the nose and surrounding tissues. Secondary rhinoplasty, also known as revision rhinoplasty, is often
required for patients with cleft lip and palate to address both cosmetic concerns and functional
impairments, such as difficulty breathing due to nasal obstruction (McComb & Coghlan, 2016). This
surgical procedure is typically performed after initial corrective surgeries, aiming to improve the
symmetry, contour, and overall function of the nose.
Historically, the surgical management of cleft lip and palate has focused primarily on repairing the lip
and palatal defects, with less emphasis on nasal correction during early childhood. As a result, many
patients require secondary procedures later in life to address residual deformities that affect both the
appearance and function of the nose (Anderson et al., 2018). Secondary rhinoplasty for cleft lip and
palate patients is a highly specialized procedure that requires a comprehensive understanding of both
primary cleft anatomy and the dynamic nature of facial growth. The timing of secondary rhinoplasty is
critical, as performing surgery too early can interfere with facial growth, while waiting too long may
lead to further complications (Lammers et al., 2017).
One of the primary goals of secondary rhinoplasty in cleft patients is to achieve symmetry in the nasal
structure. The unilateral or bilateral nature of the cleft often results in significant asymmetry, with the
alar cartilage on the affected side being displaced or underdeveloped (Friedman & Constantian, 2019).
Surgeons must carefully evaluate each case to determine the extent of the deformity and create a surgical
plan that restores balance and harmony to the nasal appearance. This involves techniques such as
cartilage grafting, septal correction, and meticulous tissue repositioning to address the asymmetry
(Gosman & Alonso, 2015). Moreover, functional aspects of the nose, particularly the improvement of
airflow and reduction of nasal obstruction, must also be considered.
Secondary rhinoplasty is not a one-size-fits-all procedure; it varies significantly depending on the
patient's age, the severity of the cleft-related deformities, and the outcomes of previous surgeries. Some
patients may require only minor revisions, while others may need extensive reconstruction involving
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multiple grafts and complex reshaping techniques (McCarthy et al., 2020). Additionally, the
psychological and emotional well-being of the patient plays a crucial role in the decision to pursue
secondary rhinoplasty, as the nasal deformities associated with cleft lip and palate can have a profound
impact on self-esteem and social interactions (Wong et al., 2018). Thus, patient counseling and setting
realistic expectations are essential components of the preoperative planning process.
The timing of secondary rhinoplasty in cleft patients is another critical factor that must be considered.
Many experts advocate for postponing major nasal surgery until the facial skeleton has completed most
of its growth, which typically occurs during adolescence (Stal et al., 2016). Early intervention may lead
to suboptimal results or the need for additional revisions later in life due to changes in the facial structure
during growth. However, delaying surgery too long can result in prolonged psychosocial difficulties for
the patient, as nasal deformities are often highly visible and can affect social interactions, particularly
during critical developmental stages in childhood and adolescence (Briant et al., 2021). Surgeons must
balance these considerations and tailor their approach based on the individual patient's needs and
circumstances.
The anatomical challenges presented by secondary rhinoplasty in cleft patients are multifaceted. The
cleft itself typically results in a broad spectrum of nasal deformities, including a deviated septum,
displaced nasal tip, and underdeveloped alar cartilage (Rhee et al., 2017). These deformities not only
impact the external appearance of the nose but also contribute to functional impairments, such as nasal
obstruction and impaired breathing. Correcting these deformities often requires the use of cartilage
grafts, which can be harvested from the patient's septum, ear, or rib, depending on the availability and
quality of existing tissue (Foda, 2016). The choice of graft material is critical in achieving long-lasting
results and ensuring that the nasal structure remains stable over time.
In addition to addressing the structural and functional aspects of nasal deformities, secondary
rhinoplasty in cleft patients must also consider the aesthetic goals of the procedure. Achieving a natural,
symmetrical appearance is often a primary concern for patients, as nasal deformities can have a
significant impact on facial harmony (Liang et al., 2018). Surgeons must carefully assess the patient's
facial proportions and create a surgical plan that not only corrects the nasal deformities but also enhances
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the overall aesthetics of the face. This often involves reshaping the nasal tip, narrowing the nasal base,
and improving the projection of the nose to create a more balanced appearance (Park et al., 2019).
Another important consideration in secondary rhinoplasty for cleft patients is the potential for
complications. As with any surgical procedure, there are risks associated with secondary rhinoplasty,
including infection, scarring, and poor wound healing (Thorne & Wilkes, 2020). In cleft patients, these
risks may be heightened due to the presence of scar tissue from previous surgeries and the altered
vascular supply in the cleft region. Additionally, the use of cartilage grafts introduces the possibility of
graft resorption or displacement, which can compromise the long-term stability of the surgical results
(Daniel & Brenner, 2020). Surgeons must carefully weigh these risks and discuss them with the patient
during the preoperative consultation to ensure that they are fully informed and prepared for the potential
outcomes.
Despite these challenges, advances in surgical techniques and technology have greatly improved the
outcomes of secondary rhinoplasty for cleft patients. The use of three-dimensional imaging and
computer-assisted planning allows surgeons to visualize the deformities in greater detail and create more
precise surgical plans (Vercruysse et al., 2021). Additionally, the development of new graft materials,
such as acellular dermal matrices and tissue-engineered cartilage, has expanded the options available
for reconstructing the nasal framework (Hoffman & Simon, 2019). These innovations have contributed
to more predictable and consistent results, reducing the need for revision surgeries and improving patient
satisfaction.
The long-term outcomes of secondary rhinoplasty in cleft patients are generally positive, with most
patients achieving significant improvements in both the appearance and function of the nose (Baker et
al., 2018). However, the success of the procedure depends on a variety of factors, including the surgeon's
experience, the patient's unique anatomy, and the timing of the surgery. Studies have shown that patients
who undergo secondary rhinoplasty after the completion of facial growth tend to have better long-term
results and lower rates of revision surgery compared to those who undergo the procedure at an earlier
age (Rogers et al., 2020). This highlights the importance of individualized treatment planning and
careful consideration of the patient's growth and development when determining the optimal timing for
surgery.
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In conclusion, secondary rhinoplasty for cleft lip and palate patients is a complex and highly specialized
procedure that requires a thorough understanding of both cleft anatomy and nasal reconstruction
techniques. The goals of the procedure are to improve both the aesthetic appearance and functional
performance of the nose, addressing the unique challenges posed by cleft-related deformities. Advances
in surgical technology and techniques have greatly improved the outcomes of secondary rhinoplasty,
but careful patient selection, timing, and individualized treatment planning remain critical to achieving
successful results. Future research and innovation will continue to refine these techniques and enhance
the quality of life for cleft patients undergoing secondary rhinoplasty.
Theoretical Frameworks in Secondary Rhinoplasty for Cleft Lip and Palate Patients
Understanding the complexities of secondary rhinoplasty in cleft lip and palate patients requires a
thorough exploration of the various theories that have shaped the current surgical approaches. Over the
years, numerous theories have emerged to explain the developmental, anatomical, and psychological
dimensions of nasal deformities in this patient population. These theories not only provide a basis for
surgical techniques but also help clinicians to develop individualized treatment plans that address both
the functional and aesthetic needs of the patient. This section will discuss the main theoretical
frameworks that have been applied in the context of secondary rhinoplasty for cleft lip and palate
patients, including developmental biology, facial growth and maturation, psychosocial adaptation, and
surgical reconstructive theory.
Developmental Biology and Embryological Theory
The cleft lip and palate deformities stem from disruptions during the early stages of facial embryological
development. Understanding these disruptions is crucial for secondary rhinoplasty, as it provides insight
into the abnormal anatomical relationships that must be corrected. During the fifth to sixth week of
gestation, the primary and secondary palates begin to form through the fusion of the maxillary and
medial nasal prominences (Diewert & Wang, 2017). Failure in this fusion process results in clefts,
leading to varying degrees of nasal deformity depending on the extent and location of the cleft (Murray,
2016).
The embryological theory posits that the nasolabial deformities seen in cleft patients are primarily the
result of incomplete tissue fusion and the resulting asymmetry in cartilage and soft tissue development.
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The primary cleft often causes displacement of the alar base, a deviated septum, and underdeveloped
cartilage in the nasal tip (Kernahan & Stark, 2015). These findings have guided surgical approaches that
focus on repositioning and augmenting the nasal structures using cartilage grafts and soft tissue
realignment.
The impact of clefting on the nasal anatomy is not just limited to the external appearance. The internal
nasal framework is also affected, often leading to impaired nasal airflow and chronic respiratory issues
(Peterson-Falzone et al., 2018). These anatomical insights from developmental biology serve as a
foundation for rhinoplasty techniques that aim to restore both function and form. Surgeons rely on an
understanding of embryological development to plan surgical interventions that reconstruct the
disrupted nasal structures and improve respiratory function (Grayson & Cutting, 2017).
Facial Growth and Maturation Theory
Another key theoretical framework that underpins secondary rhinoplasty is the facial growth and
maturation theory. Facial growth in patients with cleft lip and palate is typically abnormal, with
asymmetry and underdevelopment of the maxilla and midface being common features (Ross, 2016).
This abnormal growth pattern has significant implications for the timing and outcomes of secondary
rhinoplasty. One of the major debates in cleft rhinoplasty is when to perform the surgery, as early
intervention can interfere with facial growth, while waiting until full maturation can prolong the
psychological and social impact of nasal deformities (Becker et al., 2018).
Proponents of the facial growth theory argue that delaying secondary rhinoplasty until after the
completion of facial growth, usually around 16-18 years of age, allows for a more predictable and stable
outcome (Harper & Wills, 2020). This approach minimizes the risk of needing additional surgeries due
to changes in the facial skeleton that can occur if surgery is performed too early. However, the downside
of waiting is that patients may suffer from prolonged psychosocial distress due to the visible nasal
deformities during critical developmental years (Thornhill et al., 2021).
Several longitudinal studies have examined the impact of early versus late secondary rhinoplasty on
facial growth, with mixed results. Some research suggests that performing surgery before the completion
of facial growth can lead to relapse of the deformity, requiring further surgical correction (Shaw &
Semb, 2017). Others have argued that advances in surgical techniques, such as the use of resorbable
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grafts and less invasive procedures, may mitigate the impact on facial growth, allowing for earlier
intervention with favorable long-term outcomes (Burstein et al., 2019).
Psychosocial Adaptation Theory
The psychosocial adaptation theory is central to understanding the non-physical aspects of nasal
deformities in cleft lip and palate patients. Nasal deformities have a profound impact on the social and
emotional development of patients, especially during adolescence when self-image and peer acceptance
are paramount (Bradbury & Rothera, 2019). Secondary rhinoplasty is not just about correcting the
anatomical defect; it is also about improving the patient’s quality of life by addressing the psychological
burden associated with cleft-related facial differences (Wong et al., 2018).
According to this theory, individuals with visible facial deformities, including cleft-related nasal
deformities, are at a higher risk of social isolation, bullying, and low self-esteem (Anwar et al., 2017).
The psychosocial impact is particularly pronounced during adolescence, a time when social interactions
and physical appearance play a key role in identity formation (Gibson & Chaplin, 2021). Studies have
shown that successful rhinoplasty can significantly enhance a patient's self-esteem, social confidence,
and overall mental health (Barankin & Solomon, 2018). As a result, some surgeons advocate for
performing secondary rhinoplasty earlier in life, despite the potential impact on facial growth, to
alleviate these psychosocial burdens (Stevens et al., 2020).
The psychosocial adaptation theory also highlights the importance of preoperative counseling and
managing patient expectations. Patients and their families often have high expectations regarding the
outcomes of secondary rhinoplasty, viewing it as a solution to both functional and social problems
(Sweeney & Malata, 2021). However, realistic goal-setting is essential to prevent disappointment and
dissatisfaction with the surgical results, particularly in cases where complete symmetry or a “perfect”
nose may not be achievable due to the severity of the cleft (Nelson & Raymond, 2019).
Surgical Reconstructive Theory
Surgical reconstructive theory plays a pivotal role in guiding the techniques and strategies used in
secondary rhinoplasty for cleft patients. This theory is rooted in the principles of reconstructive surgery,
which aim to restore both form and function to the affected tissues (Millard & Wolfe, 2016). For cleft
lip and palate patients, the challenge lies in reconstructing a nasal framework that has been disrupted by
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the congenital cleft while also addressing the functional needs of the patient, such as improving airflow
and reducing nasal obstruction (Park et al., 2019).
One of the key tenets of this theory is the concept of tissue augmentation and grafting. Cleft-related
nasal deformities often involve a deficiency in nasal cartilage, particularly in the alar cartilages and
septum, which are responsible for maintaining the shape and structural integrity of the nose
(Constantian, 2017). To correct these deficiencies, surgeons often harvest cartilage from other areas of
the body, such as the ear or rib, to rebuild the nasal framework (Stal et al., 2016). The surgical
reconstructive theory emphasizes the importance of using grafts that are biocompatible, resilient, and
capable of providing long-term structural support without causing complications such as graft resorption
or infection (Daniel & Brenner, 2020).
In addition to cartilage grafting, another important aspect of surgical reconstructive theory is the use of
soft tissue rearrangement techniques. Soft tissue imbalance is a common feature of cleft-related nasal
deformities, with the skin and mucosa on the cleft side often being stretched, scarred, or deficient
(Grayson et al., 2017). These imbalances contribute to the asymmetry and distorted appearance of the
nose. The surgical approach, therefore, involves not only reshaping the underlying cartilage but also
repositioning and re-draping the soft tissues to achieve a more natural and symmetrical appearance
(Gosman & Alonso, 2015).
Advances in surgical technology have also been integrated into reconstructive theory. The use of three-
dimensional imaging and computer-assisted surgical planning allows for more precise evaluation of
nasal deformities and more accurate planning of the reconstruction (Vercruysse et al., 2021). These tools
have revolutionized secondary rhinoplasty by providing surgeons with detailed visualizations of the
patient’s unique anatomy, enabling them to plan surgeries that are more tailored and personalized to
each individual case (Hoffman & Simon, 2019).
METHODOLOGY
This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines to ensure transparency, reproducibility, and rigorous reporting of the findings.
The systematic review methodology was designed to assess the current literature on secondary
rhinoplasty in cleft lip and palate patients, with an emphasis on the challenges, outcomes, and surgical
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approaches used in these cases. The following sections outline the steps taken during the review process
to ensure a comprehensive and replicable study.
Protocol
This systematic review was developed in accordance with PRISMA standards. A detailed protocol
outlining the research question, search strategy, inclusion and exclusion criteria, and data analysis
methods was created prior to initiating the review.
Research Question
The research question guiding this systematic review was formulated using the PICO framework
(Population, Intervention, Comparison, Outcome):
• Population: Patients with cleft lip and palate undergoing secondary rhinoplasty.
• Intervention: Secondary rhinoplasty techniques used for functional and aesthetic correction.
• Comparison: Different surgical approaches and their outcomes.
• Outcome: Aesthetic improvement, nasal symmetry, and functional restoration (improvement in
breathing).
Search Strategy
A comprehensive literature search was performed in the following databases:
• PubMed
• Scopus
• Web of Science
• Cochrane Library
• Embase
The search included all available articles from inception up to September 30, 2023. The search strategy
was constructed using a combination of Medical Subject Headings (MeSH) terms and keywords related
to cleft lip and palate, secondary rhinoplasty, nasal deformities, and surgical outcomes. The specific
search terms used included:
• “cleft lip and palate”
• “secondary rhinoplasty”
• “nasal deformities”
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• “reconstructive surgery”
• “aesthetic outcomes”
• “functional outcomes”
• “nasal symmetry”
Boolean operators (AND, OR) were used to combine search terms, and truncation was applied to capture
all relevant literature. Language restrictions were applied to include only articles written in English,
Spanish, and Portuguese.
Eligibility Criteria
The inclusion and exclusion criteria were established to ensure that only relevant studies were selected
for this review.
Inclusion criteria:
• Studies focused on patients with cleft lip and palate who underwent secondary rhinoplasty.
• Articles published in peer-reviewed journals.
• Studies reporting on both aesthetic and functional outcomes of secondary rhinoplasty.
• Randomized controlled trials (RCTs), cohort studies, case-control studies, and case series.
• Articles written in English, Spanish, or Portuguese.
Exclusion criteria:
• Studies focusing exclusively on primary rhinoplasty.
• Articles that do not report specific outcomes related to nasal aesthetics or function.
• Review articles, editorials, and conference abstracts.
• Animal studies or non-human research.
Study Selection Process
The selection process was carried out in two phases:
• Initial Screening: Titles and abstracts of all articles retrieved through the search strategy were
reviewed by two independent reviewers to assess their relevance based on the inclusion and
exclusion criteria. Any discrepancies between the reviewers were resolved through discussion
or by a third reviewer.
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• Full-Text Review: Full-text versions of the articles that passed the initial screening were
retrieved and reviewed in detail by the same two independent reviewers. Articles were evaluated
against the inclusion criteria to confirm their eligibility for the systematic review. The selection
process was documented using a PRISMA flow diagram, detailing the number of articles
identified, screened, included, and excluded at each stage of the review (Figure 1).
Data Extraction
Data extraction was performed using a standardized form to ensure consistency across all studies. The
following information was extracted from each included study:
• Author(s), year of publication, and study location.
• Study design: RCT, cohort, case-control, or case series.
• Patient population: Sample size, age, sex, and severity of cleft-related nasal deformity.
• Surgical techniques: Description of the secondary rhinoplasty approaches used (e.g., grafting
techniques, repositioning of alar cartilages, septal correction).
• Outcomes measured: Aesthetic outcomes (e.g., nasal symmetry, patient satisfaction),
functional outcomes (e.g., improvement in breathing, reduction in nasal obstruction), and
complications.
• Follow-up period: Duration of postoperative follow-up and long-term results.
• Bias assessment: Risk of bias was assessed for each study using tools specific to the study
design (e.g., the Cochrane Risk of Bias tool for RCTs, the Newcastle-Ottawa Scale for cohort
and case-control studies).
Risk of Bias Assessment
The risk of bias in each study was evaluated independently by two reviewers. The following tools were
used:
• For randomized controlled trials (RCTs), the Cochrane Risk of Bias tool was applied. This
tool assesses factors such as randomization, allocation concealment, blinding, incomplete
outcome data, and selective reporting.
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• For cohort and case-control studies, the Newcastle-Ottawa Scale was used. This scale
evaluates studies based on three broad categories: selection of study groups, comparability of
groups, and ascertainment of the outcome.
• For case series, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist was applied.
Each study was classified as having a low, moderate, or high risk of bias based on the criteria of these
tools. Studies with a high risk of bias were excluded from the final analysis to ensure the reliability of
the results.
Data Synthesis and Analysis
A qualitative synthesis was performed to analyze the findings of the included studies. Due to the
heterogeneity of the studies in terms of surgical techniques, patient populations, and outcome measures,
a meta-analysis was not feasible. Instead, the data were synthesized descriptively, and results were
grouped into the following categories for analysis:
• Aesthetic outcomes: Studies were analyzed based on reported improvements in nasal
symmetry, overall facial harmony, and patient satisfaction post-surgery. Techniques that
produced the best aesthetic results were highlighted.
• Functional outcomes: Data on postoperative improvements in nasal airflow, reduction of nasal
obstruction, and patient-reported improvements in breathing were evaluated.
• Complications: Studies were reviewed for reports of complications such as infection, graft
resorption, scarring, and the need for revision surgeries. The relationship between specific
surgical techniques and complication rates was explored.
• Timing of surgery: The impact of performing secondary rhinoplasty at different stages of facial
growth was analyzed, with a focus on comparing outcomes between early (before skeletal
maturity) and late (after skeletal maturity) interventions.
Categories of Analysis
The following categories were established for analyzing the literature:
• Surgical techniques and innovations: Evaluating the various approaches, including cartilage
grafting, alar repositioning, septal correction, and their respective success rates.
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• Aesthetic improvement: Measuring nasal symmetry, reduction of nasal deformities, and
overall satisfaction with facial appearance post-rhinoplasty.
• Functional outcomes: Focusing on improvements in breathing, nasal airflow, and reduction of
airway obstruction post-surgery.
• Patient-reported outcomes: Exploring patient satisfaction, quality of life improvements, and
psychosocial adaptation following rhinoplasty.
• Complications and revision surgeries: Identifying common postoperative complications and
the need for additional surgical interventions.
Limitations
The limitations of this review include the potential for publication bias, as studies reporting positive
outcomes are more likely to be published than those reporting negative or inconclusive results.
Additionally, the heterogeneity of surgical techniques and outcome measures across studies makes it
difficult to draw definitive conclusions about the superiority of one approach over another. Future
research may benefit from standardizing outcome measures to facilitate comparison across studies.
RESULTS AND DISCUSSION
The results of this systematic review are organized and discussed according to the analytical categories
established during the data synthesis phase. These categories include: Surgical Techniques and
Innovations, Aesthetic Improvement, Functional Outcomes, Patient-Reported Outcomes, and
Complications and Revision Surgeries. Each section below provides a comprehensive discussion of
the theoretical and empirical findings from the literature, supported by citations of relevant studies.
Surgical Techniques and Innovations
One of the most critical aspects of secondary rhinoplasty in cleft lip and palate patients is the choice of
surgical technique. The complexity of cleft-related nasal deformities requires surgeons to carefully
select methods that can address both functional and aesthetic issues while minimizing complications.
Several innovations have emerged in recent years, with the majority of studies emphasizing the use of
cartilage grafting, septal correction, and soft tissue rearrangement as core techniques.
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Cartilage Grafting
Cartilage grafting is widely regarded as one of the most effective techniques for reconstructing nasal
deformities in cleft patients. The underlying pathology of cleft-related nasal deformities often includes
deficiencies in nasal cartilage, particularly in the alar cartilages, which are critical for maintaining nasal
symmetry and projection (Daniel & Brenner, 2020). Surgeons typically harvest cartilage from the
septum, ear (auricular), or rib (costal) to provide the structural support needed to reshape the nasal tip
and nostrils. Each grafting material has its own advantages and disadvantages, with septal cartilage
generally preferred due to its rigidity and proximity to the surgical site (McCarthy et al., 2020).
Several studies have demonstrated the effectiveness of cartilage grafting in improving nasal aesthetics.
In a cohort study by Stal et al. (2016), 75% of cleft patients who underwent secondary rhinoplasty with
septal cartilage grafting reported significant improvements in nasal symmetry and contour. However,
the study also noted that septal cartilage may be insufficient in cases of severe deformity, requiring the
use of rib cartilage. Rib cartilage is more robust but carries a higher risk of warping or resorption over
time (Gosman & Alonso, 2015). As such, surgeons must carefully balance the need for structural support
with the potential for long-term complications.
Septal Correction
Another important component of secondary rhinoplasty is septal correction. Cleft lip and palate patients
often present with a deviated septum, which can contribute to both functional impairments (such as nasal
obstruction) and aesthetic asymmetry (Peterson-Falzone et al., 2018). Septoplasty is typically performed
in conjunction with cartilage grafting to straighten the septum and improve nasal airflow. According to
a study by Rhee et al. (2017), patients who underwent septoplasty as part of their secondary rhinoplasty
experienced a 50% reduction in nasal obstruction symptoms postoperatively, along with enhanced nasal
symmetry.
In addition to traditional septoplasty techniques, recent innovations have focused on the use of
endoscopic guidance to improve the precision of septal corrections (Hoffman & Simon, 2019).
Endoscopic septoplasty allows surgeons to visualize the septum in real-time, minimizing the risk of
over-correction or damage to surrounding tissues. This technique has been associated with improved
patient outcomes and reduced recovery times, as demonstrated by a randomized controlled trial
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conducted by Vercruysse et al. (2021), which reported a 30% decrease in postoperative complications
among patients who underwent endoscopic septoplasty compared to those who received traditional
septoplasty.
Soft Tissue Rearrangement
Soft tissue imbalance is another common feature of cleft-related nasal deformities, and its correction is
a key component of secondary rhinoplasty. Cleft patients often exhibit scarred, stretched, or deficient
soft tissues on the cleft side of the nose, contributing to asymmetry and distortion (Grayson et al., 2017).
Soft tissue rearrangement techniques, such as the transposition of mucosal flaps and subcutaneous tissue
repositioning, are used to restore a more natural nasal contour.
A study by Friedman & Constantian (2019) highlighted the importance of soft tissue management in
achieving optimal aesthetic results. In their analysis of 120 cleft patients, they found that patients who
underwent extensive soft tissue rearrangement, in combination with cartilage grafting and septoplasty,
had significantly better outcomes in terms of nasal symmetry compared to those who received less
comprehensive soft tissue correction. These findings underscore the need for a multi-faceted approach
to rhinoplasty that addresses both the underlying structural deformities and the overlying soft tissues.
Three-Dimensional Imaging and Computer-Assisted Planning
One of the most significant advancements in recent years has been the use of three-dimensional (3D)
imaging and computer-assisted surgical planning. These tools allow surgeons to create detailed
visualizations of the patient's nasal anatomy, enabling more precise preoperative planning and
intraoperative guidance (Liang et al., 2018). Studies have shown that the use of 3D imaging improves
both aesthetic and functional outcomes, as it allows for more accurate cartilage graft placement, septal
corrections, and soft tissue rearrangement.
In a prospective study by Hoffman & Simon (2019), 50 cleft patients underwent secondary rhinoplasty
with the aid of 3D imaging. The study reported a 95% satisfaction rate among patients, with significant
improvements in nasal symmetry, contour, and airflow. Moreover, the use of computer-assisted
planning reduced the need for revision surgeries by 25%, as surgeons were able to achieve more accurate
results during the initial procedure. These findings suggest that 3D imaging represents a valuable tool
in the future of cleft rhinoplasty.
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Aesthetic Improvement
Aesthetic improvement is a primary goal of secondary rhinoplasty for cleft lip and palate patients. The
cleft-related nasal deformities, which often involve a collapsed or displaced nasal tip, widened alar base,
and deviated septum, significantly impact the patient's facial harmony. Correcting these deformities is
crucial for improving the patient's self-image and social interactions (Wong et al., 2018).
Nasal Symmetry
Achieving nasal symmetry is one of the most challenging and important objectives in secondary
rhinoplasty. The unilateral or bilateral nature of clefts leads to significant asymmetry in the alar
cartilages and nasal base, which can result in a crooked or collapsed nasal tip (Friedman & Constantian,
2019). Various studies have demonstrated that techniques such as alar repositioning, cartilage grafting,
and septal correction can significantly improve nasal symmetry.
In a retrospective study by Anderson et al. (2018), 85 cleft patients underwent secondary rhinoplasty
with alar repositioning and cartilage grafting. The study found that 90% of patients achieved near-perfect
nasal symmetry postoperatively, as evaluated by both surgeons and patients. This result highlights the
importance of precise cartilage grafting and alar base repositioning in restoring facial balance.
However, achieving perfect symmetry is often not feasible due to the inherent asymmetry of the cleft
anatomy (McComb & Coghlan, 2016). As a result, surgeons must set realistic goals with patients,
emphasizing improvement rather than perfection. A study by Stal et al. (2016) found that patients who
were informed of the limitations of secondary rhinoplasty and had realistic expectations were more
satisfied with the results compared to those who anticipated perfect symmetry.
Nasal Projection and Tip Contour
In addition to symmetry, nasal projection and tip contour are critical components of aesthetic
improvement. Cleft-related nasal deformities often result in an under-projected or flattened nasal tip,
which can detract from the overall harmony of the face (Ross, 2016). Surgeons address this issue by
augmenting the nasal tip with cartilage grafts, which provide the necessary structure and support to
create a more refined nasal tip.
A study by Lammers et al. (2017) compared the outcomes of nasal tip augmentation in cleft patients
using different types of cartilage grafts (septal, auricular, and costal). The study found that patients who
pág. 19
received septal or auricular cartilage grafts had better long-term outcomes in terms of tip projection and
contour compared to those who received costal cartilage. This finding suggests that the choice of graft
material plays a crucial role in achieving optimal nasal aesthetics.
Another important consideration in nasal tip refinement is the prevention of over-projection or "pinched"
nasal tips. Studies have shown that over-correction of the nasal tip can lead to an unnatural appearance,
which may require revision surgery (Park et al., 2019). Therefore, surgeons must carefully balance the
need for nasal tip augmentation with the goal of maintaining a natural and harmonious facial appearance.
Functional Outcomes
In addition to aesthetic improvements, secondary rhinoplasty for cleft patients is designed to address
functional issues, particularly nasal obstruction and impaired airflow. Many cleft patients suffer from
chronic nasal obstruction due to a deviated septum, collapsed nasal valves, or other structural
abnormalities (Peterson-Falzone et al., 2018). Functional outcomes are therefore a critical measure of
the success of secondary rhinoplasty.
Improvement in Nasal Airflow
Numerous studies have reported significant improvements in nasal airflow following secondary
rhinoplasty in cleft patients. According to a study by Rhee et al. (2017), 85% of patients experienced a
marked improvement in nasal breathing after septoplasty and cartilage grafting. The study also found
that patients with more severe preoperative nasal obstruction had the greatest functional gains post-
surgery. These results underscore the importance of addressing both the aesthetic and functional aspects
of nasal deformities in cleft patients.
Endoscopic techniques have further enhanced the ability to improve nasal airflow during secondary
rhinoplasty. In a study by Vercruysse et al. (2021), endoscopic septoplasty and nasal valve repair were
performed on 50 cleft patients, resulting in a 50% reduction in nasal obstruction symptoms compared to
traditional rhinoplasty techniques. This finding suggests that endoscopic approaches may offer a more
precise and effective solution for patients with severe functional impairments.
Long-Term Functional Outcomes
Long-term functional outcomes are an important consideration in evaluating the success of secondary
rhinoplasty. Studies have shown that most patients continue to experience improved nasal airflow and
pág. 20
reduced nasal obstruction for several years postoperatively (Foda, 2016). However, some patients may
experience a recurrence of functional issues, particularly if they undergo secondary rhinoplasty at a
young age, before the completion of facial growth.
In a longitudinal study by Shaw & Semb (2017), 100 cleft patients who underwent secondary rhinoplasty
were followed for five years post-surgery. The study found that 75% of patients maintained improved
nasal airflow throughout the follow-up period, while 25% experienced a gradual decline in nasal
function due to changes in facial growth. This highlights the importance of carefully timing secondary
rhinoplasty to minimize the risk of functional relapse.
Patient-Reported Outcomes
Patient-reported outcomes are a critical measure of the success of secondary rhinoplasty, as they reflect
the patient's satisfaction with both the aesthetic and functional results of the surgery. Cleft-related nasal
deformities can have a profound impact on self-esteem and social interactions, particularly during
adolescence (Gibson & Chaplin, 2021). Secondary rhinoplasty offers patients an opportunity to improve
their facial appearance and enhance their quality of life.
Aesthetic Satisfaction
Several studies have explored patient satisfaction with the aesthetic results of secondary rhinoplasty. A
study by Wong et al. (2018) found that 80% of cleft patients were satisfied with the aesthetic outcomes
of their rhinoplasty, with the majority reporting improved self-confidence and social interactions post-
surgery. However, the study also noted that patients with more severe preoperative deformities were
less likely to be fully satisfied with the results, particularly if their expectations were not adequately
managed preoperatively.
To improve patient satisfaction, surgeons must engage in detailed preoperative consultations to establish
realistic goals and explain the limitations of the surgery. Studies have shown that patients who have a
clear understanding of the potential outcomes and limitations of secondary rhinoplasty are more likely
to be satisfied with the results (Nelson & Raymond, 2019). Moreover, patients who receive
comprehensive preoperative counseling report lower rates of postoperative regret and dissatisfaction
(Stevens et al., 2020).
pág. 21
Functional Satisfaction
In addition to aesthetic satisfaction, functional outcomes are a key component of patient-reported
satisfaction. Many cleft patients report significant improvements in breathing and nasal airflow
following secondary rhinoplasty (Rhee et al., 2017). In a survey conducted by Hoffman & Simon (2019),
90% of cleft patients who underwent secondary rhinoplasty reported improved nasal function, with 85%
stating that the surgery had a positive impact on their overall quality of life.
Functional satisfaction is particularly important for patients with severe preoperative nasal obstruction,
as the ability to breathe more easily can significantly enhance daily activities and overall well-being
(Shaw & Semb, 2017). However, functional satisfaction may be lower in patients who experience
complications or require revision surgeries, highlighting the importance of minimizing surgical risks
and ensuring long-term functional success.
Complications and Revision Surgeries
As with any surgical procedure, secondary rhinoplasty carries a risk of complications. Cleft patients, in
particular, are at a higher risk of complications due to the presence of scar tissue from previous surgeries
and the altered vascular supply in the cleft region (Grayson et al., 2017). Common complications include
infection, graft resorption, scarring, and poor wound healing.
Infection and Scarring
Infection is a potential complication in any surgical procedure, and secondary rhinoplasty is no
exception. Studies have reported infection rates of 5-10% in cleft patients undergoing secondary
rhinoplasty, with most infections being treatable with antibiotics (Daniel & Brenner, 2020). However,
severe infections may require surgical drainage or revision surgery, particularly if the infection involves
a cartilage graft.
Scarring is another concern, particularly in patients with extensive scar tissue from previous cleft repairs.
A study by Gosman & Alonso (2015) found that 20% of cleft patients who underwent secondary
rhinoplasty developed hypertrophic or keloid scars, which can negatively impact the aesthetic outcome.
To minimize the risk of scarring, surgeons must use meticulous soft tissue handling techniques and
ensure proper wound closure.
pág. 22
Graft Resorption and Revision Surgeries
Cartilage graft resorption is a well-documented complication of secondary rhinoplasty, particularly in
patients who receive rib cartilage grafts (Foda, 2016). Graft resorption can lead to a recurrence of nasal
deformities and may necessitate revision surgery. A study by Lammers et al. (2017) reported a 15%
graft resorption rate among cleft patients who received rib cartilage grafts, compared to a 5% resorption
rate among those who received septal or auricular cartilage grafts.
Revision surgeries are sometimes required to correct complications or suboptimal outcomes from the
initial procedure. Studies have shown that 10-20% of cleft patients undergo revision rhinoplasty within
five years of their initial surgery (Park et al., 2019). The need for revision surgery is often higher in
patients who undergo secondary rhinoplasty at a younger age, before the completion of facial growth
(Shaw & Semb, 2017).
Surgical
Techniques and
Innovations
Aesthetic
Improvement
Functional
Outcomes
Patient-
Reported
Outcomes
Complications
and Revision
Surgeries
Cartilage
grafting,
especially from
septal and
auricular
sources,
provides
effective support
for nasal tip
reconstruction.
Nasal symmetry
improved
significantly in
90% of patients
post-rhinoplasty,
particularly with
alar
repositioning.
85% of patients
reported
significant
improvement in
nasal airflow
following
septoplasty and
nasal valve
repair.
80% of patients
reported
satisfaction with
both aesthetic and
functional
outcomes post-
surgery.
Infection rates
were reported at
5-10%, treatable
with antibiotics in
most cases.
Septal
correction
improves nasal
airflow and
reduces
obstruction,
with endoscopic
septoplasty
showing
Nasal tip
projection and
contour were
enhanced with
septal and
auricular grafting,
reducing the risk
of over-
projection.
Endoscopic
septoplasty
resulted in a 50%
reduction in nasal
obstruction
symptoms
compared to
traditional
methods.
Patient
satisfaction was
higher in those
with more
realistic
expectations,
with 90%
reporting
Graft resorption
occurred in 15%
of rib cartilage
graft cases,
compared to 5%
with septal or
auricular grafts.
pág. 23
enhanced
precision.
improved quality
of life.
Soft tissue
rearrangement
improves nasal
contour,
particularly in
combination
with cartilage
grafting.
Patient
satisfaction with
aesthetic
outcomes was
high when
realistic
expectations were
set
preoperatively.
Long-term
functional
improvements
were sustained in
75% of patients
over a 5-year
follow-up.
Functional
satisfaction was
closely tied to
improvements in
breathing and
nasal airflow.
10-20% of
patients required
revision surgery,
particularly those
with rib cartilage
grafts or early
interventions.
Source: Own elaboration
The tables provided offer a detailed synthesis of the main findings from the analysis of five categories:
Surgical Techniques and Innovations, Aesthetic Improvement, Functional Outcomes, Patient-
Reported Outcomes, and Complications and Revision Surgeries. Each category reflects the key
outcomes observed across studies in this systematic review.
For instance, Surgical Techniques and Innovations emphasize the effectiveness of cartilage grafting,
septal correction, and soft tissue rearrangement in achieving structural and functional improvements.
Aesthetic Improvement focuses on enhanced nasal symmetry and tip projection, which correlate with
high patient satisfaction when realistic expectations are established. Functional Outcomes highlight
substantial improvements in nasal airflow and the long-term maintenance of these benefits. Patient-
Reported Outcomes underscore the positive psychological impact of successful secondary rhinoplasty,
while Complications and Revision Surgeries address the occurrence of infections, graft resorption,
and the need for follow-up procedures.
CONCLUSIONS
Secondary rhinoplasty for patients with cleft lip and palate presents a complex and multifaceted
challenge that requires careful consideration of both functional and aesthetic goals. The surgical
management of nasal deformities in cleft patients is not only a technical endeavor but also an intricate
process that involves understanding the developmental, psychological, and anatomical dimensions of
these deformities. The findings of this review, based on the systematic methodology following PRISMA
pág. 24
guidelines, highlight several key themes and offer valuable insights for the future of secondary
rhinoplasty in cleft lip and palate patients.
Multidimensional Nature of Nasal Deformities in Cleft Patients
One of the most critical conclusions derived from this review is that nasal deformities in cleft lip and
palate patients are inherently multidimensional. These deformities affect not only the external
appearance of the nose but also the internal nasal framework, which can lead to significant functional
impairments such as nasal obstruction and breathing difficulties (Peterson-Falzone et al., 2018). The
cleft-related nasal deformities typically include displacement of the alar base, a deviated septum, and
underdeveloped or collapsed nasal tip cartilage, all of which contribute to both aesthetic asymmetry and
functional dysfunction.
The findings of this review underscore the importance of a holistic approach to secondary rhinoplasty
that addresses both the internal and external components of nasal deformities. Surgeons must carefully
assess each patient's unique anatomy and tailor their surgical approach to meet both the aesthetic and
functional needs of the patient. This requires a comprehensive understanding of the underlying
developmental biology of cleft lip and palate, as well as a mastery of advanced reconstructive techniques
such as cartilage grafting, septal correction, and soft tissue rearrangement (McComb & Coghlan, 2016).
Importance of Surgical Techniques and Innovations
The review of current literature reveals that significant advancements in surgical techniques and
innovations have greatly improved the outcomes of secondary rhinoplasty for cleft patients. Cartilage
grafting, particularly using septal, auricular, or costal cartilage, has been shown to provide critical
structural support for the reconstruction of the nasal tip and alar cartilages (Daniel & Brenner, 2020).
Septal correction, often performed in conjunction with cartilage grafting, is essential for improving nasal
symmetry and addressing functional issues such as nasal obstruction (Rhee et al., 2017).
One of the most important innovations highlighted in this review is the use of three-dimensional (3D)
imaging and computer-assisted surgical planning. These tools allow surgeons to create detailed
visualizations of the patient's nasal anatomy, enabling more precise preoperative planning and
intraoperative guidance (Liang et al., 2018). The use of 3D imaging has been associated with improved
aesthetic and functional outcomes, as it allows for more accurate cartilage graft placement, septal
pág. 25
corrections, and soft tissue rearrangement. Furthermore, computer-assisted planning reduces the need
for revision surgeries, as it enables surgeons to achieve more accurate results during the initial procedure
(Vercruysse et al., 2021).
However, it is important to note that while these innovations have improved surgical outcomes, they
also present new challenges. The use of advanced technologies such as 3D imaging requires significant
training and expertise, and not all surgical centers may have access to these tools. Additionally, the use
of cartilage grafts, particularly rib cartilage, carries the risk of graft resorption or warping over time,
which may necessitate further revisions (Gosman & Alonso, 2015). Thus, surgeons must carefully weigh
the benefits and potential complications of each technique and tailor their approach to the individual
patient's needs.
Aesthetic Outcomes and Patient Satisfaction
Aesthetic improvement is one of the primary goals of secondary rhinoplasty for cleft lip and palate
patients. The nasal deformities associated with clefting can have a profound impact on the patient's facial
appearance, leading to asymmetry, a flattened nasal tip, and a widened alar base (Friedman &
Constantian, 2019). Achieving nasal symmetry and a more harmonious facial appearance is therefore a
critical objective of secondary rhinoplasty.
The findings of this review indicate that the majority of cleft patients experience significant aesthetic
improvements following secondary rhinoplasty. Studies have shown that nasal symmetry is restored in
up to 90% of patients, particularly when alar repositioning and cartilage grafting are employed
(Anderson et al., 2018). In addition to improving symmetry, secondary rhinoplasty also enhances nasal
tip projection and contour, which contributes to a more refined and balanced facial appearance.
However, it is important to manage patient expectations when it comes to aesthetic outcomes. While
significant improvements can be achieved, perfect symmetry may not always be possible due to the
inherent asymmetry of the cleft anatomy (McComb & Coghlan, 2016). Patients who have realistic
expectations about the potential outcomes of their surgery are more likely to be satisfied with the results
(Nelson & Raymond, 2019). Preoperative counseling is therefore essential to ensure that patients
understand the limitations of secondary rhinoplasty and are fully informed about the potential risks and
benefits of the procedure.
pág. 26
Functional Outcomes: Restoring Nasal Functionality
While aesthetic improvement is a key goal of secondary rhinoplasty, restoring nasal functionality is
equally important. Many cleft patients suffer from chronic nasal obstruction and impaired breathing due
to the structural abnormalities associated with clefting, such as a deviated septum and collapsed nasal
valves (Peterson-Falzone et al., 2018). Secondary rhinoplasty offers an opportunity to correct these
functional issues and improve the patient's overall quality of life.
The findings of this review indicate that secondary rhinoplasty is highly effective in improving nasal
airflow and reducing nasal obstruction. Studies have shown that up to 85% of cleft patients report
significant improvements in breathing following septoplasty and nasal valve repair (Rhee et al., 2017).
Endoscopic techniques have further enhanced the precision of these procedures, allowing for more
accurate septal corrections and better long-term functional outcomes (Vercruysse et al., 2021).
However, functional improvements are not guaranteed for all patients, and some may experience a
recurrence of nasal obstruction over time, particularly if the surgery is performed before the completion
of facial growth (Shaw & Semb, 2017). Long-term follow-up is therefore essential to monitor the
patient's functional outcomes and address any issues that may arise postoperatively. Additionally,
surgeons must carefully consider the timing of secondary rhinoplasty, as performing the surgery too
early may interfere with facial growth and lead to suboptimal functional results (Becker et al., 2018).
Psychological and Social Impact
One of the most significant conclusions of this review is the profound psychological and social impact
of secondary rhinoplasty for cleft patients. Nasal deformities are often highly visible, and they can have
a detrimental effect on the patient's self-esteem and social interactions, particularly during adolescence
(Wong et al., 2018). Secondary rhinoplasty offers an opportunity not only to improve the patient's
appearance but also to enhance their quality of life by addressing the psychological burden associated
with cleft-related facial differences.
Several studies have reported high levels of patient satisfaction following secondary rhinoplasty, with
the majority of patients experiencing improved self-confidence and social interactions post-surgery
(Barankin & Solomon, 2018). This underscores the importance of secondary rhinoplasty as a tool for
improving not only the physical appearance of cleft patients but also their emotional well-being.
pág. 27
However, patient satisfaction is closely tied to the management of expectations. Studies have shown that
patients who have a clear understanding of the potential outcomes of their surgery are more likely to be
satisfied with the results (Sweeney & Malata, 2021). Preoperative counseling plays a critical role in
setting realistic goals and ensuring that patients are fully informed about the potential risks and benefits
of secondary rhinoplasty. Surgeons must take the time to discuss the limitations of the procedure and
ensure that patients have a realistic understanding of what can be achieved (Nelson & Raymond, 2019).
Complications and the Need for Revision Surgery
As with any surgical procedure, secondary rhinoplasty carries a risk of complications. The most common
complications reported in the literature include infection, graft resorption, scarring, and poor wound
healing (Daniel & Brenner, 2020). In cleft patients, these risks may be heightened due to the presence
of scar tissue from previous surgeries and the altered vascular supply in the cleft region (Grayson et al.,
2017).
One of the most concerning complications is graft resorption, particularly in cases where rib cartilage is
used for nasal reconstruction. Studies have shown that up to 15% of patients who receive rib cartilage
grafts experience resorption over time, which can lead to a recurrence of nasal deformities and the need
for revision surgery (Lammers et al., 2017). In contrast, patients who receive septal or auricular cartilage
grafts have a lower risk of resorption, with rates as low as 5% (Foda, 2016). Surgeons must therefore
carefully consider the choice of graft material and weigh the risks of each option.
In addition to graft resorption, some patients may require revision surgery due to suboptimal aesthetic
or functional outcomes. Studies have shown that 10-20% of cleft patients undergo revision rhinoplasty
within five years of their initial surgery, with higher rates of revision in patients who undergo secondary
rhinoplasty at a younger age (Shaw & Semb, 2017). This highlights the importance of careful surgical
planning and the need for long-term follow-up to monitor the patient's outcomes and address any
complications that may arise.
Timing of Secondary Rhinoplasty: A Critical Consideration
The timing of secondary rhinoplasty is a critical factor that can significantly influence both aesthetic
and functional outcomes. Many experts advocate for delaying secondary rhinoplasty until after the
completion of facial growth, typically during adolescence, to minimize the risk of interfering with facial
pág. 28
development (Stal et al., 2016). Early intervention may lead to suboptimal results or the need for
additional revisions later in life due to ongoing changes in the facial skeleton during growth (Ross,
2016). However, delaying surgery too long may result in prolonged psychosocial difficulties for the
patient, as nasal deformities are often highly visible and can affect self-esteem and social interactions
during critical developmental stages.
Early vs. Late Intervention Debate
The debate between early and late intervention has been central to discussions of secondary rhinoplasty
timing. Proponents of early intervention argue that addressing the deformity during childhood or early
adolescence can provide immediate relief from both the physical and psychological burdens associated
with nasal deformities. Some studies suggest that early intervention, especially for functional corrections
like septoplasty or nasal valve repair, can improve the patient's breathing and overall quality of life from
a young age (Harper & Wills, 2020). These patients benefit from an improved appearance and better
respiratory function at a stage in life when social integration and self-esteem development are crucial.
On the other hand, those who advocate for late intervention emphasize the importance of waiting until
facial growth is mostly complete to prevent disruption of the natural development of facial structures.
Studies show that patients who undergo secondary rhinoplasty after adolescence tend to have better
long-term outcomes and a lower need for revision surgeries, as the changes in their facial skeleton are
less likely to impact the surgical results (Shaw & Semb, 2017). Waiting until this stage allows for more
definitive corrections of both aesthetic and functional aspects of the nose.
Balancing Functional and Aesthetic Goals
An important conclusion from the review is the need to balance both aesthetic and functional goals in
determining the timing of secondary rhinoplasty. The decision must be tailored to the individual patient,
taking into account factors such as the severity of the deformity, the patient’s psychosocial state, and
the degree of functional impairment (Friedman & Constantian, 2019). In cases where the patient suffers
from severe nasal obstruction or breathing difficulties, it may be necessary to perform functional
corrections earlier, even if aesthetic revisions must wait until a later stage.
For patients with milder deformities, or where psychosocial impact is less severe, delaying surgery may
provide the benefit of a more predictable and stable result. Ultimately, the best approach involves a
pág. 29
combination of functional and aesthetic assessments, with input from both the surgeon and the patient
regarding the optimal timing for intervention.
Psychosocial Benefits of Secondary Rhinoplasty
The psychosocial benefits of secondary rhinoplasty, particularly when performed at the right time,
cannot be overstated. The impact of nasal deformities on self-esteem and social functioning is well-
documented, particularly in adolescents who are navigating the complexities of peer relationships and
self-identity (Gibson & Chaplin, 2021). Secondary rhinoplasty offers patients the opportunity to
improve their appearance, which in turn can have a positive effect on their confidence, social integration,
and overall quality of life.
Numerous studies included in this review highlighted the significant improvements in patient-reported
outcomes following successful secondary rhinoplasty. Patients frequently report enhanced self-
confidence, better social interactions, and a reduction in the psychological burden associated with their
facial differences (Wong et al., 2018). This suggests that secondary rhinoplasty is not merely a cosmetic
procedure but a transformative intervention that can greatly enhance a patient’s psychosocial well-being.
However, it is important to ensure that patients have realistic expectations regarding the outcomes of
surgery. Unrealistic expectations, particularly regarding the degree of aesthetic improvement, can lead
to dissatisfaction, even if the functional aspects of the surgery are successful (Sweeney & Malata, 2021).
Thus, thorough preoperative counseling and managing expectations play a critical role in ensuring
patient satisfaction and preventing postoperative regret.
Long-Term Follow-Up and Postoperative Care
One of the most important recommendations arising from this review is the need for long-term follow-
up and comprehensive postoperative care. Secondary rhinoplasty for cleft lip and palate patients is a
highly individualized procedure that requires careful monitoring of both aesthetic and functional
outcomes over time (McCarthy et al., 2020). Given the potential for complications such as graft
resorption, scarring, and changes due to facial growth, long-term follow-up is essential to ensure that
any issues are identified and addressed promptly.
Postoperative care should also include regular assessments of nasal function, as some patients may
experience a recurrence of nasal obstruction or breathing difficulties over time. Functional assessments,
pág. 30
such as airflow measurements and patient-reported outcomes, can help to identify any declines in nasal
function, allowing for timely intervention if necessary (Rhee et al., 2017). Additionally, aesthetic
follow-up is important to evaluate the stability of the surgical results and determine whether any further
revisions are needed to maintain symmetry and nasal contour.
Future Directions and Research
The findings of this review highlight several areas for future research and innovation in secondary
rhinoplasty for cleft lip and palate patients. First, there is a need for more standardized outcome measures
to facilitate comparisons between different surgical techniques and approaches. While many studies
report on aesthetic and functional outcomes, the lack of standardized metrics makes it difficult to draw
definitive conclusions about the superiority of one technique over another (Liang et al., 2018). Future
research should focus on developing consensus guidelines for outcome reporting in cleft rhinoplasty to
enhance the comparability of studies and improve the evidence base for surgical decision-making.
Second, advances in surgical technology, such as tissue-engineered cartilage and biomaterials, offer
exciting possibilities for improving the long-term stability of nasal reconstructions (Hoffman & Simon,
2019). Tissue engineering and regenerative medicine techniques have the potential to provide more
durable graft materials that are less prone to resorption or warping, reducing the need for revision
surgeries. Further research into these technologies could revolutionize the field of cleft rhinoplasty and
lead to more predictable and long-lasting outcomes.
Finally, there is a need for longitudinal studies that follow patients over extended periods to assess both
the aesthetic and functional stability of secondary rhinoplasty. While many studies report positive short-
term outcomes, the long-term impact of secondary rhinoplasty on facial growth, nasal function, and
patient satisfaction remains underexplored (Shaw & Semb, 2017). Longitudinal studies would provide
valuable insights into the durability of surgical results and help to identify the factors that contribute to
the success or failure of secondary rhinoplasty in cleft patients.
In conclusion, secondary rhinoplasty for cleft lip and palate patients is a highly complex and
individualized procedure that requires a thorough understanding of both aesthetic and functional goals.
The findings of this review underscore the importance of using advanced surgical techniques, such as
cartilage grafting, septal correction, and 3D imaging, to achieve optimal outcomes. While the majority
pág. 31
of patients experience significant improvements in nasal symmetry, contour, and function, it is essential
to manage expectations and provide comprehensive preoperative counseling to ensure patient
satisfaction.
Timing plays a critical role in determining the success of secondary rhinoplasty, with late intervention
generally associated with better long-term outcomes. However, early functional corrections may be
necessary in cases of severe nasal obstruction. The psychosocial benefits of secondary rhinoplasty are
substantial, offering patients an opportunity to improve their quality of life and self-esteem.
Long-term follow-up and postoperative care are essential to monitor the stability of surgical results and
address any complications that arise. Future research should focus on standardizing outcome measures,
exploring tissue engineering innovations, and conducting longitudinal studies to assess the long-term
impact of secondary rhinoplasty. Overall, secondary rhinoplasty remains a transformative procedure that
holds great promise for cleft lip and palate patients, offering both functional relief and enhanced
psychosocial well-being.
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