The Yin and Yang of Primary Unilateral Cleft Lip and Nose Repair: Balance through understanding the opposing cleft and non-cleft side changes.

INTRODUCTION: Balance is achieved through opposing interactions. Objective 3D assessment of changes during surgical treatment of the unilateral cleft lip and nasal deformity are limited and false assumptions may prevent optimal management.

METHODS: We performed anthropometric analysis on the immediate pre- and post-operative images (captured under anesthetic) of patients undergoing primary repair (n=36). Changes in dimensions and measures of balance were assessed (p<0.05).

RESULTS: Angles and ratios that reflect cleft to non-cleft side balance normalized, though alterations occurred in opposing ways. Centralization of the columella narrowed the cleft nasal base and widened the non-cleft nasal base. As the cleft columellar height elongated, the non-cleft columellar height shortened. With these changes and correction of cleft alar base retrusion, the cleft alar dome was raised. The cleft and non-cleft lateral lip heights and widths elongated while the Cupid's bow broadened, and the commissures were drawn closer together. Whereas the cleft philtral height lengthened, the non-cleft philtral height shortened. Reduction in non-cleft philtral height averaged 20% but varied with measures of pre-operative severity including columellar angle (R=0.67), the difference in philtral heights (R=0.65), and lateral deviation of subnasale (R=0.74).

CONCLUSIONS: Tissue does not need to be added to "lengthen" the columella, non-cleft philtral height shortening can be estimated, and morphology of anatomic subunits change with surgery on both cleft and non-cleft sides. It is inadequate to focus on correction of the cleft side alone without considering corresponding non-cleft side changes. Achieving balance through opposing alterations should be the principal goal of treatment.