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OBJECTIVES: Nasoalveolar moulding (NAM) has resulted in profound outcomes in the treatment of bilateral cleft lip and palate patients, including non-surgical columellar lengthening and nasal moulding. We examine an innovative alternative that is less invasive, yet provides similar results. In this study, we describe a novel approach using the Customized Nasal Clip Protocol (CNCP™) and compare the treatment outcomes of a small cohort of infants with bilateral cleft lip ± palate with published results of the Grayson nasoalveolar moulding protocol. MATERIALS AND METHODS: A cohort of six bilateral-cleft-affected patients was evaluated for this study. Standardized frontal and worm's eye view photographs were obtained, and clinical measurements were utilized to garner columellar length measurements and nostril height comparisons. The initial and post-surgical results were statistically compared with a student's t-test (p < .05). Inclusion and exclusion criteria were applied to the cohort, which will be described. RESULTS: The resulting columellar length and nostril height increases of the CNCP™ group were comparable to a published cohort of subjects that have undergone nasoalveolar moulding. The nasal changes were found to be significant with a p-value <.01. The CNCP™ cohort also had fewer clinic visits, no complications that led to complete pauses of active treatment, and the benefit of receiving comprehensive treatment that was initiated at their first clinical presentation, in comparison to traditional NAM patients. CONCLUSION: The increase of columellar length and nostril height that resulted from utilizing the CNCP™ in bilateral cleft patients met the treatment goals of presurgical infant orthopaedics, with results on par with published results of NAM. These results, paired with the reduction in patient, family, and provider burden, further support the continued use and development of the CNCP™ for appropriate patient populations.

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INTRODUCTION: A 22-day-old male infant presented with complete bilateral cleft lip and palate with prominent premaxillary segment, wide alar base, flat alar domes and no columellar tissue, thus leading to a severe facial deformity. A presurgical nasoalveolar moulding (PNAM) procedure was planned to facilitate an optimal surgical approximation of the cleft and surrounding tissues. METHODS: PNAM was performed on the basis of the hypothesis that 'The palatal shelves continue to grow unabated if adequate relief is provided by wax mock up while preparing the feeding plate'. An intraoral device, which consisted of an acrylic feeding plate, was constructed after adequate wax mock up in the cleft area for passive moulding, along with extraoral traction force through active lip taping. A nasal stent was subsequently attached to lift the nasal domes and lengthen the columella. The changes thus achieved with PNAM were assessed using innovative photographic and model analyses. RESULTS: On completion of PNAM, the qualitative photographic changes showed significant premaxillary setback, columellar lengthening and fullness of alar domes. The quantitative model analysis revealed reduction in the anteroposterior cleft gap by 5 mm and 5.5 mm on right and left sides, respectively. Transverse distance between the two palatal segments reduced by 3.5 mm, 8 mm and 8.5 mm in anterior, middle and posterior regions, respectively. CONCLUSION: Orthodontic intervention performed for 11 weeks by PNAM helped to retract the premaxilla, reduce the cleft gap, improve the arch form, approximate lip segments and distinctly lengthen the columella. Hence, it improved the morphology of the nose by correcting the flattened nasal wings. This aided the surgeon to achieve an optimal surgical repair.

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Even though it is generalized to perform synchronous lip and nasal correction, there are some cases in need of secondary correction of cleft lip nose deformity. In these procedures, the lengthening of columella plays an important role. We performed eighteen cases of the secondary cleft lip nose deformity correction using two different methods from 1997 to 2003. The central lip flap was used in eight patients and V-Y advancement flap in ten patients. Additional procedures including reverse U-incision, interdomal fixation sutures and suspension sutures were used for correction of combined deformity. Silastic nasal retainers were kept in all patients for 6 months. Both of central lip flap and V-Y advancement flap seems to be a good technique for lengthening columellar soft tissue. But new columella after V-Y advancement flap appeared to be too narrow and a bit unnatural looking and central lip flap left additional scar on the upper lip although it was conspicuous. We think that central lip flap is a better technique in a case with wide philtrum and narrow columella and V-Y advancement flap can be another choice in a columella with sufficient width.

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