Nasal Septal Anatomy in Skeletally Mature Patients with Cleft Lip and Palate

Research

JAMA Facial Plastic Surgery | Original Investigation Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate

Jonathan P. Massie, BS; Christopher M. Runyan, MD, PhD; Marleigh J. Stern, BA; Michael Alperovich, MD; Scott M. Rickert, MD; Pradip R. Shetye, DDS; David A. Staffenberg, MD; Roberto L. Flores, MD

Supplemental content at IMPORTANCE Septal deviation commonly occurs in patients with cleft lip and palate (CLP); jamafacialplasticsurgery.com however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood.

OBJECTIVES To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction.

DESIGN, SETTING, AND PARTICIPANTS This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study.

MAIN OUTCOMES AND MEASURES Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified.

RESULTS Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = −0.61; P < .01).

CONCLUSIONS AND RELEVANCE Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty. Author Affiliations: Hansjörg Wyss LEVEL OF EVIDENCE NA. Department of Plastic Surgery, New York University Langone Medical Center, New York, New York (Massie, Runyan, Stern, Alperovich, Shetye, Staffenberg, Flores); Department of Otolaryngology, New York University Langone Medical Center, New York, New York (Rickert). Corresponding Author: Roberto L. Flores, MD, Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical JAMA Facial Plast Surg. 2016;18(5):347-353. doi:10.1001/jamafacial.2016.0404 Center, 307 E 33rd St, New York, NY Published online May 26, 2016. 10016 ([email protected]).

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he nasal septum is one of the cardinal skeletal support systems of the nose1 and has previously been shown to Key Points be deviated in patients with cleft lip and palate (CLP).2-8 T Question How does the cartilaginous and bony septum In addition, the nasal airway is severely affected in patients with contribute to airway obstruction in skeletally mature patients with CLP, with nasal airflow resistances 20% to 30% higher than cleft lip and palate (CLP)? those in the general population.9,10 A variety of factors have Findings In this review of 24 skeletally mature patients with CLP, been shown to contribute to airway obstruction, including sep- septal deviation was significantly worse than that of controls in all tal deformities, atresia of the nostrils, and turbinate anatomical planes studied, and bony septum angular deviation hypertrophy.11 Whereas the latter issues are often addressed was significantly associated with anterior airway stenosis. The in the course of primary or definitive nasal repair for patients point of maximal septal deviation occurred in the bony posterior with CLP, optimal management of the septum in correcting na- half of the nasal airway in most patients. sal obstructive symptoms remains poorly defined. Meaning Resection of the bony and cartilaginous septum should Traditionally, nasal bony manipulation is avoided until be performed at the time of definitive cleft rhinoplasty for relief of skeletal maturity is reached to avoid growth deficiencies.1 How- airway obstruction in patients with CLP. ever, even during definitive rhinoplasty at adolescence or adult- hood, the main focus is the nasal cartilage and visible bony structures, with little consensus as to the surgical manage- A single rater (J.P.M.) repeated the CBCT analysis. Before ment of the bony septum.1,12-14 This lack of consensus can be measurement, CBCT scans were oriented in the horizontal attributed to the poor characterization of nasal septum plane using the infraorbital rims as a reference and in the anatomy in skeletally mature patients with CLP in the cur- vertical plane using the zygomatic arch to the infraorbital rent literature. Before treatment guidelines can be estab- rim. The measurements described below were performed on lished, a better understanding of the nasal septal anatomy in all CBCT scans. skeletally mature patients with CLP is needed. The advent of cone-beam computed tomography (CBCT) Septal Deviation allows the acquisition of high-quality 3-dimensional images Septal deviation was measured in coronal sections at the level of facial structures with reduced radiation doses compared with of the anterior nasal spine (ANS), the posterior nasal spine multisection CT.15,16 Routine acquisition of CBCT scans by our (PNS), the ANS-PNS midpoint, and the point of maximal sep- cleft lip and palate team as a component of dental evaluation tal deviation. Septal deviation was calculated as the mean of enabled us to obtain CT scans of a sizeable population of skel- the distance of the right mucosal septum and left mucosal sep- etally mature patients with CLP and age-matched control pa- tum from the midline (Figure 1A). tients. With these scans, we performed a comprehensive analysis of the anatomy of the nasal airway in skeletally mature Airway Stenosis patients with CLP. Airway stenosis was similarly measured in coronal sections at the ANS, PNS, ANS-PNS midpoint, and maximal septal deviation. Stenosis was measured as the smallest linear distance be- Methods tween the mucosal nasal septum and adjacent turbinate or lateral nasal wall (Figure 1B). Patient Selection and Study Sample This single-center retrospective review considered all skel- Bony Angle Deviation etally mature patients with CLP who underwent CBCT scan- Bony angular deviation from the vertical plane was meaning from November 1, 2011, to July 6, 2015, at the Depart- sured at the maximal septal deviation for the perpendicular ment of Plastic Surgery, New York University Langone Medical plate of the ethmoid bone (PPE) and vomer (Figure 1C and D). Center, and who were at least 15 years old at the time of CBCT. The PPE angle from the vertical plane was defined from the Patients were excluded from the study if they had a cleft pal- point of maximal septal deviation to the skull base, and the ate only. The CBCT scans were used only if they were ob- vomer angle from the vertical plane was defined from the point tained before Le Fort I osteotomy and/or formal septorhino- of maximal septal deviation to the nasal floor. In cases for which plasty. Age-matched controls were identified as patients the maximal septal deviation did not include bony septum, an- without CLP who underwent CBCT evaluation for orthog- gular measurements were not obtained. nathic surgery consultation or after facial trauma. No controls were included for whom nasal trauma was the primary Characterizing the Point of Maximal Septal Deviation reason for the CBCT scan. Institutional review board ap- The point of maximal septal deviation was identified for all pa- proval was obtained from New York University before the start tients (eFigure in the Supplement), and we noted whether this of this study. The need for informed consent was waived by point occurred in the cartilaginous or bony septum. In addi- the institutional review board. tion, the 3-dimensonal location of the maximal septal deviation was recorded for the sagittal axis (right vs left of mid- CBCT Analysis line), axial axis (superior vs inferior to the midpoint from skull The CBCT scans were analyzed using Dolphin Imaging Soft- base to nasal floor), and coronal axis (anterior vs posterior to ware (Patterson Dental) by two of us (J.P.M. and C.M.R.). the midpoint from the ANS to PNS).

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Statistical Analysis Figure 1. Sample Cone-Beam Computed Tomographic Measurements All data were analyzed using Prism software (version 6.07; Obtained for All Patients GraphPad) or SPSS (version 23; IBM). Pairwise data were analyzed using the unpaired, 2-tailed t test. Multivariable A Septal deviation B Airway stenosis linear regression was performed between the independent variables ANS septal deviation, PNS septal deviation, ANS- PNS midpoint septal deviation, PPE angle, and vomer angle and the dependent variables of ANS, ANS-PNS midpoint, and PNS airway stenosis in an effort to characterize deter- minants of airway obstruction. Intrarater and interrater reli- abilities were assessed using the Pearson product moment correlation coefficient. Statistical significance was held at P < .05. Unless otherwise indicated, data are expressed as mean (SD).

Results Patient Examination Twenty-four patients with CLP (19 male and 5 female) and 16 control patients (7 male and 9 female) were identified for inclusion in the study and were well matched with a mean (SD) age of 21 (5) and 23 (6) years at the time of CBCT, respec- C Perpendicular plate of ethmoid bone D Vomer angle tively. Ages ranged from 15 to 33 years at the time of CBCT scan for patients with CLP and from 15 to 37 years for controls. Within the CLP group, 11 patients had unilateral CLP and 13 patients had bilateral CLP. Controls underwent CBCT scans for orthognathic evaluation or after facial trauma. Intrarater reliability for 310 repeated measurements as calculated by Pearson product moment correlation was r =0.96 (P < .001); interrater reliability for 80 repeated measurements, r =0.92(P < .001).

Severity of Septal Deviation Septal deviation measured at the ANS, PNS, and ANS-PNS midpoint was significantly worse in patients with CLP compared with controls (P < .05 for all) (Figure 2A). Moreover, septal deviation within patients with CLP tended to be most severe near the midpoint of the nasal airway (4.4 [0.6] mm), A, Septal deviation is calculated as the mean distance of the right and left which was significantly more deviated than the anterior air- mucosal septum from midline (dashed red line). Yellow line indicates midline to way (2.1 [0.5] mm; P < .01) (Figure 2A). Midpoint septal right mucosal septum; green line, midline to left mucosal septum; blue line, mean septal deviation. B, Airway stenosis is measured as the smallest distance deviation represented 79% of the septal deviation observed between the nasal septum and lateral nasal wall or adjacent turbinate (arrow). at the point of maximal septal deviation (5.6 [0.7] mm). Con- C, Perpendicular plate of the ethmoid bone angle is measured from the vertical trols also exhibited a similar pattern of septal deviation, with plane. D, Vomer angle is measured from the vertical plane. the midpoint septal deviation (2.1 [0.3] mm) accounting for 78% of maximal septal deviation (27 [0.3] mm) (Figure 2A). This finding suggests that the middle to posterior nasal sep- Airway Stenosis tum is inherently more susceptible to deviation, and this Patients with CLP had a significant degree of airway stenosis association is significantly more apparent in patients with at the ANS, PNS, and their midpoint compared with controls CLP. Significant differences in septal deviation were not (P < .05 for all) (Figure 2B). In addition, in the CLP group, observed in patients with unilateral vs bilateral CLP except stenosis was critically severe at the midpoint (0.4 [0.1] mm), at the PNS (Figure 2A). Patients with unilateral CLP had which was significantly more stenotic than the ANS (1.4 nearly 3 mm greater septal deviation at the PNS vs those [0.2] mm; P < .001) and PNS (1.2 [0.2] mm; P < .001) with bilateral CLP (P < .01) (Figure 2A). In patients with uni- (Figure 2B). Stenosis at the midpoint was about 0.1 mm lateral CLP, septal deviation at the PNS (4.4 [0.8] mm) was as smaller than the stenosis observed at the point of maximal severe as at the midpoint (4.5 [0.7] mm), suggesting that the septal deviation (0.5 [0.2] mm). Significant differences were posterior nasal septum is of particular importance in this not observed between patients with unilateral vs bilateral patient population (Figure 2A). CLP (Figure 2B).

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Figure 2. Measurements of Septal Deviation, Stenosis, and Bony Angular Deviation

Patients vs controls Patients with unilateral vs bilateral CLP A Septal deviation CLP group Control group Unilateral CLP Bilateral CLP 15 15 c c a,b

10 10 c f

5 5 Septal Deviation, mm Septal Deviation, mm Septal Deviation,

0 0

ANS MID PNS MDS ANS MID PNS MDS

B Airway stenosis

5 5 Septal deviation, stenosis, and 4 b,d 4 angular measurements were compared in patients with cleft lip 3 3 and palate (CLP) vs controls (left) and b in patients with unilateral vs bilateral 2 2 CLP (right). Septal deviation and b,e stenosis were measured at the Stenosis, mm Stenosis, mm 1 1 anterior nasal spine (ANS), posterior nasal spine (PNS), ANS-PNS midpoint 0 0 (MID), and point of maximal septal deviation (MSD). Bony septum angle ANS MID PNS MDS ANS MID PNS MDS measurements were performed from the vertical plane for the C Angular measurement perpendicular plate of the ethmoid 100 100 bone (PPE) and vomer at the point of b maximal septal deviation. 80 80 a P < .01 compared with MID among patients with CLP. 60 60 b P < .05 compared with controls. c 40 40 P < .01 compared with controls. b d P < .001 compared with MID among Angle, Degrees Angle, Degrees 20 20 patients with CLP. e P < .001 compared with PNS among 0 0 patients with CLP. PPE Vomer PPE Vomer f P < .01 compared with patients with bilateral CLP.

Vomer Deviation and Nasal Airway Patency could not be built for stenosis outcomes at the ANS-PNS The vomer was significantly deviated from the vertical plane midpoint, PNS, and maximal septal deviation because we in patients with CLP (34° [5°]) vs controls (13° [2°]; P < .05) found no degree of correlation with any of the input vari- (Figure 2C). A significant difference was also observed in the ables (septal deviation of the ANS, PNS, or their midpoint, angle of the PPE (14° [2°]) from the vertical plane when com- maximal septal deviation, PPE angle, and vomer angle). As pared with controls (8° [1°]; P < .01) (Figure 2C). In addition, visualized by a univariate plot, the degree of vomer devia- no differences were observed in the PPE or vomer angle be- tion was significantly associated with anterior nasal airway tween patients with unilateral vs bilateral CLP (Figure 2C). In stenosis (r = −0.61; P < .01) (Figure 3). 3 patients, bony angular measurements could not be obtained because bone was not present at the point of maximal Maximal Septal Deviation septal deviation. In 2 patients, the PPE was visible, but the vo- The point of maximal septal deviation was most often mer was not. located in the inferior portion of the nasal airway in patients In multivariable linear regression models, the degree of with CLP (19 [79%]) and controls (10 [63%]) and was most vomer displacement from the vertical plane was the only often located in the posterior airway in both groups (CLP, 17 variable that correlated with any degree of nasal airway ste- [71%]; controls, 11 [69%]) (Table). In 37 of the total 40 nosis (eTable in the Supplement). All other variables studied, patients examined, the point of maximal septal deviation including septal deviation at the ANS, PNS, and their mid- occurred within the bony septum (eFigure in the Supple- point and the PPE angle, did not significantly correlate to ment). Within the unilateral CLP group, 7 patients demon- ANS stenosis (P > .05). Furthermore, multivariable models strated maximal septal deviation that was ipsilateral to their

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cleft side, whereas 4 exhibited maximal septal deviation on scans were obtained for orthodontic planning, and no scans the opposite side of their cleft. were obtained solely for the purpose of this study. Compared with the traditional 64-section CT scans, CBCT scans reduce the effective radiation dose by more than 6-fold.16 Although 8 Discussion a previous study by Friel et al looked at nasal anatomy in vari- ous anatomical planes at the time of mixed dentition using We present a CBCT analysis of nasal septal morphologic fea- CBCT, their study was limited in that control scans were ob- tures in skeletally mature patients with CLP. The mean pa- tained by a different imaging modality (multisection CT). Also tient age was 21 years, whereas nasal bony growth is consid- their study used a younger population, for which conclusions ered to be complete around 11 to 12 years of age in girls and 13 about nasal anatomy at skeletal maturity cannot be drawn. to 14 years of age in boys.17 The oldest cohort to be examined Our results underscore the importance of the bony sep- before this study, to our knowledge, was by Jiang et al,7 with tum to overall nasal architecture and as a potential link to air- a mean age of 16 years; however, their study group included a way obstruction. Septal deviation is more severe from the ANS- mixed-age population with patients who had not yet achieved PNS midpoint to the PNS, with more than 70% of patients with skeletal maturity (as young as 7 years). In addition, their study CLP demonstrating maximal septal deviation in the posterior was limited to analysis of nasal anatomy in a single anatomi- half of their nasal airway. Previous studies have shown that cal plane, for which few conclusions can be drawn. this area (from the midpoint to the PNS) consists of 96% bone.8 Our study takes advantage of 3-dimensional CBCT scans Therefore, septal deviation was most severe in areas related to obtain a comprehensive assessment of nasal anatomy. All to the bony septum. Further highlighting the importance of the bony septum in nasal anatomy, vomer deviation was sig- Figure 3. Correlation Between Vomer Angle and Anterior Nasal Spine nificantly associated with anterior nasal airway stenosis, sug- (ANS) Stenosis gesting that bony architecture can affect airway patency. We

5 observed no correlation between the cartilaginous septal deviation at the ANS and stenosis at any anatomical point r = −0.61; P <.01 throughout the airway. We also observed that airway steno- 4 sis was severe at the transition zone from the cartilaginous to CLP bony septum (near the midpoint), indicating that this junc- Control 3 tion is particularly susceptible to obstruction and warrants attention superiorly at the level of the cartilage and inferiorly at 2 the level of the vomer.

ANS Stenosis, mm To understand the implications of our septal data on air-

1 way obstruction requires a basic understanding of airflow dy- namics. Airway obstruction comes from 2 interrelated causes: physical airway stenosis and turbulent airflow.18 Nasal anatomy 0 allows for a delicate balance between laminar and turbulent 0 20 40 60 80 100 airflow. Under laminar flow, the force needed to achieve air- Vomer Angle, Degrees flow is proportional to the diameter of the airway opening. Tur- The univariate Pearson product moment correlation coefficient identified from bulent airflow, on the other hand, requires a force propor- multivariable regression analysis (eTable in the Supplement) is depicted tional to the diameter squared, consequently needing a (regression line) between vomer angle and nasal stenosis at the ANS for significantly greater force to produce the same airflow when patients with cleft lip and palate (CLP) and controls. compared with laminar flow.19 In the proper circumstances,

Table. Location of the Point of Maximal Septal Deviation

No. (%) of Participantsa CLP Group Control Group All Location (n = 24) (n = 16) (N = 40) Sagittal plane Right 16 (67) 10 (63) 26 (65) Left 8 (33) 6 (38) 14 (35) Axial plane Superior 5 (21) 5 (31) 10 (25) Midpoint 0 1 (6) 1 (3) Inferior 19 (79) 10 (63) 29 (73) Coronal plane Anterior 6 (25) 4 (25) 10 (25) Abbreviation: CLP, cleft lip and Midpoint 1 (4) 1 (6) 2 (5) palate. a Percentages have been rounded Posterior 17 (71) 11 (69) 28 (70) and might not total 100.

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turbulent airflow can help increase airway resistance, result- Our study has several limitations. We report a small ing in prolonged nasal mucosal contact of inspired air to al- sample size with a mix of patients with unilateral and bilat- low for humidification and warming. However, pathologic in- eral CLP. Despite this limitation, we have found statistically creases in turbulent airflow as caused by septal deviation can significant differences in septal deviation, nasal airway ste- result in resistances that further exacerbate airway obstruc- nosis, and PPE and vomer angles in patients with CLP com- tion. Thus, a deviated septum not only causes physical ste- pared with controls. Therefore, one would expect a larger nosis, but disturbs airflow exponentially by creating a turbu- sample size would only strengthen the existing significant lent environment. differences observed herein. Patients underwent CBCT Adult cleft rhinoplasty commonly highlights cartilagi- analysis as part of their orthodontic evaluation for possible nous septoplasty for cosmetic and reconstructive purposes, but orthognathic surgery, which creates a potential selection our results suggest that the bony septum merits further atten- bias to more severely affected patients with a cleft. There- tion. Based on our anatomical findings, patients with CLP who fore the results of this study may not be applicable to demonstrate airway obstruction secondary to septal deva- patients with CLP and no midface hypoplasia. In addition, tion should undergo submucous resection of the cartilagi- the anatomy of the turbinates is not directly reported in our nous septum. After this procedure, the remaining bony sep- study; however, this topic should be the subject of future tum, including the vomer and PPE, should be carefully research because turbinate hypertrophy is well appreciated inspected for any residual obstruction by the bony septum. Os- in this patient population. Furthermore, this study is ana- teophytes and other bony deviations causing airway stenosis tomical and not functional. Although this differentiation may then be removed directly using an osteotome or nasal for- presents a limitation, anatomical studies may still aid surgi- ceps (Takahashi; KLS Martin). Bony resection will require thor- cal advancement by informing which physiologic studies ough dissection of the nasal mucosa and may require resec- warrant future attention. Our results, along with several pre- tion of bone as far posterior as the sphenoid. This bony vious studies,8,20 suggest that septal contribution to airway resection increases the risk for mucosal tears, postoperative patency is one such topic. We hope these findings will spark bleeding, and in rare cases cerebrospinal fluid leak and there- interest in future studies that investigate the functional con- fore should be performed with a thorough understanding of tribution of the septum to help confirm our findings. intranasal anatomy and the techniques of submucous resection. Nevertheless, we recommend that bony septal deviation must be addressed in this patient population to relieve ob- Conclusions structive symptoms and achieve adequate nasal symmetry. Hypertrophic inferior or middle turbinates may further Skeletally mature patients with CLP demonstrate nasal septal contribute to nasal airway obstruction. Our study indirectly deviation involving the cartilaginous and bony septum. De- evaluates the involvement of turbinate hypertrophy, because viation of the bony septum is more severe than cartilaginous our stenosis measurements occurred at the areas of greatest deviation, and bony deviation correlates with airway steno- narrowing between the septum and adjacent turbinates. Pre- sis. Therefore, resection of the bony and cartilaginous surgical workup of definitive cleft rhinoplasty should include septum should be performed at the time of definitive cleft consideration of medical and surgical treatment of turbinate rhinoplasty to relieve airway obstruction and achieve nasal hypertrophy, as appropriate.20 symmetry.

ARTICLE INFORMATION Funding/Support: This study was supported by 2. Sandham A, Murray JA. Nasal septal deformity in Accepted for Publication: March 15, 2016. a Medical Research Fellowship under grant unilateral cleft lip and palate. Cleft Palate Craniofac J. 57008244 from the Howard Hughes Medical 1993;30(2):222-226. Published Online: May 26, 2016. Institute (Mr Massie). doi:10.1001/jamafacial.2016.0404. 3. Suzuki H, Yamaguchi T, Furukawa M. Rhinologic Role of the Funder/Sponsor: The funding source computed tomographic evaluation in patients with Author Contributions: Dr Flores had full access to had no role in the design and conduct of the study; cleft lip and palate. Arch Otolaryngol Head Neck Surg. all the data in the study and takes responsibility for collection, management, analysis, and 1999;125(9):1000-1004. the integrity of the data and the accuracy of the interpretation of the data; preparation, review, or data analysis. 4. Nagasao T, Miyamoto J, Yasuda S, et al. An approval of the manuscript; and decision to submit anatomical study of the three-dimensional Study concept and design: Massie, Runyan, the manuscript for publication. Alperovich, Staffenberg, Flores. structure of the nasal septum in patients with Acquisition, analysis, or interpretation of data: Previous Presentation: This paper was presented alveolar clefts and alveolar-palatal clefts. Plast Massie, Runyan, Stern, Alperovich, Rickert, Shetye, at the 73rd Annual Meeting of the American Cleft Reconstr Surg. 2008;121(6):2074-2083. Staffenberg. Palate–Craniofacial Association; April 7, 2016; 5. Ridgway EB, Andrews BT, Labrie RA, Padwa BL, Drafting of the manuscript: Massie, Runyan, Stern. Atlanta, Georgia; and the 95th Annual Meeting of Mulliken JB. Positioning the caudal septum during Critical revision of the manuscript for important the American Association of Plastic Surgeons; May primary repair of unilateral cleft lip. J Craniofac Surg. intellectual content: Massie, Runyan, Alperovich, 20, 2016; New York, New York. 2011;22(4):1219-1224. Rickert, Shetye, Staffenberg, Flores. REFERENCES 6. Kuijpers MA, Pazera A, Admiraal RJ, Bergé SJ, Statistical analysis: Massie, Rickert. Vissink A, Pazera P. Incidental findings on cone Administrative, technical, or material support: Stern, 1. Stal S, Hollier L. Correction of secondary beam computed tomography scans in cleft lip and Alperovich, Flores. deformities of the cleft lip nose. Plast Reconstr Surg. palate patients. Clin Oral Investig. 2014;18(4): Study supervision: Runyan, Alperovich, Shetye, 2002;109(4):1386-1392. 1237-1244. Staffenberg, Flores. 7. Jiang M, You M, Wang S, Wang K, Feng B, Wang Conflict of Interest Disclosures: None reported. H. Analysis of nasal septal deviation in cleft palate

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