Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States.

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort.The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery.There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal. CONCLUSIONS: Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Application of Diced Autologous Rib Cartilage for Paranasal Augmentation in Cleft Nose.

OBJECTIVE: This study aimed to investigate the clinical effect of diced cartilage on correcting nasal alar base depression in Asian cleft rhinoplasty. METHODS: A retrospective study was conducted on 25 patients with nasal deformity, who underwent the second cleft rhinoplasty between January 2018 and January 2020. Autologous costal cartilage was harvested in all the patients to reconstruct the contour of the nose, while the remaining cartilage from the surgery was cut into 1.0×1.0 mm pieces and filled into the nasal alar base. The preoperative and postoperative effects of visual images were compared and analyzed using Adobe Photoshop CS6 software. The patients were followed up for 8-18 months (mean 12 months) to investigate the satisfaction and complication rate. RESULTS: The nasal alar base depression was corrected, and the profile of malformed noses was significantly improved in 25 patients after the surgery. The postoperative effect was satisfactory, and no obvious graft shift or other complications were observed in the follow-up. CONCLUSIONS: The application of diced cartilage to correct nasal alar base depression after cleft lip surgery is a feasible method. Its advantages include mainly the crafty use of the remaining cartilage and the presentation of a more natural appearance than mass cartilage. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cartilage Grafting Outcomes in Intermediate and Definitive Cleft Rhinoplasty.

OBJECTIVE: To compare cartilage grafting outcomes in intermediate versus definitive cleft rhinoplasty. DESIGN: A retrospective chart review was conducted. The χ2 and Fisher exact tests were used for statistical analyses. Results were considered statistically significant at P < .05. PARTICIPANTS: All subjects who underwent revision cleft rhinoplasties between July 2011 and June 2019 were included. Subjects with syndromic conditions were excluded. RESULTS: A total of 46 subjects with a cleft nose deformity underwent 65 rhinoplasty procedures. The ages averaged 17 years (range 5-50) with 34 (73.9%) males and 12 (26.1%) females. In the intermediate group, 6 (28.6%) subjects required cartilage grafting as part of 6 cleft rhinoplasties, whereas 15 (71.4%) subjects underwent a total of 26 cleft rhinoplasties that did not require grafting. In the definitive group, 18 (76%) subjects required cartilage grafting over 21 cleft rhinoplasties, whereas 7 (24%) subjects underwent a total of 9 cleft rhinoplasties where cartilage grafting was not required. The difference between the number of subjects requiring cartilage grafting in the intermediate versus the definitive group was statistically significant (P = .007). Ear concha and nose were the most frequently used cartilage donor sites, with no observed complications. CONCLUSIONS: Cartilage grafting was significantly more common in the definitive rhinoplasty group. Intermediate cleft rhinoplasty during the 5- to 13-year age period was effective, with a low-risk profile. In our experience, ear concha and nose were the preferred cartilage donor sites, with effective results and an excellent safety profile.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: A 14-Year Review of Maintenance of Certification Tracer Data From the American Board of Plastic Surgery.

OBJECTIVE: To evaluate evolving practice patterns in secondary cleft rhinoplasty. DESIGN: Retrospective review of data submitted during Maintenance of Certification (MOC). SETTING: Evaluation of MOC data from the American Board of Plastic Surgery. PARTICIPANTS: Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns. INTERVENTIONS: Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period. MAIN OUTCOME MEASURES: Practice patterns were compared to EBM trends during the study period. RESULTS: A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007). CONCLUSIONS: These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

Pyriform Costal Cartilage Graft Improves Cleft-Side Alar Asymmetry in Secondary Cleft Rhinoplasty.

OBJECTIVE: The asymmetry of a retrusive cleft-side ala positioned posterior, lateral, and inferior relative to the noncleft ala is exacerbated by ipsilateral deficiency of the pyriform aperture. We describe use of pyriform costal cartilage grafts for enhanced structural foundation and alar symmetry in secondary cleft rhinoplasty. DESIGN: Retrospective case series. PATIENTS: All pyriform aperture paranasal augmentation secondary cleft rhinoplasty cases performed between May 2013 and February 2018 were included. Clinical photos were analyzed, and these results are provided in addition to a detailed description of the augmentation technique. RESULTS: Twelve total cleft patients, 10 (83.3%) unilateral cleft lip and palate, 1 (8.3%) unilateral cleft lip, and 1 cleft palate (8.3%) were included. Age averaged 18.6 ± 6.0 years with 3 (25.0%) males and 9 (75.0%) females. Costal cartilage grafting to the pyriform aperture through the gingivobuccal sulcus was used to reposition the alar base and nasal sill to a more anatomic anterior position, thereby enhancing symmetry in secondary cleft rhinoplasty. Average rib graft donor site incision was 2.5 cm. Follow-up ranged from 3.2 to 48.2 months, average 15.3 ± 14.4 months. No complications related to the pyriform cartilage graft were observed, other than one minor intraoperative breach of parietal pleura. CONCLUSIONS: We observed improvement in the anatomic contour of the cleft-side ala with costal cartilage grafting to the pyriform rim. This resulted in improved cleft-side alar form and thus overall alar symmetry. These results were obtained consistently, without significant complications. This technique is safe and provides a powerful tool to reposition the ala in secondary cleft rhinoplasty. Further studies will quantify the enhancement in nasal base symmetry.

Primary unilateral cleft lip nasal deformity repair using V-Y-Z plasty: An anthropometric study.

BACKGROUND: Secondary nose deformity after unilateral cleft lip repair is a common problem. Loss of tip projection on the cleft side of unilateral cleft lip nasal deformity can be difficult to correct due to lack of adequate support. The purpose of this study is to evaluate the surgical outcome after using V-Y-Z plasty to address unilateral cleft lip nasal deformities. METHODS: A cross-sectional study of one surgeon's outcome of 58 performed primary complete unilateral cleft lip nasal deformity repairs. All these patients met the study criterion of having anthropometric measurements at the cleft and non-cleft side of the nose performed at least 1 year postoperatively. RESULTS: Since 2012, 32 consecutive patients have undergone primary anatomical repair of the cleft nasal deformity in patients with a complete unilateral cleft. We have not found statistically significant differences between the cleft and non-cleft nostril dome height and columella length measured at least 1 year postoperatively. CONCLUSIONS: The findings suggest that the V-Y-Z plasty is a good alternative to create a more symmetric nasal tip in patients with primary unilateral cleft lip nasal deformity. Additional studies are required to evaluate functional and long-term outcomes after primary rhinoplasty in patients with unilateral cleft lip.

National Trends of Otolaryngology Involvement in Cleft Surgical Management over 10-Years.

OBJECTIVE: Surgical management of cleft lip/palate and cleft rhinoplasty have historically been performed by plastic surgeons. No study has addressed temporal trends in cleft-associated surgeries. This study assesses trends in cleft surgical management and complications in a national database. METHODS: Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric database from 2012 to 2021. Patients receiving cleft lip and/or palate repair were isolated using CPT codes. A subset receiving cleft rhinoplasty was also analyzed. The yearly proportion of otolaryngologists compared to general plastic surgeons performing surgeries was noted. Regression analysis was used to identify trends and predictors of management by OHNS. RESULTS: We identified 46,618 cases of cleft repair, of which 15.6% (N = 7,255) underwent repair with otolaryngology. On univariate Pearson correlation analysis, neither cleft rhinoplasties performed by OHNS over time (R = 0.371, 95% CI -0.337 to 0.811, p = 0.2907) nor all cases (R = -0.26, -0.76 to 0.44, p = 0.465) exhibited a significant change. On multivariable regression, the operative year was not associated with being treated by otolaryngology (p = 0.826) for all cleft cases but was associated with such in cleft rhinoplasties (OR 1.04, 1.01-1.08, p = 0.024). On multivariable analysis, the operative year was correlated with a higher rate of complications overall (OR 1.04, 1.01-1.07, p = 0.002). Surgeon specialty was not associated with complication rates. CONCLUSIONS: In the last 10 years, no change in the proportion of cleft lip/palate repair performed by OHNS was observed. Otolaryngologists are performing more cleft rhinoplasty but at a marginal rate. Otolaryngologists also manage more complex patients with multiple comorbidities compared to their colleagues. Complication rates have increased overall regardless of surgeon specialty, warranting further investigation. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:671-677, 2024.

Definitive Rhinoplasty and Orthognathic Surgery for Patients with Cleft Lip Palate.

While primary cleft lip nasal deformity has been well described, secondary cleft lip nasal deformity reflects the combination of residual deformity that follows primary operative maneuvers and growth-related nasal distortions. Secondary cleft lip nasal deformities are further associated with underlying skeletal and dentofacial abnormalities along with soft tissue constriction adding to the complexity of the deformity and posing major aesthetic and functional challenges to the multidisciplinary care team. Definitive rhinoplasties are performed to address these deformities and improve the quality of life in cleft patients following skeletal maturity and ideally after all underlying skeletal discrepancies have been corrected by orthognathic surgery. Maxillary advancement with or without mandibular setback is often required after careful planning and orthodontic preparation. Patients with cleft lip benefit tremendously from definitive rhinoplasty irrespective of inevitable residual discrepancies that remain and adjuvant therapies could enhance the overall outcome.

Comparing definitive unilateral cleft rhinoplasty with and without diced-cartilage alar-base augmentation: A retrospective cohort study.

This retrospective cohort study aimed to compare the long-term aesthetic outcomes and satisfaction of patients who underwent two techniques of definitive unilateral cleft rhinoplasty. The two cohorts, comprising patients with mature unilateral cleft deformity, were managed with definitive rhinoplasty, either with or without diced-cartilage alar-base and peri-alar augmentation (ABPA). Thirty patients were included in each cohort. Anthropometric measurements, complications, patient satisfaction scores, and third-party surgeon assessment scores were reviewed. In both cohorts, anthropometric parameters improved. Rhinoplasty with ABPA was the superior cohort in terms of columellar length (10.3 ± 1.0 in the cohort with ABPA, compared with 7.9 ± 0.6 in the cohort without ABPA; p < 0.001), alar-base angle (0.2 ± 0.2, compared with 4.3 ± 0.3; p < 0.001), and columellar deviation (2.5 ± 1.4, compared with 10.3 ± 2.1; p < 0.001). This cohort also had more symmetry in nostril height and nostril width (p < 0.001), a lower recurrence rate (one case compared with 22 cases; p < 0.001), a higher patient satisfaction score (p = 0.002), and a higher surgeon assessment score (p < 0.001, Cronbach's alpha = 0.706, Kendall's coefficient of concordance = 0.787). Within the limitations of this study, it appears that the described technique for augmenting the alar-base and peri-alar maxillary area is manageable, and yields consistent long-term results.

Cleft Rhinoplasty.

An understanding of anatomy and pathophysiology of the cleft nasal deformity is crucial to its management, including selection of correct surgical techniques for repair. Timing of intermediate and definitive rhinoplasty should be considered carefully, with definitive rhinoplasty occurring after management of facial skeletal deformities. At the time of definitive rhinoplasty, the septum, external and internal nasal valves, alar base malposition (and corresponding bony deficiency), and position and shape of the lower lateral cartilage and the columella all must be individually considered. Thorough knowledge of rhinoplasty techniques is crucial to address the cleft nasal deformity with optimal functional and aesthetic outcomes.

Quantitative analysis of aesthetic outcomes of morphofunctional septorhinoplasty for secondary cleft lip nasal deformity.

The main aim of this study was to assess nasal symmetry after morphofunctional septorhinoplasty, more specifically, symmetry of the alar base and nostrils, and nasal projection, in patients with unilateral and bilateral cleft nasal deformities. Secondary cleft rhinoplasty was performed using morphofunctional septorhinoplasty techniques in 150 patients with unilateral and bilateral cleft lip and nose deformities. Nasal changes were analysed by measuring nasal tip projection, nostril height, nostril width, alar base width, and nasal gap area preoperatively and postoperatively on standard submentovertex view 2-dimensional photographs. In the unilateral cleft group there were statistically significant improvements (p<0.001) in ratios of nasal height and width (p=0.024) and nasal gap area, and in nasal tip projection and alar base width. In the bilateral cleft group there were statistically significant improvements in nasal gap area ratio (p=0.009), nasal tip projection, and alar base width. The morphofunctional septorhinoplasty technique improved aesthetic outcomes.

Challenging Rhinoplasty for the Cleft Lip and Palate Patient.

Cleft lip and palate patients represent one of the most challenging groups of patients for septorhinoplasty, presenting as a complex surgical obstacle for even the most seasoned surgeons. These individuals have undergone several surgeries throughout their lives, resulting in a considerable amount of scar tissue, significant asymmetries and structural deficits. Key factors in successfully treating cleft lip and palate patients are the reconstruction of the absent/asymmetric cartilages and the replacement of bony structures. The use of autogenous rib cartilage allows the surgeon to create various grafts as well as fortify the soft tissue to resist persistent soft tissue deformities.

Diced costal cartilage graft combined with muscle repositioning improves Cleft-Side Alar asymmetry in Asian secondary unilateral cleft rhinoplasty: A three-dimensional evaluation.

OBJECTIVES: Asymmetry in a retrusive cleft-side ala situated posterior, lateral, and/or inferior to the non-cleft ala is aggravated by ipsilateral defect of the pyriform aperture. This study assessed diced costal cartilage graft combined with muscle repositioning in enhancing structural base and alar symmetry in secondary cleft rhinoplasty. METHODS: From 2016 to 2019, 20 consecutive patients who underwent pyriform aperture paranasal augmentation combined with muscle repair secondary unilateral cleft rhinoplasty were reviewed retrospectively. Clinical three-dimensional (3D) photos were analyzed pre- and postoperatively, and the augmentation method and muscle repositioning were described detailedly. RESULTS: Twenty cases aged 22.2 ±â€¯3.9 years were submitted to secondary cleft rhinoplasty with diced costal cartilage graft to the pyriform rim. They were followed up for 6.2-26.2 months, with postsurgical time averaging 10.3 ±â€¯3.4 months. After total lip takedown by anatomic muscle re-approximation, the cleft to non-cleft side showed enhanced alar symmetry (p < 0.001) and heightened vertical lip length (p < 0.001). Additionally, the alar base inclination was improved toward the horizontal plane (p < 0.001). CONCLUSIONS: The cleft-side ala was anatomically ameliorated after muscle repositioning combined with diced costal cartilage graft to the pyriform rim, improving alar symmetry. Complications were minimal, indicating the safety of this method.

Revisiting the unrepaired unilateral cleft lip and nasal deformity using 3D surface image analysis: A data-driven model and its implications.

BACKGROUND: Current descriptions of the unilateral cleft lip and nasal deformity (uCLND) are based upon limited sample sets and subjective observations. While those descriptions are inconsistent and contradictory, theoretical models, including Hogan's "tilted tripod" and Fisher's "nasal arch forms", have never been tested. Given that favorable outcomes of treatment remain elusive, detailed study of the deformity is critical in devising better treatments. The purpose of this study was to develop a data-driven three-dimensional (3D) model of uCLND that spans the spectrum of presentation and involves a pervasive underlying mechanism. METHODS: We studied 3D images of 100 infants with unrepaired cleft lip at 6 months of age. Objective assessment included the landmark positions, anthropometric dimensions, and shape-based measures. Cleft severity was stratified by the lateral displacement of subnasale, so that a model could be developed using linear regression. RESULTS: With progressive deviation of subnasale, the non-cleft alar base moved lateral, the cleft alar base was left posterior, and the nasal dorsum followed the caudal septum (deviating towards the non-cleft side). The "twist" resulted in opposing cleft alar dome collapse, non-cleft alar ring constriction (the non-cleft nasal sill narrowed, lateral genu rose, and alar-cheek junction became more acute), and displacement of the philtrum from midline. CONCLUSIONS: Our study not only supports theoretical models of uCLND but also clarifies vectors of change and reveals significant non-cleft side alterations. On the basis of our findings, the objectives of treatment should involve centralization of the columella and philtrum and rebalancing the nose by untwisting the orthogonal displacement of the alar bases.

Management of the Nasal Deformity in the Unilateral Cleft of the Lip and Nose.

Cleft rhinoplasty is a demanding, technique-sensitive procedure. Part art, part science; it poses several probing questions to the surgeon. The unilateral cleft nasal deformity is a distinct entity because the pursuit of symmetry in the unilateral cleft nose makes the repair much more challenging. The advent of nasoalveolar moulding, the gaining popularity of primary (early) nasal repair and greater refinements in secondary (definitive) rhinoplasty techniques have contributed to better nasal results in unilateral cleft repair. Yet, some obstacles remain. This paper aims to discuss the anatomy of the unilateral cleft nose, enumerate aims and objectives of repair at every stage, and to demonstrate the evolution and varied rationale of management of nasal deformities in the unilateral cleft lip and nose.

Comparing autologous versus allogenic rib grafting in pediatric cleft rhinoplasty.

BACKGROUND: Patients with cleft lip with or without cleft palate suffer from varying degrees of nasal deformity, often requiring nasal reconstruction to provide improved form and function. Rib cartilage is an excellent source of grafting material for nasal reconstruction and is available either as an autologous or allogenic graft. There is a paucity of literature comparing outcomes of autologous and allogenic rib grafts in pediatric cleft rhinoplasty. METHODS: A retrospective chart review was performed on patients who underwent cleft rhinoplasty with autologous or allogenic rib grafting at a tertiary pediatric hospital between January 1, 2003 and December 31, 2017. Outcome data were gathered over a 6-month postoperative period. RESULTS: There were 23 cleft rhinoplasties performed with rib graft, 12 with autologous rib and 11 with allogenic rib. Those in the autologous group tended to be older than those in the allogeneic group (15.6 ± 4.4 v 12.4 ± 5.2 years, p = 0.13). The most common types of grafts used were columellar strut (20/23), shield graft (9/23), and unilateral or bilateral batten grafts (7/23). Length of stay was significantly longer for patients who underwent autologous rib grafting compared with those with allogenic rib grafting (25.8 ± 4.7 v 11.9 ± 7.2 h, p < 0.05). Each group reported one complication. CONCLUSION: Autologous and allogenic rib grafts are safe and effective in pediatric rhinoplasty. The most common grafts used in this sample were columellar strut, batten, and shield grafts. Autologous rib grafts were more likely to be used in older patients and require longer hospital stay compared to allogenic grafts.

Long-Term Nasal Growth after Primary Rhinoplasty for Bilateral Cleft Lip Nose Deformity: A Three-Dimensional Photogrammetric Study with Comparative Analysis.

Nasal deformity is associated with congenital cleft lip and palate. Primary rhinoplasty for reconstruction of the nasal deformity at the time of bilateral cleft lip repair is a controversial issue in cleft care due to traditional teaching concerning the potential impairment of nasal growth. This study assessed long-term nasal growth in patients with bilateral cleft lip and palate who underwent primary rhinoplasty by a single surgeon between 1995 and 2002 and reached skeletal maturity (n = 39; mean: 19 ± 2 years). Normal age-, gender-, and ethnicity-matched subjects (n = 52) were enrolled for comparative analyses. Three-dimensional nasal photogrammetric measurements (10 linear, 4 angular, 6 proportional, 1 surface area, and 1 volume parameter) were collected from patients with bilateral cleft lip and palate and normal subjects. Patients who underwent rhinoplasty presented with significantly (all p < 0.05) smaller nasal tip projection and nasal tip angles, but greater values for nasal dorsum length, nasal protrusion, alar width, columellar height, dome height, columellar angle, labiocolumellar angle, nasal tip height ratio, nasal index, alar width/intercanthal distance ratio, and alar width/mouth width ratio compared to normal subjects. There were no differences (all p > 0.05) in nasal height, tip/midline deviation, nasal dorsum angle, dome-to-columella ratio, columella height/alar width ratio, area surface, and volume parameters between the two groups. This study shows that primary rhinoplasty performed in patients with bilateral cleft lip and palate during infancy does not result in deficiency of the nasal dimensions relative to controls.

Three Dimensional Rhinoplasty and Nasal Airway Improvement in Cleft-Nose Deformity.

Septorhinoplasty is particularly challenging among revision surgeries for cleft sequelae. The challenge of cleft septorhinoplasty is mainly due to the complex anatomy of nose, deformity of each of its components and the difficulty and lack of clarity in surgical management. From 2014 to 2017, 26 patients with cleft lip nose deformity were operated by the same cleft team. The study was conducted to assess the improvement in nasal airway and appearance following secondary rhinoplasty with extracorporeal septoplasty. Post operatively each patient was evaluated using the standard modified rhinoplasty outcome evaluation questionnaire, a validated instrument that aids in stratifying patients according to their subjective response. All patients reported great relief of nasal obstruction and improved breathing. More than 80% of our patients were satisfied with improved aesthetics and reported better self-confidence. Secondary cleft rhinoplasty with extracorporeal septoplasty surgery significantly improves the cosmesis and nasal airway opening, subsequently giving them improved self-confidence.

Cleft rhinoplasty columellar lengthening: Comparison of techniques.

BACKGROUND: Nasal deformity in bilateral cleft lip and palate (BCLP) correction is highly challenging. Several solution has been proposed. The aim of the present study is to assess qualitatively and quantitatively the results of Cronin's flap, Fork flap, and Abbe's flap for BCLP rhinoplasty at a follow-up period. MATERIALS AND METHODS: : Records of all BCLP rhinoplasty performed between 2010 and 2016, fulfilling inclusion and exclusion criteria were collected. From records, qualitative improvement and previously described methods of quantification of columella length were performed. These collected data were analyzed with descriptive statistics, Chi-square tests, and one-way analysis of variance tests. P ≤ 0.05 was taken as statistically significant. RESULTS: Forty-eight cases fulfilled the criteria of which 31 patients had Abbe's flap, 9 Cronin, and 8 forked flaps. The mean age of the study population was 20.33 ± 4.94 years in 21 females and 27 males with a mean follow-up of 15.3 ± 2.3 months. The success of the lengthening of columella at immediate postoperative period as compared to the preoperative columella length was not statistically different (P = 0.176) between the three flaps, while the same was statistically different at 1-year period (P = 0.031). The extent of change was very minimal for the Abbe flap with a high degree of statistical significance (P = 0.000). At 1-year postoperative period, 83.9% (n = 26) of Abbe flap patients felt their nose to be good after surgery while the same was 55.6% (n = 5) in Cronin flap design and 37.5% (n = 3) in forked flap design (P = 0.007). DISCUSSION AND CONCLUSION: Abbe flap gave the best results under most of the common BCLP rhinoplasty, and a flap choice algorithm for choice of flap was arrived based on this experience.