The Role of Postoperative Nasal Stents in Cleft Rhinoplasty: A Systematic Review

Abstract

Objective

To evaluate the role of postoperative nasal stenting in preserving nasal shape and preventing nostril stenosis in cleft rhinoplasty, and to develop a classification system for postoperative nasal stents.

Design

Systematic review.

Methods

Electronic and manual searches of scientific literature were conducted from 3 databases (PubMed, SCOPUS, OVID). Primary evidence that described postoperative nasal stenting in cleft rhinoplasty were included. Exclusion criteria included secondary evidence, non-English articles, and studies focusing on preoperative nasal stents.

Patients and Participants

Patients with cleft lip/nose of any type were included.

Main Outcome Measure(s)

Role in preservation of nasal shape & symmetry, role in prevention of nostril stenosis, complications with the use of postoperative nasal stent.

Results

Of the 13 articles, 9 papers described the preservation of nasal shape with nasal stents and three studies with a control group showed improved symmetry score. No studies evaluated the prevention of nostril stenosis; however, 2 studies reported improvement of nostril stenosis in secondary cleft rhinoplasty. The results of the included studies had significant heterogeneity. Nasal stents were classified into five types: Type I-spare parts assembled, Type II-prefabricated commercial, Type IIIa-patient specific 3D-printed static, Type IIIb-patient specific dynamic, and Type IV-internal absorbable. Total complications were 6.0%, including irritation (0.9%), infection (0.3%), and stent loss (4.6%).

Conclusion

Despite the lack of consensus with postoperative nasal stents, this review suggests its safety and role in preserving shape and improving stenosis. Our classification system highlights variability and the need for better quality studies to determine the efficacy of nasal stents.

Keywords

nonsyndromic clefting nose nasal morphology nasality rhinoplasty cleft lip cleft lip and palate systematic review

Introduction

Cleft lip-nose-palate remains one of the most common congenital deformities worldwide with an incidence of 1 in 600 live births.^1–3 Although the defect to the lip may appear as the greatest challenge to facial reconstruction, nasal asymmetry and, especially, nostril stenosis remain one of the most difficult aspects of cleft care. One of the primary problems with cleft lip is asymmetry of the nose due to disruption of the orbicularis oris.⁴ This deformity can be corrected via primary cleft lip and nose repair by closure of the cleft lip and translocation of the affected ala to the appropriate position.⁵

However, one of the major complications of this surgery is stenosis, as the wound healing cascade can lead to contracture by the myofibroblasts and circular healing can lead to obstruction.^5,6 This is particularly seen in cleft lip and nose repair as scar contracture and tissue memory lead to nasal asymmetry, and ultimately, stenosis.^4,7 This poses a particular challenge in pediatric patients whose exponential growth may further increase scarring.¹ Additionally, Asian patients, the most commonly affected demographic, often have under-developed alar cartilage and thick skin which predisposes these individuals to relapse.^5,8 These factors contribute to postoperative nasal shape relapse which is often seen in the first postoperative year.^4,9,10

To combat this problem, surgeons utilize nasal stents after rhinoplasty during cleft lip repair or revision. Previous work had demonstrated that placement of prostheses or stents can reduce the rate of contracture, obtain a more symmetric and enhanced appearance, and improve functional breathing.^8,11 The use of nasal stenting results in external molding of the surrounding alar cartilage, supplies opposition to contracture forces, and maintains nasal patency for functional breathing.^6,9,10,12,13 However, stenting is not a standardized technique, as wide variations exist in terms of types of stents, duration of stenting, and ultimately, long-term outcomes.^5,7 The objective of this systematic review was to investigate the different techniques used for postoperative nasal stenting, synthesize current evidence on postoperative nasal stenting in cleft rhinoplasty to determine its role and efficacy in prevention of nostril stenosis and preservation of nasal symmetry and lastly, to create a classification system for postoperative nasal stents. Additionally, duration of wear time, follow up period, role of various types of postoperative nasal stents in primary and secondary rhinoplasty were also evaluated.

Methods

The medical literature published in three databases (SCOPUS, PubMed, OVID) were searched for articles that included terms relating to “cleft lip” and “stent.” The Medical Subject Headings terms “cleft lip” and “stent” were included, as well as manual wildcard asterisked terms to systematically review available literature.

This full database search was completed in October 2022. We found 217 articles in the PubMed database search, 257 articles in the SCOPUS database search, and 216 articles in the OVID database search for a total of 690 studies. After duplicates were removed, there were 284 unique articles for abstract review. A title weed and abstract weed were conducted by two independent reviewers (D.N and J.M). Kappa statistics showed almost perfect agreement (Cohen's kappa = 0.98049), excluding 267 articles based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by discussion and consensus. After abstract weed, the full text of the remaining 17 articles were obtained, and 13 articles were deemed eligible for inclusion in this systematic review. Inclusion criteria involved primary evidence including prospective, retrospective, technique papers, case series that described postoperative nasal stenting in primary and secondary cleft rhinoplasty. Primary outcomes included the role of nasal stents in prevention of nasal stenosis and preservation of nostril shape postoperatively, type of nasal stents used, complications including skin irritation/necrosis, dislodgement, infection, and the classification of types of nasal stents. Secondary outcomes included evaluating the average age of patients, recommended duration of wear time, average follow up period, and the role of varying nasal stents in postoperative primary and secondary rhinoplasty. Exclusion criteria included review articles, book chapters, articles that were not in English, articles that did not specifically refer to the use of postoperative stents, letters to editors, and articles which did not have data on techniques or patient outcomes. Data on techniques, outcomes, and complications were collected. Additionally, levels of evidence of these studies were also collected.

Results

Figure 1 displays the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) diagram which demonstrates the search strategy. Thirteen studies, consisting of 524 patients with orofacial clefts met inclusion criteria. Of the 13 studies, three had a control group comparing patients with and without postoperative nasal stents and measured preservation of nasal symmetry based on objective metrics showing less nasal asymmetry and markedly improved appearance in their stented group involving a total of 140 patients.^4,13,14 Table 1 demonstrates the summary of the studies included assessing postoperative nasal stents in postoperative rhinoplasty. Nine papers described the preservation of nasal shape with use of postoperative nasal stents in 406 patients. No studies evaluated the prevention of nostril stenosis in primary cleft rhinoplasty. However, two studies reported improvement of nostril stenosis with postoperative nasal stents in secondary cleft rhinoplasty in 33 patients.^8,9

Figure 1.

A preferred reporting items for systematic reviews and meta-analyses flow diagram.

Comparative Studies Evaluating the Role of Nasal Stents in Postoperative Rhinoplasty

Despite the lack of well-designed studies to investigate the role of postoperative nasal stents in patients with cleft, it is believed that they are beneficial in prevention of cicatricial stenosis and overall symmetry of the nose. In 1998, Yeow et al published a retrospective study comparing overall nasal outcomes in a group of thirty patients with unilateral cleft nasal deformity who used nasal stents for two months postoperatively to a control group who did not use postoperative nasal stents. They demonstrated that the nasal stent group had overall improved outcomes scores based on four parameters: nostril symmetry, alar cartilage dislocation, alar base level, and columella tilt.¹⁸ Since this recommendation, different types of stents have been created with the goal to preserve nasal symmetry and prevent nostril stenosis. Although most of the data is based on empirical improvement, Table 2 shows that three studies used objective metrics when determining outcome in preservation of nasal symmetry. In 2012, Wong et al published a retrospective case control study examining nasal contour asymmetry in thirty patients concluding that their stented group had an average contour difference score at 8.6% compared to the control group at 23%.¹³ To further support the use of nasal stents, Al-Quatami et al published a recent retrospective case control study in 2022 evaluating 50 patients who underwent naso-alveolar molding and cleft rhinoplasty in both groups, showed that the stented group had less difference between cleft and non-cleft side in six anthropometric measurements including alar width, total alar base width, nasal tip projection, columella length, and nostril aperture width and height at a 12 month follow up period.¹⁴

Table 1.

Summary of the 13 Included Studies Assessing Postoperative Nasal Stents in Cleft Rhinoplasty.

Reference	Study Type	# of Patients	Age	Duration	Cleft Type	1^o vs. 2^o Rhinoplasty	Classification	Preservation of Nasal Symmetry vs. Prevention of Nostril Stenosis	Complications	Follow Up
Bajaj et al⁵	Technique	43	Unreported	24 h/day for 4-6 months	Unilateral	Primary	Spare Parts-Assembled Use of soft denture reliner with Endotracheal Tube as mold	Preservation of Nasal Symmetry	None	Unreported
Bezuhly¹⁶	Technique	10	2-3 months	1 month	Unreported	Primary	Spare Parts-Assembled Use of Pediatric Nasal O₂ Cannula	Preservation of Nasal Symmetry	None	6 months
Loftus et al¹⁷	Case Report	2	6.5-9 years	Continuous for 6 months then night time only for 6 months	Unilateral	Secondary	Spare Parts-Assembled Use of acrylic tubing	Improvement in Nostril Stenosis in Secondary Rhinoplasty in the Patient with Micronostril	Unreported	Unreported
Al Qatami et al¹⁴	Retrospective with control	50 (24 in treatment)	3-4 months	Started on average 1 month postop × 3.5 months	Unilateral	Primary	Prefabricated Commercial Stryker Nasal Stents	Preservation of Nasal Symmetry	None	12 months
Yeow et al⁴	Retrospective with control	60 (30 in treatment)	3-6 months	Continuous then night time only for 6 months	Unilateral	Primary	Prefabricated Commercial Koken Nasal Stents	Preservation of Nasal Symmetry	None	5-8 years
Cobley et al¹⁰	Technique	14	Unreported	Unreported	Unreported	Primary	Prefabricated- Commercial with Modification Modification of Koken Nasal Stent with Nusil (liquid silicone elastomer with addition of 2 wings that lie on nasal tip and philtrum	Neither, focused on retention	None	Unreported
Nakajima et al,¹⁵	Case Report	102 (51 primary) (51 secondary)	N/A	3-4 months	Both	Both	Prefabricated-Commercial with Modification Addition of moldable Silicone Rubber to Koken Splint	Preservation of Nasal Symmetry	Unreported	Unreported
Yuzurih et al,⁸	Case Report	54 (41 UCLN) (17 BCLN)	5-36 years	6 months	Both	Secondary	Prefabricated- Commercial with Modification Use of polysiloxane impression material made by Koken with high projection to sustain anterior nasal recess and everted rim to support nostril rim	Preservation of Nasal Symmetry	None	Unreported
Hennocq et al¹⁸	Prospective, Multi-center No control	72 (41 Paris) (21 Moscow) (10 Nantes)	6 months	4 months	Both	Primary	Prefabricated-Commercial, Fixed Talmant Type Splint Commercial anatomic splint (Nose Fit)	Neither, focused on tolerance	16 splint losses 3 nostril rim irritation, 1 intercurrent rhino pharyngeal infection	Unreported
Luo et al¹¹	Technique	10	Unreported	At least 6 months	N/A	Primary	Patient specific, static 3D-printed Use of dental SG resin with 3D printed technology
Cenzi et al⁹	Case Report	46	At least 4-5 years	Expansion period 15-18 h/day for 40-60 days and inactive period for 12 h/day for 3-4 months	Both	Secondary	Patient specific, dynamic Use of silicone dental impression sent to lab for incorporation of expansion screw; 0.25 mm turn q2-3days for the first 2 weeks, and then 0.25 mm weekly × 40-60 days	Preservation of Nasal Symmetry	None	Unreported
Wolfe et al⁶	Technique	31	5-65 years	24 h/day for 4-6 months then night time for 4-6 months	Unilateral	Secondary	Patient specific, dynamic Standard Porex stent for 2 weeks then custom alginate impression with miniature jack alignment; expansion 0.5-1 mm daily	Preservation of Nasal Symmetry and Improvement in Nostril Stenosis	None, but young patients unable to tolerate	Unreported
Wong et al¹³	Case control study	15	4-9 months	Resorbs in 6-8 months	Unilateral	Primary	Internal, resorbable customized Use of polyglycolic/polylactic strip placed subcutaneously	Preservation of Nasal Symmetry	1 patient had intranasal splint extrusion treated with trimming and oral Abx	2 years

Table 2.

Outcomes According to the 3 Studies Evaluating Preservation of Nasal Symmetry with Objective Metrics.

Study (Control Group: Y/N)	# of patients (Treatment/Control)	Outcome Measured	Metric of Measure	Conclusion (Statistical Significance: Y/N)
Al Qatami et al¹⁴ (Y)	50 (24/26)	Preservation of Nasal Symmetry	Anthropomorphic using molds, Alar width at max convexity, total alar base width, nasal tip projection, columella length and nostril strip aperture width/height	Stented group had less nasal asymmetry among cleft and noncleft side than control group EXCEPT tip projection (Y)
Wong et al¹³ (Y)	30 (15/15)	Preservation of Nasal Symmetry	Photogrammetric nasal analysis of alar contour	Stented group had lower rate of alar contour asymmetry by 2/3rds compared to control group (Y)
Yeow et al⁴ (Y)	60 (30/30)	Preservation of Nasal Symmetry	Photogrammetric analysis nostril symmetry, alar slump or dislocation, alar base level, columella tilt; each parameter score was used to calculate residual deformity score and overall appearance score	Stented group had overall better mean residual deformity scores and overall appearance scores in all 4 parameters (Y)

Types of Nostril Stents with Measured Outcomes in Terms of Average Duration of Wear, Complications, Age Group, and Use in Primary vs. Secondary Cleft Rhinoplasty

In reviewing the literature, we decided to classify nasal stents based on four main properties: (1.) external vs. internal, (2.) absorbable vs. nonabsorbable, (3.) the process involved in creation of the stent (spare parts assembled, prefabricated, patient specific), and lastly, (4.) whether it has static vs. dynamic properties. Stents that have been reported in the literature are predominantly external and static in nature but possess a variety of these properties. Figure 2 shows our classification system. Based on these characteristics, we were able to classify the types of stents currently described in the literature into 5 main types: Type I, II, IIIa and IIIb, and Type IV. Figure 3 provides some examples of each type of nasal stents and Table 3 shows the complication rates in total and in each nasal stent type.

Figure 2.

Classification system for postoperative nasal stents.

Figure 3.

Examples of nasal stents in each proposed group.

Table 3.

Complications According to Classification Nasal Stent Types.

Classification of Nasal Stents	Complication	Incidence (%)
Types I, IIIA, IIIB: I: External Simple, Inexpensive, Easily Assembled (n=55)IIIA: External Customized, Static, 3D printed (n=10)IIIB: External Customized, Dynamic (n=77)
	Total Complications	0 (0%)
	Skin Necrosis	0 (0%)
	Irritation	0 (0%)
	Infection	0 (0%)
	Stent Loss	0 (0%)
Type II: External Prefabricated, Commercial ± Modification, Static (n=296)
	Total Complications	20/272(7.4%)
	Skin Necrosis	0 (0%)
	Irritation	3/272 (1.1%)
	Infection	1/272 (0.37%)
	Stent Loss	16/272 (5.9%)
Type IV: Internal Resorbable Customized (n=15)
	Total Complications	1/15 (6.7%)
	Skin Necrosis	0 (0%)
	Irritation	0 (0%)
	Infection	0 (0%)
	Stent Loss	0 (0%)
	Exposure^a	1/15 (6.7%)
All Types I-IV:
	Total Complications	21/349 (6.0%)
	Skin Necrosis	0/349 (0%)
	Irritation	3/349 (0.9%)
	Infection	1/349 (0.3%)
	Stent Loss	16/349 (4.6%)
	Exposure^a	1/15 (6.7%)

Internal Resorbable Stent Group.

Type I: External, Nonabsorbable, Spare Parts Assembled, Static Nasal Stents

In developing countries, physicians found that the use of the traditional or commercial splints were extremely expensive. As a result, several physicians chose to create their own stents using simple, inexpensive, and commonly available materials. Based on our criteria, only 3 articles were included in the systematic review, consisting of 55 patients who utilized low-cost, spare parts assembled nasal stents. These low-cost materials included the use of the nasal prong segment of pediatric nasal cannula (10/55 patients),¹⁶ soft denture reliner material based on endotracheal tube mold (43/55 patients) (Figure 3A, B),⁵ and varying sizes of acrylic tubing (2/55 patients).¹⁷ Despite the cost, benefit, and accessibility, other advantages of these splints included no reported complications in any of these studies including skin necrosis, dislodgement, nasal floor dehiscence or relapse of the alar position.¹⁶ Duration of wearing these splints ranged from 1 month to 6 months continuously, with some requiring 6 months at night time following the initial 6 months of 24 h wear. One hundred percent of these stents were used in primary cheilorhinoplasty. Average age of patients who had these spare parts assembled stents were 2-3 months old. Although there are other anecdotes of fabrication of nasal stents from simple materials including the silicone urine catheter,¹⁹ and rubber of an infusion set,⁷ the three studies included were the ones that discussed technique, patient-use, complications, and outcomes.

Type II: External, Non-Absorbable, Commercially Prefabricated, Static Nasal Stents

Our review included 6 articles that describe the use of a commercially available prefabricated nasal stent with or without modifications involving a total of 352 patients. Commercial splints, whether Stryker, Koken or Talmant-type fixed splints, without modification were studied in 182 patients while modification of the Koken splints involved 170 patients (Figure 3C). Duration ranged from 4 months to 2 years with no complications reported in patients using the Stryker or Koken splints with or without modifications. In the Talmant-type fixed splint group, 16 patients lost their splint, 3 patients had minor irritation of the nostril rim and 1 patient had intercurrent rhinopharyngeal infection. Seventy percent (247/352) of these stents were used for primary repair of the cleft lip/nose and thirty percent (105/352) of these stents were used for secondary repair with overall good outcomes in nasal shape preservation.¹⁸ Average age of the commercially available prefabricated splint without modification were 3-6 months of age.

Type IIIa: External, Nonabsorbable, Patient Specific-3D Printed, Static Nasal Stent

Standard commercial splints are generally one size and do not address the diversity of nostril shapes and differing sizes of the patients with orofacial clefts, especially within a growing pediatric population. This is evident in many of the providers modifying it to customize each individual patient. One study described that the use of a patient-specific 3D printed, static nasal splints involving dental SG resin cartridges (Formlabs, Somerville, MA, USA) was optimal for biocompatibility, printing precision, and comfort in a total of 10 patients for primary rhinoplasty (Figure 3E-H).¹¹ The process involves taking impressions, scanning them into a 3D printing software for designing, and then sending the data to a 3D printing company. Average duration of stents was reported for at least 6 months. There were no complications reported. Parents reported no discomfort in children wearing them, they did not easily slip from the nasal cavity, and there was no irritation of nasal mucosa.

Type IIIb: External, Nonabsorbable, Patient Specific, Dynamic Nasal Stents

In addition to the patient specific process of nasal stent assembly, some providers aim for overcorrection by creating a dynamic component to help combat the opposing physiologic healing contraction.² There were two articles that described the use of patient specific, dynamic nasal stents in the cleft population involving 77 patients total. The fabrication process for these types of splints involves first taking an impression of the nostrils using dental resin after surgical repair and then initially and temporarily using a standard nostril stent. The impression is then sent to the dental lab where the expansion screw is mounted and placed around 2 weeks postoperatively with exchange of the commercial static stents for the patient specific, dynamic nasal stents (Figure 3I, K). Average duration of these stents involved a latency period of 2 weeks with commercial static stents, activation, or expansion period of 4-8 weeks, and then a latency period of nighttime wear for 3-6 months. Patients who had these dynamic nasal stents had to wear them for a total duration of about a year. Major disadvantages of these stents include its loose fit requiring frequent adjustments by the orthodontist or surgeon, and young patients’ inability to tolerate these stents which made them more ideal for secondary cleft rhinoplasty (100%). These splints were used in patients ages 5-65 years old which are much older than the typical age of patients undergoing primary cleft rhinoplasty.

Type IV-Internal, Resorbable, Customized, Static Nasal Splint

While most of the literature describes fabrication or modification of external nasal stents, one study investigated the role of internal nasal splints that are resorbable in a total of 15 patients with unilateral cleft lip, nose, and palate (Figure 3D).⁶ These stents were created using polyglycolic/polylactic acid strips mirroring the contralateral non-cleft alar rim and placed in the subcutaneous pocket via a rim incision. The material was resorbed in 6-8 months which accounted for the duration of these stents. One hundred percent of these stents were used in primary rhinoplasty. Complications reported for this type of splint involve partial intranasal extrusion that required nonoperative trimming management and oral antibiotics. The average age of patients who had this type of splint was 4-9 months of age.

Secondary outcomes Evaluated Including Role in Primary and Secondary Cleft Rhinoplasty, Age Group, Duration of Stent Wear, Follow Up Time, and Type of Studies

Fifty-nine percent of patients (269/453) used postoperative nasal stents in primary cleft rhinoplasty while 41% (184/453) of patients had postoperative nasal stents used in secondary cleft rhinoplasty. The age group ranged from 3 months to 65 years old. Duration of stent wear varied from 1 month to 2 years with differences notable among the varying types of splints used. Of the 13 papers, 4 papers mentioned follow up period with a range of 6 months to 8 years involving a total of 135 patients with use of the internal resorbable stents,¹³ prefabricated nasal stents,^4,14 and the easily assembled stents with using nasal prong.¹⁵ One study was prospective,¹⁷ three studies were retrospective with a control cohort,^4,13,14 and the majority involved technique papers and case series. Studies originated from 10 different countries with 4 studies originating from the United States, while the rest came from a different country. There was one multicenter published study identified. The most common journals of publication were Plastic and Reconstructive Surgery [n = 6 (46%)].

In primary cleft rhinoplasty, the prefabricated nasal stents (59%) were used most in the 4-to-6-month age group. In secondary cleft rhinoplasty, the patient specific dynamic nasal stents (42%) were used in older patients ranging from 5 to 65 years old. Postoperative nasal stents for cleft rhinoplasty were classified into five main types: Type 1-spare parts assembled (12.1%), Type II-prefabricated commercial (65.3%), Type IIIa-patient specific 3D printed-static (2.2%) Type IIIb-patient specific, dynamic (17%), and Type IV- internal absorbable (3.3%). Of those reporting duration, the pooled average nasal stent wear time was 6 months. Overall, total complications with nasal stent wear were 6.0%, including irritation (0.9%), infection (0.3%), and stent loss (4.6%). Four papers discussed follow up time with a follow up range from 6 months to 8 years.

Discussion

This study attempts to compare and classify the diversity of postoperative nasal stents used in cleft rhinoplasty. Overall, the rate of complications remained low in this systematic review, as listed in Table 3. There were only 6% reported for total complications with nasal stent wear including: 0.9% for irritation, 0.3% for infection, and 4.6% for stent loss. The overall duration of use remains vague with the overwhelming majority recommending wear time for at least 6 months with four studies recommending an additional 6-month wear time during nighttime. The average use time among the studies included were 6.5 months. One study did not include use time.⁹

Our systematic review reemphasizes the role that postoperative nasal stents play in both primary and secondary rhinoplasty. Sixty nine percent (9/13) of the studies included focused on primary rhinoplasty, 23% (3/13) focused on secondary rhinoplasty and 8% (1/13) focused on both. Dynamic stents requiring turns and frequent adjustments were not as well tolerated in younger children (no less than 4 years old) and were thus best used in older patients and for secondary rhinoplasty.

While there have been many types of nasal stents described in the literature, comparison studies are lacking. In addition, high level evidence on the use of postoperative nasal stents is scarce which ultimately leads to ambiguity in the role of postoperative nasal stents in primary and secondary cleft nose repair. Although high level evidence is lacking, Figure 3 shows the three retrospective studies with control group and objective measurements with statistical significance in preserving nasal symmetry postoperatively.^4,13,14 The results of these studies recommended the use of postoperative nasal stents in primary cleft rhinoplasty as an objective means to preserve nasal symmetry. There has yet been a study to evaluate and objectively measure the role of postoperative nasal stents in preventing nostril stenosis. However, despite this recommendation in preserving nasal symmetry, the literature reports that only 50% of providers use postoperative nasal stents in primary cleft rhinoplasty.²⁰ Nasal stent application is limited due to the following reasons: complex fabrication procedure, inadequate retention of the prefabricated design, hardness of material causing pressure sores, and ultimately, expense.⁵

Our review found that the types of stents described in the literature can be simply classified based on 4 main parameters: external vs. internal, absorbable vs. non-absorbable, process of fabrication, and static vs. dynamic properties. Figure 2 shows our classification system that leads to five main types of stents commonly described. Figure 3 provides examples of each type. While comparison studies among types of stents are lacking, Table 3 depicts common complications reported based on the type of nasal stent in our systematic review. Each group of stents has its advantages and disadvantages. For example, the inexpensive, easily assembled nasal stents are optimal in developing countries or on mission trips where commercial stents are not readily available.

While most stents described are external, there have been some internal, resorbable splints that have been described. The internal stents are more prone to exposure compared to the external stents which innately do not have this complication. However, there has been no other complication reported including skin necrosis, irritation, infection, or stent loss in the internal, resorbable stent group. In the external groups including Type I-spare parts assembled, Type IIIa-patient specific, 3D printed, static, and Type IIIb-patient specific, dynamic, there were no complications reported. Type II-prefabricated-commercial with or without modification, static stent group was the most reported stent and had the highest complication rate (7.4%) including irritation (1.1%), infection (0.37%) and predominantly, stent loss (5.9%). Despite this, the studies focusing on the external nasal stent groups (Type I, Type IIIa, and IIIb) have much less patient use compared to Type II nasal stents which makes a true comparison difficult and unattainable.

Although the prefabricated commercial stents are the most common types of stents used due to convenience, these have their own innate problems including: the tendency for them to become loose and dislodged, frequent encrusting from secretions affecting hygiene, and lack of overcorrection in certain patients.^5,10,16 As a result, there has been much innovation in terms of creating different types of nasal stents leading to the current array of stents that have been described in the literature.

In terms of 3D printing technology, advantages of this include the ability to preoperatively create this splint and avoid the postoperative cumbersome length production process.¹¹ In their study, they reported that the cost to print each stent is estimated to be around 16 US Dollars.¹¹

While most postoperative nasal stents are static in nature, two studies investigated a customized dynamic stent to combat the dynamic nature of the healing cascade.^6,9 In regard to dynamic properties, the idea was to create a device that had gradual ‘orthopedic’ action to the extent of overcorrection.⁹ In both studies, none of the patients experienced any complications and were able to maintain patent nasal airway. However, with expansile stents, there was low compliance in the younger patient population, who were unable to tolerate the device and were thus used in older patients predominantly for secondary rhinoplasty.

In 2018, Quentin et al, published a multi-centered prospective study that investigated “quality of life” via distribution of surveys to the parents of 72 unilateral and bilateral cleft patients that underwent surgery at 6 months of age using a variety of commercial stents (Type II) including non-removable- fixed Talmant splints, and removable retentive and removable non-retentive splints.¹⁸ Although this suggested that quality of life was not different among these types of splints, this does not compare quality of life with wear among the different types of stents described in this study. Thus, additional studies are warranted to determine the effect of quality of life on varying types of nasal stents.

There are many limitations of this study. None of the studies that met our inclusion criteria consisted of high-level evidence studies and there was significant heterogeneity among the studies. Only three studies had a control cohort for comparison but were retrospective studies. Only one study was prospective though there was no control group for comparison and focused more on tolerance of postoperative nasal stents. Thus, we are limited by the quality of studies available. Additionally, the lack of comparative studies does not allow for proper comparison of these different nasal stents available. Long-term follow up was not recorded in these studies and was only reported in 30% of the studies included in the systematic review. This review highlights a need for prospective investigations. Further research is needed to truly investigate the effectiveness of postoperative nasal stents and compare the different types of nasal stents available in higher quality comparative studies.

Conclusion

Based on this systematic review, various types of postoperative nasal stents can be used in both primary and secondary rhinoplasty to maintain nasal airway and preserve nasal symmetry with minimal risk of complications. Although the role of postoperative nasal stents in prevention of nasal stenosis requires further study, our review shows that three retrospective studies showed overall objective preservation of nasal symmetry with use of postoperative nasal stents. Controversy remains in the role of postoperative nasal stents and its effectiveness and the utility of the different types of nasal stents available. The literature reports that half of cleft providers do not use postoperative nasal stents which highlights a lack of universal recommendation.²⁰ However, our study demonstrates the low complication rate with the use of postoperative nasal stents having limited downside other than the onus placed on families to comply makes it a reasonable option for the preservation of nasal symmetry. Additionally, varying surgical repair strategies may act as confounding factors that would be hard to tease out to truly determine when nasal stents are most needed, when they make no difference, and when they should not be used.

Further studies providing evidence of high quality are needed to establish the role of postoperative nasal stents in cleft rhinoplasty and ultimately, in designing the “ideal” postoperative nasal stent.

Footnotes

Acknowledgements

None.

Author's Note

All guidelines in the Declaration of Helsinki were followed during the preparation of this work.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical/Consent Statement

It is not applicable and not needed given it is a systematic review.

ORCID iDs

David C. Nguyen

Janine A. Myint

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