Algorithmic Elementary-Age Nasal Reconstruction for Binder Syndrome

Background: Nasomaxillary hypoplasia, or Binder syndrome, is conventionally treated at skeletal maturity (SKM). However, our institution has employed a stratified treatment algorithm, treating severe patients with serial nasal expansion beginning at elementary school age (5-11 years) to expand the soft tissues and improve appearance prior to definitive rhinoplasty at SKM. This study evaluates the treatment patterns and outcomes of Binder syndrome employing this pathway. Methods: Eight cases of nasomaxillary hypoplasia were identified from a database of rhinoplasties performed between 2006 and 2020 at a tertiary children’s hospital. Photomorphometric analyses were conducted on basal, frontal, and lateral photographs. Goode’s ratio was used to assess change in projection, and pronasale to ala distance was measured bilaterally as a proxy of symmetry. Changes in symmetry were calculated using bilateral nasal width ratio. Results: In our sample, 6 patients (75.0%) had initial rhinoplasty prior to SKM, with 3 undergoing serial silastic implant placement, one with complicated implant placement followed by autologous reconstruction, and 2 undergoing serial expansion with allograft rib cartilage grafts. Average age at initial rhinoplasty was 6.3 (range 5.2-8.8) years for the pre-SKM group and 15.6 (range 14.1-17.1) years for the post-SKM group. Patients in the pre-SKM rhinoplasty group underwent more procedures than those at SKM (2.3 vs 1.5, respectively). The average change in nasal parameters was −0.029 for Goode’s ratio and −9.5° for nasolabial angle. The average post-operative nasal symmetry index was 0.98 representing near perfect symmetry. There was no significant difference in the degree of improvement in nasolabial angle, Goode’s ratio, or nasal symmetry between SKM and pre-SKM cohorts (all P >.05). Conclusion: Among patients with Binder syndrome, those treated initially at elementary-age were able to achieve similar improvements in nasal indices to those treated at SKM. This approach allows patients to live their key developmental years with less stigmata of their facial difference but requires more surgical intervention.