secondary deofrmities of cleft lip nose

8/10/2019 Secondary Deofrmities of Cleft Lip Nose

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CME

Correction of Secondary Deformities of theCleft Lip NoseSamuel Stal, M.D., and Larry Hollier, M.D.

Learning Objectives: After studying this article, the practitioner should be able to: 1. Describe the common secondarydeformities of the cleft lip nose. 2. Determine the appropriate timing for surgical intervention to correct the deformities.3. Determine the best method of addressing each of the individual secondary deformities of the cleft lip nose.

For both unilateral and bilateral cleft lip nasal defor-mity, the general trend has been toward operation on thecleft lip nose at the time of initial lip surgery. Secondarysurgery to further modify the nasal shape is often neces-sary, and many patients desire complete septorhinoplastyin their teen years. Many different procedures have beensuggested to address the problem, but few techniqueshave worked well and consistently. The authors define theunderlying anatomic distortion involved in the cleft lipnose and describe effective techniques for correcting thedeformity. (Plast. Reconstr. Surg. 109: 1386, 2002.)

There has been a general trend toward op-

eration on the cleft lip nose at the time ofinitial lip surgery in both the unilateral andbilateral cleft lip nasal deformity. However, sec-ondary surgery to further modify the nasalshape is frequently necessary, and a large num-ber of patients desire complete septorhino-plasty in the teen years. Although a myriad ofdifferent procedures has been suggested to ad-dress the problem, few techniques work welland consistently. We will define the underlyinganatomic distortion involved in the cleft lipnose and describe techniques that have beeneffective in correcting the deformity.

PREVENTION OFSECONDARYCLEFTNASALDEFORMITIES

Perhaps the greatest advance in cleft lip na-sal surgery has been nonsurgical: the tech-nique of nasoalveolar molding. Although in-traoral appliances have long been used to moldthe palatal shelves before lip surgery, the nosehas been relatively ignored. Grayson and col-

leagues describe a technique for nasoalveolarmolding in which an extension is placed on theanterior aspect of the intraoral appliance sothat it places pressure within the nasal vesti-bule, projecting the dome of the lower lateralcartilage.1 In the early stages of infancy, carti-lage is relatively malleable because it is underthe influence of maternal estrogens.2 In thefirst 3 to 4 months of life, as the palatal shelvesare being aligned by the intraoral componentto the device, the nasal extension permanentlyreshapes the deformed lower lateral cartilage

and stretches the vestibular lining, greatly fa-cilitating primary nasal repair (Fig. 1) and di-minishing secondary deformities.

Anatomy

The skeletal support of the nose is best de-scribed by using the tripodconcept,3,4 in whichnasal support is provided centrally by the sep-tum and laterally by the nasal sidewalls andlower lateral cartilages. Compromise of any ofthese structures will result in deviation of thetripod accordingly. This is pertinent with re-

spect to the cleft lip nasal deformity. In theunilateral deformity, the problem begins withdisplacement of the base on which the tripodrests. The cleft maxilla is laterally displacedand hypoplastic, resulting in an altered plat-form for the cleft side ala. Consequently, thisala splays laterally, with associated loss of nasaltip definition, obliquity of the alar facial angle,and septal deviation. Much the same is true forthe bilateral deformity, in which the ala has a

From the Texas Childrens Hospital, and the Division of Plastic Surgery, Baylor College of Medicine. Received for publication October 4, 2000;revised September 21, 2001.

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classic bucket-handle appearance with alar lid-ding and acute alar angulation.5 The problemis further compounded by the premaxilla,which is most often anteriorly positioned, caus-

ing distortion of the columella. The malposi-tioned osteocartilaginous framework also con-tributes to distortion of the surrounding softtissue, asymmetry, and such problems as alarlidding, presence of a plica vestibularis, andloss of tip projection.

Timing of Repair

A limited rhinoplasty is usually performed atthe time of primary lip repair.610 Generally,this involves only dissection and medial mobi-lization of the cleft lower lateral cartilage. The

most common age for revision of the cleft lipnose is between 4 and 5 years. At this age, thechilds social interactions are increasing andthe stigmata associated with the deformity maycause problems for the child. Assuming it isamenable to correction, any residual distortionof the nose that causes the parents or childsignificant concern should be addressed at thispoint. Procedures to modify the nose shouldbe coordinated with lip revision; these proce-dures are also frequently necessary during thissame time period.

The real controversy arises when complete

septorhinoplasty with modification of the os-seocartilaginous vault is considered. The con-cern is that complete rhinoplasty with osteot-omy and septal manipulation will impair facial

growth. Consequently, complete rhinoplastyhas been generally deferred until the late teenyears. However, there are data demonstratingthat nasal growth is complete at approximately11 to 12 years of age in girls and 13 to 14 yearsof age in boys.11 As such, full rhinoplasty maybe performed at this time without fear of af-fecting growth. In reality, the reason this is notdone more often in younger teenagers relatesto the issue of emotional maturity. Eventhough nasal growth is complete at approxi-mately 11 to 12 years of age in girls, it is un-usual for an 11-year-old to be mature enoughto participate in the complex decisions in-volved in a preoperative consultation for rhi-noplasty. Nevertheless, in the mature, emotion-ally stable patient in the early teen years, thereis no contraindication to a full rhinoplasty.

TECHNIQUES

Early Revisional Surgery

We must distinguish between those proce-dures we perform on the growing childs sec-ondary cleft nasal deformity and those reserved

FIG. 1. Presurgical nasoalveolar molding of the unilateral cleft lip/nasal deformity. (Left)Appearance before molding. (Right) Appearance after molding and before surgery.

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for definitive septorhinoplasty in the cleft pa-tient at the end of facial growth. During the

early period, attention is focused on reshapingthe cleft side ala by repositioning or derotatingit. Efforts to achieve this are impaired by sev-eral factors, including deficiencies in underly-ing skeletal support and vestibular lining andscarring from previous procedures. Most tech-niques have focused on the dissection of thelower lateral cartilage through an infracarti-laginous incision or through the apex of theexisting lip incisions. The entire lower lateralcartilage is freed from the overlying skin andrepositioned using sutures to a stable cephalicposition to achieve projection of the dome on

the cleft side.1215 Frequently, an external bol-ster is used, over which the suture is secured.

Although we also advocate a similar proce-dure in the growing child, we prefer to moreaggressively shape and stabilize the cleft lowerlateral cartilage in its entirety with internal su-tures. To do this, following dissection of thecartilage, the desired position of the apex ofthe dome of the lower lateral cartilage is cho-sen and a polydioxanone suture is passedthrough the mucosa and cartilage, pulling thecartilage to a more medial and cephalic posi-tion. This suture is taken out through the skinand then put back through the same skin exithole, following a different dermal pathway,

FIG. 2. Illustration of the transdermal suture suspensiontechnique of cleft lip rhinoplasty. (Above, left) Dissection ofthe cleft side lower lateral cartilage through existing lip in-

cisions or an infracartilaginous incision. (Above, right) Sutureplacement through the lower lateral cartilage at desiredpoints of increased projection. (Below) The sutureis taken outthrough the skin and is brought back through the same point.The suture is tied in the nasal vestibule, advancing the lowerlateral cartilage medially and cephalically. From Stal, S., andSpira, M. Secondary reconstructive procedures for patientswith clefts. In D. Serafin and N. G. Georgiade. Pediatric PlasticSurgery, Vol. 1. St. Louis, Mo.: Mosby, 1984. Pp. 352377.Reprinted with permission from the publisher.

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and again through the lower lateral cartilage.The suture is then tied in the vestibule to thepoint that the cartilage is advanced to the ap-propriate position (Fig. 2). This functionallyderotates the cartilage and suspends it to theoverlying dermis. As many sutures as are nec-

essary are placed along the length of the lowerlateral cartilage to position the ala and dimin-ish dead space of the larger cleft alar rim. Thistechnique helps compress the plica vestibularisand improves symmetry. The alar lidding canbe partially obviated by large bites of the liddedskin and vestibular mucosa during closure ofthe infracartilaginous incision using a 4-0 plaingut suture (Fig. 3).

These transdermal sutures cause some dim-pling, which may be minimized by placing asmall incision with a no. 11 blade through the

location where the suture is taken. This dim-pling, however, always resolves over the courseof several weeks. It also negates the need for anexternal bolster, which is problematic from twostandpoints. First, we have seen scars causedfrom excessive pressure placed on these bol-sters. Furthermore, when the bolster itself isremoved (usually at 7 to 14 days), so is thesupport for the repositioned lower lateral car-tilage. With the above technique, the lowerlateral cartilage is supported as long as the

polydioxanone suture maintains its strength,usually for 2 to 3 months.

For the bilateral cleft lip nasal deformity, thetechniques used for rhinoplasty have been cat-egorized by Cutting and colleagues into twogroups: the skin paradigm and the cartilage

paradigm.16,17 The focus of the skin paradigmhas been on augmentation of the deficientcolumella by means of flaps advanced in fromthe lateral aspect of the philtrum or the nasalfloor.18,19 However, these techniques do noth-ing to address the underlying abnormality inthe lower lateral cartilage, and they frequentlyproduce abnormally long and unusual appear-ing columellae (Fig. 4). Mullikens observa-tions on the columella after the staged forkedflap procedure show a classic pattern so oftenseen in our own patients: (1) a rectangular

columella (without a waist and with a broadbase), (2) a sharp columellar-labial angle, (3)abnormally elongated/enlarged nostrils, and(4) a tendency to an overly long columella witha disproportionate ratio of nostril length tonasal tip.5 It is our opinion that additionaltissue, especially from the lip, is not necessaryto lengthen the columella in the vast majorityof cases and should only be used conservativelyand for minimal skin advancement.

With respect to those procedures focusing

FIG. 3. Transdermal suture suspension technique in primary cleft lip rhinoplasty. (Left)Preoperative appearance. (Right) Immediate postoperative appearance.



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on the deformed lower lateral cartilages, theindividual techniques vary primarily in the in-cision used to access the domes and may be asdirect as McCombs9 gullwing incision alongthe tip or Cutting and Graysons20 prolabialunwinding flap. The basic philosophy is thesame as with the unilateral cleft nasal defor-mity. The lower lateral cartilages are dissectedout from the overlying skin envelope, and thelateral crura are advanced medially and se-cured to one another to create a more normalappearing tip. Further shaping of the tip canbe achieved with the technique describedabove using transdermal sutures.

Definitive Septorhinoplasty

Once growth is complete and the patient isemotionally mature, patients may be consid-ered candidates for full osseocartilaginousvault modification, should they so desire. Weusually prefer the open approach for thesepatients.

Before tip reshaping is begun, the support ofthe alar base must first be assessed. For patients

with a severe skeletal deficiency, augmentationshould be considered. This can be accom-plished by placing either a bone graft or blockhydroxyapatite through an intraoral incision,which is then secured in a subperiosteal loca-tion near the piriform aperture below the cleft

side ala. In patients with the most severe skel-etal deficiencies, the cause is often a retrusivemaxilla, and a Le Fort I advancement osteot-omy should be performed before any attemptis made at definitive rhinoplasty (Fig. 5).

As in the procedures performed at a youngerage, attention is given to reshaping the lowerlateral cartilages with suture techniques. How-ever, this is usually insufficient to adequatelycorrect the deformity. In the unilateral cleft lipnose, we frequently augment tip projection us-ing graft material. It is our preference in most

cases to use a strut of septal cartilage betweenthe medial crura to project and equalize thedomes. If this is also inadequate to achievesufficient projection, extended spreader graftsas described by Byrd et al. are used.21 Thisprocedure is necessary for many of our patientswith the bilateral cleft lip nasal deformity. As arule, these patients are severely deficient ofcartilage in the anterior septal angle region.These spreader grafts create a scaffold for an-atomic tip reconstruction, allowing the lowerlateral cartilage to be directly fixed to a new

appropriate septal angle, achieving maximaltip projection. Occasionally, we also use septalor auricular grafts as a stiff batten to augmentand stabilize the malformed lower lateral car-tilages. Onlay grafts of cartilage may also benecessary to improve tip definition andsymmetry.

CONCLUSIONS

Secondary cleft lip nasal deformities arecommon, but they may be minimized by the

use of nasoalveolar molding in the first severalmonths of life. Surgical correction of theseproblems should be predicated on the severityof the deformity. Residual deformities thatconcern the patient or parents should be ad-dressed at a young age by mobilization of thedeformed alae and reshaping of the tip usingintradermal sutures for support. Definitive sep-torhinoplasty may be performed, if necessary,during the early teen years once growth is com-plete. This should be accomplished by theopen approach, using cartilage grafts toachieve the desired tip projection and shape.

FIG. 4. An overly long columella, resulting in flip nasaldeformity.



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Samuel Stal, M.D.Suite 3301102 Bates, MC 3-2314Houston, Texas [email protected]

REFERENCES

1. Grayson, B. H., Santiago, P. E., Brecht,L. E.,and Cutting,C. B. Presurgical nasoalveolar molding in infantswith cleft lip and palate. Cleft Palate Craniofac. J. 36:486, 1999.

FIG. 5. Definitive cleft lip rhinoplasty and augmentation of nasal support/projection with LeFort I advancement osteotomy (staged with the rhinoplasty). (Above) Frontalview of preoperativeand postoperative appearance. (Below) Lateral view of preoperative and postoperativeappearance.



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2. Maull, D. J., Grayson, B. H., Cutting, C. B., et al. Long-term effects of nasoalveolar molding on three-dimen-sional nasal shape in unilateral clefts. Cleft PalateCraniofac. J. 36: 391, 1999.

3. Hogan, V. The tilted tripod: A theory of cleft lip nasaldeformities. In J. Huston (Ed.),Transactions of the 5thInternational Congress of Plastic and Reconstructive Sur-

gery. Melbourne, Australia: Butterworths, 1971.4. McCollough, E. G., and Mangap, D. Systematic ap-proach to correction of the nasal tip in rhinoplasty.Arch. Otolaryngol. 107: 12, 1981.

5. Mulliken, J. B. Repair of bilateral complete cleft lip andnasal deformity: State of the art.Cleft Palate Craniofac.

J. 37: 342, 2000.6. McComb, H. Primary repair of the bilateral cleft lip

nose: A four-year review. Plast. Reconstr. Surg. 94: 37,1994.

7. McComb, H. Primary repair of the bilateral cleft lipnose. Br. J. Plast. Surg. 28: 262, 1975.

8. McComb, H. Primary repair of the bilateral cleft lipnose: A 10-year review. Plast. Reconstr. Surg. 77: 701,1986.

9. McComb, H. Primary repair of the bilateral cleft lipnose:A 15-year review and a newtreatment plan. Plast.Reconstr. Surg. 86: 882, 1990.

10. Millard, D. R., Jr., and Morovic, C. G. Primary unilateralcleft nose correction: A ten-year follow-up. Plast. Re-constr. Surg. 102: 1331, 1998.

11. Akguner, M., Barutcu, A., and Karaca, C. Adolescentgrowth patterns of the bony and cartilaginous frame-work of the nose: A cephalometric study. Ann. Plast.Surg.41: 66, 1998.

12. Tajima, S., and Maruyama, M. Reverse-U incision forsecondary repair of cleft lip nose.Plast. Reconstr. Surg.60: 256, 1977.

13. Reynolds, J. R., and Horton, C. E. An alar lift in cleft liprhinoplasty. Plast. Reconstr. Surg. 35: 377, 1965.

14. Stenstrom, S. J., and Oberg, T. R. H. The nasal defor-mity in unilateral cleft lip.Plast. Reconstr. Surg.28: 295,

1961.15. Dibbell, D. G. Cleft lip nasal reconstruction: Correcting

the classic unilateral defect. Plast. Reconstr. Surg. 69:264, 1982.

16. Cutting, C. B. Primarybilateral cleftlip and nose repair.In S. Aston, R. Beasley, and C. H. M. Thorne (Eds.),Grabb and Smiths Plastic Surgery. Philadelphia: Lippin-cott Raven, 1997. P. 257.

17. Cutting, C., Grayson, B., and Brecht, L. Columellarelongation in bilateral cleft lip (Letter). Plast. Reconstr.Surg.102: 1761, 1998.

18. Millard, D. R., Jr. Closure of bilateral cleft lip and elon-gation of columella by two operations in infancy. Plast.Reconstr. Surg. 47: 324, 1971.

19. Cronin, T. D. Lengthening columella by use of skinfrom the nasal floor and alae.Plast. Reconstr. Surg.21:417, 1958.

20. Cutting, C., and Grayson, B. The prolabial unwindingflap method for one-stage repair of bilateral cleft lip,nose, and alveolus.Plast. Reconstr. Surg. 91: 37, 1993.

21. Byrd, H. S., Andochick, S., Copit, S., and Walton, K. G.Septal extension grafts: A method of controlling tipprojection and shape. Plast. Reconstr. Surg. 100: 999,1997.

Self-Assessment Examination follows onthe next page.



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Self-Assessment Examination

Correction of Secondary Deformities of the Cleft Lip Noseby Samuel Stal, M.D., and Larry Hollier, M.D.

1. ALL OF THE FOLLOWING ARE TRUE ABOUT RHINOPLASTY IN TEENS EXCEPT:A) Nasal growth in girls stops at approximately 12 years of ageB) Nasal growth in boys stops at approximately 13 to 14 years of ageC) Definitive nasal surgery should be delayed until the teen is emotionally matureD) All septal surgery in children should be delayed until cessation of growth regardless of symptomsE) Premaxillary orthopedics shows promise in helping set the stage for more normal nasal growth

2. EFFECTIVE WAYS OF IMPROVING NASAL TIP PROJECTION IN THE CLEFT PATIENT INCLUDEALL OF THE FOLLOWING EXCEPT:A) Extended spreader grafts

B) Le Fort I advancement osteotomyC) Forked flapsD) Cartilage graftsE) Cephalic suspension of the lower lateral cartilage

3. NASOALVEOLAR MOLDING CAN BE USED JUST AS EFFECTIVELY ANYTIME WITHIN THE FIRSTYEAR OF LIFE.A) TrueB) False

4. NASOALVEOLAR MOLDING IMPROVES THE LINING DEFICIENCY SEEN IN THE CLEFT LIPNASAL DEFORMITY.A) TrueB) False

5. USE OF FORK FLAPS TO AUGMENT THE COLUMELLA MAY RESULT IN WHICH OF THEFOLLOWING?A) An overly long columellaB) A sharp columellar-labial angleC) A rectangular columellaD) Enlarged nostrilsE) All of the above

6. THE BASIC GOAL IN SURGERY FOR THE UNILATERAL CLEFT LIP NASAL DEFORMITY IS TOSECURE THE CLEFT SIDE ALA IN MORE MEDIAL AND CEPHALIC POSITION.A) TrueB) False

secondary deofrmities of cleft lip nose

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