Rhinoplasty - Cleft

Considerations

•  Secondary cleft lip nasal deformity involves all tissue layers and depends on:

  • the original malformation

  • any interim surgery performed

  • growth of the nose and face

• Unilateral cleft nasal deformity results from the alar base lacking skeletal support and involves a hypoplastic and malaligned orbicularis oris muscle on the cleft side

  • Dorsal deformity = possibly directed toward the cleft side, nasal bones usually thick and wide, hump is usually not an issue 

  • Nasal base deformity = lateral, inferior, and posterior (L I P) positioning compared to the non-cleft side

    • associated abnormal nasal sill

  • Alar cartilage deformity = medial crus is shorter, while the lateral crus longer and more concave and inferiorly displaced or hooded compared to the non-cleft side

  • Septal deformity = caudal deviation to the non-cleft side, posterior septum to the cleft side

  • Tip deformity = usually deviated away from the cleft side, dome is wide and the tip is underprojected compared to the non-cleft side

• Bilateral cleft nasal deformity results from bilateral lack of skeletal support for the alar base and involves deficiency in skin and soft tissue between the vermillion-cutaneous junction of the lip and the nasal tip

  • Nasal base deformity = bilateral lateral and posterior malposition

  • Alar cartilage deformity = shortened medial crura, while the lateral crura are longer compared to normal

  • Septal deformity = widened and reduplicated 

  • Columellar deformity = shortened

  • Tip deformity = underprojected, broadened, and flattened

Timing

• Starting at birth, before 1 month of age = pre-surgical nasoalveolar molding (PNAM) works to: 

  • narrow the cleft gap

  • improve alar base symmetry in asymmetric clefts

  • expand the soft tissue envelope

  • elongate the columella

• 2-6 months = Primary rhinoplasty at the time of lip repair consists cartilage repositioning and suture techniques accessed via the standard lip repair incisions

  • close the nasal floor and sill

  • reposition the alar base via alotomy

  • reposition the alar cartilage

  • reposition the tip

• 4-6 years = Intermediate rhinoplasty for minor revisions 

  • Improve alar cartilage positioning 

  • Improve lateral vestibular webbing

  • Lengthen the columella 

• 17-18 years in females and 19 years in males = Secondary rhinoplasty after definitive orthognathic surgery

  • • total septal reconstruction

    • cartilage grafting

    • deformity camouflage 

Procedure

• • Turbinate reduction

  • Septal deformity

    • Standard posterior septum graft harvest with ample L-strut

    • Complete mobilization of the caudal septum via open approach

      • Overlapping or end-to-end graft 

      • May stabilize with extended spreader grafts 

      • Excise associated bony spur

      • Secure to anterior nasal spine

  • Columellar deformity

    • Primary correction

    • V-Y advancement flap may serve to lengthen the columella if adequate columellar width and upper lip tissue are present

      • Anteriorly pedicled rectangular flap may be elevated to provide greater length

    • Brauer-Foerster technique: fan-shaped flaps along the medial and anterior margin of the alar rim, which can be pulled medially to increase columellar projection

    • Cronin procedure: simultaneous anterior bilobed flap advancement and posterior midline columellar flap advancement

    • For the absent columella:

      • Ferris-Smith procedure: FTSG is buried beneath upper lip skin and later rotated into place

      • Serre method: doubled FTSG is buried beneath upper lip skin and later rotated into place

    • Improving the ala will improve the columella 

      • Ivy modification of the Blair procedure: medially and anteriorly rotating a laterally based nostril rim flap to lengthen the columella by repositioning the nasal ala

      • Dingman technique: medially rotating a columellar and alar-based flap

  • Alar deformity

  • Advance the alar cartilage anteriorly 

  • Restoring the normal convexity to the lateral crural

    • using the lateral crus as a free graft and flipping the concave cartilage into a convex position

    • alar strut graft

    • alar rim graft

    • onlay camouflage graft

  • Improve the hooded or flattened lateral crus

    • •  Tajima reverse-U technique: suture the superior, or cephalic edge, of the LLC to the ULC or periosteum of the ipsilateral nasal bone (or even contralateral ULC or alar cartilage) 

    • Reposition the dome

    • Thomas Rees technique: Lateral crus is severed from lateral attachment and advanced medially to be sutured to contralateral ala

    • Onlay or turn-over grafts using auricular cartilage 

      • Auricular cartilage is weak but has the ideal curvature

• Tip deformity

  • Improving the ala will improve the tip 

  • Columellar strut graft for support 

  • Tip graft for added symmetry and camouflage 

• Dorsal deformity

  • Flaring sutures

  • Spreader grafts for support and straightening 

  • Onlay grafts - cartilage and/or bone 

  • Osteotomies as needed 

  • Hump reduction with caution, as needed 

• Vestibule deformity

  • Redundant skin may be used to line a stenotic nasal vestibule

  • Harvest a laterally or medially based sliding chondrocutaneous flap using the previous lip scar

  • Introduce new skin into the nasal sill with a perialar nasolabial flap to increase the relative size of the nostril, reposition the medially displaced alar base, and increase the length of the nostril sill to more accurately match the opposite side

  • V-Y–type tissue rearrangement, as needed for webbing

Post-op

• • Standard rhinoplasty wound care, precautions, follow-up

  • Medications

    • Consider antibiotics, especially if grafts or implants are performed and/or if revision surgery

  • Complications 

High-Yield

• What is the cleft Nasal base deformity? Lateral, inferior, and posterior (L I P) positioning compared to the non-cleft side

  • What is the cause? The pull of the orbicularis oris muscle

  • Which way is the caudal septum deviated? Away from the cleft side.

  • What is the cause? Again, the pull of the orbicularis oris muscle

Links

• Rhinoplasty Archive - Cleft Lip Rhinoplasty

• eMedicine - Cleft Lip Nasal Deformity

• 2012: Cleft Nasal Deformity and Rhinoplasty