Oral Maxillofacial Surg Clin N Am 14 (2002) 453 461

Rhinoplasty in adolescent cleft patients

Deodatta V. Bendre, MD, FACS*, Ferdinand A. Ofodile, MD, FACS
Division of Plastic Surgery, Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037, USA

It is universally accepted that correction of cleft lip nose deformity remains a formidable challenge. Despite early correction of cleft lip nose deformity, one is often faced with an adolescent patient who has an acceptable upper lip but has a deformed nose. Usually, these patients come from underdeveloped countries to the United States for correction of nasal deformities. The nose forms a prominent part of the face. Ironically, a masterly executed cleft lip repair directs the beholders eyes from the deformed lip to the deformed nose. Real progress has been made in the treatment of cleft lip and palate in the last four decades. Preoperative dental orthopedics and appliances have progressed to produce a near normal maxillary dental arch. In the bilateral cleft lip and palate, positioning of a protruding premaxilla in the dental arch results in superior cleft lip repair. Many techniques have been designed to correct cleft nose deformity; however, the technical improvements in cleft nose repair have lagged behind the progress in cleft lip and palate repair. More and more cleft surgeons are beginning the correction of cleft nose at the time of cleft lip repair; however, several of the patients still require correction of cleft lip nose deformity later in life.

side is depressed (see box). The nasal tip is supported by the central pole of the tent (columella and septum) and the sides (alae) are supported by its bony floor (the maxilla). When one side of this floor (the maxilla) is depressed and hypoplastic, the ala is pulled to that side, and the columella and septum are tilted toward the normal side, which results in classic deformity of the nose [1]. There is much controversy regarding the causation of cleft lip nasal deformity. Many investigators [2 4] believe that the deformity of the nose is produced by the malpositioning of essentially normal structures, whereas others [5] contend that intrinsic defects in nasal structures result in cleft nasal deformity. Depressed and hypoplastic bony scaffolding is the most important aspect of cleft nose deformity.

Pathologic anatomy Nasal deformities of unilateral clefts have multiple components that require correction. The base of the columella is deviated toward the noncleft side. The cartilaginous septum is convex on the cleft side, which produces airway obstruction. The tip of the nose and the septum is deviated to the noncleft side. On the cleft side, the angle between medial and lateral crura is excessively obtuse, which results in depressed dome. The cartilage on the cleft side may be smaller and thinner than the normal side. The cleft-side nostril may have a web close to the pyriform aperture.

Unilateral cleft lip nose deformity A deformed nose that results from unilateral cleft of the lip and palate is likened to a tent whose one
* Corresponding author. Division of Plastic Surgery, Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037. E-mail address: dvb1@columbia.edu (D.V. Bendre).

1042-3699/02/$ see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 4 8 - 1

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Characteristics of unilateral cleft nose deformities

 A nasolabial fistula may be present  The premaxilla and maxillary

examination of the nose, lip, and palate may reveal the following characteristics: Deformity of the dental arch, including a tooth in the cleft A shortened and deviated columella Deviated and displaced septum and hypertrophied turbinate Irregularity, depression, bifidity of the tip Deformity of the ala, ala-cheek angle Nasolabial fistula Webbing of the vestibule on the cleft side Smaller or larger vestibule The objectives of corrective surgery are to (1) restore the symmetry of alar cartilages, (2) produce a cosmetically acceptable nose and a harmonious relationship between the repaired lip and the nose, (3) create a nasal sill, nasal floor, and columella of equal size on both sides, and (4) produce an ala without flare and a vestibule without webbing.

     

segments are displaced on the noncleft side The nasal pyramid is tilted to the cleft side, the turbinate on the cleft side is hypertrophied The curved nasal septum and hypertrophied turbinate result in airway obstruction The columella is short on the cleft side and its base is deviated to the noncleft side The lateral crux of the lower lateral cartilage, on the cleft side, is longer. Its base is attached backwards and downwards The dome of the lower lateral cartilage is displaced lower and to the cleft side, which results in bifid tip and excessive skin on the dome of lower lateral cartilage on cleft side Larger ala forms S-shaped curve or is flat The nasal tip is asymmetrical The nostril sill may be small or wide The nostril is smaller or larger on cleft side The entire nostril may be retropositioned The whole nose on the cleft side may be longer as measured from Radix to the alar margin

Timing of surgery The controversy that existed about timing of corrective surgery for cleft nose deformity seems to have diminished in recent years. More cleft surgeons

The nostril on the cleft side may be smaller or larger than the noncleft side. The cleft side ala buckles inward. The base of the ala is caudally displaced on the cleft side. The ala-facial angle is flattened. The nasal floor on the cleft side may be wide or narrow.

Surgical procedures In an adolescent patient, a detailed history should be obtained. Details about the previous surgery and any orthodontic treatment should be noted. Physical
Fig. 1. Alar unit rotations. (A) Blair. (B) Joseph. (C) Gillies Kilner. (D) Berkeley. (From Converse and McCarthy, Reconstructive Plastic Surgery, 2nd Edition, Philadelphia: W.B. Saunders Company, with permission.)

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Fig. 2. Correction of the narrow nostril floor. (A) Design of flap taken from the area lateral to the ala. (B) The flap has been transposed into the floor of the vestibule. (From Converse and McCarthy, Reconstructive Plastic Surgery, 2nd Edition, Philadelphia: W.B. Saunders Company, with permission.)

are correcting nasal deformities at the time of lip repair [6 8]. The lip repair includes (1) closing the primary palate, (2) correcting flared ala, (3) correcting tip deformities by elevating the depressed dome on the cleft side to more normal position, and (4) augmenting the alar platform. The procedures that produce excellent results in early years of life may not retain their earlier promise as the face grows and matures. In the past, Peet and Paterson and others [9 12] recommended delayed nasal repair. They suggested that altering the cartilages would complicate future corrective surgery, and altering nasal cartilages may complicate future nasal surgery. McIndoe and others [13 15], however, have advocated that correcting nasal deformity at the same time as cleft lip repair results in normal development of nasal structures.

Fig. 4. The Striath technique for the removal of the web of tissue that veils the apex of the naris. (A) Outline of the incision. (B) A skin flap has been raised exposing the cartilage. (C) The exposed alar cartilage is excised, and the remaining mucosal flap is incised, rotated anteromedially, trimmed, and sutured to the columella. The skin flap is rotated into the vestibule and sutured to the lateral wall. (D) Cartilage may be added to increase the projection dome of the alar cartilage. (From Converse and McCarthy, Reconstructive Plastic Surgery, 2nd Edition, Philadelphia: W.B. Saunders Company, with permission.)

In an adolescent patient, correction of nasal deformity could be performed with closed or open technique. The dental arch should be established and maxillary hypoplasia should be corrected before correction of the nasal deformity. The following deformities may require correction in a particular case: The lip may have unacceptable scarring. The columella on the cleft side may be short and the caudal end of nasal septum may be protruding on the normal side. Caudal septum may be displaced on the normal side and deviated to the cleft side. The dome of the alar cartilage may be depressed, which may result in bifid and depressed tip. The alar facial angle may be flat. The nostril on the cleft side may be large or small. There may be webbing of the skin in the vestibule.

Fig. 3. Correction of wide alar base. (A) An incision is made along the caudal border of the alar cartilage and a parallel incision is made higher in the nostril. The tissues between these incisions are undermined and detached medially, leaving a flap of skin that includes the ala. Scar tissue in the floor of the nostril is excised, as is a V of redundant labial skin, and the medial site is prepared for the alar flap. (B) The alar flap is transferred medially and sutured in place, narrowing the floor of the nostril and improving the contour. (From Converse and McCarthy, Reconstructive Plastic Surgery, 2nd Edition, Philadelphia: W.B. Saunders Company, with permission.)

Surgery Procedure for correction of cleft lip nasal deformity fall in to two categories: (1) correction of ala as one unit and (2) correction of alar soft tissue and

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Fig. 5. Correction of webbing in the lateral vestibule. (A) Z-plasty. (B) V-Y advancement. (C) Medial advancement (arrow) of a medially based flap of vestibular skin and alar cartilage in a unilateral cleft lip and nose deformity. A full-thickness skin graft is placed in the resulting lateral defect. (From Rees TD, Guy CL, Converse JM. Repair of the cleft lip nose: addendum to the synchronous technique with full thickness skin grafting of the nasal vestibule. Plast Reconstr Surg 1966;37:47; with permission.)

cartilaginous framework separately. Cartilagenous framework can be repositioned using either intranasal or extranasal incisions.

Nasal tip The dome on the cleft side must be elevated to the normal side and sutured in the elevated position. To give more definition to the tip, a tip graft with a columellar strut support may be necessary. Columella The columella may need lengthening using one of the many methods described in Fig. 1. A short columella on the cleft side is difficult to correct. A simple V-Y plasty from the tip might suffice. Nostril sill The alar base excision may be necessary for alar flare. To widen the nasal floor, a flap from the lateral aspect of the alar base may need to be transposed to the nostril sill. Conversely, to narrow the wide nasal

Cartilaginous septum The cartilaginous nasal septum may be dislocated from the vomerine groove, the caudal end may be displaced to the normal nostril, and the septum may be deviated to the normal side, which produces nasal obstruction. Submucous resection of septal cartilage may be adequate to correct septal deviation in most patients. In some patients other methods of septal alterations may be required: (1) scoring of septal cartilage on appropriate side, (2) excision of caudal part of septum that protruding in the nostril, and (3) placing the caudal septum on the nasal spine if it is dislocated.

Fig. 6. (A) Outline of the inverted V forked flap and small wedges in the nostril floors and at the vermilion borders. (B) Wound closed after the forked flap is advanced to elevate the nasal tip with formation of the Cupids bow. (From Millard DR. Columellar lengthening by a forked flap. Plast Reconstr Surg 1958;22:454; with permission.)

Fig. 7. (A,B) Outline of two triangular flaps from the scarred borders of the prolabium. (C) Rotation and interdigitation of the flaps to lengthen the columella. (From Marcks KM, Trevaskis AE, Payne MJ. Elongation of columella by flap transfer and Z-plasty. Plast Reconstr Surg 1957;20:466; with permission.)

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dome on the cleft side. She underwent revision of the scarred lip, and during open rhinoplasty, elevation of the dome on the cleft side, a columellar strut, and cartilage graft for the tip projection were performed. Preoperative, intraoperative, and immediate postoperative photographs are presented (Fig. 12).

Fig. 8. Lengthening the columella. Method of correcting the flat nasal tip with short columella. (A) Bipedicle flaps of skin and subcutaneous tissue in the floor of the nostrils are based medially on the columella and laterally on the alae. A wedge of skin removed from the lower part of each ala diminishes the vertical length of the ala. (B) Freely mobilized flaps are advanced medially and sutured together in the midline to provide the desired increase in the length of the columella. Triangles of skin on the upper lip, as shown in (A), have been resected because redundant skin is present on the lip when the alae are transferred medially. (From Cronin TD. Lengthening columella by use of skin from nasal floor and alae. Plast Reconstr Surg 1958;21:417; with permission.)

Bilateral cleft nose deformity The bilateral cleft nose deformity (see box) depends on the severity of the cleft. The more deformed the dental arch, the more pronounced the nasal deformity. A partial cleft lip and symmetrical cleft spares the nose of profound nasal deformity; however, many bilateral cleft lip deformities are asymmetrical.

Features of bilateral cleft nasal deformity

 Medial crura are displaced laterally

floor a flap from the nasal floor may be transposed to the lateral aspect of the alar base. Case 1 shows an 18-year-old woman who had her lip repaired in childhood. Note the short columella, the deformity of alar cartilage, and the depressed

 

with bases partially submerged in the prolabium Alar domes are laterally displaced, and the angle between medial and lateral crura is obtuse, which results in broad and bifid tip The lateral crura are displaced downward, which causes hooding of the nostril. Alar cartilage may protrude in the vestibule Alar bases are displaced laterally, which causes bilateral flattening of alar-facial angle and wide nostril floor Nasolabial fistulas may be present The position of cartilaginous septum depends on the asymmetry of the cleft deformity

A patient who presents in adolescence for repair of bilateral cleft lip nose deformity can pose a problem. Usually these patients have the cleft lip and palate repaired in childhood. Three basic areas must be addressed in these patients: 1. The columella may be short or nonexistent in the horizontal direction. 2. The nostril floor is wide, and there may be an oronasal fistula. 3. The nasal tip needs projection and definition.

Fig. 9. (A) Diamond-shaped excision. (B) V-Y advancement of the tip. (C) Bilateral alar wing flaps. (From Converse and McCarthy, Reconstructive Plastic Surgery, 2nd Edition, Philadelphia: W.B. Saunders Company, with permission.)

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An adolescent cleft nose deformity that remains after cleft lip surgery can be treated at any time a patient presents. Prerequisites include having a premaxilla and lateral maxillary segment that are stable and in an arch with good occlusion with the mandibular arch, ensuring that the upper and lower lips are in harmonious relation, and ensuring adequate orbicularis oris muscle approximation. A plan should be made for each individual patient and it should be carried out in a sequence (Figs. 2 13). Columella A short columella may be lengthened by several methods. When the lip scar requires revision, the Millard technique using a forked flap gives excellent results. Cronin and Upton recommended a composite graft from the ear to lengthening of columella. When tissue at the nasal tip is adequate but the floor of the nose is deficient, flaps from alar rims can be advanced in the columella. Most of the lengthened columella requires columellar strut for support. Nostrils The nostril sill may require narrowing. The same procedures for correcting a flared nostril can be used for this purpose with excellent results. Increasing the width of the nostril floor can be accomplished by

Fig. 11. Correction of the wide flaring nostrils. (A) Flap b is raised from the floor of the nasal vestibule. An incision frees the alar base. (B) The alar base flap is rotated and the resulting defect is repaired by the transposition of flap b and a V-Y closure. (From Converse and McCarthy, Reconstructive Plastic Surgery, 2nd Edition, Philadelphia: W.B. Saunders Company, with permission.)

transferring tissue from the lateral aspect of the alar base to the nostril floor. Bifid nasal tip The open rhinoplasty technique is best suited for correcting a bifid tip. The domes should be sutured together and the tip graft should be added if tip projection must be improved. The caudal part of the septum may protrude in one of the nostrils, which may require resection. Deviation of the bony pyramid may require formal rhinoplasty. In case 2, an 18-year-old woman presented for correction of bilateral cleft nose deformity. She underwent several procedures to correct her lip deformity in the past. She had a short columella and

Fig. 10. Lengthening the columella. (A) Flat nose due to a short columella in a patient with bilateral cleft lip. (B) Flaps outlined on each nostril floor. (C,D) Flaps are elevated and advanced medially. (E) Suturing of the columella and closure of the secondary defects. (From Converse JM. Corrective surgery of the nasal tip. Laryngoscope 1957;67:16; with permission.)

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Fig. 12. 18 yr old female. (A-F) Cleft lip repaired in childhood, shows short columella, deformed alar cartilage and depressed dome on cleft side. Revision of scarred lip, elevation of dome columellar strut, and tip graft.

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Fig. 12 (continued ).

Fig. 13. 18 yr old female. (A-D) Several procedures for correction of bilateral cleft lip deformity. After Abbe flap, forked flap for columella and tip graft.

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Fig. 13 (continued ).

depressed tip. The Abbe flap for correction of tight upper lip was performed, and forked flaps from the upper lip were used to lengthen the columella. A columellar strut and tip graft were used for tip projection. Preoperative and postoperative photographs are presented (Fig. 13).

Summary The cleft lip nose deformity is a difficult surgical problem to correct. It is necessary to individualize a treatment plan to achieve optimum results. A spate of articles on this subject in the latter part of last century reveals that there is no simple surgical procedure to obtain a harmonious relation between lip and nose.

Acknowledgment The authors gratefully acknowledge technical assistance provided by Hugh Lawrence, PA-C, Harlem Hospital Center Surgery Service.

References
[1] Hogan VM, Converse JM. Secondary deformities of unilateral cleft lip and nose. In: Grabb WC, Rosenstein SE, Bzoch KR, editors. Cleft lip and palate. Boston: Little, Brown & Company; 1971 Chapter 47, p. 2178.

[2] Peyton WT, Ritchie HP. Quantitative studies on congenital clefts of the lip. Arch Surg 1936;33:1046. [3] Coupe TB, Subtelny JD. Cleft palate deficiency or displacement of tissue. Plast Reconstr Surg 1960; 26:600. [4] Huffman WC, Lierle D M. Studies on the pathological anatomy of the unilateral harelip nose. Plast Reconstr Surg 1949;4:225. [5] Stark RB, Kaplan JM. Development of the cleft lip nose. Plast Reconstr Surg 1973;51:413. [6] Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year experience. Plast Reconstr Surg 1986;77:559. [7] Bardach J, Salyer KE. Surgical techniques in cleft lip and palate. Chicago: Year Book Medical Publishers; 1987. [8] McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10 year review. Plast Reconstr Surg 1985;75:791. [9] Peet EW, Patterson TJS. The essentials of plastic surgery. Oxford: Blackwell Scientific; 1963. [10] Blair VP. Nasal deformities associated with congenital cleft of the lip. JAMA 1925;84:185. [11] Gillies H, Kilner TP. Hare lip: operation for correction of secondary deformities. Lancet 1932;2:1369. [12] Marcks KM, Trevaskis AE, Berg EM, Puchner G. Nasal defects associated with cleft lip deformity. Plast Reconstr Surg 1964;34:176. [13] McIndoe AH. Correction of alar deformity in cleft lip. Lancet 1938;1:607. [14] Brown JB, McDowell F. Secondary repair of cleft lips and their nasal deformities. Ann Surg 1941;114:101. [15] OConner GB, McGregor MW, Tolleth H. The nasal problems in cleft lips. Surg Gynecol Obstet 1968; 116:503.