Cleft rhinoplasty

© Ramaiah University of Applied Sciences
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Faculty of Dental Sciences
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CLEFT RHINOPLASTY

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Contents
• Introduction
• History
• Problem
• Embryology
• Relevant anatomy
• Unilateral cleft lip nose
deformity
• Bilateral cleft lip nose
deformity
• Treatment
Timing
Presurgical naso-alveolar
moulding
Primary rhinoplast
Secondary rhinoplasty
Definative rhinoplasty
Surgical techniques
• Summary

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INTRODUCTION
• (Rhinos, "Nose" + Plastikos, "to shape")
• Surgery to alter the shape of the nose sometimes using tissue (
(skin, cartilage or bone) from elsewhere in the body or artificial
implants
• Blair and Brown first described the cleft nose in 1931, critically
identifying the nuances of the pathology.

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• Deformity may be severely asymmetric, making surgical
correction difficult.
• Patients with cleft lip may have been previously subjected to
numerous surgical interventions, leading to significant scar
tissue in the operative site
• Conversely, the surgery may adversely compromise nose
growth

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HISTORY OF THE PROCEDURE
• Cleft lip nasal deformity has received less attention than
primary lip repair or has been ignored altogether.
• Rhinoplasty for cleft lip was introduced in the 20th century.
• Most modern techniques had already been described by the
1920s-1940s, but with less refinement (leaving a conspicuous
scar).
• Currently, the literature offers numerous opinions regarding
the best surgical approach and timing of intervention

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PROBLEM
• cosmetic problems
• impaired nasal airflow
• septal deflections, atretic nostrils, turbinate hypertrophy, and cleft
lips and palates.
• Warren et al showed that children with unilateral cleft deformity
have smaller airways than children with bilateral cleft deformity.
• Although the cleft nose grows as the patient ages, it remains 30%
smaller than that of patients without cleft lip deformity.

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EMBRYOLOGY
• During normal development, the paired
median nasal processes fuse to form the
premaxilla,philtrum, columella, and nasal
tip.
• The bilateral maxillary processes form the
lateral aspects of the upper lip
• Cleft lip deformities result from a failure
of the fusion of the median nasal
processes with the maxillary processes

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• Interuption of this embryonic process creates malformation of
some or all of the upper lip, central alveolus, and primary
palate
• The extent of the associated cleft nasal deformity is related to
the extent of the interruption of the normal developmental
fusion process
• Even though the nasal defects may be subtle there is always a
nasal abnormality associated with cleft lips

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RELEVANT ANATOMY

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RELEVANT CLEFT ANATOMY
• The ala rests on an underdeveloped
premaxilla, which partly accounts for
alar base lowering and horizontal
nostril seating.
• Bone growth is retarded on the cleft
side
• nasal bones and the nasal process of
the maxilla are underdeveloped,
causing the nasal dorsum to tilt to the
cleft side

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• The ala is often underdeveloped
• dome lowering on the cleft side.
• the columella is foreshortened and lies
obliquely, with its base directed away from the
cleft side.
• The septum may lie outside of the maxillary
crest seat, and the cartilaginous portion may
be buckled, both of which may cause nasal tip
deviation.

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• Studies have confirmed the presence of
significant septal deviation in patients with
bilateral cleft lip when compared to patients
without bilateral cleft lip.
• The septum tends to deviate toward the cleft
side, with the cartilaginous base displaced off
of the maxillary crest toward the cleft side.
• This septum malposition contributes to nasal
tip tilt toward the noncleft side

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Unilateral cleft lip nose deformity
• the maxilla on the cleft side is deficient.
• Because of this, the alar base on the cleft side does not not
fuse in the midline and is positioned more posterior, lateral,
and inferior than the alar base on the noncleft side.

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• Consequently, the lateral crus of the lower lateral cartilage on the cleft
side is lengthened and the medial crura is shortened in relation to the
Lower Lateral Cartilage on the noncleft side.
• The septum is attached to the noncleft maxilla inferiorly, which causes
the septum to be deviated to the noncleft side caudally, and bowing
dorsally toward the cleft side.

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• the abnormal insertion
of the orbicularis oris
muscle causes an
asymmetric pull on the
caudal septum.
• characteristic anterior
septal deflection to the
noncleft side

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Bilateral Cleft Lip Nose Deformity
• the maxilla is deficient bilaterally,
which allows the prolabium to have
unopposed anterior growth.
• The alar bases are displaced in a
more posterior, lateral, and inferior
position
• The deficient skeletal base leads to
longer lateral crura bilaterally and
short, splayed medial crura.
• This creates an underprojected,
broad, and flat nasal tip.

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• The columella is short because of the
malposition of the prolabium and the
shortening of the medial crura.
• The short columella makes the broad
and snubbed nasal tip even more
pronounced.

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• Bilateral insertion of the orbicularis oris musculature into the
alar base contributes to the widening of the nose and
flattening of the lower lateral cartilage

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Timing of the Cleft Nasal Repair
• The decision to perform early nasal surgery is based on several
factors.
• The extent of the deformity and the potential scarring and
impact of the procedure on nasal growth.
• Advantages of early surgical intervention include minimizing
the deformity as the child grows, lessening asymmetries to
allow optimal nasal growth, and creating favorable conditions
for future surgery.

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• Historically, controversy has existed as to whether primary tip
rhinoplasty was a positive influence on the eventual
appearance of the nose in patients with clefts.
• Major septal work and cartilaginous dissection has been
thought to negatively affect nasal growth.
• However, no experimental or clinical studies have ever proved
that minor manipulations (without resection) of the nasal tip or
nasal base interfere with future nasal growth.

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• Ideal repair of a cleft nasal deformity is performed in 2 stages.
• The first includes alteration in the nose at the time of lip repair
(primary rhinoplasty), delaying a definitive repair until the
patient has completed facial growth (secondary rhinoplasty).
• In female patients, secondary rhinoplasty is generally
performed around 15 to 17 years of age, and in male patients
at approximately 16 to 18 years of age.

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Presurgical Nasoalveolar Molding
• Presurgical nasoalveolar molding (PNAM) can be used in
patients with wide or very asymmetric clefts
• reposition the malaligned alveolar segments
• narrow the cleft gap
• improve nasal tip symmetry in unilateral clefts
• elongate the columella
• expand the nasal soft tissues in bilateral clefts

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• PNAM uses an intraoral alveolar
molding device with nasal molding
prongs.
• lessen the tension across the lip
wound and lessen the nasal
deformity.
• Primary rhinoplasty can then be
performed to improve nasal
appearance and optimize nasal
growth.

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• Cutting et al. have shown nasoalveolar molding to be a
useful presurgical orthopedic method
• For many surgeons, the use of nasoalveolar molding is
unrealistic because it does not have the necessary
prosthedontic or orthodontic support.

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• Millard and Latham- pin-retained
orthopedic device (the Latham appliance)
for maxillary molding.
• The screw is activated by the parents and
the segments move into alignment in
approximately 3 to 6 weeks, depending on
the width of the cleft.
• Once the maxillary segments have been
positioned to within 2 to 3 mm
apart,Millard’s technique is performed
along with periostioplasty, thereby
creating a periostial bone tunnel across
the bony cleft.
• Reduces the need for secondary alveolar
bone grafting.

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Primary Rhinoplasty
• The purpose of primary rhinoplasty is to close the anterior
nasal floor, to relocate the displaced alar base, and to bring
early symmetry to the nasal base and tip.
• This approach allows for both a functional and aesthetic
improvement without jeopardizing nasal and facial growth.
• After the cleft lip incisions are made and the primary lip
dissection is completed, the muscle and soft tissues of the alar
base are separated from their maxillary attachments.
• The malpositioned alar base is freed by creating an internal
alotomy at the anterior head of the inferior turbinate.
• If adequate soft tissue dissection of the alar base is performed,
the cleft alar base can be repositioned (during closure) in the
optimal three dimensional position

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• Care is taken not to
violate the vestibular
skin, avoiding the
complication of
secondary adhesions
and nostril stenosis.

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• This closure is first started with
reapproximation of the musculature
of the nasal base, which allows the
cleft alar base to be reconstructed in
a manner that mirrors the noncleft
alar base.
• It is important not to narrow the sill
too much.
• A nasal base that is too wide is easy
to narrow secondarily, whereas a
stenotic sill is difficult to widen later.

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• The other component of primary cleft
rhinoplasty is to reposition the cleft
nasal tip into a more projected,
symmetric position.
• The resulting nasal tip is more
symmetric, defined, and projected

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Intermediate Rhinoplasty
• Intermediate rhinoplasty is defined as any nasal surgery
performed between the time of initial lip repair and the time of
definitive rhinoplasty when the patient reaches facial skeletal
maturity.
• Rarely used as surgeons have become more adept at primary
rhinoplasty.
• However, many patients have significant nasal deformities that
have not been adequately repaired after their initial cleft lip
procedures.
• In these cases, performing intermediate rhinoplasty minimizes
the social stigmata associated with a more noticeable nasal
deformity.

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Secondary (Definitive) Rhinoplasty
• Once the patient has reached facial skeletal maturity, definitive
septorhinoplasty can be performed.
• Structural reconstruction of the cleft nose often requires
cartilage grafting material from the rib or septum to achieve
adequate support.

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The goals of the secondary rhinoplasty are
• the creation of symmetry
• definition of the nasal base and tip
• relief of nasal obstruction
• management of nasal scarring and webbing.

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SURGICAL TECHNIQUES Approaches
• The approach to definitive cleft septorhinoplasty varies
according to surgeon preference and the requirements of the
reconstruction.
• These treatment goals include septal reconstruction and
treatment of the nasal tip, alar rim, alar base, columella, and
nasal sill.
• In most instances, all these goals can be corrected by using
either the external or endonasal approach.

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open or external approach.
• inverted-V columellar incision.
• When there is significant lack of columellar soft tissue in
unilateral clefting, the incision can be modified onto the cleft
lip with a V-to-Y closure to increase columellar soft tissue.

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• Bilateral incisions starting just anterior to
the medial crura and extending from the
dome to the mid columellar region with an
inverted V incision [vertical limb of the V
should be longer on the cleft side]
• dissect across the columella between the
skin and anterior edge of the medial crura
• The columellar flap is retracted with a
double skin hook. Dissection is extended to
the septal angle and along the nasal
dorsum upto the caudal end of the nasal
bones.

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• Septoplasty or septal repositioning.
• Alar cartilages are exposed using
hydrodissection.
• Cephalic trimming of the alar
cartilages is done on either sides &
they are hitched together
• Spreader grafts are positioned
between the nasal septum & the
upper lateral cartilages opposite the
side of the nasal septal deviation &
secured using 5-0 prolene suture

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• Columellar strut graft is positioned to
support the nasal tip.
• For a supra tip support, a minced
cartilage graft is used which is prepared
by crushing the small pieces of the
auricular cartilage in a cartilage
crusher.
• The minced cartilage is filled into the
space above the hitced alar cartilages
over the nasal dorsum & closure is
achieved with 5-0 prolene suture.

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Tajima’s Reverse U Approach:
the vertical limb of the V being longer than the noncleft side,
is extended superiorly along the nasal vestibule, till the nasal
tip to extend along the nasal skin laterally along the ala of the
nose about 3mm superior to the alar rim to end at about
2/3rds the distance towards the alar base.

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Sliding chondrocutaneous flap.
• Wang and Madorsky, called the sliding flap cheliorhinoplasty
• This flap provides additional tissue to augment the vestibular
lining and reduce the alar-columellar web, and, when
combined with the open rhinoplasty, the chondrocutaneous
flap can permit tip stability and lip refinement.

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• Two parallel markings are then made
along the previous philtral scar into the
nostril rim,incorporating the alar web.
• The medial philtral incision begins in the
lip and extends to the marginal incision of
the columella.
• The marginal incision connects with the
alar web incision then recedes laterally
into the vestibule to connect with the
lateral marginal incision.
• The lateral philtral incision also begins in
the lip and extends into the
hemitransfixion incision without
excessively narrowing the flap.
• The lateral incision extends further as an
intercartilagenous incision.

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• The columellar skin and soft tissue
envelope are raised,allowing for
adequate exposure.
• The chondrocutaneous flap is
dissected off the orbicularis oris
muscle,the contralateral medial crus,
and the muscles overlying the dome
and lateral crus

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• The composite flap is then advanced
superiorly and laterally to match the
dome of the NCS and sutured to a
columellar strut.
• If the alar web skin is excessive for
the proper vestibular lining,it is
trimmed accordingly.
• A shield tip graft is used for tip
definition and structural tip support

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Closed or endonasal approach
• The advantages of the endonasal approach include maintaining an intact
skin–soft tissue envelope.
• When cartilaginous grafts are placed under an intact envelope, the surgeon is
better able to immediately visualize the impact of the graft on the eventual
nasal contour.
• maintenance of vascular supply to the skin, allowing increased tension when
placing structural grafts.
• With the open approach, lengthening or projecting grafts can make eventual
wound closure difficult.
• Multiple endonasal incisions (transfixion, infracartilaginous, and
intercartilaginous) are often used to obtain adequate exposure to correct the
deformity

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• The intercartilaginous incision divides the junction of the upper and lower
lateral cartilages.
• The ala is retracted using a double skin hook.
• An incision is made along the inferior border of the upper lateral cartilage.
• The incision is then curved towards the septum where it meets the
transfixion incision.

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The transfixion incision is a through and through incision made at
the caudal end of the septal cartilage.
A subperichondrial dissection can be carried out on one or both
sides of the septum.

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Cartilage exposure
Pointed scissors can be used for subperichondrial dissection through the
intercartilaginous and transfixion incisions.
This illustration shows the dissection through the intercartilaginous
incision.

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Exposure of the nasal dorsum and root
Access to the nasal dorsum and the root of the nose is obtained
through the intercartilaginous incision.

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Septal Reconstruction
• In the unilateral cleft deformity, the asymmetric unopposed
pull of the orbicularis oris muscles and the deficient bony
maxilla causes the septum to deviate to the noncleft side
anteriorly.
• In the bilateral cleft lip deformity, the nasal septum is usually
midline, being deviated caudally to the less involved side if
asymmetry of the lip exists.
• Complete septal reconstruction requires adequate exposure
and complete breakdown of the ligamentous attachments that
contribute to the septal deviation.
• The septum can be approached by either an open or endonasal
approach.

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• If the septal support is not sufficient after resection of the
deviated segments, reconstruction with cartilage grafts is
needed to maintain adequate central segment support.
• Septal support can be achieved with a variety of grafting
methods.
• The septum can be supported with a caudal septal extension
graft or a caudal batten graft
• These grafts can be fashioned from different autologous
materials (septal cartilage, costal cartilage, ethmoid plate
bone).
• The Septal extension graft can be sutured to the caudal end of
the existing septum in an end-to-end or end-to-side technique

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Columellar deformity
• columella has a retracted appearance
• reseating the nasal ala in an anterior-posterior oval is thought to
naturally elongate the columella.-Blair
• The Ivy modification - laterally based nostril rim flap
• rotated medially and anteriorly
• lengthen the columella by repositioning the nasal ala.

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• Dingman technique - columellar and alar-based flap
• Rotated medially
• Nostril is also rotated via columellar and alar-based flap.

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• V-Y advancement flap
• lengthens the columella if adequate columellar width and
upper lip tissue are present

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• anteriorly pedicled rectangular flap
• provide greater length

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• The 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

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• The Cronin procedure
• Anteriorly based bilobed flap is advanced anteriorly and
posteriorly based columellar flap is advanced posteriorly

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• When the columella is completely absent a more radical
reconstruction is required .
• The upper lip is the ideal donor site for reconstruction.
• However, the upper lip is often scarred or deficient secondary
to cleft lip.
• Lower lip tissue may be transferred to the columella, or
nasolabial flaps may be recruited.
• A full-thickness skin graft may be buried below upper lip skin
for use in reconstructing the columella (ie, Ferris-Smith
technique)

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• A full-thickness skin graft is buried below upper lip skin
• Ferris-Smith technique

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• The Serre method
• Repair of the total columellar loss
• Doubled full thickness skin graft is
buried beneath upper lip skin and
rotated into place

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Treatment of the Nasal Tip
• The nasal tip in patients with congenital clefting of the lip is
poorly supported.
• In the unilateral deformity, the tip is asymmetric secondary to
the short medial crus on the cleft side
• In the bilateral deformity, the tip is usually underprojected and
the columella is short.
• Tip techniques are therefore designed to improve tip
symmetry, definition, and projection.

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• After the nasal septum is straightened and supported, the
nasal tip can be resuspended on the septum to improve tip
support and projection.
• This technique, termed the tongue-in-groove (TIG) technique,
allows the tip to be projected, deprojected, lengthened, or
shortened.
• In most clefts, the cleft side nasal tip needs projection and
rotation, because the secondary nasal deformity usually has
underprojection and hooding of the cleft tip.
• The TIG technique involves suture fixation of the medial crura
of the LLCs to the caudal end of the nasal septum.
• Typically, the cleft side alar cartilage has to be advanced more
than the noncleft side to improve the flattening of the cleft LLC
and enhance overall tip symmetry.

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• Another method used to
improve support and
projection is the columellar
strut cartilage graft.
• The columellar strut graft is a
sturdy piece of cartilage that
is placed between the medial
crura of the LLCs.
• The medial crura can be
advanced on this graft and
suture fixated to enhance
projection and support.

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Treatment of the Cleft Alar Rim
• The cleft side lateral crus of the
Lower Lateral Cartilage is usually
concave.
• This concavity is often associated
with alar malposition, with the
cartilage often being inferiorly
displaced in relation to the
position of the noncleft side LLC.
• The concavity of the alar rim
often causes external nasal valve
collapse and a functional nasal
deformity.

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• Treatment of the malpositioned alar rim can be accomplished
with a variety of techniques, including cartilage grafting and/or
suture repositioning.
• The cleft side lateral crus can be supported with
• (1) an alar rim graft
• (2) an alar strut graft
• (3) an alar turn-in flap
• (4) excision and turnover of the entire lateral crus of the LLC
with resuturing of the segment (the so-called flip-flop of the
LLC)

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Incomplete sill closure
• This defect occurs when the superior
portion of the orbicularis oris muscle is
incompletely closed.
• This defect causes a lack of symmetry of the
alar base at the level of the nasal sill.
• Reconstruction of this deformity requires
reopening of the superior aspect of the lip
and realignment of the muscle.
• a dermal flap can be added to augment the
base of the nose at the nasal sill.
• If the patient has a small deficiency at the
nasal sill and does not want surgery,
augmentation with injectable fillers can help
with nasal base symmetry

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SUMMARY
• The nose in patients with congenital cleft malformations is
often the facial feature that is most noticeable to the observer.
• The secondary nasal deformity is variable and is affected by the
extent of the original cleft, growth, and by any intervening
surgery to correct the lip or nose.
• Repair of secondary cleft nasal deformities is challenging.
• Successful reconstruction requires an understanding of the
pathologic anatomy, adequate exposure to perform
techniques, and attention to structural grafting to overcome
scarring and provide support.
• Often, graft material from the septum, rib, and/or ear is
required. Attention must be paid to both function and
appearance

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References
• Definitive Cleft Rhinoplasty for Unilateral Cleft Nasal
Deformity-MyriamLoyo
• Repair of the Unilateral Cleft Lip/Nose Deformity- J. Madison
Clark
• Rhinoplasty in adolescent cleft patients- Deodatta V.
• Cleft lip nose- sykes et al. journal of clinical plastic surgery
• Cleft Nasal Deformity and Rhinoplasty-Yoav Kaufman ;
paediatric plastic surgery journal
• SecondaryCleftRhinoplasty- SachinS et al ; JAMA facial plastic
surgery
• UNILATERAL CLEET RHINOPLASTY A Review - Simon J.
Madorsky ; otorhinolaryngology clinics of north america

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