The cleft lip nasal deformity presents one of the greatest challenges for rhinoplasty surgeons. The reasons for this challenge are multiple, but are usually because of a combination of congenital anatomic aberrancy, surgical scarring from previous reconstructive attempts, and the inevitable effects of growth.
Over the past century, several techniques have been introduced for correction of the problems associated with cleft lip nasal deformity. The sheer number and variety of methods described in the literature serve as testament to the intrinsically difficult nature of this deformity. All of the techniques attempt to address some aspect of the problem. However, complete correction of all nasal deficiencies remains an elusive goal for many patients.
Clinical Presentation
To understand what a cleft rhinoplasty technique can accomplish, the secondary nasal deformity associated with the unilateral cleft lip must be established. This unilateral deformity results from tissue deficiency of the cleft lip, deficiency in the bony premaxilla, and abnormal muscular pull on the nasal structures. The unilateral secondary nasal deformity may manifest most, if not all, of the following features:
- The dome on the cleft side is retrodisplaced.
- The columella on the cleft side is foreshortened.
- The medial crus slumps laterally.
- The lower lateral cartilage (LLC) and the alar rim form a caudal hood.
- There is an alar-columellar “web.”
- There is insufficient vestibular skin in the region of the vestibular dome.
- The nostril orientation can vary because of lateralized alar base position and deficient nasal floor.
- The alar base displacement (lateral, inferior, and posterior) is universally present in the primary cleft deformity. This can be affected by primary lip repair, primary cleft rhinoplasty, and alveolar bone grafting.
- The caudal septum is deflected into the noncleft side, but the severity of the deflection is variable.
Surgical Treatment
Primary Unilateral Cleft Rhinoplasty
Primary nasal repair at the time of primary cleft lip repair can improve the cleft lip nasal deformity by achieving greater symmetry and improved overall long-term appearance of the nose. The primary lip repair is typically performed by age 3 months of age. All efforts are made to minimize nasal tissue trauma and scarring, which may unfavorably affect subsequent growth. In this regard, an effective method for primary unilateral cleft rhinoplasty involves unilateral LLC suspension via a limited dissection.
Specifically, an intercartilaginous incision is created on the cleft side. Elevation of the nasal dorsal soft tissue is performed over the ipsilateral and slightly over the contralateral upper lateral cartilages (ULC). The LLC are not undermined or dissected in any manner. This is to minimize any potential growth inhibition. Suspension sutures are then placed to reposition the dome and lateral crus of the LLC in a superior-medial vector. This can achieve correction of the retrodisplaced dome and elevation of the displaced (lateral, inferior, and posterior) alar base (Fig. 15–1).
Adequate correction from the primary procedure can lessen or eliminate the need for secondary cleft rhinoplasty.
Secondary Unilateral Cleft Rhinoplasty
Secondary nasal surgery includes both the intermediate and the definitive rhinoplasty. Intermediate rhinoplasty is performed before nasal growth is completed and is based on two separate timing strategies. Rhinoplasty at age 4 to 6 years is done to minimize social pressures from other children in school, sometimes concomitantly with lip revision for the same reasons. Waiting until 8 to 12 years of age and after completion of orthodontic alignment and alveolar bone grafting allows a better skeletal base for correction of severe nasal deformities. The intermediate rhinoplasty techniques in general are more conservative than those of definitive rhinoplasty.
The definitive rhinoplasty is performed when maxillary and nasal growth has been completed. This usually occurs between 16 and 18 years of age. Rhinoplasty performed in this timeframe allows for more aggressive septoplasty, osteotomies, and cartilage grafting maneuvers. Each patient requires an individualized approach to timing of secondary rhinoplasty based on the severity of soft tissue and skeletal deformities.
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