Cleft Lip Rhinoplasty
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Definitive Rhinoplasty for Adult Cleft Lip Nasal Deformity §
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The cleft nasal deformity is a three-dimensional abnormality involving all layers of the nose, beginning with the skeletal platform and extending into the vestibular lining, cartilaginous infrastructure, and external nasal skin.2 The fact that cleft noses have abnormalities in all tissue layers separates them in kind and difficulty from most cosmetic rhinoplasties. At adolescence the nasal bones, ULCʼs, and septum begin to rapidly expand anteriorly and vertically. At the same time the LLCʼs (alar cartilages) become more convoluted until they take on the adult dimensions and the specific, complex, mirror image forms that make an adult nose appear normal, deformed, beautiful, or ugly. Children with significant secondary cleft lip nasal deformities have to be rebuilt with cartilage grafts after the adolescence period has passed (at age 15 in females and 17 in males). Open rhinoplasty after the nose has reached adult proportions allows the surgeons to construct a new alar cartilage framework over the hypoplastic alar cartilage and rebuild a new tip. This often requires grafts from the nasal septum (strong hyaline cartilage but short supply), conchae of the ears (relatively weak), or costal cartilages (choice for larger reconstructions requiring strong anterior projection). The goals of septorhinoplasty are to maximize functional nasal breathing and to optimize nasal and facial appearance. In most cases, the skeletal foundation, both dental and craniofacial, should be stabilized before performing definitive nasal surgery.
Physical Examination § § § § § § § § § § § § § §
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Assess the entire face starting from the forehead and proceeding to the mid and lower face. Many patients have asymmetry involving parts other than the nose and the lip. Lip symmetry and the height of the lip on both halves should be measured. Definition and symmetry of the mucocutaneous junction of the lip is important. The red lip should be evaluated for its volume and symmetry on both the front and profile views. The lower face is then observed for any chin disharmony. Special attention is devoted to the midface area, because midface hypoplasia, especially maxillary retrognathia, is a common feature of a cleft lip nasal deformity. The oral cavity is evaluated for the presence of the alveolar cleft. Bone deficiency in the paranasal region plays an important role in a successful cleft lip rhinoplasty. The occlusal abnormalities and the number of missing teeth are assessed and recorded. The profile alignment and the position of the chin are then noted. It is only after assessment of the entire face that the nose is examined in detail. The skin is first checked for its thickness. The nasal bones are examined for symmetry, length, and distance from the midline. The midvault is observed for upper lateral cartilage collapse and vertical symmetry. The shape of the nasal tip is then defined as being bulbous, boxy, narrow, or having a parenthesis deformity. Other nasal tip flaws such as asymmetry or fullness are then identified. The alar base width is determined and the thickness of the ala is compared between the two sides. The vertical position of the ala is also evaluated. The configuration of the nasal sill is observed on the front view. On the profile view, the depth of the radix, presence or absence of a dorsal hump, tip projection, and nasolabial angle is noted and documented bilaterally. The basilar view is critical for assessing the position of the nasal tip, the infratip lobule size and symmetry, shape and symmetry of the nostril length, direction of the columella, shape of the ala, and the position and symmetry of the nostril sill. The internal nose examination should include observation of stenosis of the internal and external valves, presence or absence of a deviated septum, size and shape of the turbinates, presence of synechiae, and septal perforation.
Anesthesia §
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The majority of patients who undergo cleft lip nose correction are considered American Society of Anesthesiologists class I anesthesia risk because of their youth and good health. Seldom do patients who are undergoing this type of surgery represent a high anesthesia risk, unless the cleft lip nasal deformity is associated with cardiopulmonary abnormalities. General anesthesia is preferred for the majority of patients who undergo comprehensive septoplasty and cleft lip rhinoplasty to provide a safe airway, reduce the potential for surgeon distraction, and ensure airway patency.
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The duration of surgery can range significantly, depending on the magnitude of the problem and the surgeonʼs experience. If the length of surgery exceeds 1.5 hours, it is prudent to reinject the nose with vasoconstrictive and long-lasting local anesthetic agents to afford more lasting patient comfort and lighter anesthesia, and to minimize bleeding during surgery and immediately postoperatively.
Surgical Technique
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One of the most important aspects of cleft lip rhinoplasty is the creation of a symmetric and ideally positioned maxilla, without which the outcome of rhinoplasty, no matter how well it is done, will not be optimal. § If orthognathic surgery, bone graft to the alveolar cleft site, or maxillary Incision augmentation is planned, it should be completed first.
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Because of asymmetry in the nasal frame, the majority of the cleft lip related nasal deformities are more successfully corrected through an open technique. Transverse columellar incision with central dentate flap placed between the anterior 1/3 and posterior 2/3 of the columella, at the narrowest point (waist) Incision extended superiorly 2.5 mm behind lateral edges of columella, Columella incision deepened to the middle crura of the alar cartilages with fine scissors while protecting middle crura from injury. Paired septal (columellar) branches of the superior labial arteries identified and cauterized. As flap of skin and fat elevated off the middle and lateral crura of the alar cartilage, the internal incision is extended across the nasal vestibule following the inferior edge of the lateral crus of the alar cartilage. Alar cartilage visualised as flap elevated and vestibular tissue cut at inferior edge of lateral crus of LLC, releasing skin of the nasal tip. Flap of skin and fat elevated off of perichondrium and periosteum of nasal cartilages and bones. The nature of the remaining operation varies tremendously from patient to patient.
Freeing the Deformed Alar Cartilage §
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Many patients require removal of a dorsal hump and reduction of the radix. Many patients with a cleft lip nasal deformity require nasal bone osteotomy. Almost invariably, there is some degree of asymmetry in the nasal bones, with the bones being widely and asymmetrically splayed. This may require a wedge osteotomy between the nasal bone and the midline structures to allow for medial repositioning of the nasal wall.
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The upper lateral cartilages are commonly disparate and require correction through separation, trimming, and repositioning. Most cleft lip noses would benefit from spreader grafts following reduction of the dorsal hump and osteotomy.
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Commonly, the dome on the affected side is posterior; the lateral crus extends laterally; and almost invariably, the medial crus is shorter than ideal, causing length deficiency in the columella. Extensively release deformed cleft sided LLC from its attachments to the maxilla in order to adequate reshape the cleft side ala. Cartilage and vestibular lining released from the bony edge of the widened piriform aperature as VY plasty, so that the nasal vestibule and alar margin can be projected anteriorly and also reshaped. In the case of excessively flimsy cartilage, buttressing with cartilage grafts needed to restore shape.
Nasal Tip Support §
Strong alar cartilages and tip support are needed to brace the alar cartilages and hold the nasal skin envelope in its normal dimensions and shape.
Spreader grafts § § § § § § § § § §
Straighten nasal dorsum, increase dorsum height, open internal valve. Spread the upper lateral cartilages apart and thus widen the anterior part of the nasal airway and the nasal dorsum. 1.7 – 3.0 cm long, 4 mm deep, and 1.5 mm wide. ULCʼs released from septum, trimmed, and dorsum adjusted as necessary. Mucosal tunnels created at internal vlave. Septal cartilage harvested top down if indicated leaving 1.5 cm L-Strut for nasal support. Crooked septal cartilage compressed between spreader grafts to straighten septum on AP view, so septum in line with middle of upper lip. Spreader grafts fixated to septem with 27 gauge hypodermic needles and three layers (spreader-septum-spreader) sutured tightly together with 4.0 monofilament mattress sutures. ULCʼs are anchored to the straightened midline septum with 5.0 monofilament mattress sutures passed through all 5 laters of cartilage. Next, the framework of the nasal tip is constructed to project 6-8mm above the dorsal line of the septal cartilage.
Columellar strut grafts §
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A columella strut is the most efficacious means of supporting the tip. Use of a columella strut will (1) increase the tip projection; (2) elongate the columella on the cleft side; (3) augment the subnasale, which is often deficient; (4) increase the nasolabial angle; and (5) prevent the tip from shifting caudally. A columellar strut of cartilage (or bone), as well as lateral crural grafts, form a tripod that resists the deforming force and deprojection after surgery. Columellar strut inserted into a pocket that extends deep to the feet of the medial crura and fixated in this position with a transmucosal gut suture in order to fix the height and symmetry of the alar cartilage arches. All of these patients require suturing of the medial crura to the columella strut and approximation of the footplates to narrow the columella base. This also elongates the nostril, creates fullness of the subnasale, and increases the stability of the central limb of the nasal base tripod. The strut is then sutured to the cephaic edges of the LLC medial and middle crura with several 5.0 monofilament sutures, giving the nose a stiff, strongly supported tip structure. Intradomal, transdomal, and lateral crura sutures may be required.
Tip Reconstruction, Tip grafts, and Cap grafts §
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Tip (Sheen, shield) grafts give strength to the alar cartilages and may add projection to the nasal tip. Dimensions 12-16 mm long and 9-11 mm across the top, carved with edges smoothed. Most stable if sutured to the middle crura of the existing LLCʼs with a 6.0 material. A tip graft is used if the infratip lobule volume is inadequate. Tip graft can be placed with its anterior end not projecting (invisible) or with it projecting 1-3 mm (visible). A cap graft (5-7 mm high and 9-11 mm wide) can be sutured to the cephalic end of a projecting tip graft in order to blunt the sharp projection and blend the nasal tip and supratip regions. The nasal tip graft should project 6-8 mm above the dorsal line of the nasal cartilages
Lateral crural grafts § § §
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Deformities of the lateral crus are best managed by inserting a straight graft under the cephalic edge of the lateral crus after cephalic trim of the lateral crus. Dimensions 4-5 mm wide, 1-2 cm long IF the skin of the nasal tip has a layer of thick fat, then the lateral crural graft may be inserted on top of (anterior to) the lateral crus. By fastening the lateral crural graft snugly to the lateral crus with 5.0 mattress sutures, the lateral crus can be straightened and strengthened). Strong lateral crus graft will correct the alar slump, recreate a projecting alar arch, and open the airway. This graft may also be extended medially and sutured to the columellar strut to create a tripod support for the tip. It can be extended laterally to rest on the bony edge of the piriform aperature to stabilize the lateral crus against postoperative deforming forces.
Alar margin grafts (Batten) §
Small and narrow grafts (2-3 mm wide and 10-12 mm long) slid into pockets along the alar margin to correct the classic pinched nasal tip deformity and give the base of the nose a pyramidal shape.
Cartilage grafting with small, flimsy alar cartilage §
Hypolastic cartilage(s) can be constructed from cartilage grafts and anchored to the existing alar cartilages. New arches give symmetry, normal contour, and added projection to the tip of the nose.
Dorsal onlay grafts, Radix grafts §
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Dorsal onlay graft can elevate the nasal dorsum and narrow the nasofacial angle, made from septal cartilage, costal cartilage, or diced cartilage wrapped in temporal fascia (2.7 – 3.5 cm in length and 5mm in width). Radix graft narrows the nasofacial angle and straightens the dorsum (4-5 mm wide). Raising the radix allows the surgeon to create a straight dorsal line with only minimal resection of the dorsal hump. A radix graft also makes the nasofacial angle more acute and an overprojected nasal tip appear less so.
Premaxillary grafts § §
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Advances the nasal base anteriorly and opens an acute lip – nose angle. Solid graft placed through incision in floor of nasal vestibule just posterior to the nostril sill and is placed in a carefully dissected pocket between the floor of the nose and the gingivolabial sulcus inferiorly. Shaped as a bi-taped hemispindle, measuring approximately 2.5 cm long, 10 mm high, and 7-8 mm deep.
Additional maneuvers § §
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It is often necessary to reduce the thickness of the ala by removing some of the fibrofatty tissue, especially at the alar base and along the alar rim. Placement of an alar rim graft and application of two stents externally and internally that are fixed with a through-and through suture reduces the potential for recurrence of fibrofatty tissues and creates amore pleasing transition from the alar base to the tip. It is also commonly necessary to remove some of the soft triangle lining on the affected nostril to elongate and orient it more vertically. This maneuver has the most effective role in altering the shape of the nostril. Many of these patients would benefit from augmentation of the floor of the nostril and elevation of the nostril sill on the cleft side by placement of a cartilage graft. The alar bases are then narrowed as needed and repaired using 6-0 fast absorbable catgut. The step columellar incision is repaired meticulously using 6.0 sutures. Reduction of the turbinates, especially on the side contralateral to the deviation of the septum, provides improvement in the nasal airway. A nasal splint is applied for 7 to 8 days. The patients are asked to refrain from heavy exercise for 2 to 3 weeks and use of glasses for 4 to 5 weeks.
Complications and Outcomes § Intraoperative complications include bleeding and those related to anesthesia. § Early postoperative complications could include infection, which can be minimized by perioperative use of antibiotics. § Necrosis of the skin is extremely rare and, if it occurs, commonly associated with circulatory side effects of nicotine use. § Asymmetry after this type of surgery is common, and patients should be informed that they might require additional subsequent surgery. § Because of the nature of the operation and the underlying condition, there is a higher chance of nasal obstruction preoperatively and sometimes postoperatively. § Wound dehiscence is unlikely after a meticulous repair. § The most common late complication of this operation is asymmetry. This can be at the nasal bones, nasal vault, tip of the nose, and, most commonly, at the alar base and nostril. § The inability to produce sufficient nasal tip projection or loss of tip projection because of scarring is another common late complication resulting in supratip deformity and suboptimal tip definition. The tip of the nose can become bulbous if the operation is performed at an early age. § Septal deviation can also recur, or there could be some residual (uncorrected) septal deviation caused by the magnitude of the primary deformity. These should be documented at postoperative follow-up. § A high percentage of patients with cleft nose deformity may require additional procedures. § Documentation of the nature of subsequent surgery is crucial to aid in the assessment of the results to reduce the potential for revision. § Cleft lip rhinoplasty patients are usually very satisfied. § Overall, these are the patients who benefit from surgery tremendously and are often the most grateful.
Suggested Reading: Burget G. (2009) Definitive Rhinoplasty for Adult Cleft Lip Nasal Deformity. In: Losse J, Kirschner R: Comprehensive Cleft Care (pp. 499-524). McGraw-Hill Companies. Stykes J, Jang Y. Cleft Lip Rhinoplasty. Facial Plastic Surgery Clinics of North America 17 (1): 133-144. Guyuron B. MOC-PS(SM) CME article: late cleft lip nasal deformity. Plast Reconstr Surg. 2008 Apr;121(4 Suppl):1-11.
Suggested Reading: Staffel G. Bbasic Principles of Rhiniplasty. (1996) American Academy of Facial Plastic and Reconstructive Surgery. Toruimi D, Beker D. Rhinoplasty Dissection Manuel (1999). Philadelphia: Lippincott Williams & Wilkins . Howard B, Rohrich R. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002 Mar;109(3):1128-46; quiz 1145-6. Gunter J. Landecker A, Cochran C. Frequently used grafts in rhinoplasty: nomenclature and analysis. Plast Reconstr Surg. 2006 Jul;118(1):14e-29e. Daniel R. Mastering Rhinoplasty. (2010) Springer. Available at: http://books.google.com.co/books?id=Nvz4Zus0legC&pg=PA356&lpg=PA356&dq=ma stering+rhinoplasty+reference&source=bl&ots=HuqJrjnSD8&sig=6dZNcjc_0z0VSAas7Y W4i8fvrio&hl=en&sa=X&ei=_kheUYLsNoXm9ASvnoD4BA&redir_esc=y#v=onepage&q= mastering%20rhinoplasty%20reference&f=false