Rhinoplasty in Clefts: An 18-Year Retrospective Review

Abstract

Cleft rhinoplasty has spurred much interest in literature because of the difficult task in obtaining a normal nasal form, function, and development. The pursuit of perfection has resulted in myriad techniques, modifications, and innovations to optimize results, but no one protocol or algorithm was proved to be completely satisfactory. Controversies still exist in timing, surgical approach, nonsurgical techniques, and outcome assessment. This article submits a humble contribution that might hopefully help in reaching consensus. Throughout a period of 18 years, 800 patients with different ages and types of clefts were managed by single surgeon using various procedures to correct their nasal deformities. These procedures included preoperative naso-alveolar molding, gingivoperiosteoplasty, primary closed or open rhinoplasty, postoperative nasal stents and nasal molding, and secondary open septorhinoplasty. The outcome was judged by panel assessment and computer-assisted anthropometry. Clinical results were satisfactory for most patients, parents, and surgeon panel. Computer-assisted anthropometry proved helpful in outcome assessment and analysis. Cleft rhinoplasty is neither optional nor separable from cleft lip repair. It requires clear perception of the complex pathogenesis and the governing dynamics of the cleft deformity. A perfect nose with no deformity is unusual, but a reasonably good result is attainable when the principles of nasal repair are fully grasped and faithfully applied.

Keywords

cleft palate - cleft lip nose - nasal deformities - nasal reconstruction - primary cleft rhinoplasty - secondary cleft rhinoplasty

• References

• 1 Chang HP, Chuang MC, Yang YH , et al. Maxillofacial growth in children with unilateral cleft lip and palate following secondary alveolar bone grafting: an interim evaluation. Plast Reconstr Surg 2005; 115 (3) 687-695
• 2 Gubisch W. The triple swing flap technique to correct the asymmetry of unilateral cleft lip nose deformities. Scand J Plast Reconstr Surg Hand Surg 1998; 32 (3) 287-294
• 3 Randall P. History of cleft lip nasal repair. Cleft Palate Craniofac J 1992; 29 (6) 527-530
• 4 Rifley W, Thaller SR. The residual cleft lip nasal deformity. An anatomic approach. Clin Plast Surg 1996; 23 (1) 81-92
• 5 Fisher DM, Mann RJ. A model for the cleft lip nasal deformity. Plast Reconstr Surg 1998; 101 (6) 1448-1456
• 6 Sykes JM. Surgical management of the cleft lip nasal deformity. Otolaryngol Head Neck Surg 2000; 8 (1) 54-57
• 7 Brussé CA, Van der Werff JF, Stevens HP , et al. Symmetry and morbidity assessment of unilateral complete cleft lip nose corrected with or without primary nasal correction. Cleft Palate Craniofac J 1999; 36 (4) 361-366
• 8 Kaufman Y, Buchanan EP, Wolfswinkel EM, Weathers WM, Stal S. Cleft nasal deformity and rhinoplasty. Semin Plast Surg 2012; 26 (4) 184-190
• 9 Pawar SS, Wang TD. Secondary cleft rhinoplasty. JAMA Facial Plast Surg 2014; 16 (1) 58-63
• 10 Van Beek AL, Hatfield AS, Schnepf E. Cleft rhinoplasty. Plast Reconstr Surg 2004; 114 (4) 57e-69e
• 11 Balaji SM. One-stage correction of severe nasal deformity associated with a unilateral cleft lip. Scand J Plast Reconstr Surg Hand Surg 2003; 37 (6) 332-338
• 12 Sykes JM, Senders CW. Pathologic anatomy of cleft lip, palate, and nasal deformities. In: Meyers A, , ed., Biological Basis of Facial Plastic Surgery. New York: Thieme Medical Publishers; 1993: 57-71
• 13 Armstrong GT, Burk III RW, Griffin DW, Howard PS. A modification of the primary nasal correction in the rotation-advancement unilateral cleft lip repair. Ann Plast Surg 1997; 38 (3) 236-245
• 14 Kim SK, Cha BH, Lee KC, Park JM. Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation. Plast Reconstr Surg 2004; 114 (6) 1373-1381
• 15 LaRossa D, Donath G. Primary nasoplasty in unilateral and bilateral cleft nasal deformity. Clin Plast Surg 1993; 20 (4) 781-791
• 16 Rettinger G, O'Connell M. The nasal base in cleft lip rhinoplasty. Facial Plast Surg 2002; 18 (3) 165-178
• 17 Clark JM, Skoner JM, Wang TD. Repair of the unilateral cleft lip/nose deformity. Facial Plast Surg 2003; 19 (1) 29-40
• 18 Huffman WC, Lierle DM. Studies on the pathologic anatomy of the unilateral harelip nose. Plast Reconstr Surg (1946) 1949; 4 (3) 225-234
• 19 Broadbent TR, Woolf RM. Cleft lip nasal deformity. Ann Plast Surg 1984; 12 (3) 216-234
• 20 Stenstrom SJ, Oberg TRH. The nasal deformity in unilateral cleft lip. Some notes on its anatomic bases and secondary operative treatment. Plast Reconstr Surg Transplant Bull 1961; 28: 295-305
• 21 Jackson IT, Fasching MC. Secondary deformities of cleft lip, nose, and cleft palate. In: McCarthy J, , ed., Plastic Surgery. Philadelphia, PA: WB Saunders; 1990: 2771-2777
• 22 Shih CW, Sykes JM. Correction of the cleft-lip nasal deformity. Facial Plast Surg 2002; 18 (4) 253-262
• 23 Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year experience. Plast Reconstr Surg 1986; 77 (4) 558-568
• 24 Burt JD, Byrd HS. Cleft lip: unilateral primary deformities. Plast Reconstr Surg 2000; 105 (3) 1043-1055 , quiz 1056–1057
• 25 Morselli PG. The anchor of the nasal ala in cleft lip-nose patients: a morphological description and a new surgical approach. Cleft Palate Craniofac J 2000; 37 (2) 130-136
• 26 Cutting CB, Bardach J, Pang R. A comparative study of the skin envelope of the unilateral cleft lip nose subsequent to rotation-advancement and triangular flap lip repairs. Plast Reconstr Surg 1989; 84 (3) 409-417 , discussion 418–419
• 27 Gubisch W. Functional and aesthetic nasal reconstruction in unilateral CLP-deformity. Facial Plast Surg 1995; 11 (3) 159-168
• 28 Kane AA, Pilgram TK, Moshiri M, Marsh JL. Long-term outcome of cleft lip nasal reconstruction in childhood. Plast Reconstr Surg 2000; 105 (5) 1600-1608
• 29 Fisher DM, Lo LJ, Chen YR, Noordhoff MS. Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate. Plast Reconstr Surg 1999; 103 (7) 1826-1834
• 30 Arosarena OA. Update on cleft care. Curr Opin Otolaryngol Head Neck Surg 2002; 10 (4) 303-308
• 31 Talmant JC. Nasal malformations associated with unilateral cleft lip. Accurate diagnosis and management. Scand J Plast Reconstr Surg Hand Surg 1993; 27 (3) 183-191
• 32 Horswell BB, Pospisil OA. Nasal symmetry after primary cleft lip repair: comparison between Delaire cheilorhinoplasty and modified rotation-advancement. J Oral Maxillofac Surg 1995; 53 (9) 1025-1030 , discussion 1031–1032
• 33 Papel ID. Surgical anatomy of the nose. In: Meyers A, , ed., Biological Basis of Facial Plastic Surgery. New York: Thieme Medical Publishers; 1993: 1-10
• 34 Delaire J. Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg 1978; 6 (2) 109-116
• 35 Schendel SA, Delaire J. Functional musculoskeletal correction of secondary unilateral cleft lip deformities: combined lip-nose correction and Le Fort I osteotomy. J Maxillofac Surg 1981; 9 (2) 108-116
• 36 Delaire J, Precious DS, Gordeef A. The advantage of wide subperiosteal exposure in primary surgical correction of labial maxillary clefts. Scand J Plast Reconstr Surg Hand Surg 1988; 22 (2) 147-151
• 37 Markus AF, Delaire J. Functional primary closure of cleft lip. Br J Oral Maxillofac Surg 1993; 31 (5) 281-291
• 38 González-Melgar S, Martín-Martín C. Analysis and treatment of cleft lip nasal and palate deformity. Acta Otorrinolaringol Esp 2013; 64 (5) 323-330
• 39 Bénateau H, Diner PA, Soubeyrand E, Vazquez M-P, Picard A. Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention [in French]. Rev Stomatol Chir Maxillofac 2007; 108 (4) 297-300
• 40 Talmant JC, Talmant JC, Lumineau JP. Nasal sequels of unilateral clefts: analysis and management [in French]. Rev Stomatol Chir Maxillofac 2007; 108 (4) 275-288
• 41 Park SS. Fundamental principles in aesthetic rhinoplasty. Clin Exp Otorhinolaryngol 2011; 4 (2) 55-66
• 42 Nolst Trenité GJ, Paping RH, Trenning AH. Rhinoplasty in the cleft lip patient. Cleft Palate Craniofac J 1997; 34 (1) 63-68
• 43 de Sá Nóbrega ES. Cleft lip nose: a different approach. J Craniofac Surg 2005; 16 (1) 95-99
• 44 Hurwitz DJ, Ashby ER, Llull R , et al. Computer-assisted anthropometry for outcome assessment of cleft lip. Plast Reconstr Surg 1999; 103 (6) 1608-1623
• 45 Russell KA, Waldman SD, Tompson B, Lee JM. Nasal morphology and shape parameters as predictors of nasal esthetics in individuals with complete unilateral cleft lip and palate. Cleft Palate Craniofac J 2001; 38 (5) 476-485
• 46 Nagy K, Mommaerts MY. Analysis of the cleft-lip nose in submental-vertical view, Part I—reliability of a new measurement instrument. J Craniomaxillofac Surg 2007; 35 (6–7) 265-277
• 47 Mommaerts MY, Nagy K. Analysis of the cleft lip-nose in the submental-vertical view. Part II. Panel study: which is the most important deformity?. J Craniomaxillofac Surg 2008; 36 (6) 315-320
• 48 Reddy SG, Devarakonda V, Reddy RR. Assessment of nostril symmetry after primary cleft rhinoplasty in patients with complete unilateral cleft lip and palate. J Craniomaxillofac Surg 2013; 41 (2) 147-152
• 49 Foda HM, Bassyouni K. Rhinoplasty in unilateral cleft lip nasal deformity. J Laryngol Otol 2000; 114 (3) 189-193
• 50 Fisher MD, Fisher DM, Marcus JR. Correction of the cleft nasal deformity: from infancy to maturity. Clin Plast Surg 2014; 41 (2) 283-299
• 51 Grayson BH, Cutting CB. Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J 2001; 38 (3) 193-198
• 52 Santiago PE, Grayson BH, Cutting CB, Gianoutsos MP, Brecht LE, Kwon SM. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty. Cleft Palate Craniofac J 1998; 35 (1) 77-80