A rotational method of bilateral cleft lip nose repair

Repairs of the bilateral cleft lip nasal deformity have focused on lengthening the lower columella by adding lip, nasal structure, or a piece of ear. In these methods, the raised true columella worsens the dorsal dislocation of the lateral crura of the alar cartilages and the lateral and dorsal displacement of the alar domes. We believe that lengthening the upper columella from above is more anatomic and reasonable than lengthening the lower columella. A method for reconstructing the upper columella by medial and ventral rotation of the dislocated alar domes is described. Figi's "flying bird" incision was extended to the columellar base along the nostril margin. Through this incision, the lower one-third of the nose, including the alae and nostril floors, was undermined widely. The inner layers, the nostrils, were freed from the surrounding tissues, except in the region of the columella and the septum, and rotated medially in the opposite direction of Cronin's technique. The resulting nasal shape, involving the columellar length and the concavity between the nasal tip and lateral ala, improved in 11 patients.     

The use of nasal splints in the primary management of unilateral cleft nasal deformity

Primary surgical correction of the cleft lip nasal deformity is routinely performed at the Craniofacial Center at Chang Gung Memorial Hospital. Over time, however, there is a tendency for the lower lateral cartilage to retain its memory and, subsequently, recreate the preoperative nasal deformity. Therefore, it is current practice to use a nostril retainer for a period of at least 6 months to maintain the corrected position of the nose. The aim of this study was to qualitatively assess the benefit of postoperative nasal splinting in the primary management of unilateral cleft nasal deformity. Data from two groups of 30 patients with complete unilateral cleft lips each were retrospectively collected and analyzed. The first group served as a control (no nasal splints), and the second group used the nasal retainer compliantly for at least 6 months postoperatively. All patients had their primary lip repair at 3 months of age. A photographic evaluation of the results when the patients were between 5 and 8 years of age was conducted. The parameters used to assess the nasal outcome were nostril symmetry, alar cartilage slump, alar base level, and columella tilt. The first scores were based on residual nasal deformity, and the second set were based on overall appearance. It was found that the mean scores of residual nasal deformity for all four parameters in patients who used the nasal stent were statistically better than the scores of patients who did not (p values ranged from 0.0001 to 0.005). The overall appearance scores for the four parameters in the patients who used the nasal stent after surgery were also statistically better than the scores for those who did not (p values ranged from 0.0001 to 0.01). The results show that postoperative nasal splinting in the primary management of the unilateral cleft nasal deformity serves to preserve and maintain the corrected position of the nose after primary lip and nasal correction, resulting in a significantly improved aesthetic result. Therefore, it is recommended that all patients undergoing primary correction of complete unilateral cleft deformity use the nasal retainer postoperatively for a period of at least 6 months.     

Caudal nasal deviation

Caudal nasal deviation, manifested by a "crooked tip," asymmetric nostrils, and a deviated columella, is one of the most challenging deformities encountered in rhinoplasty. This entity is often ignored by rhinoplasty surgeons, on the basis of the assumption that correction of other segments of the deviated nose will improve the caudal nose. Failure to correct this imperfection (or, occasionally, deformity) invariably produces suboptimal results. The nasal structures involved in caudal nasal deviation, namely, the septum, the lower lateral cartilages, and the anterior nasal spine, must be evaluated for identification of the anatomical blocks that have a causative role in caudal nasal deviation. The specific structures with abnormalities related to this deformity are discussed, as are techniques for the correction of the deformities. These techniques significantly augment the surgeon's repertoire of methods for addressing the subtleties of caudal nasal deviation correction and achieving predictable results.     

The residual unilateral cleft lip nasal deformity: a three-phase correction technique

The author presents a three-phase correction technique for the residual unilateral cleft lip nasal deformity. This procedure involves a sculpting excision of the alar rim, use of this alar rim as an interpositional flap in lengthening the columella, and augmentation of the nasal tip and perialar sulcus with a free ear conchal cartilage graft. The concept has been incorporated in the revisionary surgery program of 74 patients over a period of 5 years with a minimal follow-up of 2 years. The majority of the patients are operated on between the ages of 5 and 7 years based on the concept of a need for a "tidy appearance" by first grade.     

A radical method of correcting the nasal deformity in adult patients with repaired unilateral lip clefts

A method of rhinoseptoplasty is described, which combines principles of several well-known procedures, with innovations introduced by the author, for the purpose of eliminating the causes of complex distortions of the lip, maxilla, and nose in unilateral clefts. This method aims at creating a secure support for the atrophic alar cartilage with a pedicled cartilage flap taken from the normal alar cartilage. Elevation of the dome and elongation of the columella on the cleft side are achieved by interdigitating mucocutaneous flaps. To improve symmetry and relieve nasal obstruction, the ala on the normal side is also corrected, as well as the deflected septal cartilage and the anterosuperior margin of the vomer.     

Anatomy of the nasal cartilages of the unilateral complete cleft lip nose

The purpose of this study was to disclose the relationship between the anomaly of the cartilaginous framework and the nasal deformity of cleft lip. The noses of six stillborn infants with unilateral complete cleft lip were carefully dissected. The size and weight of the lower lateral cartilages were measured to determine whether there was a significant difference between the normal and involved sides. The position of the nasal cartilages was observed, and the distance between them was measured to determine whether they were normal. The surgical dissection revealed that the lower lateral cartilages from both sides were asymmetrical in three dimensions, indicating the displacement of the lower lateral cartilage on the involved side. There was displacement of the cartilaginous septum and the upper lateral cartilage. The statistical evaluation did not demonstrate a significant difference between weight and size of the two sides. One of the major causative factors of nasal deformity is displacement of the nasal cartilages. There is no hypoplasia of nasal cartilage in newborn infants with cleft lip.     

Complex nasal reconstruction

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the goals of nasal reconstruction as they apply to extensive, complex defects that may also involve the adjacent lip or cheeks. 2. Understand the advantages and disadvantages of different options for reconstruction of lining, skeletal support, and skin cover. 3. Discuss current advances in complex nasal reconstruction, including microvascular reconstruction of lining and the three-stage forehead flap. 4. Understand the concepts of laminated and prelaminated flaps and their application in complex nasal defects. SUMMARY: In this article, the authors review methods of reconstructing complex, multilayered nasal defects that may involve surrounding central facial structures. Different means of lining, skeletal support, and skin cover reconstruction are discussed. Emphasis is placed on newer, state-of-the art techniques and reinforcing basic principles.     

Bilateral cleft lip reconstruction

Over a period of 8 years 140 bilateral cleft lips were operated using a muscle-repositioning banked fork-flap cheiloplasty. The use of buccal mucosal flaps in the intercartilaginous incision is helpful to decrease scarring and contracture by facilitating alar cartilage repositioning and wound closure without tension. Adding mucosa from the inferior turbinate makes complete wound closure relatively easy without tension. A lateral lip orbicularis muscle flap with white skin roll and vermilion is recommended for reconstruction of the Cupid's bow. Muscle continuity by freeing the muscle in one sheet and repositioning in front of the premaxilla with creation of a buccal alveolar sulcus is stressed to prevent the necessity of reentering the lip in a second procedure. The elongation of the columella is done at 1 to 6 years of age by advancing nasal floor tissue onto the columella and repositioning the alar cartilages superiorly and medially. When nasal floor tissue is inadequate, columellar lengthening is done by the use of a composite free ear graft.     

Total reconstruction of the "end-stage" cleft lip and palate deformity

The purpose of this paper is to present a 5-year experience using a comprehensive surgical approach to reconstruct what we have chosen to call the "end-stage cleft lip and palate deformity." The deformity consists of varying degrees of midface retrusion, malocclusion, nasal deformity, and lip deformity. Most of the patients afflicted had unacceptable upper lip anatomy characterized by tightness and lack of cupid's bow and bulk. All had severe palatal scarring with resulting arch collapse and severe malocclusion. Most had had multiple surgical attempts to improve nasal aesthetics using standard rhinoplasty techniques with little or no improvement. The procedure involves splitting the upper lip with incisions extending into the upper buccal sulcus and rim of the nose allowing wide skeletalization of the maxilla and osteocartilagenous nasal skeleton. LeFort I or II maxillary advancement, nasal reconstruction, and upper lip modification (with Abbé flap if indicated) are done. The jaws are placed in intermaxillary fixation for 6 to 8 weeks. This comprehensive approach has been used in 16 patients, aged 15 to 29 years, with follow-up of up to 5 years. Excellent functional and aesthetic improvement has occurred in all patients, and complications have been minimal.     

Asymmetric incision for open rhinoplasty in cleft lip nasal deformity.

One of the problems in the correction of the unilateral cleft lip nasal deformity is the alar web deformity on the mediosuperior side of the nostril. A number of methods for the correction of the alar web deformity have been introduced, but no single procedure has been identified as the standard. In this report, the incision line of the open rhinoplasty was modified and the alar web deformity was corrected by using an incision and closure. Open rhinoplasty with the asymmetric incision was performed on 18 patients with unilateral cleft lip nasal deformity. The incision line used in the normal side was the usual intranasal rim incision line and that used for the columella was the transcolumella incision line. For the cleft side, an intranasal rim incision line was plotted after the rim was lifted upward with forceps to achieve symmetry of the nasal tip. After removal of the forceps, the incision line of the cleft side was displaced outside the nostril. After such an incision, the alar cartilage mobilization and suspension were performed with or without the conchal cartilage graft. All patients used nasal retainers for 6 months after the procedures. So far, satisfactory results have been obtained with the modification of the incision line for open rhinoplasty. This method is unique in designing the incision line, and its procedure is rather simple. The postoperative follow-up period has been 12 to 26 months. A long-term follow-up is still needed, especially in growing children.     

Reconstruction of proximal nasal defects with island composite nasal flaps

There are few local nasal flap options for repair of proximal nasal defects. Absence of suitable donor sites and the large dimensions of the defects limit the use of local nasal flaps in this region. Regional paranasal flaps may not be suitable in these cases because of color, texture, and donor-site scars. The composite procerus muscle and nasal skin flap, which is vascularized by the dorsal nasal branch of the angular artery, can be a useful treatment modality for proximal nasal reconstruction. Seven patients were successfully treated using the composite nasal flaps. The maximal size of the defects was 2.4 cm. In one case, the composite nasal flap was readvanced to close a new defect resulting from reexcision. The composite nasal flap has several advantages in reconstruction of proximal nasal defects. Reconstruction is performed with the same tissue and the donor defect is closed primarily. The composite nasal flap can be moved in multiple directions and has great mobility to reach every point of the proximal part of the nose with axial blood supply. Furthermore, it can be easily readvanced without additional morbidity in case of reexcision.     

Primary definitive nasal correction in patients presenting for late unilateral cleft lip repair

Almost 25 percent of unilateral cleft lip and palate patients present with their deformity in their teens or later years in the developing world. Because more than 80 percent of the world population lives in the developing world, the established protocol for repair of these deformities is not applicable to these patients. Despite the magnitude, there are no significant reports in the literature that deal with this problem. Several issues need to be addressed, but the author limits himself here to the correction of the nasal deformity. The patients at this age are very much concerned with the aesthetic outcome. Procedures described hitherto for primary nasal correction in infants are not successful in restoring nasal shape and symmetry at this late age of presentation. Our experience with radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late prompted us to extend the concept by undertaking a definitive primary correction of the nasal deformity in cleft patients presenting late. Twenty-two patients with unilateral cleft lip deformity (nine male patients and 13 female patients) with ages ranging from 13 to 22 years, presenting between August of 1997 and December of 2000, are included in this study. Of these, 11 patients had a cleft of the lip alone, eight also had a cleft of the alveolus, and three had a cleft of the palate continuous with the cleft lip. All patients showed some maxillary hypoplasia. An external rhinoplasty with lip repair was carried out in all patients. The corrective procedures on the nose included columellar lengthening; augmentation along the pyriform margin, nasal floor, and alveolus using bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; and augmentation of nasal dorsum by bone graft. Clinical follow-up ranged from 4 to 24 months, and the median follow-up period was 13 months. Results have been very good, and much better than results seen earlier with other primary rhinoplasty techniques. While repairing unilateral cleft lip in adolescents, the author thinks it would be most appropriate to address the entire gamut of the deformity in a single stage, provide complete vector reorientation, and augment the hypoplastic elements by autologous tissue. It is not just the fear of poor follow-up, but that merely correcting the lip deformity in these patients without attempting definitive rhinoplasty, in the author's opinion, would be insufficient surgical intervention.     

Reconstruction of a compound facial deformity involving the columella, nasal base, and upper lip

A compound facial defect including the columella, a wide full-thickness loss of the upper lip, and the nasal floor is a severe disfigurement. This patient was a victim of noma in childhood. This report includes a discussion of the problem and a way of solving it with possible available methods in order to obtain an acceptable result.     

The Tagliacozzi flap as a method of nasal and palatal reconstruction

A random flap of upper arm skin has been successfully used to reconstruct large nasal (seven patients) and palatal (three patients) defects. This method is an attractive alternative for nasal reconstruction in patients whose foreheads cannot be used. Problems of color match can be managed by subsequent resurfacing of the nose with a single-piece full-thickness graft taken from the supraclavicular area. Pedicle flaps can be transected 9 to 12 days after inset, thus shortening the immobilization period.     

Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation

Previously it was thought that primary correction of nasal deformity in cleft lip patients would cause developmental impairment of the nose. It is now widely accepted that simultaneous correction of the cleft lip nasal deformity has no adverse effect on nasal growth. Thus, the authors tried to evaluate the results of primary correction of cleft lip in Asian patients. Of 412 cases of cleft lip, 195 cases were corrected by means of the conventional method from June of 1992 to June of 1997, and 217 cases were corrected by simultaneous rhinoplasty from July of 1997 to October of 2001. The average patient age was 3 months. Photographs and anthropometric evaluation were used to evaluate the results. Nasal tip projection, columellar length, and nasal width were measured in 60 randomized normal children, 30 randomized children treated with the conventional method, and 30 randomized children with primary nasal repair. Data were analyzed using t tests, and the level of significance was 5 percent (p < 0.05). In cases of simultaneous repair, nasal tip projection and columellar length were increased 24.8 percent and 28.8 percent, respectively. Nasal width was increased 12.3 percent in the cases of simultaneous repair and 12.6 percent in the cases without primary rhinoplasty. Simultaneous repair of cleft lip and nasal deformity in Asian patients showed that more symmetry of nostril and nasal dome projection and better correction of buckling and alar flaring were achieved. More balanced growth and development of the alar complex was achieved, and no interference with nasal growth was encountered.     

Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal period

Auricular cartilage is soft and plastic at birth, so that congenital auricular deformities can easily be corrected nonsurgically in the early neonatal period. However, as the infant grows older, the flexibility of the auricle decreases. Alar cartilage exhibits the same elasticity as auricular cartilage in the early neonate. When a cleft lip is repaired, typically when the infant is about 3 months of age, it becomes difficult to correct the nasal deformity without surgical intervention. However, based on our experience, there is a fair possibility of correcting the cleft lip nasal deformity with a nonsurgical procedure in the early neonatal period. We performed cleft lip repair accompanied by nonsurgical correction of the nasal deformity in 44 neonates aged 2 to 7 days. A special retainer was placed in the affected nostril for 3 months. Following observation of 31 infants for 12 months or longer, their nasal shapes and symmetry were considered superior to those conventionally operated on at about 3 months of age. Except for one nasal infection, there were no complications.     

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

Neighboring flaps and cartilage grafts for correction of serious secondary nasal deformities

When the secondary nasal deformity is so serious that it presents loss of the soft structures, often its correction requires a neighboring flap besides the cartilage auto-grafts. In such serious cases, which are fortunately infrequent, the surgeon must resort to reconstructive techniques that typically provide very good results. Such is the case with the midforehead Indian flap, which rotated 180 degrees, allows reconstruction of the columella in the same surgical stage. In the same manner, Denonvilliers' flap may be employed to restore contour of the nasal ala, since its scar sequel is very acceptable, and Dieffenbach's flap may be used to reconstruct the columella. The flap of labial mucosa (which other authors have employed to correct septal perforations) is rotated 90 degrees to appose with another similar contralateral flap and is used to correct the seriously retracted columella. In this paper we present some cases that demanded the application of these techniques.