The cleft-lip nose

Secondary management of the nose in the cleft patient

The management of the cleft lip and palate patient usually requires multiple primary and secondary surgical procedures to correct the deformity. This paper presents surgical methods in the secondary management of the cleft nose and presents three case reports to help illustrate these methods.

Primary correction of the unilateral cleft lip nose

The details of surgical techniques for primary correction of the unilateral cleft lip nose and their results for 45 cases are reported. The technique employed an infracartilaginous incision on the affected side, thus allowing direct suturing of the alar cartilage onto the lateral cartilage. For the post-operative evaluation, the nasal form in both frontal and bottom views was scored for five items. In overall evaluation, the grades of "Good," "Fair," and "Poor" were derived from the total scores of five items. In the postoperative results (range of follow-up: 24 months to 84 months), 24 cases were rated "Good" (53.3%), 13 cases "Fair" (28.9%), and 8 cases "Poor" (17.8%). Thirty cases appear not to need secondary correction (66.6%). The technique is useful because the alar cartilages and lateral cartilages can be accurately sutured, and relatively stable results can be obtained.

Anthropometric and anthroposcopic findings of the nasal and facial region in cleft patients before and after primary lip and palate repair

Two populations were studied and compared to determine the effects of cleft lip and palate surgery on the nose and face. In the first, three anthropometric measurements, two nasal and one facial, were taken before primary lip repair from infants with complete unilateral cleft lip and palate (UCLP) and with bilateral cleft lip and palate (BCLP). In the second, ten measurements were taken from the nose and face of patients surgically treated for UCLP and BCLP. The high frequency of noses disproportionately wide in relation to their height in both cleft types before primary lip repair greatly decreased after surgery. Among the residual deformities after surgery for UCLP, nostril floor width asymmetry was the most frequent, followed by columella length asymmetry, flat nasal bridge, wide soft nose, flat nasal tip, and small nasal tip protrusion. In the BCLP patients, nostril floor width asymmetry was also the most common stigma, followed by flat nasal tip, wide soft nose, columella length asymmetry, flat nasal bridge and bilaterally angled alae, and small nasal tip protrusion. A subnormally flat upper face inclination was observed in UCLP and BCLP patients. Quantitative determination of these nasal stigmata in cleft lip and palate patients who have undergone primary lip repair provides valuable information for surgical correction of the cleft soft-tissue deformities.

A morbidity review of children with complete unilateral cleft lip nose at 10 +/- 1 years of age

A retrospective study of morbidity due to primary radical nasal correction was undertaken on 33 consecutive cases of complete unilateral cleft lip and palate within one year of their 10th birthday. Primary surgery was performed by one surgeon (RWP) using the Alar Leapfrog technique. Morbidity was assessed by the number of manoeuvres required for revisional surgery up to the age of 10 and was derived from the case notes. A total of 12 patients required no revision. The number of revisional manoeuvres was 39 in 27 anaesthetic sessions. Cleft lip noses treated by a technique of primary radical nasal correction (Alar Leapfrog) required a significant number of secondary manoeuvres to produce an acceptable result. This must be balanced against reduced teasing due to improved symmetry over this period.

History of cleft lip nasal repair

Surgery of the cleft lip nasal tip has lagged behind cleft lip surgery. In fact, in most early illustrations it was not even noted. Since the development of cosmetic rhinoplasty an endless array of techniques have been published. Unfortunately there are few studies of the gross anatomy.

"The open sky rhinoplasty" for correction of secondary cleft lip nose deformity, Technique and recent results

The typical nose deformity after cleft-lip repair still represents great challenge for the plastic surgeon in this field. Many methods have been designed in attempts to correct the deformity, either during primary closure of the lip or as a secondary procedure when growth of the nose is complete. In this paper the author's own technique of secondary rhinoseptoplasty in cleft-lip patients is presented. The different cartilaginous and osseous structures are approached through a transcolumellar incision and the skin of the nose completely reflected upwards. This so-called "open sky view" gives a total perspective on the entire pathology of the cleft-lip nose deformity and makes it possible to correct it accordingly. Emphasis is put on some important surgical manoeuvers. Recent results are presented and the pros and cons of this procedure discussed.

Shape and function of the unilateral cleft nose in adolescents following modified Millard lip repair

24 patients with unilateral clefts operated on (at age of 6 months) according to the Millard (1964) procedure were examined at an average age of 10.1 years. Nasal shape and function were evaluated. No change of nasal shape was found during the observation period. The results were superior to those attained by the author with the Tennison-Trauner (1952, 1957) procedure in 6 cases. 13 of the Millard (1964) cases are not expected to need secondary nasal correction at a later date.

Cleft lip nose surgery

On the basis of over 3,600 cases the surgical repair of primary and secondary nose deformities in cleft patients is discussed. The value of the modified Millard method in the management of unilateral nose deformities and the author's own approach to primary columella elongation in bilateral cleft are presented. The various methods of secondary rhinoplasties in typical and rare clefts are also discussed on the basis of numerous examples.

Early bone grafting in complete cleft lip and palate cases following maxillofacial orthopedics. V. A postoperative evaluation of nasal patency

The nasal patency of children born with complete unilateral or bilateral cleft lip and palate was studied with rhinomanometry. The children had all been early bone grafted with a "four-flap" technique. The unilateral deformities were composed of two groups. One group of 39 children (mean age 17.6 years) primarily operated without preoperative orthopedics and another group of 46 children (mean age 10.8 years), where preoperative orthopedics ("T-traction") was performed before the operation. In the bilateral group, 19 children (mean age 15.1 years), preoperative retropositioning pressure and if necessary outward rotation of the lateral maxillary segments was performed before the operation. No difference of total nasal patency was found between unilateral and bilateral cleft children. The nasal cavity of the cleft side of unilateral clefts had, however, a more pronounced nasal stenosis than each cavity of bilateral clefts. In unilateral groups a significant difference in nasal patency was found between the cleft and the noncleft side. This difference was not changed by decongestion indicating a skeletal anatomical stenosis. Nasal patency did not differ between the unilateral groups. However, considering the age difference between the two groups a further improvement of nasal patency with increasing age may possibly occur in the younger "T-traction" group.