Suez Canal Univ Med J

Vol. 11, No. 1 , March, 2008

1 -7

Correction of Secondary Deformities of the Cleft Lip Nose

Ahmed Sabry Ahme^and

Mohammed Mahmoud Ramadan

Reconstructive and Plastic Surgery Division, General Surgery Department'0 and Otolaiyngology
Department*2', Faculty of Medicine, Al-Azher University, Damietta.
Abstract
For both unilateral and bilateral cleft lip nasal deformity, the general trend has been toward operation
on the cleft lip nose at the time of initial lip surgery. Secondary surgery to further modify the nasal shape
is often necessary and many patients desire complete septorhinoplasty in their teen years. The purpose
of the study was to evaluate the results of the methods to correct secondary cleft lip nose deformity. This
study carried out on 22 patients; (five females and 17 males) with secondary cleft lip nose deformities, their
ages ranged from five to 34 years with mean 17.6 years. All of them were admitted to our department at
Al-Azher University Hospital, Damietta. There is nasal symmetry with improved nasolabial and nasofacial
relationship, improve speech, and airway Passage in 17 patients.
Keywords: Cleft Lip Nose, Secondary Deformities, Correction

Introduction
Where as cleft lip is a malformation, the
accompanying nasal deformity is primarily a
deformation of normal architectural elements. The
alar genua are splayed, the tip is- broad and the
alae nasi are flared (Figure 1), but the hallmark of
the cleft nasal deformity is short columella. There
are also deformational distortions that result from
the disjoined skeletal framework and abnormal
muscular forces. There can be some degree of
primary hypoplasia of the embryonic lateral nasal
prominences, evidenced as underdeveloped alae
nasi, and involving genua, lateral crura, and lobular
fat. These nasal distortions by the time are addressed
at a second procedure the alar cartilages are rigidly
deformed/displaced and difficult to model and
position01.
It is important to identify both aesthetic and
functional problems associated with the cleft
nose deformity21. Nasal symmetry with improved
nasolabial and nasofacial relationships and minimal
evidence of surgical intervention fulfill the esthetic
requirements. Functional objectives include a patent
airway, proper position of the maxilla to provide
Class I interdental occlusion and the achievement of
normal speech. Components of the nasal deformity

include defects of the lower cartilage on the cleft

side, the nasal septum, the columella, the nasal
tip and the entire nasal pyramid. The maxillary
cleft and hypoplasia and malpositioning of the
maxillary segments also contribute significantly
to the asymmetry. The anatomical and functional
deformity of the orbicularis muscle also contributes
to the nasal deformity'3', So, union of orbicularis
muscle from the cleft and non cleft sides in unilateral
cleft cases and from both lateral elements across the
premaxilla in bilateral cleft cases should be given
adequate emphasis'4'.
It is difficult to consistently obtain satisfactory
correction of the bilateral cleft lip and nasal
deformity'5'. There exists great variability in the
degree of tissue deficiency as well as structural
distortion and asymmetry in this group of patients.
The secondary deformity involves the nose and the
lip as well as the facial profile. It is not uncommon to
see patients withbilateral cleft lip and nasal deformity
having the following characteristic abnormalities:
depressed nasal tip with diastatic lower lateral
cartilage, wide alae, large nostrils, short columella,
wide prolabium with a lack of philtral and Cupid's
bow definition, vertically short prolabium, shallow
buccal sulcus, tight upper lip, irregular scars, and
central vermilion insufficiency*6'.

Ahmed and Ramadan

te 1

v'-dfc

Figure (1): Secondary

left
unilateral
cleft lip nose
deformity: typical
appearance, nasal
view.

t%Wm
Primary correction of the unilateral cleft lip
nasal deformity remains a challenge to the cleft
surgeon'71.
In a great number of patients, lip closure alone
leaves the typical nose deformity, with its related
functional and aesthetic problems resulting in
permanent dissatisfaction to all concerned, patients,
parents and the surgeon.The operation is performed
at the age of five to six months; the delay being in
order to facilitate extensive and careful dissection
and accurate reconstruction of tissue, which is
already better, developed'8'. No single procedure
has given sufficiently satisfactory results to provide
a surgical standard for cleft lip nasal deformity
correction'31.
Delayed correction of the nasal deformity is
a difficult procedure, often with less than ideal
aesthetic results; this is due to the continued
growth of malformed tethered and malpositioned
structures'7'.
The aim of the present study is to evaluate the
results of the methods to correct secondary cleft lip
nose deformity.
Patients and Methods
This study carried out on 22 patients (5 females and
17 males) with secondary cleft lip nose deformities;
16 of them has unilateral deformity and six cases has
bilateral deformities, their ages ranged from five to 34
years at the time of operation with mean 17.6 years. All
of them were admitted to our department at Al-Azher
University Hospital, Damielta. The primary cleft lip
repairs were performed at another institution in 74%. of
these patients.
Examination of the external nose to note symmetry of
the alar bases and nostril shape, length of the columella,
and any deformations or deficiencies of the nasal lining,

associated lip deformity due to a lack of correct muscle

recreation at primary surgery. Reconstructive options
for the cleft lip nasal deformity were discussed with the
parents and patients before choosing the procedures.
Surgical technique: General anesthesia with a cuffed
oral endotracheal tube positioned midline was used. The
nose and anterior aspect of the maxilla on the cleft side
in case of unilateral lip nose deformity or on both sides
in case of bilateral lip nose deformity are infiltrated
with 0.5% lidocaine and 1:400,000 epinephrine. When
vasoconstriction is achieved, an incision is made through
the previous scar. The lateral lip segments in case of
bilateral lip nose deformity were mobilized or lateral
lip segment in case of unilateral lip nose deformity
by incisions onto the nostril floor and by freeing the
mucosa and muscle from the premaxilla and piriform
margin, allowing medial advancement of the lateral lip
segments without tension. This procedure would reduce
the nostrils and nasal width and lengthen the upper lip.
If there was a shallow buccal sulcus, it was corrected at
the same time. A curvilinear excision of the prolabium

could also lengthen the lip. On the other hand, shortening

of a long lip was achieved by direct excision at the alar
base'6'. Orbicularis muscles are radically mobilized from
the vesti- bular nasal lining down to the edge of the
bony cleft in case of a lack of correct muscle recreation
at primary surgery'4'. Subcutaneous dissection of the
nasal skin envelope was performed on the tip and alar
subunits. Excess subcutaneous fatty tissues were trimmed
off. Adequate hemostasis was achieved. Ear cartilage
grafts were used for approximating and supporting the
medial cms of the lower lateral cartilage, sustaining the
columellar elongation and nasal tip definition. The nasal
skin was redraped and the lateral lip segments were fixed
to the columella base. Alar cinch sutures were sometimes
used to maintain the reduction of the nostrils and alar
width"".
For patients with septal deviation, a vertical incision
is made in the mucoperichondrium. over the caudal
septum, and the perichondrium and'jhe periosteum of the
septum are elevated widely anteriorly,and posteriorly*2'.
For patients with depressed alar cartilage, delivery of
alar cartilage through vertical nasal tip and rim incisions
(Figure 2c). The entire alar cartilage is freed from the
overlaying skin and suspended to the ipsilateral upper

Correction of Secondary Deformities of the Cleft Lip Nose

lateral cartilage, near its junction with the septum, and
also to the opposite alar cartilage through interdomal
sutures to a stable cephalic position to achieve projection
of the nasal tip and symmetry0*.
We correct the shorted columella by using flaps
advanced in from the lateral aspect of the philtrum'"
(Figure 2c) or the nasal floor1'"'.
Three to four 5/0 vicryl sutures are used to suture the
medial crura of the alar domes. The cranial edges of the
lateral crura are sutured securing the upward rotation of
lateral crura on the affected side. The nasal and columellar
incisions are sutured0'.
Topical Terramycin ointment is applied to the suture
lines. The nose is stabilized with tape and a splint.
The splint is left in position for one week. The patient
is advised to wear it at night to prevent trauma during
sleep.

Results
All of these cases had been followed up from
the time of operation on a monthly basis until three
months, postoperatively followed by 2-monthly
follow- up for the next six months and later on a
3-6 monthly interval up to the present. The results
were documented and clinical photographs of
anteroposterior, lateral and nasal views taken.
There were no pcrioperative complications such as
airway obstruction, bleeding, infection, or wound
disruption. A total of five patients received further
operations for nasal dorsum augmentation, nasal tip
refinement, rhinoplasty after a prior orthognathic
operation or maxillary advancement by Le Fort 1
osteotomies. There is nasal symmetry with improved
nasolabial and nasofacial relationship, improve
speech and airway passage in 17 patients as in table
1. Some results presented in figures (2-5).

Tablel: Clinical series

Point of comparison
Number of cases
Suture suspension
Cartilage graft
Orthodontic therapy
Orthognathic surgery
Orbicularis muscle union
Septosteoplasty
Further correction

Unilateral cases

Bilateral cases

16
7
5
3
6
3

Figure (2): A 15 year-old female with secondary bilateral cleft lip nose deformity. A. Preoperaiive anteroposterior
view. B. Intraoperative view showing vertical nasal tip and rim incisions and forked flap from prolabium. C.
Inlraoperative view showing delivery of alar cartilage. D. Immediately postoperative anteroposterior view after
correction. E. One-month postoperative anteroposterior view showing rectangular and overly long columella. F.
One-month postoperative nasal view showing an overly long columella resulting in flip nasal defonnity.

Ahmed and Ramadan

Figure (3): A 28 year-old man with secondary right unilateral cleft lip nose deformity with retruded upper lip, wide
right ala and large nostril A. Preoperative anteroposterior view. B. Preoperative nasal view. C. One month
postoperative nasal view. D. One month postoperative anteroposterior view.

Figure (4): A 13 year-old female with secondary left unilateral cleft

lip nose deformity. A. Preoperative anteroposterior view. B.
Preoperative nasa! view. C. postoperative anteroposterior view. D.
Postoperative nasal view.

Figure (5): A 25 year-old female with secondary bilateral cleft lip nose deformity retruded upper lip and wide alae. She
received orthodontic therapy. A. Preoperative anteroposterior view before orthodontic therapy. B. Preoperative
nasal view before orthodontic therapy. C. Preoperative anteroposterior view after orthodontic therapy. D.
Preoperative nasal view after orthodontic therapy. E. One-month postoperative anteroposterior view after insertion
of conchal cartilage graft to nasal tip. F. One-month postoperative nasal view after insertion of conchal cartilage
graft to nasal tip.

Correction of Secondary Deformities of the Cleft Lip Nose

Discussion
Nasal problems inherent in cleft lip are
challenging14'. The alar cartilage is the center point
of the cleft lip nasal deformity. In the normal infant,
the alar cartilages are situated high in the nasal tip"1'.
So most techniques have focused on the dissection
of the alar cartilage through an infracarrilagenous
incision or through the apex of existing lip
incisions'12'. Labial repair typically aggravates the
primary nasal deformity and often creates additional
distortions031.
There has been a general trend toward operation
on the cleft lip nose at the time of initial lip surgery
in both the unilateral and bilateral cleft lip nasal
deformity. However, secondary surgery to further
modify the nasal shape is frequently necessary
and a large number of patients desire complete
septorhinoplasty in the teen years. Although a
myriad of different procedures has been suggested
to address the problem02'.
The nasal growth is complete at approximately
11 to 12 years of age in girls and 13 to 14 years of
age in boys'"". The most common age for revision of
the cleft lip nose is between four and five years. At
this age, the child's social interactions are increasing
and the stigmata associated with the deformity may
cause problems for the child'12'. Bardach and Salyer
delayed secondary correction until the patient was
eight to 12 years old for three reasons: (1) to allow
completion of orthodontic correction of the skeletal
base; (2) to allow as much growth and development
of the lower lateral cartilages as possible and
thus to have a stronger, more stable support for
the reconstructed nasal tip; and (3) to allow bone
grafting of the hypoplastic maxillary segment on
the cleft side, which when performed in patients
aged eight to nine years results in a more symmetric
alar base'15'.
Salyer summarized the principles of correction of
the cleft lip nasal deformity as follows: (1) the more
severe the deformity, the earlier and more radical
the secondary procedure should be; (2) correction
of the nasal deformity is designed to improve form
and function and to alleviate psychological stress;
(3) correction of nasal deformities includes the

skeletal base, the septum, the tip, and the alae; (4)
bone grafting and cartilage augmentation may be
indicated; (5) definitive rhinoplasty is performed
when the patient is 14 years of age or older; and
(6) severe asymmetry of the skeletal base is a
contraindication to definitive rhinoplasty0''1. Jackson
and Fasching however, would advocate much earlier
correction for a severe deformity*-1'.
The columella is neither short nor deficient in
the bilateral complete cleft lip deformity; it only
looks diminutive because of the malpositioned alar
cartilages and abnormally draped soft tissue. There
is no shortage of investing skin and consequently no
need to recruit tissue for the columella from the lip
or from the sills*171.
Stal and Hollier did not augment the deficient
columella in the vast majority of cases through
flaps advanced in from the lateral aspect of the
philtrum (Millard)ilJ) or the nasal floor (Cronin)'""'
However, these techniques do nothing to address
the underlying abnormality in the lower lateral
cartilage and they frequently produce abnormally
long and unusual appearing columella021. Mulliken
observed that augmented columella after staged
forked flap procedure show a classic pattern: (I) a
rectangular columella; without a waist and with a
broad base (Figure 3c), (2) a sharp columcllar-labial
angle, (3) abnormally elongated/enlarged nostrils
(Figure 3e), and (4) a tendency to an overly long
columella with a disproportionate ratio of nostril
length to nasal lip"N'. Additional tissue, especially
from the lip, is not necessary to lengthen the
columella in the vast majority of cases and should
only be used conservatively and for minimal skin
advancement"2'.
In our study, we use nasal packing this agrees with
Millard'19' but Lo et al(f,) did not use nasal packing in
their cases. We use auricular grafts to augment and
stabilize the malformed lower cartilage to improve
tip definition and symmetry this agrees with Stal
and Hollier112'.
Hemostasis was obtained by compression and
coagulation; no injection to avoid tissue swelling
and distortion that may create difficulty for precise
incision and approximation of the corresponding
landmarks'6', in our series hemostasis was obtained
with local infiltration with adrenaline.

Ahmed and Ramadan

In our study we use Muiliken technique0' of a

vertical nasal tip and rim incisions to mobilize the
alar cartilage on the cleft side in superior direction,
reduce tip bifidity and increase anterior projection
of the cleft dome. There was other procedure such as
Tajima's technique'20' of a reverse "U" rim incision
was used for secondary correction of cleft lip nose
deformity. Narrowing of the nostril on the cleft
side (observed when Millard(21) C-flap based to the
side of columella was planned) can be avoided by
placing an adequately sized "C" flap at the nostril
sill. The design of the "C" flap and its base at the
septal mucosa rather than at the columella''1'.
The open tip rhinoplasty has many advantages
>when combined with the repair of the cleft lip. It
permits mobilization and repositioning of unscarred

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Correspondence to:
Ahmed Sabry Ahmed
Reconstructive and Plastic Surgery Division
General Surgery Department
Faculty of Medicine, Al-Azher University, Damiclln

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