Clinical Review & Education

Review

Secondary Cleft Rhinoplasty

Sachin S. Pawar, MD; Tom D. Wang, MD

CME Quiz at
The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a jamanetworkcme.com and
CME Questions page 76
formidable challenge for the facial plastic surgeon. The underlying anatomic deformities
combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult
procedure for even the most experienced surgeons. Numerous techniques for secondary
cleft rhinoplasty have been described in the literature over the past several decades, yet the
lack of wide adoption of any given technique highlights the great variability seen with this
problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of
the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or
webbing have driven the progressive evolution of techniques developed to correct various
aspects of the cleft nasal deformity. Despite the number of techniques that have been Author Affiliations: Author
affiliations are listed at the end of this
published, very few studies have looked specifically at outcomes in secondary cleft article.
rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of Corresponding Author: Tom D.
the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral Wang, MD, Division of Facial Plastic
and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty. and Reconstructive Surgery,
Department of OtolaryngologyHead
and Neck Surgery, Oregon Health and
JAMA Facial Plast Surg. 2014;16(1):58-63. doi:10.1001/jamafacial.2013.1562 Science University, 3303 SW Bond
Published online November 7, 2013. Ave, Mail Code CH5E, Portland, OR
97239 (wangt@ohsu.edu).

T
he cleft nasal deformity presents a formidable challenge in
rhinoplasty surgery. The 3 main factors contributing to this
deformity are congenital anatomic deficiency or aber-
rancy, surgical scarring from previous reconstructive attempts, and
changes related to growth.
The number of rhinoplasty techniques described in the litera-
ture and often the number of revision procedures endured by the
patient are a testament to the difficult nature of secondary or revi-
sion rhinoplasty in the cleft nasal deformity. All of the described tech-
niques attempt to address some aspect of the problem. However,
complete correction of all of the deficiencies of some noses re-
mains an elusive goal for many, hence the common need for revi-
sions in these challenging patients. It should also be noted that each
patient presents a unique challenge due to a combination of fac-
tors, and certain techniques may be more suitable than others in in-
dividual cases.
Herein, we will discuss anatomy of the cleft nasal deformity, re-
pair strategies and timing, surgical techniques for both unilateral and
bilateral cleft nasal deformity, and outcomes for secondary cleft
rhinoplasty.
of the orbicularis to the ala results in pulling the alar base laterally
and inferiorly. In addition, the lack of maxillary skeletal support con-
tributes to alar displacement laterally, inferiorly, and posteriorly.2
Common features of the unilateral cleft nasal deformity are listed
in the Table, and a patient photograph illustrating the clinical fea-
tures is shown in Figure 1.
Bilateral Cleft Nasal Deformity
The bilateral cleft nasal deformity shares many of the features found
in the unilateral cleft nasal deformity; however, the defects tend to
be more symmetrical. There are 4 major defects in patients with a
corrected bilateral cleft, including a short columella, lack of nasal tip
projection and definition, a pseudo hump, and lateralized and cau-
dally rotated alar bases.4 In contrast to unilateral clefts, the septum
is often midline in the bilateral cleft lip nasal deformity. When there
is deviation in this setting, it is usually deviated caudally toward the
less involved side.2 Common features of the bilateral cleft nasal de-
formity are listed in the Table, and a patient photograph illustrating
the clinical features is shown in Figure 2.

Repair Strategies and Timing

Anatomy of the Cleft Nasal Deformity
Unilateral Cleft Nasal Deformity
The unilateral cleft nasal deformity is characterized by 3-dimen-
sional asymmetry of the nasal tip and alar base.1 The anatomic de-
formities result from tissue deficiency of the cleft lip, deficiency in
the bony premaxilla, and abnormal muscle pull on the nasal struc-
tures. Discontinuity of the orbicularis oris and its insertion into the
columella on the noncleft side tend to pull the columella and cau-
dal septum to the noncleft side. On the cleft side, the attachment
Primary Cleft Rhinoplasty
Although details of presurgical nasoalveolar molding and primary
cleft rhinoplasty are beyond the scope of this article, it is important
to acknowledge that these techniques are playing an increasingly
important role in the correction of the cleft nasal deformity and have
implications for secondary cleft rhinoplasty. In fact, primary rhino-
plasty at the time of cleft lip repair is now considered by many au-
thors to be a standard of care.3 In general, primary lip repair is per-
formed by 3 months of age, preferably with presurgical nasoalveolar

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 Secondary Cleft Rhinoplasty Review Clinical Review & Education

molding, which narrows the cleft gap, improves alar base symme-
try, and elongates the columella. The goals of primary cleft rhino-
plasty include closure of the nasal floor and sill, repositioning of the
alar base, and symmetric repositioning of the lower lateral carti-
lage (LLC). All attempts are made to minimize nasal tissue trauma
and scarring, which may potentially affect subsequent growth. In
their recent retrospective review of 116 secondary rhinoplasty pa-
tients, Haddock et al5 report that patients who underwent primary
cleft rhinoplasty had more nasal tip symmetry and required less com-
plex surgery at the time of secondary rhinoplasty. Maximizing na-
sal outcomes at the time of primary lip closure can help achieve bet-
ter secondary cleft rhinoplasty outcomes.6
Secondary Cleft Rhinoplasty
Secondary cleft rhinoplasty includes intermediate and definitive rhi-
noplasty. Intermediate rhinoplasty refers to procedures that are per-
formed before the completion of nasal growth, between the time
of the lip repair and definitive rhinoplasty. These procedures are gen-
erally less involved, more conservative, and have the goals of achiev-
ing symmetry during continued nasal growth and achieving a plat-
form for more successful definitive repair. Three situations have been
described that warrant intermediate procedures, including severe
nasal obstruction caused by caudal septal deviation, a deformity not
addressed with primary rhinoplasty, and a child who is experienc-
ing severe emotional distress from peer psychological pressure.2

Table. Clinical Features of the Cleft Nasal Deformitya

Cleft Nasal Deformity

Location Unilateral Bilateral
Nasal tip Medial crus of LLC shorter on cleft side Medial crura of LLC short bilaterally
Lateral crus of LLC longer on cleft side Lateral crura of LLC long bilaterally and
May be caudally displaced with hooding displaced caudally
of the alar rim Alar domes poorly defined and widely
Alar dome on cleft side is flat and displaced separated, producing an amorphous tip
laterally
Columella Short on cleft side Short
Base directed to noncleft side Wide base
Nostril Horizontal orientation on cleft side Horizontal orientation bilaterally
Alar base Displaced laterally, posteriorly, and inferiorly Displaced laterally, posteriorly, and inferiorly
Abbreviation: LLC, lower lateral
Nasal floor Usually absent Usually absent bilaterally
cartilage.
Nasal septum Caudal deflection to noncleft side and posterior Usually midline, however will deviate a
Adapted from Sykes and Jang1 and
deviation to cleft side toward less affected side if cleft on one side
is incomplete Lee et al.3

Figure 1. Secondary Unilateral Cleft Lip Nasal Deformity

A B

A, Anteroposterior view;
B, basal view.

Figure 2. Secondary Bilateral Cleft Lip Nasal Deformity

A B

A, Anteroposterior view;
B, basal view.

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 Clinical Review & Education Review
There are 2 distinct timing strategies in intermediate
rhinoplasty.7 In one scenario, the intermediate rhinoplasty is per-
formed when the patient is 4 to 6 years of age because this some-
times coincides with the timing of lip revision if necessary and the
time in which peer psychological pressure tends to mount. The other
scenario involves waiting until the patient is 8 to 12 years of age or
after the completion of orthodontic alignment and alveolar bone
grafting. This allows for a better skeletal base for longer-lasting cor-
rection of severe nasal deformities.
Definitive rhinoplasty is performed after the completion of max-
illary and nasal growth. It is important to note that secondary cleft
nasal reconstruction should only be performed after correction of
the underlying skeletal base by alveolar bone grafting, LeForte I ad-
vancement, or prosthetic reconstruction of the anterior maxilla in
bilateral clefts.8 Definitive rhinoplasty usually occurs at 14 to 16 years
of age in girls and 16 to 18 years of age in boys. Rhinoplasty at this
time is definitive in that more aggressive septoplasty, osteotomies,
and cartilage grafting maneuvers may be performed without con-
cerns for affecting nasal and midfacial growth. The goals of defini-
tive rhinoplasty include final creation of lasting symmetry, achiev-
ing definition of the nasal base and nasal tip, relief of nasal
obstruction, and management of nasal scarring and webbing.2 Each
patient will require a personalized approach to timing of secondary
rhinoplasty, based on the severity of soft-tissue and skeletal defor-
mities as well as previous procedures performed. This combination
of the underlying anatomic and pathophysiologic changes, coupled
with scarring from previous procedures, makes secondary rhino-
plasty or revision of the cleft lip nose extremely challenging for the
facial plastic surgeon.
Surgical Techniques
The numerous techniques that have been published for repair of sec-
ondary cleft nasal deformities are a testament not only to the chal-
lenging nature of these defects but also to the fact that not any 1 tech-
nique will be suitable for all patients.
Unilateral Cleft Nasal Deformity
A wide variety of techniques have been described for correction of
the unilateral cleft nasal deformity and have evolved over the past sev-
eral decades. In 1932, Gillies and Kilner9 introduced a superior ad-
vancement of the composite chondrocutaneous hemicolumella flap
using a midcolumellar incision. In 1964, Converse10 provided the first
major modification of this technique by replacing the midcolumellar
incision with a marginal incision. The medial crura composite flap was
advanced superiorly and sutured to the contralateral dome. The de-
fect at the base of the columella was then repaired with an auricular
composite graft. In 1954, Potter11 advocated a similar concept but from
the opposite direction, using a lateral-to-medial advancement of the
lateral crural composite chondrocutaneous flap. The resultant de-
fect created in the lateral vestibular skin was closed in a V-to-Y fash-
ion. Potters11 technique is still used by some surgeons.
Tajima and Maruyama12 advanced the evolution in cleft lip rhi-
noplasty with the description of the reverse-U incision in 1977. This
method was an extension of the marginal incision into a rim inci-
sion at the point of the alar web, in the region of the soft-tissue tri-
angle. The skin of the web was incorporated with the vestibular skin
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Secondary Cleft Rhinoplasty
and the LLC flap. The flap was then suspended cephalically and me-
dially by sutures from the LLC to the ipsilateral upper lateral carti-
lage and the septum. Conversion of external skin of the alar web to
nasal lining to correct the alar-columellar web also corrects the de-
ficiency of vestibular skin associated with the cleft lip nasal defor-
mity. The Tajima reverse-U technique continues to be used and has
been modified by several authors.13,14 Another popular technique
was described by Dibbell15 in 1982. This technique uses incisions
within the nostril rim and excision of soft tissue to correct the alar
web and rotation of the medial crus. This results in increased sym-
metry of the nasal tip and narrowing of the alar base.
Flores et al16 described an open rhinoplasty approach using a
combination of both the Dibbell and Tajima techniques to correct
the nostril apex overhang and reposition the depressed LLC and lat-
erally displaced ala on the cleft side. They reported that avoidance
of an upper lip incision with this technique is an advantage, particu-
larly in those patients who have a well-healed lip scar from primary
lip repair. In studying their outcomes with photogrammetric analy-
sis, they found a notable reduction of alar base width, increase in
columellar height, and decrease in the amount of nostril apex over-
hang. They also showed a significant increase in symmetry be-
tween the cleft and noncleft sides.
There are numerous other techniques that have been de-
scribed for modification of the LLCs in the cleft nasal deformity, in-
cluding both suture17,18 and cartilage grafting techniques.17,19-21 Some
of these surgeons have used a combination of suture and cartilage
grafting techniques to achieve optimal outcomes. Bashir et al17 and
Stal and Hollier18 compared their suture only technique using me-
dial crural sutures, interdomal sutures, and transdomal sutures with
a suture plus graft technique and reported better nasal tip projec-
tion results with the latter combined technique.
The alar web is also a challenging aspect of the cleft nasal
deformity, and a variety of methods have been described to cor-
rect this including direct skin excision, Z-plasty, and the Tajima
reverse-U incision. Agarwal and Chandra22 studied this deformity
in 25 adults with unilateral cleft nasal deformity and found that
the alar cartilage on the cleft side was in close proximity to the
alar rim and inferiorly displaced in all their cases. They also noted
significant differences in the length, width, and angle at the genu
of the cleft lateral crus vs the noncleft lateral crus. They described
a technique in which the excess caudal border of the LLC is
excised, and the excess overlying skin is then rolled into the nasal
vestibule. Wang et al23 describe correction of the alar web using a
nasal alar rim flap, which can then be adapted to either reduce
the width of the alar base or reconstruct the nostril sill depending
on direction of transfer of the flap. The authors report satisfactory
results over an 8-year period.
Regardless of the specific technique(s) used, an external or open
approach is preferred by most surgeons because it allows maximal
visualization and adequate exposure for placement and suturing of
structural grafts.1,16 In general, repair of the cleft nasal deformity fol-
lows a traditional open rhinoplasty sequence with septoplasty, place-
ment of a columellar strut for symmetry and support of the nasal tip,
modification of the LLCs to improve tip definition and symmetry, and
tip grafting to improve tip support and to camouflage residual tip
asymmetries and/or irregularities. Some patients will also require os-
teotomies to correct any bony deviations and may require addi-
tional dorsal augmentation or support.24
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 Secondary Cleft Rhinoplasty
The senior authors (T.D.W.) preferred technique for second-
ary rhinoplasty involves the use of the sliding chondrocutaneous flap
or sliding cheilorhinoplasty. This technique, first described by
Vissarionov25 in 1989, has been published previously and amalgam-
ates many of the other cleft-lip rhinoplasty concepts mentioned
herein into a single unified technique.7,26-28 The sliding cheilorhi-
noplasty is designed to address the deficiencies present on the cleft
side of the nose, including lowered height of the dome, malposi-
tion of the LLC, lateralization of the alar base, presence of an alar-
columellar web, and vestibular lining deficit. A laterally based chon-
drocutaneous flap based on the LLC, vestibular skin, and lip scar
tissue is used to address these problems, typically through an ex-
ternal rhinoplasty approach. Increased stability and symmetry of the
nasal tip between the cleft and noncleft sides is achieved by com-
bining this technique with the structural grafting consisting of a colu-
mellar strut and shield graft. The sliding cheilorhinoplasty tech-
nique is shown in Figure 3.
Bilateral Cleft Nasal Deformity
Much like the technique used to correct the unilateral cleft nasal de-
formity, a variety of techniques have been described for the correc-
tion of the bilateral cleft nasal deformity. These techniques seek to
improve columellar length and achieve proper nasal tip projection.
In addition, many procedures also seek to address the upper lip soft-
tissue deficiency at the time of secondary rhinoplasty. As in sur-
gery for the unilateral cleft nasal deformity, external rhinoplasty is
favored because of the greater exposure afforded by this ap-
proach. As described herein, the septum is often midline in the bi-
lateral cleft nasal deformity; therefore, septoplasty is performed only
for those patients who have a symptomatic deviation or for har-
vest of autogenous cartilage grafts.
Common techniques to address the short columella include bi-
lateral forked flaps, Cronin advancement flaps, V-Y advancement
flaps from the nasal tip, and a small V-Y advancement flap from the
upper lip.29-31 Several of these techniques have evolved, with sev-
eral surgeons describing modifications and combined techniques.
Forked flaps, first described by Millard29 in 1958, have been modi-
fied more recently by several authors.32,33 However, other sur-
geons, including both Mulliken34 and Noordhoff,35 who had earlier
adopted the staged forked flap technique for columellar elonga-
tion, later abandoned this technique in favor of primary rhino-
plasty at the time of cleft repair. This marked a philosophical shift
from the so-called skin paradigm to the cartilage paradigm for colu-
mellar lengthening by repositioning of the alar domes and sculpt-
ing of the nasal soft tissues.
Cho et al36 described a technique using bilateral reverse-U
incisions and V-Y plasty combined with an open rhinoplasty
approach in 32 patients over a 12-year period. In patients with a
severely short columella, these authors used a composite graft
from the helical root to provide additional columellar length. They
reported a notable improvement in average columellar height and
correction of the nasal tip depression as well as the alar-
columellar web. Other authors have also used composite grafts to
address the shortened columellar length. Cheon and Park 37
reported on their experience with 137 patients who had conchal
composite grafts placed for repair of a shortened columella and
cite the avoidance of using upper lip tissue as an advantage. They
suggest that their technique is a suitable alternative in patients
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Review Clinical Review & Education
Figure 3. Sliding Cheilorhinoplasty
A
B
A, The original Vissarionov technique. B, Modified combined technique.
Left, outline of lip scar, chondrocutaneous flap, alar-web incision, and
transcolumellar incision. Middle, laterally based chondrocutaneous flap
elevated, along with external rhinoplasty exposure. Right, chondrocutaneous
flap advanced superior-laterally, secured with columellar strut and nasal tip
graft. Reproduced with permission from Wang and Madorsky.28
with a severely short columella and soft-tissue deficiency or scar
contracture of the upper lip.
Jackson et al31 described their approach consisting of columel-
lar lengthening using a central lip advancement flap, open rhino-
plasty, nasal mucosal advancement, and alar base narrowing. They
reviewed their experience in 32 patients with bilateral cleft lip who
underwent secondary procedures to address the nasal deformity.
Columellar length was increased by 3 to 7 mm in all patients, and they
noted improvement in the nasal tip and decrease in the interalar dis-
tance. The authors suggest that a limitation of the fork flap tech-
nique is the lack of mucosal lengthening, which consequently re-
sults in disappointing long-term results because of contraction
associated with inadequate mucosa. Additional disadvantages in-
clude possible scarring and deformation of the columella and risk of
tissue necrosis at the columellar base.31
Alar cartilage deformity and deficient nasal tip projection are also
challenges in the bilateral cleft nasal deformity. Garri et al38 re-
ported on their technique of a double-arch tip rhinoplasty as adapted
from Wolfe39 to improve nasal tip projection. In this technique, con-
chal cartilage is harvested and then divided into a columellar strut,
and 2 additional symmetrical portions that are secured over the na-
tive LLCs to reconstruct the arches. Garri et al38 compared their out-
comes in a group of patients who underwent the Wolfe double-
arch tip rhinoplasty with those of another group who underwent LLC
release and tip grafting. They found a significantly greater increase
in columella length with the double-arch tip rhinoplasty compared
with tip grafting. The double-arch tip rhinoplasty group also had a
33% greater increase in tip projection.
Outcomes in Secondary Cleft Rhinoplasty
To date, there has been a relative paucity of studies specifically look-
ing at outcomes in secondary cleft rhinoplasty. Unfortunately, as with
JAMA Facial Plastic Surgery January/February 2014 Volume 16, Number 1 61
 Clinical Review & Education Review Secondary Cleft Rhinoplasty

other areas of facial plastic surgery, there is great variability in sec-
ondary cleft nasal deformities and the surgical techniques used to
correct them. While a handful of studies have looked at patient-
reported subjective outcomes and aesthetic outcomes, there are
even fewer studies examining patient-reported or objective func-
tional outcomes.
Aesthetic outcomes have been studied both through subjec-
tive assessment by patients and surgeons. Some studies have looked
at aesthetic outcomes using both preoperative and postoperative
photographic assessment40-42 as well as using newer technologies
as 3-dimensional laser surface scanning to assess 3-dimensional na-
sal changes following surgery.43,44 One application for these types
of aesthetic outcome measures is to help understand the effects and
outcomes of particular surgical techniques. For example, Pitak-
Arnnop et al40 compared panel perceptions of patients who under-
went secondary cleft rhinoplasty with and without columellar graft-
ing and found that columellar grafting was associated with higher
rankings of postoperative nasal aesthetics.
While there are no standardized outcome measures specifi-
cally for cleft rhinoplasty, there are a variety of tools available to study
functional outcomes.45 Interestingly, despite the lack of studies look-
ing at functional outcomes, Hens et al46 noted that nasal obstruc-
tion was a motivating factor in 97% of their patients who under-
went secondary cleft rhinoplasty. This highlights the importance of
functional considerations in secondary cleft rhinoplasty and the need
for further research in this area. Huempfner-Hierl et al42 per-
formed a prospective study of 68 patients undergoing secondary
cleft rhinoplasty and assessed functional outcomes using active an-
terior rhinomanometry, rhinoresistometry, and acoustic rhinom-
etry preoperatively and 6 months postoperatively. They also stud-
ied aesthetic outcomes by comparing anthropometric data from
standardized preoperative and postoperative photographs. Al-
though analysis of functional respiratory data showed a significant
increase in nasal volume, no change in nasal airflow and hydraulic
diameter could be found.42 Although objective, quantitative out-
come measures have an important role in facial plastic surgery, it
could be argued that patient satisfaction is ultimately what mat-
ters the most. Overall, patient subjective outcomes following sec-
ondary cleft rhinoplasty tend to be positive with a relatively high sat-
isfaction rate. Hens et al46 surveyed 30 patients who underwent
secondary cleft rhinoplasty regarding nasal function and general sat-
isfaction of the procedure using the validated Rhinoplasty Out-
come Evaluation (ROE). They found that there was significant sub-
jective improvement in ROE scores and in specific scores for aesthetic
appearance and nasal breathing. Patients tended to report a greater
improvement in nasal aesthetics compared with nasal function.46
In conclusion, although presurgical nasoalveolar molding and
the widespread adoption of primary rhinoplasty at the time of pri-
mary cleft lip repair has and will continue to improve outcomes, there
will undoubtedly continue to be a need for secondary rhinoplasty
in the patient with cleft lip. Hopefully, because of these earlier in-
terventions, the severity of the deformities seen later in life will re-
quire a less aggressive approach. Despite that, the secondary cleft
nasal deformity continues to be a challenging problem because of
the underlying complexity in nasal form and function. The multi-
tude of surgical approaches to the cleft-lip nose is proof to the dif-
ficulty of this reconstructive problem and underscores the need for
future studies examining both subjective and objective outcome
measures as they relate to nasal aesthetics and function in second-
ary cleft rhinoplasty. A thorough understanding of the deformity and
the methods for its correction forms the foundation for successful
reconstruction.

ARTICLE INFORMATION
Accepted for Publication: April 23, 2013.
Published Online: November 7, 2013.
doi:10.1001/jamafacial.2013.1562.
Author Affiliations: Division of Facial Plastic and
Reconstructive Surgery, Department of
Otolaryngology and Communication Sciences,
Medical College of Wisconsin, Milwaukee (Pawar);
Division of Facial Plastic and Reconstructive
Surgery, Department of OtolaryngologyHead and
Neck Surgery, Oregon Health and Science
University, Portland (Wang).
Author Contributions: Drs Pawar and Wang had
full access to all of the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition of data: Both authors.
Analysis and interpretation of data: Both authors.
Drafting of the manuscript: Pawar.
Critical revision of the manuscript for important
intellectual content: Both authors.
Administrative, technical, or material support: Both
authors.
Study supervision: Wang.
Conflict of Interest Disclosures: None reported.
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