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Cleft lip nose and secondary
deformities of cleft lip, nose
and palate
Dr Sumer Yadav
Mch - Plastic and reconstructive sur...
Introduction
 Improvement in lip repair results
 Less satisfactory in nasal deformity
1. Cleft lip and palate abn studie...
 Brown and mcdowell – not to appear in
public and retire
 Not acceptable
 Multidisciplinary concept
 Interconnected so...
Degree of deformity
 Original defect
 Method of repair
 Craniofacial growth patterns
 Orthodontic therapy
 Prosthodon...
Pathogenesis
1. Agenesis of tissue from deficiency of
mesoderm and ectoderm in primary palate
region
2. Mechanical stresse...
 After cleft is established the premaxilla
segment begins to move forward at 6th
week ,
pulled by growing nasal septum to...
 When medial and lateral crura of alar
cartilage are pulled apart --- lowering of alar
arch in dorsal direction --- fasci...
 Shortening of columella in bilateral clefts is
due to wide distraction of the alar cartilages.
the alar domes are separa...
Anatomy
the unilateral cleft
sumeryadav2004@gmail.com
 Severity is directly related to extent of lip deformity
and alveolar cleft
 Asc with high orbicularis defects , def of ...
 Maxilla cleft and hypoplasia
 Incomplete rotation of alar cartilage
 Hypoplasia of lateral crus of alar cartilage
 Di...
Etiology
 Intrinsic defect or def of growth and development of
the nasal structures
 Intrinsic hypoplasia of involved so...
Pathologic anatomy
1. Nasal tip; alar cartilage and columella
2. Lateral bony platform ; piriform aperture
3. Midline supp...
sumeryadav2004@gmail.com
Tilted tripod
 The tripod consists of dorsal portion of septum and
nasal bones and 2 alar arms
 Tilting result from maxi...
sumeryadav2004@gmail.com
 When one of bony platform is def the tripod
collapse on the ipsilateral ala and deflects
the septum into the contralater...
Basic tenet of Cleft development
 Failure to reconstruct the nasal floor in
primary cleft repair leaves the nose attached...
Pathologic anatomy
1. Tip of nose is deviated toward noncleft side
2. Dome on cleft side is retrodisplaced
3. Angle betwee...
Pathologic anatomy
1. Naris is retrodisplaced
2. Columella is shorter in AP dimension
3. Medial crus is displaced
4. Colum...
Caudal rotation of alar cartilage
 Importance
 Alar cartilage must be lifted to shorten on the side of
cleft and to leve...
Reasons for unsatisfactory result
following primary repair
 Alar cartilage should be lifted at start of opn
before nostri...
Presurgical orthopedic procedures
 Displaced tissue should be returned to their
normal positions before a defect is repai...
Surgical procedures
 Hemirhinoplasty to reposition the displaced alar cartilage
 Elevate the alar cartilages with its at...
sumeryadav2004@gmail.com
 Scissors inserted through the upper buccal sulcus of ant nasal
spine to liberate the medial crus of alar cartilage in co...
 Correct site of dome and first lifting suture is
selected by points of forceps lifting from inside the
nasal vestibule
...
 The nostril sill is augmented with local flaps
and muscle union is established beneath the
floor of nose
 At completion...
Bilateral cleft lip nose primary repair
 PSO alignment of bony platform ,premaxilla
is centraised and twisting is correct...
sumeryadav2004@gmail.com
 For minor deformities, a closed approach
 significant reconstruction, the open approach
 When significant inferior tur...
Timing of the definitive nasal
deformity correction
 It is deferred until
1. closure of the possibly coexisting
oronasal/...
Reasons
 To achieve a symmetric result it is critical that the
alar bases start at a spatially symmetric level.
 depress...
Preoperative evaluation
sumeryadav2004@gmail.com
Timetable for definitive repair
sumeryadav2004@gmail.com
Timing
 Simultaneous repair
 Preschool age
 Puberty / adolescence
sumeryadav2004@gmail.com
Timing of repair
1. Simultaneous primary lip and alveolar repair
Interfere with nasal and maxillary growth due to
postoper...
Bardach and salyer
delayed till 8 to 12 yrs
 To allow completion of orthodontic correction of
skeletal base
 To allow gr...
Nasal growth is completed by 16yr in females
and 18 yr in females
Highest growth activity was in
suprapremaxillary and ant...
 Rational approach is rotation advancement lip repair
with primary closure of cleft nostril floor and
repositioning of al...
3 Puberty / adolescence
By 16 to 18 yr canine teeth have erupted and
bone grafting has been performed providing
bony suppo...
Salyer principles of CLN deformity
1. The more severe the deformity , the earlier and more radical
the secondary procedure...
Corrective surgery techniques
 To restore nasal symmetry , the alar cartilage must be
modified by repositioning , suspens...
Rotation of cleft lip lobule and external
incisions
 Blair excision and rotation advancement –
superior and medial rotati...
sumeryadav2004@gmail.com
 Joseph – semilunar excision of dorsal skin to
correct the downward displacement of ala
brought the dome of alar cartilag...
Gilles and killner
 Extended Blair procedure by lengthening
the midcolumellar incisions upward over the
cleft side of dom...
Berkeley
 Extensive rotation upward and medially of
entire half of nose on cleft side
 Extensive mobilization of lobular...
sumeryadav2004@gmail.com
Hugo and Tumbusch
 Instead of rotation the nostril floor into
columella , they incorporated lip skin and scar
to lengthen...
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
Black
 Deglove the lower nasal skeleton and enhance
exposure through rim and upper labial sulcus
incisions
 Tajima “C” f...
Advantages of external incision
1. Wide exposure
2. Increased alar mobilisation
3. Stability
4. Superior correction of sev...
External approach for nasal tip
1. Erich flying wing incision
2. Figi combination of flying wing and midcolumellar
incisio...
sumeryadav2004@gmail.com
Alar cartilage mobilisation and
suspension
 Potter –
Complete exposure of deformed alar cartilage,
delivery of lateral cr...
sumeryadav2004@gmail.com
 Spira excised noncleft crus to fill lateral
vestibular defect on cleft side . A suture from
alar base passing thought th...
 Rees
dissected the entire lateral crus on the cleft side from
the nasal skin and mucosa and weakened the
cartilage by sc...
 Reynolds and horton
Suspension of cleft alar lateral crus to both
ipsilateral and contralateral upper lateral
cartilage....
Tajima and maruyama
 reverse U incision with suture suspension of
repositioned alar cartilages . On nostril on cleft side...
sumeryadav2004@gmail.com
 The deformed alar cartilage flap is properly
positioned and sutured to contralateral alar cartilage
of noncleft side and...
sumeryadav2004@gmail.com
Technique of correction of web in
lateral vestibule
sumeryadav2004@gmail.com
Incision and relocation of alar cartilage
 Humby – incision and transposition of the upper portion of
unaffected lateral ...
Incision and relocation of alar cartilage
 Barsky relocated and suspended the cephalic border of lateral
crus of cleft si...
sumeryadav2004@gmail.com
sumeryadav2004@gmail.com
Graft augmentation
 Lamont cephalic margin of uninvolved ala to augment the
cleft alar dome
 Fomon ear cartilage graft o...
sumeryadav2004@gmail.com
 Tessier Minerva helmet or lily conchal cartilage
 Chait – C shaped cartilage inserted through an
incision in columella ...
Others
 Silicone
 Costal cartilage
 Dermal fat graft
 Surgicel
 Foreign body implant
sumeryadav2004@gmail.com
Lengthening of columella
 Always shortened columella
 At 6 yrs
 Early repair results in downward slippage of
columella ...
sumeryadav2004@gmail.com
 Bipedicle flaps are formed based medially on
columella and laterally on alae
 The medial incision that separates the
co...
 Adjacent tissue of cheek are freed form the
maxilla
 Columella septal incision is sutured with the
columella in a more ...
sumeryadav2004@gmail.com
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secondary deformities of cleft LIP AND NOSE

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secondary deformities of cleft LIP AND NOSE

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secondary deformities of cleft LIP AND NOSE

  1. 1. Cleft lip nose and secondary deformities of cleft lip, nose and palate Dr Sumer Yadav Mch - Plastic and reconstructive surgeon sumeryadav2004@gmail.com
  2. 2. Introduction  Improvement in lip repair results  Less satisfactory in nasal deformity 1. Cleft lip and palate abn studies more 2. Lip line beneath the nose deemphasize the lip, whereas nose is always more obvious Total interrelated lip , nose ,maxilla & palate deformity poorly analysed sumeryadav2004@gmail.com
  3. 3.  Brown and mcdowell – not to appear in public and retire  Not acceptable  Multidisciplinary concept  Interconnected so isloated operation give less than optimal results  Systematic evaluation , integrated plan and quality surgical technique sumeryadav2004@gmail.com
  4. 4. Degree of deformity  Original defect  Method of repair  Craniofacial growth patterns  Orthodontic therapy  Prosthodontic rehabilitation sumeryadav2004@gmail.com
  5. 5. Pathogenesis 1. Agenesis of tissue from deficiency of mesoderm and ectoderm in primary palate region 2. Mechanical stresses as cleft widens in utero sumeryadav2004@gmail.com
  6. 6.  After cleft is established the premaxilla segment begins to move forward at 6th week , pulled by growing nasal septum to which it is attached by septopremaxillary ligament.  The alar base region is retroposed because of lack of forward development of maxilla  There is increased widening of the distance between base of columella and alar base sumeryadav2004@gmail.com
  7. 7.  When medial and lateral crura of alar cartilage are pulled apart --- lowering of alar arch in dorsal direction --- fascia nasalis is tightened  The infundibulum between two cartilages disappears and alar arch is forced to tilt downward in a caudal direction.  Lower edge of alar cartilage is also displaced dorsally sumeryadav2004@gmail.com
  8. 8.  Shortening of columella in bilateral clefts is due to wide distraction of the alar cartilages. the alar domes are separated and ant parts of medial crura are displaced away from tip of nasal septum  The columella is therefore progressively shortened towards its base at its junction of prolabium sumeryadav2004@gmail.com
  9. 9. Anatomy the unilateral cleft sumeryadav2004@gmail.com
  10. 10.  Severity is directly related to extent of lip deformity and alveolar cleft  Asc with high orbicularis defects , def of nostril sill , nasal spine and the maxilla  Components of nasal deformity 1. Defect of lower lateral cartilage on cleft side 2. Nasal septum 3. Columella 4. Nasal tip 5. Nasal pyramid sumeryadav2004@gmail.com
  11. 11.  Maxilla cleft and hypoplasia  Incomplete rotation of alar cartilage  Hypoplasia of lateral crus of alar cartilage  Distortion of alar cartilage by mechanical forces  Loss of orbicularis muscle continuity  Abnormal muscle tension on nasal str esp alar base  Malpositioning of maxillary segments sumeryadav2004@gmail.com
  12. 12. Etiology  Intrinsic defect or def of growth and development of the nasal structures  Intrinsic hypoplasia of involved soft tissue and cartilages  Failure of neural crest cells to migrate results in absence of mesodermal penetration of soft tissue in cleft region  Tissue def of cleft lip , a def of maxilla or abnormal muscular pull on nasal structures sumeryadav2004@gmail.com
  13. 13. Pathologic anatomy 1. Nasal tip; alar cartilage and columella 2. Lateral bony platform ; piriform aperture 3. Midline supporting structures ; cartilaginous septum and anterior nasal spine sumeryadav2004@gmail.com
  14. 14. sumeryadav2004@gmail.com
  15. 15. Tilted tripod  The tripod consists of dorsal portion of septum and nasal bones and 2 alar arms  Tilting result from maxillary hypoplasia with secondary deformity of septum and cleft ala  Convex deformity of septum and vertical bending of septum posterior to junction of membranous and cartilaginous portions of septum  Restriction of caudal border of septum in ant thrust causes it to bend toward the normal nostril sumeryadav2004@gmail.com
  16. 16. sumeryadav2004@gmail.com
  17. 17.  When one of bony platform is def the tripod collapse on the ipsilateral ala and deflects the septum into the contralateral normal naris  With marked hypoplasia the septum is lifted out of the vomerine groove and encroaches on opposite nostril sumeryadav2004@gmail.com
  18. 18. Basic tenet of Cleft development  Failure to reconstruct the nasal floor in primary cleft repair leaves the nose attached directly to lip through the intact orbicularis and to palate through the lateral mucoperiosteum of alveolar cleft  Although the lip defect may improve with time the primary nasal deformity will never improve sumeryadav2004@gmail.com
  19. 19. Pathologic anatomy 1. Tip of nose is deviated toward noncleft side 2. Dome on cleft side is retrodisplaced 3. Angle between medial and lateral crura on cleft side is excessively obtused 4. Buckling of alar cartilage 5. Alar facial groove on cleft side is absent 6. Bony def of maxilla on cleft side 7. Circumference of naris is greater on cleft side sumeryadav2004@gmail.com
  20. 20. Pathologic anatomy 1. Naris is retrodisplaced 2. Columella is shorter in AP dimension 3. Medial crus is displaced 4. Columella is positioned obliquely 5. Nasolabial fistula 6. Absence of nasal floor 7. Hypertrophy of inferior turbinate on cleft side 8. Displacement of noncleft maxillary segment sumeryadav2004@gmail.com
  21. 21. Caudal rotation of alar cartilage  Importance  Alar cartilage must be lifted to shorten on the side of cleft and to level the nostril rims  Elevation of the alar cartilage with the attached nasal lining corrects the oblique fold within the vestibule  When alar cartilage is lifted , the compound curve that produces the typical flare of cleft lip nostril is avoided sumeryadav2004@gmail.com
  22. 22. Reasons for unsatisfactory result following primary repair  Alar cartilage should be lifted at start of opn before nostril floor is closed so that vault of the vestibule is established and limning is in position  Scarring from incision made in nostril lining causes contraction and stenosis  Large changes in size and shape of nose that occur during growth spurts sumeryadav2004@gmail.com
  23. 23. Presurgical orthopedic procedures  Displaced tissue should be returned to their normal positions before a defect is repaired  Maxillary segments are aligned and displacement of nasal septum is reduced sumeryadav2004@gmail.com
  24. 24. Surgical procedures  Hemirhinoplasty to reposition the displaced alar cartilage  Elevate the alar cartilages with its attached vestibular lining to recreate the vault of vestibule and to obliterate the vestibular ridge  Dissection through upper buccal sulcus deep to base of nostril . The alar base is separated from piriform aperture  Continue over ant surface of alar cartilage and extends to completely undermine the skin of nose till across the nasal tip over the lower part of upper lateral cartilage on non cleft side  Wide undermining for easy lift and contraction and shortening of lengthened skin on cleft side of nose sumeryadav2004@gmail.com
  25. 25. sumeryadav2004@gmail.com
  26. 26.  Scissors inserted through the upper buccal sulcus of ant nasal spine to liberate the medial crus of alar cartilage in columella from its attachment to overlying skin  If alveolar arch is cleft , a mucosal flap is preserved from the pared margin of lateral lip element based on ant buccal sulcus end  The nostril linining is freed from lower part of cartilaginous septum and from lateral wall of nose  The alar cartilage rotated upward and forward raising the nostril rim and reestablishing the vault of vestibule with obliteration of vestibular fold  The infundibulum is reestablished and upper edge of alar cartilage lies above and sup to caudal border of upper lateral cartilage sumeryadav2004@gmail.com
  27. 27.  Correct site of dome and first lifting suture is selected by points of forceps lifting from inside the nasal vestibule  The suture pass through mucosa and alar cartilage upward and medially to emerge in nasion toward noncleft side  A second elevating suture is passed through lateral crus of alar cartilage  bolsters are used to lift and round out dome and lateral wall of vestibule  These make the nostril in level with contralateral side and established the vestibular vault sumeryadav2004@gmail.com
  28. 28.  The nostril sill is augmented with local flaps and muscle union is established beneath the floor of nose  At completion of lip repair remove ,replace and realign the direction of lifting suture  Do not attempt to realign the cartilaginous septum completely – fibrosis and scarring sumeryadav2004@gmail.com
  29. 29. Bilateral cleft lip nose primary repair  PSO alignment of bony platform ,premaxilla is centraised and twisting is corrected  2 stages permit  First columella so lengthened to release the nasal tip and elevation of alar cartilages  6 wks latter simultaneous repair of lip and nose sumeryadav2004@gmail.com
  30. 30. sumeryadav2004@gmail.com
  31. 31.  For minor deformities, a closed approach  significant reconstruction, the open approach  When significant inferior turbinate hypertrophy is present, turbinate reduction to enable better visualization of the nasal cavity. then open rhinoplasty.  V-shaped columella incision; the nose is skeletonized; and all cartilaginous and bony deformities are visualized. The entire septal cartilage exposed by lateral reflection of the medial crura of the lower nasal cartilages.  dissect the mucoperichondrium on either side of the septal cartilage to fully expose the septum, the perpendicular plate of the ethmoid bone, the crest of the maxilla, the vomer, and the anterior nasal spine.  If only the caudal portion of the septum deviates from the midline, free this portion from the underlying maxilla and nasal spine.. The septum is secured in the midline with sutures to the nasal spine. Cartilage grafts and strut used to maintain the contour and provide support.. Symmetry of the domes with cartilage repositioning or augmentation using cartilage grafts.  Osteotomies when skeletal deformities and deviations are present and composite grafts from the ear are to correct significant lining deficiencies. The incision is closed in a V-Y fashion to provide additional columella length.  Finally, if the cleft side nostril is significantly smaller than that of the non-cleft side, corrected with composite graft from the conceal bowl of the ear. sumeryadav2004@gmail.com
  32. 32. Timing of the definitive nasal deformity correction  It is deferred until 1. closure of the possibly coexisting oronasal/palatal fistulas, 2. bone grafting of the alveolus and the hypoplastic maxilla 3. orthodontic alignment of the maxillary dentition. sumeryadav2004@gmail.com
  33. 33. Reasons  To achieve a symmetric result it is critical that the alar bases start at a spatially symmetric level.  depressed base on the cleft side is raised, through alignment of the maxillary segments, alveolar bone grafting, or osteotomies during orthognathic surgery.  If the alar base is still depressed, onlay cortical bone grafting is done  When oronasal and/or palatal fistulas are present, saliva and food particles regurgitate into the nasal cavity, irritating the nasal mucosa and creating tissue thickening which exacerbates the airway obstruction. sumeryadav2004@gmail.com
  34. 34. Preoperative evaluation sumeryadav2004@gmail.com
  35. 35. Timetable for definitive repair sumeryadav2004@gmail.com
  36. 36. Timing  Simultaneous repair  Preschool age  Puberty / adolescence sumeryadav2004@gmail.com
  37. 37. Timing of repair 1. Simultaneous primary lip and alveolar repair Interfere with nasal and maxillary growth due to postoperative scarring Technical difficult – small and fragile cartilages 2 preschool age Social pressure at 4 to 6 yr sumeryadav2004@gmail.com
  38. 38. Bardach and salyer delayed till 8 to 12 yrs  To allow completion of orthodontic correction of skeletal base  To allow growth and development of lower lateral cartilages for support stable stronger support for reconstructed nasal tip  To allow bone grafting of hypoplastic maxillary segment on cleft side --- more symmetric alar base , improving conditions for nasal deformity correction at latter stage sumeryadav2004@gmail.com
  39. 39. Nasal growth is completed by 16yr in females and 18 yr in females Highest growth activity was in suprapremaxillary and anterior border of septal cartilage between 6 -10 yrs.so no septal resection or revision before 20 yr Vomer is essential for general nasal growth and downward and forward growth of maxilla till 7 to 8 yrs sumeryadav2004@gmail.com
  40. 40.  Rational approach is rotation advancement lip repair with primary closure of cleft nostril floor and repositioning of alar base .  Onlay bone grafts or surgical augmentation of hypoplastic piriform aperture to elevate the cleft alar platform should represent the extent of primary procedure  Secondary correction of residual nasal deformity by limited septoplasty, reconstruction of nasal tip and alar cartilages and cartilage grafts is also appropriate sumeryadav2004@gmail.com
  41. 41. 3 Puberty / adolescence By 16 to 18 yr canine teeth have erupted and bone grafting has been performed providing bony support for nasal base with augmentation of hypoplastic maxilla Osteotomies of maxilla and correction of skeletal or occlusal abnormalities should precede def rhinoplasty as advancement of maxilla may alter nasal contour sumeryadav2004@gmail.com
  42. 42. Salyer principles of CLN deformity 1. The more severe the deformity , the earlier and more radical the secondary procedure should be 2. Correction of nasal deformity is designed to improve form and function and to alleviate psychological stress 3. Correction of nasal deformities include  Skeletal base  Septum  Alae 4 Bone grafting and cartilage augmentation may be indicated 5 Definitive rhinoplasty at 14 yr or more 6 Severe asymmetry of skeletal base is a contraindication to definitive rhinoplasty sumeryadav2004@gmail.com
  43. 43. Corrective surgery techniques  To restore nasal symmetry , the alar cartilage must be modified by repositioning , suspension, alteration in size or augmentation with graft  Techniques 1. External approach 2. Alar cartilage mobilization and suspension 3. Alar cartilage incision and repositioning 4. Graft augmentation 5. Orthognathic procedures 6. Bone grafting 7. Vestibular web revisions 8. Nostril hood modification sumeryadav2004@gmail.com
  44. 44. Rotation of cleft lip lobule and external incisions  Blair excision and rotation advancement – superior and medial rotation of alar base to correct abnormal orientation of nares and advanced the downwardly displaced medial crura by a midcolumellar incision that extended under the alar base . Wedge excision for caudal dislocation of alar margin  External scarring so abandoned  Various modification described sumeryadav2004@gmail.com
  45. 45. sumeryadav2004@gmail.com
  46. 46.  Joseph – semilunar excision of dorsal skin to correct the downward displacement of ala brought the dome of alar cartilage into a more normal position  Crickelair – justified external incisions in marked abnormalities . Medial advancement of alar base is done in all these procedure sumeryadav2004@gmail.com
  47. 47. Gilles and killner  Extended Blair procedure by lengthening the midcolumellar incisions upward over the cleft side of dome  Willie correction– Joseph dorsal incision was part of rotation advancement of alar columella  A separate rim incision corrected downward displacement of ala sumeryadav2004@gmail.com
  48. 48. Berkeley  Extensive rotation upward and medially of entire half of nose on cleft side  Extensive mobilization of lobular complex  abandoned sumeryadav2004@gmail.com
  49. 49. sumeryadav2004@gmail.com
  50. 50. Hugo and Tumbusch  Instead of rotation the nostril floor into columella , they incorporated lip skin and scar to lengthen the columella on cleft side  Dibbel – excision of excess alar rim skin ,mobilization of alar cartilage from the skin and rotation of nostril peripherally rather than rotation of half of columella  Disadvantage is fresh lip scar sumeryadav2004@gmail.com
  51. 51. sumeryadav2004@gmail.com
  52. 52. sumeryadav2004@gmail.com
  53. 53. Black  Deglove the lower nasal skeleton and enhance exposure through rim and upper labial sulcus incisions  Tajima “C” flap extension for simultaneous exposure and skin tailoring sumeryadav2004@gmail.com
  54. 54. Advantages of external incision 1. Wide exposure 2. Increased alar mobilisation 3. Stability 4. Superior correction of severe deformities Disadvantage 1. Scar on nasal tip indications 1. Severe deformities 2. Thick alar skin 3. Previous unsuccessful intranasal procedures sumeryadav2004@gmail.com
  55. 55. External approach for nasal tip 1. Erich flying wing incision 2. Figi combination of flying wing and midcolumellar incision 3. Gilles extended the columella incision into the cleft floor 4. Potter – only acceptable ext approach Incision at columella base and dev of columella flap Less scar and excellent access to alar cartilage sumeryadav2004@gmail.com
  56. 56. sumeryadav2004@gmail.com
  57. 57. Alar cartilage mobilisation and suspension  Potter – Complete exposure of deformed alar cartilage, delivery of lateral crus and suturing of domes. Columellar flaps raised exposing both lateral crura  Mcindoe exposing both ala and securing alar domes to each other and to septal angle . The lateral cartilage and crura secured to septum and skin .raw defect closed with composite graft of cartilage and skin or left to epithelize sumeryadav2004@gmail.com
  58. 58. sumeryadav2004@gmail.com
  59. 59.  Spira excised noncleft crus to fill lateral vestibular defect on cleft side . A suture from alar base passing thought the nasal spine and caudal septum provide maintenance of nostril sill width  Stenstrom – z plasty to narrow alar base with a buried suture anchoring the alar base to septum sumeryadav2004@gmail.com
  60. 60.  Rees dissected the entire lateral crus on the cleft side from the nasal skin and mucosa and weakened the cartilage by scoring to establish a contour similar to noncleft dome. suture to contralateral upper lateral cartilage and medial crura maintained the corrected height of dome Lateral vestibular defect closed with comp graft sumeryadav2004@gmail.com
  61. 61.  Reynolds and horton Suspension of cleft alar lateral crus to both ipsilateral and contralateral upper lateral cartilage. Elevation and suspending the cleft of alar cartilage are facilitated by excision of a portion of alar cartilage sumeryadav2004@gmail.com
  62. 62. Tajima and maruyama  reverse U incision with suture suspension of repositioned alar cartilages . On nostril on cleft side a reverse U incision begins in membranous septum curving forward slightly over nostril rim parallel to dome of them cartilage and reentering the nose to end just lateral to fold in nasal vestibule  chondromuccutaneous flap of alar cartilage is raised and widely undermined .  Additional undermining over contralateral alar cartilage & upper lateral cartilage frees entire nasal skin for redraping . sumeryadav2004@gmail.com
  63. 63. sumeryadav2004@gmail.com
  64. 64.  The deformed alar cartilage flap is properly positioned and sutured to contralateral alar cartilage of noncleft side and lateral cartilages of both sides by rotationg the reverse u flap medially and superiorly  Nakajima added a z plasty in lateral nasal vestibule  Straith – correction of alar columella web by modified Z plasty technique sumeryadav2004@gmail.com
  65. 65. sumeryadav2004@gmail.com
  66. 66. Technique of correction of web in lateral vestibule sumeryadav2004@gmail.com
  67. 67. Incision and relocation of alar cartilage  Humby – incision and transposition of the upper portion of unaffected lateral crus across midline to augment lateral crus of cleft side  Kazanjian elevation of medial crura of both alar cartilage as medially based flaps ; sutured together vertically after division from the lateral crus . Excision of alar base weges and semilunar excision of skin from alar web area also modified nostril width and projection  Brown and McDowell divided cleft lateral crus and repositioned it across the midline over its own medial crus and dome ;suspended to contralateral dome through an intranasal incision sumeryadav2004@gmail.com
  68. 68. Incision and relocation of alar cartilage  Barsky relocated and suspended the cephalic border of lateral crus of cleft side to dorsum of the septum divided the medial crus on the cleft side through an external incision and suspended the dome area to contralateral dome  Whitlow-constable – figi type external incision and crossed bilateral alar winged flaps suspended through the skin by pull out bolster sutures  These hinged flaps depend on cartilage integrity to maintain the elevation and position of remaining alar cartilage. Prerequisites are strong well developed cartilaginous component that can withstand stresses necessary to move attached soft tissue sumeryadav2004@gmail.com
  69. 69. sumeryadav2004@gmail.com
  70. 70. sumeryadav2004@gmail.com
  71. 71. Graft augmentation  Lamont cephalic margin of uninvolved ala to augment the cleft alar dome  Fomon ear cartilage graft over lateral crus in columella and ant nasal spine  Musgrave and dupertuis multitiered cartilage graft  Millard columella strut graft  Gorney & falces gull wing conchal graft formed by suturing conchal grafts together with their convexities apposing one another  Dibbell shaped costal cartilage into a bowie knife strut for placement in a pocket created in columella and membranous septum sumeryadav2004@gmail.com
  72. 72. sumeryadav2004@gmail.com
  73. 73.  Tessier Minerva helmet or lily conchal cartilage  Chait – C shaped cartilage inserted through an incision in columella rim extends into floor of nose . Support and augments nasal sill. Placed sup to alar cartilage & secured to medial crura of both alar cartilage  Thomson – incision of alar to produce medially based flap resulting in lengthening of columella . Nasal tip and perialar sulcus are augmented with a conchal cartilage graft sumeryadav2004@gmail.com
  74. 74. Others  Silicone  Costal cartilage  Dermal fat graft  Surgicel  Foreign body implant sumeryadav2004@gmail.com
  75. 75. Lengthening of columella  Always shortened columella  At 6 yrs  Early repair results in downward slippage of columella and lip over the premaxilla .  Advancing skin from the floor of nose and base of ala into columella  Converse used skin from floor of nose  Millard forked flaps from the prolabium  Brauer and Foerester V Y principle in wide sumeryadav2004@gmail.com
  76. 76. sumeryadav2004@gmail.com
  77. 77.  Bipedicle flaps are formed based medially on columella and laterally on alae  The medial incision that separates the columella form the septum is continued laterally and posteriorly across the floor of the nose to make flaps progressively wider.  If alae are excess remove half thickness wedge and remaining half is advanced medially  The flaps are sutured in midlinesumeryadav2004@gmail.com
  78. 78.  Adjacent tissue of cheek are freed form the maxilla  Columella septal incision is sutured with the columella in a more forward position  Cronin technique  Z plasty  Ear cartilage elliptical piece sutured convex to convex surface ends are left in spreading position posteriorly against spinous process  The ant ends sutured to medial crura sumeryadav2004@gmail.com
  79. 79. sumeryadav2004@gmail.com
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secondary deformities of cleft LIP AND NOSE

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