secondary deformities of cleft LIP AND NOSE

Cleft lip nose and secondary
deformities of cleft lip, nose
and palate
Dr Sumer Yadav
Mch - Plastic and reconstructive surgeon
sumeryadav2004@gmail.com

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

 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

Degree of deformity
 Original defect
 Method of repair
 Craniofacial growth patterns
 Orthodontic therapy
 Prosthodontic rehabilitation

Pathogenesis
1. Agenesis of tissue from deficiency of
mesoderm and ectoderm in primary palate
region
2. Mechanical stresses as cleft widens in utero

 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

 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

 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

Anatomy
the unilateral cleft

 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

 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

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

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

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

 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

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

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

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

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

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

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

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

 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

 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

 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

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

 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.

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.

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.

Preoperative evaluation

Timetable for definitive repair

Timing
 Simultaneous repair
 Preschool age
 Puberty / adolescence

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

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

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

 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

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

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

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

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

 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

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

Berkeley
 Extensive rotation upward and medially of
entire half of nose on cleft side
 Extensive mobilization of lobular complex
 abandoned

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

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

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

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

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

 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

 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

 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

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 .

 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

Technique of correction of web in
lateral vestibule

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

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

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

 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

Others
 Silicone
 Costal cartilage
 Dermal fat graft
 Surgicel
 Foreign body implant

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

 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

 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

secondary deformities of cleft LIP AND NOSE

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secondary deformities of cleft LIP AND NOSE