Management of the Nasal Deformity in the Unilateral Cleft of the Lip and Nose

Abstract

Cleft rhinoplasty is a demanding, technique-sensitive procedure. Part art, part science; it poses several probing questions to the surgeon. The unilateral cleft nasal deformity is a distinct entity because the pursuit of symmetry in the unilateral cleft nose makes the repair much more challenging. The advent of nasoalveolar moulding, the gaining popularity of primary (early) nasal repair and greater refinements in secondary (definitive) rhinoplasty techniques have contributed to better nasal results in unilateral cleft repair. Yet, some obstacles remain. This paper aims to discuss the anatomy of the unilateral cleft nose, enumerate aims and objectives of repair at every stage, and to demonstrate the evolution and varied rationale of management of nasal deformities in the unilateral cleft lip and nose.

Keywords: Cleft nasal deformity; Cleft rhinoplasty; Unilateral cleft lip; Unilateral cleft nose.

Fig. 1

The unilateral cleft nasal deformity, features apparent in frontal (a) and basal views (b) (as described in previous table)

Fig. 2

Correction of nasal asymmetry, presurgical elongation of columella, correction of nasal cartilage deformity, increasing the surface area of the nasal mucosal lining and uprighting the columella. As nasoalveolar moulding progresses (pictures ‘a’ through ‘e’); the desired changes are apparent

Fig. 3

Results of NAM without primary rhinoplasty. At one week of age prior to NAM (a, d). At 4 months of age, after NAM and just prior to primary surgery (b, e). Postoperative views at the age of 5 years (c, f)

Fig. 4

Primary open rhinoplasty—direct visualisation of the LLCs, via a trans-columellar incision incorporated into the cheiloplasty incision. Incision markings (a), after exposure (b)

Fig. 5

Closed primary rhinoplasty involves ‘blind’ dissection of the LLCs through the medial and lateral cheiloplasty incisions

Fig. 6

Our approach to semi-open primary rhinoplasty involves a reverse-U (Tajima) incision on the cleft side and a marginal incision on the non-cleft side. Incision marking on cleft side (a), Tajima incision (b), dissection over the cartilage plane and release of fibrofatty tissue (c), approximation of LLCs with inter-domal stitches using 4-0 polydioxanone suture (d), excision of skin over the cleft side ala and closure of nasal incisions (e)

Fig. 7

After NAM and prior to primary surgery (a, c), one year after cheiloplasty and semi-open rhinoplasty (b, d)

Fig. 8

‘Preschool rhinoplasty’ primarily focuses on improving the lower third of the nasal structure, and mitigation of the deformity, setting the stage for secondary or definitive rhinoplasty. Preoperative (a) and postoperative (b) basal views. (Picture courtesy—The Charles Pinto Centre for Cleft Lip and Palate, Thrissur, Kerala)

Fig. 9

Adult unilateral cleft nose reconstruction includes manipulation of the bony pyramid and septal work with placement of cartilage grafts for support and reinforcement. Preoperative views prior to maxillary advancement and definitive rhinoplasty (a, c, e), and post-Le Fort 1 advancement and definitive rhinoplasty (b, d, f). (Picture courtesy—Mr N.A. Nasser)