eMedicine Specialties > Plastic Surgery > Craniofacial

Craniofacial, Bilateral Cleft Nasal Repair: Follow-up

Author: Donald R Laub Jr, MS, MD, FACS, Associate Professor, Departments of Surgery and Pediatrics, University of Vermont College of Medicine; Interim Chief of Plastic and Reconstructive Surgery, Fletcher-Allen Health Care
Coauthor(s): David W Leitner, MD, Professor, Department of Surgery, Division of Plastic Reconstructive and Cosmetic Surgery, University of Vermont College of Medicine, Burlington
Contributor Information and Disclosures

Updated: Jul 23, 2009

Outcome and Prognosis

One of the ironies of caring for children with clefts is that the final outcome of treatment is not known until the patients are adults, at which point the surgeon may be nearing retirement. Surgeons are, therefore, indebted to those surgeons who have the experience of large numbers of patients and who have documented their long-term results. Macomb found few unfavorable outcomes until his patients reached adolescence. This experience highlights growth as the "fourth dimension" in an already complex problem.16

Many of the unfavorable outcomes of cleft nasal surgery are described as occurring after the forked flap technique. McComb originally lengthened the columella with forked flaps taken from the prolabium. He found that the following 3 deformities developed as patients approached adolescence:

  • The columella was excessively long compared to control subjects, which led to larger-than-normal nostrils.
  • The base of the columella tended to drift inferiorly onto the upper lip, creating a more obtuse nasolabial angle and allowing the scars from the forked flap to drift downward and become more noticeable.
  • The nasal tip remained broad as the cartilages continued to splay at the domes.
Cutting and Grayson describe another potential problem with using forked flaps.22 When forked flaps banked in the whisker position are rotated into the columella, the rotation can cause the upper lip to bunch up. Additional tissue excision and reopening of old scars may be necessary to correct this complication. Additionally, it rotates a noticeable midline scar into the columella. Cutting and Grayson point out that procedures that use prolabial skin exclusively to reconstruct the columella and use the lateral lip segments to reconstruct the entire lip place tension on the lip and maxilla.22 This tension can lead to midfacial retrusion.

Garri et al compared the result of their secondary nasal reconstruction for bilateral cleft nose; they found the results of open rhinoplasty superior to composite grafting for columellar advancement.49 This is further evidence that the "cartilage paradigm" yields better outcomes than the "skin paradigm."

Lee et al presented a study that showed improved appearance in children with bilateral cleft lip nasal deformity treated with nasoalveolar molding (NAM).40

Future and Controversies

The number and variety of methods for treatment of the bilateral cleft lip nasal deformity indicate the difficult nature of the problem. Perfect anatomic reconstruction is impossible, even if completed within the first few months of life. The possibility of fetal correction of bilateral cleft lip is intriguing; however, the benefits of fetal surgery must outweigh the risks of miscarriage and fetal demise.

 


More on Craniofacial, Bilateral Cleft Nasal Repair

Overview: Craniofacial, Bilateral Cleft Nasal Repair
Workup: Craniofacial, Bilateral Cleft Nasal Repair
Treatment: Craniofacial, Bilateral Cleft Nasal Repair
Follow-up: Craniofacial, Bilateral Cleft Nasal Repair
Multimedia: Craniofacial, Bilateral Cleft Nasal Repair
References
Further Reading
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References

  1. Millard DR. Cleft Craft. Vol 2: Bilateral and Rare Deformities. Boston: Little Brown & Co; 1977.

  2. Manchester WM. The repair of bilateral cleft lip and palate. Br J Surg. Nov 1965;52(11):878-82. [Medline].

  3. Millard DR Jr. Embryonic rationale for the primary correction of classical congenital clefts of the lip and palate. Ann R Coll Surg Engl. May 1994;76(3):150-60. [Medline].

  4. Millard DR Jr, Latham RA. Improved primary surgical and dental treatment of clefts. Plast Reconstr Surg. Nov 1990;86(5):856-71. [Medline].

  5. Trier WC. Repair of bilateral cleft lip: Millard's technique. Clin Plast Surg. Oct 1985;12(4):605-25. [Medline].

  6. Broadbent TR, Woolf RM. Cleft lip nasal deformity. Ann Plast Surg. Mar 1984;12(3):216-34. [Medline].

  7. Cronin TD, Upton J. Lengthening of the short columella associated with bilateral cleft lip. Ann Plast Surg. Jan 1978;1(1):75-95. [Medline].

  8. Mulliken JB. Correction of the bilateral cleft lip nasal deformity: evolution of a surgical concept. Cleft Palate Craniofac J. Nov 1992;29(6):540-5. [Medline].

  9. Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft lip: review, revisions, and reflections. J Craniofac Surg. Sep 2003;14(5):609-20. [Medline].

  10. Mulliken JB. Repair of bilateral complete cleft lip and nasal deformity--state of the art. Cleft Palate Craniofac J. Jul 2000;37(4):342-7. [Medline].

  11. Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg. Jul 2001;108(1):181-94; examination,195-6. [Medline].

  12. Mulliken JB. Mulliken Repair of Bilateral Cleft Lip and Nasal Deformity. In: Losee JE, Kirschner RE. Comprehensive Cleft Care. New York: McGraw Hill; 2008:Ch. 20, pp. 343-30.

  13. Nakajima T. Early and one stage repair of bilateral cleft lip and nose. Keio J Med. Dec 1998;47(4):212-8. [Medline].

  14. Nakajima T, Ogata H, Sakuma H. Long-term outcome of simultaneous repair of bilateral cleft lip and nose (a 15 year experience). Br J Plast Surg. Apr 2003;56(3):205-17. [Medline].

  15. McComb H. Primary repair of the bilateral cleft lip nose: a 10-year review. Plast Reconstr Surg. May 1986;77(5):701-16. [Medline].

  16. McComb H. Primary repair of the bilateral cleft lip nose: a 15-year review and a new treatment plan. Plast Reconstr Surg. Nov 1990;86(5):882-9; discussion 890-3. [Medline].

  17. McComb H. Primary repair of the bilateral cleft lip nose: a 4-year review. Plast Reconstr Surg. Jul 1994;94(1):37-47; discussion 48-50. [Medline].

  18. Salyer KE. Discussion: Primary repair of the bilateral cleft lip nose: a 15-year review and a new treatment plan. Plast Reconstr Surg. Nov 1990;86(5):pp. 890-3. [Medline].

  19. Bardach J, Salyer KE. Correction of Secondary Bilateral Cleft-Lip and Nasal Deformities. In: Bardach J, Salyer KE. Atlas of Craniofacial and Cleft Surgery. Vol. II. Philadelphia: Lippincott- Raven; 1999:Ch 14, pp. 609-678.

  20. Noordhoff MS. Bilateral cleft lip reconstruction. Plast Reconstr Surg. Jul 1986;78(1):45-54. [Medline].

  21. Chen PK, Noordhoff MS. Bilateral Cleft Lip and Nose Repair. In: Losee JE, Kirschner RE. Comprehensive Cleft Care. New York: McGraw Hill; 2008:Ch. 20, pp. 331-342.

  22. Cutting C, Grayson B. The prolabial unwinding flap method for one-stage repair of bilateral cleft lip, nose, and alveolus. Plast Reconstr Surg. Jan 1993;91(1):37-47. [Medline].

  23. Cutting CB. Bilateral Cleft Lip Repair. In: Mathes SJ. Plastic Surgery. Vol IV. 2nd ed. Philadelphia: Elsevier; 2005:Ch. 94, pp. 217-248. [Full Text].

  24. Cutting C, Grayson B, Brecht L, Santiago P, Wood R, Kwon S. Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair. Plast Reconstr Surg. Mar 1998;101(3):630-9. [Medline].

  25. Cutting C, Grayson B, Brecht L. Columellar elongation in bilateral cleft lip. Plast Reconstr Surg. Oct 1998;102(5):1761-2. [Medline].

  26. Cutting CB, Kamdar MR. Primary bilateral cleft nasal repair. Plast Reconstr Surg. Sep 2008;122(3):918-9. [Medline].

  27. Mossey PA, Little J. Epidemiology of oral clefts: An international perspective. In: Wyszynski DF. Cleft Lip and Palate: From Origin to Treatment. New York: Oxford University Press; 2002:Ch. 12, pp. 127-158.

  28. Marazita ML. Segrigation Analyses. In: Wyszynski DF. Cleft Lip and Palate: From Origin to Treatment. New York: Oxford University Press; 2002:Ch. 18, pp. 222-239.

  29. Chong SS, Cheah FS, Wang-Jabs E. Genes Implicated in Lip and Palate Development. In: Wyszynski DF. Cleft Lip and Palate: From Origin to Treatment. New York: Oxford University Press; 2002:Ch. 3, pp. 25-42.

  30. Carinci F, Pezzetti F, Scapoli L, Martinelli M, Avantaggiato A, Carinci P, et al. Recent developments in orofacial cleft genetics. J Craniofac Surg. Mar 2003;14(2):130-43. [Medline].

  31. Cohen MM. Syndromes with Orofacial clefting. In: Wyszynski DF. Cleft Lip and Palate: From Origin to Treatment. New York: Oxford University Press; 2002:Ch. 6, pp. 53-65.

  32. Sperber GH. Formation of the Primary Palate. In: Wyszynski DF. Cleft Lip and Palate: From Origin to Treatment. New York: Oxford University Press; 2002:Ch. 1, pp. 5-13.

  33. Jones MC. Facial clefting. Etiology and developmental pathogenesis. Clin Plast Surg. Oct 1993;20(4):599-606. [Medline].

  34. Pool R, Farnworth TK. Preoperative lip taping in the cleft lip. Ann Plast Surg. Mar 1994;32(3):243-9. [Medline].

  35. Griswold ML Jr, Sage WF. Extraoral traction in the cleft lip. Plast Reconstr Surg. May 1966;37(5):416-21. [Medline].

  36. Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Clin Plast Surg. Apr 2004;31(2):149-58, vii. [Medline].

  37. Mulliken JB. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg. Apr 1985;75(4):477-87. [Medline].

  38. LaRossa D, Donath G. Primary nasoplasty in unilateral and bilateral cleft nasal deformity. Clin Plast Surg. Oct 1993;20(4):781-91. [Medline].

  39. Delaire J. Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg. May 1978;6(2):109-16. [Medline].

  40. Lee CT, Garfinkle JS, Warren SM, Brecht LE, Cutting CB, Grayson BH. Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate. Plast Reconstr Surg. Oct 2008;122(4):1131-7. [Medline].

  41. Stal S, Hollier Jr LH. Secondary Deformities of the Cleft Lip, Nose, and Palate. In: Mathes SJ. Plastic Surgery. Vol. IV. 2nd ed. Philadelphia: Elsevier; 2005:Ch. 98, pp. 339-364. [Full Text].

  42. Bruner TW, Boyd V, Stal S, Hollier LH. Correction of Secondary Bilateral Cleft Lip and Nose Deformities. In: Losee JE, Kirschner RE. Comprehensive Cleft Care. New York: McGraw Hill; 2008:Ch. 31, pp. 487-497.

  43. Ozaki W, Chaffoo RA, Vu KC, Markowitz BL. Comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using conchal composite grafts. J Craniomaxillofac Surg. Apr 2006;34(3):150-5. [Medline].

  44. Lo LJ, Kane AA, Chen YR. Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited. Plast Reconstr Surg. Oct 2003;112(5):1219-27. [Medline].

  45. Burget G. Definitive Rhinoplasty for Adult Cleft Lip Nasal Deformity. In: Losee JE, Kirschner RE. Comprehensive Cleft Care. New York: McGraw Hill; 2008:Ch. 32, pp. 498-523.

  46. Strauss RP. Cleft palate and craniofacial teams in the United States and Canada: a national survey of team organization and standards of care. The American Cleft Palate-Craniofacial Association (ACPA) Team Standards Committee. Cleft Palate Craniofac J. Nov 1998;35(6):473-80. [Medline].

  47. Morovic CG, Cutting C. Combining the Cutting and Mulliken methods for primary repair of the bilateral cleft lip nose. Plast Reconstr Surg. Nov 2005;116(6):1613-9; discussion 1620-2. [Medline].

  48. Thomas C, Mishra P. Open tip rhinoplasty along with the repair of cleft lip in cleft lip and palate cases. Br J Plast Surg. Jan 2000;53(1):1-6. [Medline].

  49. Garri JI, O'Leary K, Gabbay JS, Urrego AF, Heller JB, O'Hara CM. Improved nasal tip projection in the treatment of bilateral cleft nasal deformity. J Craniofac Surg. Sep 2005;16(5):834-9. [Medline].

  50. Cutting CB, LaRossa D, McComb H, Millard DR, Mulliken J, Noordhof MS, et al. The Smile Train Presents: Virtual Surgery Videos [video/audiotape]. New York: The Smile Train; 2007. Cutting CB.

  51. Noordhoff MS. An Integrated Approach to the Primary Lip/Nasal Repair in Bilateral Cleft Lip and Palate. Plastic Surgery Hyperguide. Available at http://www.plasticsurgery.hyperguides.com/noordhoff.asp. Accessed Feb. 20, 2009.

  52. Byrd HS, Ha RY, Khosla RK, Gosman AA. Bilateral cleft lip and nasal repair. Plast Reconstr Surg. Oct 2008;122(4):1181-90. [Medline].

  53. Jackson IT, Yavuzer R, Kelly C, Bu-Ali H. The central lip flap and nasal mucosal rotation advancement: important aspects of composite correction of the bilateral cleft lip nose deformity. J Craniofac Surg. Mar 2005;16(2):255-61. [Medline].

  54. Matsuo K, Hirose T. A rotational method of bilateral cleft lip nose repair. Plast Reconstr Surg. Jun 1991;87(6):1034-40. [Medline].

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Further Reading

The history of the development of surgery of the cleft lip and palate is extensively chronicled by D. Ralph Millard in his encyclopedic, 3-volume text: Cleft Craft. 1

Losee and Kirschner have edited a definitive text on the multidisciplinary treatment of individuals with clefts: Comprehensive Cleft Care. The chapters by Mulliken, 12 Chen and Noordhoff, 21 Bruner et al, 42 and Burget 45 examine the subject of the treatment of the bilateral cleft nasal defect from different viewpoints.

The chapters by Cutting 23 and Stal and Hollier 41 in Mathes text Plastic Surgery also examine the subject in great depth.

The video series edited by Cutting and produced by The Smile Train is a excellent resource for visualizing the complex 3-dimensional surgery described. 50 Noordhoff also has a video presentation on bilateral cleft lip treatment available at the Plastic Surgery Hyperguide. 51

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Keywords

craniofacial, bilateral cleft nasal repair, cleft nasal repair, cleft nose, bilateral cleft nose, nasal cleft, orofacial cleft, cleft lip, cleft deformity, bilateral cleft lip, cleft lip nasal deformity, hare lip, harelip, trisomy 13, trisomy 21, Down's syndrome, Down syndrome, Waardenburg syndrome, Waardenburg's syndrome, van der Woude syndrome, van der Woude's syndrome, fetal alcohol syndrome, FAS

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Contributor Information and Disclosures

Author

Donald R Laub Jr, MS, MD, FACS, Associate Professor, Departments of Surgery and Pediatrics, University of Vermont College of Medicine; Interim Chief of Plastic and Reconstructive Surgery, Fletcher-Allen Health Care
Donald R Laub Jr, MS, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, AO Foundation, Association for Academic Surgery, International College of Surgeons, Northeastern Society of Plastic Surgeons, and Vermont State Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

David W Leitner, MD, Professor, Department of Surgery, Division of Plastic Reconstructive and Cosmetic Surgery, University of Vermont College of Medicine, Burlington
David W Leitner, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Plastic and Reconstructive Surgery, and Northeastern Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Larry Hollier, Jr, MD, Assistant Professor, Department of Plastic Surgery, Baylor University College of Medicine
Larry Hollier, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, AO Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

R Edward Newsome, MD, Program Director and Chief of Plastic Surgery, Henderson Chair in Surgery, Assistant Dean for Graduate Medical Education, Tulane University School of Medicine
R Edward Newsome, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Plastic and Reconstructive Surgery, American Society of Plastic Surgeons, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

 
 
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