eMedicine Specialties > Plastic Surgery > Craniofacial

Craniofacial, Bilateral Cleft Nasal Repair: Treatment

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

Treatment

Surgical Therapy

The surgical treatment of the cleft nose falls into 3 phases:

  • Primary (at the same time as repair of the lip)
  • Early secondary (in the child before skeletal maturity)
  • Late secondary (in the adolescent or adult after skeletal maturity)

Preoperative Details

A protruding premaxilla places tension across a bilateral cleft lip repair; presurgical orthopedic appliances are often applied to correct this. Two categories of appliances are used, passive and active.

Passive appliances maintain the distance between the 2 maxillary segments while external force is applied to encourage posterior repositioning. This external force can be external taping,34 a head cap with elastic straps across the prolabium,35 or a even a surgical lip adhesion. The NasoAlveolar Molding (NAM) device of Grayson and Cutting is an elaborate example of a passive orthopedic system.36

Active appliances are fixed intraorally and apply traction through mechanical means such as elastic chains, screws, and plates. The Latham device, used by Millard, is an active orthopedic device.4

Presurgical orthopedic devices are a controversial topic in cleft treatment. Arguments against their use include possible long-term growth effects, occlusal misalignment, and feeding difficulty.

Intraoperative Details

Primary repair

No single procedure can successfully repair clefts of various severities. The ultimate goal of the surgery should be to achieve the best possible result by the time the child is ready to attend school, with a view to final open rhinoplasty, as necessary, at craniofacial maturity. Some principles should be kept in mind.

Mulliken has elucidated some of the principles of primary treatment of the bilateral cleft lip with nasal deformity.37

  • Maintain symmetry
  • Secure primary muscle union
  • Select the proper prolabial size and configuration
  • Form the median tubercle and mucocutaneous ridge from lateral lip tissue
  • Construct the nasal tip and columella by anatomic placement of the alar cartilages

LaRossa and Donath38 emphasize the following:

  • The maxilla also should be managed presurgically.
  • The lower lateral cartilage (LLC) should be released from any soft tissue attachments, including the vestibular lining, to prevent any tendency for the cartilages to return to their previous positions.
  • The alar bases must be repositioned and the nasal floor repaired.
  • Bolstered sutures or stents are useful in maintaining the final cartilage shape.
Delaire has emphasized the physiologic reconstruction of cleft lip and nasal deformities with focus on the muscle reconstruction not only of the lip but around the nose.39

If the cleft is not wide, with a sufficiently sized prolabium, primary nasal repair is recommended. The nasal repair is accomplished after elevation of the prolabium by dissection within the columella between the medial crura of the LLCs and up over the domes.

Lengthening the columella by advancing skin from ...

Lengthening the columella by advancing skin from the prolabium (large red arrow) tends to increase the angle of the lower lateral cartilages (small red arrows) and broadens the tip.

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Lengthening the columella by advancing skin from ...

Lengthening the columella by advancing skin from the prolabium (large red arrow) tends to increase the angle of the lower lateral cartilages (small red arrows) and broadens the tip.


This may be done through rim incisions, Nakajima variation of the rim incisions, Cutting's retrograde approach, or some combination of these. In order to free up the transverse nasalis musculature and achieve narrowing of the ala, this lateral dissection is extended over the lateral nasal wall. The orbicularis oris muscle is freed from the lateral element skin and underlying periosteum. The prolabial vermilion is rolled down into the vestibule and lip mucosal repair is done. The transverse nasalis is then sutured to the caudal septum in the region of the nasal spine, correcting the transverse alar base positions, and the orbicularis repair is completed beneath the prolabium. The dermal sutures described by Salyer are useful to resuspend the LLCs to the upper lateral cartilages (ULCs), and to narrow the nasal tip.

In a wide cleft with severe nasal deformity, nasoalveolar molding (NAM) may be employed at an institution that can offer the needed equipment and support, to a patient with a compliant and diligent family. NAM offers a minimally invasive presurgical advantage in the shape of the vestibule and tip and may increase the amount of columellar tissue, which makes the intraoperative repair easier with less dissection.40

Early secondary repair

Secondary repair has been directed toward columellar lengthening and narrowing the broad nasal tip. The "cartilage paradigm" is part of the modern approach to this surgery.41,42 Composite skin cartilage grafts from the ear may be required.43 An useful technique in the situation of midline tissue deficiency and scarring is the Abbé cross-lip flap.44 (For more information, see eMedicine article Craniofacial, Bilateral Cleft Lip Repair.)


Late secondary repair

After the patient's face is skeletally mature, the cleft nasal deformity can be treated with open rhinoplasty techniques in addition to the techniques available for early secondary repair. (For more information, see Rhinoplasty, Basic Open Technique.) These techniques allow the surgeon to use more advanced techniques of structural support of the nose.45 (For more information, see Structural Support for Correction of Cleft Nasal Deformity.)

Postoperative Details

Postoperative care is designed to prevent stress that may cause dehiscence. Many authors advocate 2 weeks of syringe feeding and arm bolsters with nothing placed in the mouth or over the lip and nasal base (ie, no pacifiers). Authors have shown good results without such onerous restrictions.

The repair is reviewed after 2 weeks, and the nasal stents are removed if they have not already fallen out. The wound should be assessed for any signs of infection or dehiscence.

Follow-up

The standard of care for treatment of children affected with cleft lip and palate is to be enrolled in a multidisciplinary clinic throughout childhood.46 Residual deformities can be assessed at long-term team follow-up appointments to determine whether any further surgery is necessary.

Complications

One of the potential complications that must be kept in mind in operating on the nose an infant that is an obligate nasal breather has the potential for creating obstructive sleep apnea.

A possible complication that may be encountered in single-stage procedures is the loss of a portion of the prolabium. This may occur if its blood supply is compromised by simultaneously separating the prolabium from the premaxilla and performing a nasal tip dissection. Cutting believes that his retrograde approach to the nasal tip is less likely to compromise this circulation.23,24 Indeed, he has even shown good results combining this approach with the rim incisions of Mulliken.47 Thomas et al showed that the open rhinoplasty techniques could be applied to primary bilateral lip repair without incidence of loss of the prolabial flap.48

Hypertrophic scarring is possible, even in this age group. Noordhoff et al feel that early recognition and massage of the lip scar are important in prevention.21

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

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  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].

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  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].

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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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