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Unilateral Cleft Nasal Repair Treatment & Management

  • Author: Mimi T Chao, MD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Nov 20, 2015
 

Surgical Therapy

Surgical approach to the nasal defect

"A well mended harelip would pass unnoticed at a cocktail party were it not for the nose."[16] Despite multiple technical procedures described, no one protocol has proven to be completely satisfactory in the repair of all cleft lip nasal deformities.[21] Still, controversy remains as to the optimum corrective approach, the best techniques for exposure and repair, and, most significantly, the timing of the correction.[60]

Some surgeons believe that early nasal surgery (1) interferes with growth, resulting in nasal hypoplasia; (2) introduces scars, making secondary correction difficult[61] ; (3) damages infantile cartilage; and (4) makes repair technically harder because of the small size of the nose and immature cartilage.[4]

Reconstructive surgeons historically have been reluctant to perform rhinoplasty on a growing nose; however, the use of prudent operative techniques has created growing acceptance to correcting nasal deformities prior to puberty.[20] With less traumatic techniques, a loss of integrity of the cartilaginous nasal framework does not usually result in growth inhibition in the region of the mid face when the septum is not subjected to aggressive resection.[25] While primary repositioning and manipulation of the nasal septum and changing its abnormal position in infancy have a positive effect on nasal development, it may have a negative effect on maxillary growth.[29]

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Preoperative Details

Unilateral nasal cleft repair is often performed during cleft lip closure. The author advocates this combination of procedures. Presurgical orthopedics with or without gingivoperiosteoplasty accomplish nasal platform symmetry, which enables columella lengthening and correction of the alar cartilage position, as well as the flaring alar base at the time of rotation-advancement of the lip.[62] Nasal correction during cleft lip repair relieves the patient of the burden of an otherwise obvious nasal deformity that is noticeable even after secondary repair.

Several steps are taken prior to cleft nasal repair to ensure the best possible outcome.[63] Maxillary segments can be aligned with presurgical orthopedics. The bony structures are usually approximated within a few weeks, allowing for a gingivoperiosteoplasty if desired by the surgeon. This maneuver creates a more symmetrical platform for the lip and nose by normalizing the position of the alveolar segments and closing the anterior cleft.[64] This may be combined with nasal molding as described by Grayson.[65]

These presurgical steps allow the septum to assume a more vertical position after the alignment of the 2 maxillary segments with the use of the presurgical orthodontics and nasal molding. This sets the stage for cleft lip closure and primary nasal repair by age 6-7 months.[64] While nasal alveolar molding (NAM) improves the nasal shape both preoperatively and immediately after surgery, long-term results are less definitive.[66, 67] Although the general perception is that NAM has a positive effect on the cleft nose morphology, there is variability in both protocol and outcome between different treatment centers.[68, 69] Further long-term studies are needed to confirm the efficacy of this intensive early intervention.[70, 71, 72, 73] Presurgical NAM should not be considered adequate to replace rhinoplasty at the time of primary lip and nose repair.[74]

NAM also has the added burden of weekly visits for the patient and the parents; it should be tailored to a select population. Alternatives to presurgical orthopedics include lip adhesion and external lip taping. While these methods do not improve nasal shape directly, they help to narrow the cleft and makes for a less tense closure at the time of lip and nose repair.

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Intraoperative Details

Primary cleft nasal deformities

Current surgical practice is to repair the nasal defect at the time of the primary lip repair. While surgical techniques varies between surgeons,[75] the general concepts are as follows:

  • Freeing the abnormal nasal cartilage from the overlying skin envelope to correct the slumped lower lateral cartilage
  • Supraperiosteal undermining over the maxilla to adequately mobilize the lateral nasolabial elements
  • Suturing the dome and/or suspending the lower lateral cartilage to the upper lateral cartilage [76] to reconstruct the nasal tip
  • Centralizing the caudal portion of the cartilaginous septum without aggressive resection
  • Controlling the width of the alar base with alar cinch sutures
  • Closing the nasal floor
  • Reconstructing the nasal sill with lateral lip element advancement
  • Transmucosal-transcutaneous effacement suturing to eliminate vestibular webbing, if necessary

Access to the nasal cartilaginous framework does not require external incisions. Aside from the incisions used for the cleft lip repair, and intranasal incision carried upward just anterior to the inferior turbinate releases the lateral crus from the piriform and helps to centralize the deformed lower lateral cartilage. A rim incision can be used if interdomal suture placement for tip support is desired, especially when a resection of the rim is contemplated to refine nostril symmetry primarily. Although the piriform rim is routinely depressed and retruded, adequate mobilization of the alar base and careful closure of the orbicularis muscle may prevent postoperative alar depression.[77]

Children who underwent primary nasal repair at the time of lip repair had improved symmetry and more balanced-growth than children who did not received primary nasal repair, with increased nasal tip projection, decreased nasal width, and near normal columellar length in the first 3 years of life.[78]

Despite different techniques used, the results usually deteriorate in time, even with intentional over-correction at the time of primary repair. This may be because of scar formation, a difference in configuration between the ala on the cleft side and contralateral side, a discrepancy between the lining of the nose and the skin coverage,[20] or differential nasal growth between the cleft and the noncleft sides.[66] The images below show a cleft lip and nose repair.

Cleft nasal deformity can be seen even in patients Cleft nasal deformity can be seen even in patients with incomplete cleft lip.
The nasal cartilage is displaced laterally, inferi The nasal cartilage is displaced laterally, inferiorly, and posteriorly, and has inadequate form and support.
Cleft nose repair at the time of cleft lip repair Cleft nose repair at the time of cleft lip repair with rim incision, interdomal suturing, and alar base cinching. These techniques restore the position and tip support for the cleft nose.
Additional view of patient shown above. Additional view of patient shown above.

Secondary cleft nasal deformities

Currently, secondary rhinoplasty is the norm rather than the exception when it comes to cleft lip and nose deformity.[79] Ideally, the timing of the definitive secondary rhinoplasty should be when the patients are at bony maturity and all necessary orthodontic and orthognathic procedures have been completed.[80] The appearance of the nose depends not only on its form but also on its cephalometric relation to the facial skeleton. Advancing the maxilla after a definitive rhinoplasty is akin to pulling out the foundation after a house has been built. Careful counseling of young adults with cleft lip and nose in this situation is crucial, as many are rightfully anxious to proceed with their secondary rhinoplasty.

Secondary nasal deformities may be separated by regions into the dorsum, the tip, and the ala. Each region has algorithms to address issues of form, symmetry, and projection.[8] Historically, unit arrangement was used to address deformed nostril through external skin incisions extending into the dorsal skin of the nostril. The anomalous portion is then rotated as a unit of skin cartilage and, occasionally, its underlying mucosa.[3] This technique has largely fallen out of use for secondary cleft rhinoplasty because of the unpredictability of the external nasal scars.

Surgeons, such as Gorney, advocate that external scars should be avoided at all costs. These authors advocate that internal incisions should be used to expose the abnormal cartilage. They then are rearranged into more normal anatomic relationships and are held in position with various fixation techniques to the upper lateral cartilage, the contralateral cartilage, or the normal opposite alar dome. Many authors have illustrated good results for repair of minor deformities.[81, 82, 20, 65] The major advantage is that it avoids an external scar. Early results from this approach appeared cosmetically acceptable; however, the structural support elements are bolstered and can show signs of deterioration.

Current thinking that considers every cleft lip nasal patient as a candidate for open rhinoplasty is based on wide exposure and good surgical control of the external approach.[83] The external approach perhaps started with Duffenbach in 1845.[84] Multiple variations have been described and modified.[5] The nasal approach, or "flying gull wing" incision, is placed on the infratip of the nose.[85] The incision extends from one alar margin to the other. Exposure is somewhat limited and does not allow good symmetric vision of all the distorted structures.

Blair initially described a midcolumellar approach in 1925.[13] This approach has proved popular, and several authors modified it over the next half-century.[1, 86] The incision starts along the nasal sill and extends up until the mid line of the columella over the dome. The incision then curves toward the affected side and ends at the lateral part of the lower lateral cartilage. The advantage is good exposure on the affected structures, but disadvantages include allowing upper rotation on the cleft side only.

A third or transcolumellar approach is a modification of the original Rethi approach.[87, 82] The incision begins on one side, along the margin of the lower lateral cartilage. It then proceeds medially toward the caudal margin of the medial crus and continues along the columella up to its mid portion. The incision then continues in a similar way into the contralateral side. This approach allows repair and visualization of both sides of the nose.[88]

Regardless of surgical incision, a combination of nasal osteotomies, cartilage rearrangement, septoplasty, and rib/septal/ear cartilage struts and grafts are needed to create symmetry, a more refined tip, improved projection, and better nasal airway in the patient with cleft nasal deformities.[8, 80]

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Postoperative Details

After the surgery, patients are generally kept overnight in the hospital for pain control and airway observation. In the younger patients, they must be able to maintain hydration orally prior to discharge from the hospital. Bottle feeding should not have a negative effect on postoperative wound healing, but the use of pacifier should be discouraged. The use of elbow splints helps to discourage very young patients from playing with the incisions. The authors routinely use preoperative antibiotics and postoperative oral antibiotics for 5-7 days to prevent nasal tip infections.

Multiple techniques have been suggested to prevent subsequent deformation, such as suspending the slumped alar cartilage to a fixed point or using a cartilage stent to stabilize the columella.[15] Wong et al described implanting a resorbable plate as an internal nasal splint but had problems with postoperative exposure and extrusion.[89] A dynamic nostril splint in surgery of the nasal tip was developed by Guarda in an attempt to keep the nose symmetric as it grows.[19] The use of postoperative nasal silicone splints is also believed to preserve the correction.[90] The authors occasionally employ postoperative silicone splinting in primary nasal repairs and use either silicone splints or nasal packing more routinely in secondary rhinoplasties. If aggressive undermining of the nasal skin was performed, external nasal splints (Aquaplast or similar) are also helpful to immobilize the redraped skin.

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Follow-up

Postoperative patients are seen on a weekly basis until the surgeon is satisfied with healing. Cleft lip and nose repair is a major event for many parents and families, since the patient looks very different after surgery. Availability and reassurance in the immediate postoperative period are important as families adjust to their "new" baby. Routine follow-up with a comprehensive cleft team on an a frequent basis is necessary for multidisciplinary evaluation of the child's growth and development.

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Complications

The most common complication in cleft rhinoplasty is asymmetry. Patients and their parents should be counseled extensively regarding expectations and the need for future procedures. If the unilateral columella lengthening and alar base balance do not provide adequate nostril symmetry, the growth of the nose through puberty may produce a cosmetically unacceptable result. This problem can be corrected with a rhinoplasty when the patient is aged 16 years or older.[81]

Intraoperative bleeding and anesthesia-related complications such as postoperative laryngospasms, aspiration, and prolonged hospitalization should be discussed. Nasal tip infection is yet another potential complication due to multiple sutures placed to maintain protection. Despite careful surgical techniques, postoperative scar formation is unpredictable and can result in obvious hypertrophic scarring.

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Outcome and Prognosis

The approach to the cleft lip nasal deformity has evolved over the years. The previous hesitation of primary nasal repair at the time of lip repair has largely been assuaged by long-term studies that have shown no detrimental effects on nasal growth with early surgery. In support of early cleft lip nose repair, McComb reviewed his first 10 consecutive cases of primary cleft lip nose repair after 18 years.[30] His results supported the observation that growth of the cleft side of the nose is unaffected by early primary nasal surgery and that the vertical shortening of the nose by the alar lift technique is preserved into adult life. Residual nasal asymmetry resulted secondary to the septal deviation.

Nonetheless, even with primary repair, most children need secondary nasal revisions of varying magnitude. Definitive open septorhinoplasty should be delayed until the teenage years and after maxillary advancement, should it be necessary.[91]

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Future and Controversies

Controversies still exist regarding presurgical orthopedics, nasal molding, the optimal timing of surgery, what technique to use, and how aggressive the surgical intervention should be prior to skeletal maturity. However, the ultimate goal for children with cleft lip, nose, and palate is to "achieve optimal facial balance and harmony, normal speech, beautiful smile, and full dentition with normal occlusion, resulting in an attractive face with stigmata of clefting at a conversational distance."[9] The future for the plastic surgeon is to achieve this goal with the fewest procedures and the lowest burden on patients and their families.

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Contributor Information and Disclosures
Author

Mimi T Chao, MD Consulting Surgeon, Pediatric Plastic Surgery, Children's Hospital Central California; Clinical Instructor Volunteer, UCSF Fresno Pediatrics Residency Program, University of California, San Francisco, School of Medicine

Mimi T Chao, MD is a member of the following medical societies: Alpha Omega Alpha, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society of Craniofacial Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph E Losee, MD, FAAP, FACS Chief, Division of Pediatric Plastic Surgery, The Children’s Hospital of Pittsburgh; Director, Pittsburgh Cleft and Craniofacial Center, University of Pittsburgh School of Medicine; Professor of Surgery (Plastic) and Pediatrics, Department of Surgery, Division of Plastic Surgery, Program Director, Plastic Surgery Residency Program, Program Director, Craniofacial Fellowship, University of Pittsburgh School of Medicine; Director, Reconstruction Transplantation Program, University of Pittsburgh Medical Center

Joseph E Losee, MD, FAAP, FACS is a member of the following medical societies: Alpha Omega Alpha, American Cleft Palate-Craniofacial Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Pennsylvania Medical Society, Plastic Surgery Research Council, Sigma Xi, Allegheny County Medical Society, American Association of Pediatric Plastic Surgeons, Northeastern Society of Plastic Surgeons, Ohio Valley Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, American Society of Craniofacial Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

S Anthony Wolfe, MD Chief, Division of Plastic Surgery, Miami Children's Hospital; Voluntary Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami School of Medicine

S Anthony Wolfe, MD is a member of the following medical societies: American Academy of Pediatrics, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society of Plastic Surgeons, Florida Medical Association, Southeastern Society of Plastic and Reconstructive Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

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: AO Foundation, Alpha Omega Alpha, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Zachary Segal, MD; W Scott McDonald, MD; and Seth R Thaller, MD, DMD, FACS, FAAP to the development and writing of this article.

References
  1. Ortiz-Monasterio F, Olmedo A. Corrective rhinoplasty before puberty: a long-term follow-up. Plast Reconstr Surg. 1981 Sep. 68(3):381-91. [Medline].

  2. O'Connor GB, McGregor MW, Tolleth H. The management of nasal deformities associated with cleft lips. Pac Med Surg. 1965 Sep-Oct. 73(5):279-85. [Medline].

  3. Gorney M. Rehabilitation for the post-cleft nasolabial stigma. Clin Plast Surg. 1988 Jan. 15(1):73-82. [Medline].

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

  5. Mazzola RF. Secondary unilateral cleft lip nose: the external approach. Facial Plast Surg. 1996 Oct. 12(4):367-78. [Medline].

  6. Rifley W, Thaller SR. The residual cleft lip nasal deformity. An anatomic approach. Clin Plast Surg. 1996 Jan. 23(1):81-92. [Medline].

  7. Anderl H, Hussl H, Ninkovic M. Primary simultaneous lip and nose repair in the unilateral cleft lip and palate. Plast Reconstr Surg. 2008 Mar. 121(3):959-70. [Medline].

  8. Byrd HS, El-Musa KA, Yazdani A. Definitive repair of the unilateral cleft lip nasal deformity. Plast Reconstr Surg. 2007 Oct. 120(5):1348-56. [Medline].

  9. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose repair: a 33-year experience. J Craniofac Surg. 2003 Jul. 14(4):549-58. [Medline].

  10. Rose W. Harelip and Cleft Palate. London, England: HK Lewis; 1891.

  11. Randall P. History of cleft lip nasal repair. Cleft Palate Craniofac J. 1992 Nov. 29(6):527-30. [Medline].

  12. Byrd HS. Cleft Lips I: Primary deformities (overview). Selected Readings in Plastic Surgery. 1997. 8(21):1-37.

  13. Blair VP. Nasal deformities associated with congenital cleft of the lip. JAMA. 1925. 84:185.

  14. Blair VP, Brown JB. Nasal abnormalities, fancied and real surgery. Gynecol Obstet. 1931. 53:797.

  15. Brown JB, McDowell F. Simplified design for repair of single cleft lip. Surg Gynecol Obstet. 1945. 80:12.

  16. Gillies H, Millard DR. The Principles and Art of Plastic Surgery. Boston, Mass: Little Brown & Co; 1966. 320-37.

  17. Berkeley WT. The cleft-lip nose. Plast Reconstr Surg Transplant Bull. 1959 Jun. 23(6):567-75. [Medline].

  18. Musgrove RH. Surgery of nasal deformities associated with cleft lip. Plast Reconstr Surg. 1961. 28:261-74.

  19. Cenzi R, Guarda L. A dynamic nostril splint in the surgery of the nasal tip: technical innovation. J Craniomaxillofac Surg. 1996 Apr. 24(2):88-91. [Medline].

  20. Nolst Trenite GJ, Paping RH, Trenning AH. Rhinoplasty in the cleft lip patient. Cleft Palate Craniofac J. 1997 Jan. 34(1):63-8. [Medline].

  21. Brusse CA, Van der Werff JF, Stevens HP, et al. Symmetry and morbidity assessment of unilateral complete cleft lip nose corrected with or without primary nasal correction. Cleft Palate Craniofac J. 1999 Jul. 36(4):361-6. [Medline].

  22. Aufricht G. Presentation at: The Annual Meeting of the American Society of Maxillo-Facial Surgeons. Philadelphia, Pa: 1955.

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

  24. Matthews D. The nose tip. Br J Plast Surg. 1968 Apr. 21(2):153-67. [Medline].

  25. Cronin TD, Denkler KA. Correction of the unilateral cleft lip nose. Plast Reconstr Surg. 1988 Sep. 82(3):419-32. [Medline].

  26. McIndoe A, Rees TD. Synchronous repair of secondary deformities in cleft lip and nose. Plast Reconstr Surg. 1959. 24:150-61.

  27. Berkeley WT. Correction of secondary cleft-lip nasal deformities. Plast Reconstr Surg. 1969 Sep. 44(3):234-41. [Medline].

  28. McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Plast Reconstr Surg. 1985 Jun. 75(6):791-9. [Medline].

  29. Smahel Z, Mullerova Z, Nejedly A. Effect of primary repositioning of the nasal septum on facial growth in unilateral cleft lip and palate. Cleft Palate Craniofac J. 1999 Jul. 36(4):310-3. [Medline].

  30. McComb HK, Coghlan BA. Primary repair of the unilateral cleft lip nose: completion of a longitudinal study. Cleft Palate Craniofac J. 1996 Jan. 33(1):23-30; discussion 30-1. [Medline].

  31. Smahel Z, Mullerova Z, Skvarilova B, Havlova M. Differences between facial configuration and development in complete and incomplete unilateral cleft lip and palate during the prepubertal period. Acta Chir Plast. 1991. 33(1):47-56. [Medline].

  32. Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year experience. Plast Reconstr Surg. 1986 Apr. 77(4):558-68. [Medline].

  33. Gelbe H. The nostril problem in unilateral harelips and its surgical management. Plast Reconstr Surg. 1954. 18:65.

  34. Stenstrom J, Oberg RH. The nasal deformity in unilateral cleft lips. Plast Reconstr Surg. 1961. 28:295.

  35. Green MF. The embryological, developmental and functional importance in the repair of the nasal musculature to reduce the deformity of the cleft lip nose. Scand J Plast Reconstr Surg Hand Surg. 1987. 21(1):1-5. [Medline].

  36. Byrd HS, Salomon J. Primary correction of the unilateral cleft nasal deformity. Plast Reconstr Surg. 2000 Nov. 106(6):1276-86. [Medline].

  37. McComb HK. Primary repair of the bilateral cleft lip nose: a long-term follow-up. Plast Reconstr Surg. 2009 Nov. 124(5):1610-5. [Medline].

  38. Morselli PG, Pinto V, Negosanti L, Firinu A, Fabbri E. Early correction of septum JJ deformity in unilateral cleft lip-cleft palate. Plast Reconstr Surg. 2012 Sep. 130(3):434e-41e. [Medline].

  39. Haddock NT, McRae MH, Cutting CB. Long-term effect of primary cleft rhinoplasty on secondary cleft rhinoplasty in patients with unilateral cleft lip-cleft palate. Plast Reconstr Surg. 2012 Mar. 129(3):740-8. [Medline].

  40. Gosla-Reddy S, Nagy K, Mommaerts MY, et al. Primary septoplasty in the repair of unilateral complete cleft lip and palate. Plast Reconstr Surg. 2011 Feb. 127(2):761-7. [Medline].

  41. Hoffman W. Unilateral Cleft Lip Repair. Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. 2nd ed. Quality Medical Publishing; 2007. Vol 1: 439-453.

  42. Bernstein L. Maxillofacial clefts. Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, eds. Otolaryngology. 3rd ed. Philadelphia, Pa: WB Saunders; 1991. Vol 3: 1983.

  43. Kyrkanides S, Bellohusen R, Subtelny JD. Asymmetries of the upper lip and nose in noncleft and postsurgical unilateral cleft lip and palate individuals. Cleft Palate Craniofac J. 1996 Jul. 33(4):306-11. [Medline].

  44. Siegel MI, Mooney MP, Kimes KR, Gest TR. Traction, prenatal development, and the labioseptopremaxillary region. Plast Reconstr Surg. 1985 Jul. 76(1):25-8. [Medline].

  45. Stark RB, Kaplan JM. Development of the cleft lip nose. Plast Reconstr Surg. 1973 Apr. 51(4):413-5. [Medline].

  46. Millicovsky G, Ambrose LJ, Johnston MC. Developmental alterations associated with spontaneous cleft lip and palate in CL/Fr mice. Am J Anat. 1982 May. 164(1):29-44. [Medline].

  47. Johnston MC, Millicovsky G. Normal and abnormal development of the lip and palate. Clin Plast Surg. 1985 Oct. 12(4):521-32. [Medline].

  48. Millard DR. The Unilateral Deformity. Cleft Craft: The Evolution of its Surgery. Boston, Mass: Little Brown & Co; 1976. Vol 1: 20.

  49. Huffman WC, Lierle DM. Studies on the pathologic anatomy of the unilateral hare-lip nose. Plast Reconstr Surg. 1949. 4:225.

  50. Kyrkanides S, Bellohusen R, Subtelny JD. Skeletal asymmetries of the nasomaxillary complex in noncleft and postsurgical unilateral cleft lip and palate individuals. Cleft Palate Craniofac J. 1995 Sep. 32(5):428-33. [Medline].

  51. Farkas LG, Deutsch CK, Hreczko TA. Asymmetries in nostrils and the surrounding tissues of the soft nose--a morphometric study. Ann Plast Surg. 1984 Jan. 12(1):10-5. [Medline].

  52. Atherton JD. A descriptive anatomy of the face in human fetuses with unilateral cleft lip and palate. Cleft Palate J. 1967 Apr. 4:104-14. [Medline].

  53. Li AQ, Sun YG, Wang GH, Zhong ZK, Cutting C. Anatomy of the nasal cartilages of the unilateral complete cleft lip nose. Plast Reconstr Surg. 2002 May. 109(6):1835-8. [Medline].

  54. Bardach J, Cutting C. Anatomy of unilateral and bilateral cleft lip and nose. Bardach J, Morris HL, eds. Multidisciplinary Management of Cleft Lip and Palate. Philadelphia, Pa: WB Saunders; 1990. 154-8.

  55. Latham RA. The pathogenesis of the skeletal deformity associated with unilateral cleft lip and palate. Cleft Palate J. 1969 Oct. 6:404-14. [Medline].

  56. Warren DW, Drake AF. Cleft nose. Form and function. Clin Plast Surg. 1993 Oct. 20(4):769-79. [Medline].

  57. Wahlmam U, Kunkel M, Wagner W. Preoperative assessment of airway patency in the planning of corrective cleft nose surgery. Mund Kiefer Gesichtschir. 1998 May. 2 Suppl 1:S153-7. [Medline].

  58. Drake AF, Davis JU, Warren DW. Nasal airway size in cleft and noncleft children. Laryngoscope. 1993 Aug. 103(8):915-7. [Medline].

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

  60. Chowchuen B, Keinprasit C, Pradubwong S. Primary unilateral cleft lip-nose repair: the Tawanchai cleft center's integrated and functional reconstruction. J Med Assoc Thai. 2010 Oct. 93 Suppl 4:S34-45. [Medline].

  61. Jeong HS, Lee HK, Shin KS. Correction of Unilateral Secondary Cleft Lip Nose Deformity by a Modified Tajima's Method and Several Adjunctive Procedures Based on Severity. Aesthetic Plast Surg. 2011 Jul 15. [Medline].

  62. Puckett CL, Wells HG Jr. The gull wing incision in cleft lip rhinoplasty. Cleft Palate J. 1987 Apr. 24(2):163-7. [Medline].

  63. Morioka D, Sato N, Kusano T, et al. Difference in nasolabial features between awake and asleep infants with unilateral cleft lip: Anthropometric measurements using three-dimensional stereophotogrammetry. J Craniomaxillofac Surg. 2015 Oct 25. [Medline].

  64. Demirseren ME, Ohkubo F, Kadomatsu K, Hosaka Y. A simple method for lower lateral cartilage repositioning in cleft lip nose deformity. Plast Reconstr Surg. 2004 Feb. 113(2):649-52. [Medline].

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

  66. Molina F. Distraction of the maxilla. McCarthy JG, ed. Distraction of the Craniofacial Skeleton. 1st ed. New York: Springer-Verlag; 1999. 308-20.

  67. Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH. Nasoalveolar molding improves long-term nasal symmetry in complete unilateral cleft lip-cleft palate patients. Plast Reconstr Surg. 2009 Mar. 123(3):1002-6. [Medline].

  68. Alajmi H, Tahiri Y, Jamal B, Gilardino MS. Montreal children's hospital formula for nasoalveolar molding cleft therapy. Plast Reconstr Surg. 2013 Feb. 131(2):349-53. [Medline].

  69. Liao YF, Hsieh YJ, Chen IJ, Ko WC, Chen PK. Comparative outcomes of two nasoalveolar molding techniques for unilateral cleft nose deformity. Plast Reconstr Surg. 2012 Dec. 130(6):1289-95. [Medline].

  70. van der Heijden P, Dijkstra PU, Stellingsma C, van der Laan BF, Korsten-Meijer AG, Goorhuis-Brouwer SM. Limited evidence for the effect of presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: a call for unified research. Plast Reconstr Surg. 2013 Jan. 131(1):62e-71e. [Medline].

  71. Smith DM, Macisaac ZM, Losee JE. Discussion: Limited evidence for the effect of presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: a call for unified research. Plast Reconstr Surg. 2013 Jan. 131(1):72e-4e. [Medline].

  72. Grayson BH. Discussion: Limited evidence for the effect of presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: a call for unified research. Plast Reconstr Surg. 2013 Jan. 131(1):75e-6e. [Medline].

  73. Abbott MM, Meara JG. Nasoalveolar molding in cleft care: is it efficacious?. Plast Reconstr Surg. 2012 Sep. 130(3):659-66. [Medline].

  74. Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS. Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: a single surgeon's experience. Plast Reconstr Surg. 2010 Oct. 126(4):1276-84. [Medline].

  75. de Sá Nóbrega ES. Cleft lip nose: a different approach. J Craniofac Surg. 2005 Jan. 16(1):95-9. [Medline].

  76. Yeow VK, Chen PK, Chen YR, Noordhoff SM. The use of nasal splints in the primary management of unilateral cleft nasal deformity. Plast Reconstr Surg. 1999 Apr. 103(5):1347-54. [Medline].

  77. Salyer KE. Early and late treatment of unilateral cleft nasal deformity. Cleft Palate Craniofac J. 1992 Nov. 29(6):556-69. [Medline].

  78. Latham RA. Orthopedic advancement of the cleft maxillary segment: a preliminary report. Cleft Palate J. 1980 Jul. 17(3):227-33. [Medline].

  79. Gassling V, Koos B, Birkenfeld F, Wiltfang J, Zimmermann CE. Secondary cleft nose rhinoplasty: Subjective and objective outcome evaluation. J Craniomaxillofac Surg. 2015 Nov. 43 (9):1855-62. [Medline].

  80. Cronin ED, Rafols FJ, Shayani P, Al-Haj I. Primary cleft nasal repair: the composite V-Y flap with extended mucosal tab. Ann Plast Surg. 2004 Aug. 53(2):102-8; discussion 109-10. [Medline].

  81. Millard DR Jr, Morovic CG. Primary unilateral cleft nose correction: a 10-year follow-up. Plast Reconstr Surg. 1998 Oct. 102(5):1331-8. [Medline].

  82. Miyamoto J, Nagasao T, Nakajima T, Ogata H. Evaluation of cleft lip bony depression of piriform margin and nasal deformity with cone beam computed tomography: "retruded-like" appearance and anteroposterior position of the alar base. Plast Reconstr Surg. 2007 Nov. 120(6):1612-20. [Medline].

  83. Masuoka H, Kawai K, Morimoto N, Yamawaki S, Suzuki S. Open rhinoplasty using conchal cartilage during childhood to correct unilateral cleft-lip nasal deformities. J Plast Reconstr Aesthet Surg. 2012 Jan 23. [Medline].

  84. Guyuron B. MOC-PS(SM) CME article: late cleft lip nasal deformity. Plast Reconstr Surg. 2008 Apr. 121(4 Suppl):1-11. [Medline].

  85. Black PW, Hartrampf CR Jr, Beegle P. Cleft lip type nasal deformity: definitive repair. Ann Plast Surg. 1984 Feb. 12(2):128-38. [Medline].

  86. Gubisch W. Functional and aesthetic nasal reconstruction in unilateral CLP-deformity. Facial Plast Surg. 1995 Jul. 11(3):159-68. [Medline].

  87. Cho BC, Lee JH, Cohen M, Baik BS. Surgical correction of unilateral cleft lip nasal deformity. J Craniofac Surg. 1998 Jan. 9(1):20-9. [Medline].

  88. Duffenbach JF. Dil Operative "Chirugie" Leipzieg, Brochaus. 1845. 362-92.

  89. Wong GB, Burvin R, Mulliken JB. Resorbable internal splint: an adjunct to primary correction of unilateral cleft lip-nasal deformity. Plast Reconstr Surg. 2002 Aug. 110(2):385-91. [Medline].

  90. Kim SK, Cha BH, Lee KC, Park JM. Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation. Plast Reconstr Surg. 2004 Nov. 114(6):1373-81. [Medline].

  91. Patil PG, Patil SP, Sarin S. Nasoalveolar molding and long-term postsurgical esthetics for unilateral cleft lip/palate: 5-year follow-up. J Prosthodont. 2011 Oct. 20(7):577-82. [Medline].

  92. Freeman AK, Mercer NS, Roberts LM. Nasal asymmetry in unilateral cleft lip and palate. J Plast Reconstr Aesthet Surg. 2013 Jan 22. [Medline].

  93. Gillies H, Kilner TP. Hare-lip: operations for the correction of secondary deformities. Lancet. 1932. 2:1369.

  94. Gosla-Reddy S, Nagy K, Mommaerts MY, et al. Primary septoplasty in the repair of unilateral complete cleft lip and palate. Plast Reconstr Surg. 2011 Feb. 127(2):761-7. [Medline].

  95. Haddock NT, McRae MH, Cutting CB. Long-term effect of primary cleft rhinoplasty on secondary cleft rhinoplasty in patients with unilateral cleft lip-cleft palate. Plast Reconstr Surg. 2012 Mar. 129(3):740-8. [Medline].

  96. Janiszewska-Olszowska J, Gawrych E, Wedrychowska-Szulc B, Stepien P, Konury J, Wilk G. Effect of primary correction of nasal septal deformity in complete unilateral cleft lip and palate on the craniofacial morphology. J Craniomaxillofac Surg. 2012 Dec 26. [Medline].

  97. Lewis MB, Winkler AA, Silverman RP. Correction of the unilateral cleft lip nasal deformity with a composite cartilage-vestibular lining flap. Plast Reconstr Surg. 2007 Oct. 120(5):1357-62. [Medline].

  98. Liou EJ, Subramanian M, Chen PK, Huang CS. The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study. Plast Reconstr Surg. 2004 Sep 15. 114(4):858-64. [Medline].

  99. Morselli PG, Pinto V, Negosanti L, Firinu A, Fabbri E. Early correction of septum JJ deformity in unilateral cleft lip-cleft palate. Plast Reconstr Surg. 2012 Sep. 130(3):434e-41e. [Medline].

  100. Ridgway EB, Andrews BT, Labrie RA, Padwa BL, Mulliken JB. Positioning the caudal septum during primary repair of unilateral cleft lip. J Craniofac Surg. 2011 Jul. 22(4):1219-24. [Medline].

  101. Wolfe SA. A pastiche for the cleft lip nose. Plast Reconstr Surg. 2004 Jul. 114(1):1-9. [Medline].

 
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Typical appearance of cleft nasal deformities.
Cleft nasal deformity can be seen even in patients with incomplete cleft lip.
The nasal cartilage is displaced laterally, inferiorly, and posteriorly, and has inadequate form and support.
Cleft nose repair at the time of cleft lip repair with rim incision, interdomal suturing, and alar base cinching. These techniques restore the position and tip support for the cleft nose.
Additional view of patient shown above.
 
 
 
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