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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
74
P. Rossell-Perry
Unilateral Complete Cleft Lip Nose
The author’s classication for nose deformity associated with cleft lip and palate is
the rst description in the literature. First, I present the conventional description for
cleft lip nose.
This type of cleft affects the lip, nose, and maxilla in one side and involves the
structural framework as well as the soft tissue of the nose. The abnormal insertion
of facial muscles produces an imbalance compounded by the skeletal hypoplasia,
and nasal deformity includes an abnormal position of the nasal tip and septum creating a characteristic uneven appearance of the nostril in association with functional
disturbances, and collapse of the maxillary arch worsens the nose deformity.
In summary, it is characterized by asymmetry, columellar deviation, displaced
alar base wider and retrodisplaced affected nostril, and decient maxilla. Even
when total septal correction is not performed primarily, anterior correction appears
to be an essential component according to Tse [6].
According to a study by David Chong, some differences exist between the right
and left sides, with more hypoplasia observed in the right unilateral cleft lips. This
condition may affect the outcome of the primary nose repair [7].
In summary, the unilateral complete cleft lip nose deformity is characterized by
the following [8] (Figs.3.9, 3.10, and 3.11):
Nose asymmetry
Columellar deviation
Cleft nostril buckle inward
Maxilla deciency
Fig. 3.9 Unilateral
complete cleft lip nose
deformity
3 Classication
Fig. 3.10 Unilateral
complete cleft lip nose
deformity
Fig. 3.11 Unilateral
complete cleft lip nose
deformity
75
Displaced alar base
Deviated caudal septum
Deviated premaxilla
Posterolaterally displaced alar base and pyriform aperture
Increased angle between medial and lateral crura
Shortened medial crus and lengthened lateral crus
Malpositioned upper and lower lateral cartilage
76
P. Rossell-Perry
Unilateral Incomplete Cleft Lip Nose (Figs.3.12, 3.13, and3.14)
The incomplete form has a cleft affecting the white roll and vermillion associated
with nose compromise characterized by downward displacement of the nasal ala
and intact nasal sill. The nasal septum may be affected but in a mild form in comparison with complete forms. Incomplete cleft lip cases with a Simonart band
should be considered as complete forms. In consideration of the ndings of the
author, all nose deformities associated with incomplete cleft lips should be treated,
and the technique used for the nasal repair of an incomplete forms should not be the
same as the methods used for complete forms.
Fig. 3.12 Unilateral
incomplete cleft lip nose
deformity
Fig. 3.13 Unilateral
incomplete cleft lip nose
deformity
3 Classication
Fig. 3.14 Unilateral
incomplete cleft lip nose
deformity
Fig. 3.15 Unilateral
microform cleft lip nose
deformity
77
Unilateral Microform Cleft Lip Nose (Figs.3.15, 3.16, and3.17)
This type of unilateral cleft lip is dened as a lip notch less than 3mm above the normal
peak. The characteristics of the microform cleft lip include the philtral groove, notched
lip and vermillion-cutaneous junction, and a minor nasal deformity. Uncommonly, this
type of cleft lip may affect the muscular component without an obvious cleft lip and
associated with nose deformity, which is commonly minor in comparison with other
types of unilateral cleft lip involving a depressed nasal sill, alar hooding, and alar base
asymmetry, and its correction is sometimes limited to the nasal sill shortening.
78
Fig. 3.16 Unilateral
microform cleft lip nose
deformity
Fig. 3.17 Unilateral
microform cleft lip nose
deformity
P. Rossell-Perry
Bilateral Complete Cleft Lip Nose
The bilateral form affects the lip, nose, and maxilla on both sides in association with
protruding premaxilla and retropositioned lateral maxillary segments due to congenital hypoplasia.
The nose is characterized by a symmetric short columella (or absent), broad
depressed nasal tip, and wide nose. The nasal septum is less commonly affected in
comparison with unilateral forms and is usually observed in asymmetrical forms.
3 Classication
79
Adequate and early management of the skeleton is mandatory of the skeleton to
provide good support for the soft tissue repair, and most of severe secondary deformities are caused by late treatment of the skeletal component. It is a common mistake that the performance of primary lip and nose repair with a severe skeletal
malformation result in a sequel difcult to be repaired. It is accepted that skeletal
component cannot be surgically corrected at early age because of the facial growth
disturbance; therefore, early use of presurgical orthopedics or lip adhesion is essential in order to produce skeletal segment alignment to facilitate soft tissue repair.
The use of presurgical orthopedics is indicated during the rst weeks of life for
skeletal alignment, but the efcacy of nasal molding is under debate actually
because of the lack of supporting scientic evidence [9–14].
In summary, the bilateral complete cleft lip nose deformity is characterized by
the following [8] (Figs.3.18, 3.19, and 3.20):
Grossly symmetric
Wide nose and depressed tip
Short columella
Wide nostrils
Flared alae and vestibular webbing
Displaced alar domes
Increased angle between alar cruras
Protrusive premaxilla
Bilateral hypoplastic maxilla
Inferiorly displaced nasal septum
Absent nasal oor
Fig. 3.18 Bilateral
complete cleft lip nose
deformity
80
Fig. 3.19 Bilateral
complete cleft lip nose
deformity
Fig. 3.20 Bilateral
complete cleft lip nose
deformity
P. Rossell-Perry
Bilateral Incomplete Cleft Lip Nose (Figs.3.21, 3.22, and3.23)
The incomplete bilateral cleft lip involves the lip tissues and preserves the nasal
sills. The skeletal deformity is preserved or affected in a mild form and may include
incomplete cleft palate. A nasal sill is present but the columella is short and the
nasal tip has a poor projection. Associated nasal deformities are usually more symmetric than complete nasal deformities. The presence of bilateral microforms is
rare, and usually they are usually combined with complete or incomplete forms. The
use presurgical orthopedics is not indicated for these forms.
3 Classication
Fig. 3.21 Bilateral
incomplete cleft lip nose
deformity
Fig. 3.22 Bilateral
incomplete cleft lip nose
deformity
81
82
Fig. 3.23 Bilateral
incomplete cleft lip nose
deformity
Fig. 3.24 Bilateral
combined cleft lip nose
deformity
P. Rossell-Perry
Bilateral Cleft Lip Combined Forms (Figs.3.24, 3.25, and3.26)
Bilateral cleft lips are not always symmetric and may present a combination of
complete, incomplete, and microforms; nasal deformities are asymmetric and
require different treatments for each side. This type of cleft lip has difculty achieving nose symmetry after the surgical repair. Presurgical orthopedics are an alternative for treating complete deformities on one side.
3 Classication
Fig. 3.25 Bilateral
combined cleft lip nose
deformity
Fig. 3.26 Bilateral
combined cleft lip nose
deformity
83
The treatment of the nose using the nasal molding also has uncertain effects, and
the outcome is mostly related to the primary surgery. It is also important to mention
also that the nasal molding used in presurgical orthopedics is always associated with
primary cleft rhinoplasty; therefore, it is not possible to estimate whether the outcome is due to the molding, surgery, or both.