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t side)
Int
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.25 1. Vestibular
marginal border of the
nasal vestibule (black line).
A: Alar cartilage covered
by transitional epithelium
(red color area) B: Nasal
vestibule. C: Columella.
D.Nasal tip
165
Nasal tip
Marginal incisión
Nasal vestibule
ercartilaginous
incision
Lateral lip
Alar cartilage
(cleft side)
Alar cartilage
(non clef
Columella
Medial Lip
Fig. 6.26 Diagram of intercartilaginous incision during rotational composite ap cleft rhinoplasty
166
Fig. 6.27 Rotational
composite ap incisions
used for incomplete cleft
lip nose repair. A:
Rotational composite ap.
B: Nasal vestibule. C:
Nasal tip. D: Columella. 1:
Marginal incision. 2:
Intercartilaginous incision
(Bisturí incision)
Fig. 6.28 Rotational
composite ap after
marginal and
intercartilaginous incisions
in a patient with unilateral
incomplete cleft lip.
1. Marginal incision.
2. Intercartilaginous
incision. A. Rotational
composite ap. B. Nasal
vestibule. C. Nasal tip.
D. Columella
P. Rossell-Perry
2
2
Incisions After local anesthetic inltration and supercial lip incisions following
lip markings using 11 blade scalpel, the nasal repair is started. A full-thickness nasal
incisions through the vestibular skin are performed following vestibular markings
(marginal and intercartilaginous) around the alar cartilage of the cleft side using 15
blade scalpel to create the composite ap. It is recommended the excision of a small
triangle from the lateral corner of the ap to avoid redundancy of tissue after closure
(ear dog) of the donor site.
Rotational Composite Flap andNasal Tip Dissection
After identication of the alar cartilage through the marginal incision and using ne
scissors, the composite ap (vestibular skin and alar cartilage) is dissected and elevated from lateral to medial side including alar cartilage and vestibular skin. Then,
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
167
the nose dissection continues with the nasal tip including both sides through the
vestibular incision and on the supracartilaginous plane separating the nasal skin
from the cartilaginous structure of the nose (alar cartilages, domes, and lower dorsum). Both alar domes should be separated from the overlaying skin in order to
facilitate the reposition of the structures from the cleft side (Figs.6.29, 6.30, and
6.31). Some bleeding appears during this dissection; however, because of the closed
approach of the nose, it is not possible to observe any important vessel to be cauterized. The bleeding uses to stop after application of the nasal transcutaneous stitches.
In addition, the use of postoperative nasal packing (recommended after using the
VYZ cleft rhinoplasty) is also optional in these cases.
Nasal Septum
The septal deviation associated with the incomplete cleft lips may vary in a wide
spectrum, and some incomplete cleft lips have an important deviation; therefore in
more severe nasal deformities associated with the incomplete cleft lips, the reposition of the nasal septum may be performed (Figs.6.7, 6.8, and 6.9). This is achieved
after dissection of the anterior nasal spine area through the medial lip incision in a
similar form as I described before for the Mc Comb modied technique. After dissection and release of the noncleft nasal oor periosteum from the spine, the caudal
septum is moved medially for suture xation using 5/0 PDS (Fig.6.9). I actually
consider this maneuver as an alternative method since the columella can be perfectly repositioned only by muscular action. The caudal septoplasty is not correcting the whole septal deformity; therefore, a secondary correction is always necessary.
In cases with nasal deformity associated with microform cleft lips, caudal septum
treatment is not required.
Nasal Tip Reconstruction
Personally, I consider that the nose repair should be performed before the lip repair
because the access to the nose through the nonrepaired cleft lip is easier than the
access after lip repair. After elevating the rotational composite ap, it is displaced
medially in a rotational form; this maneuver let us reposition the anterior portion of
the nasal dome beside the dome at the noncleft side. This is a three-dimensional
movement in three vectors: medial, posterior, and superior. I like to perform the
xation of the cartilage structures using the 5/0 PDS transcutaneous sutures. This
material is monolament being less reactive and producing less skin reaction and
granulomas. These transcutaneous stitches are important to obliterate the space created after tip dissection and prevent the development of hematomas. Stitches are
placed through the skin, starting from inside the nose and then exiting the skin at the
level of the supraalar crease; the needle then returns through the same hole and
nally enters the inside of the nose in front of the initial entrance, where the sutures
are tied (Figs.6.32, 6.33, 6.34, 6.35, and 6.36).
This is the recommended sequence (Fig.6.36):
First stitch: After identication of the alar dome in the composite ap, this is medi-
ally displaced and xed using a vertical transcutaneous stitch at the medial side
of the supra alar crease. Then, the alar cartilage dome is in correct position.
168
)
a
P. Rossell-Perry
Nasal vestibule
Composite flap
Lateral lip
Nasal tip
Alar cartilage
(cleft side)
Alar cartilage
(non cleft side
Columella
Medial Lip
b
Shadow area:
nasal tip
Rotational
composite
flap incision
dissection
Fig. 6.29 Diagram of nasal tip dissection during unilateral rotational composite ap cleft rhinoplasty. A: Nasal tip dissection through the rotational composite ap incision. B: Shadow area:
Extension of nasal tip dissection
t side)
of composit
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.30 Diagram of
rotational composite ap
elevation after nasal tip
dissection.
1. Marginal incision.
2. Intercartilaginous
incision. A. Rotational
composite ap. B. Nasal
vestibule. C. Nasal tip.
D. Columella
169
Nasal tip
Nasal vestibule
Cartilage
component of
composite flap
Skin component
e flap
Area of excision
from the
composite flap
Lateral lip
Alar cartilage
(cleft side)
Alar cartilage
(non clef
Columella
Medial Lip
Fig. 6.31 Rotational composite ap elevation in a patient with unilateral incomplete cleft lip
170
Nasal v
Nasal v
Point of
Point of
P. Rossell-Perry
Point of
needle entrance
Composite flap
estibule
Lateral Lip
Point of
needle exit
Fig. 6.32 Transcutaneous stitch technique sequence (initial step)
needle entrance
needle exit
Nasal tip
Columella
Medial Lip
Composite flap
estibule
Lateral Lip
Fig. 6.33 Transcutaneous stitch technique sequence (second step)
Nasal tip
Columella
Medial Lip
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.34 Transcutaneous stitch technique sequence (third step)
171
Fig. 6.35 Transcutaneous stitch technique sequence (nal step)
172
P. Rossell-Perry
Fig. 6.36 Nasal tip reconstruction using transcutaneous stitches during rotational composite ap
cleft rhinoplasty
Second stitch: Placed at the level of the lateral border of the ap using a similar
vertical stitch at the level of the supra alar crease. These two sutures mobilize the
ap medially after rotation and leaves a triangular donor site laterally.
Third stitch: Between the two alar domes using a transcutaneous stitch at the level
of the midpoint of the alar domes. This suture creates the tip projection and de-
nition according to the natural parameters of the patient.
Four stitch: Used to close the donor area of the ap. This is a lateral triangular raw
surface which is closed using a simple stitch by advancement of the vestibu-
lar skin.
Fifth stitch: Necessary to correct the position of the alar cartilage in relation to the
upper lateral cartilage of the nose. There is a luxation of the alar cartilage and
requires a reposition over the upper lateral cartilage using a vertical transcutane-
ous stitch placed lateral to the internal nasal valve.
Finally a few simple stitches may be used to align correctly the borders of the
composite ap. An important recommendation is not to exceed using these transcutaneous stitches because it may create a compromise of the vascular supply of the
ala and develops necrosis (Figs.6.37, 6.38, and 6.39).
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.37 Final closure of
rotational composite ap
cleft rhinoplasty in a
patient with incomplete
unilateral cleft lip. A:
Rotational composite ap.
B: Nasal vestibule. C:
Nasal tip. D: Columella
Fig. 6.38 A 3-month-old
patient with unilateral
incomplete cleft lip
(preoperative view)
173
Nasal Floor
The repair of the nasal floor is the final step of cleft rhinoplasty and represents
the correction of the most anterior portion of the nasal floor (vestibular segment). Based on our surgical protocol for cleft lip and palate repair, the other
segments are closed in different times during primary and secondary palate
174
Fig. 6.39 Immediate
postoperative view of the
patient in Fig.6.38
operated using the
rotational composite ap
technique
P. Rossell-Perry
B
A
AB
Fig. 6.40 Diagram of nasal oor repair during the rotational composite ap technique for unilateral cleft lip nose repair A. Alar base ap. B. Columellar base ap