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6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
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205
The Bilateral Cleft Lip Nose Deformity
PercyRossell-Perry
Contents
Introduction 207
The Incomplete Bilateral Cleft Lip Nose Deformity (Figs.7.7, 7.8, and7.9) 211
Complete Bilateral Cleft Lip Nose Deformity (Figs.7.10, 7.11, and7.12) 213
The Bilateral Cleft Lip Combined Forms (Figs.7.13, 7.14, and7.15) 216
Surgical Protocol 217
References 218
Introduction
Nasal deformity in bilateral cleft lip is complex and varies from minor to severe
(Figs.7.1, 7.2, and 7.3); James Barrett Brown mentioned “Bilateral cleft lip is twice
as difcult to repair as unilateral, and the results are only half as good” also Ralph
Millard Jr. said “the presence of the projecting premaxilla and how it is to be handled has always been and continues to be a difcult variable and at the core of some
of the controversies” [1].
The nasal tip is commonly attened, the columella is absent, and the alar base is
very wide in combination with muscular distortion and severe dentoskeletal disturbance (Figs.7.4, 7.5, and 7.6).
Skeletal deformity is characterized by prominent premaxilla (to different degrees)
and hypoplastic maxillary segments. The existing discrepancy between the central
and lateral segments creates a complex scenario for lip and nose reconstruction.
As Harold Gillies mentioned in relation to complex deformities, “the skeleton is
rst” [1]; the basic treatment of these problems should consider rst consider
7
P. Rossell-Perry (*)
Health of Science Faculty, School of Human Medicine, Peruvian University Union (UpeU),
Lima, Peru
e-mail: percy.rossell@upeu.edu.pe
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
P. Rossell-Perry (ed.), Atlas of Primary Cleft Rhinoplasty,
https://doi.org/10.1007/978-3-031-68012-0_7
207
208
Fig. 7.1 Mild bilateral
cleft lip nasal deformity
Fig. 7.2 Moderate
bilateral cleft lip nasal
deformity
P. Rossell-Perry
skeletal repair; however this is not possible to be done because of the growth disturbance of the bones produced by its early correction.
The different types of presurgical orthopedics help us to improve skeletal proportions in order to facilitate the lip and nose repair in bilateral cleft lip forms. The
surgical type (represented by the lip adhesion) and nonsurgical type (represented by
lip taping, elastic bandage, nasoalveolar molding, and others) help us to improve
skeletal proportions to prevent bad outcomes and complications after primary bilateral cleft lip and nose repair. The nasal septum does not have an important role in
7 The Bilateral Cleft Lip Nose Deformity
Fig. 7.3 Severe bilateral
cleft lip nasal deformity
Fig. 7.4 Mild nasal tip
and columella deformity in
the bilateral cleft lip
209
210
Fig. 7.5 Moderate nasal
tip and columella
deformity in the bilateral
cleft lip
Fig. 7.6 Severe nasal tip
and columella deformity in
the bilateral cleft lip
P. Rossell-Perry
the nose deformity associated with the bilateral cleft lip in comparison with unilateral forms. The nasal oor is usually wider than normal and requires shortening
during lip repair.
The alar cartilages are affected bilaterally, appearing dislodged from their natural
position and wider and rotated outwardly in a are.
The vestibule of the nose seems to be stretched bilaterally, and this nding supports the use of vestibular lengthening techniques as the bilateral VYZ is used to
normalize the position of the cartilages of the tip of the nose [2].
7 The Bilateral Cleft Lip Nose Deformity
211
The effects of these methods reproduce the temporal effects of the nasal molding
using presurgical orthopedics; therefore, the author named this technique as the
“surgical nasoalveolar molding.”
Two basic types of bilateral cleft lip have been described, as follows: complete
and incomplete forms. But these types may be presented in combination with
mild forms.
Nasal deformity associated with the bilateral cleft lip correlates well according
to these different types.
Microforms are associated with incomplete or complete forms and should be
identied to develop an adequate surgical plan for the treatment of bilateral cleft
lip nose.
The Incomplete Bilateral Cleft Lip Nose Deformity (Figs.7.7,
7.8, and7.9)
The spectrum of incomplete cleft lips may vary from microforms to extended
incomplete clefts on one or both sides of the bilateral cleft lip. Nose deformity usually correlates with the severity of these forms.
Based on nose components, we may describe the characteristics of the incomplete bilateral cleft lips and their applications to the surgical treatment.
Nasal oor The nasal oor has four sections as follows: nostril sill, primary palate
(alveolus), secondary palate (hard palate), and soft palate. The nostril sill and
Fig. 7.7 Incomplete
bilateral cleft lip nose
deformity
212
Fig. 7.8 Incomplete
bilateral cleft lip nose
deformity
Fig. 7.9 Incomplete
bilateral cleft lip nose
deformity
P. Rossell-Perry
primary palate may be partially affected by incomplete forms. This is why the nasal
deformity associated with these types of clefts is mild.
Columella The columella in incomplete bilateral cleft lip nose forms is short but
longer that those in complete forms requiring both types of lengthening.
Alar base The alar base in incomplete cleft lips is wider than that in the normal
population and requires bilateral shortening. The requirement for alar base shortening depends on the severity of the nose deformity on each side.
7 The Bilateral Cleft Lip Nose Deformity
Nasal tip Flattening of the nasal tip is common and depends on the degree of the
alar cartilage distortion. The lack of the tip projection in bilateral cleft lip requires
improvement even in incomplete forms.
Nasal septum The nasal septum is not affected as it is in its complete form.
However, there may be partial deviation in combined forms when a complete form
is combined with minor forms (incomplete).
Alar cartilage Inward buckling and retrodisplacement of the alar dome are
observed on both sides, affecting the form and extension of the vestibule.
Nostril These components are more symmetric than unilateral clefts; however,
asymmetry may exist between the two sides. Wide nostrils were also observed on
both sides.
Maxilla The existence of a cleft may vary among patients with incomplete cleft
lips. Sometimes there is a simple notch or absence of any cleft or combination of
both. Commonly, all of these variants have an aligned maxillary arch in the bilateral
cleft lips.
213
Complete Bilateral Cleft Lip Nose Deformity (Figs.7.10, 7.11,
and7.12)
This is the most complex nasal deformity of the cleft lip and palate involving distortion of the skeleton and soft tissues.
The most important factor associated with the severity of the nasal deformity in
complete bilateral cleft lips is the position of the premaxilla. Severely protruding
premaxilla is related to severe nasal deformities characterized by short or absent
columella, underprojected nasal tips, laterally displaced alar bases, and ared
alae [3].
Therefore, it is essential in complete bilateral cleft lip nose repair and early premaxilla management (using different strategies such as Naso Alveolar Molding or
bilateral lip adhesion before primary cleft rhinoplasty.
Based on the nose components, we may describe the characteristics of the complete bilateral cleft lips and their application in surgical treatment.
Nasal oor The nasal oor has four sections as follows: nostril sill, primary palate
(alveolus), secondary palate (hard palate), and soft palate. All these elements in the
bilateral complete cleft lip and palates are absent. The nostril sill is repaired primarily using the lateral and medial elements of the cleft and is supported by the muscular reconstruction. The alar bases (lateral elements of the cleft) are attached to the
skeletal structure (the pyriform aperture of the maxilla). They should be released for
proper alignment of both sides during primary repair.
214
Fig. 7.10 Complete
bilateral cleft lip nose
deformity
Fig. 7.11 Complete
bilateral cleft lip nose
deformity
P. Rossell-Perry
This segment is usually wider and shortening is necessary during nasal
oor repair.
Muscular repair is also important for providing support for the nasal sills. The
presence of the Simonart’s band is not relevant for reconstructive purposes, and it is
usually resected during primary lip and nose repair.
7 The Bilateral Cleft Lip Nose Deformity
Fig. 7.12 Complete
bilateral cleft lip nose
deformity
215
Columella Repair of the shortening or absence of the columella is the key point in
bilateral cleft lip nose deformity. Initially, it was repaired by columellar lengthening
using lip tissues (Millard banked forked ap method); however, the outcome appears
to be unnatural. Later, Mulliken proposed columellar repair using nasal tissues considering that “the columella is in the nose.” Actually, based on this concept, the
columella is repaired by bilateral alar cartilage and dome repositioning [4].
Nasal tip This structure is commonly affected and characterized by attening
because of the inwards buckling and retrodisplacement of the alar domes on both
sides. Corrections of the alar cartilage structures allow us to improve the columellar
length and nasal tip projection.
Nasal septum This structure may be affected in asymmetric forms of bilateral cleft
lips and may require correction. However, this approach is limited to the caudal portion during primary lip repair.
Alar cartilage Bilateral malpositioning of these structures is associated with columellar and nasal tip deformities in bilateral cleft lips. These ndings also explain the
vestibular shortening observed in these patients. The use of presurgical orthopedics
such as NAM (nasoalveolar molding) expands the nasal vestibule; however, this
effect is temporary; primary rhinoplasty is always necessary for long-term outcomes. The most important effect of the presurgical treatments for bilateral cleft lip
nose repair is on the prominent premaxilla. The author described the “surgical nasal
molding” to surgical extension of the vestibule without presurgical treatment [2].
Premaxilla The skeletal structure of the complete bilateral cleft lip plays an impor-
tant role in the nose deformity. Early management is essential to provide an adequate scenario for primary lip and nose correction in bilateral cleft lips. The