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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
236
P. Rossell-Perry
Nasal Septum
The septal deviation associated with the bilateral cleft lips is less frequently observed
in comparison with unilateral forms; therefore its early correction is not necessary.
However, it may be considered in asymmetrical forms. In these cases, the caudal
septum is corrected as in unilateral cleft lips (see Chap. 6).
Nasal Tip Reconstruction
After elevating the rotational composite ap in both sides, they are displaced
medially in a rotational form and xed using ve 5/0 PDS transcutaneous sutures.
These sutures 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, where the sutures are tied (Figs.8.20, 8.21, 8.22 and 8.23; see Figs.
6.32, 6.33, 6.34 and 6.35).
Fig. 8.20 Transcutaneous
stitch. Second stitch of the
recommended sequence
coming inside the nose at
the lateral segment of the
rotational composite ap
and coming out at the
supraalar crease level
Fig. 8.21 Transcutaneous
stitch. Stitch is tied
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
Fig. 8.22 Final closure of
the rotational composite
ap (left side)
Fig. 8.23 Comparative
view between both sides
after using the rotational
composite ap cleft
rhinoplasty on the left side
in a patient with
incomplete bilateral
cleft lip
237
This is the recommended sequence (Fig.8.24).
First stitch: After identication of the alar dome in both sides, these are medially
displaced and xed using oblique transcutaneous stitch on each side. Then, the
alar domes are placed in correct position in both sides. Special attention must be
paid at the level of the soft triangle avoiding skin retraction due to the lack of
cartilage in this area.
Second stitch: Placed at the level of the lateral border of the ap using a vertical
stitch at the level of the supra alar crease in both sides. These two sutures mobi-
lize the ap medially after rotation and leave a triangular donor site laterally.
Third stitch: Between the two alar domes using a transcutaneous stitch at the level
of the anterior border of the alar domes.
238
First stitch
Second stitch
Second stitch
P. Rossell-Perry
Sixth stitch
Fourth stitch
Fig. 8.24 Sequence of transcutaneous stitches used during rotational composite ap cleft rhinoplasty for bilateral cleft lip
Sixth stitch
Third stitch
Fourth stitch
Fifth stitch
Fourth stitch: Used to close the donor areas of the aps. They are lateral triangular
raw surfaces which are closed by advancement of the vestibular skin.
Fifth stitch: The suture enters through the caudal septum and exits at the same level
on the opposite side, and then the needle enters through the columella (alar
medial crus and skin) in both sides; nally the sutures are tied.
Sixth 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 at the level of the supra alar
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
Fig. 8.25 Final
appearance of the nose
after using the rotational
composite ap cleft
rhinoplasty for bilateral
cleft lip
239
crease in both sides. An important recommendation is not to exceed using these
transcutaneous stitches because it may create a compromise of the vascular sup-
ply of the ala and develops necrosis and also may develop granulomas. Finally,
few simple stitches may be used to align correctly the borders of the composite
ap in both sides (Fig.8.25).
Nasal Floor
The nasal oor reconstruction is performed during the cleft lip repair, and this is
involving the use of two aps: a medial cutaneous ap lateral to the base of the columella and a lateral ap, which is composed of the base of the ala in both sides. A
suture of prolene 4/0 is used through the alar base dermis of each side, passing
beneath the philtral ap and tied in midline narrowing the interalar distance and
minimizing the postoperative nasal widening (Fig. 8.26). The lateral aps (alar
bases) are advanced and sutured side to end to the medial ap. During cheiloplasty,
the levator labii superioris alaeque nasi and orbicularis oris muscles are identied
and repaired at the midline using PDS suture supporting the nal position of the
nasal base in both sides (Fig.8.27).
240
P. Rossell-Perry
B
A
BB
AA
Fig. 8.26 A suture of prolene is used through the alar base dermis of each side and tied in midline
narrowing the interalar distance during rotational composite ap technique for bilateral cleft lip
nose repair
Prolabium
ancement
oris muscle
whit
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
241
Lateral
columellar
base flap
and Alae
Orbicularis
oris muscle
a. Peripheral
orbicularis
oris muscle
Vermillion-
e roll flap
Marginal orbicularis
Lateral
columellar
base flap
Fascicle of
levator labii
superioris
alaeque nasi
muscle
Labio nasal
adv
flap
Vermillionwhite roll flap
Fig. 8.27 Muscular reconstruction is providing support to the base of the nose during rotational
composite ap for bilateral cleft lip nose repair
242
Cases (Figs.8.28, 8.29, 8.30, 8.31, 8.32 and8.33)
Fig. 8.28 Case 1.
Preoperative view of a
3-month-old infant with
incomplete bilateral
cleft lip
Fig. 8.29 Case 1.
Immediate postoperative
view of the infant shown in
Fig.8.28 after undergoing
nasal repair using the
rotational composite ap
technique
P. Rossell-Perry
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
Fig. 8.30 Case 1.
Long-term postoperative
view of the infant shown in
Fig.8.28 after undergoing
nasal repair using the
rotational composite ap
technique
Fig. 8.31 Case 2.
Preoperative view of a
3-month-old infant with
incomplete bilateral
cleft lip
243
244
Fig. 8.32 Case 2. A
1-year postoperative view
of the infant shown in
Fig.8.31 after undergoing
nasal repair using the
rotational composite ap
technique without
presurgical orthopedics
(frontal view)
Fig. 8.33 Case 2. A
1-year postoperative view
of the infant shown in
Fig.8.31 after undergoing
nasal repair using the
rotational composite ap
technique (worm eye view)
P. Rossell-Perry
The VYZ Technique inComplete Bilateral Cleft Lip Nose
The combination of the V-Y advanced ap and lateral Z plasty is an effective form
of bilateral cleft lip nose repair based on our previous studies [3] (Figs.8.34 and
8.35). The combination of these two techniques produces an expansion of the
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
245
Fig. 8.34 The VYZ cleft
rhinoplasty. Surgical
marking diagram. 1. V
composite ap. 2. Marginal
incision. (a) and (b) Z plasty
branch B. Nasal vestibule
a
b
Fig. 8.35 The VYZ cleft
rhinoplasty. Medial VY
advancement and lateral Z
plasty transposition using
transcutaneous stitches