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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
10 Cleft Rhinoplasty-Related Complications andManagement
307
Fig. 10.22 Nose relapse after primary cleft rhinoplasty using Mc Comb modication technique.
Upper left: Unilateral complete cleft lip and palate. Upper right: Nasal tip dissection using the Mc
Comb modication technique. Lower left: Immediate postoperative view of the nose. Lower right:
Postoperative view after 3years observing relapse of the nose
The most common poor outcome after primary cleft rhinoplasty is the nose
deformity relapse. I do not agree with other authors who consider that relapse is due
to cartilage memory because a signicant number of our patients had a low rate of
relapse. We personally believe that the relapse is mostly associated with deciencies
in the surgical procedure [14] (Fig.10.22). In another study published by the author,
we observed an increased rate of nose deformity relapse using conservative methods for primary cleft rhinoplasty, such as Mc Comb [28]. In a recent study published
by the author, it is observed that 34.37% of total nostril symmetry and minor revisions were required in 56.26% of the studied patients [14] Yao and Mulliken reported
that 65% of unilateral cleft patients underwent nasal revision after primary cleft
nose repair, and Salyer observed a lower revision rate of 35% [29, 30].
Next, I present the poor outcomes associated with primary cleft rhinoplasty
according to the affected anatomical segment.
308
ab
cd
P. Rossell-Perry
Fig. 10.23 Nasal tip asymmetry after primary cleft rhinoplasty. (a) Preoperative view illustrating
the nasal tip asymmetry after primary repair. (b) Cartilaginous structure of the asymmetric nose: 1.
Nasal septum. 2. Nasal dorsum. 3. Cleft side alar cartilage. 4. Noncleft side alar cartilage. (c) 1.
Noncleft side alar cartilage. 2. Cleft side alar cartilage. 3. Nasal dorsum (nonvisible in this view).
4. Deviated nasal septum. (d) Appearance of cartilaginous structure after septoplasty. 1 and 2. Alar
cartilages
Nasal Tip
Asymmetry, lack of tip projection, and a pinched nose are common bad outcomes
after primary cleft rhinoplasty (Figs.10.23, 10.24 and 10.25). Relapse of the nasal
deformity occurs mostly due to surgical deciency. The author addresses nasal tip
asymmetries based on vestibular lengthening to prevent the scar contracture and
deformity recurrence. Different surgical techniques used for treating secondary
deformities are based on vestibular lengthening and alar cartilage repositioning, as
well as the Potter’s and Cronin’s techniques [31, 32]. These methods allow the nasal
cartilage to be repositioned, resulting in symmetry of the nasal tip. My personal
technique is based on the combination of Potter’s technique and Berkeley’s lateral
Z plasty in combination with septoplasty to improve respiratory obstruction [31,
33]. This is the same method described by the author for primary cleft rhinoplasty
10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.24 Nasal tip
asymmetry after unilateral
primary cleft rhinoplasty.
1. Deviated nasal septum.
2. Nasal tip asymmetry. 3.
Alae. 4. Nostril
Fig. 10.25 Nasal tip
asymmetry after primary
cleft rhinoplasty
309
[13]. Cartilaginous grafts are used to reinforce the area from which the alar cartilage
has been displaced medially using the V-Y technique. The surgical approach is left
to the surgeon’s preference and can be performed openly or closed. Open rhinoplasty has the advantage of allowing direct access to the septum after dissection
between both medial crura. Minor deformities can be corrected using the rotational
composite ap technique, which is another method that the author describes initially in the correction of primary incomplete cleft lip nasal deformities. Another
technique used by the author is the Nakajima’s vestibular Z plasty which is described
for the treatment of secondary deformities [34] (Fig. 10.26). Recently the author
310
Nasal tip
car
e
car
e
Postoperatory
P. Rossell-Perry
a
Alar
tilages
Alar
tilages
Alar cartilages
Z plasty
Nasal vestibul
Columella
Preoperatory
Nasal tip
b
Alar cartilages
Z plasty
Nasal vestibul
Columella
Fig. 10.26 (a, b) Nakajima technique for secondary cleft nasal deformity
10 Cleft Rhinoplasty-Related Complications andManagement
311
(P.R.P) published an innovative method resecting small portion of vestibular skin
for minor secondary deformities (Figs. 10.27, 10.28, 10.29 and 10.30).
The pinched nose is another poor outcome and this is associated with a lack of
structural support. It is a permanent sinking of the vestibular wall, obstructing the
nostril and creating an alar groove. Removal or medial displacement of the alar
cartilage may produce this outcome. Surgical techniques such as VYZ rhinoplasty
used the medial displacement of the alar cartilage and when this procedure is performed aggressively. It requires surgical treatment, and it is based on cartilage grafts
placed below the nasal skin at the level of the donor site of the displaced alar
cartilage.
Fig. 10.27 A 5-year-old
male patient with nasal tip
asymmetry after unilateral
primary cleft rhinoplasty
Fig. 10.28 Immediate
postoperative after nasal
tip correction using the
semilunar vestibular skin
resection method
312
Fig. 10.29 Mild nasal tip
asymmetry after primary
cleft rhinoplasty in a
patient with incomplete
cleft lip
Fig. 10.30 Mild nasal tip
asymmetry in a patient
with incomplete cleft lip
after correction using the
vestibular marginal skin
excision
P. Rossell-Perry
10 Cleft Rhinoplasty-Related Complications andManagement
313
Nasal Ala
Most likely, it is the most common component associated with bad outcomes after
primary cleft rhinoplasty. The asymmetry of the ala is observed due to its position
(lower, higher, or shortened). This nondesirable outcome can be prevented performing an adequate preoperative lip marking, preserving the integrity and location of
the base of the ala. Sometimes, the subnasal sulcus is not clearly visible; its location
can be easily located by exion of the ala during preoperative marking. The diagnosis is made through careful physical examination of the lip, and the difference
between the position of the cleft and noncleft alar bases will determine the diagnosis
and the degree of malposition.
Nasal Ala intheLower Position
Frequently, this outcome has been considered an expected result after primary cheilorhinoplasty and has been explained as a consequence of the absence of bony support (alveolar cleft). However, this is not true, and the bad outcome is related to a
deciency of the surgical procedure to provide adequate support to the alar base
(Figs.10.31, 10.32 and 10.33). A study published by the author studying a group of
unilateral cleft lip patients followed for 5 years after primary cleft rhinoplasty
revealed a well-positioned alar base using oral muscles to provide structural support
[35]. Common causes include curved or straight line primary cheiloplasty, surgical
marking deciency, and decient repair of the labial muscles. The linear incision
methods for unilateral cleft lip repair may produce this outcome because the position
of the ala is used to compensate the lip height deciency. Therefore, adequate lip
markings before the procedure are important, and the subnasal sulcus (sometimes
Fig. 10.31 Nasal ala in
the lower position.
Diagram illustrating the
outcome after nose
asymmetry correction
314
Fig. 10.32 Nasal ala in
the lower position.
Diagram illustrating the
surgical technique used for
its correction
P. Rossell-Perry
Fig. 10.33 Nasal ala in
the lower position.
Diagram illustrating the
nose asymmetry associated
with right ala in lower
position
10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.34 A 3-year-old male patient born with unilateral cleft lip who developed nose asymmetry after primary cleft rhinoplasty. Secondary deformity is treated using a Z plasty
315
difcult to identify) should be located and preserved in a good position at the end of
the surgery. Another cause of this bad outcome is decient repair of the labial muscles. The upper lip muscles can support the alar base even in the presence of a wide
alveolar cleft and lack of skeletal support. The alar fascicle of the levator labii superioris alaeque nasi muscle provides support through insertion at the level of the base
of the caudal septum during lip repair. This bad outcome can be corrected performing
a secondary muscular reconstruction or using an asymmetric Z plasty (Fig.10.34).
Nasal Ala inUpper Position
This bad outcome is observed as a result of inadequate muscular repair of the lip.
To prevent this problem, the subnasal sulcus should be identied preoperatively
and marked. For its diagnosis, a comparison between cleft and noncleft side alar base
positions should be done as I mentioned before. The observed difference will allow
the design of the skin area to be corrected for proper repositioning of the alar base.
Alar Nose Shortening (Figs.10.35, 10.36, 10.37 and10.38)
Two events are associated with this poor outcome, inadequate surgical technique
higher placement of the subnasal incision (related to the rotation advancement
316
Fig. 10.35 Alar nose
shortening. Diagram
illustrating the nose
asymmetry associated with
short left ala position
Fig. 10.36 Alar nose
shortening. Diagram
illustrating the surgical
technique used for its
correction
P. Rossell-Perry