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10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.37 Alar nose
shortening. Diagram
illustrating the outcome
after nose asymmetry
correction
Fig. 10.38 A 5-year-old
male patient born with
unilateral cleft lip who
developed nose asymmetry
characterized by alar
shortening after primary
cleft rhinoplasty
317
318
P. Rossell-Perry
method) and congenital hypoplasia of the ala. If the subnasal incision is not properly located and it is placed higher, then the surgeon leaves a short nasal ala because
part of the nasal ala is included in the lip. The second event is the congenital hypoplasia of the ala (a rare condition), and another associated problem is the alar necrosis after primary cleft rhinoplasty. Its diagnosis is made by carefully observing the
alar’s length measured from the alar base to the nasal tip and comparing the two
sides. Its correction is challenging since it requires the addition of tissues to compensate for the deciency. The use of composite grafts from the auricular helix has
become the alternative of choice to repair these sequelae (Fig.10.39) [36]. The main
disadvantage is the viability and contracture of these composite grafts, which reduce
their size and change their color and texture. An alternative is the reduction of the
noncleft side; however, this is altering the anatomy of the ala and affecting the natural appearance of the nose.
Columella
Secondary columellar deciencies may be observed in association with the use of
Mohler’s cheiloplasty especially with the extended modication published by
Cutting [37]. The use of columellar tissue for lip repair reduces the width of the
columellar region and leaves a visible scar. Sometimes, the defect is minor and does
not require any revision. The indication for surgery depends on surgeon’s criteria
and patient’s expectation.
Fig. 10.39 Diagram illustrating the surgical technique used for alar shortening based on auricular
composite graft technique
10 Cleft Rhinoplasty-Related Complications andManagement
319
Nasal Sill: Wider Nasal Sill
This is a common nondesirable outcome after cleft lip repair and has been reported
by different authors. This outcome is observed as a result of decient surgical technique considering also the pulling action of the facial muscles or by hypertrophy of
the lip scar. This problem is easier to correct by skin resection and the amount is
determined by establishing the differences between cleft and noncleft alar base
widths. This bad outcome is often associated with nasoalveolar stulas (Figs. 10.40,
10.41, 10.42, 10.43 and 10.44).
Narrower Nasal Sill
Alar tissue may be hypoplastic; therefore, it could explain this bad outcome; however, this is mostly due to bad planning and execution of the primary surgical correction, and scar contracture may also be associated with this bad outcome too. The
overcorrection technique, a surgical method popularized by centers such as Chang
Gung University Craniofacial center from Taiwan, uses the nostril and nasal base
overcorrection during primary cleft rhinoplasty. I do not agree with this concept
because the nose may be overcorrected after long term and its repair is more difcult [38]. Its diagnostic is made similar to that of the previous case, in which the
position of the alar bases is located and their diameter differences are established. A
Fig. 10.40 Wider nasal
oor. Diagram illustrating
the nose asymmetry
associated with right
widening alar
320
Fig. 10.41 Wider nasal
oor. Diagram illustrating
the surgical technique used
for its correction
Fig. 10.42 Wider nasal
oor. Diagram illustrating
the outcome after nose
asymmetry correction
P. Rossell-Perry
10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.43 A 6-year-old
female patient born with
unilateral cleft lip who
developed nose asymmetry
characterized by alar
widening after primary
cleft rhinoplasty
Fig. 10.44 Postoperative
view after 1year of the
patient presented in
Fig.10.40
321
lateral ap from the cheek can be used to correct this secondary deformity, and the
ap diameter is equal to the difference between the two alar bases.
The nasal oor is an anatomical structure made up of three anatomical segments:
the nasal vestibule and the hard and soft palates. The anterior segment of the nasal
oor (vestibular segment) is repaired during primary repair using three aps: lateral
(nasal ala), medial (base of the columella), and posterior (mucosal ap raised from
the lips) aps.
322
P. Rossell-Perry
Nasal Vestibule
The vestibule is an important functional area of the nose, and its involvement during
primary cleft rhinoplasty may affect breathing. Thus, the incisions made in this
anatomical segment may produce scar retractions or synechiae, and this is the reason why the use of nasal conformers is recommended after primary cleft rhinoplasty. They can be associated with patient idiosyncrasy but also with the use of
extended incisions through the nasal vestibule during primary cleft rhinoplasty (i.e.,
VYZ cleft rhinoplasty). Its diagnosis is made through the physical examination and
airway obstruction symptoms (Figs.10.45, 10.46, 10.47 and 10.48). Treatment of
these conditions is challenging for the reconstructive surgeons, and recurrence is a
common problem. Management is surgical, and different techniques are used for
Fig. 10.45 Contracture of
the nasal vestibule scar.
Diagram illustrating the
surgical technique
markings used for
correction of the nose
vestibular scar contracture
Fig. 10.46 Contracture of
the nasal vestibule scar.
Postoperative diagram
illustrating the correction
of the vestibular scar
contracture using the VYZ
method
10 Cleft Rhinoplasty-Related Complications andManagement
323
this purpose, ranging from skin grafts to local aps. The conservative use of steroid
inltration seems to help although only in the early stages and should be used in
combination with nasal stents. In a recent study, we observed a reduced rate of this
bad outcome after using these devices [39]. The proposed surgical technique for its
correction is the V-Y composite ap plus lateral Z plasty in combination with postoperative nasal conformers. In addition, due to the increased rate of recurrence, the
use of postoperative nasal stents for at least 6months is recommended. The purpose
of this technique is to lengthen the nasal vestibule while the scar contracture is
breaking.
Fig. 10.47 A 10-year-old
patient who developed a
severe scar contracture of
the nose after primary cleft
rhinoplasty
Fig. 10.48 Immediate
postoperative view of the
patient presented in
Fig.10.47 illustrating scar
contracture release after
correction using the VYZ
method
324
P. Rossell-Perry
Poor Outcomes Associated withBilateral Primary
Cleft Rhinoplasty
Compared with unilateral cleft lip, the bilateral cleft lip is more frequently associated with bad outcome and complications [1]. Brown described the nature of the
bilateral cleft lip and palate as follows: “twice as difcult to repair compared to the
unilateral cleft lips with outcomes that were half as good” [40]. Sir Harold Gillies,
pioneer of reconstructive surgery, noted “the skeleton rst,” highlighting the importance of rebuilding the skeletal structure rst in craniofacial reconstruction [40].
During primary lip and nose repair, the soft tissues are corrected before the skeleton
which explains many of the bad outcomes observed after bilateral cleft lip surgery.
Asymmetries, hypertrophic scars, and dental skeletal sequelae are commonly
observed after primary bilateral cleft lip surgery due to the unrepaired skeleton.
Another important factor is that due to the low incidence of bilateral cases (compared to unilateral cases), it takes more time for surgeons to acquire the necessary
experience to treat them. Bad outcomes are often observed after bilateral cleft lip
surgery, mostly in severe cases, and practiced by inexperienced surgeons. Based on
the author’s classication, a severe bilateral cleft lip and palate is one that has an
alveolar cleft wider than 1cm [1]. The author described the clock diagram, a practical scheme to illustrate this pathology in a better way [41]. An effective and timely
interdisciplinary team management is essential to prevent these nondesirable outcomes. The use of presurgical treatment helps to improve the quality of the results
but should be provided early (during the rst weeks of life). These devices mobilize
the cleft segments and premaxilla in a more anatomical position facilitating the
primary surgical repair and preventing sequelae, and they are indicated for severe
cases. When the lip and nose are repaired under tension, there are increased rates of
dehiscence, hypertrophic scarring, premaxilla malpositioning, and nasal sequelae.
Presurgical nasal molding combined with alveolar molding (known as NAM) was
developed by the University of New York based on Matsuo’s ndings and is an
alternative for facilitating nasal surgery; however, there is a lack of scientic evidence supporting its long-term effect, and similar outcomes can be achieved by
using primary cleft rhinoplasty alone [42]. Different publications show a signicant
improvement in outcomes for bilateral nasal deformity after primary repair minimizing the psychological impact of patients [43, 44].
The secondary nasal deformity of bilateral cleft lip presented the following
characteristics:
• Bad alar cartilage positioning and lack of projection of the nasal tip.
• Absent or short nasal columella. “Short” columella resulting from lateral dis-
placement of the alar cartilage. In fact, this is not short; it is “hidden in the nose,”
as Mulliken pointed out for bilateral cleft lips.
10 Cleft Rhinoplasty-Related Complications andManagement
325
• Obtuse labial columellar angle
• Wide nasal oor
• Ectopic insertion of nasal muscles
• Different degrees of maxillary hypoplasia
Some surgical technique shortcomings described in the literature are the use of
banked fork aps using lip tissues for nose repair which results in an unnatural outcome (Millard), skin resection from the soft triangle of the nose proposed by Tajima
and Mulliken bringing a turned-up appearance of the nose and visible scars affecting vestibular function, and the Mc Comb’s method which is associated with a high
rate of nasal deformity relapse [28].
The author’s philosophy for the secondary correction of the bilateral cleft lip
nose deformity is based on the following principles:
• Any severe bilateral cleft lip form (alveolar gap greater than 1cm) should receive
presurgical treatment at an early age before primary cleft rhinoplasty. Older
patients may be treated by vomer osteotomy and setback of the premaxilla.
• Columellar lengthening is based on alar cartilage reposition and vestibular
lengthening, via the VYZ technique [13].
• Compared with unilateral clefts, the need for septal correction is less frequent,
and this is mostly used for nonsymmetrical bilateral cleft lips.
• Any severe aesthetic or functional condition should be treated at an early age;
this is before school age, preventing the psychosocial and functional impact of
the patient. Any minor sequela can be corrected later in adulthood.
Careful physical examination and photographic documentation are recommended to address aesthetic and functional problems to be treated.
The anatomical areas to be analyzed include the nasal tip, columella, vestibule,
alar bases, and septum.
Nasal Tip
The lateral displacement of alar cartilages in bilateral cleft lip is the reason for the
lack of projection and denition. The proposed surgical technique for secondary
nasal tip correction is based on medial repositioning of the alar cartilages which
allows lengthening of the columella and nasal tip projection and lengthening of the
nasal vestibule.
The technique used is a combination of V-Y (Potter’s concept) and lateral Z
plasty (Berkeley’s concept), and it is indicated for complete bilateral cleft lips [31,
33]. By lengthening the nasal vestibule, it is possible to reposition the alar cartilages
326
P. Rossell-Perry
improving the nasal tip projection, and the lateral Z plasty prevents scar contracture
of the lateral incisions. The surgical approach can be performed in an open or closed
manner. Cartilaginous grafts are required to reinforce the area of the nasal vestibule
that remains without cartilaginous reinforcement after medial displacement of the
alar cartilages. An alternative for bilateral incomplete cleft lip cases is the rotational
composite ap technique. This is based on the medial displacement of the composite ap through rotation, but really the alar cartilage is displaced in three dimensions
(vectors) as medial, vertical, and posterior movements (Fig.10.49). In case of minor
deformities, the vestibular marginal skin excision is a good alternative providing
long-term nasal symmetry [45] (Figs.10.50, 10.51 and 10.52).
Fig. 10.49 Lack of tip
projection in a patient with
bilateral cleft lip after
primary cleft rhinoplasty