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10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.50 Nasal ala
asymmetry in a patient
with bilateral cleft lip after
primary cleft rhinoplasty
Fig. 10.51 Nasal ala
asymmetry in a patient
with bilateral cleft lip after
primary cleft rhinoplasty
327
328
Fig. 10.52 Nasal ala
asymmetry in a patient
with bilateral cleft lip after
primary cleft rhinoplasty
P. Rossell-Perry
Nasal Ala
Nose asymmetry is the most common form of presentation of bad outcomes after
primary cleft rhinoplasty. The nasal ala may be in wider, higher, or lower position
when they are compared to the opposite side. It is important to be considered that all
bilateral cleft lips are mostly asymmetric and the objective of the primary surgery is
to create a symmetric lip and nose. The surgical alternatives for their treatment are
similar than those presented for unilateral secondary deformities. The diagnosis is
made through careful physical examination of the lip, and the difference between
the position of the right and left alar bases will determine the diagnosis and the
degree of malposition.
Nasal Ala Asymmetry
This complication may be observed on one or both sides and is considered an
expected result after primary cheilorhinoplasty as a consequence of the absence of
bony support. The muscular hypoplasia observed in cleft segments of the bilateral
forms does not allow the surgeon to provide an adequate support of the alar bases in
comparison with unilateral cleft lips. In addition, the skeletal discrepancy between
the premaxilla and cleft segments does not help to position the alar bases properly
(Figs.10.50, 10.51 and 10.52). Common causes are Manchester type of primary
cheiloplasty, skeletal discrepancy, and decient repair of the labial muscles. The
Manchester technique for bilateral cleft lip repair may develop a lower position of
10 Cleft Rhinoplasty-Related Complications andManagement
the ala because the oral muscles are not repaired and a lack of support for the alar
base may exist [46]. The skeletal discrepancy creates a decient support for the
nasal ala because of the hypoplasia of the lateral cleft segments. This bad outcome
can be corrected using secondary muscular repair and an asymmetric Z plasty or a
combination of both procedures for severe cases.
329
Alar Nose Shortening
A short alar nose is not common and is associated with congenital hypoplasia of the
ala, surgical technique deciencies, or complications such as alar necrosis (rare). Its
diagnosis is made by comparing the alar’s length measured from the alar base to the
nasal tip between both 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 to repair these sequelae [36]. The
main disadvantage is the viability and contracture of these composite grafts, which
reduce their size and change color and texture. An alternative is a combined method
in which one cleft side is reduced and the other is grafted; however, this method also
alters the anatomy of the ala and affects the natural appearance of the nose.
Columella
Secondary columellar deciencies are common after primary bilateral cleft rhinoplasty and short or absent columella are frequently observed. The most frequent
sequelae observed after primary reconstruction of the nasal columella in patients
with bilateral cleft lips are short, wide columella and outcomes after repair using
regional aps or grafts.
Short Columella
This sequel is related to the absence of primary nasal surgery or poor reconstruction
(Figs.10.53, 10.54 and 10.55). The objective for secondary surgery of nasal columella in adults is lengthening of the columella by 1cm, on average, but we have to
consider the height of the columella. The anthropometric parameters vary depending on the patient’s age and race (Farkas) [47]. The surgical treatment for short columella is based on vestibular lengthening, which was previously described in detail
in Chap. 6. This method has been described in the literature by the author as the
V-Y-Z method. In addition, the use of the rotational composite ap method may be
effective for incomplete bilateral cleft lips [13, 48].
330
Fig. 10.53 Short
columella in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
Fig. 10.54 Short
columella in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
P. Rossell-Perry
10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.55 Short
columella in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
331
Wide Columella
It is characterized by the presence of a wide columella and is usually accompanied
by a wide philtrum, which is probably due to tissue expansion and scar retraction of
the nostrils. It is also associated with congenital defects of the nasal pyramid with
widening of the nasocolumellar area, as observed in syndromic patients (Fig.10.56).
Its diagnosis is established through physical examination, and correction is performed by resection of the excess skin and plication of the cartilaginous structures
giving the columella a more natural appearance.
Nasal Sill: Wider Nasal Sill
This is a common nondesirable outcome after cleft lip repair that has been reported
by different authors and is more frequently observed in bilateral cleft lip surgery.
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 bad
outcome is often associated with nasoalveolar stulas (Figs. 10.57, 10.58 and
10.59). This problem is easier to correct by skin resection, and the amount is estab-
lished by determining the differences between both alar base widths. The technique
used for its correction is based on resection of the excess of the skin of the wider alar
base (or both if necessary) considering the anthropometric parameters. Based on
this concept, the length of the alar base should be equal to the vertical length of the
philtrum; therefore, the rst step is determining the desired lip height according to
332
Fig. 10.56 Wide
columella in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
Fig. 10.57 Wider nasal
sill in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
P. Rossell-Perry
the width of the largest lateral segment. If the lip height is greater than the estimated
width, it is better to reduce it; otherwise, it will be a disproportionate and longer lip.
In contrast, if the labial height is less than the largest lateral segment, this height
should be taken as the desired lip height. It is important to understand that the
10 Cleft Rhinoplasty-Related Complications andManagement
Fig. 10.58 Wider nasal
sill in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
333
Fig. 10.59 Wider nasal
sill in a patient with
bilateral cleft lip after
primary cleft rhinoplasty
objective in the reconstruction of the secondary bilateral cleft lip deformity is the lip
symmetry and better proportions of the anatomical subunits. After estimation of the
desired lip height, the alar bases can be shortened and positioned considering that
the alar diameter is equal to the lip height. This correction can be performed by
resecting a skin lozenge as necessary to ensure symmetry.
334
P. Rossell-Perry
Narrower Nasal Sill
Alar tissue may be hypoplastic and therefore could explain this bad outcome; however this is mostly due to poor planning of the primary surgical correction and scar
contracture. Overcorrection is a well-known method developed to prevent nose
deformity relapse and was popularized by centers such as Chang Gung University
in Taiwan [38]. Soft tissue resection may cause permanent long-term deciency and
its repair is more difcult. Oversized nostrils and narrower nasal oors are consequences of these techniques. Its diagnosis is similar to that of the previous case, in
which the width of the nasal oor on both sides was measured and the differences
in the nasal oor diameter were determined. A 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 nasal oor widths.
Nasal Vestibule
The nasal vestibule is a functional area of the nose and under the point of view of
cleft lip nose repair is critical. This anatomical area is frequently affected by the
development of scar contractures (Fig.10.60). Nasal breathing may be severely
affected by scar contractures and synechia of the vestibule of the nose. Any primary
cleft rhinoplasty based on vestibular incisions should consider the complementary
use of nasal stents postoperatively during for at least 6months to prevent these
adverse outcomes [49, 50].
A recent study published by us observed that the group of patients operated using
postoperative nasal stents had lower rate of these postoperative complications [39].
Fig. 10.60 Bilateral Nasal
vestibule scar contracture
10 Cleft Rhinoplasty-Related Complications andManagement
335
The diagnosis is made through the physical examination of the airway and patient’s
symptoms. Its treatment is surgical after initial conservative management including
corticoid injection from skin grafts to local aps in combination with postoperative
nasal stents at least during 6months.
The conservative use of corticoid inltration seems to help although only in
early time; however, it is difcult to apply when children are awake. If the conservative treatment is not successful, the surgical treatment is needed. The technique used for these sequelae is the V-Y-Z method in combination with
postoperative nasal stents (orthonostric devices) for at least 6months (Figs.10.61,
10.62 and 10.63).
Fig. 10.61 VYZ surgical technique for treatment of bilateral nasal vestibule scar contracture.
Upper: Surgical markings. Lower: VY advancement and lateral Z plasty for scar release and vestibular lengthening
336
Fig. 10.62 Postoperative nasal conformers used to prevent scar contracture relapse
Fig. 10.63 Custom-made
acrylic nasal conformer
used in a patient with
unilateral cleft lip during
short-term postoperative
period
P. Rossell-Perry
In case of more severe contractures and synechia, the use of auricular composite
grafts is an alternative. The graft should be larger than the defect because of the
secondary contracture of the graft.