April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Reprinted by permission of Plast Reconstr Surg. 2017; 140(1):166e-176e.

MOC-CME

Evidence-Based Medicine: Secondary Correction of Cleft Lip Nasal Deformity

Alexander C. Allori, M.D., M.P.H. John B. Mulliken, M.D. Durham, N.C.; and Boston, Mass.

Learning Objectives: After reading this article, the participant should be able to: 1. Understand the components of unilateral and bilateral cleft lip nasal deformity. 2. Assess the deformity. 3. Design a treatment plan for secondary correction of cleft lip nasal deformity. 4. Discuss methods for managing sub- optimal outcomes. Summary: Correction of cleft lip nasal deformity has been addressed in this Maintenance of Certification/Continuing Medical Education series a number of times—a testament to the complexity of the topic. In this addition to the series, the authors provide a principle-based approach toward management of unilateral and bilateral cleft lip nasal deformity with an emphasis on timing in- tervention, role for intermediate correction, and methods for cleft rhinoplasty after completion of nasal growth. ( Plast. Reconstr. Surg. 140: 166e, 2017.)

C orrection of cleft lip nasal deformity has been addressed in this Maintenance of Certifica- tion/Continuing Medical Education series a number of times—a testament to the complexity of the topic. Monson et al. 1 discussed primary nasal correction with cleft labial repair; Henry et al. 2 and Zbar and Canady 3 provided systematic reviews of the literature on the evaluation and management of cleft lip nasal deformity; and Byrd et al. 4 and Guyuron 5 shared their insights on secondary cleft rhinoplasty. The interested reader should review these articles because each is complementary to the others. In this article, we provide a principle- based approach toward management of unilat- eral and bilateral cleft lip nasal deformity with an emphasis on timing intervention, role for interme- diate correction, and methods for cleft rhinoplasty after completion of nasal growth. Anatomical Basis of cleft lip nasal deformity Cleft lip nasal deformity is present in all forms of cleft lip with or without cleft palate. The degree of nasal deformity parallels the severity of labial cleft- ing: complete, which is greater than incomplete, From the Division of Plastic, Maxillofacial and Oral Surgery, Duke Children’s Hospital, Duke University School of Medicine; and the Department of Plastic and Oral Sur- gery, Boston Children’s Hospital, Harvard Medical School. Received for publication February 25, 2016; accepted May 20, 2016. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003475

which is greater than the lesser form. Even in a min- imicroform cleft lip, there is a slight nasal abnor- mality that often becomes more obvious with time. Nasal deformity is also worse whenever there is a cleft of the alveolus and secondary palate. Primary Cleft Lip Nasal Deformity Primary cleft lip nasal deformity is defined as nasal distortion caused by a cleft lip. Features of unilateral and bilateral cleft lip nasal defor- mity differ because of asymmetry (Table 1), but the anatomical basis is very similar. In primary unilateral cleft lip nasal deformity, the wide piri- form aperture and maxillary hypoplasia displace the cleft-side alar base laterally, inferiorly, and posteriorly. The anterior nasal spine, anterocau- dal septum, and base of the columella tilt toward the noncleft side. The lower lateral cartilage is splayed across the cleft and also dislocated from the ipsilateral upper lateral cartilage. There has been debate regarding whether the cartilaginous

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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