April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 140, Number 1 • Correction of Cleft Lip Nasal Deformity

Table 1. Characteristics Constituting Secondary Cleft Lip Nasal Deformity Anatomical Feature Unilateral CLND

Bilateral CLND

Upper two-thirds  Nasal root Lower one-third  Alar root  Dorsum

Minor widening and deviation Deviated toward noncleft side

Moderate widening and deviation

Midline

Inferiorly/posteriorly displaced on cleft side

Inferiorly/posteriorly displaced, bilaterally

 Alar base  Nasal tip

Wide on cleft side

Wide bilaterally

Asymmetric, with relatively more projection and definition on noncleft side and “effacement” on cleft side Short hemicolumella on cleft side; base deviated toward noncleft side Flattened nostril on cleft side, with or without recurvatum Obliquely oriented on cleft side; contralateral side usually vertically oriented in Caucasians; may be variably round or obliquely oriented in other ethnicities

Flat, broad, weak tip projection

 Columella

Short bilaterally

 Alar lobule and rim  Nostril shape

Flattened nostrils, with or without recurvatum Obliquely oriented, bilaterally

Intranasal

 Vestibule  Septum

Vestibular web on cleft side

Vestibular webs, bilaterally

Anterocaudal septum and anterior nasal spine deviated to noncleft side; posterior septum deviated to cleft side

Midline anterocaudal septum; variable pos- terior deviation

 Turbinates

Hypertrophied on noncleft side

Hypertrophy variably present

Facial

 Maxilla

Ipsilateral malar flattening and maxillary hypoplasia/retrusion (class III malocclusion)

Bilateral malar flattening and maxillary hypoplasia/retrusion (class III malocclusion)

CLND, cleft lip nasal deformity.

framework of the nose is hypoplastic compared with the noncleft side. Anatomical dissections of stillborn children by Atherton, 6 McComb, 7 and Li et al. 8 confirm that the lower lateral cartilage is of normal length, width, and thickness. Kim et al. 9 demonstrated that the medial footplate is inferiorly displaced and, consequently, the genu is drawn medially and the lateral crus is tethered laterally. In addition to deformation of the lower lateral cartilage, the upper lateral cartilage may be pulled inferomedially by the deviated anterocau- dal septum. 10 Often, the soft tissue in the cleft-side alar lobule is slightly hypoplastic; however, LaRossa and Donath 11 wrote that this difference does not interfere with construction of a nostril of similar size and shape to the other side. The features of primary bilateral cleft lip nasal deformity corre- late with the symmetry of the bilateral cleft lip. Most often, bilateral cleft lip with or without cleft palate is symmetrical (complete or incomplete on both sides) because the deforming forces on each side of the nose are in balance. There is no displacement of the anterior nasal spine or the anterocaudal septum, although the vomer and body of the septum can be bowed. The alar bases are displaced laterally. The lower lateral cartilages are stretched across the clefts and dis- sociated from the upper lateral cartilages, result- ing in the severely shortened columella that is accentuated by protrusion/proclination of the

premaxilla. In bilateral incomplete cleft lip with or without cleft palate, the premaxilla is in nor- mal position and the columella is short but less obvious than in the complete form. In asymmet- rical bilateral cleft lip with or without cleft palate (i.e., complete–incomplete, complete–lesser- form, or incomplete–lesser-form), the nasal deformity is similar to that of unilateral cleft lip with or without cleft palate. Many components (but not all) of the cleft lip nasal deformity can be corrected at the time of primary labial repair, as reviewed for unilateral cleft lip with or without cleft palate elsewhere. 12,13 A video of the senior author’s technique for pri- mary correction of unilateral cleft lip nasal defor- mity can be found at http://links.lww.com/PRS/ B92 . Key maneuvers include the following: (1) centralizing the anterocaudal septum; (2) elevat- ing the medial crus of the lower lateral cartilage; (3) releasing the lateral crus; (4) medializing and securing the alar base; (4) repositioning the lower lateral cartilage with interdomal and intercartilag- inous sutures; and (5) correcting any vestibular web. 14 The senior author’s (J.B.M.) technique for primary correction of the bilateral cleft lip nasal deformity is described in textbooks. 15,16 Secondary Cleft Lip Nasal Deformity Secondary cleft lip nasal deformity is defined as those distortions that persist despite primary operative maneuvers. Expressed mathematically,

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