April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2017

whereas in bilateral cleft lip nasal deformity, the problem is one of omission (inadequate correction or simply ignoring the nasal malformation). Growth-related nasal distortions occur dur- ing puberty and are often worse in children with unilateral cleft lip with or without cleft palate. In unilateral cleft lip nasal deformity, deviation of the posterior septum toward the cleft side and hypertrophy of the inferior turbinate on the non- cleft side result in bilateral nasal airway obstruc- tion, dorsal deviation, and asymmetry of the alar domes. In bilateral cleft lip nasal deformity, the alar bases widen progressively, the vomer stays midline, but the columella does not grow. The conglomeration of features in secondary cleft lip nasal deformity is summarized for unilat- eral and bilateral cleft lip with or without cleft pal- ate in Table 1 and illustrated in Figures 1 and 2. Specific findings depend on the initial type and

secondary

primary nasal deformity

= [

] + [

]

residual

iatrogenic

− [ ] growth related .

+

Residual deformity is a result of “failure to cor- rect,” undercorrection, or relapse. Iatrogenic defor- mities include expected (although undesirable) changes and the unintended results of technical error. For example, as the alar base is moved medi- ally in closure of the nasal floor, the lower lateral cartilage bends into recurvatum and a vestibular web often appears. The alar base may be malpo- sitioned and nasal tip cartilages may be damaged. Scarring can result in a stenotic “micronostril.” 17 In contemporary correction of unilateral cleft lip nasal deformity, the problem is usually one of com- mission (doing too much, or doing it incorrectly),

Fig. 1. Asymmetric cleft lip nasal deformity. ( Above ) A 6 year-old boy with repaired bilateral asymmetric cleft lip, alveolus, and Veau type III palate: complete on the right and band on the left. The nasal deformity approximates that of unilateral cleft lip nasal deformity. ( Below ) Two months after right nasal revision at the time of alveolar bone grafting: elevation of lower lateral cartilage andmattress suture-fixation to ipsilateral upper lateral cartilage, elevation of the vestibular web with tacking suture to the piriform rim, and dermal graft to the median tubercle.

238