April 2020 HSC Section 4 - Plastic and Reconstructive Problems

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

Fig. 2. Bilateral cleft lip nasal deformity. ( Above ) A 7 year-old girl with straight-line repair of bilateral complete cleft lip, alveolus, and Veau type IV palate. ( Below ) Six years after complete nasolabial revision: interalar width (alaris to alaris) narrowed 42 to 31 mm, columellar height (subnasale to columella) elongated 3.8 to 6.8 mm, and tip projection (subnasale to pronasale) increased 13 to 14.5 mm.

severity of the cleft, method of primary repair, and distortions that occur with facial growth.

bones, which in the cleft patient are often widely set and deviated. The middle third is composed of the dorsum and sidewalls. In the patient with unilateral cleft lip with or without cleft palate, the nasal dor- sum is typically deviated toward the noncleft side, often with an irregular and asymmetric dorsal aes- thetic line. The presence of a dorsal hump or other irregularity in profile view should also be noted. The lower third is composed of the nasal tip, colu- mella, soft triangles, alar rims, lobules, and bases. In secondary cleft lip nasal deformity, there is poor tip projection; asymmetric tip-defining points; boxy tip with widened interdomal angle; flattening of the alar rim or recurvatum; angulation of the colu- mella with deviation of the anterocaudal septum to the noncleft side; and displacement of the alar base laterally, inferiorly, and posteriorly (because of malar deficiency). Complicating matters, earlier operations can introduce a variety of iatrogenic deformities. Maxillofacial intervention may also

Preoperative Assessment The first step in the preoperative evaluation of secondary cleft lip nasal deformity is taking a complete, accurate history and reviewing all prior operative notes. Assessment for cleft rhinoplasty should follow standard and systematic nasofa- cial analysis. 18 As with an aesthetic rhinoplasty, the evaluation should take into account overall facial harmony—including the proportion and symmetry of all structures from the forehead to the chin. Special attention should focus on the midface, which is often relatively hypoplastic and retrognathic. The thickness and quality of the nasal skin is examined. Nasal form is traditionally considered in “thirds”: The upper third is comprised of the nasal

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