April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2017

affect nasal form. For example, alveolar bone graft- ing usually corrects posterior displacement of the alar base (although it does not improve the lateral or inferior displacement). 19 Also, Le Fort I maxil- lary advancement elevates the nasal tip, widens the columellar angle, and usually increases intera- lar width, particularly in a bilateral cleft lip nasal deformity. 20 Anthropometry is a useful adjunct to quanti- tate nasal form. Measurements to assess symmetry include subnasale to alaris (sn-al), subnasale to columella (sn-c), subnasale to crista philtri infe- rior (sn-cphi), and alaris to alaris (al-al). Projec- tion is assessed by subnasale to pronasale (sn-prn), with the ratio of sn-c to sn-prn ideally close to 40 percent. Tip rotation is assessed by measuring the columella-labial angle. 21,22 In the patient with repaired cleft lip with cleft palate, particularly the bilateral deformity, 23 this angle is often obtuse in childhood and adolescence but narrows slightly by young adulthood. 24 Functional Assessment Nasal airway obstruction is present in over 60 percent of patients with cleft lip nasal defor- mity. 25,26 Intranasal examination often reveals septal deviation, maxillary bony spurs, turbinate hypertrophy, vestibular webbing, and external or internal valve collapse. 12,27 The Cottle maneuver 28 and “adhesive breathing strip test” 29 are useful ways to uncover clinically significant nasal obstruction caused by internal valve collapse. For children old enough to self-report (i.e., older than 8 years), the validated patient-reported Nasal Obstructive Symptom Evaluation scale is a practical and infor- mative method for characterizing frequency and severity of obstructive symptoms. 30 Many patients with cleft lip nasal deformity are so accustomed to poor nasal airflow that they become habitual mouth breathers and thus may underreport fre- quency or severity of nasal obstructive symptoms. Nasometry provides objective confirmation of impeded nasal airflow but is unnecessary for the clinical diagnosis of nasal airway obstruction. Timing of Correction There is traditional teaching that early attempts at primary correction of the cleft lip nasal deformity are at best ineffectual (in the long term) and potentially cause irreparable harm to the nasal cartilaginous and soft tissues. 31–34 There- fore, primary correction of the nasal deformity was deferred, leaving the cleft lip nasal deformity to be addressed secondarily.

As techniques improved in the 1970s, more surgeons began to repair the unilateral nasal deformity primarily and showed better results with- out obvious interference with nasal growth. 7,35–39 A decade later, reports appeared of one-stage primary correction of the bilateral cleft lip nasal deformity by Mulliken, 40 Trott and Mohan, 41 Cut- ting et al., 42 and others. 43 Long-term follow-up studies demonstrated that synchronous correc- tion of both unilateral 44 and bilateral 23,45 cleft lip nasal deformity resulted in better outcomes and reduced the complexity of operative maneuvers required during secondary rhinoplasty. Because of the success of the techniques for primary “tip rhinoplasty,” particularly in unilateral cleft lip nasal deformity, many surgeons warned against performing additional nasal revisions in later childhood. We recommend a conservative and strategic approach: Consider any nasal (or labial) revisions that may be warranted at the time of alveolar bone grafting, although the benefits and risks of such an intervention must be care- fully weighed. In this calculus, one must include the functional issues, psychosocial concerns, and future requirements. In general, we recom- mend only proceeding with intermediate repair of severe nasal deformities, deferring interven- tions for minor and moderate nasal deformities until young adulthood (after orthognathic cor- rection). In general, we strongly advise against any operations during puberty, when the nose is growing and changing rapidly. There are oppor- tunities for intermediate correction whenever the child is under general anesthesia for other rea- sons, including the following: (1) preschool (age 4 to 5 years), if a procedure is needed for velo- pharyngeal insufficiency; (2) school age (5 to 8 years), if myringotomy and tympanostomy tubes are needed; and (3) middle school (during the period of mixed dentition, age 8 to 10 years), at the time of the alveolar bone graft. Intermediate Correction during Childhood/Early Adolescence Nowadays, most children will have undergone a primary nasal correction at the time of unilateral cleft labial repair; however, some will exhibit obvi- ous residual or iatrogenic deformities. There are also a number of patients who present in child- hood or in early adolescence with an untouched nasal deformity. In these instances, we recom- mend focusing on the indicated improvements of the lower-third of the nose—specifically, reeleva- tion of the lower lateral cartilage, centralization of

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