April 2020 HSC Section 4 - Plastic and Reconstructive Problems

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

the anterior caudal septum, and repositioning the alar base. There are no indications in childhood for septal resection, onlay grafting, transcolumel- lar incisions, or cutaneous excision, among others. These maneuvers are best undertaken at the time of rhinoplasty after skeletal maturity. If scheduled earlier, the revision may be effective only in the short term (given the upcoming pubertal growth and a worsening of the cleft lip nasal deformity). There is also the worrisome possibility of interfer- ing with future growth and introducing a scar that could complicate future rhinoplasty. Techniques that may be safely performed at an intermediate stage for unilateral cleft lip nasal deformity are described below and demonstrated in Video 1. ( See Video, Supplemental Digital Con- tent 1 , which displays intermediate correction of unilateral cleft lip nasal deformity. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C222 .) Many of the same manipulations are applicable to bilateral cleft lip nasal deformity. Centralization of the Anterocaudal Septum The anterocaudal septum can be released from its ligamentous attachments to the deviated ante- rior nasal spine and anterior vomer. This is accom- plished through a membranous septal incision on the noncleft side. The anterocaudal septum is released, gently abraded on the concave side, and fixed in the medialized position with 4-0 polydioxa- none suture through the premaxillary periosteum. It may also be secured to the cleft-side alar nasi with a spanning “alar-cinch” suture, particularly if medial

repositioning of the alar base is necessary (see below). Repositioning of the Alar Base In the unilateral cleft lip nasal deformity, the alar base is typically displaced in the x , y , and z axes (i.e., inferiorly, laterally, and posteriorly, respectively). Anterior movement along the z axis is improved with skeletal augmentation (bone grafting). 19 Y-V–plasty is recommended for repo- sitioning in the x and y dimensions (Fig. 3). Hori- zontal narrowing of the alar base width is achieved by advancing the alar base into the stem of the Y. If a change in the vertical position of the alar base is also required, the angle of the stem of the Y is adjusted. Typically, the alar base on the cleft side is too low, so some degree of endonasal rotation is needed. The width of the alar base should be slightly overcorrected medially by approximately

Fig. 3. Alar base repositioning by means of Y-V advancement. Alar base width is reduced by advancing the V (alar base flap) into the stem of the Y. The degree of endonasal rotation is con- trolled by adjusting the angle of the stem of the Y.

Video 1. Supplemental Digital Content 1, which displays interme- diate correction of unilateral cleft lip nasal deformity, is available in the “Related Videos” section of the full-text article on PRSJour- nal.com or, for Ovid users, at http://links.lww.com/PRS/C222 .

241