April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2017

1 mm and secured to the maxillary periosteum. Note that if this procedure is performed at the time of alveolar bone grafting, the maxillary peri- osteumwill have likely been dissected off the bone. Alternatively, the alar base can be secured in its new position by suturing it to the muscular layer. An “alar cinch” spanning suture may be placed to the periosteum of the anterior nasal spine and/or anterocaudal septum. Repositioning of the Lower Lateral Cartilage Repositioning the lower lateral cartilage to improve nostril flattening and recurvatum is an option at the time of intermediate correction in a manner similar to that used at primary correction. As depicted in Figure 4, a semiopen approach is made through a rim incision drawn along the line of recurvatum. In bilateral cases, rim incisions are made on each side. Fibrofatty tissue is excised off the anterior surface of the lower lateral cartilage. With downward traction on the lower lateral carti- lage, the transverse portion of the nasalis muscle is incised to expose the caudal edge of the upper lateral cartilage. Next, the lower lateral cartilage is elevated, holding the genu upward with a cotton-tip applicator. An interdomal suture is placed between the medial crura using 4-0 polydioxanone suture in mattress fashion. In addition, two intercartilaginous suspension mattress sutures are placed between the lower lateral cartilage and the ipsilateral upper

lateral cartilage: one at the genu, and the other at the superior margin of the lateral crus. Chondromucosal Advancement In modern unilateral cleft labial repair, usually some effort is made to lengthen the columella and lift the medial footplate. Thus, the medial and mid- dle crura should be in normal anatomical position. The residual deformity of the lower lateral cartilage is likely caused by inferior displacement and attach- ment of the lateral crus of the lower lateral cartilage to the piriform rim. Thus, any maneuver designed to further elevate the medial crus (e.g., Dibbel pro- cedure 46 ) is unnecessary. If the medial crus was not positioned at the time of cleft labial repair, and especially when the alar base is displaced laterally, a combined Dibbel “clockwise” rotation and Tajima inverted-U may be appropriate. 47 Chondromucosal V-Y advancement is designed to elevate the lateral crus of the lower lateral car- tilage (considering the left nostril; this is seen as a “counterclockwise” rotation). This procedure can be used as a separate step during intermedi- ate correction of severe cleft lip nasal deformity, as originally described by Potter. 48 Alternatively, it is used as an adjunct to traditional open rhinoplasty techniques, at which time the mobilized lateral crus may be reinforced by a lateral crural strut. 12,49,50 ( See Video, Supplemental Digital Content 2 , which displays cleft rhinoplasty for correction of bilateral

Fig. 4. Intermediate correction of the cleft lip nasal deformity. ( Above, left ) Preop- erative unilateral cleft lip nasal deformity. ( Above, center ) Nostril rim incision used to expose the ipsilateral lower lateral cartilage, the medial aspect of the contralateral lower lateral cartilage, and the ipsilateral upper lateral cartilage. Subcutaneous tis- sue may be removed to thin the nasal tip. ( Above, right ) Interdomal sutures reduce the interdomal angle, thus narrowing the nasal tip and increasing tip projection. Intercartilaginous sutures between the cleft-side lower lateral cartilage and the ipsi- lateral upper lateral cartilage resuspend the lower lateral cartilage superiorly and anteriorly. ( Below, left ) The vestibular web is corrected by lenticular excision of skin and tacking suture. ( Below, right ) Completed repositioning of the lower lateral carti- lage and correction of the vestibular web.

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