April 2020 HSC Section 4 - Plastic and Reconstructive Problems

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

at the time of cleft labial repair and other possible intermediate procedures, cleft rhinoplasty is a sec- ondary (or tertiary) procedure. After skeletal maturity (typically 15 years or older for women and 17 years or older for men), cleft rhinoplasty uses any of the methods above in combination with standard aesthetic techniques. Of course, the specific manipulations used are chosen to fit the needs of a particular patient. Gen- erally, mature cleft rhinoplasty includes manipula- tion of the bony pyramid and nasal septum and commonly incorporates cartilage grafts. In gen- eral, we recommend an open approach at this age and the following maneuvers (as appropriate) to address the cleft lip nasal deformity: 1. Nasal airway: a. Inferior turbinate reduction. b. Septal resection. c. Spreader graft (or spreader flap). 2. Upper two-thirds: a. Component reduction of nasal dorsum. b. Osteotomy and infracture of nasal bones. 3. Lower third: a. Centralization of the anterocaudal septum. b. Columellar strut. c. Chondromucosal V-Y advancement of lower lateral cartilage with lateral crural strut (if necessary). d. Cephalic trim with “auto-batten” graft. e. Tip-defining interdomal and intradomal sutures. h. Intercartilaginous sutures to elevate and secure lower lateral cartilage to upper lateral cartilage. i. Alar base repositioning. Mature cleft rhinoplasty is a tremendous topic in its own right, and it is not possible to thoroughly describe each of thesemaneuvers in this text. Many of these techniques are depicted in Video 2 ( see Video, Supplemental Digital Content 2 , http:// links.lww.com/PRS/C223 ), as applied to correction of bilateral cleft lip nasal deformity. The reader is referred to many of the excellent resources avail- able for rhinoplasty and cleft rhinoplasty. 4,5,12,53–56 f. Tip onlay grafts. g. Alar rim grafts.

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/C223 .) Although the Potter technique has also been effectively combined with the Tajima inverted-U 51 as a method of addressing excessive skin overhang at the nostril rim, caution is advised in considering any cutaneous excision at the rim, especially near the soft triangles. 52 Correction of the Vestibular Web An alternative to chondromucosal advance- ment is reelevation and fixation of the lower lat- eral cartilage as described for primary nasal repair by Patel and Mulliken. 14 This strategy is often combined with correction of the vestibular web (Fig. 4). The web forms as a result of medial dis- placement of the lower lateral cartilage that is teth- ered by the piriform ligament; it often becomes more prominent during primary cleft nasolabial repair. A lenticular excision of vestibular skin is made at the mucocutaneous junction overlying the crest of the web, and the tail of the lateral crus is released to allow the lower lateral cartilage to move upward. The lower lateral cartilage can be resecured to the ipsilateral upper lateral cartilage through a rim incision. The edges of the vestibu- lar wound are tacked down to the periosteum of the piriform aperture to open the internal naris. Cleft Rhinoplasty in Adulthood Mature cleft rhinoplasty is arguably the most challenging form of nasal correction. As many patients have undergone synchronous correction of the cleft lip nasal deformity (“tip rhinoplasty”) Video2. Supplemental Digital Content 2,whichdisplays cleft rhino- plasty for correction of bilateral cleft lip nasal deformity, is available in the“RelatedVideos”section of the full-text article on PRSJournal. comor, for Ovid users, at http://links.lww.com/PRS/C223 .

Complications The most common “complication” in cleft rhinoplasty is persistent asymmetry and

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