Rhinoplasty in patients following cleft deformities is a challenging task requiring an experienced surgeon to restore a normal appearance. Cleft facial deformity may involve the following characteristics: nose deformity, skeletal deformities, dental deformities, and lip deformities.
The ideal timing for rhinoplasty in those patients depends on age, severity of the deformity, understanding of the surgery, and willingness for the surgery.
The open rhinoplasty approach is preferred especially in cleft patients for better exposure, foundation and support reconstruction. We prefer dividing the surgical approach into three stages. First stage: nose foundation. Second stage: structural correction and contouring. Third Stage: aesthetical improvement. The most common complication in cleft rhinoplasty is a residual asymmetry of the nose.
37 Rhinoplasty: Secondary Cleft Nasal Deformity
Rhinoplasty in patients following cleft deformities is a challenging task requiring an experienced cleft team to restore a normal appearance. It may be needed due to cleft nose anatomical deformity; growth-related or iatrogenic deformities after primary correction.
Studies have shown that in cleft patients the medial nasal process remains centralized and fails to fuse with the maxillary process. Furthermore, there is discontinuation of the orbicularis oris which affects the aberrant clinical features of the cleft nose. 1 – 3
The abnormal insertion of orbicularis oris into the columellar base creates the characteristic view of deformed columella and deviated caudal septum. The insertion of orbicularis into the subalar cartilage results in flattening of the lower lateral cartilage.
Cleft facial deformity may involve the following characteristics:
Nose deformity: Wide nose, broad and depressed tip, short columella.
On the cleft side: Wider and retro-displaced nostril, posteriorly and laterally displaced nostril, short medial crus, long lateral crus, deviation of the septum toward the cleft side and inferior turbinate hypertrophy on the non-cleft side.
Skeletal deformities: Midface retrusion, zygomatic hypoplasia, mandibular pseudo-prognathism, pyriform asymmetry, nasal pyramid deviation.
Dental deformities: Class III malocclusion, maxillary arch constriction, cleft dental gaps, alveolar fistulae.
Lip deformities: Short, deficient red or white lip, retracted vermillion, scarred or deviated vermillion.
An example of nasal deformity is shown in ▶ Fig. 37.1 and ▶ Fig. 37.2.
37.2 Anatomy of the Nose
The main anatomical structures of the nose are illustrated in ▶ Fig. 37.3 and ▶ Fig. 37.4.
The structural nose component can be divided into three parts:
The envelope composed of the outer skin and soft tissue: thinner and mobile skin in the upper two-thirds.
Bony and cartilaginous framework.
Inner mucosal lining.
Blood supply of the nose is very rich. It is composed of mainly two arteries:
Ophthalmic artery: Anterior ethmoidal, dorsal nasal, external nasal arteries—all these arteries supply mainly the proximal part of the nose.
Facial artery: Superior labial and angular arteries supply mainly the nasal tip. 4
37.3 Preoperative Assessment
Preoperative evaluation should include complete history. The surgeon should be familiar with previous operations, and follow standard and systemic nasofacial analysis. 5
The child’s capability of understanding and accepting the surgical procedure and postoperative care is a mandatory condition for proceeding.
There are few basic principles that always guide us during secondary rhinoplasty cases:
Aesthetics subunits (▶ Fig. 37.4).
Always look on the whole nose not just on a specific point.
Use cartilage grafts, overdo the support, avoid local flaps for columella, and avoid tissue excision except in alar bases.