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Cleft Rhinoplasty

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Cleft Rhinoplasty

Cleft lip and palate are the kinds of craniofacial deformities. Cleft lip can be basically of two types: unilateral and bilateral cleft lips. A cleft lip can also be a complete one or an incomplete one. In an incomplete cleft lip, the nose is not involved. In a complete cleft lip either a unilateral or bilateral cleft, the nose is also involved, and a cleft in the nose is seen.

Unilateral cleft nasal deformity characteristic features include

    Disturbance of the muscle ring covering the nasal sill,

  • A splayed cleft-sided medial crus.
  • Malpresentation and hypoplasia of the lower lateral cartilage.
  • A flattened nasal dome.
  • Pathologic tethering of the accessory chain of the lower lateral cartilage to the piriform aperture, and
  • Soft tissue deficiency of the nasal floor.

Characteristic structural deformities on the cleft side include

  • A retrusive maxillary segment,
  • A septum that deviates posteriorly,
  • Abnormal insertions of the lip and cheek musculature to the alar base, and vestibular lining deficiency.
  • Malfunction of the cleft ala external valve culminates from alar base malposition,
  • An imbalanced muscular pull, and
  • Unusual attachment of the cheek muscles to the lateral crus,
  • Tip projection is further compromised by a foreshortened columella, which lies obliquely, with its base directed away from the cleft side.

The characteristic features of a bilateral cleft nose consist

  • A shortened or absent columella, a deficient or absent anterior nasal spine,
  • A flattened nasal tip laterally and posteriorly displaced alar bases with accessory chain tethering to the piriform,
  • Splayed nasal alae.
  • Retrusive maxillae, and
  • The recession of the medial crural footplates.
  • Often a protrusive premaxilla accentuates the relative flattening of the nasal tip and shortened columella.

Timings

    For unilateral cleft lip deformity, the timeline is as follows

  • Presurgical orthopedics (nasoalveolar molding) from 0 to 3 months of age.
  • Primary cleft nasal repair at the time of cheiloplasty (at approximately 3 months of age).
  • Secondary cleft rhinoplasty at the time of skeletal maturity (at approximately 14 to 16 years of age for girls and 16 to 18 years of age for boys).

The surgical goals of the primary cleft nasal repair include the following

  • Recreation of the nasal sill.
  • Release and repositioning of the affected ala.
  • Augmentation of the nasal lining deficiency on the cleft side.
  • A three-point release of the lower lateral cartilage.
  • Balancing of the nasal domes.

The timeline for bilateral clefts is similar, with the exception that the primary nasal repair is divided into two stages

  • At the time of the primary cheiloplasty, the nasal repair is limited to alar repositioning and lateral nasal lining augmentation.
  • At approximately 18 months of age, the columella is lengthened (as modified from Cronin and Upton), and the nasal domes are unified.
  • We delay the definitive adult/adolescent rhinoplasty until the postpubertal growth spurt in the bony dorsum and the anterior septum is complete. This occurs roughly after the age of 14 years in females and 16 years in males. We avoid the routine practice of repeated rhinoplasty procedures throughout the patient’ childhood because the ant scarring can compromise the final long-term.

DEFINITIVE ADOLESCENT/ADULT RHINOPLASTY

    Although successful completion of the surgical objectives of a primary cleft rhinoplasty may offer excellent outcomes, however, extrinsic (scar, deformation) and intrinsic (hypoplasia) factors may lead to progressive adverse changes to the cleft nasal deformity during growth. In adolescents and adults, recurrent alar and tip deformities are common and unilateral airway obstruction from septal deviation can be seen. Most patients with complete cleft lip and nasal deformity will likely benefit from definitive rhinoplasty as an adolescent/adult. The surgical approach can be tailored based upon the degree of residual deformity and whether an adequate primary repair was performed. Patients can thus be segregated into two categories, type I and type II.

Type I – Minimal to moderate deformity

Type II – Moderate to severe deformity

    For type I patients, the common residual deformity includes an under-projected tip, septal deviation (often with airway obstruction), cleft-side lower lateral cartilage weakness (and external nasal valve malfunction), dorsal deformity, and deficient piriform aperture (maxillary deficiency). The most common maneuvers include columellar strut grafts or extended spreader grafts for increased tip projection, alar contour grafts, functional septoplasty, and augmentation of the piriform aperture.

    For type II patients, standard rhinoplasty maneuvers are often insufficient to overcome cicatricial forces or tissue deficiency, especially lining. Rib cartilage grafts are used in greater frequency for donor cartilage because of its increased rigidity. The most common maneuvers for these patients include columellar strut grafts (rib), lateral crural strut grafts, extensive secondary release of the lateral crus with repositioning, only or tip grafts, and correction of soft tissue deficiencies (composite cartilage or mucosal grafts).

FAQ's

Frequently Asked Questions

We like to assist our clients with a knowledgeable and in-depth collective approach to answer for all your queries and fears with our FAQ mega-base.

Cleft nose deformity is a congenital and developmental deformity caused by the unequal pull of muscles of expression around the opening of the mouth. Harelip or cleft lip is an abnormal birth condition where the upper lip is deformed from birth. This is usually associated with a deformity of the nose called as a cleft lip nose deformity.

Open rhinoplasty which involves exposing structures of the nose completely is the preferred method. The reason being that cleft lip causes a deformity in the nose tip, septum, bones as well as cartilages. Many a time, the lip has also to be recorrected because of the widening of the scar.

The cost of cleft rhinoplasty depends on the surgical plan and the complexity of the procedure. Since these procedures are customized, costs can be provided only after a treatment plan is made.

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