Nasal Entrance Correction in Unilateral Cleft Lip Repair Alexander St F. Metz, MD, DDS,* Roman Pf€ ortner, MD,y Claus Schmeling, MD, PhD,z Gunnar Rieger, MD, PhD,x and Christopher Mohr, MD, DDS, PhDk Purpose:
Correction of cleft nose deformity in patients with unilateral cleft lip is challenging and involves primarily the nasal cartilage and the nasal entrance. No consensus on the most effective surgical technique has been reached. This article describes a surgical procedure for nasal entrance correction.
Patients and Methods:
In this retrospective study, 30 adult patients underwent secondary nasal entrance corrections. According to a modified Van der Meulen technique, a nasal alar rim flap with anatomic repositioning of the alar cartilage was applied. Symmetry and esthetic results were evaluated by semiquantitative photographic analysis.
Results:
In all patients, the nasal tip was narrowed considerably, and a lifting of the nasal tip was achieved. Columellar elongation averaged 40%, and the form of the nostril was changed from horizontally oval to longitudinally oval.
Conclusion:
The described technique is well suited for a sustainable correction of complex cleftinduced deformities without visible scars in adult patients. Ó 2015 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:2038.e1-2038.e7, 2015
Even after cleft lip and palate surgery, the ‘‘cleft nose,’’ with an unfavorable shape, cannot always be avoided. The nasal cartilage and the nasal entrance are mainly involved in this deformity. Cleft nose deformity consists of a flattening of the nasal tip with a tendency toward a nasal bi-tip. The nasal entrance appears to be transversely oval with a shortened columella and a depressed alar rim. There is no standard procedure for an operative nose correction.1,2 Furthermore, the optimal timing (before vs after the patient attains adulthood) remains controversial.3-5
mity (Figs 1, 2): on the left side in 17 cases and on the right side in 13 cases. Six months previously, 23 patients had undergone a nasal septoplasty. The median follow-up period was 28 months (mean, 47.6 months; range, 6 to 214 months). SURGICAL TECHNIQUE
Secondary nasal entry corrections were performed in 30 adult patients (20 men, 10 women; average age, 17 yr). The same operative procedure was applied to all patients. All patients had unilateral cleft defor-
Initially, a medially based triangular flap is marked in the area of the alar rim. This surgical step is critical, because the width of the base of the triangular flap determines the extent of the columellar elongation. Next, the triangular flap is prepared without involving the underlying alar cartilage (Figs 3, 4). After a hemi-transfixion incision is made and the mucoperichondrium is prepared, the medial crus of the greater alar cartilage is completely freed from the surrounding tissue (Fig 4).
Received from the Kliniken Essen-Mitte, Evang; Huyssens-Stiftung/
Essen, Henricistr 92, D-45136 Essen, Germany; e-mail: alexander.
Knappschaft GmbH; Department of Oral and Craniomaxillofacial
[email protected]
Surgery, University Hospital of Essen, Essen, Germany.
Received January 9 2015
Patients and Methods
*Consultant. yConsultant.
Ó 2015 Published by Elsevier Inc on behalf of the American Association of Oral
zConsultant.
and Maxillofacial Surgeons
xConsultant.
0278-2391/15/00902-7
Accepted June 19 2015
kDepartment Head.
http://dx.doi.org/10.1016/j.joms.2015.06.167
Address correspondence and reprint requests to Dr Metz: Department of Oral and Cranio-Maxillofacial Surgery, University Hospital of
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METZ ET AL
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FIGURE 4. Mobilization of the medial crus of the greater alar cartilage. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015. FIGURE 1. Cleft nose deformity, en face view. Flattening of the nasal tip with a tendency toward a nasal bi-tip and a depressed alar rim. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 5. Access to the medial crus of the opposite side in severe deformities. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015. FIGURE 2. Cleft nose deformity, view from below. Transverse oval nasal entrance with a shortened columella. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 3. Marking of the medially based triangular flap.
FIGURE 6. Fixation of the elevated alar cartilage by mattress sutures.
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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NASAL ENTRANCE CORRECTION IN CLEFT LIP REPAIR
FIGURE 7. A, Marking of the columellar cutback. B, The medially based triangular flap is placed into the columellar cutback. C, The triangular flap has been placed into the columellar cutback; sutures in situ. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 8. Photographic analysis of the nostrils for determination of the length-to-width ratio and the percentage of columellar length. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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The flap, which is placed in the columella and the nasal septum, can be shaped through transfixion sutures, which are retained for at least 14 days. All other sutures are removed after 7 days. Symmetry and esthetic results were examined by semiquantitative photographic analysis, and this examination included determination of the length-to-width ratio of the nostrils, the percentage of the length of the columella, and the vertical position of the alar rims (Figs 8, 9). Statistical analyses included t tests for quantitative variables. P values less than .05 were considered statistically significant. All analyses were performed with IBM SPSS 21.0 (IBM Corp, Armonk, NY). This retrospective study was approved by the institutional review board of the University Hospital of Essen (Essen, Germany). FIGURE 9. Photographic analysis, en face view. Determination of the vertical position of the alar rims. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
For subsequent repositioning of the cartilage, mobilization must be performed beyond the nasal tip cartilage, and the dorsal nasal envelope must be widely undermined. For severe deformity, the surgeon has access to the medial crus of the opposite side through the already performed hemi-transfixion incision (Fig 5), which can easily be extended to a transfixion incision. Then, the repositioning can be carried out by elevating the alar cartilage to the appropriate anatomic level. Next, the alar cartilages are fixed in the correct position with mattress sutures, and the nasal tips are merged into one by interdomal mattress sutures. During this procedure, the lateral crus remains attached to the alar rim (Fig 6). A columellar cutback is performed directly below the base of the triangular flap (Fig 7A), so that the triangular flap can be placed into the columella and can contribute to its elongation (Fig 7B, C).
Results The triangular flaps of all patients healed without complications. The scars at the edge of the alar rim were no longer visible after a certain time (Fig 10). The nasal tip was narrowed considerably, and a lifting of the nasal tip was achieved (Figs 11, 12). Longterm follow-up showed sustainable results (Fig 13). With regard to the length of the nasal entrance, the average preoperative length deficit on the cleft side amounted to 25%. A complete correction of the deficit was achieved by this surgery. On average, even an overcorrection of 10% (P < .001) was reached. Thus, the elongation of the columella on the cleft side averaged 40% (Fig 14). The preoperative length-to-width ratio of the nasal entrance on the side of the cleft was 0.75. This ratio changed to 1.15 (P < .001) postoperatively, indicating that through this surgery, the form of the nostril was converted from horizontally oval to longitudinally oval (Fig 15). On the nonaffected side, the length-to-width ratio changed from 1.05 to 1.15 (P < .001). Obviously, an
FIGURE 10. Pre- and postoperative morphologic features of the nostrils. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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NASAL ENTRANCE CORRECTION IN CLEFT LIP REPAIR
FIGURE 11. Results after 1 year, en face view. The nasal tip has narrowed and the depressed alar rim has been elevated. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 12. Results after 1 year. The nasal tip has narrowed and the depressed alar rim has been elevated. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 13. Stable result 3.5 years postoperatively. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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FIGURE 14. Pre- and postoperative length of the nasal entrance (cleft side).
FIGURE 16. Pre- and postoperative length-to-width ratio of the nasal entrance (healthy side).
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
average 10% elongation and narrowing of the nostril were achieved on the unaffected side (Fig 16). In all patients, the alar rim was elevated to the correct height compared with the healthy side.
Discussion
FIGURE 15. Pre- and postoperative length-to-width ratio of the nasal entrance (cleft side). Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
In cases of a complex cleft nose deformity, it is difficult to correct all deformities in a single surgery. The original technique by Van der Meulen6 was specifically described for columellar elongations in patients with bilateral cleft lip. This technique helped avoid the undesirable scars that can appear after lengthening of the columella by the classic forked flap technique as described by Millard.4 In the present technique, in contrast to the original Van der Meulen technique, the medial crus of the major alar cartilage is not dissected, but is completely freed by a hemitransfixion incision. After elevation of the entire medial crus, the tip cartilages are merged by mattress sutures. For severe deformity, correction of the contralateral alar cartilage also is possible by a transfixion incision. The nasal cartilage, which serves as a scaffold for the soft tissue, is repositioned and, therefore, the results appear sustainable. A disadvantage of this technique is that the achievable increase in columellar length is limited owing to the extent of excess skin at the edge of the alar rim. Another disadvantage is that no correction of the broadened base of the alae of the nose can be achieved through this surgery.1 Also, when viewed from below, the affected nostril appears slightly larger than the nostril on the healthy side, which also might result from a bony deformity of the nasal floor. In cases of mutilating deformity, a correction of the nose is carried out before pediatric patients
2038.e7 enroll in school. In all other cases, surgery should be performed after the conclusion of the growth spurt to avoid unwanted scarring of the surrounding soft tissue, and then the remaining deformities can be corrected surgically. Considerable improvement in symmetry and esthetics was achieved in all patients. The present technique is well suited for a sustainable correction of complex cleft-induced deformities in adult patients, especially in patients with depressed alar rims. Compared with an open rhinoplasty, there is no visible scarring.
NASAL ENTRANCE CORRECTION IN CLEFT LIP REPAIR
References 1. Mohr C: Outcome of Van der Meulen columellar extension in bilateral lip-jaw-palate clefts. Mund Kiefer Gesichtschir 1:284, 1992 2. Wang TD: Secondary rhinoplasty in unilateral cleft nasal deformity. Clin Plast Surg 37:383, 2010 3. Cronin TD, Upton J: Lengthening of the short columella associated with bilateral cleft lip. Ann Plast Surg 1:75, 1978 4. Millard DR Jr: Results of surgical lengthening of the short nose in the bilateral cleft lip patient. Plast Reconstr Surg 62:438, 1978 5. Randall P: History of cleft lip nasal repair. Cleft Palate Craniofac J 29:527, 1992 6. Van der Meulen JC: Columellar elongation in bilateral cleft lip repair: Early results. Plast Reconstr Surg 89:1060, 1992
Correction of cleft nose deformity in patients with unilateral cleft lip is challenging and involves primarily the nasal cartilage and the nasal entrance. No consensus on the most effective surgical technique has been reached. This article describes a surgical procedure for nasal entrance correction.
Patients and Methods:
In this retrospective study, 30 adult patients underwent secondary nasal entrance corrections. According to a modified Van der Meulen technique, a nasal alar rim flap with anatomic repositioning of the alar cartilage was applied. Symmetry and esthetic results were evaluated by semiquantitative photographic analysis.
Results:
In all patients, the nasal tip was narrowed considerably, and a lifting of the nasal tip was achieved. Columellar elongation averaged 40%, and the form of the nostril was changed from horizontally oval to longitudinally oval.
Conclusion:
The described technique is well suited for a sustainable correction of complex cleftinduced deformities without visible scars in adult patients. Ó 2015 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:2038.e1-2038.e7, 2015
Even after cleft lip and palate surgery, the ‘‘cleft nose,’’ with an unfavorable shape, cannot always be avoided. The nasal cartilage and the nasal entrance are mainly involved in this deformity. Cleft nose deformity consists of a flattening of the nasal tip with a tendency toward a nasal bi-tip. The nasal entrance appears to be transversely oval with a shortened columella and a depressed alar rim. There is no standard procedure for an operative nose correction.1,2 Furthermore, the optimal timing (before vs after the patient attains adulthood) remains controversial.3-5
mity (Figs 1, 2): on the left side in 17 cases and on the right side in 13 cases. Six months previously, 23 patients had undergone a nasal septoplasty. The median follow-up period was 28 months (mean, 47.6 months; range, 6 to 214 months). SURGICAL TECHNIQUE
Secondary nasal entry corrections were performed in 30 adult patients (20 men, 10 women; average age, 17 yr). The same operative procedure was applied to all patients. All patients had unilateral cleft defor-
Initially, a medially based triangular flap is marked in the area of the alar rim. This surgical step is critical, because the width of the base of the triangular flap determines the extent of the columellar elongation. Next, the triangular flap is prepared without involving the underlying alar cartilage (Figs 3, 4). After a hemi-transfixion incision is made and the mucoperichondrium is prepared, the medial crus of the greater alar cartilage is completely freed from the surrounding tissue (Fig 4).
Received from the Kliniken Essen-Mitte, Evang; Huyssens-Stiftung/
Essen, Henricistr 92, D-45136 Essen, Germany; e-mail: alexander.
Knappschaft GmbH; Department of Oral and Craniomaxillofacial
[email protected]
Surgery, University Hospital of Essen, Essen, Germany.
Received January 9 2015
Patients and Methods
*Consultant. yConsultant.
Ó 2015 Published by Elsevier Inc on behalf of the American Association of Oral
zConsultant.
and Maxillofacial Surgeons
xConsultant.
0278-2391/15/00902-7
Accepted June 19 2015
kDepartment Head.
http://dx.doi.org/10.1016/j.joms.2015.06.167
Address correspondence and reprint requests to Dr Metz: Department of Oral and Cranio-Maxillofacial Surgery, University Hospital of
2038.e1
METZ ET AL
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FIGURE 4. Mobilization of the medial crus of the greater alar cartilage. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015. FIGURE 1. Cleft nose deformity, en face view. Flattening of the nasal tip with a tendency toward a nasal bi-tip and a depressed alar rim. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 5. Access to the medial crus of the opposite side in severe deformities. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015. FIGURE 2. Cleft nose deformity, view from below. Transverse oval nasal entrance with a shortened columella. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 3. Marking of the medially based triangular flap.
FIGURE 6. Fixation of the elevated alar cartilage by mattress sutures.
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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NASAL ENTRANCE CORRECTION IN CLEFT LIP REPAIR
FIGURE 7. A, Marking of the columellar cutback. B, The medially based triangular flap is placed into the columellar cutback. C, The triangular flap has been placed into the columellar cutback; sutures in situ. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 8. Photographic analysis of the nostrils for determination of the length-to-width ratio and the percentage of columellar length. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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The flap, which is placed in the columella and the nasal septum, can be shaped through transfixion sutures, which are retained for at least 14 days. All other sutures are removed after 7 days. Symmetry and esthetic results were examined by semiquantitative photographic analysis, and this examination included determination of the length-to-width ratio of the nostrils, the percentage of the length of the columella, and the vertical position of the alar rims (Figs 8, 9). Statistical analyses included t tests for quantitative variables. P values less than .05 were considered statistically significant. All analyses were performed with IBM SPSS 21.0 (IBM Corp, Armonk, NY). This retrospective study was approved by the institutional review board of the University Hospital of Essen (Essen, Germany). FIGURE 9. Photographic analysis, en face view. Determination of the vertical position of the alar rims. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
For subsequent repositioning of the cartilage, mobilization must be performed beyond the nasal tip cartilage, and the dorsal nasal envelope must be widely undermined. For severe deformity, the surgeon has access to the medial crus of the opposite side through the already performed hemi-transfixion incision (Fig 5), which can easily be extended to a transfixion incision. Then, the repositioning can be carried out by elevating the alar cartilage to the appropriate anatomic level. Next, the alar cartilages are fixed in the correct position with mattress sutures, and the nasal tips are merged into one by interdomal mattress sutures. During this procedure, the lateral crus remains attached to the alar rim (Fig 6). A columellar cutback is performed directly below the base of the triangular flap (Fig 7A), so that the triangular flap can be placed into the columella and can contribute to its elongation (Fig 7B, C).
Results The triangular flaps of all patients healed without complications. The scars at the edge of the alar rim were no longer visible after a certain time (Fig 10). The nasal tip was narrowed considerably, and a lifting of the nasal tip was achieved (Figs 11, 12). Longterm follow-up showed sustainable results (Fig 13). With regard to the length of the nasal entrance, the average preoperative length deficit on the cleft side amounted to 25%. A complete correction of the deficit was achieved by this surgery. On average, even an overcorrection of 10% (P < .001) was reached. Thus, the elongation of the columella on the cleft side averaged 40% (Fig 14). The preoperative length-to-width ratio of the nasal entrance on the side of the cleft was 0.75. This ratio changed to 1.15 (P < .001) postoperatively, indicating that through this surgery, the form of the nostril was converted from horizontally oval to longitudinally oval (Fig 15). On the nonaffected side, the length-to-width ratio changed from 1.05 to 1.15 (P < .001). Obviously, an
FIGURE 10. Pre- and postoperative morphologic features of the nostrils. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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FIGURE 11. Results after 1 year, en face view. The nasal tip has narrowed and the depressed alar rim has been elevated. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 12. Results after 1 year. The nasal tip has narrowed and the depressed alar rim has been elevated. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
FIGURE 13. Stable result 3.5 years postoperatively. Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
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FIGURE 14. Pre- and postoperative length of the nasal entrance (cleft side).
FIGURE 16. Pre- and postoperative length-to-width ratio of the nasal entrance (healthy side).
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
average 10% elongation and narrowing of the nostril were achieved on the unaffected side (Fig 16). In all patients, the alar rim was elevated to the correct height compared with the healthy side.
Discussion
FIGURE 15. Pre- and postoperative length-to-width ratio of the nasal entrance (cleft side). Metz et al. Nasal Entrance Correction in Cleft Lip Repair. J Oral Maxillofac Surg 2015.
In cases of a complex cleft nose deformity, it is difficult to correct all deformities in a single surgery. The original technique by Van der Meulen6 was specifically described for columellar elongations in patients with bilateral cleft lip. This technique helped avoid the undesirable scars that can appear after lengthening of the columella by the classic forked flap technique as described by Millard.4 In the present technique, in contrast to the original Van der Meulen technique, the medial crus of the major alar cartilage is not dissected, but is completely freed by a hemitransfixion incision. After elevation of the entire medial crus, the tip cartilages are merged by mattress sutures. For severe deformity, correction of the contralateral alar cartilage also is possible by a transfixion incision. The nasal cartilage, which serves as a scaffold for the soft tissue, is repositioned and, therefore, the results appear sustainable. A disadvantage of this technique is that the achievable increase in columellar length is limited owing to the extent of excess skin at the edge of the alar rim. Another disadvantage is that no correction of the broadened base of the alae of the nose can be achieved through this surgery.1 Also, when viewed from below, the affected nostril appears slightly larger than the nostril on the healthy side, which also might result from a bony deformity of the nasal floor. In cases of mutilating deformity, a correction of the nose is carried out before pediatric patients
2038.e7 enroll in school. In all other cases, surgery should be performed after the conclusion of the growth spurt to avoid unwanted scarring of the surrounding soft tissue, and then the remaining deformities can be corrected surgically. Considerable improvement in symmetry and esthetics was achieved in all patients. The present technique is well suited for a sustainable correction of complex cleft-induced deformities in adult patients, especially in patients with depressed alar rims. Compared with an open rhinoplasty, there is no visible scarring.
NASAL ENTRANCE CORRECTION IN CLEFT LIP REPAIR
References 1. Mohr C: Outcome of Van der Meulen columellar extension in bilateral lip-jaw-palate clefts. Mund Kiefer Gesichtschir 1:284, 1992 2. Wang TD: Secondary rhinoplasty in unilateral cleft nasal deformity. Clin Plast Surg 37:383, 2010 3. Cronin TD, Upton J: Lengthening of the short columella associated with bilateral cleft lip. Ann Plast Surg 1:75, 1978 4. Millard DR Jr: Results of surgical lengthening of the short nose in the bilateral cleft lip patient. Plast Reconstr Surg 62:438, 1978 5. Randall P: History of cleft lip nasal repair. Cleft Palate Craniofac J 29:527, 1992 6. Van der Meulen JC: Columellar elongation in bilateral cleft lip repair: Early results. Plast Reconstr Surg 89:1060, 1992
