BritishJcurna! of Phstic Surgery (1957). 28, 262~267
PRIMARY REPAIR OF THE BILATERAL CLEFT LIP NOSE By HAROLDMCCOMB, F.R.C.S., F.R.A.C.S. Princess Margaret Hospital for Children, Perth, Western Australia SIGNIFICANTnasal deformity usually persists after repair of a bilateral cleft lip. The nose tip is depressed and tethered to the upper lip by a short columella. Downward rotation of the alar cartilages causes drooping of the nostril margins (McComb, 1975) with broadening of the nose tip, and the lower edges of the alar cartilages push up oblique ridges under the lateral walls of the nostrils. The alar bases are flared and the perimeters of the nostril margins are flattened obliquely (Fig. I). Subsequent lengthening of the columella restores the position of the nose tip, but if the downward rotation of the alar cartilages is not corrected there is persistent drooping of the nostril margins and oblique ridges remain across the lateral nostril walls. Lengthening of the columella increases the perimeter of the nostril margins which must then be reduced, usually by alar base excisions (Fig. 2). The nasal deformity which is associated with cleft lip is an integral part of the total deformity. The best chance for its correction is at the time of primary lip repair when wide dissection and mobilisation of the soft tissues is performed. Failure to correct the nasal deformity at the time of primary repair leaves the nasal cartilages bound in an abnormal position, tethered by shortage and malalignment of the covering skin and nostril lining. Pre-surgical correction of the displaced segments of the maxillary arch has made possible a fresh approach to complete treatment of the nasal deformity at the time of primary lip repair. The orthodontist commences treatment as soon as possible after birth. Having gained control of the maxillary segments, and corrected the forward displacement of the pre-maxilla as far as possible by preliminary orthopaedic procedures, a plate is fitted which holds the pre-maxilla in position and dispenses with restraining strapping.
FIG. I. FIG. 2.
Typical
nasal deformity with short columella and downward rotation following primary repair of bilateral cleft lip.
After lengthening
of the columella
there is persisting
262
downward rotation
of the alar cartikges of the alar cartilages.
PRIMARY
FIG. 3.
REPAIR
OF THE BILATERAL
The first stage in treatment
FIG. 4.
Lengthening
CLEFT
is lengthening
LIP NOSE
of the columella.
of the columella by a forked flap,
263
264
BRITISH
JOURNAL
OF PLASTIC
SURGERY
The first step in operative treatment is reconstruction of the columella (Fig. 3). This is performed at about 6 weeks of age. Measurement shows that the columella length in infants, from the base of the columella to the level of the intercrural angles of the nostril margins, is 5 mm. This distance remains surprisingly constant until the child is about g months old. The columella is increased to this length by a forked flap (Millard, 1958) which is cut from the sides of the prolabium (Fig. 4). It is essential that the prongs of the flap are quadrilateral in shape, with only triangular tips, so that the tissue is simply advanced up into the columella from the sides of the prolabium without causing any undue narrowing of the prolabium at the base of the columella. If completely triangular flaps are used and advanced into the columella, the prolabium becomes waisted and globular (Fig. 5), and is liable to post-operative oedema. Narrowing across the columellar base then makes the subsequent lip repair tight and difficult. At first it was thought that dissection across the base of the prolabium might damage the blood supply to this tissue when it was incorporated in the lip repair 4 weeks later. However, care has been taken to limit the dissection of the prolabial skin from the premaxilla at the time of lip repair and no problems have been encountered. The mucosal portion of the prolabium is completely dissected free during repair of the lip, and is turned down between the mucosa of the lateral elements.
FIG. 5.
The forked flaps (A) are essentially quadrilateral to avoid narrowing of the base of the prolabium which occurs with triangular flaps (B).
PRIMARY
REPAIR
OF THE
BILATERAL
CLEFT
LIP
NOSE
265
After reconstruction of the columella, the maxillary segments are retained by a sucking plate, sometimes assisted with fresh elastic strapping across the recently healed prolabium. Combined repair of the lip and nose is then performed at 3 months of age. After dissection of the lip flaps, all the skin of the nose is elevated, from the nose tip to the nasion, by sharp pointed scissors introduced through the incisions in the upper buccal sulci. Particular care is taken to elevate the skin from over the alar cartilages so that their downward rotation and displacement can be corrected. The first sutures which are placed in the repair are 2 mattress sutures of s/o silk which are threaded from within the nostrils through the intercrural angles of the alar cartilages and passed subcutaneously to emerge in the region of the nasion. Gentle traction on these sutures corrects the downward rotation of the alar cartilages, elevates the nostril margins and nostril lining, and restores the shape and position of the nose tip (Fig. 6). In this way the nostril floor is repaired with the lining and alar cartilages held in The lip is then repaired. their normal position. Where possible alar-base flaps are used to build up the nostril floors. A triangle of mucosa from the prolabium is incorporated in the centre of the lip. At the completion of the operation the long elevating mattress sutures are tied over small gauze bolsters. The original sutures are sometimes replaced at this stage to provide a better direction of elevation. The alar cartilages are often quite stable alone in their new elevated position. Finally, a through-and-through mattress suture is placed at the level of each supraalar groove fixing together the nasal lining and cover to obliterate the potential dead space in the lateral walls of the nose. It is essential that the maxillary segments are in reasonably good alignment before this plan of treatment can be applied. In this way it has been possible to correct the nasal deformity at the time of repair of bilateral clefts of the lip (Fig. 7). It should
FIG. 6. intercrural
Upward rotation of the alar cartilages by long elevating mattress sutures: C, Repair angles. b, Elevation of the cartilages by gentle traction. alignment.
a, Sutures pick up the with tissues in correct
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FIG.
7.
JOURNAL
OF PLASTIC
Results of treatment
SURGERY
in two patients.
PRIMARY
REPAIR
OF
THE
BILATERAL
CLEFT
LIP
267
NOSE
be emphasised that the effects of this treatment on long-term growth and development of the nose have yet to be judged. REFERENCES MCCOMB, HAROLD (1975). Treatment of the unilateral cleft lip nose. structive Surgery, 55, 596. MILLARD, D. RALPH (1958). Columella lengthening by a forked flap. structive Surgery, 22, 454.
Phtic
and Recon-
Plastic and Recon-