CME

Cleft Rhinoplasty
Allen L. Van Beek, M.D., Agnieszka S. Hatfield, M.D., and Ellie Schnepf, B.S.N.
Edina and Minneapolis, Minn.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe features of the unilateral
and bilateral cleft nasal deformities and associated growth changes. 2. Assess the extent of cleft nasal deformity. 3.
Recognize current trends and principles of cleft nasal reconstruction. 4. Recognize differences in primary versus
secondary cleft nasal correction.

Reconstruction of the cleft nasal deformity can often FEATURES OF UNILATERAL AND BILATERAL CLEFT
pose a significant challenge to a rhinoplasty surgeon. Prin- NASAL DEFORMITIES
cipal features of unilateral and bilateral cleft nasal defor-
mities and their changes with growth are discussed. This Infants presenting with a unilateral cleft lip
article reviews current trends in cleft nasal rhinoplasty (Figs. 1 and 2) have inferior and wide lateral
associated with early and late intervention. Finally, the displacement of the lower lateral cartilages.
authors review their own data on the applications of what
are deemed current trends in reconstructive rhinoplasty The nasal vestibule volume is increased on the
associated with cleft deformities. (Plast. Reconstr. Surg. cleft side. The often-shortened columella is dis-
114: 57e, 2004.) placed toward the cleft. The associated hori-
zontal and vertical displacement of the nostril’s
lower lateral cartilages makes consideration of
The three-dimensional combination of rigid the lower lateral cartilages an integral part of
skeletal, firm cartilaginous, and plastic skin primary lip repair. However, controversy exists
cover makes the nose a unique part of one’s regarding direct lower lateral cartilage manip-
facial appearance. The nose has become a fre- ulations during primary lip repair in infants.
quently adjusted, reconstructed, enhanced,
and even pierced part of the human anatomy.
Volumes have been scribed about the compli-
cated anatomy and how it can be adjusted to
enhance appearance or function. A nose al-
tered radically by a congenital defect has a
major impact on both appearance and func-
tion. Rhinoplasty is a challenging surgical pro-
cedure, and alteration of the three-dimen-
sional aspects of the nose created by congenital
changes will challenge the surgeon’s skill and
judgment.
Features of unilateral and bilateral cleft na-
sal deformities, growth changes, and assess-
ment methods are discussed. We review cur-
rent trends in cleft nasal rhinoplasty associated
with both early and secondary intervention.
Our data on the applications of what are FIG. 1. Displacement of the lower lateral cartilage and loss
deemed current trends in reconstructive rhino- of skeletal foundation are the key features of the unilateral
plasty of cleft deformities are reviewed. cleft deformity.

Received for publication February 3, 2003; revised May 15, 2003.

DOI: 10.1097/01.PRS.0000133424.05413.BF
57e
58e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

FIG. 2. Abnormalities associated with bilateral cleft nasal deformity before

the authors’ surgical intervention when the patient was 6 years old and after
further correction at age 14. The Abbé flap and tip reconstruction were
performed in the interval.

FIG. 3. Preoperative lateral views of the same patient shown in Figure 2.

The bilateral cleft presents with even more metrical columellar alar angles. From the lateral
distortion of the nose. A short or near-absent perspective (Fig. 6), one can see altered columel-
columella, widely displaced lower lateral carti- lar show, poor tip projection, rhinion promi-
lages, a protuberant or even horizontal premax- nence, an obtuse nasal labial angle, and short
illa, and collapse of the maxillary arch behind the nasal length. From the caudal perspective (Fig.
premaxilla are all noted in Figures 3 and 4. 7), one can see a lateral alar web, asymmetrical
lower lateral cartilages and nostrils, columellar
EFFECTS OF GROWTH ON CLEFT FEATURES scarring, a displaced caudal septum, abnormal
Characteristic alterations of appearance and hair location, and blunt angulation of the inter-
anatomy associated with cleft nasal deformity af- mediate crus lower lateral cartilage.
ter facial growth are shown from various perspec- Columellar show may be increased or de-
tives. From the frontal perspective (Fig. 5), one creased from the usual 3 to 5 mm noted in
can see a twisted nose, a wide nasal base, flared adolescents and adults. A decrease occurs
nostrils, oblique tip-defining points, and asym- when the lower lateral cartilage is flared and
Vol. 114, No. 4 / CLEFT RHINOPLASTY 59e

FIG. 4. Inferior view of a 6-year-old patient with lower lateral

cartilage collapse associated with cleft nasal deformity.

FIG. 6. Diagram for documenting abnormalities, sketch

planning, and educating patients and parents.

results in lack of support for tip projection

against the shortened columellar skin envelope
and lateral displacement.
Lack of midline alignment of structures is
common in unilateral and bilateral clefting.
The central incisors, philtrum, and columella
may not be aligned in the midline and may not
be able to be aligned because of the conse-
quences of the maxillary defect and lip repair
qualities. This makes it difficult to put the fa-
cial elements into the usual spatial alignment
that the mind is accustomed to visualizing. Add
to this dilemma a lip repair that does not have
FIG. 5. Inferior view of abnormalities associated with cleft horizontal alignment of Cupid’s bow peaks and
nasal deformity in a 6-year-old patient. LLC, lower lateral the task of formulating a rhinoplasty plan be-
cartilage. comes daunting.
displaced inferiorly. An increase may occur be- DEFORMITY ASSESSMENT
cause of a buckle or notch effect on the lower
lateral cartilage from primary rhinoplasty ad- Determining the most effective surgical plan
justment of the nose or if lower lateral cartilage for any rhinoplasty must begin with an assess-
is not modified during the acute repair. It may ment of the internal nasal structures and their
even persist despite further attempts at correc- changes (Fig. 9). The following are important
tion (Fig. 8). issues to be answered during the examination:
Tip projection is reduced because the lower •Is the septum attached or displaced off the
lateral cartilage displacement on the cleft side crest of the vomer?
60e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

FIG. 9. Appearance of unilateral cleft lip deformity.

•Has a pharyngeal flap or sphincteroplasty

been performed and does it impede airflow
FIG. 7. Measurements of the nasal dimensions help with through the nose?
perceptions and planning.
•Is nasal and sinus mucous drainage
adequate?
•Is breathing at rest oral, nasal, or both?
What occurs when exercising? Is sleep apnea a
problem?1– 4
Assessment of the external appearance by
measurements and observation is important
when constructing a surgical plan. To assist in
surgical planning, measurements are recorded
(Fig. 10) and then repeated postoperatively to
assess progress, growth, and results. These nu-
merical data are used to plan surgery and pro-
mote thoroughness. There is an art to studying
facial characteristics and understanding the
three-dimensional relationships that are nor-
FIG. 8. When planning correction, perceive where the tip- mal and attractive. Altering those relationships
defining points would be located on the displaced lower while attempting to improve form or function
lateral cartilage. This is the key to accurate suture placement is a complex combination of the art and sci-
in early repairs.
ence of plastic surgery.5
Actual measurements help begin the process
•Is the caudal septum attached to the nasal of planning. How far does the lower lateral car-
spine or is it deflected into the nostril tilage have to be positioned to be similar to the
aperture? contralateral side both across the base and from
•Is the middle portion of the cartilaginous the frontal perspective? How deep is the concav-
quadrilateral plate deformed? ity in the sill because of muscle paucity or skeletal
•What is the status of the inferior turbinates? deficiency? If the septum is deflected, where
Will they obstruct airflow if nasal volume should it be positioned and anchored? Are the
decreases? medial crura of the lower lateral cartilage curved
•Is the floor of the nasal vestibule obstructed into the naris aperture and are they symmetrical?
with exophytic scar from palate closure or The measurements and answers that are ob-
bone grafting? tained will serve as a guide in estimating how
Vol. 114, No. 4 / CLEFT RHINOPLASTY 61e

FIG. 12. Humby provided support for the displaced lower

lateral cartilage by using the cephalic “excess” of the con-
tralateral lower lateral cartilage for support.

FIG. 10. Skeletal and muscle deficits, a protruding max-

illa, and a short columella are major abnormalities associated
with the bilateral cleft deformity.

much length and tip support can be created by

plicating lower lateral cartilages to each other or
to a columellar strut graft (Fig. 11).

EVOLVING CONSENSUS
Many techniques1,5– 8 have been advocated
for attaching the lower lateral cartilages to
each other or to the upper lateral cartilages
(Figs. 12 through 18). Results in follow-up re-
ports indicate that those techniques, while
seemingly satisfactory initially, provided an in-
adequate correction with growth and time and
required additional reconstruction. The com-
mon feature seemed to be tip definition and FIG. 13. Walter utilized Humby’s concept but also used
the ipsilateral cephalic “excess” of the lower lateral cartilage
(LLC) to lengthen the nasal dorsum. He realized that an
excessively obtuse nasal labial angle could be corrected by
lengthening the nasal dorsum.

lower lateral cartilage collapse because of a

lack of persistent tip support.9 –12
Plication of the medial and intermediate crura
of the lower lateral cartilages was advocated by
Converse in 1964 (Fig. 19). Converse was surely
attempting to gain symmetry and support. Rigid
columellar support was not provided, so correc-
tion relied on the contralateral lower lateral car-
tilage for enough support to maintain position
and projection. Millard believed inadequate skin
FIG. 11. Skoog sutured the lower lateral cartilage to the cover was the dominant issue. In some cases,
upper lateral cartilage for support of the displaced lower however, he must have believed that lower lateral
lateral cartilage. cartilage support was also insufficient to maintain
62e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

FIG. 14. Byars divided the ipsilateral medial crus and used
it to elevate the lower lateral cartilage. It also reduced support
for the nasal tip provided by the medial crura of the lower
lateral cartilage. FIG. 15. Erich gained access to the nasal structures by
using an open rhinoplasty technique.
shape, as he advocated placing unsecured struts
of cartilage between the medial crura to provide (Fig. 21). After a strong framework is recon-
more support for the lower lateral cartilages in structed, skin cover can be adjusted so that it
some of his patients. contours around the new lower lateral cartilage
Another vexing issue is the web created in framework. That change in planning produced
the lateral vestibule of the nose (Fig. 20). It is improved results in the appearance of the re-
created by the displaced lateral crura of the constructed cleft nasal deformity.
lower lateral cartilage being brought to a more Many authors2,16,17,19 believe that correcting the
medial position and also by additional connec- displaced framework structures at the time of the
tive tissue between the lower lateral cartilage initial lip repair is desirable (Figs. 22 through
and overlying skin. Z-plasties, V-Y advance- 24). Critics were fearful that early adjustment of
ments, and flap rotations usually do not com- nasal cartilage structures would produce growth
pletely correct the web, and over the long term discrepancies. Adequate periods of follow-up
they may constrict the nasal vestibule or nostril have shown that the nose does grow normally
and require a secondary correction.13,14 after early adjustment of position and configura-
With that history as the background, sur- tion of the cartilaginous portions of the nose.
geons realized that skin and soft-tissue alter- The methods of adjusting the nose during
ations for many patients did not provide long- primary cleft lip repair (Figs. 25 through 27)
term correction against the relentless seem to have a few basic goals: (1) to provide
resistance of deformed skeletal and cartilagi- tip support by suturing the lower lateral carti-
nous structures associated with clefts. That rec- lages to each other and to the upper lateral
ognition heralded a new era of reconstruction cartilages; (2) to stabilize the abnormal lower
in the 1990s that was initiated by many differ- lateral cartilage in a more anatomic and sym-
ent authors within a similar time period.2,12,14 –18 metrical position18; (3) to establish a muscle
The concepts now applied are early interven- and soft-tissue sill across the nasal base20; and
tion, strong columellar support for nasal tip (4) to correct the webbed lateral alar mucosa
projection, and construction of a nasal frame- by plicating skin and mucosa.7
work that mimics the appearance, symmetry, Early intervention and adjustment of the
and position of a normal lower lateral cartilage lower lateral cartilages in the cleft nose is ben-
Vol. 114, No. 4 / CLEFT RHINOPLASTY 63e

FIG. 17. Tajima achieved additional ipsilateral lower lat-

eral cartilage elevation by suturing the lower lateral cartilage
to the contralateral upper lateral cartilage.

FIG. 18. Tajima realized the asymmetry of the nostril

needed to be addressed; the reverse-U flap added another
FIG. 16. Trott’s approach. dimension to planning.

eficial, but this approach usually does not pre-

vent secondary reconstruction when the adult rhinoplasty” was performed by the same surgeon
characteristics of the nose become appar- when the patient was of preschool age. At sec-
ent.11,21 Another concern is that early interven- ondary rhinoplasty performed by the authors,
tion can make secondary procedures more dif- these patients were often found to have dis-
ficult because of scarring or damage to the rupted intermediate crura, greatly altered anat-
lower lateral cartilage from dissection or su- omy of the lower lateral cartilages, and visible
tures associated with immediate intervention. nasal scars. These circumstances significantly
complicated their definitive nasal reconstruction
AUTHORS’ DATA AND RECOMMENDATIONS and statistical assessment. In this series of pa-
We have reviewed available data from 21 cleft tients, the most definitive correction and the cal-
nasal reconstructions performed by the senior culated mean measurements for each category
author during the past 4 years. The amount of are shown in Table I.
change achieved between preoperative and post- Presently, the principles most often applied
operative measurements and the incidence of involved placing a columellar strut graft, using
some of the techniques used are listed in Tables spanning sutures, bone grafting the maxillary
I and II, respectively. In this series of patients, defect, and using mucosal and skin-plicating
most cleft lip primary repairs were performed by sutures (Fig. 27).
other surgeons and primary adjustment of the Because the characteristics and size of the lip
lower lateral cartilage was not done. Often a “tip and nose change in proportion to age, plan-
64e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

FIG. 19. Converse and Millard clearly understood the FIG. 21. In establishing symmetrical tip-defining points, a
need for producing lower lateral cartilage symmetry and sup- secured columellar cartilage graft is used for reinforced sup-
port for tip projection. Millard added unsecured struts of port to maintain projection while skin adaptation occurs.
cartilage between the medial crura for lower lateral cartilage
support.

FIG. 22. Byrd’s technique for primary nasal intervention.

FIG. 20. The alar web created in the cleft nose is a per-
sistent problem. TDP, tip-defining point. secondary management of the cleft nose defor-
mity easier. It is emphasized that manipulating
ning for shape and size is essential during the the lower lateral cartilages during primary lip
ages of 8 of 14 years (Fig. 28). Our surgical repair requires technical expertise, loupe mag-
corrections usually occur at two or three differ- nification, and an understanding of the pre-
ent time intervals. In early infancy, adjustments maxilla segment and protection of its vascular
of the lower lateral cartilages occur in conjunc- anatomy.22
tion with the cleft lip repair. Secondary adjust- Pediatric anesthesiologists, understanding
ment of the lower lateral cartilages occurs be- parents, patient support groups, cleft team in-
tween the ages of 5 and 8 years because of volvement, and parent education about the
significant distortion of the nasal tip’s shape. cleft team’s long-term plans are important ad-
The final correction occurs when the nose has juncts to providing parents with confidence
reached its nearly adult shape, when the pa- and satisfaction.
tient is between 12 and 15 years of age. The
bilateral defects usually require three proce- PRIMARY CLEFT NASAL REPAIR TECHNIQUE
dures, whereas unilateral deformities usually We prefer to perform adjustments of the
require only two adjustments of the nose. lower lateral cartilages during lip repair by us-
These principles have been used to success- ing a lateral rim incision patterned after a mod-
fully manage early and late cleft nasal deformi- ified open incision23 (Fig. 29). The lower lat-
ties associated with unilateral and bilateral cleft eral cartilages are visualized and the perceived
repairs. Although controversy still persists, intermediate crus apices are marked with
early intervention in skilled hands may make methylene blue dye as reference points. The
Vol. 114, No. 4 / CLEFT RHINOPLASTY 65e
and has less potential of interfering with the
premaxilla’s circulation. After the released lat-
eral alar ligament is reattached across the mid-
line to the contralateral alar base, if buckling
or irregularity occurs in the lower lateral carti-
lage, additional tip projection support or lower
lateral cartilage repositioning may be required.
To reposition the lower lateral cartilages sym-
metrically within the skin envelope and to hold
them in position when nasal mucosa incisions
are closed, the cartilage is included in the mu-
cosal closure. Transcutaneous plicating sutures
can be used to position the cartilages if posi-
tioning cannot be accurately accomplished
when the mucosa incisions are closed.2 If nec-
essary, the upper lip skin under the nostril can
be deepithelialized and the nostril can be re-
inset to establish symmetry with the contralat-
eral nostril. Since the lower lateral cartilages
have been found to be nearly symmetrical in
shape,24 though displaced, in our opinion, re-
secting or moving portions of the lower lateral
FIG. 23. Salyer and Kirschbaum both advocated early in- cartilage should be delayed until definitive re-
tervention with alteration of lower lateral cartilage position. constructive rhinoplasty is performed.
Salyer realized the value of plication to prevent web formation Initial management of the lower lateral carti-
and buckling of the lower lateral cartilage. lage components may decrease the need for early
secondary surgical correction of the lower lateral
intermediate portions of the lower lateral car- cartilages in the unilateral cleft nasal deformity.
tilages are then plicated together with poly- However, despite early intervention in the bilat-
dioxanone suture to produce symmetry. A su- eral cleft at the time of the lip repair, lack of tip
ture is placed joining the left and right medial projection, an associated short columella, and
crura’s junction with the left and right inter- displaced lower lateral cartilages often result in
mediate crura. An interdomal suture is placed secondary surgical intervention when the patient
to bring the genu of the two intermediate reaches preschool age.
crura together. The tissue attachments to the
flared ala are released, and the lateral liga- SECONDARY CLEFT NASAL REPAIR TECHNIQUE
ment-like attachment and associated muscle In our experience, the most difficult of all
are preserved. Byrd and Salomon20 advocate rhinoplasties is correction of the bilateral cleft
bringing some of the muscle from the lateral nasal deformity with short nasal projection and
lip segment with the lateral component of the an obtuse nasal labial angle. Plication of the
lower lateral cartilage and attaching it to the intermediate crura concomitant with the lip
columella. As an extension of Farrior’s tech- repair does not provide tip support to over-
nique,18 we prefer to fix the lower lateral carti- come the short columellar length, and plica-
lage lateral crura across the midline through tion of the lower lateral cartilages does not
the premaxilla area to the contralateral alar provide enough projection. Supporting the
base with a spanning-type suture (Fig. 26). Us- lower lateral cartilages by suturing them to the
ing this maneuver, the connective tissue at- upper lateral cartilages has been demonstrated
tached to the lower lateral cartilage is still su- to have only short-term benefit; this approach
tured to the midline but without tension. does not provide adequate projection and con-
Adjusting this suture tension also supports the tributes to an obtuse nasal labial angle. Second-
cleft repair and narrows the nasal base. This ary columellar lengthening by manipulations
exerts pressure across the entire base of the of the skin envelope of the nose fails because
nose rather than against the already displaced the skin cannot, over the long term, hold shape
maxillary midline components. It also tends to against rigid distortion of the displaced under-
level the horizontal position of the nasal base lying lower lateral cartilages. Eventually, carti-
66e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

FIG. 24. Summation of technical points advocated by many authors.

FIG. 25. Tip grafts to the caudal area of the intermediate

segment of the lower lateral cartilage are placed for tip def-
inition during the final stage of reconstruction.

lage determines the skin’s shape because of

stress relaxation of the skin around the unsup-
ported cartilage framework.
In tip rhinoplasty correction performed at
preschool age, a modified open technique is FIG. 26. Three-dimensional illustration of the authors’
used to provide access (Fig. 29). The lower preferred technique in the final stages of reconstruction.
lateral cartilages are adjusted with interdomal
and/or intradomal sutures. In the bilateral caudal portion of the septum as a batten-type
cleft, skin is recruited from the nasal dorsum graft to lengthen the nose, or to the posterior
and the nostril is pushed to a new position with septum in the vicinity of the nasal spine if only
a rigid cartilage strut graft secured with sutures projection is required. The strut is taken from
between the medial crura of the lower lateral sources other than the septum and is used to
cartilages. The strut is then attached to the hold the intermediate crus in a projecting po-
Vol. 114, No. 4 / CLEFT RHINOPLASTY 67e
but in bilateral cleft rhinoplasty patients, revi-
sion and additional tip projection support are
required when they reach the teenage years.
At present, we have not used a bioabsorbable
device in place of cartilage, but such a device
can be an alternative strut if it can provide
support long enough to permit the redraping
of skin to accommodate the nasal framework.25
RECOMMENDED SURGICAL MANAGEMENT AT AGE 12
TO 14 YEARS

In all of our cleft patients, the final adjust-

ments in nasal reconstruction occurred either
when the patient was as a teenager or later in
life.26 The final rhinoplasty is done through an
open approach (Fig. 30). The lower lateral
cartilages, which are often surrounded by scar,
FIG. 27. Three-dimensional illustration of the authors’ must be carefully visualized. Septal abnormali-
preferred technique for maintaining lateral vestibule volume ties are corrected. After any required adjust-
and shape. BG, bone graft.
ments in the nasal dorsum, septal cartilage can
be obtained for use during reconstruction of
TABLE I the nose. Other sources of graft material are
Preoperative and Postoperative Measurements the rib, ear, skull, and ilium.27–29
The nasal labial angle can be decreased by
Before After using a caudal tip graft or, in extreme cases,
Surgery Surgery by extending the septum with batten-type
Base width 38.7 35.6 grafts fixed to the cephalic edge of the me-
Columellar projection 23.4 26.6
Tip width 22.2 18
dial crura (Fig. 31). The cephalic portions of
Nasal labial angle increase 97 10 the lower lateral cartilages have also been
Nasal labial angle decrease ⫺12 used for this purpose (Fig. 14). Symmetrical
lower lateral cartilages are created by using a
TABLE II combination of intradomal and interdomal
Incidence of Techniques sutures and spanning sutures. Direct adjust-
ment of the caudal border of the lower lat-
Technique No. of Cases eral cartilages is occasionally helpful.30,31 Os-
Columellar strut 20/21 (95%) teotomies of the nasal pyramid will be
Nasal tip 19/21 (90%) required to correct the crooked nose defect
Spreader 5/21 (24%) if the deviation begins at the nasion. Osteot-
Onlay/batten 4/21 (19%)
Alar wedge resected 8/21 (38%) omy may not be required if the crooked nose
deflection begins at the rhinion.32 Osteotomy
may be required when the nasal pyramid is
sition to help adjust the nasal labial angle and wide and if the nasal dorsum is excessively
nasal length. After the strut is secured, the prominent and requires reduction. The lat-
lower lateral cartilage immediately becomes elon- eral alar web can be corrected by thinning
gated and maintains that position long term. Tip the thickened lateral nasal wall and plicating
definition is adjusted using domal sutures sup- the mucosa to the skin and to the adjacent
ported by the columellar strut graft. Initially, the piriform margin (Fig. 28). Repositioning of
projection will be prominent. After the adult the nostril on the upper lips to match the
characteristics and size of the nose are expressed, position, width, and shape of the contralat-
tip projection may be slightly inadequate. At that eral lower lateral cartilage can be achieved by
time, additional tip support is provided by plac- deepithelializing the symmetrically deter-
ing septal grafts on the caudal side of the inter- mined location on the skin and reinsetting
mediate crura of the lower lateral cartilage. the ala. If buckling of the lower lateral carti-
Using this technique, no decrease in growth lage persists after columellar support has
of the lower lateral cartilages has been noted, been provided, it is possible to correct this using
68e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

FIG. 28. The slow but relentless changes in proportions and structural shape during growth must
be considered during planning.

FIG. 29. Dotted lines represent intranasal incisions and solid

lines represent visualized incisions.

FIG. 31. In severe bilateral cleft nasal deformity, the nasal

dorsum and columella are short with a very obtuse nasal labial
angle. Tip projection and support are essential, but to prevent
the obtuse angle, the nasal dorsum must be lengthened.
Expanding on Walter’s technique, batten grafts are very help-
ful with correction.

is difficult and has the same potential complica-

tions as noncleft rhinoplasty.34
SUMMARY
The principles delineated for correction of
the cleft nasal deformity are emphasized in
FIG. 30. During open rhinoplasty, a transcolumellar inci- great detail. These principles apply to both
sion is used. Planning that incision is essential. Often a prior unilateral and bilateral deformities. A recon-
incision may exist on the columella, and vascular compromise
of the elevated columellar skin can occur if scars compromise
structed, sturdy framework that has the desired
the base of the flap. three-dimensional qualities of a normal nose
will produce a dramatic change in the shape,
narrow strips of cartilage33 placed and sutured function, and appearance of the nose. Nasal
adjacent to the rim margin to smooth the defor- function, symmetry, projection, length, width,
mity. Reconstruction of the cleft nasal deformity and tip definition are the goals of the rhino-
Vol. 114, No. 4 / CLEFT RHINOPLASTY 69e
plasty surgeon. Those goals are also now ob- lateral cleft lip and palate: The Alor Setar experience.
tainable in individuals with severe cleft nasal Br. J. Plast. Surg. 46: 363, 1993.
17. Trott, J. A., and Mohan, N. A preliminary report on one
deformity by applying the principles developed stage open tip rhinoplasty at the time of the lip repair
over the past decades.5,35,36 in bilateral cleft lip and palate: The Alor Setar expe-
Allen L. Van Beek, M.D. rience. Br. J. Plast. Surg. 46: 215, 1993.
7373 France Avenue South 18. Farrior, R. T. The cleft lip nose: An update. Facial Plast.
Edina, Minn. 55435 Surg. 9: 241, 1993.
19. Mulliken, J. B. Primary repair of bilateral cleft lip and
nasal deformity. Plast. Reconstr. Surg. 108: 181, 2001.
REFERENCES 20. Byrd, H. S., and Salomon, J. Primary correction of the
unilateral cleft nasal deformity. Plast. Reconstr. Surg.
1. Millard, D. R. Cleft Craft: Vol. 2, Bilateral and Rare Defor- 106: 1276, 2000.
mities, 1st Ed. Boston, Mass.: Little, Brown, 1976. 21. Habel, G. Repair of unilateral and bilateral cleft noses:
2. Salyer, K. E. Early and late treatment of unilateral cleft An experience of 103 cases. Ann. R. Australas. Coll.
nasal deformity. Cleft Palate Craniofac. J. 29: 556, 1992. Dent. Surg. 11: 259, 1991.
3. Fisher, D. M., and Mann, R. J. A model for the cleft lip 22. Ersek, R. A. Necrosis of the nasal tip. Plast. Reconstr.
nasal deformity. Plast. Reconstr. Surg. 101: 1448, 1998. Surg. 97: 491, 1996.
4. Ellis, D. A., and Gilbert, R. W. Analysis and correction 23. Holmstrom, H., and Luzi, F. Open rhinoplasty without
of the crooked nose. J. Otolaryngol. 20: 14, 1991. transcolumellar incision. Plast. Reconstr. Surg. 97: 321, 1996.
5. Randall, P. History of cleft lip nasal repair. Cleft Palate 24. Park, B. Y., Lew, D. H., and Lee, Y. H. A comparative study
Craniofac. J. 29: 527, 1992. of the lateral crus of alar cartilages in unilateral cleft lip
6. Cook, T. A., Davis, R. E., and Israel, J. M. The extended nasal deformity. Plast. Reconstr. Surg. 101: 915, 1998.
Skoog technique for repair of the unilateral cleft lip 25. Stal, S., and Hollier, L. The use of resorbable spacers for
and nose deformity. Facial Plast. Surg. 9: 195, 1993. nasal spreader grafts. Plast. Reconstr. Surg. 106: 922, 2000.
7. Tajima, S. Follow-up results of the unilateral primary 26. Marsch, J. L. When is enough enough? Secondary sur-
cleft lip operation with special reference to primary gery for cleft lip and palate patients. Clin. Plast. Surg.
nasal correction by the author’s method. Facial Plast. 17: 37, 1990.
Surg. 7: 97, 1990. 27. Ortiz Monasterio, F., and Ruas, E. J. Cleft lip rhino-
8. Converse, J. M., Hogan, V. M., and Barton, F. E. Sec- plasty: The role of bone and cartilage grafts. Clin. Plast.
ondary deformities of cleft lip, cleft lip and nose, and Surg. 16: 177, 1989.
cleft palate. In J. M. Converse (Ed.), Reconstructive 28. Celik, M., and Tuncer, S. Nasal reconstruction using
Plastic Surgery, Vol. 4, 2nd Ed. Philadelphia, Pa.: Saun- both cranial bone and ear cartilage. Plast. Reconstr.
ders, 1977, Pp. 2165-2204. Surg. 105: 1624, 2000.
9. Coghlan, B. A., and Boorman, J. G. Objective evalua- 29. Takato, T., Harii, K., Yonehara, Y., Komuro, Y., Susami,
tion of the Tajima secondary cleft lip nose correction. T., and Uoshima, K. Correction of the cleft nasal
Br. J. Plast. Surg. 49: 457, 1996. deformity with an L-shaped iliac bone graft. Ann. Plast.
10. Cho, B. C., and Baik, B. S. Correction of cleft lip nasal Surg. 33: 486, 1994.
deformity in Orientals using a refined reverse-U inci- 30. Foda, H. M., and Bassyouni, K. Rhinoplasty in unilateral
sion and V-Y plasty. Br. J. Plast. Surg. 54: 588, 2001. cleft lip nasal deformity. J. Laryngol. Otol. 114: 189, 2000.
11. Kane, A. A., Pilgram, T. K., Moshiri, M., and Marsh, J. L. 31. Ellenbogen, R., and Blome, D. W. Alar rim raising.
Long-term outcome of cleft lip nasal reconstruction in Plast. Reconstr. Surg. 90: 28, 1992.
childhood. Plast. Reconstr. Surg. 105: 1600, 2000. 32. Thatte, R. L., Deshpande, S. N., and Thatte, M. R. A
12. Mulliken, J. B. Correction of the bilateral cleft lip nasal radical approach in the treatment of the deviated
deformity: Evolution of a surgical concept. Cleft Palate nose. Br. J. Plast. Surg. 43: 596, 1990.
Craniofac. J. 29: 540, 1992. 33. Gunter, J. P., Rohrich, R. J., and Friedman, R. M. Classi-
13. Morselli, P. G. The anchor of the nasal ala in cleft lip-nose fication and correction of alar-columellar discrepancies
patients: A morphological description and a new surgical in rhinoplasty. Plast. Reconstr. Surg. 97: 643, 1996.
approach. Cleft Palate Craniofac. J. 37: 130, 2000. 34. Tardy, M. E., Cheng, E. Y., and Jernstrom, V. Misad-
14. Kirschbaum, J. D., and Kirschbaum, C. A. The chon- ventures in nasal tip surgery. Otolaryngol. Clin. North
dromucosal sleeve for the unilateral cleft lip nasal Am. 20: 797, 1987.
deformity. Ann. Plast. Surg. 29: 402, 1992. 35. McComb, H. Primary repair of the bilateral cleft lip
15. Walter, C. Nasal deformities in cleft lip cases. Facial nose: A 4-year review. Plast. Reconstr. Surg. 94: 37, 1994.
Plast. Surg. 11: 169, 1995. 36. Reichert, H., and Gubisch, W. Various techniques of
16. Trott, J. A., and Mohan, N. A preliminary report on secondary nose correction in unilateral cleft-lip pro-
open tip rhinoplasty at the time of lip repair in uni- cedure. Ann. Plast. Surg. 26: 18, 1991.