Se condary
Rhinoplasty in
Unilateral Cleft
Nasal Deformity
Tom D. Wang, MD
KEYWORDS
 Cleft-lip  Revision rhinoplasty  Alar-columellar web
The cleft-lip nasal deformity presents a formida-
ble challenge in rhinoplasty. The 3 main factors
contributing to this deformity are congenital
anatomic deficiency or aberrancy, surgical scar-
ring from previous reconstructive attempts, and
changes related to growth.
Various techniques have been proposed for the
correction of this problem. The sheer number of
methods described in the literature serves as
a testament to the intrinsically difficult nature of
this deformity. All these techniques attempt to
address some aspect of the problem. However,
complete correction of all nasal deficiencies
remains an elusive goal for many.
UNILATERAL CLEFT NASAL DEFORMITY
The unilateral deformity results from tissue defi-
ciency of the cleft lip, deficiency in the bony
premaxilla, and abnormal muscle pull on the nasal
structures. The unilateral secondary nasal defor-
mity may comprise most, if not all, of the following
features:
1. The dome on the cleft side is retrodisplaced
and less well-projected.
2. The columella on the cleft side is foreshortened.
3. The medial crus slumps laterally.
4. The lower lateral cartilage (LLC) and the alar rim
form a caudal hood.
5. There is an alar-columellar web.
6. There is insufficient vestibular skin in the region
of the vestibular dome.
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery,
Oregon Health and Science University, 3303 SW Bond Avenue, Mail Code: CH 5E, Portland, OR 97239-450, USA
E-mail address: wangt@ohsu.edu
Clin Plastic Surg 37 (2010) 383–387
doi:10.1016/j.cps.2009.12.013
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7. The nostril orientation can vary due to lateral-
ized alar-base position and deficient nasal
floor.
8. The alar-base displacement (lateral, inferior,
and posterior) is universally present in the
primary cleft deformity. This can be affected
by primary lip repair, primary cleft rhinoplasty,
and alveolar bone grafting.
9. The caudal septum is deflected into the non-
cleft side, but the severity of the deflection is
variable.
Primary Unilateral Cleft Rhinoplasty
Primary nasal repair at the time of primary cleft-lip
repair can help improve the cleft-lip nasal defor-
mity by achieving better symmetry and improved
overall long-term appearance of the nose. The
primary lip repair is typically performed by the
time the patient is 3 months old. All efforts are
made to minimize nasal tissue trauma and scar-
ring, which may unfavorably affect subsequent
growth. In this regard, an effective method for
primary unilateral cleft rhinoplasty involves unilat-
eral LLC suspension via limited dissection.
Adequate correction from the primary proce-
dure may lessen or eliminate the need for
secondary cleft rhinoplasty.
Secondary Unilateral Cleft Rhinoplasty
plasticsurgery.theclinics.com
Secondary nasal surgery includes intermediate
and definitive rhinoplasty. Intermediate rhinoplasty
is performed before nasal growth is completed
and is based on 2 separate timing strategies.
384 Wang

Rhinoplasty is done between the ages of 4 and 6
years, sometimes concomitantly with lip revision,
to minimize any peer psychological pressure.
Waiting until 8 to 12 years of age and until after
the completion of orthodontic alignment and alve-
olar bone grafting allows a better skeletal base for
correction of severe nasal deformities. In general,
the intermediate rhinoplasty techniques are more
conservative than those of definitive rhinoplasty.
Definitive rhinoplasty is performed when maxil-
lary and nasal growths are complete. This usually
occurs between 16 and 18 years of age. Rhino-
plasty performed in this time frame allows for
more aggressive septoplasty, osteotomies, and
cartilage grafting maneuvers. Each patient
requires an individualized approach to timing of
secondary rhinoplasty, based on the severity of
soft tissue and skeletal deformities.
The author’s preferred technique for secondary
rhinoplasty is the sliding cheilorhinoplasty. This
technique is designed to address the deficiencies
present on the cleft side of the nose, including low-
ered dome height, LLC malposition, lateralized
alar base, alar-columellar web, and vestibular
lining deficit. This is accomplished using a laterally
based chondrocutaneous flap of LLC, vestibular
skin, and lip scar tissue, which is advanced supe-
riorly and laterally. This procedure is usually per-
formed through an external rhinoplasty approach
with structural cartilage grafting to maintain nasal
tip support and contour.
Technique
The sliding cheilorhinoplasty technique uses the ex-
isting upper lip scar as part of the advancement flap
for increasing the vestibular internal lining. The
vermilion is marked with methylene-blue tattoo
marks (Fig. 1).
Two parallel incisions are then marked, which
center on and encompass the unilateral upper lip
scar that is to be revised. The width of this flap
depends on the width of the original scar but
should be at least 5 mm. The length of this flap is
dictated by the amount of the lip scar that needs
to be revised. The markings of these 2 parallel inci-
sions are then extended into the nose. At the
columella, the medial incision becomes contin-
uous with the marginal incision. This incision is
extended superiorly to encompass any alar
webbing and is marked to create a rim margin
that is symmetric to the contralateral normal rim.

Fig. 1. (A) Outline of lip scar, chondrocutaneous flap, alar-web incision, and transcolumellar incision. (B) Laterally
based chondrocutaneous flap elevated, along with external rhinoplasty exposure. (C) Chondrocutaneous flap
advanced superior-laterally, secured with columellar strut and tip graft.

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 Rhinoplasty in Unilateral Cleft Nasal Deformity
Fig. 2. Gillies and Kilner technique with superior
advancement of hemicolumella.
This incision is then merged with the continuation
of the marginal incision laterally.
The lateral lip incision transitions into an inter-
cartilaginous incision intranasally, and is carried
superiorly and then laterally, outlining the entirety
of the LLC. The lateral attachment of the flap is
maintained to preserve flap vascularity.
Local anesthetic solution is infiltrated for hemo-
stasis. The amount that is least necessary for
vasoconstriction should be used to minimize
tissue distortion.
Starting from the lip incision, the flap is elevated
and extended superiorly and laterally, encom-
passing the lip scar and the LLC. Again, the lateral
attachment of the flap is maintained for flap vascu-
larity. The remainder of the nasal dorsum and the
Fig. 3. (A) Secondary unilateral cleft nasal deformity. Note the tip asymmetry and alar-columellar web. (B) Note
the correction of tip asymmetry and alar-columellar web.
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385
contralateral LLC is then exposed via the standard
external rhinoplasty approach.
Any septal work may be accomplished at this
time, including septoplasty and harvesting of
grafting material. Care should be taken to leave
sufficient dorsal caudal support for the nose.
A columellar pocket is next created. A colu-
mellar strut, which is used to anchor the cleft
side LLC to the contralateral normal LLC, may be
carved from either the septal or auricular cartilage.
Symmetry of vestibular dome height is crucial in
the positioning of the LLC. This symmetry typically
requires advancement of the medial crus of the
cleft LLC superiorly to match the vestibular dome
heights bilaterally. This superior flap advancement
in turn uses the residual lip scar as an internal
nasal vestibular lining. Once the appropriate
vestibular dome position has been established,
the medial crura of the LLCs are secured to the
strut with horizontal mattress sutures.
The upper lip is then repaired with tension-
bearing sutures placed within the orbicularis
musculature.
Once the base of the nose has been stabilized,
attention is directed toward the nasal tip. Cephalic
trim of the LLC may be performed as indicated. A
shield-type tip cartilage graft can be sutured into
position to maintain tip projection and to augment
tip support. This graft also has the added
advantage of allowing camouflage of minor tip
asymmetries.
Closure of all incisions is then performed. Slight
infolding of the alar-columellar web tissue on reap-
proximation of the marginal incision improves alar
386 Wang

margin symmetry. The routine intranasal and
external dressings and splint are then applied.
DISCUSSION
Many different techniques have been described
for correction of the unilateral cleft nasal deformity.
In 1932, Gillies and Kilner introduced a superior
advancement of the composite chondrocutane-
ous hemicolumella flap (Fig. 2). This technique
used a midcolumellar incision. In 1964, Converse
provided the first major modification of this tech-
nique by replacing the midcolumellar incision
with a marginal incision. The medial crura
composite flap was advanced superiorly and
sutured to the contralateral dome. The defect at
the base of the columellar was repaired with an
auricular composite graft.
Potter, in 1954, advocated a similar concept,
but from the opposite direction. He used a
lateral-to-medial advancement of the lateral crural
composite chondrocutaneous flap. The resultant
defect created in the lateral vestibular skin was
closed in a V-to-Y fashion. Potter’s technique is
still used by some surgeons today.
Tajima and Maruyama advanced the evolution in
cleft-lip rhinoplasty with the description of the
‘‘reverse-U’’ incision in 1977. This method was
an extension of the marginal incision into a rim inci-
sion at the point of the alar web. The skin of the

Fig. 4. (A) A patient with secondary cleft-lip nasal deformity is shown prerevision. Note the tip asymmetry, alar-
columellar web, and poor upper lip alignment. (B) The same patient is shown after cleft-lip nose revision. Note
the improvement in tip symmetry, alar web, and upper lip alignment. (C) Secondary cleft-lip nasal deformity is
shown before revision. (D) After cleft-lip nose revision. (E) Prerevision, base view. (F) Post cleft-lip nose revision,
base view.

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 Rhinoplasty in Unilateral Cleft Nasal Deformity 387

web was incorporated with the vestibular skin and
the LLC flap. The flap was then suspended cephal-
ically and medially from the LLC to the ipsilateral
upper lateral cartilage and the septum by sutures.
Conversion of external skin of the alar web to nasal
lining, which is done to correct the alar-columellar
web, also corrects the deficiency of vestibular skin
associated with the cleft-lip nasal deformity.
Effective repair of the cleft-lip nasal deformity
addresses the insufficiency of vestibular skin with
a simpler approach. The LLC is mobilized as
a composite flap along with the vestibular skin.
The direction of mobilization, that is, lateral-to-
medial or medial-to-lateral, is of less importance
than the advancement of a robust chondrocutane-
ous flap. The repositioned cartilage allows for
increased stability of repair (Figs. 3 and 4).
An aggressive incisional approach to the alar-
columellar web allows correction of this difficult
area. The web skin can be either converted into
vestibular lining or discarded according to the
patient’s needs.
The approach that is outlined in this article amal-
gamates many of the above-mentioned cleft-lip
rhinoplasty concepts into a single unified tech-
nique. Increased stability and symmetry of the
nasal tip is achieved by combining these tech-
niques with the open rhinoplasty approach, a colu-
mellar strut, and a structural shield graft.
The multitude of surgical approaches to the cleft-
lip nose is proof to the difficulty of this reconstruc-
tive problem. A thorough understanding of the
deformity and the methods for its correction forms
the foundation for successful reconstruction.

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