Original Articles Cleft Lip Nasal Deformity T. Ray Broadbent, M.D. and Robert M. Woolf, M.D. The nasal deformity in the clef lip patient is produced by the lower lateral cartilage being subluxed inferiorly and lat- erally, which falsely lengthens the nose. the cleft side. The columella is not short. 1 simply extends laterally to a dipped area in the rim of the nostzl. The cleft lip nasal deformity is correctable atthe time of primary lip repair by advancing the lower lateral cartilage superiorly and me: dially. The correction will last with the cartilage fixed to the upper lateral cartilage-septal junction, its normal position. AA deficient repair will not improve. A good repair will last, will not interfere with growth of the nose, and will free the patient from years of unnecessary embarrassment. Correction of the cleft lip nasal deformity in the adult requites repositioning ofthe lower lateral cartilage similar to what can be and should be done in the infant. From the Division of Plastic Surgery, Primary Children’s Hospital, 324 10th Ave, Salt Lake City, UT. 84103. ‘Address reprint requests to Dr, Broadbent, 216 | T. Ray Broadbent ‘The cleft ip nasal deformity is often left alone at the time of primary lip repair. The reasons given are: We must do nothing to interfere with the growth of the nose; the repair is ineffective; and resulting scars make good correction at the time of rhinoplasty difficult. The purpose of this article is to disclaim these reasons, and more important, to explain the anatomy and present a method of correction of the cleft lip nasal deformity which is predictable, lasting, and can be accomplished at the time of primary lip repair. ‘There is growing evidence that more surgery can be done in children than previously thought without in- terfering with growth [10]. Surgery may, in fact, actu- ally assist growth. Early craniofacial surgery is a prime example [5]. Many years ago, we began repairing the nasal tip deformity at the time of primary lip repair. As the patients grew into adulthood, we found that we had not retarded growth (Fig 1A, B). We also leamed that deficiencies in the repair did not get better (Fig 1C-E}. The child did not grow out of it, as we have all too often heard. On the other hand, in those instances, when a good repair was achieved, it lasted (Fig 2A, B). ‘The challenge clearly is to fix the lip and nose right in the beginning. In the care of patients with cleft lip, palate, and nasal deformities, we have seen and tried many proce- dures (6, 7, 12]. We have concluded that the triangular flap repair and the rotation advancement repair are good ones. The former is more often used than the latter. Wherever one may be in his or her evolution of lip and palate surgery, the nose should no longer be overlooked or relegated to a separate operation some- time in the future. Anatomy The nasal tip is made of skin, lower lateral cartilages, ‘mucosa, and septum, The skin and mucosa are normal in the infant, The septum is tilted, and it, with the distortion accompanying the alveolar cleft, tilts the base of the nose away from the cleft side and the tip of + the nose to the cleft. The main defect in the nose is in the position of the lower lateral cartilage, which on the cleft side is subluxed. The cartilage has fallen down, and, as a roof caves in, the dome of the nostril has caved in with the cartilage displaced inferiorly and laterally, falsely lengthening the cleft side of the nose (Fig 3A-D), The lower lateral cartilage on the noncleftBroadbent and Woolf: Cleft Lip Nasal Deformity Fig 1. Nasal tip repair at the time of primary lip repait. (A) Preoperative view at age 6 weeks. (B) Postoperative view, ‘age 20 years. No retardation of normal growth and develop- ‘ment. (C) Preoperative view of a second patient at age 7 ‘weeks, (D) Postoperative view at 16 months. (E) Postopera tive view at 7 years. Deficiencies do not improve with time. ‘They become larger and more evident. 27Annals of Plastic Surgery Vol 12 No 3 March 1984 B Fig 2, Cleft lip nasal deformity. (A) Preoperative view at age 6 weeks. (B) Postoperative view, 16 years, Proper correc: tion lasts. 218 Fig 3, Unilateral cleft lip nose, (A) Front view—lower lat- eral cartilage is subluxed inferiorly and laterally. (B) Post- (operative view at age 2% years. (C) In the infant, lengthen- ing of nose on cleft side due to dropping down of lower lateral cartilage is seen. (D) In the adult, similar long rela- tionships on the cleft side persist. (Photo courtesy of Mr. Harold McComb, Perth, Australia, (E) Columella base is shifted off-center, away from cleft side, (F) Correction, 18 ‘months postoperatively.Broadbent and Woolf: Cleft Lip Nasal Deformity 219‘Annals of Plastic Surgery Vol 12 No 3 March 1984 20 side is normal, though the nostril floor is shifted off center (Fig 3E-F]. The upper lateral cartilages are nor- ‘mal in their relationship to the septum, to which they are firmly fixed. All of these relationships have been well demonstrated in infant dissections by Harold ‘McComb (Fig 44—C). ‘As one views the cleft nose from beneath, one al- ways sees a dip in the rim of the nostril on the cleft side (Figs 4B and 5A, B), Similarly, as one views the highlights in front view photographs, one regularly sees the tip highlight on the cleft side displaced downward and lateral as compared with its noncleft counterpart, Pulling up superiorly and medially, on a hook placed in the nostril at the level of the dip in the nostril rim, shifts the subluxed lower lateral cartilage up to the nostril dome level and shifts the photo- graphic highlight into balance with the opposite side (Fig 5C, D). This produces a good nasal tip, and it is apparent at this point that the scemingly short col- umella is no longer short, and indeed, it is not (Fig 6A, B). The top of the columella is at the dip in the nostril zim, and elevating the “caved-in roof” places the lower lateral cartilage into the tip with its medial crux com- ing to the midline, correctirig the columella length and flat nasal tip deformity (see Figs 5 and 6). We contend that the columella, in the unilateral cleft and probably even in bilateral clefts, is normal in propor- tion but simply out of position. The “C” flap in the rotation advancement lip repair serves no meaningful purpose, in our opinion, as regards columella length [8, 9]. Rotation of the columella upward, along with the floor of the nose [3], is likewise inappropriate, for the rotation should be, if anything, in the reverse direc- tion. To get the lower lateral cartilage shifted su- periorly and medially may require freeing the alar base at its maxillary attachment. This is true in bilat- eral clefts also and equally true in adults requiring correction of cleft lip nasal deformities. It is usually not necessary, however, to make extemal incisions to correct the unilateral cleft lip deformity (1~4, 11].Broadbent and Woolf: Cleft Lip Nasal Deformity Fig 4. Infant dissection in unilateral clef lip. (A) Normal infant, showing relationship of lower lateral cartilages to each other and to the upper lateral cartilages, Forceps on dome of lower lateral cartilages. (B) Typically flat nasal tip (on the cleft side with lower lateral cartilage subluxed in- feriorly and laterally. Columella base is slid off-center to- ward noncleft side. (C) Elevation of lower lateral cartilage 0 position of lower lateral cartilage on normal right side. Columella base is shifted to midline also, Forceps holding lower lateral cartilage against upper lateral cartilage and septum to which itis sutured. Note normal columella ength when lower lateral cartilage is lifted. (Photo courtesy of Mr. Harold McComb, Perth, Australia) 201Annals of Plastic Surgery Vol 12 No 3 March 1984 Fig 5. Cleft lip nasal deformity. (A) Front view. Dot marks dip in alae rim that is, infact, the dome of the nostil and upper medial extent of the columella, (B) Postoperative View at agé 8 years (C) Preoperative view in a second pas tient—highlight on nasal tip is displaced down with its undetlying cartilage. (D) Postoperative view at age 15 months, Highlight isin essential alignment or balance with the opposite side, as is the lower lateral cartilage. 202,Broadbent and Woolf: Cleft Lip Nasal Deformity Fig 6, (A) Preoperative view—columella looks shor. (B) ‘One week postoperatively—columella is not short but nor- ‘mal when lower lateral cartilage is put up into the nasal tip. (C) Preoperative view in a second patient—columella looks short. (D) One week postoperatively—normal nostril ‘and columella length, No separate procedures to lengthen columella, 23Annals of Plastic Surgery Vol 12 No 3 March 1984 A Procedure Unilateral Cleft Lip Nasal Deformity The incision in the superior buccal-labial sulcus (at the time of the cleft lip repair) goes into the nose, running between the upper and lower lateral carti- lages, extending completely to the nasal tip (Fig 7A). The upper border of the lower lateral cartilage is undermined between the skin and cartilage about 2 to 3mm, The nasal tip space over the dome of the lower lateral cartilage and the lower part of the ipsilateral ‘upper lateral cartilage is freely spread open to allow the lower lateral cartilage to advance into the tip space without soft tissue blockage (Fig 7B). A hook is placed in the nose, at the dip in the nostril rim. The nasal rim with its lower lateral cartilage is pulled firmly upward and medially toward the septum and nasal tip. The upper border of the lower lateral cartilage is seen to advance toward the tip, sliding along its more firmly ‘fixed upper lateral cartilage border (Fig 8). The amount 24 Fig 7. Correction of cleft lip nose, (A) Incision marked be- ‘tween upper and lower lateral cartilages, extending to the ‘nasal tip. (B) Area undermined to allow advancement of Jower lateral cartilage into nasal tip without soft tissue blockage (see text) of slide (5 to 10 mm) will depend on the width of the cleft and the extent of inferior and lateral displace- ment of the lower lateral cartilage. To fix this posi- tion, two or three 4-0 catgut sutures reapproximate the upper and lower lateral cartilages in the tip area. The key suture is the first one. It catches the edge of the lower lateral cartilage and the junction of the up- per lateral cartilage and septum to which that cartilage is fixed (Figs 4C and 9A). This is a fixed, solid point to which the lower lateral cartilage is hung, The suture is, tied and the advanced position of the lower lateral cartilage is made fast (Fig 9B, C). The alar base is ro- tated toward the columella base (don’t produce a ste- nosis) and adjusted horizontally and in its vertical po-Broadbent and Woolf: Cleft Lip Nasal Deformity Fig 8. Correction of cleft lip nose. (A) Lower lateral carti- age ready for lift into nasal tip, Note silver clips on either side of incision, at same level, before alar lift. (B) Lower Jateral cartilage lifted into nasal tip. Note sliding ad- vancement of the single silver clip on the edge of the lower ateral cartilage as the cartilage is pulled up into normal position. Two silver clips on the edge of the upper lateral cartilage are in the same position as before the lower lat- eral cartilage was lifted. sition to balance the normal side (Fig 9D). If the correction is inadequate, remove that first key suture, advance the lower lateral cartilage further, and try again. The correction must be right at the time of the repair. It will hold but will not get better by itself Figs 10-12}. Bilateral Cleft Lip Nasal Deformity The anatomical disarray of the lower lateral cartilage is similar but double in bilateral clefts (Fig 13). The 205 same corrective procedure can be used in bilateral clefts but is less effective. To be successful in the cor- rection of the bilateral cleft lip nose; one may have to split open the nasal tip, excise blocking soft tissue, and suture the lower lateral cartilage domes together (Figs 188, 14A-E). Adult Cleft Lip Nasal Deformity Essentially, the same procedure is used in adults with cleft lip nasal deformities. In the adult we may also use an alar rim incision, and if necessary, completely “ free the lower lateral cartilage as a single pedicled mucoperichondrial flap based at the tip of the nose. ‘The entire flap can then be advanced into the tip but must be adjusted carefully to give proper symmetry. Procedures, e.g, trimrning the lower lateral cartilage, that would normally be done with a tip rhinoplasty, are done at the same time. We thus do in the adult what could have been done in the child (Figs 15-17) ‘This means that the years of ridicule and frustrationAnnals of Plastic Surgery Vol 12 No 3 March 1984 Fig 9. (A) Nasal anatomy. Lower lateral cartilage is seen in- ferior o junction of upper lateral cartilage and septum— dot—a fixed point to which lower lateral cartilage is ad- vanced and sutured. (See also Fig 4C,) (B) Key suture, ‘Suture passes through the upper edge of lower lateral cart- lage to the fixed point of upper lateral cartilage and septum junction. (C) Alar cartilage lifted superiorly and medially {into nasal dome and sutured. (D) Ala adjusted in its vert cal and horizontal position to balance normal side. 226Broadbent and Woolf: Cleft Lip ‘Nasal Deformity UES eee iain c Fig 10, Incomplete unilateral clef lip nasal deformity. (A) Preoperative view at age 8 weeks. (B) Postoperative view, ‘age 6 years. (C) Preoperative view of a second patient, age 10 weeks.(D) Postoperative view, age 11 years. 27‘Annals of Plastic Surgery Vol 12 No 3. March 1984 Fig 11. Complete unilateral cleft lip nasal deformity. (A) Preoperative view at age 6 weeks. (B) Postoperative view, cage 5 years. (C} Preoperative view in a second patient, age 8 weeks. (D) Postoperative view, age 15 months. 28Broadbent and Woolf: Cleft Lip Nasal Deformity Fig 12. Complete long-term unilateral cleft ip nasal defor. ‘Fig 13. Infant dissection, bilateral cleft lip. (A) Lower lat- tity. (See also Figs 1 and 2, (A) Preoperative view at age 6 eral cartilages in their cleft inferior, an lateral position, ‘weeks, (B) Postoperative view, age 20 years. vray from each other in the midline and away from the ‘septalupper lateral cartilage junction area. Note bilateral dips in alar rims marking the domes of the nostrils and up-° « per limits of columella (dot). (B) Lower lateral cartilages lifted into position against septum and upper lateral cat lage to create columella, nostril, and nasal tip. Alar bases rotated toward base of columélla, (Photo courtesy of Mr. Harold MeComb, Perth, Australia) 209Annals of Plastic Surgery Vol 12 No 3 March 1984 Fig 14. Bilateral cleft lip and nasal deformity. (A, B) Pre- ‘operative views at age 3 months. (C) Operative view—na- sal tip split to suture lower lateral cartilages together at the nasal tip. (D, E} Postoperative views, age 1 year 230Broadbent and Woolf: Cleft Lip Nasal Deformity Fig 15, Unilateral cleft lip and nasal deformity, adult. (A) Preoperative view at age 8 weeks. (B) Postoperative view, ‘age 14 years, Lower lateral cartilage inadequately lifted into the nasal tip as an infant. (C) Postoperative view, age 16 years, one and one-half years after adult tip corrections. Lower lateral cartilage advanced into tip as could have been done at age 8 weeks. Note balance of tip highlights. 231Annals of Plastic Surgery Vol 12 No 3 March 1984 Fig 16. Long-term adult unilateral cleft lip nasal deformity. (See also Figs 1, 2, 12, 17) (A) Preoperative view—lower laveral cartilage subluxed inferiorly and laterally, age 6 weeks. (B) Postoperative view, age 5 years. Operative inac- curacies persist. (C) Postoperative view, age 11 years. Inac- curate correction of lower lateral cartilage position persists. (D) Postoperative view, age 17 years, two years after tip cor- rection. Lower lateral cartilage advanced into nasal tip. 232Broadbent and Woolf: Cleft Lip Nasal Deformity st 7 Ss Fig 17. Long-term adult unilateral cleft lip nasal deformity. . (A) Preoperative view at age 9 weeks. (B, C) Postoperative views, age 15 years. Typical cleft lip nose—lower lateral ‘cartilages uncorrected. (D, £) Pastoperative views, age 18 years, two years after adult tip correction. Lower lateral ‘cartilage lifted into proper position and anchored to junc- tion of septum and upper lateral cartilage. 233Annals of Plastic Surgery Vol 12 No 3 March 1984 of the patient with a cleft lip nasal deformity are avoidable, References 1, Berkley WT: The cleft ip nose. Plast Reconstr Surg 23567, 1959 2. Criklait GF, Ju DM, Symonds FC: Method for alaplasty in cleft lip nasal deformities. Plast Reconste Surg 24:588, 1959 3. Cronin TD: Lengthening columella by use of skin from nasal floor and ala, Plast Reconstr Surg 21:417, 1958 4, Dibbell DG: Cleft lip nasal reconstruction: correcting the classic unilateral defect, Plast Reconstr Surg 69:264, 1982 5. Edgerton MT, et al: Feasibility of exaniofacial osteoto- mies in infants and young children, Past Reconstr Surg 56464, 1975 [Abst] 6. Le Mesurier AB: Treatment of complete unilateral hare- lips. Plast Reconstr Surg 11:506, 1953 7, Millacd DR: Extensions of the rotationadvancemeint principle for wide unilateral cleft lip Past Reconstr Surg 42:535, 1968 8, Millard DR Jr: The unilateral cleft lip nose, Plast Re- constr Surg 34:169, 1964 9. Millard DR: Extensions of the rotation-advancement principle for wide unilateral cleft lips, Plast Reconstr Surg 42:535, 1968 10, Oniz-Monasterio F, Olmedo AA: Corrective shinoplasty before putierty: a long-term follow-up. Plast Reconstr Surg 68:381, 1981 11, Pegram M: Repair of congenital short columella, Past Reconstr Surg 14:305, 1954 12, Tennison CW: Repair of unilateral elefe lip by stencil method, Plat Reconstr Surg 9115, 1952 234