Primary Repair of the Bilateral Cleft Lip Nose: A 15-Year Review and a New Treatment Plan Harold McComb, F.R. Perth, Western Australia FRAC, For 15 yearsa forked flap has been used for columella reconstruction in primary repair of the bilateral cleft lip nose. With the adolescent growth spurt, three unfavora- ble features have become apparent: (I) the columella may grow too long and the nostrils too large, (2) often the asal tip remains broad, and (8) there is drift of the columellar base and the lip-columellar angle is trans- gressed by scar. This procedure has therefore been dis- continued. A new treatment plan is presented in which the columella is reconstructed from tissues in the splayed- out nasal tp. The bilateral cleft lip nose is characterized by a short columella and a broad, depressed nasal tip. The key to correction of this deformity lies in the displaced alar cartilages. In unilateral cleft lips it has been found that the associated nasal deformity can be corrected at the time of lip repair by elevating the slumped alar cartilage on the side of the cleft.' In the bilateral cleft lip nose it seemed a logical step to elevate both alar cartilages after they have been first released by lengthening the columella. The columella is lengthened by a primary forked flap taken from the sides of the prolabium. The nasal development of these children has been followed closely. When the first group was reviewed at 10 years of age, the results appeared to be reasonably satisfactory.” However, as they approach their adolescent growth spurt at 15 years of age, three undesirable features have become obvious. First, the nostrils are often larger than normal (Figs. 1, below, left, and 2, below, left). Thisis due to an increase in the length of the columella. The columellar growth in 23 bilateral cleft children who have had primary columella lengthening has been compared with growth in a sample of 375 normal Caucasian children (Fig. 3). In almost every case, the recon- structed columella is longer than normal. The second undesirable feature is broadening of the nasal tip (Figs. 1, above,right, and 2, above, rright). This is due to persistent, wide separation of the domes of the alar cartilages. The third feature is downward drift of the columellar base (Figs. 1, below, right (corrected), 2, below, right, and 4, right}. The normal lip- columellar angle is also transgressed by scarring from the primary columella reconstruction. Because of these defects that seem to be inher- ent in the forked-flap procedure, this method of primary reconstruction of the columella has been discontinued. Embryologically, the prolabium belongs in the lip. Its use in the columella has been a convenient compromise. Nasal dissections in stillborn infants show that the alar domes have been pulled apart and the columellar crura are increasingly separated from the nasal spine to the domes of the alae. The columella has in fact been unzipped and its com- ponent parts lie within the broad nasal tip (Fig. 5). Ideally, then, the columella should be recon- structed from these tissues that already lie within the nasal tip: The columellar crura should be brought together, and the alar domes should be united. Furthermore, this reconstruction does not violate the normal lip-columellar junction Broadbent and Woolf* have demonstrated the From the Department of Plastic Surgery at the Princess Margaret Hospital for Children, Received for publication August 10, 1980: revised 82 onal Congress on Cleft Palate and Related Craniofacial Anomalies, in Jerusalem, Ira, in June of 1989)Vol. 86, No. 5 / BILATERAL CLEFT LIP NOSE 883 Fic. 1. Appearance at 15 years of age. The nasal tip is broad and the nostrils are large. The ccolumellar base has been adjusted by a secondary procedure.884 PLASTIC AND RECONSTRUCTIVE SURGERY, November 1990 Fic. 2. Appearance at 15 years of age. The nasal tip is broad and the nostrils are large. There is some caudal drift of the columellar base,Vol. 86, No. 5 / BILATERAL CLEFT LIP NOSE 885 CCOLUMELLA LENGTH (nvm) FiG. 3. Columellar growth in 23 bilateral clefis (open triangles) cor iren. In almost every case the reconstructed columel is longer than normal Fic. 4, Appearance at 15 years of age. There is some drift of the columellar base.886 PLASTIC AND RECONSTRUCTIVE SURGERY, November 1990 Fic. 5. In the bilateral cleft lip nose the alar domes are pulled apart. The columellar erura are progressively sepa rated from the nasal spine to the domes of the alae. The columellar elements lie within the broad nasal tip. (Repro- duced by permission from W. C. Trier, Cleft Lip Nazal Deformity, In D. Serafin and N. G. Georgiade, Pediatric Plastic Surgery St Louis: Mosby, 1984.) Fic. 6. (a) Nasal tip incisions outline half the colume width above each nostri vim. (8) Elevation of the triangular Aap exposes the separated ala domes and columella errs (6) The alar domes and nasal vestibules are positioned with 7. (Above) Edges of the columellar incisions undermined to void a grooved sear, (Center) The columella is sutured to a length of 5 mm. (Below) The lifting sutures are removed. Lateral mattress sutures are used to obliterate dead space. lifiing sutures before the nostril floors are closed. (d) Ten: sion is taken out of the masal tip by repairing the nostril floors and establishing lip adhesions. The alar domes and columellar crura are then sutured, The columella re-formsVol. 86, No. 5 / BILATERAL CLEFT LIP NOSE be safely separated from the premaxills feasibility of uniting the alar cartilages at the time of primary lip repair. The first step in primary reconstruction of the bilateral cleft lip nose is the use of preoperative orthopedics to narrow the soft-tissue clefts and realign the bony platform. Surgical repair of the bilateral lip and nasal deformity is performed in two stages. At the first stage, tension is taken out of the nasal tip by repairing the nostril floors and creating long lip adhesions. The columella is 887 Fic. 8. Lip repair is completed 4 weeks afier nasal reconstruction, when the prolabium can reconstructed from tissues within the nasal tip. At the second stage, 1 month later, the prola- bium is lifted away from the premaxilla and mucomuscular flaps are advanced to complete the lip repair. To reconstruct the columella, a point is marked in the midline where it begins to broaden ‘out into the nasal tip (Fig. 6, a). In a severe case, this might be right back at the columellar base. Incisions are marked out, each outlining half the888 PLASTIC AND RECONSTRUCTIVE SURGERY, November 1990 Fic. 9. Postoperative appearance at 6 months. width of the columella and extending around and above each nostril rim. These incisions are continued well laterally The skin of the nose is widely undermined by sharp-pointed scissors that are introduced through each upper buccal sulcus. Each alar base is freely mobilized. The lip dissection is com- pleted, the triangular nasal flap that has been outlined is elevated, exposing the alar cartilages (Fig. 6, 8). The alar domes are cleaned, and the intervening soft tissue is carefully removed. ‘The nasal scars fade quickly It is necessary to release the tension in the nasal tip before the alar domes can be sutured together. This is achieved by closing the lip clefts and repairing the nostril floors. Lifting sutures are inserted to position the alar domes with the attached lining of the nasal vestibules. The nostril floors are then repaired, and long lip adhesions are established (Fig. 6, ¢). When the tension across the nasal tip is removed, the alar domes can be easily sutured together, and the columella re-forms (Fig. 6, d).Vol. 86, No. 5 / BILATERAL CLEFT LIP NOSE The skin edges above the nostril rims are carefully undermined to allow eversion of the suture lines (Fig. 7, above). The skin flaps are sutured together to reconstitute a columella that is 5.0 mm in length, measured from its base to the level of the intercrural angles of the nostril margins’ (Fig. 7, center). The triangular flap of covering nasal skin is sutured in position, paying in the long edges against the shorter edges around the nostril rims (Fig. 7, below). Finally, the elevating sutures are removed. They are no longer necessary to hold the alar domes that are now sutured together. Lateral mattress sutures are inserted to obliterate the dead space beneath the nasal skin. Initially, the bilateral lip and nostril deformity was corrected in a single stage: The columella was reconstructed from the nasal tip, and the prolabium also was lifted from the premaxilla to complete the lip repair. However, the nasal tip dissection does jeopardize the blood supply to the prolabium, and in one patient the mucosal apex of the prolabial flap was lost. The repair is now performed in two stages. The prolabium is left attached to the premaxilla while the nose is repaired at the first stage. 889 ‘The second stage is performed 1 month later when the prolabium can be safely separated from the premaxilla. The lip adhesions are undone and the lateral mucomuscular flaps are brought together in front of the premaxilla to re-form the oral sphincter and to reconstitute the upper buccal suleus (Fig. 8). The nasal scars fade quickly, good tip projec- tion is achieved, and the lip-columellar angie is undisturbed (Fig. 9). A preliminary follow-up report will be presented when the first consecu- tive group of children reaches 3 years of age Harold McComb 20 Colin Street West Perth, Western Australia Australia 6005 REFERENCES L. McComb, H. Primary correction of unilateral cleft lip, nasal deformity: A 10-year review. Plast. Reconztr. Surg, 75: 791, 1986. 2 McComb H. Primary repair of the bilateral cleft lip nose: A 10-year reviews, Plast Reconstr. Surg. 77: 701 1986. 3. Broadbent, T. R., and Woolf, R. M, Cleft lip nasal deformity. Ann. Plast Surg. 12: 216, 1984