SPECIAL TOPIC

Primary Repair of the Bilateral Cleft Lip Nose:

A Long-Term Follow-Up
Harold K. McComb,
F.R.A.C.S., F.R.C.S., F.A.C.S.
Perth, Western Australia, Australia
Background: The author previously published a method of primary repair of
bilateral cleft lip nasal deformity using an open tip rhinoplasty to enable cor-
rection of the displaced and deformed alar cartilages.
Methods: The first 10 consecutive children who had this treatment have been
followed through to adulthood. They are now 18 to 19 years old, and the
long-term results of this primary nasal repair are reviewed.
Results: In general, the repair has been effective and stable. There has been no
interference with growth. In most cases, the external nasal scars are barely
noticeable.
Conclusions: In primary treatment of the bilateral cleft lip nose, an open tip
rhinoplasty enables accurate replacement of the alar cartilages and correction
of the deformity. It justifies the creation of an external scar that is usually
unnoticeable. (Plast. Reconstr. Surg. 124: 1610, 2009.)

T
he key to treatment of the cleft lip nose is
correction of the displaced and deformed alar
cartilages. In a bilateral cleft, the alar cartilages
are pulled apart and flattened (Fig. 1). The inter-
crural angles are separated widely and the colu-
mellar crura are unzipped down toward the col-
umellar base. As a result, the columella disappears
into a broad nasal tip and the lower margins of the
alar cartilages push up oblique ridges within the
nasal vestibules.
In 1990, a method of primary repair of the
bilateral cleft lip nose was described.1An early fol-
low-up was published in 1994.2 Essentially, an
open-tip rhinoplasty is performed at the time of lip
repair that enables accurate replacement of the
alar cartilages and consequent reestablishment of
the columella and narrowing of the nasal tip (Fig.
2). The distorted skin over the tip is rearranged by Fig. 1. In the bilateral cleft lip nose, the alar domes are pulled
a V-Y plasty. No incisions are made in the nostril apart. The columellar crura are separated progressively back to-
lining, which carry the risk of stenosis in an in- ward the nasal spine. The elements of the columella disappear
fant’s nose. into the broad nasal tip. (Reproduced with permission from Trier
The first 10 children who had this treatment WC. Cleft lip nasal deformity. In: Serafin D, Georgiade NG, eds.
have been followed through to early adult life. Of Pediatric Plastic Surgery. St. Louis: Mosby; 1984.)
particular interest is the long-term appearance of
the external nasal scars and the effectiveness and
stability of the repair. The final outcome of treat-
From Princess Margaret Hospital for Children. ment of cleft patients depends on the interaction
Received for publication October 8, 2007; accepted February of intrinsic growth patterns, muscle forces, and
26, 2009.
Presented at Cleft & Cranio-Maxillofacial Anomalies, Royal
Children’s Hospital, in Melbourne, Australia, September 20
through 23, 2007. Disclosure: The author has no financial interest to
Copyright ©2009 by the American Society of Plastic Surgeons disclose in relation to the content of this article.
DOI: 10.1097/PRS.0b013e3181b98b5d

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Volume 124, Number 5 • Bilateral Cleft Lip Nose

Fig. 2. Nasal tip incisions are made half the width of the columella above
each nostril rim. Elevation of the triangular flap exposes the separated
alar domes and the columellar crura. Tension is taken out of the nasal tip
by repairing the nostril floors. The alar domes and columellar crura are
then sutured. The columella reforms and the tip is narrowed.

the effects of scarring, and can only be judged
when the patients are fully grown.
The first patients are now 18 to 19 years old.
One patient (shown in Fig. 6, below, right) was lost
to follow-up when he was 14 years old. All of the
patients have had alveolar bone grafts. Further
treatment is planned for some patients, but at this
age, it is reasonable to make a final assessment of
their nasal development.
The effectiveness of a new procedure can be
judged best by examining the results in an uns-
elected group of consecutive patients. The follow-
ing are the long-term results in the first 10 patients
who had this primary repair of their bilateral cleft
lip nasal deformity. Full presentation of the results
is limited by publishing space, but each of the
patients’ noses is viewed from below to show the
most critical aspect of their nasal development
and the final appearance of the nasal scars. A more
accurate assessment would be made by also exam-
ining preoperative and lateral views in each case.
Two patients are shown in more detail. The
first patient (Fig. 3) is 19 years old and works as an
artist. She has van der Woude syndrome. Four
months ago, she had an advancement genioplasty
and shaving of a small dorsal nasal hump that was
approached through the original nasal tip scar.
The development of her nose is satisfactory, but
the nasal scar is still a little vascular following the
recent surgery.
The second patient is a medical student (Fig.
4) who is now 18 years old. At 9 years of age, he
had a further procedure to narrow his nasal tip by
joining the intercrural angles of the alar cartilages
more closely, with the addition of a cartilage graft.
This was performed through the site of the orig-
inal nasal scar, which is barely noticeable despite
this further surgery.
Nasal views from below in each of the other
eight patients are shown (Figs. 5 and 6). One
patient, a trainee aircraft mechanic (Fig. 6, above,
left), had a costochondral cantilever nasal graft
and columellar strut to accentuate his nasal bridge
line at 17 years of age, and narrowing of his left
nostril. One patient (Fig. 6, above, right) is very
dysmorphic, and this is reflected in her nasal de-
formity. She is unemployed. At 13 years of age, the
width of her nostrils was adjusted and lateral full-
ness of her nasal tip was trimmed. She is due for
correction of her hanging columella and an Abbe
flap. The remaining six patients have had no fur-
ther surgery to their noses. One patient, a university
student (Fig. 6, below, left), has had a maxillary ad-
vancement and is due for final adjustment of her
nostrils. Two patients (Fig. 5, above, left and below,
right) are due to have maxillary advancement osteot-
omies. One patient, a hairdresser (Fig. 5, above,
right), has irregular nostrils when seen from below,
but she is satisfied with her appearance and does not
want further treatment. The last patient (Fig. 6, be-
low, right) was adopted as a baby from Sri Lanka. He
was lost to follow-up at age 14 years.
In general, the nasal development of each of
the patients has been satisfactory. There has been
no interference with growth, and in most cases,
the nasal scars are unnoticeable unless deliber-
ately examined from below. In some patients,
there has been a tendency for thickening and
slight bulbousness of the nasal tip. This slowly

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 Plastic and Reconstructive Surgery • November 2009

Fig. 3. A 19-year-old patient with stable nasal correction. The nasal tip scar is slightly pink from recent
opening to shave a nasal hump.

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Volume 124, Number 5 • Bilateral Cleft Lip Nose

Fig. 4. An 18-year-old patient with stable nasal correction and minimal external scarring.

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 Plastic and Reconstructive Surgery • November 2009

Fig. 5. Nasal views from below of four of the remaining eight subjects in a consecutive group of 10 patients.

Fig. 6. Nasal views from below of the remaining four of eight subjects in a consecutive group of 10 patients.
Only two of these patients (above, left and right) have had further nasal surgery.

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Volume 124, Number 5 • Bilateral Cleft Lip Nose

improves with growth. The nasal scars are almost ACKNOWLEDGMENTS

always insignificant on ordinary viewing.
An open tip rhinoplasty in the primary treat-
ment of a bilateral cleft lip nose enables accurate
replacement of the alar cartilages. It justifies cre-
ation of an external nasal scar that is usually neg-
ligible and, in any case, hard to see.
Harold K. McComb, F.R.A.C.S., F.R.C.S., F.A.C.S.
20 Colin Street
West Perth, Western Australia 6005, Australia
harold@iexpress.net.au
The author is indebted to Drs. Tony Baker, David
Gillett, and Mark Moore for ongoing treatment of these
patients.
REFERENCES
1. McComb H. Primary repair of the bilateral cleft lip nose: A
15-year review and a new treatment plan. Plast Reconstr Surg.
1990;86:882–889; discussion 890–893.
2. McComb H. Primary repair of the bilateral cleft lip nose: A
4-year review. Plast Reconstr Surg. 1994;94:37–47; discussion
48–50.

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