PRIMARY REPAIR OF UNILATERAL CLEFT LIP NASAL DEFORMITY HAROLD McCOMB, FRACS, FRCS, FACS ‘Twenty-one years ago, the author developed a deformity, which was published in 1975. new method of primary repair of unilateral cleft lip nasal Essentially this consisted of raising the slumped alar cartilage at the time of lip repair, without making incisions in the nasal lining, The first 10 children were followed up through to adult life (the end of their second decade), During this time, the repair remained stable, and there was no interference with normal nasal growth and development. Copyright © by W.B. Saunders Company KEY WORDS: unilateral clft lip, cleft ip nasal deformity Long-term follow-up studies, through to adult life, show that primary repair of clef lip nasal deformity does rot interfere with normal nasal growth and develop- ment.! Correction of the deformity is stable.* ANATOMY ‘The alar cartilage is the centerpoint of cleft lip nasal de- formity. In unilateral clefts, the alar cartilage is splayed out, and it is rotated caudally downward. The lower border of the lateral crus produces an oblique ridge in the nasal vestibule, and the nostril rim droops. ‘The alar dome is pulled laterally and downward, caus- ing irregularity of the nasal tip and shortening of the columella on the cleft side (Fig 1).° If the nostril is repaired without lifting the alar carti- lage, a compound curve is created in the nostril, which results in the typical flare of the cleft-lip nose. Lifting the slumped alar cartilage is an essential step in treatment of the unilateral cleft lip nose. PRESURGICAL ORTHOPEDICS If the cleft is complete, preliminary alignment of the max- illary segments by presurgical orthopedics is desirable, but it is not absolutely essential. The main value of pre- surgical orthopedics is to facilitate the soft tissue repair. ‘When the underlying bony skeleton is correctly aligned, tension in the repair is minimized and the soft tissues can, be placed more easily in their correct position. ‘The patient should be treated early, while the facial skeleton is soft and can be molded easily. Presurgical orthopedics is begun on the day of birth when impres- sions of the alveolar arch are taken. On the following, day, a guiding plate is fitted with external elastic strap- ping. Maxillary alignment is complete by 4 to 6 weeks of age. THE REPAIR ‘The lip and nose are repaired simultaneously between 6 and 12 weeks of age._ If the repair is performed earlier, the nasal tissues are delicate and difficult to handle The lip and nase on the side of the cleft are infitrated with 0.5% lignocaine and 1:200,000 adrenalin to minimize blood loss. After drawing and lightly incising the lip markings, incisions are made in the mucosa of the upper buccal sulcus on each side of the cleft. Sharp-pointed scissors are introduced through the i cision in the lateral upper buccal sulcus, and they are used to free the skin entirely from the nasal skeleton on the side of the cleft. This dissection extends from the nostril rim below to the nasion above, and across to the opposite side of the nasal tip (Fig 2). ‘The scissors are next inserted through the incision in the upper buccal sulcus on the medial side of the cleft, freeing the skin from the columellar crura and extending up across the nasal tip to join the previous dissection from the lateral side. This dissection completely and widely undermines the nasal skin on the cleft side ofthe nose. "The lip incisions and dissection are then completed, ‘The first sutures that are placed in the repair are long lifting mattress sutures that raise the slumped alar carti- lage on the side of the cleft to its normal level. 5-0 silk sutures are used mounted on long straight cutting edge needles. Usually 2 mattress sutures are required. The first suture is passed from within the nasal vesti- ble, through the intercrural angle of alar cartilage to lift Operative Techniques in Plastic and Reconstructive Surgery, Vol 2, No 3 (August), 1995: pp 200-205Fig 1. In the unilateral clett ip nose the alar cartilage Is ro- tated downwards; the nostril rim droops (A) and the lower border of the lateral crus produces an oblique ridge in the ‘vestibule (B). The nasal tip is irregular. the alar dome. The needle point enters the dead space that has been previously dissected and passes up through the dissected area to emerge in the region of the nasion (Fig 3). The suture is looped over a small gauze bolster that rounds out the dome of the vestibule (Fig 4). ‘A second similar suture is passed from within the nasal vestibule, through the lateral crus of the alar cartilage, ‘emerging at the nasion after traversing the dissected dead. space (Fig 5). Gentle traction on these sutures elevates, the alar cartilage and the nostril rim to a i position (Fig 6). It is important not to overcorrect the nasal elevation because this can result in permanent rais- ing of the nostril margin on the cleft side. UNILATERAL CLEFT LIP NOSE REPAIR Fig 2. Sharp-pointed scissors are introduced through the upper buccal sulcus and used to completely undermine the ‘nasal skin on the side of the cleft. When the nostril rims are level, the nasal floor and lip tissues are repaired. The nasal lining must be lifted and. ‘moved to its correct position before the nasal floor is re- paired (Fig 7). If the floor of the nose is sutured while the nasal cartilage is slumped, the misplaced nasal lining, which is circumferentially shortened, will subsequently ppull the alar cartilage back into its original position of downward rotation. ‘At the completion of the repair, the direction of the original lifting sutures is usually altered to finally adjust the shape of the nostril. The sutures are removed and replaced to obtain better rounding and symmetry of the nostril rim. The sutures are lightly tied over small bol- sters to maintain the nasal symmetry. It is sometimes difficult to avoid minor dimpling of the contour above the nostril margin. Longitudinal studies have shown that this slight iregularity smooths off spontaneously during, the adolescent growth spurt of nasal development. Finally a lateral suture is added on the side of the nose to obliterate the dead space created by the initial dissec- tion (Figs 8 and 9).Fig 4. A small bolster Is used to round out the dome. Fig 3. A mattress suture picks up the alar dome. It passes ‘through the dissected dead space and emerges at the nasion. 202 HAROLD MecOMB:) (. © ) (am Fig 6. Gentle traction on the sutures lifts the alar cartilage. ‘The clet lip nasal stigmata disappear and the nostri floor is Fig 5. A second mattress suture is passed through the lat. ‘e" repaired. feral crus of the alar cartilage. UNILATERAL CLEFT LIP NOSE REPAIR 203Fig 7. The nasal lining, HAROLD McCOMBPOSTOPERATIVE MANAGEMENT ‘The elevating sutures and the lateral mattress suture are removed on the 7th postoperative day. By this time the nasal skin has shortened and healed, so that the lifted, alar cartilage is held in place. ESSENTIAL FEATURES OF THE REPAIR () Very wide undermining of the nasal skin on the side ‘of the cleft; (2) No incisions are made in the nasal lining; (@) The first and last sutures used in the repair are the Tong, lifting mattress sutures. UNILATERAL CLEFT LIP NOSE REPAIR, REFERENCES 1. McComb H: Treatment ofthe unilateral clef lip nose, Plast. Recon- ste. Surg. 5558601, 1975 2, McComb H: Primary corection of unilateral ef ip nasal deform- ty: A lObyear review. Past Reconstr Surg 7791-797, 1985. 5. McComb Ht Results of primary repair ofthe unilateral cle lip nose: Completion ofan 18-year longitudinal study. 7h International Con- frees on Cleft Palate and Related Craniofacial Anomalies, 1983, 4. McComb HK, Coghlan BA: Results of primary repair ofthe unit eal cleft ip nose: Completion ofa longitudinal stay. Cleft Palate} (in press) 5. McComb H: The nasal deformity in Cleft, in Kemahan DA, Rosen stein SW, (eds: Cleft Lip and Palate: A‘System of Management Baltimore, MD, Willams and Wilkins, 199, pp 6873 205