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Columella lengthening using a cartilage graft in the bilateral cleft lip-associated nose
J Oral MaxillofacSurg 53:149-157, 1995
Columella Lengthening Using a Cartilage Graft in the Bilateral Cleft Lip-Associated Nose: Choice of Cartilage According to Age TSUYQSHI TAKATO, MD,* YOSHIYUKI YONEHARA, MD,1AND TAKAHUMI SUSAMI, DDS:::I: Purpose: This article describes the technique of columellar lengthening using a cartilaginous strut in patients with a severely deformed bilateral cleftlipassociated nose. Materials and Methods: When the upper lip is not deficient, and especially when resection of lip scar tissue is indicated, the Millard forked flap technique is recommended. Advancement of the prolabium into the columella for lengthening, combined with an Abb6 flap for upper lip reconstruction, is indicated when a deficient upper lip is unable to provide adequate donor tissue. A cartilaginous strut is inserted behind the forked flap or the advanced prolabium. According to the age of the patient, septal cartilage, costal cartilage, or ear cartilage is selected. Ten patients with a severely deformed bilateral cleftlipassociated nose underwent these procedures. Results: In each case, the columella was lengthened satisfactorily. In four patients, the scar became hypertrophic at the base of the columella and scar revision was performed secondarily. Conclusions: A cartilaginous strut is the key to avoiding the tendency toward retraction or thickening of the lengthened columella. It gives a slight lift to the tip, provides more definition, and improves the columellar contour.
In complete bilateral clefts, the columella is usually short, the nasal tip is depressed, the alar bases are flared, and there is almost no nasolabial angle in profile. The optimal columellar lengthening procedure should be selected according to the particular nasolabial deformity and the age of the patient. However, whatever methods may be used, it is extremely difficult
to produce natural a columellar contour. The reconstructed columella tends to become thick and retracted. The addition of a cartilaginous strut is the key to avoiding the tendency toward thickening or retraction. It gives a lift to the tip, provides more definition, and improves the columellar contour. In adults, the septal cartilage is usually used. In younger patients, ear cartilage or costal cartilage is chosen so as not to disturb nasal growth. This method of correction has consistently produced good, long-lasting results. In this article, the surgical methods are described and three patients are presented.
Received from the Department of Oral Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan. * Associate Professor. f Attending Surgeon. :) Orthodontist. Address correspondence and reprint requests to Dr Takato: Department of Oral Surgery, Faculty of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113, Japan.
Materials and M e t h o d s When the upper lip is not deficient, and especially when resection of lip scar tissue is indicated, we use
© 1995 American Association of Oral and Maxillofacial Surgeons 0278-2391/95/5302-000853.00/0
149
150
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
i
i
i i
',o,;
FIGURE 1. Diagram of technique for advancement of the prolabium into the columella combined with an Abb6 flap for upper lip reconstruction.
the Millard forked flap technique. 1-4 Advancement of the prolabium into the columella for lengthening, combined with an Abb6 flap for upper lip reconstruction, is indicated when a deficient upper lip is unable to yield donor tissue (Fig 1). 5 The cartilaginous strut is inserted between the two medial crura in a pocket just large enough to accept the strut and prevent migration. The strut is secured with a 4-0 nylon transfixion suture across the base of the columella (Fig 2). According to
nasal bone
Q
19
19
FIGURE 3. Cartilage used for a columellar strut. 1) Ear cartilage (two pieces are sutured together); 2) costal cartilage (area indicated by oblique lines); and 3) septal cartilage (area indicated by oblique lines)i
the age of the patient, septal cartilage, costal cartilage, or ear cartilage is chosen (Fig 3). W h e n the columellar lengthening procedure is performed after adolescence, a septal cartilage strut is u s e d . 6'7 W h e n it is performed prior to adolescence, a costal cartilage strut is used. Ear cartilage is selected only during the preschool years. Ten patients with the severely deformed bilateral cleft lip-associated nose underwent these procedures. In four patients aged from 5 to 7 years, ear cartilage was used and the columella was lengthened with the forked flap. Costal cartilage was used in two patients aged 11 and 13 years. In the remaining four adult patients, septal cartilage was used. In these six patients, the columella was lengthened by advancing the prolabium, combined with an Abb6 flap for the upper lip reconstruction. The clinical follow-up ranged from 18 months to 5 years.
Results
cartilage
• .-°....
In each case, the columella was lengthened satisfactorily. In six patients whose columella was reconstructed with the advanced prolabium, the lengthened columella became naturally slim. In the four patients whose columella was reconstructed with the forked flap, it became slightly thicker in width. In these four patients, the scar became hypertrophic at the base of the columella and the scar revision was performed secondarily.
Report of Cases
cartilage strut Case 1
% FIGURE 2. Diagram of the corrected columella: the nasolabial angle is approximately 90°.
A 7-year-old boy presented with a strikingly short columella, flattened nasal tip, and almost no nasolabial angle in profile (Fig 4). The Millard forked flap technique was performed to lengthen the columella. A spindle-shaped strip of cartilage was procured from each ear, sutured together (Fig 3), and inserted behind the forked flap. Although the lengthened columella was slightly thickened, the nasal pro-
TAKATO, YONEHARA, AND SUSAMI
151
FIGURE4. Case 1: A 7-year-oldboy with bilateral cleft lip-associated nasal deformity. A, Preoperative frontal view. B, Preoperative lateral view. C, PreoperaUvebasal view.
jection and profile improved. At follow-up 3 years after surgery, the reconstructed nasal shape was maintained (Fig 5).
Case 2 An 11-year-old boy showed a deficient upper lip, a short columella, a depressed nasal tip, and flared alar bases (Fig 6). The whole prolabium was advanced to lengthen the columella and the philtrum was reconstructed with Abb6 flap. A
strip of costal cartilage (1.0 x 2.0 cm) was procured and inserted behind the advanced prolabium. Both the lip and the nasal contour improved (Fig 7). The reconstructed nasal shape was maintained at follow-up 2 years later.
Case 3 A 16-year-old boy showed a deficient upper lip, a short columella, and flared alar bases (Fig 8). A technique similar
"]52
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
FIGURE 5. Case 1 photographs 3 years after operation. A, Frontal view. B, Lateral view. C, Basal view.
to that in Case 2 was used to lengthen the columella and a strip of septal cartilage (1.2 × 2.3 cm) was inserted behind the advanced prolabium. Although the scar at the base of the columella became hypertrophic, both the lip and the nasal contour improved (Fig 9).
Discussion The bilateral cleft-associated nasal deformity is characteristic. Social pressures heighten the patient's
awareness o f the residual cleft lip nasal deformity, and consequently demands for correction intensify even during the preschool years. The short columella is the first region to be addressed and a wide variety of approaches have been d e s c r i b e d Y -13 Treatment can vary according to the severity of the problem and the age of the patient. The forked flap technique with advancement of the prolabium into the columella, combined
TAKATO, YONEHARA, AND SUSAMI
153
FIGURE 6. Case 2: An 11-year-old boy with bilateral cleft lipassociated nasal deformity. A, Preoperative frontal view. B, Preoperative lateral view. C, Preoperative basal view.
with an Abb6 flap, are the most effective procedures to lengthen the severely shortened columella. W e have not been able to obtain satisfactory results, however, using only such methods, because the lengthened colu-
mella became thick and retracted. Therefore, we added a columellar strut graft, which was proposed by Millard to increase nasal tip projection. 6'7'14 This method is more effective than previous methods for columellar
154
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
FIGURE 7. Case2 photographs 2 years after operation. A, Frontal view. B, Lateral view. C, Basal view.
lengthening. The additional cartilaginous strut embedded along the caudal border of the medial crus prevents collapse of the lengthened columella. A cantilevered iliac bone graft may be substituted when simultaneous augmentation rhinoplasty is indicated. 5 The donor site for the cartilage can vary according to the age of the patient. Although our preferred donor site for columellar grafts is the septum in adult patients, the removal of this cartilage may interfere
with nasal growth in younger patients. 6'7 When the operation is performed prior to adolescence, costal cartilage is used. Because costal cartilage is likely to result in warping, we use only the center of the cartilage according to the principle of a " b a l a n c e d cross-section." i5 This entails removal of all the perichondrium surrounding a full-thickness section of costal cartilage, as well as the outer layers, in a balanced profile (Fig 3). During the preschool years,
TAKATO, YONEHARA, AND SUSAMI
]55
FIGURE 8. Case 3: A 16-year-old boy with bilateral cleft lipassociated nasal deformity. A, Preoperative frontal view. B, Preoperative lateral view. C, Preoperative basal view.
ear cartilage is c h o s e n to support the forked flap, because the elongation is small in length. The d o n o r scar is not visible. B e c a u s e ear cartilage is rather soft, we take a piece f r o m each ear and suture them together. In these y o u n g patients, c o m p a r e d with adults, the reconstructed columella tends to b e c o m e thicker in width. This occurs because the small
forked flap is difficult to trim fully without interfering with flap viability. In this series, more satisfactory results were obtained than previously when cartilage struts were not used. W e believe that the requirement for success and prevention of relapse in columella lengthening is the cartilage strut, which provides additional structural sup-
156
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
FIGURE 9. Case 3: Photographs 2 years after operation. A, Frontal view. B, Lateral view. C, Basal view.
port and achieves the desired nasal projection and profile. References 1. Millard DR: Columella lengthening by a forked flap. Plast Reconstr Surg 22:454, 1958
2. Millard DR: The triad of columella deformities. Plast Reconstr Surg 31:370, 1963 3. Rehrmann A: Construction of the upper lip, columella, and orbicularis muscle in bilateral clefts. J Maxillofac Surg 3:2, 1975 4. Millard DR: Cleft Craft, vol II. Boston, MA, Little, Brown, 1977, pp 523-542 5. Jackson IT, Fasching MC: Plastic Surgery, vol 4. Philadelphia, PA, Saunders, 1990, pp 2771-2802
TAKATO, YONEHARA, AND SUSAMI 6. Nishimura Y, Ogino Y: Autogenous septal cartilage graft in the correction of cleft lip nasal deformity. Br J Plast Surg 31:222, 1978 7. Nishimura Y, Kumoi T: External septorhinoplasty in the cleft lip nose. Ann Plast Surg 26:526, 1991 8. Brown JB, McDowell F: Secondary repair of cleft lips and their nasal deformities. Am Surg 114:101, 1941 9. Marcks KM, Trevaskis AE, Payne MJ: Elongation of columella by flap transfer and Z-plasty. Plast Reconstr Surg 20:466, 1957 10. Cronin TD: Lengthening columella by use of skin from nasal floor and alae. Plast Reconstr Surg 21:417, 1958
157 11. Brauer RO, Foerster DW: Another method to lengthen the columella in the double cleft patients. Plast Reconstr Surg 38:27, 1966 12. Trauner R, Trauner M: Results of cleft lip operations. Plast Reconstr Surg 40:209, 1967 13. Potter J: The nasal tip in bilateral hare lip. Br J Plast Surg 21:173, 1968 14. Millard DR: Composite lip flap and grafts in secondary cleft deformities. Br J Plast Surg 17:22, 1964 15. Gibson T, Davis WB: The distortion of autogenous cartilage grafts; Its cause and prevention. Br J Plast Surg 10:257, 1958
Columella Lengthening Using a Cartilage Graft in the Bilateral Cleft Lip-Associated Nose: Choice of Cartilage According to Age TSUYQSHI TAKATO, MD,* YOSHIYUKI YONEHARA, MD,1AND TAKAHUMI SUSAMI, DDS:::I: Purpose: This article describes the technique of columellar lengthening using a cartilaginous strut in patients with a severely deformed bilateral cleftlipassociated nose. Materials and Methods: When the upper lip is not deficient, and especially when resection of lip scar tissue is indicated, the Millard forked flap technique is recommended. Advancement of the prolabium into the columella for lengthening, combined with an Abb6 flap for upper lip reconstruction, is indicated when a deficient upper lip is unable to provide adequate donor tissue. A cartilaginous strut is inserted behind the forked flap or the advanced prolabium. According to the age of the patient, septal cartilage, costal cartilage, or ear cartilage is selected. Ten patients with a severely deformed bilateral cleftlipassociated nose underwent these procedures. Results: In each case, the columella was lengthened satisfactorily. In four patients, the scar became hypertrophic at the base of the columella and scar revision was performed secondarily. Conclusions: A cartilaginous strut is the key to avoiding the tendency toward retraction or thickening of the lengthened columella. It gives a slight lift to the tip, provides more definition, and improves the columellar contour.
In complete bilateral clefts, the columella is usually short, the nasal tip is depressed, the alar bases are flared, and there is almost no nasolabial angle in profile. The optimal columellar lengthening procedure should be selected according to the particular nasolabial deformity and the age of the patient. However, whatever methods may be used, it is extremely difficult
to produce natural a columellar contour. The reconstructed columella tends to become thick and retracted. The addition of a cartilaginous strut is the key to avoiding the tendency toward thickening or retraction. It gives a lift to the tip, provides more definition, and improves the columellar contour. In adults, the septal cartilage is usually used. In younger patients, ear cartilage or costal cartilage is chosen so as not to disturb nasal growth. This method of correction has consistently produced good, long-lasting results. In this article, the surgical methods are described and three patients are presented.
Received from the Department of Oral Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan. * Associate Professor. f Attending Surgeon. :) Orthodontist. Address correspondence and reprint requests to Dr Takato: Department of Oral Surgery, Faculty of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113, Japan.
Materials and M e t h o d s When the upper lip is not deficient, and especially when resection of lip scar tissue is indicated, we use
© 1995 American Association of Oral and Maxillofacial Surgeons 0278-2391/95/5302-000853.00/0
149
150
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
i
i
i i
',o,;
FIGURE 1. Diagram of technique for advancement of the prolabium into the columella combined with an Abb6 flap for upper lip reconstruction.
the Millard forked flap technique. 1-4 Advancement of the prolabium into the columella for lengthening, combined with an Abb6 flap for upper lip reconstruction, is indicated when a deficient upper lip is unable to yield donor tissue (Fig 1). 5 The cartilaginous strut is inserted between the two medial crura in a pocket just large enough to accept the strut and prevent migration. The strut is secured with a 4-0 nylon transfixion suture across the base of the columella (Fig 2). According to
nasal bone
Q
19
19
FIGURE 3. Cartilage used for a columellar strut. 1) Ear cartilage (two pieces are sutured together); 2) costal cartilage (area indicated by oblique lines); and 3) septal cartilage (area indicated by oblique lines)i
the age of the patient, septal cartilage, costal cartilage, or ear cartilage is chosen (Fig 3). W h e n the columellar lengthening procedure is performed after adolescence, a septal cartilage strut is u s e d . 6'7 W h e n it is performed prior to adolescence, a costal cartilage strut is used. Ear cartilage is selected only during the preschool years. Ten patients with the severely deformed bilateral cleft lip-associated nose underwent these procedures. In four patients aged from 5 to 7 years, ear cartilage was used and the columella was lengthened with the forked flap. Costal cartilage was used in two patients aged 11 and 13 years. In the remaining four adult patients, septal cartilage was used. In these six patients, the columella was lengthened by advancing the prolabium, combined with an Abb6 flap for the upper lip reconstruction. The clinical follow-up ranged from 18 months to 5 years.
Results
cartilage
• .-°....
In each case, the columella was lengthened satisfactorily. In six patients whose columella was reconstructed with the advanced prolabium, the lengthened columella became naturally slim. In the four patients whose columella was reconstructed with the forked flap, it became slightly thicker in width. In these four patients, the scar became hypertrophic at the base of the columella and the scar revision was performed secondarily.
Report of Cases
cartilage strut Case 1
% FIGURE 2. Diagram of the corrected columella: the nasolabial angle is approximately 90°.
A 7-year-old boy presented with a strikingly short columella, flattened nasal tip, and almost no nasolabial angle in profile (Fig 4). The Millard forked flap technique was performed to lengthen the columella. A spindle-shaped strip of cartilage was procured from each ear, sutured together (Fig 3), and inserted behind the forked flap. Although the lengthened columella was slightly thickened, the nasal pro-
TAKATO, YONEHARA, AND SUSAMI
151
FIGURE4. Case 1: A 7-year-oldboy with bilateral cleft lip-associated nasal deformity. A, Preoperative frontal view. B, Preoperative lateral view. C, PreoperaUvebasal view.
jection and profile improved. At follow-up 3 years after surgery, the reconstructed nasal shape was maintained (Fig 5).
Case 2 An 11-year-old boy showed a deficient upper lip, a short columella, a depressed nasal tip, and flared alar bases (Fig 6). The whole prolabium was advanced to lengthen the columella and the philtrum was reconstructed with Abb6 flap. A
strip of costal cartilage (1.0 x 2.0 cm) was procured and inserted behind the advanced prolabium. Both the lip and the nasal contour improved (Fig 7). The reconstructed nasal shape was maintained at follow-up 2 years later.
Case 3 A 16-year-old boy showed a deficient upper lip, a short columella, and flared alar bases (Fig 8). A technique similar
"]52
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
FIGURE 5. Case 1 photographs 3 years after operation. A, Frontal view. B, Lateral view. C, Basal view.
to that in Case 2 was used to lengthen the columella and a strip of septal cartilage (1.2 × 2.3 cm) was inserted behind the advanced prolabium. Although the scar at the base of the columella became hypertrophic, both the lip and the nasal contour improved (Fig 9).
Discussion The bilateral cleft-associated nasal deformity is characteristic. Social pressures heighten the patient's
awareness o f the residual cleft lip nasal deformity, and consequently demands for correction intensify even during the preschool years. The short columella is the first region to be addressed and a wide variety of approaches have been d e s c r i b e d Y -13 Treatment can vary according to the severity of the problem and the age of the patient. The forked flap technique with advancement of the prolabium into the columella, combined
TAKATO, YONEHARA, AND SUSAMI
153
FIGURE 6. Case 2: An 11-year-old boy with bilateral cleft lipassociated nasal deformity. A, Preoperative frontal view. B, Preoperative lateral view. C, Preoperative basal view.
with an Abb6 flap, are the most effective procedures to lengthen the severely shortened columella. W e have not been able to obtain satisfactory results, however, using only such methods, because the lengthened colu-
mella became thick and retracted. Therefore, we added a columellar strut graft, which was proposed by Millard to increase nasal tip projection. 6'7'14 This method is more effective than previous methods for columellar
154
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
FIGURE 7. Case2 photographs 2 years after operation. A, Frontal view. B, Lateral view. C, Basal view.
lengthening. The additional cartilaginous strut embedded along the caudal border of the medial crus prevents collapse of the lengthened columella. A cantilevered iliac bone graft may be substituted when simultaneous augmentation rhinoplasty is indicated. 5 The donor site for the cartilage can vary according to the age of the patient. Although our preferred donor site for columellar grafts is the septum in adult patients, the removal of this cartilage may interfere
with nasal growth in younger patients. 6'7 When the operation is performed prior to adolescence, costal cartilage is used. Because costal cartilage is likely to result in warping, we use only the center of the cartilage according to the principle of a " b a l a n c e d cross-section." i5 This entails removal of all the perichondrium surrounding a full-thickness section of costal cartilage, as well as the outer layers, in a balanced profile (Fig 3). During the preschool years,
TAKATO, YONEHARA, AND SUSAMI
]55
FIGURE 8. Case 3: A 16-year-old boy with bilateral cleft lipassociated nasal deformity. A, Preoperative frontal view. B, Preoperative lateral view. C, Preoperative basal view.
ear cartilage is c h o s e n to support the forked flap, because the elongation is small in length. The d o n o r scar is not visible. B e c a u s e ear cartilage is rather soft, we take a piece f r o m each ear and suture them together. In these y o u n g patients, c o m p a r e d with adults, the reconstructed columella tends to b e c o m e thicker in width. This occurs because the small
forked flap is difficult to trim fully without interfering with flap viability. In this series, more satisfactory results were obtained than previously when cartilage struts were not used. W e believe that the requirement for success and prevention of relapse in columella lengthening is the cartilage strut, which provides additional structural sup-
156
COLUMELLA LENGTHENING USING A CARTILAGE GRAFT
FIGURE 9. Case 3: Photographs 2 years after operation. A, Frontal view. B, Lateral view. C, Basal view.
port and achieves the desired nasal projection and profile. References 1. Millard DR: Columella lengthening by a forked flap. Plast Reconstr Surg 22:454, 1958
2. Millard DR: The triad of columella deformities. Plast Reconstr Surg 31:370, 1963 3. Rehrmann A: Construction of the upper lip, columella, and orbicularis muscle in bilateral clefts. J Maxillofac Surg 3:2, 1975 4. Millard DR: Cleft Craft, vol II. Boston, MA, Little, Brown, 1977, pp 523-542 5. Jackson IT, Fasching MC: Plastic Surgery, vol 4. Philadelphia, PA, Saunders, 1990, pp 2771-2802
TAKATO, YONEHARA, AND SUSAMI 6. Nishimura Y, Ogino Y: Autogenous septal cartilage graft in the correction of cleft lip nasal deformity. Br J Plast Surg 31:222, 1978 7. Nishimura Y, Kumoi T: External septorhinoplasty in the cleft lip nose. Ann Plast Surg 26:526, 1991 8. Brown JB, McDowell F: Secondary repair of cleft lips and their nasal deformities. Am Surg 114:101, 1941 9. Marcks KM, Trevaskis AE, Payne MJ: Elongation of columella by flap transfer and Z-plasty. Plast Reconstr Surg 20:466, 1957 10. Cronin TD: Lengthening columella by use of skin from nasal floor and alae. Plast Reconstr Surg 21:417, 1958
157 11. Brauer RO, Foerster DW: Another method to lengthen the columella in the double cleft patients. Plast Reconstr Surg 38:27, 1966 12. Trauner R, Trauner M: Results of cleft lip operations. Plast Reconstr Surg 40:209, 1967 13. Potter J: The nasal tip in bilateral hare lip. Br J Plast Surg 21:173, 1968 14. Millard DR: Composite lip flap and grafts in secondary cleft deformities. Br J Plast Surg 17:22, 1964 15. Gibson T, Davis WB: The distortion of autogenous cartilage grafts; Its cause and prevention. Br J Plast Surg 10:257, 1958