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Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps from the unaffected side
British Journal of Plastic Surgery (2005) 58, 312–317
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps from the unaffected side Ikkei Tamada, Tatsuo Nakajima*, Hisao Ogata, Fumio Onishi Department of Plastic Surgery, Keio University Hospital, Tokyo 160-8582, Japan Received 24 June 2002; accepted 9 November 2004
KEYWORDS Cleft lip; Nose deformity; Subcutaneous pedicle flap
Summary We used three types of subcutaneous pedicle flaps harvested from the unaffected side of the nostril to repair postoperative nose deformity caused by primary cleft lip surgery. By moving the subcutaneous pedicle flap from a nearby tissue-rich area, it was possible to achieve a favourable symmetrical nasal contour for the narrowing of the nostril cavity, depression of the nostril floor and the columella deviation of the affected side. The method, we used here is technically simple. We believe this procedure is a method of choice for repairing small deformities of the nose occurring after primary or secondary cleft lip surgery. Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
The secondary repair of the cleft lip and nose often involves deviations of the columella toward the affected side, narrowing of the nostril cavity on the affected side or depression of the nasal floor. It is not uncommon to encounter cases that require specialised techniques other than the previously reported Rethi procedure,1 modified reverse U procedure,2,3 or inverted trapezoid suture4,5 to achieve adequate left-right symmetry of the nasal cavity. In such situations, we previously performed repairs using a Z-plasty of the superior border of the nostril rim (soft triangle) or a local flap. If these procedures are insufficient, the areas with
* Corresponding author. Tel.: C81 03 5363 3814. E-mail address: [email protected] (I. Tamada).
tissue defect were treated with full-thickness skin graft, auricular cartilage graft or palatal mucosal graft.6 In this report, we transfer excess tissue from the peri-nostril area of the unaffected side to the affected side as a subcutaneous pedicle flap. It is possible to achieve a symmetrical nasal contour for correcting narrowed nostril cavity and depression of the nasal floor. We report on the three types of subcutaneous pedicle flaps used here and describe case examples.
Materials and methods We repaired postoperative deformities of cleft lip and nose using three types of subcutaneous pedicle
S0007-1226/$ - see front matter Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.11.012
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps
313
Surgical procedure Subcutaneous pedicle flap unaffected nostril floor In this method, tissue from the base of the nostril at the unaffected side is used as the subcutaneous pedicle skin flap and is moved to the affected side, with the intention of repairing the depressed alar base and adjusting the width of the nasal floor to achieve left-right symmetry. Harvest of the flap is approached via modified open reverse-U incision. The pedicle of the flap is soft tissue below the columella, including the small amount of orbicularis oris muscle (Fig. 1(A)).
Subcutaneous pedicle skin flap of the nasal membro-septal region A spindle shaped mucosa and nasal septum cartilage is harvested from unaffected nasal fontanelle. It is everted 1808 as a subcutaneous pedicle flap and is moved to the affected side. It is intended to widen the anterior part of affected nasal cavity, correct columella deviation, and achieve symmetry of the nose. The pedicle of the flap is the areola tissue between the alar cartilages (Fig. 1(B)).
Subcutaneous pedicle muco-cartilage flap Figure 1 Scheme of our procedure. (A) Subcutaneous pedicle flap from the unaffected nostril floor. The pedicle is small amount of orbicularis oris muscle. (B) Subcutaneous pedicle mucoseptal flap on the nasal fontanelle is everted 1808 and moved to the affected side. Figure below shows the cross section of caudal portion of the mucoseptal area. The pedicle of the flap is areola tissue between the alar cartilages. (C) Subcutaneous pedicle mucoseptal flap is moved 908 to the nostril rim. The pedicle of the flap is areola tissue between the alar cartilages.
In this method, a composite of the skin, mucosa and cartilage around the caudal portion of the nasal fontanelle of the unaffected nasal septum is transferred 908 as a subcutaneous pedicle flap, and is moved to the upper nostril rim. This flap covers the tissue defect of upper border of affected side and gives support the damaged alar cartilage. The pedicle of the flap is similar to the method-2 (Fig. 1(C)).
Case report flaps in eight cases (12 flaps). Majority of the cases were treated via open reverse-U approach. Such approach gave a good intra-operative view, and made our subcutaneous pedicle flap technique easier. Flaps are harvested from unaffected side of the nostril, which showed complete survival. Results were satisfactory with respect to nasal contour. Some clinical cases are seen in Figs. 2–4. In these cases, operation was performed via open reverse-U approach, and inverted trapezoid suturing and box suturing were added to obtain well defined nasal contour.3,4
Case 1 A 28-year-old male presented to our department with a narrowing of the left nostril floor (Fig. 2(A)). Nose deformity was repaired by the reverse-U method. For widening the nostril floor, a subcutaneous pedicle skin flap from the nostril floor of the unaffected side was moved to the affected side. At 1 year after the surgery, the appearance of the external nose and lip remained favourable (Fig. 2(B)).
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Figure 2 Case 1. (A) Preoperative view. Subcutaneous pedicle flap on the unaffected nostril floor is transferred to the affected side. (B) One year after the operation.
Case 2 A 22-year-old female presented to our department
with postoperative cleft lip nose deformity. The patient had a typical cleft lip nose deformity and narrowing of the nostril cavity on the affected side.
Figure 3 Case 2. (A) Preoperative view. (B) The subcutaneous pedicle muco-septal cartilage flap is everted 1808 and move to the affected side. (C) One year after the operation. Nasal contour has become symmetrical with no functional disturbance. (D) Flap showed good survival.
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps
315
Figure 4 Case 3. (A) Preoperative view. Notch caused by scar on the left nostril rim and narrowed left nostril is visible. (B) Ten months after surgery. Both flaps showed good survival with good nasal symmetry. (C) and (D) Flap is turned 908 for covering tissue defect of the nostril rim. (E) and (F) Another subcutaneous pedicle flap is elevated on the right alar base and transferred to the left.
She complained endonasal obstruction (Fig. 3(A)). Using the open reverse-U method and the inverted trapezoid suture, the deformity of the nasal cartilage was corrected. To create identification of the alar groove, alar cartilages were fixed together at four points to their subcutaneous tissue located above. The subcutaneous pedicle septal
muco-chondral flap was elevated from unaffected side and everted 1808 and moved to the affected side for widening the narrowed nostril cavity (Fig. 3(B)). One year after the operation, the nasal contour kept good symmetry, with no endonasal obstruction (Fig. 3(C)). The subcutaneous pedicle flap showed good survival (Fig. 3(D)).
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Discussion
Figure 5 Cooperative procedures we used. (A) Open reverse-U incision. From this access, not only inverted trapezoid suturing and box suturing, (showed below) but also subcutaneous pedicle flap techniques are easily produced and transferred to the cleft side. (B) and (C) Inverted trapezoid suturing technique. By using this technique, we can achieve the distinct alar groove, and the elevated aleolar tissue makes the clear contour of the nostril tip. (D) Two or three additional box sutures are placed subcutaneously over the nasal dorsum to make a well-defined nasal bridge. The knot of the suture is buried through a stab incision.
Case 3 A 34-year-old male presented to our department with postoperative nasal deformity of cleft lip nose. In spite of the secondary cleft lip nose revision in another hospital, the patient had narrowing of the left nostril cavity, notch on the upper border of the left nostril rim, due to scar formation (Fig. 4(A)). The external nose was corrected by the open reverse-U method together with combined subcutaneous pedicle flaps. Subcutaneous pedicle flap including skin, mucosa and a piece of nasal septal cartilage was made on the right anterior nasal fontanelle, and turned 908 for covering the tissue defect of the left upper nostril rim (Fig. 4(C) and (D)). Since the flap contains the cartilage, it is useful not only for covering the defect surrounding the nasal cavity but also giving support and strength to the alar cartilage. Furthermore, the hair contained in the flap helps achieving the natural texture of the inner surface of the nostril cavity. In this case, another subcutaneous pedicle flap from the nostril floor was also designed on the right alar base and moved to the affected alar base (Fig. 4(E) and (F)). Ten months after the surgery, the shape of the nostril rim and the nostril floor remains natural contour with good symmetry (Fig. 4(B)).
Potter7 reported the procedure using subcutaneous pedicle flaps from tissues in the nasal cavity for the secondary repair of the cleft lip and nose. Fujimori et al.8 reported their procedure in repairing of the soft triangle. Onizuka9 reported the repair of cleft at the base of the nasal cavity. These procedures differ from our method in that the subcutaneous pedicle flaps are harvested from the affected side. We use excess tissue from the nasal cavity on the unaffected side as a donor of the subcutaneous pedicle flap and move it to the tissue-poor area on the affected side. Since the flap is harvested from an unexposed area, the scar is not apparent postoperatively. The use of subcutaneous pedicle flaps in the secondary repair of unilateral cleft lip and nose is suitable for the correction of small deformities remaining around the nostril, in which the amount of tissue around the nostril of unaffected side is relatively abundant. The objective of the techniques, we presented here is to obtain the symmetrical nasal contour by correcting the volume difference between affected and unaffected side. Specifically, it may be suitable for such cases that the tissue defect on the affected side is too large to repair with a local flap alone. It is also suitable for such cases that conventional skin grafting, auricular cartilage composite grafting or palatal mucosa grafting would be required. In using the techniques, we presented here, it is very important to consider the various contributory factors involved in the nose deformity, such as columella deviation or narrowing of the nostril cavity, and to have a good appreciation of the importance of those factors in a give patient. And then, an appropriate selection should be made among the three patterns of procedures presented here. As we already reported on other papers, inverted trapezoid suture and box suturing approached from open reverse-U incision (Fig. 5(A)–(D)) are useful methods for repairing postoperative nasal deformities. But asymmetry of the nostril often needs another supplementary surgical technique. The subcutaneous pedicle flap method we reported here can answer that purpose. Particularly, in cases like case-2 or case-3 we presented here, the open reverse-U incision approach helps not only precise subcutaneous pedicle flap technique but also easy correction of nasal cartilages. In these cases, our subcutaneous pedicle flap procedures may act a rather supportive role in gaining symmetrical nasal contour. So we consider, in using this subcutaneous pedicle flap techniques, inverted trapezoid suture and box suture to be choices for better outcome.
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps We introduce three types of subcutaneous pedicle flaps for secondary repair of cleft lip nose deformity. This technique differs from the previously reported techniques in that tissue from the unaffected side is used. In this technically simple procedure, excess tissue of the unaffected side is moved to the tissuepoor area of the affected side for correcting the narrowing of the nostril and columella deviation, and for achieving the symmetry of the nostril floor. The procedures we present here are suitable for small deformities of the nose which remains after primary or secondary cleft lip nose surgery.
References 1. Rethi A. Uber die korrektiven operationen der nasendeformitaten. Chirurg 1929;1:1103–13.
317
2. Nakajima T, Yoshimura Y, Kami T. Refinement of the ‘reverseU’ incision for the repair of cleft lip nose deformity. Br J Plast Surg 1986;39:345–51. 3. Harashina T. Open reverse-U incision technique for secondary correction of unilateral cleft lip nose deformity. Br J Plast Surg 1990;43:557–64. 4. Nakajima T, Yoshimura Y. Secondary repair of unilateral cleft lip nose deformity with bilateral reverse-U access incision. Br J Plast Surg 1998;51:176–80. 5. Nakajima T. Early and one stage repair of bilateral cleft lip nose deformity. Keio J Med 1998;47:212–8. 6. Nakajima T, Yoshimura Y. Secondary correction of bilateral cleft lip nose deformity. J Craniomaxillofac Surg 1990;18: 63–7. 7. Potter J. Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg 1954;13:358–66. 8. Fujimori R, Harita Y. Elongation of the nostril and columella using an island flap. Br J Plast Surg 1982;35:171–6. 9. Onizuka T. Our cleft lip repair. Keiseigeka 1986;29:281–92 [Japanese].
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps from the unaffected side Ikkei Tamada, Tatsuo Nakajima*, Hisao Ogata, Fumio Onishi Department of Plastic Surgery, Keio University Hospital, Tokyo 160-8582, Japan Received 24 June 2002; accepted 9 November 2004
KEYWORDS Cleft lip; Nose deformity; Subcutaneous pedicle flap
Summary We used three types of subcutaneous pedicle flaps harvested from the unaffected side of the nostril to repair postoperative nose deformity caused by primary cleft lip surgery. By moving the subcutaneous pedicle flap from a nearby tissue-rich area, it was possible to achieve a favourable symmetrical nasal contour for the narrowing of the nostril cavity, depression of the nostril floor and the columella deviation of the affected side. The method, we used here is technically simple. We believe this procedure is a method of choice for repairing small deformities of the nose occurring after primary or secondary cleft lip surgery. Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
The secondary repair of the cleft lip and nose often involves deviations of the columella toward the affected side, narrowing of the nostril cavity on the affected side or depression of the nasal floor. It is not uncommon to encounter cases that require specialised techniques other than the previously reported Rethi procedure,1 modified reverse U procedure,2,3 or inverted trapezoid suture4,5 to achieve adequate left-right symmetry of the nasal cavity. In such situations, we previously performed repairs using a Z-plasty of the superior border of the nostril rim (soft triangle) or a local flap. If these procedures are insufficient, the areas with
* Corresponding author. Tel.: C81 03 5363 3814. E-mail address: [email protected] (I. Tamada).
tissue defect were treated with full-thickness skin graft, auricular cartilage graft or palatal mucosal graft.6 In this report, we transfer excess tissue from the peri-nostril area of the unaffected side to the affected side as a subcutaneous pedicle flap. It is possible to achieve a symmetrical nasal contour for correcting narrowed nostril cavity and depression of the nasal floor. We report on the three types of subcutaneous pedicle flaps used here and describe case examples.
Materials and methods We repaired postoperative deformities of cleft lip and nose using three types of subcutaneous pedicle
S0007-1226/$ - see front matter Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.11.012
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps
313
Surgical procedure Subcutaneous pedicle flap unaffected nostril floor In this method, tissue from the base of the nostril at the unaffected side is used as the subcutaneous pedicle skin flap and is moved to the affected side, with the intention of repairing the depressed alar base and adjusting the width of the nasal floor to achieve left-right symmetry. Harvest of the flap is approached via modified open reverse-U incision. The pedicle of the flap is soft tissue below the columella, including the small amount of orbicularis oris muscle (Fig. 1(A)).
Subcutaneous pedicle skin flap of the nasal membro-septal region A spindle shaped mucosa and nasal septum cartilage is harvested from unaffected nasal fontanelle. It is everted 1808 as a subcutaneous pedicle flap and is moved to the affected side. It is intended to widen the anterior part of affected nasal cavity, correct columella deviation, and achieve symmetry of the nose. The pedicle of the flap is the areola tissue between the alar cartilages (Fig. 1(B)).
Subcutaneous pedicle muco-cartilage flap Figure 1 Scheme of our procedure. (A) Subcutaneous pedicle flap from the unaffected nostril floor. The pedicle is small amount of orbicularis oris muscle. (B) Subcutaneous pedicle mucoseptal flap on the nasal fontanelle is everted 1808 and moved to the affected side. Figure below shows the cross section of caudal portion of the mucoseptal area. The pedicle of the flap is areola tissue between the alar cartilages. (C) Subcutaneous pedicle mucoseptal flap is moved 908 to the nostril rim. The pedicle of the flap is areola tissue between the alar cartilages.
In this method, a composite of the skin, mucosa and cartilage around the caudal portion of the nasal fontanelle of the unaffected nasal septum is transferred 908 as a subcutaneous pedicle flap, and is moved to the upper nostril rim. This flap covers the tissue defect of upper border of affected side and gives support the damaged alar cartilage. The pedicle of the flap is similar to the method-2 (Fig. 1(C)).
Case report flaps in eight cases (12 flaps). Majority of the cases were treated via open reverse-U approach. Such approach gave a good intra-operative view, and made our subcutaneous pedicle flap technique easier. Flaps are harvested from unaffected side of the nostril, which showed complete survival. Results were satisfactory with respect to nasal contour. Some clinical cases are seen in Figs. 2–4. In these cases, operation was performed via open reverse-U approach, and inverted trapezoid suturing and box suturing were added to obtain well defined nasal contour.3,4
Case 1 A 28-year-old male presented to our department with a narrowing of the left nostril floor (Fig. 2(A)). Nose deformity was repaired by the reverse-U method. For widening the nostril floor, a subcutaneous pedicle skin flap from the nostril floor of the unaffected side was moved to the affected side. At 1 year after the surgery, the appearance of the external nose and lip remained favourable (Fig. 2(B)).
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I. Tamada et al.
Figure 2 Case 1. (A) Preoperative view. Subcutaneous pedicle flap on the unaffected nostril floor is transferred to the affected side. (B) One year after the operation.
Case 2 A 22-year-old female presented to our department
with postoperative cleft lip nose deformity. The patient had a typical cleft lip nose deformity and narrowing of the nostril cavity on the affected side.
Figure 3 Case 2. (A) Preoperative view. (B) The subcutaneous pedicle muco-septal cartilage flap is everted 1808 and move to the affected side. (C) One year after the operation. Nasal contour has become symmetrical with no functional disturbance. (D) Flap showed good survival.
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps
315
Figure 4 Case 3. (A) Preoperative view. Notch caused by scar on the left nostril rim and narrowed left nostril is visible. (B) Ten months after surgery. Both flaps showed good survival with good nasal symmetry. (C) and (D) Flap is turned 908 for covering tissue defect of the nostril rim. (E) and (F) Another subcutaneous pedicle flap is elevated on the right alar base and transferred to the left.
She complained endonasal obstruction (Fig. 3(A)). Using the open reverse-U method and the inverted trapezoid suture, the deformity of the nasal cartilage was corrected. To create identification of the alar groove, alar cartilages were fixed together at four points to their subcutaneous tissue located above. The subcutaneous pedicle septal
muco-chondral flap was elevated from unaffected side and everted 1808 and moved to the affected side for widening the narrowed nostril cavity (Fig. 3(B)). One year after the operation, the nasal contour kept good symmetry, with no endonasal obstruction (Fig. 3(C)). The subcutaneous pedicle flap showed good survival (Fig. 3(D)).
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I. Tamada et al.
Discussion
Figure 5 Cooperative procedures we used. (A) Open reverse-U incision. From this access, not only inverted trapezoid suturing and box suturing, (showed below) but also subcutaneous pedicle flap techniques are easily produced and transferred to the cleft side. (B) and (C) Inverted trapezoid suturing technique. By using this technique, we can achieve the distinct alar groove, and the elevated aleolar tissue makes the clear contour of the nostril tip. (D) Two or three additional box sutures are placed subcutaneously over the nasal dorsum to make a well-defined nasal bridge. The knot of the suture is buried through a stab incision.
Case 3 A 34-year-old male presented to our department with postoperative nasal deformity of cleft lip nose. In spite of the secondary cleft lip nose revision in another hospital, the patient had narrowing of the left nostril cavity, notch on the upper border of the left nostril rim, due to scar formation (Fig. 4(A)). The external nose was corrected by the open reverse-U method together with combined subcutaneous pedicle flaps. Subcutaneous pedicle flap including skin, mucosa and a piece of nasal septal cartilage was made on the right anterior nasal fontanelle, and turned 908 for covering the tissue defect of the left upper nostril rim (Fig. 4(C) and (D)). Since the flap contains the cartilage, it is useful not only for covering the defect surrounding the nasal cavity but also giving support and strength to the alar cartilage. Furthermore, the hair contained in the flap helps achieving the natural texture of the inner surface of the nostril cavity. In this case, another subcutaneous pedicle flap from the nostril floor was also designed on the right alar base and moved to the affected alar base (Fig. 4(E) and (F)). Ten months after the surgery, the shape of the nostril rim and the nostril floor remains natural contour with good symmetry (Fig. 4(B)).
Potter7 reported the procedure using subcutaneous pedicle flaps from tissues in the nasal cavity for the secondary repair of the cleft lip and nose. Fujimori et al.8 reported their procedure in repairing of the soft triangle. Onizuka9 reported the repair of cleft at the base of the nasal cavity. These procedures differ from our method in that the subcutaneous pedicle flaps are harvested from the affected side. We use excess tissue from the nasal cavity on the unaffected side as a donor of the subcutaneous pedicle flap and move it to the tissue-poor area on the affected side. Since the flap is harvested from an unexposed area, the scar is not apparent postoperatively. The use of subcutaneous pedicle flaps in the secondary repair of unilateral cleft lip and nose is suitable for the correction of small deformities remaining around the nostril, in which the amount of tissue around the nostril of unaffected side is relatively abundant. The objective of the techniques, we presented here is to obtain the symmetrical nasal contour by correcting the volume difference between affected and unaffected side. Specifically, it may be suitable for such cases that the tissue defect on the affected side is too large to repair with a local flap alone. It is also suitable for such cases that conventional skin grafting, auricular cartilage composite grafting or palatal mucosa grafting would be required. In using the techniques, we presented here, it is very important to consider the various contributory factors involved in the nose deformity, such as columella deviation or narrowing of the nostril cavity, and to have a good appreciation of the importance of those factors in a give patient. And then, an appropriate selection should be made among the three patterns of procedures presented here. As we already reported on other papers, inverted trapezoid suture and box suturing approached from open reverse-U incision (Fig. 5(A)–(D)) are useful methods for repairing postoperative nasal deformities. But asymmetry of the nostril often needs another supplementary surgical technique. The subcutaneous pedicle flap method we reported here can answer that purpose. Particularly, in cases like case-2 or case-3 we presented here, the open reverse-U incision approach helps not only precise subcutaneous pedicle flap technique but also easy correction of nasal cartilages. In these cases, our subcutaneous pedicle flap procedures may act a rather supportive role in gaining symmetrical nasal contour. So we consider, in using this subcutaneous pedicle flap techniques, inverted trapezoid suture and box suture to be choices for better outcome.
Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps We introduce three types of subcutaneous pedicle flaps for secondary repair of cleft lip nose deformity. This technique differs from the previously reported techniques in that tissue from the unaffected side is used. In this technically simple procedure, excess tissue of the unaffected side is moved to the tissuepoor area of the affected side for correcting the narrowing of the nostril and columella deviation, and for achieving the symmetry of the nostril floor. The procedures we present here are suitable for small deformities of the nose which remains after primary or secondary cleft lip nose surgery.
References 1. Rethi A. Uber die korrektiven operationen der nasendeformitaten. Chirurg 1929;1:1103–13.
317
2. Nakajima T, Yoshimura Y, Kami T. Refinement of the ‘reverseU’ incision for the repair of cleft lip nose deformity. Br J Plast Surg 1986;39:345–51. 3. Harashina T. Open reverse-U incision technique for secondary correction of unilateral cleft lip nose deformity. Br J Plast Surg 1990;43:557–64. 4. Nakajima T, Yoshimura Y. Secondary repair of unilateral cleft lip nose deformity with bilateral reverse-U access incision. Br J Plast Surg 1998;51:176–80. 5. Nakajima T. Early and one stage repair of bilateral cleft lip nose deformity. Keio J Med 1998;47:212–8. 6. Nakajima T, Yoshimura Y. Secondary correction of bilateral cleft lip nose deformity. J Craniomaxillofac Surg 1990;18: 63–7. 7. Potter J. Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg 1954;13:358–66. 8. Fujimori R, Harita Y. Elongation of the nostril and columella using an island flap. Br J Plast Surg 1982;35:171–6. 9. Onizuka T. Our cleft lip repair. Keiseigeka 1986;29:281–92 [Japanese].