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A modified technique to correct the cleft lip nasal deformity
14
J. Cranio-Max.-Fac.Surg. 17 (1989)
j. Cranio-Max.-Fac.Surg. 17 (1989) 14-16 © GeorgThiemeVerlagStuttgart • New York
A Modified Technique to Correct the Cleft Lip Nasal Deformity Giirhan Ozcan Plasticand ReconstructiveSurgeryClinic(Head:Dr. G. Ozcan,M.D.), VakifGurebaHospital,Istanbul,Turkey
Introduction In the unilateral cleft lip nose, the alar cartilage is rotated caudally downwards so that the dome is retroposed on the cleft side. The cartilaginous septum, the nasal spine and the maxilla are not normal, depending on the severity of the cleft. It should not be overlooked that the alar cartilage on the normal side is also slightly deformed, depending on the distortion of the cartilage on the cleft side. If the lip only is repaired, leaving the alar cartilage in its displaced position, the nostril rim droops on the side of the cleft and the rotated alar cartilage becomes twisted. If both the lip and nose are repaired simultaneously, proper contour and position of the nostrils may promote more normal growth. Reports of about 10 to 15 years follow-up by experienced cleft lip surgeons demonstrate that the early primary correction of the cleft lip nasal deformity does not interfere with the nasal growth, unless destructive surgery is performed (AnderI, 1985; McComb, 1985; Salyer, 1986). But still today, a lot of plastic surgeons hesitate to correct the deformity at the primary operation mainly because of the difficulties in dealing with the delicate nasal structures of the baby and the achievement of satisfactory results. The alar cartilages provide the key to the cleft lip nasal problem. But the columella on the cleft side must be lengthened and the cleft alar base properly aligned. Technique
Primary repair Millard's (1976) rotation-advancement technique is routinely utilized for lip repair. A c-flap will lengthen the columella and will be aligned with the nostril base. Usually, a sufficiently large c-flap is available in most cases. After incising the alar base from a b-flap on the circum-malar line, the incision enters the nasal vestibule, cutting the alar base free from the maxilla and proceeding along the intercartilaginous line, and the alar cartilage is freed from its overlying skin. The c-flap is released by an incision posteriorly in the membranous septum on the cleft side only half way under the nasal tip and not to join the intercartilaginous incision. Then the dissection between the medial crura of the alar cartilages frees the inferiorly placed cleft side crus
Summary Repositioning the collapsed alar cartilage, lengthening the columella and correct repositioning of the alar base of the cleft side are the main components of the cleft lip nostril repair. The rotation-advancement lip procedure was performed in all primary cases, and to some extent for necessary revision in secondary cases. For elevating and supporting the displaced alar cartilage "Skoog's mattress key stitch" was used. The columella was lengthened with a c-flap. In the secondary cases the c-flap was kept long and wide enough, so that its de-epithelialized distal part was used to augment the depression of the cleft side alar base. In all primary cases, a lateral mucosal L-flap was inserted into the intercartilaginous incision. 17 primary and 15 secondary cases were repaired using this technique. Follow-up of the patients from one to four years demonstrated no interference with nasal growth in primary cases and no recurrence of the deformity in any case. Three secondary cases required additional minor corrections. Key words Cleft lip - Nose deformity - Congenital anomaly
to facilitate its advancement ahead of the c-flap along the short side of the columella. Undermining continues across the nasal tip to the normal cartilage of the opposite side. The mucosa is freed from the undersurface of the alar cartilage for a width of approximately 2 to 4 ram. Care must be taken not to perforate this very thin mucosa. Exposure is particularly important medially, where the alar cartilage must be well mobilized to permit repositioning in an overlapping fashion on top of the upper cartilage. The lower portion of the cartilage maintains its mucosal attachments. In order to reposition the alar cartilage, "the key stitch" of Skoog (1974) is used. Skoog (1974) found this mattress suture to be perfect for advancing the alar cartilage to overlap the upper lateral cartilage in its anatomical position, and it should be performed correctly. The needle is first passed through the nasal mucosa and upper cartilage close to the septum, about 4 mm away from the incised border. The alar cartilage lining is picked up about 7 mm laterally, and the two borders are united with the mattress suture. The needle never passes through the alar cartilage. The alar cartilage will then lie in a normal overlapping position on top of the upper cartilage (Skoog, 1974). But at this step the key suture is not tied. 5 - 0 vicryl suture material is used here. When the drooping alar arch is lifted with a hook to match the normal nostril, a defect opens on the short side of the columella, and the c-flap naturally moves toward this area into the upper gap of the back-cut incision of the rotation flap. It is fixed in front with a few 6 - 0 silk sutures (Millard, 1976). The lateral mucosal flap of the advancement flap vermilion is sutured into the lateral nasal vestibular defect. This will maintain the forward position of the alar base. After insertion of Millard's 1-flap into the intercartilaginous incision is completed, the
A Modified Technique to Correct the Cleft Lip Nasal Deformity
J. Cranio-Max.-Fac. Surg. 17 (1989)
15
Fig. 1 a, b The cleft lip nostril deformity of a secondary case. The lip had been corrected primarily with an indefinite procedure similar to straight line closure.
Fig.2a, b Postoperative appearance after lip revision and correction of the secondary cleft nostril deformity.
Skoog's "key suture" is tied. There is usually excess tissue at the alar base. Denudation of the epithelium of the tip of the alar base flap will enable it to be pulled under the cflap and sutured to the septum at the nasal spine for permanent fixation, symmetrical with the normal side. Secondary repair Secondary cleft lip nostril repair generally includes some scar revison. Depending on the remaining deformities and widened scars, the rotation and advancement flap design is marked out. The same procedure as the primary repair is performed, but there is no available lateral mucosal 1-flap to insert into the intercartilaginous gap. In those secondary cases showing remarkable depression underneath the alar base, the whole scar area on the philtrum can be elevated as a c-flap, most of it being denuded of epithelium and buried under the alar base. Results Since 1983 I have performed this technique in 17 primary and 15 secondary cases. The primary cases were aged from
3 months to 5 years. Among them ten had complete and five had incomplete cleft lips. The secondary cases were aged from 5 to 24 years. Eight of the secondary cases had been primarily corrected with the Millard technique, two with the Le Mesurier technique and five with an indefinite technique similar to straight line closure. Follow-up of the cases ranged from 6 to 42 months. Five secondary cases were reoperated on for minor corrections, such as alar web trimming or dome augmentation. Improvement of the cleft nasal deformity was permanent. No contracture of the vestibular scar was noted and no other complication was encountered in any case. Discussion and Conclusions Long term observations prove that careful handling of the growing tissue does not interfere with nasal growth (Anderl, 1985; McComb, 1985; Salyer, 1986). The correction of the cleft lip nasal deformity is not just a matter of setting the malpositioned alar cartilage at a higher position, as the correction necessitates lengthening the columella
16
J. Cranio-Max.-Fac. Surg. 17 (1989)
and creation of the new alar base on the cleft side, both requiring the use of some local flaps. These local flaps are best available at the primary operation, when the lip is repaired. However, the aim is not to be totally corrective (including maxillary hypoplasia, nasal spinal and septal deviations) at the primary operation, but to improve the deformity to the extent that no further surgery will be needed until adolescence in the majority of cases. This achievement prevents the permanent dissatisfaction of all concerned (parents, surgeon, child) with the unrepaired nostril deformity. The moderate residual deformity that may occur in some cases after primary cleft lip and nose correction, is very easy to manage. More harm is done when the nasal deformity is not corrected at the time of primary lip repair. Secondary correction is difficult for some available local flaps have already been used; nevertheless, it is possible to obtain a normal appearance in secondary cases without cartilage excision. Of course, in an adult, secondary cleft lip nasal repair as a combined procedure with only cartilage grafting, corrective rhinoplasty and deviated septal correction can be added. These are not included in this text (Figs. 1 and 2). Intranasal incision carries the risk of contracture especially in primary cases. I do not fear contracture for two reasons: Firstly, I always leave undisturbed mucosa between the intercartilaginous and membranous septal incisions; secondly, the high contracture potential of the intercartilaginous scar is reduced by the insertion of the lateral lip vermilion flap. This modified technique does not always correct all cleft
G. Ozcan: A Modified Technique to Correct the Cleft Lip nasal problems. But increasing experience and greater attention to minor details are rewarded with better results. The advantages of primary repair are: 1. Patient, surgeon and family are happy with the result. 2. The child does not carry the inferiorly rotated nostril and the flared alar base until adolescence. 3. Early achievement of proper contour and position of the lower lateral cartilage seems to promote more normal nostril growth. 4. At the primary lip repair, local tissues and flaps offer optimal facilitation for cleft lip nostril repair. 5. Secondary minor revisions are easy to perform. References
Anderl, H.: Simultaneous repair of lip and nose in the unilateral cleft (a Long Term Report). In: I. T. Jackson, B. C. Sommerlad (eds.): Recent Advances in Plastic Surgery. Churchill Livingstone, New York 1985 McComb, H.: Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Hast. Reconstr. Surg. 75 (1985) 791 Millard, D.R.: Cleft Craft: The unilateral deformity. Vol. 1. Little, Brown, Boston 1976 Salyer, K.E.: Primary correction of the unilateral cleft lip nose: a 15-year experience. Hast. Reconstr. Surg. 77 (1986) 558 Skoog, T.: Plastic surgery. Almqwist and Wiksell, Stockholm 1974
Dr. G. Ozcan Halaskargazicad. 356/6 Sisli-Istanbul Turkey
J. Cranio-Max.-Fac.Surg. 17 (1989)
j. Cranio-Max.-Fac.Surg. 17 (1989) 14-16 © GeorgThiemeVerlagStuttgart • New York
A Modified Technique to Correct the Cleft Lip Nasal Deformity Giirhan Ozcan Plasticand ReconstructiveSurgeryClinic(Head:Dr. G. Ozcan,M.D.), VakifGurebaHospital,Istanbul,Turkey
Introduction In the unilateral cleft lip nose, the alar cartilage is rotated caudally downwards so that the dome is retroposed on the cleft side. The cartilaginous septum, the nasal spine and the maxilla are not normal, depending on the severity of the cleft. It should not be overlooked that the alar cartilage on the normal side is also slightly deformed, depending on the distortion of the cartilage on the cleft side. If the lip only is repaired, leaving the alar cartilage in its displaced position, the nostril rim droops on the side of the cleft and the rotated alar cartilage becomes twisted. If both the lip and nose are repaired simultaneously, proper contour and position of the nostrils may promote more normal growth. Reports of about 10 to 15 years follow-up by experienced cleft lip surgeons demonstrate that the early primary correction of the cleft lip nasal deformity does not interfere with the nasal growth, unless destructive surgery is performed (AnderI, 1985; McComb, 1985; Salyer, 1986). But still today, a lot of plastic surgeons hesitate to correct the deformity at the primary operation mainly because of the difficulties in dealing with the delicate nasal structures of the baby and the achievement of satisfactory results. The alar cartilages provide the key to the cleft lip nasal problem. But the columella on the cleft side must be lengthened and the cleft alar base properly aligned. Technique
Primary repair Millard's (1976) rotation-advancement technique is routinely utilized for lip repair. A c-flap will lengthen the columella and will be aligned with the nostril base. Usually, a sufficiently large c-flap is available in most cases. After incising the alar base from a b-flap on the circum-malar line, the incision enters the nasal vestibule, cutting the alar base free from the maxilla and proceeding along the intercartilaginous line, and the alar cartilage is freed from its overlying skin. The c-flap is released by an incision posteriorly in the membranous septum on the cleft side only half way under the nasal tip and not to join the intercartilaginous incision. Then the dissection between the medial crura of the alar cartilages frees the inferiorly placed cleft side crus
Summary Repositioning the collapsed alar cartilage, lengthening the columella and correct repositioning of the alar base of the cleft side are the main components of the cleft lip nostril repair. The rotation-advancement lip procedure was performed in all primary cases, and to some extent for necessary revision in secondary cases. For elevating and supporting the displaced alar cartilage "Skoog's mattress key stitch" was used. The columella was lengthened with a c-flap. In the secondary cases the c-flap was kept long and wide enough, so that its de-epithelialized distal part was used to augment the depression of the cleft side alar base. In all primary cases, a lateral mucosal L-flap was inserted into the intercartilaginous incision. 17 primary and 15 secondary cases were repaired using this technique. Follow-up of the patients from one to four years demonstrated no interference with nasal growth in primary cases and no recurrence of the deformity in any case. Three secondary cases required additional minor corrections. Key words Cleft lip - Nose deformity - Congenital anomaly
to facilitate its advancement ahead of the c-flap along the short side of the columella. Undermining continues across the nasal tip to the normal cartilage of the opposite side. The mucosa is freed from the undersurface of the alar cartilage for a width of approximately 2 to 4 ram. Care must be taken not to perforate this very thin mucosa. Exposure is particularly important medially, where the alar cartilage must be well mobilized to permit repositioning in an overlapping fashion on top of the upper cartilage. The lower portion of the cartilage maintains its mucosal attachments. In order to reposition the alar cartilage, "the key stitch" of Skoog (1974) is used. Skoog (1974) found this mattress suture to be perfect for advancing the alar cartilage to overlap the upper lateral cartilage in its anatomical position, and it should be performed correctly. The needle is first passed through the nasal mucosa and upper cartilage close to the septum, about 4 mm away from the incised border. The alar cartilage lining is picked up about 7 mm laterally, and the two borders are united with the mattress suture. The needle never passes through the alar cartilage. The alar cartilage will then lie in a normal overlapping position on top of the upper cartilage (Skoog, 1974). But at this step the key suture is not tied. 5 - 0 vicryl suture material is used here. When the drooping alar arch is lifted with a hook to match the normal nostril, a defect opens on the short side of the columella, and the c-flap naturally moves toward this area into the upper gap of the back-cut incision of the rotation flap. It is fixed in front with a few 6 - 0 silk sutures (Millard, 1976). The lateral mucosal flap of the advancement flap vermilion is sutured into the lateral nasal vestibular defect. This will maintain the forward position of the alar base. After insertion of Millard's 1-flap into the intercartilaginous incision is completed, the
A Modified Technique to Correct the Cleft Lip Nasal Deformity
J. Cranio-Max.-Fac. Surg. 17 (1989)
15
Fig. 1 a, b The cleft lip nostril deformity of a secondary case. The lip had been corrected primarily with an indefinite procedure similar to straight line closure.
Fig.2a, b Postoperative appearance after lip revision and correction of the secondary cleft nostril deformity.
Skoog's "key suture" is tied. There is usually excess tissue at the alar base. Denudation of the epithelium of the tip of the alar base flap will enable it to be pulled under the cflap and sutured to the septum at the nasal spine for permanent fixation, symmetrical with the normal side. Secondary repair Secondary cleft lip nostril repair generally includes some scar revison. Depending on the remaining deformities and widened scars, the rotation and advancement flap design is marked out. The same procedure as the primary repair is performed, but there is no available lateral mucosal 1-flap to insert into the intercartilaginous gap. In those secondary cases showing remarkable depression underneath the alar base, the whole scar area on the philtrum can be elevated as a c-flap, most of it being denuded of epithelium and buried under the alar base. Results Since 1983 I have performed this technique in 17 primary and 15 secondary cases. The primary cases were aged from
3 months to 5 years. Among them ten had complete and five had incomplete cleft lips. The secondary cases were aged from 5 to 24 years. Eight of the secondary cases had been primarily corrected with the Millard technique, two with the Le Mesurier technique and five with an indefinite technique similar to straight line closure. Follow-up of the cases ranged from 6 to 42 months. Five secondary cases were reoperated on for minor corrections, such as alar web trimming or dome augmentation. Improvement of the cleft nasal deformity was permanent. No contracture of the vestibular scar was noted and no other complication was encountered in any case. Discussion and Conclusions Long term observations prove that careful handling of the growing tissue does not interfere with nasal growth (Anderl, 1985; McComb, 1985; Salyer, 1986). The correction of the cleft lip nasal deformity is not just a matter of setting the malpositioned alar cartilage at a higher position, as the correction necessitates lengthening the columella
16
J. Cranio-Max.-Fac. Surg. 17 (1989)
and creation of the new alar base on the cleft side, both requiring the use of some local flaps. These local flaps are best available at the primary operation, when the lip is repaired. However, the aim is not to be totally corrective (including maxillary hypoplasia, nasal spinal and septal deviations) at the primary operation, but to improve the deformity to the extent that no further surgery will be needed until adolescence in the majority of cases. This achievement prevents the permanent dissatisfaction of all concerned (parents, surgeon, child) with the unrepaired nostril deformity. The moderate residual deformity that may occur in some cases after primary cleft lip and nose correction, is very easy to manage. More harm is done when the nasal deformity is not corrected at the time of primary lip repair. Secondary correction is difficult for some available local flaps have already been used; nevertheless, it is possible to obtain a normal appearance in secondary cases without cartilage excision. Of course, in an adult, secondary cleft lip nasal repair as a combined procedure with only cartilage grafting, corrective rhinoplasty and deviated septal correction can be added. These are not included in this text (Figs. 1 and 2). Intranasal incision carries the risk of contracture especially in primary cases. I do not fear contracture for two reasons: Firstly, I always leave undisturbed mucosa between the intercartilaginous and membranous septal incisions; secondly, the high contracture potential of the intercartilaginous scar is reduced by the insertion of the lateral lip vermilion flap. This modified technique does not always correct all cleft
G. Ozcan: A Modified Technique to Correct the Cleft Lip nasal problems. But increasing experience and greater attention to minor details are rewarded with better results. The advantages of primary repair are: 1. Patient, surgeon and family are happy with the result. 2. The child does not carry the inferiorly rotated nostril and the flared alar base until adolescence. 3. Early achievement of proper contour and position of the lower lateral cartilage seems to promote more normal nostril growth. 4. At the primary lip repair, local tissues and flaps offer optimal facilitation for cleft lip nostril repair. 5. Secondary minor revisions are easy to perform. References
Anderl, H.: Simultaneous repair of lip and nose in the unilateral cleft (a Long Term Report). In: I. T. Jackson, B. C. Sommerlad (eds.): Recent Advances in Plastic Surgery. Churchill Livingstone, New York 1985 McComb, H.: Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Hast. Reconstr. Surg. 75 (1985) 791 Millard, D.R.: Cleft Craft: The unilateral deformity. Vol. 1. Little, Brown, Boston 1976 Salyer, K.E.: Primary correction of the unilateral cleft lip nose: a 15-year experience. Hast. Reconstr. Surg. 77 (1986) 558 Skoog, T.: Plastic surgery. Almqwist and Wiksell, Stockholm 1974
Dr. G. Ozcan Halaskargazicad. 356/6 Sisli-Istanbul Turkey