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Correction of noses associated with clefts of lip and palate
N. S&wenzer: Correction of Noses Associated with Clefts of Lip and Palate
91
Obwegeser, H. L., E. Steinhaeuser: Ein neues Ger/it
Ware, W., M. Ashamalla: Pulpal response following
zur Vitalit~tsprfifung der Z/ihne mit Kohlens/iureschnee. Schweiz. Mschr. Zahlheilk. 73 (1963) 1001 Poswillo, D.: Early pulp changes following reduction of open bite by segmental surgery. Int. J. oral Surg. 1 (1972) 87 Saxer, A.: Die Vitalit/itsprtifung der Z/ihne. Diss., Univ. Zfirich 1958 Schroeder, H.: Die MSglichkeiten orthodontischer Osteotomien und ihr Einflut~ anf das Leben der Pulpa. Dtsch. zahn/irztl. Wschr. 40/41 (1934) 946 Seltzer, S.: Advances in biology of the human dental pulp. Oral Surg. 32 (1971) 454
anterior maxillary osteotomy. Oral Surg. 60 (1971) 156 Wassmund, M.: Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer, Bd. I. Meuser, Leipzig 1935 Wunderer, S.: Die Prognathie-Operation mittels frontal gestieltem Maxillafragment. Ust. Z. Stomat. 59 (1962) 98 Walter ]. Pepersack, M.D., D.M.D., Kieferchirurgische Abteilung, Plattenslrasse 11, Postfach, CH-8028 Zilri&, Switzerland
J. max.-fac. Surg. 1 (1973) 91-95 © Georg Thleme Verlag, Stuttgart
Correction of Noses Associated with Clefts of Lip and Palate Norbert Schwenzer Department of Oral and Maxillo-Facial Surgery of the Institute of Dental Medicine, University of Tubingen, W. Germany (Head: Prof. N. Schwenzer, M.D., D.M.D.)
Summary A supplementary correction of the nose in clefts of lip and palate cannot always be avoided, even where primary repair in infancy was optimal. The degree of existent deformity is, by far, dependent on the severity of the cleft and on the traumatisation during the primary surgical intervention. Since only in mild deformities do the usual procedures in the corrective nasal plastic operation yield satisfactory results, but however, not in severe cases, the author prefers uncovering the nasal framework using the Decortication Technique. The necessary nasal correction is, as a rule, achieved together with the often essential correction or reoperation of the lip. If convenient, the anterior portion of the cleft alveolus is simultaneously corrected. In extreme cases, autologous or homologous preserved cartilage is additionally used to build the cartilaginous nasal framework. Examples have been included to illustrate the technique.
Key-Words: Secondary rhinoplasty, cleft lip and palate. Introduction In modern surgery of cleft lip a n d palate, the actual closure of cleft should be accorded the same significance as the establishment of normal form and function of nose. Although through the improvement on the methods of p r i m a r y repair -
which also includes p r i m a r y osteoplasty -- favourable conditions for later development of the nose can be created, corrective surgery is, in most adult cases, unavoidable. This fact is explicable when one examines the morphology of the nose in cleft lip, which has been fully described by Huffman and Lierle (1949), Trauner and Wirth (1957), Lindsay and Farhas (1972). The following characteristics are peculiar to noses of cleft lips: 1. Flattened ala on the cleft side. Its lateral crus is displaced caudo-dorsally and is atrophied. T h e medial crus is, in unilateral clefts, distorted to the healthy side. 2. Deviation of lamina quadrangularis to the healthy side. 3. Dorsal and lateral displacement of m a x i l l a r y portion of the cleft side which forms the bony base of the nose. The above-mentioned anomalies could be more or less pronounced. The degree of severity is directly dependent on: a) the form of cleft, that is, severe nasal deforrnities are expected more frequently in complete clefts than in isolated clefts of lip,
92
b)
N. Schwenzer traumatisation during primary operation, especially when the nasal cartilage is damaged in infancy or the nostril base was incised, e. g. according to Lindemann Procedure (1931). Adverse effects on nasal development are also produced through external incisions on the nasal tip like those suggested, for instance, by Gelbke (1964).
Not the least is the role played by the individually constitutionally determined nasal form which, although also present in cleft patients, are however generally masked by the fore-mentioned conspicuous characteristics. The cleft-induced malformations of individual nasal components are dependent on tissue displacement. They lead to a deformity in three dimensions and possess the following typical changes which require correction:
Depending on the severity of the deformity, the following corrections are necessary for functional (impaired nasal breathing) and aesthetic reasons: 1. Positional correction of alar base together with a reoperation of lip and closure of residual cleft of alveolus and nostril floor; eventually with osteoplasty. The base of ala is thus elevated. 2. Elongation of the columella - this is imperative especially in bilateral clefts - and straightening of the cartilaginous septum. 3. Elevation of the depressed alar cartilage and correction of nasal tip (mostly narrowing procedure). 4. Widening and rounding of nostril on cleft side through Z-plasty.
5. dorsal displacement of alar base,
Based on our experience, this variety of individual measures do not always permit rhinoplasty according to conventional rules, especially when severe nasal deformities are present. Rehrmann also made reference to this in 1955. More frequently, extensive displacement of cartilage and subsequent necessary implants are such that the whole bony framework of the nose must be exposed.
6. deviation with projecting septal border at the nostril base,
Technique:
1. Unequal size and shape of nostrils, 2. short and false position of columella, 3. flaring nostril base, 4. flattened and hanging ala on cleft side,
7. short nasal mucosa on the cleft side. In bilateral clefts, these anomalies are found on both sides, so that a degree of symmetry is present. The often abnormally short columella is, however, very noticeable and almost always leads to a pronounced retruded nose, which is equally disturbing functionally and aesthetically as in noses of single clefts. The deformities are also often intensified by mutilating scars of the lips, which frequently result in their shortening. In most eases, additional residual fistulae are present in alveolus and nostril floor.
General Considerations We are often confronted with the necessity to reconstruct the lip and nose. Like other authors, we also achieve this, as a rule, in one operation, since the problem should be regarded as a unit and not isolated (McIndoe and Rees 1959). Solely in children up till the age of about 15 do we avoid any corrections on the cartilaginous nasal frame.
In such cases, we adopt the Decortication Technique (Rdthi 1929, 1933) or the "Open Reduction" which are otherwise unusual in the plastic surgery of the nose, and accept the disadvantage of visible scars. We prefer the incision lines at the base of the columella, which are less conspicuous, and, if need be, allow for elongation of columella. However, access through vestibular incisions are also possible in easier cases. Depending on the grade of severity, we have classified the deformity in three groups, each with a different approach:
Group I: Mild nasal deformity with asymmetry predominantly at the nasal tip. In this case, the alar base.may be merely mildly flaring and dorsally displaced. This situation is mostly found in isolated cleft lips. Technique: For the displacement of the alar cartilage on the cleft side, vestibular rim incision on both sides suffices. On the cleft side, we lead the incision further along columellar rim. After elevation of soft tissue and exposure of alar cartilage on both sides, the medial crus of the cleft side is
Correction of Noses Associated with Clefts of Lip and Palate cut as suggested by Erich (1953). Thereafter, it is brought to the level of the healthy medial crus and sutured together with chrom catgut. Additional trimming of the healthy alar cartilage often permits a normalisation of the nasal tip. The correc-
Fig. 1 Typical flattening of alar of cleft side in cleft lip. Correction of nasal tip after extrusion of alar cartilage using the luxation technique, and reoperation of lip in one operative sitting. The nostril was re-lined with a muscle flap.
Fig. 2 Nasal deformity i n a i e f t sided total cleft, The upper lip was widened using an Abbe flap, The nose was never operated again after the primary repair. Correction of the nose using the decortication technique. The insertion of the left alar base was re-lined with the rib transplant.
93
tion of the position of the atar base is achieved along with lip correction, which, in most cases, requires an incision up to the nostril. Thus the possibility of construction of muscle flap (Ragnell 1955) and Z-plasty are given (Fig. 1).
N. Schwenzer
94
Fig.
3 a
Incision line for exposure of nasal frame-
work.
Fig, 3b Principle of complete reconstruction of alar cartilage by imbedding a homologous cartilage transplant.
Fig. 4 Typical nasal deformity in left-sided total cleft with crookedness of bony nose. Correction of the nose with the decortication technique and simultaneous osteotomy.
Group I1: Deformity of the whole nose with severe displacement of alar cartilage, low and dorsal position of attachment of alar cartilage, often combined with residual perforation in the nostril floor (Fig. 2). Technique: Weprefer a simultaneous correction of lip and nose, and if need be, with osteoplasty (rib) in order to fill out the cleft alveolus and re-line the alar base (Schuchardt and Pfeifer, 1961). Ex-
posure of the nasal framework is achieved with the Decortication Technique (Rdthi 1929, 1933), which Sercer and Miindnich (1962) acclaimed capable of affording a clear view. A subcutaneous mobilisation of the cartilaginous framework would, in such cases, lead to unsatisfactory results. After detachment of nasal soft tissue along with the columellar flap, an optimal trimming of the cartilaginous framework under view is possible (Fig. 3a). Apart
Correction of Noses Associated with Clefts of Lip and Palate from the fore-mentioned approximation of both alar cartilages, a re-collapse of the tip can be avoided by fixing the alar cartilage of the cleft side with the triangular cartilage. If desired, the septum can be corrected after Cottle (1950). We elongate the short columella of the cleft side by interposing a triangular flap pedieulated at the ala (Trauner 1959, Neuner 1968). Furthermore, we often achieve additional Z-plasty after Straith (1940) at the upper commisura of the nostril, and thus pattern it similar to the healthy side. In bilateral clefts, in which the elongation of the mostly abnormally short eolumella is imperative, we prefer a philtrum-columellar flap which is larger and stretches further into the white border of lip as that suggested by Potter (1955). A n additional elongation of the lip, if need be, is achieved with rotation flap encircling both alar bases. Group Ill: Severe nasal deformities with loss of cartilage or very extensive dystopia and atrophy, mostly as a result of insufficient operative technique during primary surgery. In these cases, additional transplants of cartilage are necessary. Technique: Exposure and correction of the nasal framework is likewise achieved with the Decorti-
95
cation Technique. Very often, parts of the cartilaginous structure must be replaced. The required material is either autologous rib cartilage, especially where osteoplasty nmst necessarily be done, or otherwise a homologous preserved rib cartilage (Fig. 3b). The preservation is done in cialite, an organic compound of mercury. The cartilage implant serves as a partial or total replacement of alar cartilage, for re-lining nasal dorsum, or for improvement of the tip. If osteotomy is necessary because of a crooked nose, this can, of course, be combined with decortication (Fig. 4). For inner support of the naris, especially where the septum should also be corrected, we prefer sponge. After decortication, plaster of Paris bandage is applied as external nasal splint. Conclusion
W e have made the experience, that the shape of the nose, even in most severe cases, could be satisfactorily re-modelled using the forementioned procedures. Additional outward scars resulting from the deeortication are inconspicuous and can be accepted into the bargain if the shape of the nose is normalised.
References
Cottle, M. H.: Modified nasal septum operations, eye, ear, nose, throat. Mth. Chicago 29 (1950) 480 Erich, ]. B.: Technique for correcting flat nostril in cases of repaired harelip. Plast. reconstr. Surg. 12 (1953) a20 Gelbke, H.: Wiederherstellende und plastische Chirurgie, Bd. III. Thieme, Stuttgart 1964 Hulk'man, W. C., D. M. Lierle: Studies of the pathologic anatomy of the unilateral hare lip nose. Plast. reconstr. Surg. 4 (1949) 225 Lindemann, A.: Neue Gesichtspunkte zur plastischen Deckung angeborener und erworbener Defekte. Chirurg 3 (1931) 358,414 Lindsay, W. K., L. G. Farkas: The Use of Anthropometry in Assessing the Cleft-Lip Nose. Plas{. reconstr. Surg. 49 (1972) 287 McIndoe, A. H., Th. Rees: Synchronous repair of secondary deformities in cleft lips and nose. Plast. reconstr. Surg. 24 (1959) 150 Neuner, 0.: Zur Rehabilitation der Naseneingangsund Oberlippenpartie. Chir. plast, reconstr. 5 (1968) 189 Potter, ].: Some nasal tip deformities due to alar cartilage abnormalities. Plast. reconstr. Surg. 15 (1955) 502 Ragnell, A.: Korrekturplastik nach Lippenspaltenoperation. Fortschr. Kiefer- u. Gesichtschir. 1 (1955) 84
Rehrmann, A.: Eine Methode zur Formvcrbesserung der Nase und Lippe nach der Operation einseitiger Ifippenspalten. Dtsch. zahn~irztl. Z. 10 (1955) 104,6 Rdthi, A.: lFber die korrektiven Operationen der N asendeformitfiten. I. Die H6&erabtragung. Chirurg 1 (1929) 1103, 1113; 5 (1933) 5O5 Schuchardt, K., G. Pfeifer: Erfahrungen fibe~ primSrc und sekundfire Osteoplastik bei Patienten mit Lippen Kiefer-Gaumenspalten. [Isterreich, Z. Stomat. 58 (1961) 40 Sercer, A., K. Miindnich: Plastische Operationen an dcr Nase und an der Ohrmuschel. Thieme, Stuttgart 1962 Straith, C. L.: Elongation of the nasal columella. Plast. reconstr. Surg. 1 (1940) 79 Trauner, R.: Lippen-Kiefer-Gaumenspalten. In: Die Zahn-, Mund- und Kieferheilkunde, Bd. 1II/2. Hrsg. yon H/iupl-Meyer-Schuchardt. Urban & Schwarzenberg, Mfinchen 1959 (S. 777 ft.) Trauner, R., F. Wirth: Die Nasenkorrekturen bei einseitigen Lippen-Kiefer-Gamnenspalten. Z. l,aryng Rhinol. 36 (1957) 621
Prof. Norbert Schwenzer, M.D., D.M.D., Abt. flir Kiefer- und Gesichtschirurgie, 74 Tilbingen, Osianderstral,~e 2-8
91
Obwegeser, H. L., E. Steinhaeuser: Ein neues Ger/it
Ware, W., M. Ashamalla: Pulpal response following
zur Vitalit~tsprfifung der Z/ihne mit Kohlens/iureschnee. Schweiz. Mschr. Zahlheilk. 73 (1963) 1001 Poswillo, D.: Early pulp changes following reduction of open bite by segmental surgery. Int. J. oral Surg. 1 (1972) 87 Saxer, A.: Die Vitalit/itsprtifung der Z/ihne. Diss., Univ. Zfirich 1958 Schroeder, H.: Die MSglichkeiten orthodontischer Osteotomien und ihr Einflut~ anf das Leben der Pulpa. Dtsch. zahn/irztl. Wschr. 40/41 (1934) 946 Seltzer, S.: Advances in biology of the human dental pulp. Oral Surg. 32 (1971) 454
anterior maxillary osteotomy. Oral Surg. 60 (1971) 156 Wassmund, M.: Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer, Bd. I. Meuser, Leipzig 1935 Wunderer, S.: Die Prognathie-Operation mittels frontal gestieltem Maxillafragment. Ust. Z. Stomat. 59 (1962) 98 Walter ]. Pepersack, M.D., D.M.D., Kieferchirurgische Abteilung, Plattenslrasse 11, Postfach, CH-8028 Zilri&, Switzerland
J. max.-fac. Surg. 1 (1973) 91-95 © Georg Thleme Verlag, Stuttgart
Correction of Noses Associated with Clefts of Lip and Palate Norbert Schwenzer Department of Oral and Maxillo-Facial Surgery of the Institute of Dental Medicine, University of Tubingen, W. Germany (Head: Prof. N. Schwenzer, M.D., D.M.D.)
Summary A supplementary correction of the nose in clefts of lip and palate cannot always be avoided, even where primary repair in infancy was optimal. The degree of existent deformity is, by far, dependent on the severity of the cleft and on the traumatisation during the primary surgical intervention. Since only in mild deformities do the usual procedures in the corrective nasal plastic operation yield satisfactory results, but however, not in severe cases, the author prefers uncovering the nasal framework using the Decortication Technique. The necessary nasal correction is, as a rule, achieved together with the often essential correction or reoperation of the lip. If convenient, the anterior portion of the cleft alveolus is simultaneously corrected. In extreme cases, autologous or homologous preserved cartilage is additionally used to build the cartilaginous nasal framework. Examples have been included to illustrate the technique.
Key-Words: Secondary rhinoplasty, cleft lip and palate. Introduction In modern surgery of cleft lip a n d palate, the actual closure of cleft should be accorded the same significance as the establishment of normal form and function of nose. Although through the improvement on the methods of p r i m a r y repair -
which also includes p r i m a r y osteoplasty -- favourable conditions for later development of the nose can be created, corrective surgery is, in most adult cases, unavoidable. This fact is explicable when one examines the morphology of the nose in cleft lip, which has been fully described by Huffman and Lierle (1949), Trauner and Wirth (1957), Lindsay and Farhas (1972). The following characteristics are peculiar to noses of cleft lips: 1. Flattened ala on the cleft side. Its lateral crus is displaced caudo-dorsally and is atrophied. T h e medial crus is, in unilateral clefts, distorted to the healthy side. 2. Deviation of lamina quadrangularis to the healthy side. 3. Dorsal and lateral displacement of m a x i l l a r y portion of the cleft side which forms the bony base of the nose. The above-mentioned anomalies could be more or less pronounced. The degree of severity is directly dependent on: a) the form of cleft, that is, severe nasal deforrnities are expected more frequently in complete clefts than in isolated clefts of lip,
92
b)
N. Schwenzer traumatisation during primary operation, especially when the nasal cartilage is damaged in infancy or the nostril base was incised, e. g. according to Lindemann Procedure (1931). Adverse effects on nasal development are also produced through external incisions on the nasal tip like those suggested, for instance, by Gelbke (1964).
Not the least is the role played by the individually constitutionally determined nasal form which, although also present in cleft patients, are however generally masked by the fore-mentioned conspicuous characteristics. The cleft-induced malformations of individual nasal components are dependent on tissue displacement. They lead to a deformity in three dimensions and possess the following typical changes which require correction:
Depending on the severity of the deformity, the following corrections are necessary for functional (impaired nasal breathing) and aesthetic reasons: 1. Positional correction of alar base together with a reoperation of lip and closure of residual cleft of alveolus and nostril floor; eventually with osteoplasty. The base of ala is thus elevated. 2. Elongation of the columella - this is imperative especially in bilateral clefts - and straightening of the cartilaginous septum. 3. Elevation of the depressed alar cartilage and correction of nasal tip (mostly narrowing procedure). 4. Widening and rounding of nostril on cleft side through Z-plasty.
5. dorsal displacement of alar base,
Based on our experience, this variety of individual measures do not always permit rhinoplasty according to conventional rules, especially when severe nasal deformities are present. Rehrmann also made reference to this in 1955. More frequently, extensive displacement of cartilage and subsequent necessary implants are such that the whole bony framework of the nose must be exposed.
6. deviation with projecting septal border at the nostril base,
Technique:
1. Unequal size and shape of nostrils, 2. short and false position of columella, 3. flaring nostril base, 4. flattened and hanging ala on cleft side,
7. short nasal mucosa on the cleft side. In bilateral clefts, these anomalies are found on both sides, so that a degree of symmetry is present. The often abnormally short columella is, however, very noticeable and almost always leads to a pronounced retruded nose, which is equally disturbing functionally and aesthetically as in noses of single clefts. The deformities are also often intensified by mutilating scars of the lips, which frequently result in their shortening. In most eases, additional residual fistulae are present in alveolus and nostril floor.
General Considerations We are often confronted with the necessity to reconstruct the lip and nose. Like other authors, we also achieve this, as a rule, in one operation, since the problem should be regarded as a unit and not isolated (McIndoe and Rees 1959). Solely in children up till the age of about 15 do we avoid any corrections on the cartilaginous nasal frame.
In such cases, we adopt the Decortication Technique (Rdthi 1929, 1933) or the "Open Reduction" which are otherwise unusual in the plastic surgery of the nose, and accept the disadvantage of visible scars. We prefer the incision lines at the base of the columella, which are less conspicuous, and, if need be, allow for elongation of columella. However, access through vestibular incisions are also possible in easier cases. Depending on the grade of severity, we have classified the deformity in three groups, each with a different approach:
Group I: Mild nasal deformity with asymmetry predominantly at the nasal tip. In this case, the alar base.may be merely mildly flaring and dorsally displaced. This situation is mostly found in isolated cleft lips. Technique: For the displacement of the alar cartilage on the cleft side, vestibular rim incision on both sides suffices. On the cleft side, we lead the incision further along columellar rim. After elevation of soft tissue and exposure of alar cartilage on both sides, the medial crus of the cleft side is
Correction of Noses Associated with Clefts of Lip and Palate cut as suggested by Erich (1953). Thereafter, it is brought to the level of the healthy medial crus and sutured together with chrom catgut. Additional trimming of the healthy alar cartilage often permits a normalisation of the nasal tip. The correc-
Fig. 1 Typical flattening of alar of cleft side in cleft lip. Correction of nasal tip after extrusion of alar cartilage using the luxation technique, and reoperation of lip in one operative sitting. The nostril was re-lined with a muscle flap.
Fig. 2 Nasal deformity i n a i e f t sided total cleft, The upper lip was widened using an Abbe flap, The nose was never operated again after the primary repair. Correction of the nose using the decortication technique. The insertion of the left alar base was re-lined with the rib transplant.
93
tion of the position of the atar base is achieved along with lip correction, which, in most cases, requires an incision up to the nostril. Thus the possibility of construction of muscle flap (Ragnell 1955) and Z-plasty are given (Fig. 1).
N. Schwenzer
94
Fig.
3 a
Incision line for exposure of nasal frame-
work.
Fig, 3b Principle of complete reconstruction of alar cartilage by imbedding a homologous cartilage transplant.
Fig. 4 Typical nasal deformity in left-sided total cleft with crookedness of bony nose. Correction of the nose with the decortication technique and simultaneous osteotomy.
Group I1: Deformity of the whole nose with severe displacement of alar cartilage, low and dorsal position of attachment of alar cartilage, often combined with residual perforation in the nostril floor (Fig. 2). Technique: Weprefer a simultaneous correction of lip and nose, and if need be, with osteoplasty (rib) in order to fill out the cleft alveolus and re-line the alar base (Schuchardt and Pfeifer, 1961). Ex-
posure of the nasal framework is achieved with the Decortication Technique (Rdthi 1929, 1933), which Sercer and Miindnich (1962) acclaimed capable of affording a clear view. A subcutaneous mobilisation of the cartilaginous framework would, in such cases, lead to unsatisfactory results. After detachment of nasal soft tissue along with the columellar flap, an optimal trimming of the cartilaginous framework under view is possible (Fig. 3a). Apart
Correction of Noses Associated with Clefts of Lip and Palate from the fore-mentioned approximation of both alar cartilages, a re-collapse of the tip can be avoided by fixing the alar cartilage of the cleft side with the triangular cartilage. If desired, the septum can be corrected after Cottle (1950). We elongate the short columella of the cleft side by interposing a triangular flap pedieulated at the ala (Trauner 1959, Neuner 1968). Furthermore, we often achieve additional Z-plasty after Straith (1940) at the upper commisura of the nostril, and thus pattern it similar to the healthy side. In bilateral clefts, in which the elongation of the mostly abnormally short eolumella is imperative, we prefer a philtrum-columellar flap which is larger and stretches further into the white border of lip as that suggested by Potter (1955). A n additional elongation of the lip, if need be, is achieved with rotation flap encircling both alar bases. Group Ill: Severe nasal deformities with loss of cartilage or very extensive dystopia and atrophy, mostly as a result of insufficient operative technique during primary surgery. In these cases, additional transplants of cartilage are necessary. Technique: Exposure and correction of the nasal framework is likewise achieved with the Decorti-
95
cation Technique. Very often, parts of the cartilaginous structure must be replaced. The required material is either autologous rib cartilage, especially where osteoplasty nmst necessarily be done, or otherwise a homologous preserved rib cartilage (Fig. 3b). The preservation is done in cialite, an organic compound of mercury. The cartilage implant serves as a partial or total replacement of alar cartilage, for re-lining nasal dorsum, or for improvement of the tip. If osteotomy is necessary because of a crooked nose, this can, of course, be combined with decortication (Fig. 4). For inner support of the naris, especially where the septum should also be corrected, we prefer sponge. After decortication, plaster of Paris bandage is applied as external nasal splint. Conclusion
W e have made the experience, that the shape of the nose, even in most severe cases, could be satisfactorily re-modelled using the forementioned procedures. Additional outward scars resulting from the deeortication are inconspicuous and can be accepted into the bargain if the shape of the nose is normalised.
References
Cottle, M. H.: Modified nasal septum operations, eye, ear, nose, throat. Mth. Chicago 29 (1950) 480 Erich, ]. B.: Technique for correcting flat nostril in cases of repaired harelip. Plast. reconstr. Surg. 12 (1953) a20 Gelbke, H.: Wiederherstellende und plastische Chirurgie, Bd. III. Thieme, Stuttgart 1964 Hulk'man, W. C., D. M. Lierle: Studies of the pathologic anatomy of the unilateral hare lip nose. Plast. reconstr. Surg. 4 (1949) 225 Lindemann, A.: Neue Gesichtspunkte zur plastischen Deckung angeborener und erworbener Defekte. Chirurg 3 (1931) 358,414 Lindsay, W. K., L. G. Farkas: The Use of Anthropometry in Assessing the Cleft-Lip Nose. Plas{. reconstr. Surg. 49 (1972) 287 McIndoe, A. H., Th. Rees: Synchronous repair of secondary deformities in cleft lips and nose. Plast. reconstr. Surg. 24 (1959) 150 Neuner, 0.: Zur Rehabilitation der Naseneingangsund Oberlippenpartie. Chir. plast, reconstr. 5 (1968) 189 Potter, ].: Some nasal tip deformities due to alar cartilage abnormalities. Plast. reconstr. Surg. 15 (1955) 502 Ragnell, A.: Korrekturplastik nach Lippenspaltenoperation. Fortschr. Kiefer- u. Gesichtschir. 1 (1955) 84
Rehrmann, A.: Eine Methode zur Formvcrbesserung der Nase und Lippe nach der Operation einseitiger Ifippenspalten. Dtsch. zahn~irztl. Z. 10 (1955) 104,6 Rdthi, A.: lFber die korrektiven Operationen der N asendeformitfiten. I. Die H6&erabtragung. Chirurg 1 (1929) 1103, 1113; 5 (1933) 5O5 Schuchardt, K., G. Pfeifer: Erfahrungen fibe~ primSrc und sekundfire Osteoplastik bei Patienten mit Lippen Kiefer-Gaumenspalten. [Isterreich, Z. Stomat. 58 (1961) 40 Sercer, A., K. Miindnich: Plastische Operationen an dcr Nase und an der Ohrmuschel. Thieme, Stuttgart 1962 Straith, C. L.: Elongation of the nasal columella. Plast. reconstr. Surg. 1 (1940) 79 Trauner, R.: Lippen-Kiefer-Gaumenspalten. In: Die Zahn-, Mund- und Kieferheilkunde, Bd. 1II/2. Hrsg. yon H/iupl-Meyer-Schuchardt. Urban & Schwarzenberg, Mfinchen 1959 (S. 777 ft.) Trauner, R., F. Wirth: Die Nasenkorrekturen bei einseitigen Lippen-Kiefer-Gamnenspalten. Z. l,aryng Rhinol. 36 (1957) 621
Prof. Norbert Schwenzer, M.D., D.M.D., Abt. flir Kiefer- und Gesichtschirurgie, 74 Tilbingen, Osianderstral,~e 2-8