Secondary management of the nose in the cleft patient

Copyright © Mun]~sgaard 1993

Int. ,L Oral MaxilloJbc. Surg. 1993; 22:195-199 Printed in Denmark. All rights reserved

Inwma~ionalJoumalof

Oral8c MaxillofacialSurgery 1SSN 0901-5027

Aesthetic and reconstructivesurgery

SecondaoJ management of the nose in the cleft patient

Victor d. Matukas, Patrick d. Louis Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Alabama at Birmingham, Birmingham, Alabama, USA

V. J. Matukas, P. J. Louis." Secondary management o f the nose in the cleJ~patient. Int. J. Oral Maxillofac. Surg. 1993; 22." 195 199. © Munksgaard, 1993 Abstract. The management of the cleft lip and palate patient usually requires multiple primary and secondary surgical procedures to correct the deformity. This paper presents surgical methods in the secondary management of the cleft nose and presents three case reports to help illustrate these methods.

Primary cleft lip and palate procedures usually leave the cleft patient with residual problems that may have to be dealt with later. These can be divided into three broad categories: 1) a residual oronasal fistula and lack of bone for the erupting cuspid, 2) skeletal abnormalities secondary to impaired facial growth (usually maxillary hypoplasia), and 3) various deformities of the nasal area (usually the tip and nostrils). These residual deformities can be addressed by secondary surgical procedures, and these procedures may be combined or staged. If cuspid eruption and bony support are a factor, then bone grafting of the residual oronasal fistula should take place when the cuspid root is about onehalf formed, thus retaining eruptive forces 4. This places the timing of surgery at 9-12 years of age, thus precluding definitive skeletal and nasal surgery at that time. When lateral incisor eruption and bony support are a consideration, bone grafting should take place at an even earlier age 3'9. If cuspid eruption and bony support are not a factor, bone grafting of the residual oronasal fistula has no age limitation and can be done at any time. Definitive correction of skeletal and nasal deformities is best done after puberty and preferably when facial growth has ceased. The cleft nose requires special considerations because of the complexity of the primary deformity of the nose and maxilla. Common nasal deformities after primary cleft repair include: 1) tip deflection to the noncleft side, 2) dome

deflection on the cleft side, 3) absent alar facial groove on the cleft side, 4) larger nares on the cleft side, 5) shorter columella on the cleft side, 6) real or apparent maxillary deficiency, and 7) lack of paranasal support on the cleft side 8. For full correction of the deformities of the nose in the cleft patient, the maxilla, the paranasal region, and the nose may all require correction. These can be addressed at one sitting, or they can be staged. First, the maxilla is corrected by a Le Fort I osteotomy. This will improve the position of the upper lip and nasal tip ~°,u. Next, the oronasal fistula is closed, and bone grafting is performed. The paranasal region is also grafted at this time to improve alar base support. Lastly, the nose is corrected. This paper will present a surgical approach to manage these problems with emphasis on correction of the nostril/ tip/columella complex. Cases will also be presented to help illustrate these corrections. Methods

The uniqueness of repairing a cleft nose lies in creating symmetry and addressing the nostril/tip/columella complex. If the maxilla requires surgical repositioning, it is addressed first. Usually a Le Fort 1 osteotomy is needed to advance the maxilla. Incisions are made to create soft-tissue flaps in the region of the alveolar cleft to facilitate closure of the oronasal fistula ~,5. After the maxilla is downfractured and mobilized, clo-

Key words: cleft nose; nostril/tip/columella complex; nasal floor reduction; nostril rotation,

Accepted for publication 1 February 1993

sure of the nasal floor and palate is performed with the local flaps created. The maxilla is then repositioned in its predetermined position and fixed there with miniplates in the paranasal and zygomatic buttress regions v. After the maxilla is rigidly fixed, the alveolar cleft is grafted with autogenous bone. Augmentation of the paranasal region on the side of the cleft with autogenous bone is performed at this time. The incisions are closed and the nose is then addressed. An open rhinoplasty in usually employed. The authors feel that special control of the symmetry of the nostril/ tip/columella complex is more easily handled with direct vision. The standard columella incision is modified by inverting it and placing it at the base of the columella. This allows for a V-Y closure which lengthens and narrows the columella area (Fig. 1A). The dissection is carried anteriorly and superiorly, exposing the lower lateral cartilages, the upper lateral cartilages, and the bony dorsum (Fig. 1B). After complete exposure of the underlying nasal skeleton, the tip of the nose is assessed and the surgical maneuvers planned. The dorsum is addressed first. Usually the cleft nose dorsum must be narrowed by standard lateral osteotomies, i f hump removal is desirable, both cartilaginous and bony removal is accomplished before lateral osteotomies. The upper lateral cartilages are always separated from the septum to allow for uniform narrowing of the nose.

196

Matukas and Lou&

A

B

C

D

E

F/g. /.

After the dorsum is corrected, attention is turned to the nostril/tip/colume|la complex. Both lower lateral cartilages are completely exposed. In unilateral cleft cases, the lower lateral cartilage on the cleft side is elevated to correspond in height with the normal side. This is accomplished by separating the medial crura from each other in the midline and the medial crux on the cleft side from the anterior nasal spine. Fixation is achieved by horizontal mattress

suture between the crura, with the affected side being sutured in a more projected posture. In bilateral cleft cases, both cartilages are sutured together at a more projected posture. In all of the present cases, a columella strut was employed to hold the lower lateral cartilages in this position and to prevent tip relapse. The graft is placed between the medial crura and sutured into position (Fig. 1C). If further projection is required, a tip graft can be placed (Fig. 1D). These grafts (columella and tip) can be attained from either septal, or auricular autogenous cartilage, or from bank costochondral cartilage. Equal success has been achieved with all three sources. After the grafts are secure, a V-Y closure is performed to lengthen the columella (Fig. 1E). The nostrils are addressed next. In unilateral clefts, the cleft side nostril is flatter and larger. In bilateral clefts, both nostrils are large and must be narrowed in a symmetric fashion. In evaluating the nostril, a distinction must be made between nostril flare and nostril size. In the former, a Weir procedure is utilized (Fig. 2). In the latter, a nasal floor reduction and nostril rotation are employed8 (Fig. 3). In all cases presented, the latter procedure was em-

ployed to decrease nostril size and rotate the alar crease medially. This method also has the added benefit of further increasing tip projection. Usually, a small portion of the lip repair scar is resected and closed at this time.

A

B F~g. 2.

A

B Fig. 3.

Management of the cleft nose

197

F~g. 4.

Case reports Case 1

A 28-year-old white man with bilateral congenital cleft lip and palate, who had undergone initial closure of his soft palate and lip at age 4 months, presented with midface hypoplasia, congenitally missing lateral incisors, and large bilateral alveolar clefts. The patient underwent a Le Fort I osteotomy in which the blood supply to the premaxilla was preserved by maintaining the integrity of the labial mucosa and its attachment to the premaxilla. The maxilla was rigidly fixed with four miniplates and a maxillary splint. The alveolar clefts were

grafted with iliac bone, and the oral and nasal mucosal fistulae were closed. The paranasal regions were augmented with autogenous bone. A simultaneous rhinoplasty was performed as described (Fig. 4). Case 2

A 22-year-old white man with bilateral congenital cleft lip and palate deformities presented with nostril asymmetry, lack of nasal tip projection, a widened columella, midface hypoplasia, and bilateral oronasal fistulae. The patient had previously undergone the following procedures: repair of cleft lip and soft

palate at ages 3 months and 18 months, respectively, and revision lip and nasal surgery at age 6 years. A three-piece Le Fort I osteotomy with maxillary advancement, repair of the oronasal fistulae, alveolar cleft grafting, and augmentation of the paranasal areas with iliac bone was performed. An open rhinoplasty with nostril floor reduction, as described in this paper, was performed as a separate surgical operation (Fig. 5). Case 3

An 18-year-old black man with leftsided congenital cleft lip and palate was

198

M a t u k a s and Louis"

Fig. 5.

referred for evaluation and treatment (Fig. 6). At the time of initial presentation, the patient was noted to have a nasal deformity with depression of the lower left lateral cartilage and deviation of the tip of the nose to the left side. The cuspid and lateral incisor had erupted, but there was a residual oronasal fistula. The midface was hypoplastic and the maxillary midline was deviated to the left. At age 18 years, the patient underwent a two-piece Le Fort I osteotomy with advancement and iliac crest bone grafting to the alveolar cleft and left paranasal region. Closure of the nasal floor and the oral mucosa was

achieved at this time. The patient also underwent bilateral sagittal split osteotomies of the mandible with reduction during the same operation. At age 19 years, the patient underwent an external septorhinoplasty with modifications, as described in this paper. Discussion

There is little doubt that primary procedures to repair both unilateral and bilateral clefts usually cannot completely prevent the previously listed secondary deformities. Newer methods minimize these problems, but do not

eliminate them 2,6. Modern orthognathic and reconstructive surgical methods in the teenage to adult group permit adequate correction of the functional and esthetic stigmata of cleft lip and palate patients. The debate on whether to opt for simultaneous or staged procedures still goes on. In the authors' view, this is an individual decision based on the patient's and the surgeon's desires. We feel that in most cases, with rigid fixation of the orthognathic procedure, corrections of the nose at the same time can be performed l°'H. Results with staged procedures may be marginally better, but

Management o f the cleft nose

B

199

C

E

One without the other will produce limited outcomes.

illofacial surgery. J Oral Surgery 1973: 1: 79 81. 8. SMrr~ HW. The atlas of cleft lip and palate surgery. In: LEE KJ, ed.: Comprehensive surgical atlases in otolaryngology and head and neck surgery. New York: Grune Stratton, 1983: 287-93. 9. STOELINGAPJW, HAERSPEJJ, LEENENR J, SOUBRY R J, BLIJDORP PA, SCIIOENAERS JHA. Late management of secondarily grafted clefts, lnt J Oral Maxillofac Surg 1990: 19:97 102. 10. WALTZPD. Simultaneous rhinoplasty and orthognathic surgery. In: EPKER B, ed.: Oral and maxillofacial surgery clinics of North America. Vol. II, Philadelphia: WB Saunders, 1990:339 50. 11. WAITEPD, MATUKASVJ. Indications for simultaneous orthognathic and septorhinoplastic surgery. J Oral Maxillofaciai Surgery 1991: 49:133 40.

Fig. 6.

the inconvenience and cost of two hospitalizations and anesthetics must be considered. In the cases presented, one patient underwent simultaneous orthognathic and nasal surgery, and the other two underwent staged procedures. N o difference in outcome for any of the patients was noted. The determining factor in performing simultaneous orthognathic and nasal surgery is the stability of the osteotomy segments. If rigid fixation of the osteotomy segments cannot be achieved, then staged procedures should be performed. Finally, regardless of sequence, patient expectations must be considered before and after surgery. N o amount of surgery will achieve perfect anatomy and symmetry in most of these patients. The surgeon, however, must address the maxillary and paranasal hypoplasia (if present) before correcting the nose. An amalgamation of what is called orthognathic surgery and reconstructive surgery will give the best total results.

References 1. ABYHOLM FE, BERGLAND O, SENIB G.

Secondary bone grafting of alveolar clefts. Scand J Plast Reconstr Surg 1981: 15:127 40. 2. BERKELEYWT. The cleft lip nose. Plast Reconstr Surg 1959: 23: 567-75. 3. BOYNE P J, SANDS NR. Combined orthodontic-surgical management of plato-alveolar cleft defects. Am J Orthod Dentofacial Orthop 1976: 70: 20-37. 4. EL DEED M, MESSER LB, LEHMERT MW, HEBDA TW, WAITEDE. Canine eruption into grafted bone in maxillary alveolar cleft defects. Cleft Palate .1 1982: 19: 9-16. 5. EPKER B, FISH L. Dentofacial deformities: integrated orthodontic and surgical correction. Vol. II. St Louis, MO: CV Mosby, 1986:642 99. 6. MALLARDDR JR. Cleft craft. Vol. I. Boston: Little Brown, 1976: 1958. 7. MICHELETFX, DYMESJ. Osteosynthesis with miniaturized screwed plates in max-

Address: Victor J. Matukas Department of Oral and Maxillofacial Surgery School of Dentistry University of Alabama at Birmingham Birmingham, Alabama 35294, USA