CME

Correction of Secondary Deformities of the

Cleft Lip Nose
Samuel Stal, M.D., and Larry Hollier, M.D.

Learning Objectives: After studying this article, the practitioner should be able to: 1. Describe the common secondary
deformities of the cleft lip nose. 2. Determine the appropriate timing for surgical intervention to correct the deformities.
3. Determine the best method of addressing each of the individual secondary deformities of the cleft lip nose.
For both unilateral and bilateral cleft lip nasal deformity, the general trend has been toward operation on the
cleft lip nose at the time of initial lip surgery. Secondary
surgery to further modify the nasal shape is often necessary, and many patients desire complete septorhinoplasty
in their teen years. Many different procedures have been
suggested to address the problem, but few techniques
have worked well and consistently. The authors define the
underlying anatomic distortion involved in the cleft lip
nose and describe effective techniques for correcting the
deformity. (Plast. Reconstr. Surg. 109: 1386, 2002.)

leagues describe a technique for nasoalveolar

molding in which an extension is placed on the
anterior aspect of the intraoral appliance so
that it places pressure within the nasal vestibule, projecting the dome of the lower lateral
cartilage.1 In the early stages of infancy, cartilage is relatively malleable because it is under
the influence of maternal estrogens.2 In the
first 3 to 4 months of life, as the palatal shelves
are being aligned by the intraoral component
to the device, the nasal extension permanently
reshapes the deformed lower lateral cartilage
and stretches the vestibular lining, greatly facilitating primary nasal repair (Fig. 1) and diminishing secondary deformities.

There has been a general trend toward operation on the cleft lip nose at the time of
initial lip surgery in both the unilateral and
bilateral cleft lip nasal deformity. However, secondary surgery to further modify the nasal
shape is frequently necessary, and a large number of patients desire complete septorhinoplasty in the teen years. Although a myriad of
different procedures has been suggested to address the problem, few techniques work well
and consistently. We will define the underlying
anatomic distortion involved in the cleft lip
nose and describe techniques that have been
effective in correcting the deformity.

Anatomy

The skeletal support of the nose is best described by using the tripod concept,3,4 in which
nasal support is provided centrally by the septum and laterally by the nasal sidewalls and
lower lateral cartilages. Compromise of any of
these structures will result in deviation of the
tripod accordingly. This is pertinent with respect to the cleft lip nasal deformity. In the
unilateral deformity, the problem begins with
displacement of the base on which the tripod
rests. The cleft maxilla is laterally displaced
and hypoplastic, resulting in an altered platform for the cleft side ala. Consequently, this
ala splays laterally, with associated loss of nasal
tip definition, obliquity of the alar facial angle,
and septal deviation. Much the same is true for
the bilateral deformity, in which the ala has a

PREVENTION OF SECONDARY CLEFT

NASAL DEFORMITIES

Perhaps the greatest advance in cleft lip nasal surgery has been nonsurgical: the technique of nasoalveolar molding. Although intraoral appliances have long been used to mold
the palatal shelves before lip surgery, the nose
has been relatively ignored. Grayson and col-

From the Texas Childrens Hospital, and the Division of Plastic Surgery, Baylor College of Medicine. Received for publication October 4, 2000;
revised September 21, 2001.

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CORRECTION OF CLEFT LIP NOSE

FIG. 1. Presurgical nasoalveolar molding of the unilateral cleft lip/nasal deformity. (Left)
Appearance before molding. (Right) Appearance after molding and before surgery.

classic bucket-handle appearance with alar lidding and acute alar angulation.5 The problem
is further compounded by the premaxilla,
which is most often anteriorly positioned, causing distortion of the columella. The malpositioned osteocartilaginous framework also contributes to distortion of the surrounding soft
tissue, asymmetry, and such problems as alar
lidding, presence of a plica vestibularis, and
loss of tip projection.
Timing of Repair

A limited rhinoplasty is usually performed at

the time of primary lip repair.6 10 Generally,
this involves only dissection and medial mobilization of the cleft lower lateral cartilage. The
most common age for revision of the cleft lip
nose is between 4 and 5 years. At this age, the
childs social interactions are increasing and
the stigmata associated with the deformity may
cause problems for the child. Assuming it is
amenable to correction, any residual distortion
of the nose that causes the parents or child
significant concern should be addressed at this
point. Procedures to modify the nose should
be coordinated with lip revision; these procedures are also frequently necessary during this
same time period.
The real controversy arises when complete

septorhinoplasty with modification of the osseocartilaginous vault is considered. The concern is that complete rhinoplasty with osteotomy and septal manipulation will impair facial
growth. Consequently, complete rhinoplasty
has been generally deferred until the late teen
years. However, there are data demonstrating
that nasal growth is complete at approximately
11 to 12 years of age in girls and 13 to 14 years
of age in boys.11 As such, full rhinoplasty may
be performed at this time without fear of affecting growth. In reality, the reason this is not
done more often in younger teenagers relates
to the issue of emotional maturity. Even
though nasal growth is complete at approximately 11 to 12 years of age in girls, it is unusual for an 11-year-old to be mature enough
to participate in the complex decisions involved in a preoperative consultation for rhinoplasty. Nevertheless, in the mature, emotionally stable patient in the early teen years, there
is no contraindication to a full rhinoplasty.
TECHNIQUES
Early Revisional Surgery

We must distinguish between those procedures we perform on the growing childs secondary cleft nasal deformity and those reserved

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April 1, 2002

FIG. 2. Illustration of the transdermal suture suspension

technique of cleft lip rhinoplasty. (Above, left) Dissection of
the cleft side lower lateral cartilage through existing lip incisions or an infracartilaginous incision. (Above, right) Suture
placement through the lower lateral cartilage at desired
points of increased projection. (Below) The suture is taken out
through the skin and is brought back through the same point.
The suture is tied in the nasal vestibule, advancing the lower
lateral cartilage medially and cephalically. From Stal, S., and
Spira, M. Secondary reconstructive procedures for patients
with clefts. In D. Serafin and N. G. Georgiade. Pediatric Plastic
Surgery, Vol. 1. St. Louis, Mo.: Mosby, 1984. Pp. 352377.
Reprinted with permission from the publisher.

for definitive septorhinoplasty in the cleft patient at the end of facial growth. During the
early period, attention is focused on reshaping
the cleft side ala by repositioning or derotating
it. Efforts to achieve this are impaired by several factors, including deficiencies in underlying skeletal support and vestibular lining and
scarring from previous procedures. Most techniques have focused on the dissection of the
lower lateral cartilage through an infracartilaginous incision or through the apex of the
existing lip incisions. The entire lower lateral
cartilage is freed from the overlying skin and
repositioned using sutures to a stable cephalic
position to achieve projection of the dome on

the cleft side.1215 Frequently, an external bolster is used, over which the suture is secured.
Although we also advocate a similar procedure in the growing child, we prefer to more
aggressively shape and stabilize the cleft lower
lateral cartilage in its entirety with internal sutures. To do this, following dissection of the
cartilage, the desired position of the apex of
the dome of the lower lateral cartilage is chosen and a polydioxanone suture is passed
through the mucosa and cartilage, pulling the
cartilage to a more medial and cephalic position. This suture is taken out through the skin
and then put back through the same skin exit
hole, following a different dermal pathway,

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CORRECTION OF CLEFT LIP NOSE

and again through the lower lateral cartilage.

The suture is then tied in the vestibule to the
point that the cartilage is advanced to the appropriate position (Fig. 2). This functionally
derotates the cartilage and suspends it to the
overlying dermis. As many sutures as are necessary are placed along the length of the lower
lateral cartilage to position the ala and diminish dead space of the larger cleft alar rim. This
technique helps compress the plica vestibularis
and improves symmetry. The alar lidding can
be partially obviated by large bites of the lidded
skin and vestibular mucosa during closure of
the infracartilaginous incision using a 4-0 plain
gut suture (Fig. 3).
These transdermal sutures cause some dimpling, which may be minimized by placing a
small incision with a no. 11 blade through the
location where the suture is taken. This dimpling, however, always resolves over the course
of several weeks. It also negates the need for an
external bolster, which is problematic from two
standpoints. First, we have seen scars caused
from excessive pressure placed on these bolsters. Furthermore, when the bolster itself is
removed (usually at 7 to 14 days), so is the
support for the repositioned lower lateral cartilage. With the above technique, the lower
lateral cartilage is supported as long as the

polydioxanone suture maintains its strength,

usually for 2 to 3 months.
For the bilateral cleft lip nasal deformity, the
techniques used for rhinoplasty have been categorized by Cutting and colleagues into two
groups: the skin paradigm and the cartilage
paradigm.16,17 The focus of the skin paradigm
has been on augmentation of the deficient
columella by means of flaps advanced in from
the lateral aspect of the philtrum or the nasal
floor.18,19 However, these techniques do nothing to address the underlying abnormality in
the lower lateral cartilage, and they frequently
produce abnormally long and unusual appearing columellae (Fig. 4). Mullikens observations on the columella after the staged forked
flap procedure show a classic pattern so often
seen in our own patients: (1) a rectangular
columella (without a waist and with a broad
base), (2) a sharp columellar-labial angle, (3)
abnormally elongated/enlarged nostrils, and
(4) a tendency to an overly long columella with
a disproportionate ratio of nostril length to
nasal tip.5 It is our opinion that additional
tissue, especially from the lip, is not necessary
to lengthen the columella in the vast majority
of cases and should only be used conservatively
and for minimal skin advancement.
With respect to those procedures focusing

FIG. 3. Transdermal suture suspension technique in primary cleft lip rhinoplasty. (Left)
Preoperative appearance. (Right) Immediate postoperative appearance.

1390

FIG. 4. An overly long columella, resulting in flip nasal

deformity.

on the deformed lower lateral cartilages, the

individual techniques vary primarily in the incision used to access the domes and may be as
direct as McCombs9 gullwing incision along
the tip or Cutting and Graysons20 prolabial
unwinding flap. The basic philosophy is the
same as with the unilateral cleft nasal deformity. The lower lateral cartilages are dissected
out from the overlying skin envelope, and the
lateral crura are advanced medially and secured to one another to create a more normal
appearing tip. Further shaping of the tip can
be achieved with the technique described
above using transdermal sutures.
Definitive Septorhinoplasty

Once growth is complete and the patient is

emotionally mature, patients may be considered candidates for full osseocartilaginous
vault modification, should they so desire. We
usually prefer the open approach for these
patients.
Before tip reshaping is begun, the support of
the alar base must first be assessed. For patients

PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2002

with a severe skeletal deficiency, augmentation

should be considered. This can be accomplished by placing either a bone graft or block
hydroxyapatite through an intraoral incision,
which is then secured in a subperiosteal location near the piriform aperture below the cleft
side ala. In patients with the most severe skeletal deficiencies, the cause is often a retrusive
maxilla, and a Le Fort I advancement osteotomy should be performed before any attempt
is made at definitive rhinoplasty (Fig. 5).
As in the procedures performed at a younger
age, attention is given to reshaping the lower
lateral cartilages with suture techniques. However, this is usually insufficient to adequately
correct the deformity. In the unilateral cleft lip
nose, we frequently augment tip projection using graft material. It is our preference in most
cases to use a strut of septal cartilage between
the medial crura to project and equalize the
domes. If this is also inadequate to achieve
sufficient projection, extended spreader grafts
as described by Byrd et al. are used.21 This
procedure is necessary for many of our patients
with the bilateral cleft lip nasal deformity. As a
rule, these patients are severely deficient of
cartilage in the anterior septal angle region.
These spreader grafts create a scaffold for anatomic tip reconstruction, allowing the lower
lateral cartilage to be directly fixed to a new
appropriate septal angle, achieving maximal
tip projection. Occasionally, we also use septal
or auricular grafts as a stiff batten to augment
and stabilize the malformed lower lateral cartilages. Onlay grafts of cartilage may also be
necessary to improve tip definition and
symmetry.
CONCLUSIONS

Secondary cleft lip nasal deformities are

common, but they may be minimized by the
use of nasoalveolar molding in the first several
months of life. Surgical correction of these
problems should be predicated on the severity
of the deformity. Residual deformities that
concern the patient or parents should be addressed at a young age by mobilization of the
deformed alae and reshaping of the tip using
intradermal sutures for support. Definitive septorhinoplasty may be performed, if necessary,
during the early teen years once growth is complete. This should be accomplished by the
open approach, using cartilage grafts to
achieve the desired tip projection and shape.

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CORRECTION OF CLEFT LIP NOSE

FIG. 5. Definitive cleft lip rhinoplasty and augmentation of nasal support/projection with Le
Fort I advancement osteotomy (staged with the rhinoplasty). (Above) Frontal view of preoperative
and postoperative appearance. (Below) Lateral view of preoperative and postoperative
appearance.

Samuel Stal, M.D.

Suite 330
1102 Bates, MC 3-2314
Houston, Texas 77030
sxstal@texaschildrenshospital.org

REFERENCES
1. Grayson, B. H., Santiago, P. E., Brecht, L. E., and Cutting,
C. B. Presurgical nasoalveolar molding in infants
with cleft lip and palate. Cleft Palate Craniofac. J. 36:
486, 1999.

1392
2. Maull, D. J., Grayson, B. H., Cutting, C. B., et al. Longterm effects of nasoalveolar molding on three-dimensional nasal shape in unilateral clefts. Cleft Palate
Craniofac. J. 36: 391, 1999.
3. Hogan, V. The tilted tripod: A theory of cleft lip nasal
deformities. In J. Huston (Ed.), Transactions of the 5th
International Congress of Plastic and Reconstructive Surgery. Melbourne, Australia: Butterworths, 1971.
4. McCollough, E. G., and Mangap, D. Systematic approach to correction of the nasal tip in rhinoplasty.
Arch. Otolaryngol. 107: 12, 1981.
5. Mulliken, J. B. Repair of bilateral complete cleft lip and
nasal deformity: State of the art. Cleft Palate Craniofac.
J. 37: 342, 2000.
6. McComb, H. Primary repair of the bilateral cleft lip
nose: A four-year review. Plast. Reconstr. Surg. 94: 37,
1994.
7. McComb, H. Primary repair of the bilateral cleft lip
nose. Br. J. Plast. Surg. 28: 262, 1975.
8. McComb, H. Primary repair of the bilateral cleft lip
nose: A 10-year review. Plast. Reconstr. Surg. 77: 701,
1986.
9. McComb, H. Primary repair of the bilateral cleft lip
nose: A 15-year review and a new treatment plan. Plast.
Reconstr. Surg. 86: 882, 1990.
10. Millard, D. R., Jr., and Morovic, C. G. Primary unilateral
cleft nose correction: A ten-year follow-up. Plast. Reconstr. Surg. 102: 1331, 1998.
11. Akguner, M., Barutcu, A., and Karaca, C. Adolescent
growth patterns of the bony and cartilaginous framework of the nose: A cephalometric study. Ann. Plast.
Surg. 41: 66, 1998.

PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2002

12. Tajima, S., and Maruyama, M. Reverse-U incision for

secondary repair of cleft lip nose. Plast. Reconstr. Surg.
60: 256, 1977.
13. Reynolds, J. R., and Horton, C. E. An alar lift in cleft lip
rhinoplasty. Plast. Reconstr. Surg. 35: 377, 1965.
14. Stenstrom, S. J., and Oberg, T. R. H. The nasal deformity in unilateral cleft lip. Plast. Reconstr. Surg. 28: 295,
1961.
15. Dibbell, D. G. Cleft lip nasal reconstruction: Correcting
the classic unilateral defect. Plast. Reconstr. Surg. 69:
264, 1982.
16. Cutting, C. B. Primary bilateral cleft lip and nose repair.
In S. Aston, R. Beasley, and C. H. M. Thorne (Eds.),
Grabb and Smiths Plastic Surgery. Philadelphia: Lippincott Raven, 1997. P. 257.
17. Cutting, C., Grayson, B., and Brecht, L. Columellar
elongation in bilateral cleft lip (Letter). Plast. Reconstr.
Surg. 102: 1761, 1998.
18. Millard, D. R., Jr. Closure of bilateral cleft lip and elongation of columella by two operations in infancy. Plast.
Reconstr. Surg. 47: 324, 1971.
19. Cronin, T. D. Lengthening columella by use of skin
from the nasal floor and alae. Plast. Reconstr. Surg. 21:
417, 1958.
20. Cutting, C., and Grayson, B. The prolabial unwinding
flap method for one-stage repair of bilateral cleft lip,
nose, and alveolus. Plast. Reconstr. Surg. 91: 37, 1993.
21. Byrd, H. S., Andochick, S., Copit, S., and Walton, K. G.
Septal extension grafts: A method of controlling tip
projection and shape. Plast. Reconstr. Surg. 100: 999,
1997.

Self-Assessment Examination follows on

the next page.

Self-Assessment Examination
Correction of Secondary Deformities of the Cleft Lip Nose
by Samuel Stal, M.D., and Larry Hollier, M.D.
1. ALL OF THE FOLLOWING ARE TRUE ABOUT RHINOPLASTY IN TEENS EXCEPT:
A) Nasal growth in girls stops at approximately 12 years of age
B) Nasal growth in boys stops at approximately 13 to 14 years of age
C) Definitive nasal surgery should be delayed until the teen is emotionally mature
D) All septal surgery in children should be delayed until cessation of growth regardless of symptoms
E) Premaxillary orthopedics shows promise in helping set the stage for more normal nasal growth
2. EFFECTIVE WAYS OF IMPROVING NASAL TIP PROJECTION IN THE CLEFT PATIENT INCLUDE
ALL OF THE FOLLOWING EXCEPT:
A) Extended spreader grafts
B) Le Fort I advancement osteotomy
C) Forked flaps
D) Cartilage grafts
E) Cephalic suspension of the lower lateral cartilage
3. NASOALVEOLAR MOLDING CAN BE USED JUST AS EFFECTIVELY ANYTIME WITHIN THE FIRST
YEAR OF LIFE.
A) True
B) False
4. NASOALVEOLAR MOLDING IMPROVES THE LINING DEFICIENCY SEEN IN THE CLEFT LIP
NASAL DEFORMITY.
A) True
B) False
5. USE OF FORK FLAPS TO AUGMENT THE COLUMELLA MAY RESULT IN WHICH OF THE
FOLLOWING?
A) An overly long columella
B) A sharp columellar-labial angle
C) A rectangular columella
D) Enlarged nostrils
E) All of the above
6. THE BASIC GOAL IN SURGERY FOR THE UNILATERAL CLEFT LIP NASAL DEFORMITY IS TO
SECURE THE CLEFT SIDE ALA IN MORE MEDIAL AND CEPHALIC POSITION.
A) True
B) False