|Year : 2022 | Volume
| Issue : 2 | Page : 113-119
Indocleftcon 2022 Founders Lecture: In search of the perfect cleft lip nose
Puthucode V Narayanan
The Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
|Date of Submission||25-Jun-2022|
|Date of Acceptance||06-Jul-2022|
|Date of Web Publication||23-Aug-2022|
Dr. Puthucode V Narayanan
The Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Narayanan PV. Indocleftcon 2022 Founders Lecture: In search of the perfect cleft lip nose. J Cleft Lip Palate Craniofac Anomal 2022;9:113-9
|How to cite this URL:|
Narayanan PV. Indocleftcon 2022 Founders Lecture: In search of the perfect cleft lip nose. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Oct 2];9:113-9. Available from: https://www.jclpca.org/text.asp?2022/9/2/113/354288
I fully understand that this is an oration that has been delivered by great stalwarts, including my mentor Dr. H.S. Adenwalla in the erstwhile years. I am extremely grateful to Dr. Krishnamurthy, Dr. Jayakumar, Dr. Pramod, and the entire organizing team for entrusting me with this honor. I hope I do live up to their expectations.
I dedicate this oration to my Chief Dr. Hirji Sorab Adenwalla, who taught me all that I know in clefts, and especially spotted my passion for the correction of the cleft lip nose and encouraged me in every possible way.
“Trifles make perfection, and perfection is no trifle,” said Michelangelo, and this holds good, especially with regard to cleft lip rhinoplasty where attention to every small detail is essential.
The unilateral and bilateral cleft lip deformities are associated with characteristic changes in the nose.
In the case of the unilateral clefts, [Figure 1] the cleft side hemicolumella is shorter, ala is depressed and grooved, there is an alar flare with a widened nostril, the anterior nasal spine is displaced to the noncleft side, the anterior septum is deviated to the noncleft side, and the cleft side alar base is high riding in view of the associated bony deformities.
|Figure 1: A child with unilateral cleft lip with associated nasal deformity|
Click here to view
In the case of the bilateral patients [Figure 2], although there is a symmetry, the columella is short, the tip is broad with splayed-out medial crura, and the nostrils are wide with alar flare.
|Figure 2: A child with bilateral cleft lip with associated nasal deformity|
Click here to view
In general, cleft rhinoplasties are considered among the more difficult procedures requiring great finesse and judgment and attention to detail.
Almost all that I have been doing in these patients have been procedures done earlier by my mentor Dr. Adenwalla. All that I have done is to persist with those maneuvers that worked in the long run.
At the Charles Pinto Center, we have been approaching cleft lip nasal deformities in different stages. Let us first discuss unilateral clefts.
We follow the Millard's rotation advancement procedure in all unilateral cleft lips at about 6 months of age.
| Columella|| |
The hemicolumellar shortening is adequately tackled by the use of the C flap for lengthening, as advocated by Millard. It has been mentioned by some that such a lengthening effect is a myth. We beg to differ. Here is an example of a child with only cleft lip repair [Figure 3].
| Alar Groove and Depression|| |
During primary rhinoplasty,, we perform an extensive closed alar cartilage dissection in the plane between the alar cartilage and the skin. This has helped in eliminating the alar groove. We use modified McComb sutures as described by Demirseren et al. for the nostril web and also to raise the depressed cleft side alar cartilage. However, these are not easy to place accurately, and they often do not produce the desired results in the long run. With such an approach, we have obtained good results in many patients [Figure 4].
|Figure 4: (a) Before cleft lip repair. (b) Postoperative cleft lip repair after 6 1/2 years|
Click here to view
However, in others, even though there are no gross deformities of the nose on follow-up, we often see a soft triangle droop. If this is significant, we now offer to do an open rhinoplasty at around 5½ to 6 years.
In the earlier years, this was not the case. For such blemishes, we favored minor procedures like the Kilner inroll with crescentic excision of the alar vestibular lining, including a sliver of the underlying cartilage. While this sometimes showed an improvement initially, almost always, there was a relapse requiring another procedure later.
Then, we attempted the Tajima's reverse-U incision on the cleft side alar rim and inserted a conchal cartilage graft as an onlay alar cartilage graft [Figure 5]. Again, this did not fare well in the long run, and we gave up this and other such attempts and instead went ahead with a formal open rhinoplasty with a sutural fixation technique that we have developed in patients with a significant blemish.
|Figure 5: (a) After Tajima and Conchal graft. (b) 2 years postoperative after Tajima and conchal graft|
Click here to view
| Incisions|| |
We have found that the Tajima reverse-U incision on the cleft side is the best to obtain alar rim symmetry. However, this is a tricky incision to master and often leads to an alar notch even in experienced hands. Thus, we have revised our protocol, and in patients with a moderate alar rim height disparity, we use the Tajima reverse-U incision on the cleft side and an infracartilaginous incision on the noncleft side [Figure 6].
|Figure 6: Incision for Tajima's reverse-U on the cleft side and infracartilaginous incision on the cleft side|
Click here to view
In patients with either a very slight height disparity or gross disparity, we resort to bilateral infracartilaginous incisions [Figure 7].
In all patients, we use a V at the base of the columella that is connected along the sides of the columella to the alar incisions in the early years, we used an unequal V as described by Bardach, but gave this up as in our hands, it was producing unnaturally long columella.
An incision at the base of the columella has been frowned upon. There are two scars: a transverse, one at the base of the columella, which is anyway scarred from the Millard lip repair. The other scar is a vertical one in the midline of the upper lip. It was illustrated to us by Ian Jackson that these incisions heal without scarring, and we have found this to be true. Here is an example [Figure 8]. We boldly advocate this V incision to everyone.
|Figure 8: Child who had rhinoplasty including V incision at the base of columella-long-term result|
Click here to view
We then proceed with the dissection inferiorly along the sides of the columella. The medial crura are immediately beneath the incision, and their position can be predicted accurately. Gentle dissection allows the identification of the medial crura, and the entire columella skin envelope is raised with an adequate soft-tissue cushion for vascularity. This approach was learned by us from Prof. US Nayak at a workshop in JIPMER, Pondicherry.
The dissection then proceeds along the curve of the columella alar junction onto the lateral crus using Converse tip scissors. The alar dissection proceeds in the subperichondrial plane along the lateral crura, all the way laterally almost down to the alar base. Once the dissection is completed, we can identify the lower, the upper lateral cartilage, and the septum in the middle.
Invariably, the cleft-side lower lateral cartilage is inferiorly placed as compared to its counterpart [Figure 9].
Next, we raise the cleft-side lower lateral cartilage to the level of the noncleft side one by a suture technique. This is the key suture. It passes from the noncleft-side upper lateral cartilage through the septum and onto the upper border of the cleft side lower lateral. It returns, taking a bite on the upper border of the cleft side lower lateral as a mattress, again passing through the septum and exiting at the noncleft side upper lateral [Figure 10]. We use nonabsorbable 4-0 nylon for this and other sutures. When this suture is tied, the cleft side lower lateral is elevated to the level of that on the other side. Often, just this one suture alone produces a dramatic effect, as has been demonstrated by us in different workshops.
|Figure 10: Key suture noncleft upper lateral-septum-cleft lower lateral-cleft lower lateral-septum-noncleft upper lateral|
Click here to view
When we demonstrated this technique in a live operative workshop at Coimbatore for an Association of Plastic Surgeons of India Conference, Prof. Sam C Bose, was in the audience. He commented that this was an original and effective suture and though he knew of more that 30 sutural methods, this was new.
We have looked up the literature and have been unable to find any mention of an exactly similar technique described elsewhere. If indeed this is accepted as an original technique, I would like to call it as the Adenwalla suture, after my mentor.
| Columellar Support|| |
We strengthen the columella by buried intermedial crura sutures. These should be placed between the medial edges of the crura and not the lateral edges. Originally, we were following the latter technique, leading to the unnatural-looking columella. We rectified our technique after watching Dr. Mimis Cohen at a workshop in Chennai [Figure 11].
| Nasal TIP Esthetics|| |
Earlier, we were unaware of the proper method to obtain natural narrow nasal tips. We learned from Prof. Gubisch at the Marien hospital, Stuttgart, the technique of effective tip narrowing using trans- and inter-modal sutures [Figure 12].
| Septum|| |
In primary unilateral rhinoplasties, we always perform an aggressive septal repositioning in all complete clefts. This protocol was established in the 1970s by Dr. Adenwalla.
We separate the deviated septal cartilage from the perichondrium on both sides, score the cartilage on the noncleft side, and excise a sliver from the inferior border. Previously, we also shortened the cartilage anteriorly. However, we now refrain from such excision, as it weakens the anterior septum. We do not encroach onto the bony septum. Then, we fix the septum in the midline. Earlier, we sutured it to the newly formed nasal floor. However, this caused a deviation of the septum to the cleft side in some patients, and hence, we now fix the septum to the midline mucoperiosteum.
Until recently, the primary septal correction was criticized as being detrimental to the growth of the nose. However, the long-term studies by Anderl et al., Smahel et al., and our own experience have shown that early septal correction is safe and actually produces much better noses functionally and esthetically.
During preschool rhinoplasty, we avoid any septal work as we have already done that during the primary procedure in our patients. Patients with significant septal deviation may need bony septal correction as well, and this can be done only after the growth is completed. However, we certainly correct the septal cartilage deviation earlier if there is significant nasal obstruction. Here is a girl [Figure 13] had undergone primary cleft lip repair elsewhere without any rhinoplasty. She had gross septal deviation with nasal obstruction. This is a 8-year-follow-up after rhinoplasty and septoplasty.
|Figure 13: (a) Before open rhinoplasty and septoplasty. (b) 8 years postoperative after open rhinoplasty and septoplasty|
Click here to view
In patients who present with septal deviation after the growth is complete, we perform a septal repositioning along with open rhinoplasty. We now resort to the dorsal approach to the septum, having learned this at Stuttgart. We strongly recommend this approach. It is easily mastered. What is more, one can dissect the septum from its perichondrial attachments on both sides without breaching the latter in even the most convoluted of septal deviations. To get to the correct subperichondrial plane, we use a combination of sharp dissection using a scalpel and dissection with the plastic instrument, which is excellent for this purpose.
Once the septum is separated from its lining envelope on both sides, it is also separated from its bony attachments inferiorly.
We usually harvest a good cartilage graft leaving behind a strong anterior and dorsal support.
The septum is anchored to the midline peritoneum with 4-0 nylon. The anterior septum is reinforced with an anterior septal strut graft.
If there is a weak internal valve, as evidenced by a positive Cottle's test preoperatively, we use spreader grafts on one or both sides to improve the function.
Septal transfixing sutures are used to prevent a septal hematoma.
The septal lateral cartilage junction is restored with sutures.
| Grafts|| |
As already mentioned, we use septal cartilage grafts to reinforce the anterior septum and also as spreader grafts. We also use the grafts to strengthen the columella and as alar rim grafts, when necessary.
In addition, we dice the grafts and use them for the dorsum and the supra tip areas.
However, we avoid onlay alar cartilage grafts as far as possible. This was not always the case. Till the early 2000s, we used to rely a lot on onlay alar cartilage grafts, often stacking them up in multiple tiers. That was before we began using the sutural technique. While the appearance was satisfactory early on, we were repeatedly dejected on seeing the long-term results.
The fate of the onlay alar cartilage grafts and the need to avoid such stages were explained by Dr. Court Cutting in his talks at the Smile Train Surgeons conference in Mumbai in 2004.
Here is a patient with a dorsal hump and a cleft lip nasal deformity [Figure 14]. She was operated on at our center by a visiting rhinoplasty expert, who corrected the hump with an osteotomy, but used an onlay conchal cartilage graft for the ala. Although it seemed to be satisfactory in the immediate postoperative period, she soon came back saying that it was as if nothing had been done to her ala in the first place.
|Figure 14: Preoperative, after, and 6 months after onlay alar cartilage graft|
Click here to view
In most cases, we have been able to use septal cartilage graft alone for our cleft rhinoplasties. Only when the augmentation required is gross, has it been neccessary to use costal cartilage grafts.
We used to favor strips of grafts for augmentation initially but have changed over to diced grafts after watching the results of Prof. Gubisch. The diced grafts produce a much more natural appearance and can also be molded postoperatively for some time.
| Osteotomy|| |
When necessary, we use lateral, medial, and transverse osteotomies. We were able to refine our technique again after the Stuttgart visit.
With this kind of wholesome approach in primary, preschool, and, when necessary, secondary rhinoplasties, we have been able to get a good improvement in most of the patients [Figure 15].
|Figure 15: (a) Before sutural fixation and excision frontal view. (b) Four years after sutural fixation and excision frontal view. (c) Before sutural fixation and excision worm's eye view. (d) Four years after sutural fixation and excision worm's eye view|
Click here to view
| Problem Areas|| |
Bony platform-related issues
When there is a gross pyriform area depression, correction of the nasal deformity alone does not provide a satisfactory result. Augmentation of the bony platform is necessary, and hence, we defer the rhinoplasty until after the alveolar bone graft, at which time enough bone is also used to elevate the pyriform area.
We have tried other methods like the “Turkish Delight,” where we use diced cartilage graft in rolled-up Surgicel for the augmentation. We have also used hydroxyapatite. These methods give unpredictable results.
Nostril Symmetry is elusive. This is especially true when one nostril is smaller. We have tried Z plasty, V to Y advancement, etc., When volume expansion of the nostril is necessary, it is even trickier. Full-thickness grafts have been advocated but may not take well in this setting.
High-riding nostrils are best prevented by good presurgical orthodontics. In primary repair, we try and avoid this by Jackson's unequal Z plasty. This reduces the problem in most cases.
Once it is established, correction is difficult. We have tried Z plasty to bring the alar base down. A good cinch suture often works better. However, any attempt to bring the alar base down works at cross purposes, with the alar lifting maneuvers necessary in these patients.
| Bilateral Cleft Lip Nasal Correction|| |
In bilateral cleft lip patients, there is usually symmetry of the nose. The columella is short. The tip is broad. Alar flaring is seen. The septum is usually in the midline.
State-of-the-art involves primary nasal correction in these patients. However, for this, the premaxilla must be aligned with the lateral bony shelves. This is the consensus among most experts.
At our center, we did not have access to presurgical orthodontics initially. Although we now do have such a facility, we still do not get proper alignment of the bony shelves. Hence, we do not perform primary rhinoplasty in bilateral cleft patients. Instead, we do a columellar lengthening and open rhinoplasty at 5½–6 years. We use bilateral Tajima reverse-U incisions connected by lateral columellar incisions to a V at the base of the columella [Figure 16]. We use a sutural technique as in unilateral patients but use the key Adenwalla suture bilaterally.
With this approach, we have been able to get acceptable results. Here are such patients [Figure 17]. I'm sure that it will be agreed that they have not been disadvantaged by the lack of primary rhinoplasty.
|Figure 17: (a) Before bilateral cleft lip repair frontal view. (b) After bilateral cleft lip repair and rhinoplasty frontal view. (c) Before bilateral cleft lip repair Worm's eye view. (d) After bilateral cleft lip repair and rhinoplasty worm's eye view|
Click here to view
When patients turn up in adulthood with bilateral cleft lip nose deformities, we offer a similar approach to them also.
| Conclusion|| |
Thus, we have been addressing these complex deformities with various techniques. While we have been able to provide an improvement in most of them, we ourselves have been able to derive satisfaction only in some. Perfection is certainly elusive. We shall continue to strive toward that goal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Adenwalla HS, Narayanan PV. Primary unilateral cleft lip repair. Indian J Plast Surg 2009;42 Suppl: S62-70.
Narayanan PV, Adenwalla HS. Primary rhinoplasty at the time of unilateral cleft lip repair: A review and our protocol. Cleft Lip Palate Craniofac J 2015;2:92-7.
Demirseren ME, Ohkubo F, Kadomatsu K, Hosaka Y. A simple method for lower lateral cartilage repositioning in cleft lip nose deformity. Plast Reconstr Surg 2004;113:649-52.
Narayanan PV, Adenwalla HS. Unfavourable results in the repair of the cleft lip. Indian J Plast Surg 2013;46:171-82.
] [Full text]
Anderl H, Hussl H, Ninkovic M. Primary simultaneous lip and nose repair in the unilateral cleft lip and palate. Plast Reconstr Surg 2008;121:959-70.
Smahel Z, Mullerova Z, Nejedly A. Effect of primary repositioning of the nasal septum on facial growth in unilateral cleft lip and palate. Cleft Lip Palate Craniofac J 1999;36:310-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]