Pre-operative situation (left) and 1 year following septorhinoplasty (right)
What is a unilateral cleft-lip deformity?
Typically the tip of the nose is asymmetrical with the hemitip on the cleft side showing underprojection, overrotation and poor definition. It is as if that part of the tip has sunken into the cleft. The ala on the cleft side frequently shows poor projection from the facial plane and unfavorable inset, attributing to tip asymmetry.
The cartilaginous nasal septum deviates away from the cleft and can cause nasal obstruction due to vestibular narrowing. It also contributes to crookedness of the columella and the midvault area. The posterior septum usually deviates away from the cleft and a prominent septal spine is frequently encountered.
The vestibular floor on the cleft side usually is deep, caused by absence of bone and poor continuity of the orbicularis oris muscle.
The bony nasal pyramid can be crooked and wide or unaffected.
How to correct the unilateral cleft-lip nose?
1. External rhinoplasty approach
2. Septal correction/reconstruction with medial fixation of the caudal border onto the premaxilla or corrected anterior nasal spine
3. spreadergraft placement to correct loss of middorsal volume on the cleft side adding to symmetry and dorsal septal support
4. dome defining sutures with a LC-steal on the cleft side
5. lateral crural under/overlay to add support and shape of the ala and scroll area
6. tongue in groove to set tipprojection and rotation
7. rimgrafts and capgraft to favor tip contouring, definition and support
8. dorsal contouring with rasping or hump osteotomy
9. osteotomies when indicated (usually only lateral low-low-low and transverse for infraction).
10. inner lining lengthening on cleft side with a v-to-y closure (alternatively composite graft skin-cartilage or buccal mucosa)
11. augmentation of the facial plane underneath the ala on the cleft side using perpendicular plate bone (usually the septal spine)
12. correction of alar inset to symmetrical heights
* Auricular cartilage or rib cartilage might be needed.
** The severity of the unilateral cleft lip nose is very diverse and the final surgical plan needs to be tailored to each individual situation.