Rhinoplasty for Patients

with Cleft Lip-Palate

Functional and Aesthetic Concerns

Tsung-yen Hsieh, MDa, Isabelle Gengler, MD

a
,
Travis T. Tollefson, MD, MPHb,*

KEYWORDS
 Cleft lip  Cleft palate  Cleft rhinoplasty  Nasal deformities  Surgical techniques
 Nasal valves  Septal deviation

KEY POINTS
 Understanding the unique anatomic challenges in patients with cleft lip and palate, such
as septal deviation, asymmetry of the cartilaginous frame work, and bony and soft tissue
deformities is essential for successful surgical planning in cleft rhinoplasty.
 Techniques such as thorough septoplasty, structural grafting, management of the soft tis-
sues, and the use of advanced suturing methods are crucial for achieving desired
aesthetic and functional outcomes.
 Primary rhinoplasty can be performed during initial lip repair, intermediate rhinoplasty
before skeletal maturity, and definitive rhinoplasty after skeletal maturity, balancing
growth concerns, and deformity severity.

INTRODUCTION

Many patients with cleft lip and cleft palate have anatomic features that affect the form
and function of their nose. The shape and function of the nose is affected by the defi-
cient bony maxilla, dentoalveolar arch/teeth, and lip soft tissues, impacting them both
structurally and aesthetically. This article will define the characteristic nasal defor-
mities found in patients with cleft lip and palate and describe the associated surgical
techniques and considerations in cleft rhinoplasty with focus on the nasal valves in
both unilateral and bilateral cleft lip nasal deformities. Overall, concepts will include

a
Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck
Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; b Facial Plastic and
Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, University of
California Davis Medical Center, University of California Davis, 2521 Stockton Boulevard, Suite
7200, Sacramento, CA 95817, USA
* Corresponding author.
E-mail address: [email protected]

Otolaryngol Clin N Am - (2024) -–-

https://doi.org/10.1016/j.otc.2024.07.017 oto.theclinics.com
0030-6665/24/ª 2024 Elsevier Inc. All rights are reserved, including those for text and data mining,
AI training, and similar technologies.
2 Hsieh et al

correction of septal deflections, structural cartilage grafting, suture techniques, and

nostril soft tissue rearrangements.

BACKGROUND

Cleft lip and/or palate is the most common congenital orofacial anomaly, as 6000 to
8000 children are born with it every year in the United States (1 in 700 births). Accord-
ing to the National Institute of Dental and Craniofacial Research, cleft lip and cleft pal-
ate affect 1 in 1600 births, with isolated cleft lip defects in 1 in 2800 births, and 1 in
1700 births with cleft palate only.1 The etiology of orofacial clefts is complex and multi-
factorial including genetic, syndromic, environmental, and toxic factors.2–5 The classi-
cally described nasal, oral, and pharyngeal deformities can first impact optimal
swallowing and nutrition.6
Once these early concerns are addressed, the cleft nasal deformity that persists is
one of the hardest technical challenges for the surgeon. The complex nasal architec-
ture that results from either unilateral or bilateral cleft lip deformity can be made even
more challenging in older children, considering postsurgical changes, scarring, and
modified facial growth.7

ANATOMIC CONSIDERATIONS OF THE CLEFT LIP NASAL DEFORMITY

Due to the complexity of the nasal anatomy and patient-specific deformities that are
observed in patients with cleft lip and palate, classifications and nomenclatures
have been described8 to guide the novice surgeon in evaluating the cleft nose. This
article proposes a description of the nasal anatomy in both unilateral and bilateral cleft
lip, and divides the evaluation of the nose into 3 anatomic parts: the nasal tip and colu-
mella, the nasal septum, and the nasal valve. Having a thorough understanding of
each patient’s unique cleft nasal anatomy is critical for surgical planning and patient’s
specific nasal reconstruction.
Unilateral Cleft Lip and Nasal Deformity
Patients with unilateral cleft lip have several nasal characteristics derived from local
embryologic development and muscle attachments that will not be reviewed in this
article. On the cleft side, the skeletal deficiency of the maxilla leads to dysmorphic
nasal ala with a shorter medial crus and elongated lateral crus, which contribute to
nasal tip asymmetry and posterior displacement of the tip. The length and volume
of both lower lateral cartilage is comparable to patients without cleft deformity, but
the lack of muscle attachments and the resulting vector forces result in cartilage defor-
mity. The nostril appears flattened on the cleft side, and the caudal septum and nasal
spine further displaced toward the non-cleft side.9,10 These deformities are summa-
rized in Box 1 and can be seen in Fig. 1.
Bilateral Cleft Lip and Nasal Deformity
Patients with bilateral cleft lip and palate usually present with an overall more symmet-
ric nasal deformity with some similarities to unilateral cleft patients, but also with crit-
ical anatomy differences that impact rhinoplasty surgery. Due to medial and inferior
maxillary deficiency, both alar bases are positioned more laterally and posteriorly,
contributing to an overall wider and flatter nose. In cases of complete bilateral cleft,
the prolabial tissue extends from the nasal septum and is significantly affected during
surgical correction of the nasal deformity. The lower lateral cartilage has a shorter
medial crura and a longer lateral crura, which further widens the alar bases. Due to
the severity of the nasal under-projection, the definition of the tip is poor, the height
 Functional and Aesthetic Concerns 3

Box 1
Clinical characteristics of unilateral cleft nasal deformity

Asymmetric tip, usually posteriorly deviated to the cleft side

Posterior cartilaginous and bony septum deviated to the cleft side
Caudal septum deviated to the non-cleft side
Flattening of the nostril on the cleft side
Shorter medial crura and lengthened lateral crura (LLC length is intact)
Alar base is displaced laterally, inferiorly, and posteriorly
Maxillary deficiency on the cleft side
Anterior nasal spine is displaced to the non-cleft side

of the nose is decreased, and the remnant columellar skin becomes a limiting factor in
reconstructive surgery. The orbicularis oris muscle is absent in the prolabial region and
the premaxilla is protruding, which contributes to the short, and sometimes non-
existent, columella. Patients with bilateral cleft experience bilateral nasal obstruction
secondary to bilateral nasal valve static collapse against the reconstructed nasal floor,
while the septum usually remains midline. The external nasal valve is narrow on both
sides due to the severe flattening of the nose, and the internal nasal valve is obstructed
by the plica vestibularis, from the redundant lower lateral cartilage.11 These defor-
mities are summarized in Box 2 and can be seen in Fig. 2.

EVALUATION OF THE NASAL TIP AND COLUMELLA

When evaluating the nasal deformity of patients with cleft lip and palate, the surgeon
should first consider overall tip support and tip deformity. The major support of the
nasal tip is the strength and shape of the medial crura and their relationship with
the distal nasal septum, as well as the attachment of the lower lateral cartilage to
the caudal aspect of the upper lateral cartilage. The significant asymmetry of the lower
lateral cartilages and the soft tissue of the nasal base will create a significant nasal
deformity. Assessing the strength of the nasal tip, its symmetry, the length of the
medial crura, and the amount of available soft tissue at the columella are important
clinical findings to start surgical planning. In case of bilateral cleft, tip support is

Fig. 1. Infant with unilateral cleft lip and palate demonstrating features of unilateral cleft
lip nasal deformity.
4 Hsieh et al

Box 2
Clinical characteristics of bilateral cleft nasal deformity

Nasal tip is broad, flat, with poor definition, and grossly asymmetric
Tip is underprojected and posterolaterally displaced domes
Dysmorphic lower lateral cartilages bilaterally
Medial crura is shorter and lateral crura is longer
Short columella with lack of soft tissue
Wider alar base and flattening of both nostrils
Bilaterally absent or deficient nasal floor

very deficient, and reconstruction will depend on the amount of columellar skin, the
length of both medial crura, the height of the premaxilla, and the possible associated
septal deformity.12 A step-by-step guide to analyze nasal deformity prior to surgery is
described in Table 1.

EVALUATION OF THE NASAL SEPTUM DEFORMITY

A deviated septum will invariably impact nasal symmetry in the mid vault and
contribute to chronic nasal obstruction. Careful treatment of septal deviation is critical
to improve overall cosmetic appearance without negative impact on nasal growth. Pa-
tients with unilateral cleft lip and palate display a posterior cartilaginous and bony
septum deviated toward the cleft side while the caudal septum is deviated to the
non-cleft side (Fig. 3). Often, the caudal septum is also displaced from its maxillary
crest attachment. The strength and thickness of the nasal septum should also be
considered, especially in bilateral cleft cases. Finally, the height of the caudal septum
in relationship with the premaxilla will also impact the type of surgical reconstruction
considered and the grafts required.

ASSESSMENT OF THE NASAL VALVES

The lateral nasal valve is composed of the nasal septum, the position and strength of
the lateral crura (LLC), and the relationship of the lateral crura and septum with the

Fig. 2. Patient with bilateral cleft lip and palate demonstrating features of bilateral cleft lip
nasal deformity. (A) Frontal view. (B) Base view.
 Functional and Aesthetic Concerns 5

Table 1
Step-by-step preoperative nasal deformity analysis

Nasal tip and columella Tip projection, rotation, and support

Dome asymmetry
Length and deformity of the columella
Amount of residual prelabial tissue
Amount of columellar scar tissue from prior lip surgery
Septum Length and deformity of the caudal septum
Posterior bony spur and deviation
Attachment to the maxillary crest
Saddle nose deformity
Nasal valve and LLC Length and position of medial and lateral crura
Lateral crura dynamic collapse
Alar base widening
INV static narrowing
Inferior turbinate hypertrophy

nostril sill13 The elongated and weak lateral crura on the cleft side nose in a unilateral
cleft lip deformity tends to collapse against the caudal septum, and is sometimes
directly in contact with the nostril sill. Specific nomenclatures have been proposed
to evaluate the severity of the dynamic collapse of the lateral nasal valve. Maximum
nasal inspiration can help grade the severity of the nasal collapse as a percentage
of airway obstruction,14 as well as assess the strength of the crura. In patients with
bilateral cleft, the length of the medial crura is a more relevant component of the pre-
operative assessment.
The internal nasal valve is composed of the nasal septum, the caudal border of the
upper lateral cartilage, the head of the inferior turbinate, and the redundant tissue that
surrounds these structures.15 The internal nasal valve can display both static and dy-
namic collapse in patients with cleft lip and palate, which will affect breathing function,
but also olfaction by narrowing the olfactory cleft, and nasal aesthetics due to a narrow
mid vault. The internal nasal valve angle is considered normal between 10 and 15 .16 It

Fig. 3. Intraoperative demonstration of cartilaginous deformities and asymmetry in a pa-

tient with unilateral cleft lip. The figure demonstrates severe caudal septal deflection to
the non-cleft side with significant differences of the lower lateral alar cartilages in shape,
position, and symmetry.
6 Hsieh et al

is the narrowest area in the nose, which makes it critical to assess prior to rhinoplasty.
The direct and indirect Cottle maneuver can define the extent of the internal nasal
valve narrowing. The surgeon can also differentiate between anatomic obstruction
versus mucosal swelling by introducing oxymetazoline in the patient’s nose.

TIMING AND SEQUENCE OF SURGICAL OPTIONS

Surgeons have differing opinions regarding optimal time to address the nose. If not
addressed during primary cleft lip repair, intermediate rhinoplasty may be performed
during palatoplasty or later time. Definitive cleft rhinoplasty is often performed in the
late teenage years after “skeletal maturity.” Advocates for delayed surgery cite
weak anecdotal evidence that early surgery may affect facial growth. Factors that
may influence timing of surgeries include concern for growth and development,
severity of deformity, psychosocial considerations, functional concerns, and surgeon
preference. The authors’ approach has been to wait until maturity prior to definitive
surgery unless there is significant deformity that requires earlier intervention.

Presurgical Management Prior to Primary Cleft Lip Repair and Rhinoplasty

Presurgical infant orthopedics (PISO) have been utilized for the manipulation of the
premaxilla since the sixteenth century for patients with cleft lip and palate.17 The tech-
niques have improved significantly since then. The nasoalveolar molding (NAM) appli-
ances combine an orthodontic device on the premaxilla and lateral alveolar segments
with nasal stents. The concept of molding is theorized increase serum maternal estro-
gen increases elasticity of cartilage via estrogen-mediated release of proteoglycans
and hyaluronic acid.18,19
Primary objectives of NAM are the following (1) bring maxillary segments closer, (2)
retract the premaxilla posteriorly to approximate the maxillary segments in bilateral
cleft, and (3) expand the nasal mucosal lining and soft tissues as well as mold the lower
lateral cartilages to be more symmetric.20,21
It is worth noting that the use of PSIO is debated due to limited long-term outcomes,
lack of clear objective outcome measures, and differences in techniques.22 Therefore,
the decision to utilize NAM should consider socioeconomic impact on the parents,
parental compliance and cleft severity.17,23

Primary Rhinoplasty
Primary cleft rhinoplasty is performed at the time of the cleft lip repair. The objective of
the primary cleft rhinoplasty is to achieve early symmetry before deformities become
more pronounced with growth. This may reduce the severity of future deformity, thus
decreasing the need for multiple revision surgeries.24 Special care to avoid excessive
dissection can prevent excessive scarring, devascularization or inadvertent stenosis
of the external nasal valves.

Intermediate Rhinoplasty
Intermediate cleft rhinoplasty is defined as rhinoplasty performed after primary lip
repair but before definitive (mature) rhinoplasty at near full skeletal and facial develop-
ment. Evidence for intermediate rhinoplasty is limited, with the literature focusing on
primary and definitive rhinoplasty. A nuanced approach is important for intermediate
rhinoplasty as the patients may present with a variety of deformities, scarring, and
functional issues. Most cleft surgeons consider the lip and nose as a single unit. There-
fore, presurgical NAM and maneuvers performed during primary lip repair can have
considerable implications on nasal outcomes. Thus, in the setting of the intermediate
 Functional and Aesthetic Concerns 7

stage, small revision techniques are typically applied rather than large reconstructive
surgeries.

Orthognathic Surgery and Alveolar Bone Grafting

There is typically maxillary skeletal deficiency and need for establishing a bony foun-
dation for these cases. A multidisciplinary approach with orthodontic preparation and
alveolar bone grafting where needed typically happens in the first decade of life. Sur-
gically treatable dentofacial malocclusion (orthognathic surgery), alveolar bone graft-
ing, closure of alveolar clefts/fistulae, and dental preparation should be completed
prior to the definitive rhinoplasty to establish the maxillary bony foundation.25,26

Definitive (Mature) Cleft Rhinoplasty

Definitive rhinoplasty is performed once nasal and midface growth is completed, usu-
ally at ages 14 to 16 in females and ages 16 to 18 in males. The goals of definitive rhi-
noplasty are to create symmetry and definition of the nose, correct nasal obstruction,
repair nasal scarring/stenosis. A customized approach is crucial in the success of
definitive cleft rhinoplasty as there are a variety of nasal deformities that include the
type and severity of the original lip and nasal defect, changes in nasal growth over
time, and sequelae of prior primary and/or intermediate cleft rhinoplasties.27

SURGICAL TECHNIQUES
Primary Cleft Rhinoplasty
Unilateral cleft lip primary rhinoplasty
Primary cleft rhinoplasty in unilateral cleft nasal deformity aims to reconstruct the nasal
tip symmetry and decrease excess alar hooding on the cleft side. Dissection begins
with elevation of the lower lateral cartilages (LLCs) from the soft tissue envelope
through the columellar portion of the lip incision (Fig. 4). Next, the cleft side LLC is
mobilized to a more cephalad and medial position. This can be accomplished through
the Skoog technique where an intracartilaginous or marginal rhinoplasty is made to

Fig. 4. Demonstration of primary cleft rhinoplasty approach utilizing the lip incisions for ac-
cess to dissect between the lower lateral cartilages and the soft tissue envelope.
8 Hsieh et al

access and secure the cleft side lower lateral cartilages to the upper lateral cartilages
(ULCs) and septum to achieve a more symmetric position of the cleft side external
nasal valve. Another approach to repositioning the cleft side LLC is to utilize triangular
fixation sutures (Fig. 5). Transnasal sutures out to the alar crease and back into the
nasal vestibule while holding the cleft side LLC cephalad and medially can achieve
similar goals of creating symmetry of the external nasal valves.
To address excessive hooding on the cleft side, elliptical excision of the soft tissue
hooding or transposition flap utilizing a rim incision (Tajima reverse U) can remove and
reposition the soft tissues to decrease hooding of the cleft side nose and repair the
external nasal valve on the cleft side (Fig. 6).
Lastly, alar base cinching suture can be utilized to place the cleft side alar base in a
more symmetry position to the cleft alar base. Often this is done in conjunction with the
nasal sill repair as part of the cleft lip repair (Fig. 7).

Bilateral cleft lip primary rhinoplasty

In bilateral cleft nasal deformity, primary rhinoplasty is typically performed to reduce
alar flare, reposition the LLC, reconstruct the nasal sills, project the nasal tip and
lengthen the columella.28–30 These objectives can be accomplished through bilateral
partial marginal incisions to expose the nasal tip fat pad. Excess fibrofatty tissue be-
tween the LLCs is removed. Bilateral lateral crural steal (LCS) techniques are then per-
formed and the LLCs sutured together in the midline in a more projected position of the
nasal tip. Nostril hooding can be addressed similarly to the unilateral primary cleft rhi-
noplasty using elliptical excision or the Tajima reverse U rim incision31 and soft tissue
transposition to expand the external nasal valves. Alar base cinching sutures are often
utilized as well to facilitate nasal sill positioning. A traditional approach is to add soft
tissue and skin from the lip to the columella using a V-Y columellar lengthening.

Fig. 5. Illustration of triangular fixation sutures, which are full thickness mattress sutures
that can help position the lower lateral cartilages. Note that symmetric positioning of these
sutures can be placed to provide the desired effect on the lower lateral cartilages to create
symmetry.
 Functional and Aesthetic Concerns 9

Fig. 6. Tajima reverse-U incision with Z-plasty modification. The lateral wall Z-plasty intro-
duces internal lining to the cleft side vestibule by transposing flap (A) and flap (B).

With the concepts of Mulliken and others, many (including the authors) prefer to go by
the philosophy that the “columella is in the nose”28 and lengthen the columella by
transferring soft tissue triangle of the nostril skin into the columella along with LCS
of the lower lateral cartilages. This is performed instead of incisions on the lip that re-
cruit soft tissues from the former prolabium/lip (Fig. 8)
In primary cleft rhinoplasty, nasal conformers are often utilized to support the nos-
trils for up to 6 weeks. Nasal conformers should be placed without blanching of the
nasal tip skin to avoid pressure necrosis.32 The evidence of nasal conformer’s effec-
tiveness is heterogeneous as shown in a recent systematic review published in 2023
by Nguyen and colleagues, which suggests that stenting is safe and can assist in

Fig. 7. Preoperative and postoperative photos demonstrating primary rhinoplasty, utilizing

various techniques including triangular fixation sutures, Tajima reverse U incision with skin
excision and transposition flaps, and alar cinching suture, with improvement in positioning,
symmetry, and nasal airway. (A) frontal view. (B) base view.
10 Hsieh et al

Fig. 8. V-Y advancement flap schematic demonstrating lengthening of the columella by re-
cruiting tissue from the upper lip.

preserving the nasal shape and decrease nostril stenosis.33 The length of time for stent
placement is based on the receptiveness of patient, family, and surgeon with little ev-
idence to suggest a clear answer.

DEFINITIVE (MATURE) CLEFT RHINOPLASTY

Surgical Approach
Utilization of endonasal versus external approach to definitive cleft rhinoplasty is
determined by surgeon preference and the extent of reconstruction. In definitive cleft
rhinoplasty, there are many factors to consider including the nasal septum, nasal tip,
alar rim, alar base, columellar, nasal sill, as well as potential need for revisions of the
previous cleft lip repair. These cases can be particularly challenging due to both the
extent of the initial deformity as well as scar formation/deformities secondary to prior
sutures.

Techniques for Correction of Nasal Deformities with Focus on Nasal Valves

Internal nasal valves
The reconstruction of the internal nasal valve will involve correction of the nasal
septum, the ULCs, the scroll area and the inferior turbinates. Beginning with the nasal
septum, exposure and detachment of all the mucosal, ligamentous, scar, cartilaginous
connections causing septal deviation is crucial. A septoplasty is performed to correct
the septal deviation that may affect nasal breathing, but also to harvest septal cartilage
for later grafting. Spreader grafts and extended spreader grafts can provide further
support to the dorsal septum. These grafts are placed between the dorsal nasal
septum and ULCs (Fig. 9). These grafts can provide support to the nasal dorsum.
Asymmetric spreader grafts can also be positioned to correct and straighten dorsal
nasal septal deviations. Lastly, spreader, extended spreader and/or autospreader
flaps can enlarge the cross-sectional area of the internal nasal valve to improve nasal
airway.34–36 Other maneuvers to expand/support the internal nasal valves such as
suspension sutures, nasal implant placement, or radiofrequency treatments can
also be utilized.37–42 In patients with turbinate hypertrophy, turbinate reduction and
out-fracture can be performed concomitantly.

External nasal valve

Techniques to repair the external nasal valve in cleft rhinoplasty can be challenging
secondary to the existing cleft nasal and lip deformities as well as scar formation
 Functional and Aesthetic Concerns 11

Fig. 9. Spreader graft placement for dorsal septal support and expansion of internal nasal
valves.

from previous surgeries. The caudal septum/columella, the nasal ala, and nasal sill all
need to be corrected.
To adequately expose the caudal nasal septum, the ligaments connecting the
medial crura are often divided. If the caudal septum is severely deviated to the non-
cleft side from unimpeded pull of the orbicularis oris and deficient maxilla, it needs
to be separated from the nasal spine, mobilized, and repositioned to the midline by
securing the caudal septum to the periosteum of the midline maxilla. If necessary,
an anterior, inferior wedge of cartilage can be resected from the caudal septum to
assist with the septal repositioning (Fig. 10). Caudal extension grafting is often utilized
to provide more septal support,43 as well as to provide positioning for the nasal tip.
These can be fixated in an end-to-end or end-to-side manner to the existing caudal
nasal septum. These grafts can be harvested from septal cartilage, or costal cartilage.
While auricular cartilage may also be used, the curvature and decreased strength in
the cartilage may be less ideal for large structural grafts.
The nasal tip can then be addressed to establish symmetry, definition and projec-
tion. Once the caudal septum is straightened and supported, tongue in groove (TIG)
technique can be performed to suspend and position the nasal domes and define
the nasal tip position.44 In unilateral cleft nasal deformity, the cleft side nasal tip is
under-projected with hooding of the ala. The TIG technique can be performed asym-
metrically by suspending the cleft side alar cartilage further than the noncleft side to
the midline structure (caudal septum, columellar strut, or caudal septal extension
graft), thereby correcting the cleft LLC flattening and improve symmetry as well as
to improve the cleft side external nasal valve. In bilateral cleft nasal deformity, this
similar technique can be utilized to project the nasal tip and provide better support
to the external nasal valves.
The alar rims all need to be addressed to improve external nasal valve function in
cleft rhinoplasty. In unilateral cleft nasal deformity, alar malpositioning results in flat-
tening of the cleft lateral crus of the LLC with inferior and posterior displacement of
the cartilage. The resulting concave deformity can create nasal valve collapse. LCS
technique,45 which advances the lateral crura into the medial crura can decrease
12 Hsieh et al

Fig. 10. Caudal septal repositioning. (A) deflection of the caudal septum toward the non-
cleft side. An anterior inferior wedge of curve caudal septum resected to allow reposition-
ing of the septum to the midline. (B) Caudal Septum is sutured to the periosteum of the
nasal spine in a more midline position.

the malpositioning in the lateral crus of the LLC in cleft nasal deformities and provide
more symmetry as well as less flattening of the lateral crus. In this technique, the
vestibular skin is separated from the undersurface of the alar cartilage. If there is sig-
nificant restriction of the mucosa, a Z-plasty may be performed to help release mu-
cosa. Once the lateral crura is mobilized without restriction from the vestibular skin,
the lateral crus is then advanced medially in a curvilinear fashion onto the medial
crus and fixed in its new position using mattress sutures (Fig. 11). Interdomal sutures
and TIG techniques can be performed after to recreate the nasal tip complex and sup-
port the external nasal valves. If additional ala support is needed, traditional rhino-
plasty techniques can be employed including lateral crural strut grafts (placed
between the alar cartilage and vestibular skin down to the pyriform aperture), alar
batten grafts (placed over the alar cartilages to the pyriform aperture), alar rim/articu-
lated rim grafts (nonanatomic graft placed within the soft tissues of the alar rim), alar
turn in flaps (the cephalic portion of the LLC is transposed on a pedicle and placed un-
der the remaining LLC) (Fig. 12). These techniques provide a more laterally positioned
alar rim with improved support to the LLC, thereby improving the functional of the
external nasal valve.46
In severely concave deformities of the LLC, a flip-flop technique can be utilized. The
lateral crura of the LLC is dissected completely off of the underlying vestibular skin.
The lateral crura is then completely excised, turned over, and sutured back to the
medial crura and the vestibular lining, creating a more convex shape of the ala.47
Similar to primary cleft rhinoplasty, webbing, significant soft tissue hooding, stenotic
scar can be addressed with utilization of rotational flaps, transposition flaps, elliptical
soft tissue excision, or Tajima reverse U technique. If there is significant soft tissue
contracture, skin grafting or composite grafting may be required.
There is often poor support of the nasal bases on the cleft side secondary to skeletal
deficiency. In addition, previous malpositioning of the alar facial junction or the inser-
tion of the alar base can become more exaggerated with growth. These deformities
 Functional and Aesthetic Concerns 13

Fig. 11. Lateral Crural Steal Technique—The lateral crura area advanced onto the medial
crura, resulting in an increase in the length of the medial crura at the expense of the lateral
crura. The medial crura are secured onto the caudal septal extension graft (or native
septum/columellar strut) in a mattress fashion to provide symmetry and support.

need to be addressed to achieve better symmetry. Poor skeletal support of the ala
base can be addressed with premaxillary cartilage or bone grafting on the cleft-side
maxilla and pyriform aperture. This can be placed through a sublabial or nasal sill inci-
sion, yet a water-tight closure and sound technique are required for adequate bone
graft take.

Fig. 12. Structural grafts to external nasal valve support including alar batten graft (placed
over the LLC), lateral crural strut graft (placed under the LLC), and alar rim graft (placed
along the alar rim).
14 Hsieh et al

While there are classic descriptions for unilateral and bilateral cleft lip nasal defor-
mity, the nasal findings can have significant variability along a spectrum of severity.
In addition, both congenital and iatrogenic (post-surgical) changes to the nasal archi-
tecture make each case unique. Thus, a patient-centered approach to cleft septorhi-
noplasty is essential (Fig. 13).

COMPLICATIONS AND MANAGEMENT

Complications of cleft nasal surgery can be secondary to infections, suture abscess,

scarring, residual or recalcitrant septal deviation, recurrent nostril hooding, nasal
asymmetry, nasal stenosis resulting in nasal obstruction. Measures to decrease risk
of potential complications include (1) meticulous soft tissue dissection and conserva-
tion, (2) thoughtful design of incisions to avoid constriction, (3) structural cartilage
grafting to provide nasal support, (4) careful presurgical assessment of maxillary
bone, dentition, lip scarring and volume, soft tissue thickness, (5) antibiotic

Fig. 13. Example case of a patient with unilateral cleft lip and palate who underwent defin-
itive cleft rhinoplasty. In this patient, the cleft nasal deformity was corrected with extensive
septoplasty, bilateral extended spreader grafts, caudal extension graft, bilateral lateral
crural strut grafts, tip graft and premaxillary cartilage grafting. Autologous septal and costal
cartilage was utilized for the structural grafting. (A) Preoperative in frontal, oblique, profile
views. (B) Postoperative in similar views.
 Functional and Aesthetic Concerns 15

stewardship. As described by rhinoplasty clinical practice guidelines,48 perioperative

antibiotics are utilized for the first 24 hours after surgery unless risk factors are present,
such as revision case, significant cartilage grafting or patient immunosuppression.

SUMMARY

Patients with cleft lip nasal deformity need a thorough examination to accurately diag-
nose and treat the contributions of the nasal valve to nasal airway obstruction. The aim
of cleft rhinoplasty is to improve patient quality of life through improving symmetry,
proportion of tip projection, and nasal airway function. Reconstruction requires treat-
ing the underlying abnormal anatomy with cartilage grafting and suture techniques,
but carefully executed alar rim soft tissue adjustments for the alar hooding. The nasal
valve treatment will require an assessment of soft tissue symmetry and asymmetric
grafts are common making this one of the most challenging rhinoplasty surgeries to
plan, execute and manage.

CLINICS CARE POINTS

 When considering the patient complaints regarding nasal obstruction in a typical rhinoplasty
practice, many patients have multifactorial nasal complaints. The rhinoplasty surgeon must
accurately question the patient about their expectations to best meet their needs, especially
when the complexity of rhinoplasty for cleft lip nasal deformities is considered.
 Our approach is to talk with the parents and patients early in their adolescent cleft care cycle.
Consultations include gathering patient reported outcome measures including SCHNOS,
NOSE, and Cleft-Q, which are helpful for pre and postoperative assessment.
 Effective management of cleft lip and palate patients requires a multidisciplinary approach
involving orthodontists, speech therapists, and surgeons, along with long-term follow-up to
address evolving anatomic and functional issues.

DISCLOSURE

The authors have nothing to disclose.

REFERENCES

1. Cleft lip & palate | national institute of dental and craniofacial research. (n. d).
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