Summary of Secondary Cleft Deformities and Surgery

## Introduction Cleft rhinoplasty addresses the correction of nasal deformities associated with cleft lip and/or palate. The goal is to improve both nasal aesthetics and airway function, and the surgery can be primary or secondary. This material summarizes the systematic nasal examination, principles of surgical planning, access options, and common techniques and grafts used in secondary correction. > Definition: Cleft rhinoplasty is a surgical procedure aimed at correcting osseocartilaginous and soft tissue deformities of the nose associated with congenital cleft. ## Nasal Examination Breakdown — Four Views For an organized and repeatable nasal examination, it's helpful to divide it into four views: ### 1) Frontal view - Examination order: from external to internal, top to bottom, medial to lateral. - Assess: - Nasal skin thickness - Symmetry and size of nasal bones in the upper nasal vault - Middle vault: vertical symmetry, upper lateral cartilage (ULC) collapse, internal nasal valve (Cottle's maneuver) - Lower vault: assessment of the nasal tip (bulbous, boxy, narrow, bracket-shaped), asymmetry - Columella: height and width of hemicolumellae - Nasal alae (ala): height, width, vertical position, base position, condition of the nasal sill - Pyriform rim and maxilla: presence of hypoplasia ### 2) Profile view Assess five characteristics: - Radix depth - Dorsum: presence of a hump (dorsal hump) - Nasal tip projection - Relationship between columella and alar margin (alar margin retraction) - Nasolabial angle ### 3) Worm’s eye / basilar view - Tip position - Infratip lobule: size, shape, symmetry - Columella: direction and dimensions - Nostrils: dimensions and symmetry, condition of the nasal sill - Alae: shape and symmetry ### 4) Internal Examination - Internal and external nasal valves as potential causes of breathing disorders - Septum: deviation, spurs, perforation - Inferior turbinates: hypertrophy - Nasal vestibule: synechiae (adhesions) > Definition: Cottle's maneuver is a manual lateral pull in the area of the nasal wall to assess the function of the internal nasal valve and confirm whether its reinforcement improves patency. ## Assessment of Secondary Nasal Deformity - Patients who have not undergone primary correction typically exhibit the characteristic features of a "cleft nose." In contrast, those who have undergone primary correction present with a spectrum of deformities, which vary depending on the quality of the initial surgery and subsequent changes due to scarring and growth. - A positive observation is that primary correction often leads to simpler and more successful definitive procedures. - The assessment involves a detailed medical history (with particular attention to breathing difficulties) and a thorough physical examination. Supplementary methods include photographic documentation, anthropometry, and nasometry. ## Indications for Surgical Timing - The decision depends on the severity of the deformity, the patient's wishes, and optimal age. - Revisions before school age (4–5 years) aim to modify the shape and position of the lateral alar segment. - Bone and septal modifications are typically performed after growth cessation; the nose is considered nearly fully developed at 11–12 years in girls and 13–14 years in boys. - In the presence of midfacial hypoplasia, definitive rhinoplasty is postponed until the completion of orthognathic correction. ## Treatment Goals for Secondary Cleft Nasal Deformity Primary Goals in Correction: - Increase nasal tip projection - Increase bony dorsum projection - Adjust alar base position - Improve the contour of the alar rim / lateral crus - Create a sharp alar-facial relationship - Ensure an adequate nasolabial angle - Improve nasal airway patency ## Approach to the Nasal Skeleton Table: Comparison of Open and Closed Approaches | Criterion | Closed Approach | Open Approach | |---|---:|---:| | Invasiveness | Lower | Higher | | Surgical field visib