The cleft nose and reconstruction

A cleft nose is a sequence spread across a childhood: a repair at three months, sometimes a second at five or six, and a definitive rhinoplasty once the face has finished growing. The argument in this literature is how much to do at each stage, since operating early was long feared to stunt the nose and operating late means a child grows up with a visibly asymmetric face. The evidence now says the fear was largely wrong: eight of nine studies that measured growth found no restriction, and between 43% and 100% of children who had a primary rhinoplasty avoided a revision later.

171papers on file 40this page is written from 10journals, 2011–2026 36open access, full text 122with a plain-language summary

Where these 171 papers were published

54Plastic and Reconstructive SurgeryPlast Reconstr Surg
35Aesthetic Plastic SurgeryAesthetic Plast Surg
21Facial Plastic SurgeryFacial Plast Surg
19Aesthetic Surgery JournalAesthet Surg J
17Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
9JAMA Facial Plastic SurgeryJAMA Facial Plast Surg
7Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
5Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
3Archives of Facial Plastic SurgeryArch Facial Plast Surg
1Clinics in Plastic SurgeryClin Plast Surg

22011 42012 22013 122014 82015 112016 62017 122018 102019 182020 142021 82022 132023 172024 182025 162026

49 further papers on this topic came in through the history rather than the archive query: GOLDMAN IB 1957, Sheen JH 1984, Furlan S 1995, Santoni-Rugiu P 1997 and 45 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

Operating on the nose during the lip repair does not stunt it

Twenty-five studies systematically reviewed: ten assessed primary rhinoplasty subjectively and all supported it; sixteen assessed it objectively and fifteen supported it; eight of nine studies that specifically examined nasal growth and development found no restriction. Across five studies with at least six years of follow-up, between 43% and 100% of patients avoided a later revision rhinoplasty. Risk of bias was significant in most of those studies, but the direction is unanimous, which is why primary rhinoplasty at the time of lip repair is now standard in most centres.

Rests on: Zelko et al., systematic review of 25 studies · Chong et al., primary rhinoplasty in unilateral cleft lip.

Deliberate overcorrection at the first operation holds for eighteen years

103 children who had primary rhinoplasty with Tajima overcorrection between 2000 and 2005, measured at skeletal maturity against 30 who had primary rhinoplasty without overcorrection and 27 non-cleft controls: the overcorrected group came closest to the controls on FACE-Q satisfaction and on photogrammetric symmetry, and needed no intermediate operation. A separate 146-patient cohort photographed at 1, 5, 10, 15 and 18 years found the residual asymmetry appears early, stays minor and stays stable. Symmetry measured incrementally after primary repair settles by about four months and holds.

Rests on: Murali et al., overcorrection at skeletal maturity · Huang et al., morphology after facial maturation · Abdurrob et al., longitudinal anatomic analysis.

The middle operation is the contested one

Intermediate rhinoplasty, done in mixed dentition, has no consensus behind it. The largest series, 342 patients and 372 operations over eighteen years, found the graft chosen predicted whether another operation followed: an iliac crest cartilage graft independently predicted fewer subsequent rhinoplasties, as did a V-Y chondromucosal flap in unilateral clefts and a columellar strut in bilateral ones. Repositioning the septum at five or six years improved nostril symmetry and caudal deviation at both short and long follow-up. The Tajima reverse-U incision works best in children aged 4 to 13 with mild to moderate deformity, held at five years.

Rests on: Ng et al., eighteen years of intermediate rhinoplasty · Kim et al., septal repositioning at preschool age · Liu et al., the Tajima technique at five years.

At maturity the operation is a structural rhinoplasty with a septal graft at its centre

194 unilateral and 92 bilateral cleft patients operated at skeletal maturity by one surgeon with a reverse-U incision and a septal extension graft: measured in three dimensions, the underprojected, up-rotated, deviated tip and short bridge all moved toward matched normal controls, with a 4% complication rate in the bilateral series. The residual gaps are consistent, nostril height ratio, alar width ratio, and upper lip deficiency, which the nose operation cannot fix.

Rests on: Saito et al., 194 unilateral cases · Saito et al., 92 bilateral cases · Xia et al., nasal sill classification in 276 patients.

The cleft nose is an airway problem as well as a shape problem

Obstruction is present in mild to moderate severity before secondary cleft rhinoplasty and improves measurably after it, in blockage, in trouble breathing and in getting enough air on exertion. The details matter: lateral crural strut grafting was associated with improvement, alar revision and tip sutures with worsening of specific symptoms, and children who had a nasal stent afterwards reported less trouble breathing. A septal cartilage rim graft placed at the primary repair left a measurably straighter septum ten years later.

Rests on: Carlson et al., airway after secondary cleft rhinoplasty · Ueno et al., ten-year septal outcome · Al-Qatami et al., postsurgical nostril retainer.

Reconstruction after collapse follows the same logic, whatever caused it

A nose that has lost its structure (from surgery, trauma, disease or a cleft) is rebuilt on the same principles: assess the lining, assess the skin, then rebuild the framework. A 60-patient saddle-nose algorithm sorts the deformity into four types, records septal perforation in 10%, and treats the mucosal lining as decisive; where the skin envelope is contracted, filler has been used to expand it before reconstructing underneath. Total skeletal reconstruction after multiple failed rhinoplasties, a mean of 3.2 previous operations in 25 patients, improved both breathing and appearance scores. Preservation principles have now been applied even here, with a reverse spare roof technique for the saddle nose.

Rests on: Battista et al., saddle nose algorithm · Sazgar et al., total skeletal reconstruction · Ferreira and Santos, the reverse spare roof technique.

By stage

The cleft nose over a lifetime, and the reconstructive problems that share its methods.

Before surgery: moulding

Presurgical nasoalveolar moulding shapes the cleft nostril before the lip is repaired, and a nostril retainer afterwards holds it. In 50 consecutive children, adding a postsurgical retainer to moulding and primary lip-nose surgery changed measured nasal form against moulding and surgery alone.

Key papers: Al-Qatami et al. · Farouk, eighteen years and 800 patients.

Primary rhinoplasty, at the lip repair

Repositioning the alar base, centralising the columella, improving tip projection, minimising trauma. Done through a Tajima reverse-U incision, often with deliberate overcorrection, and, in the current literature, with a septal cartilage graft for rim support and preservation principles borrowed from adult rhinoplasty, including releasing and repositioning the Pitanguy ligament in six infants.

Key papers: Chong et al. · Murali et al. · Ueno et al. · Tanikawa et al., preservation principles in cleft infants.

Intermediate rhinoplasty, in the school years

Done for symmetry before the social cost of the deformity accumulates, argued against because the face is still growing. The eighteen-year series shows it is the graft choice rather than the age that predicts whether another operation follows.

Key papers: Ng et al. · Kim et al. · Liu et al..

Definitive rhinoplasty, at skeletal maturity

An open structural operation: reverse-U incision, septal extension graft, dorsal augmentation, alar base work and often lip revision in the same sitting. Where autologous cartilage is short, irradiated homologous costal cartilage has been used in 96 of 165 cleft rhinoplasties with complication rates comparable to autologous (12% against 10%), though fewer of the homologous complications needed an operation to fix.

Key papers: Saito et al. · Saito et al. · Jenny et al., irradiated homologous cartilage in cleft rhinoplasty.

The nostril, the sill and the alar base

The base-view deformity is what remains visible after everything else is corrected. A 276-patient classification of nasal sill morphology gives it a common language and a technique per type; composite grafts from the ear rebuild an alar-nostril ring destroyed by over-resection; a philtral flap reconstructs a missing columella.

Key papers: Xia et al. · Sazgar et al., alar nostril ring correction · Bastaninejad et al., the philtral flap.

The saddle nose and the collapsed dorsum

Loss of dorsal support from septal surgery, trauma, disease or cocaine. Graded by severity, planned around the lining and the skin, rebuilt with septal, conchal or costal cartilage. And, in the newest report, with preservation logic applied in reverse to raise the roof rather than lower it.

Key papers: Battista et al. · Ferreira and Santos · Sazgar et al..

The incision, in a nose that has been opened before

A prospective comparison of 52 reconstructive rhinoplasties found a V-shaped columella-labial incision with V-Y closure gave greater projection and columellar height than the standard mid-columellar incision with no difference in scar; in 91 multiply operated noses the same incision produced no dehiscence and no vascular event.

Key papers: Sazgar et al., prospective incision comparison · Sazgar et al., 91 compromised noses · Sazgar et al., a preferred incision.

Planning a reconstruction in three dimensions

For craniofacial cases, in-house virtual planning with printed cutting guides and splints helped harvest and shape septal and costochondral grafts accurately and shortened operating time in a children's hospital workflow.

Key paper: Rubio-Palau et al., in-house virtual planning.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

Unilateral and bilateral cleft lip nasal deformity: the nose that comes with a cleft lip: on the cleft side the alar base sits low and lateral, the columella is short and deviated, the lower lateral cartilage is flattened and the septum deviates away. [41563425]
Primary, intermediate and secondary (definitive) rhinoplasty: the operation done with the lip repair in infancy, the one done in the school years, and the one done at skeletal maturity. Each has its own literature and its own argument. [36409217, 39560597, 37797231]
Nasoalveolar moulding (NAM): pre-surgical moulding of the alveolus and nostril in the first weeks of life to narrow the cleft and lift the nostril before surgery. [35787611]
Nostril retainer (nasal stent): a splint worn in the nostril after surgery to hold its shape while it heals; associated with better measured form and less reported obstruction. [35787611, 36696324]
Tajima reverse-U incision: the standard incision for the cleft nasal tip, used with deliberate overcorrection in the primary operation. [36730430, 38967637]
Overcorrection: deliberately setting the cleft-side nostril beyond symmetry at the primary operation, because it relapses toward the middle as the child grows. [36730430, 41949992]
V-Y chondromucosal flap: a lining flap used in unilateral cleft correction; independently predicted fewer subsequent operations in the intermediate series. [39560597]
Iliac crest cartilage graft: cartilage taken from the pelvis, used in intermediate cleft rhinoplasty; the graft choice associated with fewer further operations. [39560597]
Irradiated homologous costal cartilage: sterilised donor rib, used in cleft rhinoplasty to avoid a chest harvest in a child. [33370059]
Septal extension graft: the graft fixed to the caudal septum that sets tip projection and rotation; the centre of the definitive cleft operation. [37797231, 38314894]
Nasal sill: the floor of the nostril where it meets the lip; classified in four types on the base view to guide secondary correction. [39572464]
Saddle nose deformity: collapse of the dorsum from lost septal support, graded by severity, with the mucosal lining and skin condition deciding what can be rebuilt. [42324394]
Reverse spare roof technique: preservation logic applied upward: raising a saddled dorsum instead of lowering a humped one. [35357956]
Total skeletal reconstruction: rebuilding the entire nasal framework after multiple failed operations, in patients averaging 3.2 previous rhinoplasties. [33506865]
Photogrammetric analysis: measuring symmetry from standardised photographs; how most of the long-term cleft outcomes here are quantified. [36730430, 36976783]

The papers this rests on

The 40 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

APS
Reconstructive Approach to Saddle Nose Deformity: A Diagnostic-Therapeutic Algorithm and the Preoperative Use of Hyaluronic Acid Filler for Skin Expansion in Rhinoplasty
Battista RA, Ferraro M, Nobile A et al.

2026PMID 42324394Summary
APS
A Novel Classification of Nasal Sill Morphology Provides Strategies for Secondary Cleft Rhinoplasty
Xia Y, Yuan J, Wang Z et al.

2025PMID 39572464Summary
PRS
Primary Cleft Rhinoplasty: A Systematic Review of Results, Growth Restriction, and Avoiding Secondary Rhinoplasty
Zelko I, Zielinski E, Santiago CN et al.

2023PMID 36409217Summary
ASJ
Spreader Graft vs Spreader Flap in Rhinoplasty: A Systematic Review and Meta-Analysis of Aesthetic and Functional Outcomes
Keyhan SO, Fallahi HR, Cheshmi B et al.

2022PMID 34864854Summary
ASJ
Mucoperichondrial Spreader Flap Application for Middle Vault Reconstruction in Rhinoplasty: A Review of 857 Cases
Cabbarzade C

2021PMID 33492387
FPS
Rebuilding the Middle Vault in Rhinoplasty: A New Classification of Spreader Flaps/Grafts
Apaydin F

2016PMID 28033640Summary
FPS
Rhinoplasty in Clefts: An 18-Year Retrospective Review
Farouk A

2015PMID 26579870Summary
ASJ
Dorsal Width and Functional Outcomes with use of Autospreader Flaps in Cosmetic Rhinoplasty
Jabbour N, Pelligrini W, Shehan J et al.

2026PMID 42415377Summary
APS
A Prospective Comparison of Inverted V Mid-columellar and V-Shaped Columellar-Labial Incisions in Reconstructive Rhinoplasty
Sazgar AA, Aalizade A, Zeyfoalzam M et al.

2026PMID 41998166Summary
APS
Columella Reconstruction Using the Philtral Flap in Patients with Columellar Deformity in Revision Rhinoplasty
Bastaninejad S, Kanani B, Ferreira MG et al.

2026PMID 41731229Summary
APS
Letter to the Editor: "Lateral Crural Mid-Down Flap Technique in Primary Rhinoplasty"
Mao F, Peng Y, Huang J

2026PMID 41535507
APS
Response to the Letter to the Editor: "Lateral Crural Mid-Down Flap Technique in Primary Rhinoplasty"
Kaderi S, Ekinci C, Karabağlı Y

2026PMID 41879850Full text
APS
Self-Retaining, Double-Ended Surgical Retractor: A Novel Instrument for Rhinoplasty and Reconstructive Procedures
Kayiran O

2026PMID 42380315Summary
FPS
Angulated Cephalic Strip Flap in Lateral Crura Reduction: A Scroll Area Preservation Technique in Rhinoplasty
Generalow A, Kovacevic M, Stigger T et al.

2026PMID 39965762Summary
FPSAM
Cartilage Shaping Ex-Vivo Using Low-Temperature Radiofrequency: An Accessible, Controlled Option for Cosmetic and Reconstructive Rhinoplasty
Garcia JA, Park C, Vernon D et al.

2026PMID 40019820
FPSAM
V-Shaped Columella-Labial Incision: A Preferred Incision for Reconstructive Rhinoplasty in Severely Compromised Noses
Sazgar AA, Sazgar MA, Zarei R et al.

2026PMID 41681113
PRS
Long-Term Outcome of Primary Rhinoplasty with Overcorrection in Patients with Unilateral Cleft Lip: Avoiding Intermediate Rhinoplasty
Murali SP, Denadai R, Sato N et al.

2023PMID 36730430Summary
PRS
Nasal Morphological Changes after Facial Maturation in Patients with Unilateral Cleft Lip Following Primary Overcorrected Rhinoplasty
Huang CW, Charoenvicha C, Huang JG et al.

2026PMID 41949992Summary
FPSAM
Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes
Abdurrob A, Shumrick CM, Scott AR et al.

2023PMID 36976783Summary
PRS
Efficacy of Postsurgical Nostril Retainer in Patients with Unilateral Cleft Lip and Palate Treated with Presurgical Nasoalveolar Molding and Primary Cheiloplasty-Rhinoplasty
Al-Qatami F, Avinoam SP, Cutting CB et al.

2022PMID 35787611Summary
PRS
Primary Septal Cartilage Graft for Unilateral Cleft Rhinoplasty: 10-Year Follow-Up Results and the Effect on Septal Deviation
Ueno K, Fukui M, Yao CF et al.

2026PMID 41100821Summary
PRS
Long-Term Surgical Outcomes of Intermediate Cleft Rhinoplasty
Ng JJ, Cheung L, Massenburg BB et al.

2025PMID 39560597Summary
PRS
Septal Reposition during Intermediate Cleft Rhinoplasty: A Second Chance for Correcting Caudal Septal Deviation
Kim YC, Kwon JG, Koh KS

2024PMID 37467053Summary
PRS
Septal Extension Graft in Cleft Rhinoplasty: Patients with Secondary Unilateral Cleft Lip Nasal Deformity
Saito T, Lonic D, Lo CC et al.

2024PMID 37797231Summary
ASJ
Secondary Bilateral Cleft Rhinoplasty: Achieving an Aesthetic Result
Saito T, Lo CC, Tu JC et al.

2024PMID 38314894Summary
PRS
Long-Term Outcome of Secondary Cleft Rhinoplasty in Patients with Secondary Nasal Deformity: Optimal Indications for Tajima Technique
Liu Y, Zhang C, Yao M et al.

2025PMID 38967637Summary
PRS
A Longitudinal Study of Improvement in Nasal Airway Obstruction after Secondary Cleft Rhinoplasty
Carlson AR, Kosyk MS, Zapatero ZD et al.

2023PMID 36696324Summary
PRS
Safety of Irradiated Homologous Costal Cartilage Graft in Cleft Rhinoplasty
Jenny HE, Siegel N, Yang R et al.

2021PMID 33370059Summary
PRS
Introducing Preservation Rhinoplasty Principles to Cleft Nasal Surgery: Unveiling the Role of Nasal Ligaments in Infant Anatomy
Tanikawa D, Sá Á, Figueroa Á et al.

2026PMID 40358520Summary
PRS
Primary Rhinoplasty in Unilateral Cleft Lip
Chong DK, Tanikawa DYS, Fell M

2026PMID 41563425Summary
ASJ
In-House Virtual Planning and 3D-Printed Surgical Guides for Reconstructive Rhinoplasty
Rubio-Palau J, Gonçalves J, Malet-Contreras A et al.

2025PMID 39161317Summary
ASJ
The Effectiveness of Skeletal Reconstruction in Severe Post-Rhinoplasty Nasal Deformity
Sazgar AA, Hajialipour S, Razfar A et al.

2021PMID 33506865Summary
ASJ
Strategic Use of the V-Shaped Columella-Labial Incision for Reconstructive Rhinoplasty in Severely Compromised Noses
Sazgar AA, Sazgar MA, Zarei R et al.

2025PMID 40408098Summary
ASJ
Single-Stage Alar Nostril Ring Correction Using Auricular Composite Grafts in Reconstructive Rhinoplasty
Sazgar AA, Sazgar AK, Hatami N et al.

2025PMID 39676167Summary
FPSAM
Patient Outcomes in Lateral Crural Repositioning and Reconstruction in Revision Rhinoplasty
Abdelhamid AS, Kimura KS, El Abany A et al.

2024PMID 37115534Summary
PRS
Y-Columellar Strut Graft: A Method for Reconstructing the Nasal Tip in Primary and Revision Rhinoplasty
Martino C, Salzano FA, Martino D et al.

2023PMID 36729933Summary
PRS
Use of the Interalar Ligament Flap for Tip and Supratip Contouring in Primary Open Structural Rhinoplasty
Marianetti TM, Segreto F, Iademarco A et al.

2024PMID 37749799Summary
FPSAM
Preservation Rhinoplasty in the Saddle Nose: The Reverse Spare Roof Technique
Ferreira MG, Santos M

2022PMID 35357956Summary
PRS
"Pedicled Flaps for Nasal Septal Perforation and Graft Framework: Enhancing Outcomes in Preservation and Structural Rhinoplasty"
Mariño-Sanchez F, Alobid I, Santamaría-Gadea A

2025PMID 41071182Summary
ASJ
Comparison of Functional and Cosmetic Outcomes Between Dorsal Preservation and Spreader Flap Rhinoplasty: A Randomized Trial
Zarei R, Most SP, Amali A et al.

2024PMID 38366551Summary

What is still contested

The timing of the intermediate operation has no consensus: the risk-to-benefit balance in mixed dentition is still argued, and the largest series concludes that what is grafted matters more than when. [39560597]
The primary-rhinoplasty evidence is unanimous in direction and weak in method, 25 studies with significant risk of bias in most. [36409217]
No trial compares overcorrection against no overcorrection prospectively; the eighteen-year evidence is a retrospective cohort with historical comparison groups. [36730430]
Homologous against autologous cartilage in children is decided in one 165-case series with a median follow-up of 256 days, short for a graft question. [33370059]
Upper lip deficiency persists after every technique measured here, and no nasal operation addresses it. [38314894]
Outcome measures differ by centre (FACE-Q, photogrammetry, panel assessment, NOSE), so the long-term series cannot be pooled.
The saddle nose and total reconstruction literature is entirely single-surgeon case series; the algorithms are experience, published as algorithms. [42324394, 33506865]