Cleft lip rhinoplasty

What repeats

Five findings that hold across the literature.

The deformity is a list of separate parts, and each has its own repair

Secondary correction of the unilateral cleft nose is set out in seven areas: hypoplasia of the bone at the piriform rim, the septum, the dorsum, the shape of the tip, the projection of the tip, the shape of the ala and the position of the alar base. The alar base is the part with its own review literature, because the foot of the nostril sits on bone that did not form.

Rests on: Rohrich et al., secondary rhinoplasty for unilateral cleft nasal deformity · Chong et al., primary rhinoplasty in unilateral cleft lip · DeVictor and Tollefson, correcting the alar base · alar base modification.

Correction is staged, and the stages have names and ages

Fifty-nine surgeons on 40 cleft teams accredited by the American Cleft Palate Craniofacial Association answered a survey on how they operate. Of those who perform an intermediate rhinoplasty, 88.1% do so, first considering it at a mean age of 5.83 years. The definitive operation is considered at a mean age of 15.86 years. Intermediate operations are more often closed, definitive operations more often open, and autologous cartilage is used far more at the definitive stage.

Rests on: Shah et al., national survey of cleft teams · Olds and Sykes, cleft rhinoplasty · open versus closed rhinoplasty.

Asymmetry left after the infant operation improves as the face grows

One hundred and forty-six children with a unilateral cleft lip had a Tajima overcorrected rhinoplasty at the time of their lip repair in 2002 and 2003, and were photographed at 1, 5, 10, 15 and 18 years of age. Nostril asymmetry improved over that span in both complete and incomplete clefts. Nostril height, nostril width, nasal width and the columella angle all changed with time. Nostril base height did not, which is the paper's argument for getting height right at the first operation.

Rests on: Huang et al., nasal morphology after facial maturation.

The middle-stage operation reduces later surgery in some hands

Three hundred and forty-two patients had 372 intermediate cleft rhinoplasties at one centre between 2006 and 2023. Iliac crest cartilage was used in 165 of them, ear cartilage in 36, no graft at all in 150. Iliac crest grafting predicted fewer subsequent rhinoplasties independent of age, sex, cleft severity and surgeon. Of the 60 patients followed past their eighteenth birthday, 55.0% needed no further rhinoplasty.

Rests on: Ng et al., long-term outcomes of intermediate cleft rhinoplasty · rib cartilage grafts.

What is placed at the first operation is still measurable ten years later

Sixty children with a complete unilateral cleft lip and palate were compared at ten years: 23 had a septal cartilage graft placed along the alar rim during the primary repair, 37 did not. The graft group had greater height at the medial quarter of the nostril and a smaller deviated septal angle. Nasolabial angle and tip projection ratio were no different, so the graft did not restrict growth.

Rests on: Ueno et al., primary septal cartilage graft at ten years · the caudal septum and the airway.

By the stage of the correction

The same nose is operated on more than once, and each stage does a different job.

At the lip repair, in infancy

Primary cleft rhinoplasty repositions the alar base, centres the columella and lifts tip projection while the lip is being closed, and presurgical nasoalveolar molding shapes the nose before it. Fifty children treated with molding and primary lip and nose surgery were compared at about 12 months of age: the 24 who also wore a nostril retainer had less difference between the cleft side and the other side on five of six measurements.

Two cohorts from one hospital measured what that adds. In 208 children with a unilateral cleft lip, 155 had a primary rhinoplasty at the lip repair and 53 did not. Laypersons ranked the primary rhinoplasty group higher at a mean age of 4.9 years, and those children had a smaller columellar deviation angle and better nostril symmetry. Children stented for under 20 days were rated worse on the lateral view, 2.4 against 2.1, and children operated before 5.3 months of age had lower nasal projection, a Goode ratio of 0.56 against 0.62. In the second cohort, 109 patients answered the CLEFT-Q at a median age of 10.2 years, 85 of them having had a primary rhinoplasty and 24 not. Among those who went on to an intermediate operation, nose scores were 75 in the primary rhinoplasty group against 57 in the other. Children without a primary rhinoplasty were more than twice as likely to need the intermediate one, 71% against 33%.

Rests on: Ng et al., primary rhinoplasty long-term cohort · Ryan et al., patient-reported outcomes of primary cleft rhinoplasty · Chong et al. · Al-Qatami et al., postsurgical nostril retainer.

Before the lip repair, with a moulding plate

Nasoalveolar molding is a plate worn in the mouth with a nasal stent, fitted in the first weeks of life to narrow the cleft and lift the flattened nostril before any operation. A systematic review of twelve studies with follow-up past four years of age found children who had it were more likely to have good to excellent frontal nasal form than children who had no appliance at all, a risk ratio of 2.4 with a confidence interval of 1.24 to 3.68, and the same for the vermillion border at 1.8, from 1.19 to 2.71. Against other passive plates it showed no advantage, and cephalometric measurements did not differ. A second meta-analysis looked only at midface growth, pooling 171 children at a mean age of 8.5 years, 89 with molding and 82 without. The molding group had a smaller SNA angle by 1.96 degrees and a smaller ANB angle by 2.22 degrees, which the authors read as possible midface hypoplasia.

Rests on: Padovano et al., long-term effects of nasoalveolar molding · Moshal et al., nasoalveolar molding and midface growth · Hoshal et al., controversies in cleft rhinoplasty.

In the school years

The intermediate operation is done in mixed dentition and is deliberately conservative, to limit scarring. A Tajima reverse-U series grouped patients by age and found the corrected shape held at five years in the 4 to 13 group, with FACE-Q nostril satisfaction moving from 79.72 before surgery to 85.95 at one week and holding at 82.61 at five years.

Rests on: Liu et al., Tajima technique long-term outcome · Ng et al..

At the end of facial growth

The definitive rhinoplasty comes after the facial skeleton is treated, because jaw surgery moves the base of the nose. Cartilage from the septum, ear or rib rebuilds the framework here. In the one randomised comparison of tip support at this stage, projection fell progressively over a year with a columellar strut and stabilised by six months with a septal extension graft.

How often it has to be done again has been pooled. Twenty-three studies covering 842 patients aged over 12 compared the cartilage used to project the tip: 362 had septal cartilage, 348 costal and 132 conchal. The pooled rate of residual deformity was 0.7% and did not differ by graft. The pooled revision rate was 6.7% and did differ.

Rests on: Deng et al., deformity and revision rates after secondary cleft rhinoplasty · Olds and Sykes · Hoshal et al., controversies in cleft rhinoplasty · Acil et al., septal extension graft versus columellar strut · chin augmentation with rhinoplasty.

When the cleft is bilateral

The bilateral cleft nose is short in the columella, flat in the bridge and wide across transversely oriented nostrils. Ninety-two patients at skeletal maturity had a bilateral reverse-U flap with a septal extension graft from one surgeon between 2013 and 2021, with a complication rate of 4%. Deficiency of the upper lip did not improve.

Rests on: Saito et al., secondary bilateral cleft rhinoplasty · the butterfly graft.

What to ask about cleft rhinoplasty

Questions the evidence supports asking.

How many operations are planned, and what goes in as support

Ask for the schedule and the graft. The surveyed teams put the intermediate operation at a mean of 5.83 years and the definitive one at a mean of 15.86 years, and 65% of them use autologous cartilage in more than three quarters of definitive cases. Septum, ear, rib and iliac crest are all in use, and the choice tracks the stage.

Rests on: Shah et al. · Ng et al. · rib cartilage grafts · the tip archive.

Will operating now change how the nose grows

This is the standing argument in the field, and three sets of long-term measurements answer it. The ten-year comparison found that a septal cartilage graft placed in infancy left nasolabial angle and tip projection ratio no different from children who had no graft. Thirty-nine patients with a bilateral cleft who had a primary rhinoplasty between 1995 and 2002 were photographed in three dimensions at skeletal maturity, at a mean age of 19, and compared with 52 matched normal subjects: tip projection and tip angle were smaller, dorsum length, protrusion, alar width and columellar height were greater, and height, surface area and volume were the same, so the nose was not undersized. A systematic review of twelve studies of primary rhinoplasty in bilateral cleft lip found nine supporting the operation, eight reporting no restriction of nasal growth, and four following 158 patients to an average of 15 years, of whom 77% never needed a secondary rhinoplasty.

Rests on: Seo et al., long-term nasal growth after primary rhinoplasty · Di Chiaro et al., systematic review of primary rhinoplasty in bilateral cleft lip · Ueno et al. · Hoshal et al..

Will my child breathe better afterwards

The cleft septum is deviated and the airway on the cleft side is narrow. Ask what is planned for the septum, how breathing will be measured before and after, and what the guideline requires be recorded before an operation from age 15 onward.

Rests on: Ueno et al. · Rohrich et al. · the plain language summary · nasal airway obstruction.

The terms, defined

The words used about the cleft nose.

• Cleft lip nasal deformity: the set of nasal changes that comes with a cleft lip. [34076624]
• Primary rhinoplasty: nasal correction done at the time of the lip repair, in infancy. [41563425]
• Intermediate rhinoplasty: the middle operation, done in mixed dentition. [36381488]
• Definitive rhinoplasty: the final operation, after facial growth and jaw surgery. [34782130]
• Nasoalveolar molding: presurgical shaping of the infant nose and gum before lip repair. [32191966]
• Nostril retainer: a device worn after the primary repair to hold the nostril shape. [35787611]
• Tajima reverse-U incision: the rim incision used to lift and reshape the cleft-side nostril. [38967637]
• Piriform hypoplasia: the missing bone under the foot of the nostril on the cleft side. [34076624]
• Septal extension graft: cartilage fixed to the septum to hold tip projection. [37567945]
• FACE-Q: the patient-completed questionnaire used as the endpoint in these series. [38967637]
• CLEFT-Q: the cleft-specific questionnaire children answer about their own nose and face. [40590056]
• Midface hypoplasia: the middle of the face growing forward too little, read as the SNA angle. [39668661]
• Columellar deviation angle: the lean of the column between the nostrils, measured on photographs. [39782695]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It covers patients aged 15 and over, which is the definitive stage of cleft correction.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapter

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a chapter on this operation, written for surgeons.

• Cleft Lip Rhinoplasty

The reference summary

Cleft Lip in StatPearls, on the National Library of Medicine's Bookshelf, covers the embryology, the classification and the staged treatment in full text at no charge.

The societies

• American Society of Plastic Surgeons, cleft lip and palate repair patient information.
• American Cleft Palate Craniofacial Association, the body that accredits the teams surveyed above, with material for patients and families.

The trials in progress

• Intermediate Cleft Rhinoplasty in Unilateral Cleft Lip Patients, status unknown, 20 participants.
• Aesthetic and Functional Self-Assessment Following Rhinoseptoplasty in Unilateral Cleft Lip and Palate, recruiting, 80 participants.

What is not settled

• Whether the intermediate operation is worth doing at all is open. The largest series calls the risk-to-benefit ratio debated and asks for patient-reported outcomes it did not collect. [39560597]
• Practice varies widely between accredited teams. The survey drew responses from 20.7% of them. [36381488]
• Only one comparison in this literature is randomised, and it compares two tip grafts. [37567945]
• Long-term shape after primary overcorrection is reported from one centre's cohort operated in 2002 and
  2003. No independent series follows a different technique to 18 years. [41949992]
• Whether an infant graft restricts growth is answered by one ten-year comparison of 60 children, one photogrammetric cohort measured at skeletal maturity and one systematic review, none of them randomised. [41100821] [31052470] [36409865] [32191966]
• The two meta-analyses of nasoalveolar molding disagree. One finds better nasal form than no appliance at all, the other finds smaller SNA and ANB angles and reads that as worse midface growth. Neither pools a trial. [33882703] [39668661]
• Revision rates after the definitive operation differ by the cartilage used, and the meta-analysis that found that calls its own sample heterogeneous. [40082132]