Achieving midvault symmetry in unilateral cleft nose deformity rhinoplasty

Abstract

Background

The objective of the study was to provide aesthetic improvement in unilateral cleft nose deformity by reconstructing the midvault of cleft side alone with unilateral osteotomies, simulating symmetry with the normal side, together with tip reconstruction. While most of the literature emphasizes on tip reconstruction, few of them focus on techniques of repositioning the slanting nasal sidewall, which aids in achieving the desired symmetry. We describe a method of repositioning the bony nasal vault to a more lateral and symmetrical orientation by making unilateral osteotomies.

Results

Eighteen patients of unilateral cleft nose deformity underwent rhinoplasty between March 16 and January 20. All patients had prior primary cleft lip repair. Thirteen patients underwent primary rhinoplasty while 5 underwent secondary rhinoplasty having undergone primary rhinoplasty elsewhere. Follow-up was from 1 to 3 years. Results were evaluated using Rhinoplasty Outcome Evaluation [ROE] Questionnaire, and Asher McDade Aesthetic Index [AMAI] Rating. Pre- and post-operative scores were compared.

All patients were subjectively satisfied. The ROE and AMAI scores showed statistically significant improvement from pre-operative scores.

Conclusion

Obtaining symmetry in cleft nose deformity is a surgical challenge even in experienced hands. Using structural grafts only on the cleft side we attempted to create a near normal symmetry and achieve a natural nasal appearance, with satisfactory improvement from both patient’s and surgeons’ perspective.

Level of evidence

Case series- 4

Background

Cleft lip deformity is a complex three-dimensional congenital facial deformity which leads to poor functional, aesthetic and social outcomes [1]. Unilateral cleft lip is accompanied by a nasal deformity of the same side. This deformity comprises an aberrant orbicularis oris muscle insertion resulting in a shorter columella, wider flat nostril, caudal septal deviation to the opposite side, inward buckling of ala with a concave dome, and a poorly defined and ill projected tip with vestibular webbing.

The lip and the nose are central facial features. Aesthetic outcome of their surgical correction is appreciated by the patient and the surgeon only by achieving near normal bilateral symmetry. This perfection, however, is seldom achieved [2] and poses a reconstructive challenge for the rhinoplasty surgeon [1, 3, 4].

Even though there is a consensus in modern practice to do a rhinoplasty at the time of primary cleft lip repair [5,6,7], there still exists a vast patient pool where a primary cheiliorhinoplasty was not done, with an untouched nasal deformity. Secondary or revision rhinoplasty is also indicated for residual defects or secondary defects accentuated by time and growth [8,9,10].

In order to optimize the aesthetic symmetry of unilateral cleft lip nasal deformity correction, we follow an anatomic technique involving reconstruction and restoration of the cleft side alone and to fashion it akin to the normal side. This helps us achieve better symmetrical results as compared to camouflaging the deformity with onlay grafts. We focus on the technique of midvault repair, which is the region defined by the attachment of the upper lateral cartilages to the nasal bones superiorly and the cartilaginous septum in the midline. While the principle deformity in such patients is of the tip, inadequate management of the nasal midvault can have adverse effects on the functional and aesthetic outcome.

Methods

Between March 2016 to January 2020, 18 cases of unilateral cleft lip nose deformity, aged 18 to 26 years (mean age 21 years) were operated by the same surgeon at a tertiary care center in Indore, India. 8 patients were male (mean age 22 years) and 10 patients were female (mean age 20 years). An administrative review board approval was obtained for the study, and as such the study being a retrospective compilation of surgical techniques employed, involved minimal to no risk to the patients. All the surgical procedures were in strict accordance with the Code of Ethics of the Helsinki Declaration. Written informed consents were taken from all patients for the procedure as well as for publishing and sharing of their photos with appropriate concealment of identity for scientific purpose. They all underwent unilateral cleft rhinoplasty with the same method under general anesthesia. The indications of surgery were primarily aesthetic improvement of the nose. None of the cases had undergone a primary rhinoplasty at the time of primary cleft lip repair. Thirteen cases underwent rhinoplasty for the first time with us and the remaining 5 cases had previous rhinoplasty operation elsewhere in childhood. Their past surgical records were not available; however, they presented with the typical features of a unilateral cleft nasal deformity, despite having undergone a previous rhinoplasty in childhood. No exclusion criteria were stated. All cases had undergone prior Orthodontics treatment and maxillary augmentation. The patients were followed up for 1 year to more than 3 years. The results were evaluated by comparing the before and after treatment answers of the Rhinoplasty Outcome Evaluation (ROE) questionnaire, which was a patient-based questionnaire; and Asher McDade Aesthetic Index rating, which was an observer-based rating based on pre- and post-operative photographic evaluation by a single observer. All the questionnaires were undertaken pre-op and at 1 year post-op. The data was statistically analyzed using single tailed paired t test.

Surgical technique

All the cases were operated by the open rhinoplasty approach, using the standard stair step trans-columellar and infra-cartilaginous incision.

The nasal skin and soft-tissue envelope is elevated and the structural deformity is visualized and assessed (Fig. 1).

Fig. 1

Exposure of the anatomic deformity after raising the skin and soft tissue envelope

The nasal septum is approached by sharp dissection between the medial crura of the two lower lateral cartilages. The caudal septum is visualized between these two cartilages and dissection continued in the submucoperichondrial plane.

A portion of the septal cartilage, where available; along with the bony part is harvested for reconstruction, leaving behind at least 1.2 cm of the dorso-caudal septal strip.

Caudal septum deviation correction

In a majority of the cases the caudal septum is deviated to the non-cleft side. The deviated caudal septum is mobilized, repositioned, and fixed in the midline, by drilling a hole in the anterior nasal spine or its remnant. In case of inadequate septal length, a septal extension graft is used. If the spine is deviated to the non-cleft side, then the caudal septum can be fixed on the opposite side.

Any dorsal hump and irregularity is corrected by rasping and upper lateral cartilage trimming.

In unilateral cleft lip nose deformity, the whole lateral wall of nose including the nasal bone, the upper lateral cartilages and the lower lateral cartilages of the cleft side appears to be imbalanced with respect to the normal side. The root of the nasal dorsum is usually directed toward the side of the cleft, resulting in the tip of the nose deviating away from the cleft. We do not propose to do major changes but try to correct the abnormal anatomy on the cleft side by readjusting structures and correcting deficiency.

Technique for reconstructing the midvault of the deficient cleft side

The upper lateral cartilage on the cleft side is separated from the dorsal septum, preserving the underlying mucoperichondrium.

Para-median/medial osteotomy is done only on the cleft side using a piezotome saw for precision and preservation of mucosa.

Percutaneous transverse and low to low lateral osteotomy is done using a 2-mm osteotome on the cleft side.

The above combination of a para-median, transverse and lateral osteotomies on the cleft side alone helps in mobilizing the lateral nasal wall of the cleft side (Fig. 2).

Fig. 2

Paramedian, transverse, and lateral osteotomies only on the cleft side, the cleft side is mobilized and elevated with an elevator

The mobilized lateral wall is then elevated and moved upwards and outwards (laterally), to the same level as the normal side.

A lengthened/extended spreader graft (rib cartilage or septal cartilage) is used, which extends up to the nasal bones and keeps the mobilized lateral wall in the elevated position, fixed with 4-0 PDS sutures across the upper lateral cartilage and septum to the opposite side.

Layered strips of cartilage wrapped in fascia or diced cartilage in fascia is placed over the dorsum to smoothen the dorsal profile when required (Fig. 3).

Fig. 3

Extended spreader graft to support and keep the lateralized cleft side in the elevated position

Correcting the lower lateral cartilage deformity and tip

A few studies state that the length of the lower lateral cartilage on the cleft side is equal to the non-cleft side, differing primarily in shape and position [11,12,13,14]. The medial crus is shorter and the lateral crus longer on the cleft side and the angle between them is obtuse, resulting in a less defined and wider dome [15].

The lower lateral cartilage is completely separated from the vestibular skin and then released from its attachment to the piriform ligament.

At times the cartilage is too wide, and a cephalic trimming may be required to achieve symmetry with the non-cleft side. The lateral crus is mobilized medially to create a new dome with an increased height, which is comparable to the dome of the non-cleft side. The two domes are then sutured together into a more cephalic position creating a monodome. Columellar strut or septal extension graft is used to increase the tip projection and anchor the new dome. Alar batten grafts and extension grafts are used to support and rest the lateral crus (Fig. 4).

Fig. 4

Nasal tip reconstruction, lateral crural steal, and alar batten graft (sliced rib cartilage)

Vestibular skin is mobilized and anchored with the new dome and the lateral crus, which in some cases may fall short and a lateral release incision may be required, to avoid skin tension. Onlay shield grafts are used to give better definition to the ill-defined nasal tip when required. Cartilage chips were inserted into the nasal floor by sublabial/vestibular floor incisions to fill any nasal floor defect.

No columella lengthening procedures were required.

Result

Based on the Rhinoplasty Outcome Evaluation (ROE) questionnaire, all patients experienced improved appearance of the nose and felt less stigmatization from society. All scores of the six questions improved significantly in the postoperative 1 year, compared with the preoperative scores. Responses were evaluated using single-tailed paired t test and p value was calculated. The mean pre-operative score was 1.102 and the mean post-operative score was 3.120. The p value was < 0.00011, which was significant at 0.05 significance level.

For the observer-based Asher McDade rating, the mean pre-op score was 4.125 and mean post-op score was 2.125. There was no difference in the means of the male and female patients. This difference in the pre- and post-op scores was significant with a p value of < 0.0001.

No patients complained of tip stiffness, change in tip shape, or vestibular stenosis in the 1–3-year follow-up (Figs. 5, 6, 7 and 8, Tables 1, 2, 3, and 4).

Fig. 5

Comparative pre- and post-operative pictures at 2 years follow-up. A Pre-operative frontal view. B Postoperative frontal view. C Pre-operative left lateral view. D Post operative left lateral view. E Pre-operative basal view. F Postoperative basal view

Fig. 6

Comparative pre- and post-operative pictures at 2 years follow-up. A Pre-operative frontal view. B Postoperative frontal view. C Pre-operative left lateral view. D Post-operative left lateral view. E Pre-operative basal view. F Postoperative basal view

Fig. 7

Comparative pre- and post-operative pictures at 2 years follow-up. A Preoperative frontal view. B Postoperative frontal view. C Pre-operative left oblique view. D Post operative left oblique view. E Preoperative basal view. F Postoperative basal view

Fig. 8

Comparative pre- and post-operative pictures at 3 years follow-up. A Preoperative frontal view. B Postoperative frontal view. C Pre-operative Right oblique view. D Post operative right oblique view. E Pre-operative basal view. D Postoperative basal view. F Pre-operative left lateral view. G Post operative left lateral view

Table 1 ROE questionnaire pre-op

Table 2 ROE questionnaire post-op

Table 3 AMAI rating pre-op

Table 4 AMAI rating post-op

Discussion

The unilateral cleft lip nose deformity is a common problem. The annual incidence of cleft lip palate deformity is 28,600, which means 3 infants with clefts are born every hour [16]. Significant components of unilateral cleft lip nose deformities have been well- documented by Huffman and Lierle and involves the following [17, 18]:

Aberrant orbicularis oris muscle insertion [19, 20].

This results in the following:

• Shorter columella on the cleft side.

• Wider nostril on the cleft side.

• Caudal septum deviation to the non-cleft side.

• Anterior nasal spine is displaced to the non-cleft side.

• The cleft side ala is buckled inward.

• The cleft side alar dome is depressed.

• Poorly defined nasal tip with less projection.

• External nasal valve defect.

• Vestibular webbing [20].

Cleft nasal deformity is a complicated problem that should be addressed during multiple stages of the patient’s life. Even though there is a consensus in modern practice to do a rhinoplasty at the time of primary cleft lip repair [5,6,7], there still exists a vast patient pool where a primary cheiliorhinoplasty was not done. Secondary rhinoplasty is best approached after nasal growth has concluded and done via an open technique to fully visualize the nasal structures [20].

A patient with cleft nasal deformity appreciates the surgical outcome of rhinoplasty, when the surgeon can achieve near normal aesthetic symmetry of the cleft side with that of the non-cleft side of the nose. This perfection is however, seldom achieved [2].

Significant component for success of cleft rhinoplasty is placement of cartilage grafts for tip support and reinforcement. Use of the cartilage grafts reinforces the structural support of the nose and allows for improved tip definition. It also prevents wound contracture and collapse [20]. While most of the literature emphasizes the tip procedures, few of them focus on the midvault technique [15, 18, 21]. Karnahan et al. in 1980 described the Tajima procedure consisting of a reverse U-shaped incision to expose the alar cartilages and permit suture fixation [22], Jeong et al. in 2012 described a modified Tajima’s method and one point suture fixation of the alar cartilage [23]. However, most of the literature in our review aims at the reconstruction and repositioning of the alar cartilages with little focus on the nasal bony deformity. Cleft nose deformity usually presents with sloping or concavity of the lateral nasal wall of the cleft side which gives a flattening appearance, along with the lower lateral cartilage deformity. This deformity of the middle third of the nose is usually addressed with onlay grafts and spreader grafts [24]. We highlight the technique of using unilateral osteotomies on the cleft side to lateralize it, instead of using an onlay graft, together with the use of interposition of extended spreader grafts to overcome the concavity. This is in contrast to the most commonly described techniques of bilateral osteotomies and onlay grafts to camouflage the concave side of the lateral nasal wall, or by infracturing of the nasal bones to achieve narrowing of the dorsum [25]. Several studies also exist to classify the nasal deformities, although there is no uniformity or a standard globally accepted classification. We did not attempt to classify the degree of the nasal deformity of our patients, as they had all undergone prior lip and palate repair with maxillary augmentation, while five patients had a prior rhinoplasty. All our patients in this study presented with similar and typical features mainly involving unilateral dorsal asymmetry with alar and nostril asymmetry. We therefore approached all the patients with the same surgical technique and found consistent results.

The three basic steps performed by our center to optimize the aesthetic symmetry of our cleft lip nasal deformity cases are as follows:

• 1) Caudal septum deviation is corrected. The deviated septum is mobilized and moved to the non-cleft side and fixed in a more medial position, this provides a stable foundation to the nasal tip.

• 2) Mobilization of the cleft side lateral nasal wall in a superior and lateral direction, to match the level with that of the normal side, stabilized and supported by an extended spreader graft.

• 3) Nasal tip symmetry is achieved by separating the lateral crura completely from the vestibular skin and the pyriform aperture. It is then mobilized medially to create a new dome, matching with that of the normal side. The two domes are then sutured together.

Employing these techniques, we were able to achieve satisfactory results in terms of patient satisfaction, which reflected in statistically significant improvement in the responses of patients’ self-evaluated ROE questionnaire; as well as in terms of an observer based AMAI rating. None of our patients complained of tip stiffness, change in tip shape or vestibular stenosis in the duration of follow-up. Achieving perfect symmetry in cleft lip noses with natural results is not only an uphill and challenging, but also a nearly impossible task, but achieving ‘near symmetry’ using autologous cartilage which is acceptable to the patient as well as an outside observer is certainly possible. The advantages of using autologous cartilage was mainly the inexpensiveness, since cadaveric and irradiated cartilage grafts are costly, and most of our patients were from a humble socioeconomic background. It also has an advantage of long term acceptability and integration, which can be an issue with artificial graft material and can lead to graft rejection and infection. There was minimum donor site morbidity and none of the patients complained of any long-term donor site problems.

Conclusion

To obtain symmetry of the cleft and the non-cleft side is a surgical challenge even in the most experienced hands. The deformed soft tissue and skeletal foundation are further complicated by the long-term effects of continuing asymmetric anatomic growth and surgical scarring from previous surgeries.

Our approach used is an anatomic technique, where only structural grafts are used to reconstruct the cleft side to simulate the non-cleft side of the nose. Usually, nasal dorsal and lateral wall onlay grafts are used in cleft rhinoplasty to create an illusion of symmetry. However, with this anatomic technique employing only structural grafts, we were able to achieve a more natural and non-operated nasal appearance.

In our opinion, satisfactory aesthetic improvement can be achieved with this technique, as indicated by the ROE questionnaire and AMAI assessment results.

Summary

• ☐ý Cleft lip-nose deformity is a complex three-dimensional congenital facial deformity which has a functional, aesthetic and social impact on the patient’s life.

• ☐ý Aesthetic outcome of surgical correction is appreciated by the patient and the surgeon only by achieving near normal bilateral symmetry. This perfection, however, is seldom achieved ² and poses a reconstructive challenge for the rhinoplasty surgeon.

• ☐ý We have reported a series of 18 patients of unilateral cleft nose deformity, who underwent rhinoplasty (13 primary and 5 secondary) for aesthetic improvement of nasal appearance.

• ☐ý While most of the literature on cleft rhinoplasty focuses on tip reconstruction, few of them highlight the midvault technique. Cleft nose deformity usually presents with sloping or concavity of the lateral nasal wall of the cleft side, along with the lower lateral cartilage deformity.

• ☐ý The key step in our technique that we would like to highlight is the use of unilateral osteotomies only on the cleft side, to lateralize and raise the entire lateral nasal wall and make it appear symmetrical to the non-cleft side, supported and fixed with the help of extended spreader graft interposed between the upper lateral cartilage and septum.

• ☐ý This technique is different from the routinely followed steps of bilateral osteotomies to reposition the nasal vault.

• ☐ý The tip reconstruction is done by using septal extension graft or columellar strut to increase the projection and provide stable support. Lateral crural steal of the flattened ala is done to bring the two alar domes to the same level and sutured together.

• ☐ý Our results were satisfactory and stable, in a 1–3-year follow-up period.

• ☐ý Patients reported subjective satisfaction as reflected in the significant improvement in their ROE questionnaire responses. Observer based evaluation of AMAI rating also improved significantly.