The Unrecognized Skeletal Components of the Cleft Lip Nose Deformity

Abstract

Sir: We read with great interest the article entitled “Definitive Repair of the Unilateral Cleft Lip Nasal Deformity” by Dr. Byrd et al. on secondary cleft rhinoplasty.1 They have very correctly identified the two major groups of these patients who have different severities of cleft nose deformities. The pathologic features of cleft nose deformity have been clearly elucidated; however, there remain certain factors that, in our opinion, exert significantly deforming influences on the function, dynamics, and aesthetics of the lower third of the nose. First, the primary repair of the cleft lip must address the nasal septum in addition to the already described operative steps. The nasal septum in this situation is always displaced, especially in its caudal part, and presents in the noncleft vestibule. The body of the septum blocks the cleft vestibule, and the dynamics of this were illustrated in our recent article.2 This deformity can be well appreciated on three-dimensional computed tomographic reconstructions in adult age groups, where the septal deviation and accompanying deformity of the vomerine groove are unmistakable (Fig. 1). In this case, the vomerine groove is significantly skewed from the midline, and a hypertrophied anterior nasal spine is also present. The septal deformity was not corrected during primary surgery, with the resultant full-blown septocolumellar and vomerine deformity becoming apparent in adult life. Clinically, this deformity manifests more on the basal view, especially in the area of the columella, which is malaligned in an oblique direction, with its base deviated to the noncleft side and the tip deviated to the cleft side (Fig. 2).Fig. 1.: A three-dimensional computed tomographic scan of a 24-year-old woman with secondary cleft lip nose deformity. The skeletal components of hypertrophied anterior nasal spine, skewed vomerine groove, and deficient pyriform fossa are noteworthy.Fig. 2.: Clinical photograph of the same patient (basal view) demonstrates the clinical consequence of the uncorrected skeletal components of the right-sided cleft lip nose deformity.Thus, the analysis of any cleft nose deformity at any age must include an inquiry regarding residual septal deformity, physical examination to specifically study the columellar deviation, and a computed tomographic scan to confirm these findings. The operative algorithm must take into account the septocolumellar influences on the tip aesthetics and plan to eliminate them to achieve consistent results. The frontal and lateral postoperative views of Byrd et al.’s patients show a good result regarding nasal cartilage sculpturing and grafting procedures, but the basal view shows deviation of the columellar base toward the noncleft side and tip deviation toward the cleft side along with a deficient cleft side nose sill, although the authors do mention a septal straightening maneuver. This indicates the presence of a residual deviated nasal septum and consequent malaligned septocolumellar infrastructure. The skeletal components of the unilateral cleft lip nose deformity thus include a deficient inferior rim of pyriform fossa, hypertrophied anterior nasal spine, and skewed vomerine groove besides the well-described feature of ipsilateral maxillary hypoplasia. In addition, the nose sill needs to be addressed regarding the muscle and skeletal deficiency and qualifies for a place in the algorithm. The nasal sill is also deficient on the postoperative photographs. Many techniques have been described for augmenting the nose sill, and we have been using a superiorly based turnover orbicularis oris muscle flap for this purpose in addition to performing the other cartilage sculpturing and grafting procedures.3 Our recommendations for cleft lip rhinoplasty would be septoplasty with relocation of the caudal part of the septum, excision of the septospinal ligament, relocation of the anterior nasal spine, and augmentation of the nose sill in addition to the standard maneuvers for reconstructing the cartilage infrastructure of the nose.4,5 Rajiv Agarwal, M.Ch. Department of Plastic Surgery Chhatrapati Shahuji Maharaj Medical University Ramesh Chandra, F.R.C.S. Doctors Clinic Lucknow, India