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Secondary Cleft Rhinoplasty: Enhancing Nasal Form and Function for Cleft Lip Patients.

Updated: 6 days ago

Dr Srinjoy Saha, Clinical Professor of Plastic Surgery and Consultant Plastic Surgeon, Apollo Hospitals Kolkata, India.


Rhinoplasty in Cleft Children: The Final Step of a Long Reconstruction Journey.


Children born with facial clefts of the lip and palate have deficient facial growth. On the cleft side, facial bones do not grow well. These also include the nasal bones and cartilages. Even after correcting lip and palate defects, the nasal deformity lingers. Thus, children with cleft lip and palate require a final surgery called a rhinoplasty. 


Preoperative cleft lip patient with nasal deformity
Frontal, oblique, and basal views of a cleft lip patient before secondary cleft rhinoplasty. The images highlight the nasal deformity, including asymmetry, deficient growth on the cleft side, and abnormal nostril shape.

The Necessity for Secondary Cleft Rhinoplasty.


Skilled plastic surgeons use rhinoplasty to re-create natural, symmetric nasal contours. They rebuild the nose's support systems and fix deficient areas. Following that, a deformed nose appears smoother and more symmetric. These contours are in harmony and balance with the rest of the face. Most importantly, it has a substantial psychological impact. It ends the visible cleft stigma and lets patients feel comfortable with their looks.


Age Considerations for Secondary Cleft Rhinoplasty.


A rhinoplasty significantly improves the appearance and function of the nose. As plastic surgeons, we perform this extensive nose surgery once the patient's face has stopped growing. Typically, it occurs around the ages of 16 to 18 for girls and 17 to 19 for boys.


Postoperative results of secondary cleft rhinoplasty
Frontal, oblique, and lateral view photographs of a cleft lip patient after undergoing secondary cleft rhinoplasty surgery. The images demonstrate an improved, more symmetrical nasal shape.

Understanding The Long Journey of Cleft Lip Palate Repair.


Children born with cleft lips have a gap or opening in their upper lip. In cleft palate, the gap is in the roof of the mouth. A child may have an opening in one or both areas. 


To fix these birth defects, they need many surgeries from a very young age. The first surgeries happen when they're babies. These surgeries close the cleft lip and palate openings, enabling proper eating, breathing, hearing, and speaking.


As the child grows older, they may need more procedures. These will be on their gums, jaws, and other facial areas. This complex journey of cleft repairs often spans throughout childhood.


A Lingering Nose Deformity in Cleft Children.


Even after the initial cleft surgeries, most children still have deformed noses. Their noses may look crooked or off-centre. One nostril may appear more narrow or more deformed than the other. Sometimes, the nasal tip cartilages may collapse inward, leading to a pinched or asymmetrical appearance.


Preoperative cleft nasal deformity (oblique view).
Oblique view photographs of a cleft lip patient before secondary cleft rhinoplasty surgery, showing the differences in nasal tip and nostril shape between the cleft (left) and normal (right) sides.

Enhancing Nasal Structure with Grafts.


As plastic surgeons, we use grafts or implants to reconstruct and support the nasal framework during surgery. We may source these grafts from the patient's cartilage or bones (autologous) or synthetic (non-autologous) materials.


Autologous Materials.


We may use cartilage from the patient's nasal septum or rib to create thin grafts. The grafts provide essential support by acting as pillars, braces, or supports strategically placed in specific areas. These cartilage grafts help straighten, project, and strengthen the collapsed nostril area. They also reinforce the nasal sidewalls on the cleft side.


Non-autologous Materials.


In some cases, we may use unique implants made up of porous, high-density polyethylene to fix areas of deficiency. We can carve these custom implants into shapes like struts or battens. We build up the collapsed nasal lining and sidewall, which need more projection.


Improved nostril shape after secondary cleft rhinoplasty (basal view).
Basal view photographs comparing a cleft lip patient's nostril shape before and after secondary cleft rhinoplasty surgery, highlighting the improvements in nostril symmetry.

Secondary Cleft Rhinoplasty: An Amazing Nose Reconstruction Procedure.


Surgical Approaches: Closed versus Open Techniques.


As plastic surgeons, we may perform rhinoplasty using a closed or open approach. During the closed approach, we make incisions inside the nostrils. With the open approach, we also make incisions across the thin strip of skin lying between the nostrils, called the columella.


The open approach is considered best for cleft rhinoplasty. It allows us better sight and access to the nose's structure, helping us perform more complex reconstructions.


The Open Surgical Approach.


The rhinoplasty starts with making an upside-down "V" shaped incision. The cut goes across the columella, the strip of skin between the nostrils. Now, we carefully lift the skin over the nasal tip and the bridge while retaining as much soft tissue as possible. Additionally, we make small incisions along the nostril creases.


The nose appears depressed on the cleft side. Up here, the incision goes along the nostril crease. It goes slightly further down towards the nasal opening, providing more soft tissue in that area. These extra bits of tissue stop implants from poking through later.


Next, we locate and free up the remnants of the lower lateral cartilage lying on the cleft side. We then trim away the misshapen cartilage. We leave just a tiny portion at the tip of the nose. Finally, we stitch close any holes or tears in the mucosa.


Intraoperative reconstruction during secondary cleft rhinoplasty.
Intraoperative photographs during secondary cleft rhinoplasty, showing the reconstruction of the columella and dorsum with grafts (left) and the new nasal shape as the nasal envelope drapes over the newly built structure (right).

Creating Pockets for the Implants.


We lift off the soft tissues, creating space around the nasal framework. Then, we start rebuilding and reshaping the nose. The first step is to create a pocket just under the premaxilla bone above the upper gum area.


Small, rectangular implants get inserted through the columellar incision into this pocket area. These "plumper" implants help build up the deficient pre-maxillary region. We carve them by hand from thin, porous sheets of permanent implant.


Building Up the Nasal Tip.


The next area we work on is the nasal tip and columella. Another thin implant gets carefully positioned between the medial crural cartilage foot plates. It acts as a strut to support and project the tip. This columellar strut is secured in place using dissolvable sutures.


If needed, we refine the position and shape of the cartilage at the nasal tip. We bind and shape the tip using permanent sutures, making it more symmetrical with the opposite side.


Reinforcing the Nostril Area.


One of the critical implants used in cleft rhinoplasty is the nasal valve batten graft. This implant looks like a curved rod or batten. We insert it into a pocket created along the nasal sidewall on the cleft side.


The batten reinforces and projects the collapsed nostril area, stopping further collapse when breathing. It is carefully placed just before the nasal bones, above the nostril. Permanent sutures secure it to the remaining nasal cartilage.


Improved nostril shape after secondary cleft rhinoplasty (basal view).
Basal view photographs comparing a cleft lip patient's nostril shape before and after secondary cleft rhinoplasty surgery, highlighting the improvements in nostril symmetry.

Augmenting the Tip and Bridge.


After fixing the nostrils, we now focus on hiding any dents or lopsidedness in the tip and bridge. We insert a standard pre-shaped nasal dorsal implant into a pocket over the nasal bones.


We may shave down the implant carefully or file the nasal bones slightly. These procedures ensure that the implant lays perfectly smooth. Shaping and layering the implant hides any remaining depressions or irregularities.


Final Augmentation and Closure.  


In cases of more severely deformed noses, additional implants may be necessary to improve the nasal floor or pre-maxillary areas. These implants are inserted through a separate incision inside the nose to create smooth, full contours without indentations or irregularities.


Once all the implants are in place, the soft nasal tissues are put back in shape. The incisions are closed using a mix of dissolvable and permanent sutures.


Finally, we apply a nasal splint over the nasal bridge. It keeps everything still and the new nasal shape safe during healing. We insert nasal packings in each nostril. They stabilize the area and prevent bleeding or fluid buildup in the first few days.


We remove the nasal splint, packings, and sutures about a week after the rhinoplasty surgery. We expect some swelling and bruising to occur. The patient should quickly notice improvements. Breathing gets better, and their face becomes more symmetrical. Their nasal shape also becomes much smoother.


Immediate postoperative nasal contours after secondary cleft rhinoplasty
Intraoperative photographs immediately after secondary cleft rhinoplasty surgery, showing the new contours of the nasal bridge (left, bird's eye view) and the new shape of the nasal tip and nostrils (right, basal view).

Pearls and Pitfalls of Secondary Cleft Rhinoplasty.


Helpful Hints for Patients:


• Secondary cleft rhinoplasty is often done in two separate surgeries. Patients should know this from the beginning. 


• The first surgery is usually done under general anaesthesia. The second one may need local anaesthesia with some sedation to relax.


• Having a second surgery means there will be an extra cost. Patients should prepare for this additional expense.


Potential Challenges to Be Aware Of:


• If the patient has very thick skin on their nose, swelling may last a long time after surgery.


• Patients with thick skin on their nasal tip get unsatisfactory results. Even after reshaping the cartilages, their thick skin makes the tip look overly prominent.


• During the first consultation, a plastic surgeon may say, "I can't do what you're asking for". It means the patient has been evaluated and found to be unfit for surgery. The patient did not appear to value nor understand what was good and safe. He's politely asking the patient to go elsewhere!


Postoperative swelling after secondary cleft rhinoplasty.
Postoperative photograph of a cleft lip patient one week after secondary cleft rhinoplasty surgery, showing the significant swelling around the nose that masks the underlying nasal contours.

The Most Important Things to Consider Before Secondary Cleft Rhinoplasty.


Immediate Risks and Considerations.


Like any major surgery, patients must be aware of the risks of cleft rhinoplasties. These risks include bleeding during surgery, nasal blockage, the need for more surgery, and implant movement or extrusion. There are anaesthesia issues like post-operative laryngospasms.


Other risks include extended hospital stays and nasal infections. Despite careful surgical techniques, unpredictable and hypertrophic scarring can occur. Cleft patients often have many previous operations. Due to fibrosis, their wounds tend to heal badly.


Still, the benefits of cleft rhinoplasty far outweigh its risks. When done by experts, rhinoplasty brings many benefits to cleft patients. It improves breathing, facial harmony, and self-esteem.


Improved nose shape after secondary cleft rhinoplasty (lateral view).
Lateral view photographs comparing a cleft lip patient's nose shape before and after secondary cleft rhinoplasty surgery, showing the enhanced nasal appearance and profile.

Specific Long-term Risks and Potential Complications


The main long-term risks and potential complications associated with cleft rhinoplasty include: 

  • Persistent nasal obstruction and asymmetry.

  • Deviations of the nasal apex.

  • Excessive resorption or protruding deformations of the grafts.

  • Failure of autologous, allogenic, or alloplastic grafts over the long term.

  • Visible scars, skin necrosis, and nasal system dysfunction.

  • Morbidity associated with donor sites for autologous grafts.

  • Failure to achieve the desired nasal contour or normal appearance.

  • Persistent septal deviation leading to residual nasal asymmetry.


Plastic surgeons need to talk a lot with patients and parents. They should discuss what to expect and what is necessary for future procedures. Most children will need more nasal surgeries later.


Recovery & Downtime


  • Patients usually need rest for several days to speed up healing.

  • The process involves a recovery period. We expect swelling and bruising to peak within the first few days.

Improved nose shape after secondary cleft rhinoplasty (oblique view).
Oblique view photographs comparing a cleft lip patient's nose shape before and after secondary cleft rhinoplasty surgery, demonstrating the improvements in nasal symmetry and appearance.

Post-operative Care & General Precautions.


The key points regarding post-operative care for patients undergoing cleft rhinoplasty are:


Pain Management

  • Patients may experience some discomfort for 1-3 weeks after surgery and may require pain medication like paracetamol.

  • Patients need to avoid aspirin as it causes bleeding.


Appearance and Wound Care

  • After the surgery, the patient will have stitches in the lip and nose. The area around the stitches may appear pink and slightly swollen.

  • To clean the suture line on the lip and nose, gently use a cotton bud dipped in boiled and cooled water. 

  • Apply a jelly-based antibiotic ointment to prevent the wound from drying.

  • Remove the outer stitches in 6-7 days.

  • Massage the scars. The scar may appear shorter in the weeks following the surgery, causing the lip to look 'pulled up.' However, this will improve over time with gentle massage.


Recovery and Activity Restrictions

  • 2-3 weeks are needed before healing is complete.

  • Carefully avoid bumping the patient's nose, as the area is fragile.

  • Patients who undergo secondary cleft rhinoplasty require complete rest for several days to accelerate healing.

  • Patients should avoid rigorous physical activity for several days after surgery.

  • Avoid showering and instead bathe carefully.


Follow-up

  • Review appointment with your plastic surgeon within 1-4 weeks as directed.


The Longevity of Transformative Results


  • The results of secondary cleft rhinoplasty usually last a lifetime. But, the nose may take 6 to 18 months to settle to its final look.

  • The procedure improves breathing and gives a more appealing, balanced nasal shape. The results are long-lasting if patients take proper care after the surgery.


Before and after secondary cleft rhinoplasty (frontal view).
Frontal view photographs comparing a cleft lip patient's appearance before and after secondary cleft rhinoplasty surgery, showing enhanced nasal symmetry.

A Transformative Result: Improving Nasal Airway Obstruction and Aesthetics.


Rhinoplasty is an extensive and invasive procedure. Still, it is the only procedure that makes a difference. It significantly improves the lives of cleft patients who have long struggled with deformed noses. It restores normal breathing and nasal function and fixes the look that has marked them since birth.


A rhinoplasty surgery rebuilds the nose to fix symmetry, projection, and smooth contours. It fixes the stigma of the cleft lip nasal deformity. Thereby, it significantly boosts the patient's self-confidence. Finally, the patients get comfortable with their appearance. 


Rhinoplasty is the final step of facial cleft reconstruction. It is crucial for achieving a normal-looking face.


Collage of different stages of secondary cleft rhinoplasty.

Disclaimer: 

This article and the information contained within it are for educational purposes only. It should not be construed or used as a medical opinion or advice. This article does NOT intend to supplement the advice of a trained, licensed medical professional in your area.

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