Rhinoplasty persists as one of the most challenging plastic surgery procedures. Through one’s career, it is an ebb and flow of time periods where you think you have it all figured out followed by other periods where you have some complications and disappointing outcomes. When it comes to the congenital nasal deformity, such as cleft lip and palate, those rhinoplasty challenges become magnified.
The cleft nose deformity is a highly variable one that is influenced by the magnitude of the underlying cleft problem. Facial clefts are widely different, from the incomplete microform cleft lip to the severe bilateral cleft lip and palate. In every case, however, the nasal anatomy is not only altered but often deficient as well. Even in the relatively simple unilateral cleft lip and palate, the overlying alar cartilage and skin are not only malpositioned but short of structure. The bilateral cleft lip and palate patient has a severe shortage of columellar skin which will be a lifelong limiting factor.
Adult cleft rhinoplasty does differ from childhood or adolescent nasal surgery. In variably, the nose has been operated on multiple times, is scarred, the anatomy markedly hard to decipher, and cartilage grafts of the septum or ears have been depleted. The patient usually has had lifelong difficulty with breathing, although they be well adapted by this time. There is usually no simple operation that will make any significant nasal change.
Adult cleft nose patients generally present as two types. Those that have had a series of rhinoplasties since childhood, have had significant improvement in both appearance and function, and are looking to mainly optimize nasal aesthetics. Conservely, the other more challenging group are those, that despite earlier efforts or lack thereof, are nasal cripples with severe external distortions and significant airway obstruction.
I find that most adult cleft rhinoplasties need to be approached with the concept of total or near nasal reconstruction. One must be prepared to take much of the nose apart and almost start form the beginning. It is imperative to disassemble the anatomy and begin rebuilding the framework, rather than trying to tweak or patch the existing anatomy in many cases.
Cartilage grafts are always needed and a good straight pieces are favored and the most useful. It is rarely a problem that too much cartilage was used or you ever have too much. I consider synthetic implants rarely appropriate for this type of rhinoplasty and will likely lead to some implant-related complication down the road. As a result, rib graft harvesting can fulfill these needs the best and one must enter the procedure with this as the first step. Never let the graft supply dictate how the operation is to be performed as this is one variable that can be controlled and is predictable. In some cases, an ear cartilage for tip modification may only be needed. But for dorsal augmentation, middle vault reconstruction with spreader grafts, columellar struts, and lower alar batten grafting, rib cartilage allows any and all of these to be performed without limitation.
Dr. Barry Eppley
Indianapolis, Indiana