**6. Surgical treatment**

**Figure 4:**

**Intraoperative**

No single procedure has given sufficiently satisfactory results to provide a surgical standard for CLND correction. Despite considerable progress in the treatment of patients with cleft lip and palate, there is still no agreement about the optimal treatment method. Secondary deformity after the primary operation is a significant problem encountered in cleft-lip repair [23]. The knowledge and experience of the surgeon in rhinoplasty is the keystone for correcting deformity. Use of four basic techniques in rhinoplasty such as onlay grafting, suturing methods, cartilage transection, reorientation and cartilage repositioning can help the cosmetic surgeon to overcome many of the problems inherent to these patients. Familiarity with the numerous techniques in this regard and selection of the proper one to treat the existing deformity is essential. No matter which technique is used it is important to address all parts of the deformity and set all parts in anatomic position. Nostril asymmetry is one of the main complaints of adult patient with unilateral cleft nose deformities. In 1977, Tajima and Mar‐ uyama introduced an operation in which the deformed alar cartilage was fixed to the upper lateral cartilage through a reverse-U incision, and the insufficient area within the nostril was filled with the overhanging alar web tissues. We use this method for the correction of severe asymmetric nostrils. To obtain ideal treatment outcomes in unilateral cleft nose deformity the below list of procedures are used.


Internal or external osteotomy can be used (Figure 5) [8, 24]. Internal or external osteotomy can be used **(Figure 5)** [8, 24].

**Figure 5: A, Before surgery: B, Intraoperative: C, Immediately Figure 6.** A, Before surgery: B, Intraoperative: C, Immediately after surgery: D, one week post surgery

**after surgery: D, one week post surgery** In bilateral cleft nose deformity although confronted with almost symmetric In bilateral cleft nose deformity although confronted with almost symmetric deformities the lengthening of the columella, correction of the depressed nasal tip, bilateral dislocation of alar cartilage and eversion of the alar bases are on the top of the clinician's concern. There are many ways to elongate the shortness of the columella such as forked flap, v-y advancement, prolabium advancement flap combined with an Abbe flap, composite graft and skin rim rotation flap [26]. Using strong and proper struts, repositioning and reshaping lower lateral cartilages, supraperiosteal dissection of the pyriform area to allow the reposition of nasal

deformities the lengthening of the columella , correction of the depressed

nasal tip, bilateral dislocation of alar cartilage and eversion of the alar bases

are on the top of the clinician's concern. There are many ways to elongate

the shortness of the columella such as forked flap, v‐y advancement,

prolabium advancement flap combined with an Abbe flap, composite graft

and skin rim rotation flap [26]. Using strong and proper struts ,repositioning

correcting alar component, use of different suturing methods and augmentation with autog‐ enous grafts can help to achieve almost ideal results (Figure 6).

**Figure 7.** A and B, before surgery basal and lateral view, C: intraoperative D and E: 6 months after surgery

## **7. Outcomes**

**9.** Using Z- plasty incision in vestibular pica for vertical lengthening.

**14.** Strut, tip, sheen and batten grafts are help to restore the nasal tip.

**MEDICAL‐EDITED CHAPTER FOR AOMFS VOL 2**

deformity.

A

C 

**12.** Using autogenous graft for augmentation

792 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**15.** Unequal alar base resection

**16.** Release depressor septi muscles

**13.** Augmentation approach is better than reduction

Internal or external osteotomy can be used (Figure 5) [8, 24].

**10.** Reshaping and repositioning of lower lateral cartilage is essential for correcting nostril

**11.** Using multiple sutures to stabilize the final shape of lower and upper lateral cartilages.

Internal or external osteotomy can be used **(Figure 5)** [8, 24].

B

D 

**Figure 5: A, Before surgery: B, Intraoperative: C, Immediately**

In bilateral cleft nose deformity although confronted with almost symmetric deformities the lengthening of the columella, correction of the depressed nasal tip, bilateral dislocation of alar cartilage and eversion of the alar bases are on the top of the clinician's concern. There are many ways to elongate the shortness of the columella such as forked flap, v-y advancement, prolabium advancement flap combined with an Abbe flap, composite graft and skin rim rotation flap [26]. Using strong and proper struts, repositioning and reshaping lower lateral cartilages, supraperiosteal dissection of the pyriform area to allow the reposition of nasal

In bilateral cleft nose deformity although confronted with almost symmetric

deformities the lengthening of the columella , correction of the depressed

nasal tip, bilateral dislocation of alar cartilage and eversion of the alar bases

are on the top of the clinician's concern. There are many ways to elongate

the shortness of the columella such as forked flap, v‐y advancement,

prolabium advancement flap combined with an Abbe flap, composite graft

and skin rim rotation flap [26]. Using strong and proper struts ,repositioning

**after surgery: D, one week post surgery**

**Figure 6.** A, Before surgery: B, Intraoperative: C, Immediately after surgery: D, one week post surgery

Normalized esthetics of the lip and nose is on the top of the specific goals of surgical care for children born with cleft lip and palate followed by nasal airway patency and normal speech [25]. The focus of secondary correction of unilateral cleft-lip nose deformity has been nasal symmetry. Importance has been placed on correction of the cleft-lip nasal deformity by translocation of the alar cartilage with its attached vestibular lining into a normal position, thereby establishing the normal vault and shape of the cartilage.[23] There is no doubt that definitive rhinoplasty should logically only be undertaken after reconstruction of skeletal base and correction of the jaws relationship. The key point is overcorrecting the cleft-side nostril and its alar cartilage is believed to produce better symmetry compensating for possible relapse during the postoperative period [12]
