SPECIAL TOPIC

Structural Approach to Secondary Repair of the

Unilateral Cleft Lip Nasal Deformity
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

Dean M. Toriumi, MD
Summary: Management of the unilateral cleft lip nasal deformity is complex
Chicago, IL because of the underlying significant asymmetry of the lower lateral cartilages
and soft tissues of the nasal base. Suturing and grafting techniques may leave
the patient with residual asymmetries of the nasal tip and nostrils. Some of
this residual asymmetry may be attributable in part to the anchoring effect of
the vestibular skin attachments to the lower lateral cartilages. This article dis-
cusses the use of lateral crural release, repositioning, and support with lateral
crural strut grafts to manage the nasal tip. The technique involves freeing the
vestibular skin from the undersurface of the lateral crura and domes and place-
ment of lateral crural strut grafts with or without amputation of the ipsilateral
dome and lateral crura to allow precise resuturing to the caudal septal exten-
sion graft. This technique is coupled with the use of a caudal septal extension
graft to stabilize the nasal base and provide a strong foundation for the repair.
Treatment of the nasal base may require skeletal augmentation to aid in creat-
ing symmetry of the alar insertions. Costal cartilage is needed in most cases to
provide adequate structural support. Nuances in technique are discussed to
help maximize outcomes. (Plast. Reconstr. Surg. 153: 193, 2024.)

M
anagement of the unilateral cleft lip Definitive management usually involves
nasal deformity is one of the most chal- manipulation of the existing cartilage structure
lenging problems for the rhinoplasty sur- through the use of composite flaps, columellar
geon. The primary surgery is usually performed struts, suturing techniques, and tip grafting.4,9–20
early in life and entails a multitude of different Many patients achieve excellent outcomes; how-
techniques, including nasoalveolar molding and ever, residual asymmetries of the nasal tip and
surgery.1–3 Later in life, these patients frequently nasal base frequently persist.
present for secondary or definitive correction.1,3,4 One of the major problems with the unilateral
Many present with functional problems, but it is cleft lip nasal deformity is that the soft-tissue enve-
the aesthetic concern that frequently prompts the lope and vestibular skin attachments to the ipsilat-
patient to seek definitive surgical correction.5,6 eral lower lateral cartilage can restrict movement
The unilateral cleft lip nasal deformity is com- of the lower lateral cartilages. After the applica-
plicated by significant asymmetry of the nasal tip tion of struts and tip grafts, the vestibular lining
cartilages and soft tissues of the nasal base.7,8 The continues to limit free movement of the domes
focus of this article is definitive rhinoplasty of the and lateral crura from moving into a position that
unilateral cleft lip nasal deformity. This surgery can mirrors the noncleft side. This anchoring effect
be performed after the patient has completed their frequently leaves patients with noticeable tip
skeletal growth phase and has reached their mid to asymmetry that can worsen with time as the ves-
late teens.5 Many patients wait until adulthood to tibular lining scars and contracts. Composite flaps
undergo the surgery, when it is convenient from are good options but frequently require extended
both a professional and financial point of view.

Disclosure statements are at the end of this article,

From the Department of Otolaryngology–Head and Neck
following the correspondence information.
Surgery, Section of Facial Plastic and Reconstructive
Surgery, Rush University Medical School.
Received for publication April 4, 2020; accepted January
10, 2023. Related digital media are available in the full-text
Copyright © 2023 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000010687

www.PRSJournal.com 193
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2024

external incisions and some residual tip asymme- describe our novel approach with the use of LCR
tries usually persist.4,8,15 for definitive repair of the unilateral cleft lip nasal
With the advent of new nasal tip techniques deformity.
in rhinoplasty, major changes can be made in
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024

nasal tip contour by releasing vestibular skin

attachments from the lower lateral cartilages with TECHNIQUE
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

grafting and lower lateral cartilage repositioning. The external rhinoplasty approach is used
Gunter and Friedman21 described the use of lat- to expose the lower lateral cartilages and mid-
eral crural strut grafts sutured to the undersur- dle nasal vault. The medial crura are dissected
face of the lateral crura to change nasal tip shape. apart to expose the caudal septum, allowing any
Sheen22 and Constantian23 have described reposi- necessary septal work to be performed. This
tioning of the lateral crura through an endonasal also provides the exposure necessary to place an
approach to correct cephalically positioned lat- end-to-end caudal septal extension graft that is
eral crura. fixated with extended spreader grafts anteriorly
By combining the use of lateral crural strut and thin splinting cartilage grafts posteriorly.
grafts and repositioning of the lateral crura, the Good fixation of the caudal septal extension graft
surgeon commands maximal control of nasal tip is critical to minimize shifting or rotation of the
contour, projection, position of the ala, and lat- nasal tip structures.
eral wall support.24–26 Adequate cartilage-grafting material is needed
We routinely use caudal septal extension to complete the reconstruction. In most cases, we
grafts to fixate the medial crura, creating a stable harvest costal cartilage using a 10- to 11-mm chest
pivot point for repositioning the lateral crura.27,28 incision made over the sixth or seventh ribs.29
A free-floating columellar strut is usually not suf- If a large amount of septal cartilage is available,
ficient support, because the medial crura/dome it may be sufficient for the repair. Ear cartilage
complex can torque and rotate when the lateral is too thick and not strong enough to perform
crura are repositioned. The caudal septal exten- the reconstruction. It is preferable to use thinly
sion grafts essentially extend the septum cau- carved costal cartilage that is strong but does
dally to allow a more stable point to fixate the tip not add excessive thickness to the sidewall of the
cartilages. nose. Leaving native costal perichondrium on
Lateral crural repositioning (LCR) is an effec- the undersurface of the lateral crural strut grafts
tive treatment for patients with the unilateral cleft helps control the curvature of the grafts and mini-
lip nasal deformity. By dissecting the vestibular mize late warping.30
skin off of the undersurface of the lateral crura, The caudal septal extension graft is usually
the surgeon has the freedom to execute complete fashioned in the shape of an obtuse triangle, with
control of shaping of the lateral crura and domes. the narrower margin oriented inferiorly to allow
In many patients with a unilateral cleft lip nasal maximal control of tip rotation (Fig. 1). In most
deformity, the lateral crura diverge off of the mid- patients, rotation needs to be limited, hence the
dle/medial crura asymmetrically and at an unfa- wider margin is oriented superiorly. The longest
vorable angle. In these cases, the lateral crura axis of the obtuse triangle is oriented caudally
must be dissected from the vestibular skin and to provide extra length for projection of the tip.
then amputated from the middle/medial crura. Extended spreader grafts, thin cartilage splint-
This can be performed on the ipsilateral side of ing grafts, or ethmoid bone with drilled holes are
the deformity or bilaterally. Then the free domal used to stabilize the caudal septal extension graft
segment can be resutured to the caudal septal (Fig. 1). The medial crura are fixated to the caudal
extension graft to create the proper symmetric septal extension graft with a 5-0 plain gut suture
orientation of the domes. Lateral crural strut on a straight septal needle and 5-0 polydioxanone
grafts provide additional support to the reposi- suture placed between the middle/medial crura
tioned cartilages. With the stability provided by (Ethicon, Inc.). Nasal tip position can be con-
the caudal septal extension graft, the lateral crura trolled by moving the medial crura anteriorly or
can be moved into independent pockets. Once in posteriorly on the caudal septal extension graft.
position, the vestibular skin can be repositioned Movement anteriorly will tend to open the naso-
and sutured under the domes to allow contouring labial angle and will be beneficial in most cleft
of the nostrils. In some cases, composite skin or cases. This maneuver will advance the columella/
cartilage grafts may be needed to provide extra upper lip junction anteriorly and help correct any
lining to account for inherent deficiencies. We premaxillary deficiency. Care must be taken to

194
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 153, Number 1 • Secondary Repair of Unilateral Cleft Lip
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

Fig. 1. Caudal septal extension graft placed end to end with existing caudal septum.

make sure the caudal septal extension graft is in

the midline to avoid creating tip asymmetry and
to maximize nostril symmetry.
In preparation for dissecting the vestibular
skin off of the undersurface of the lateral crura,
1% lidocaine with 1:100,000 epinephrine is
injected directly on the undersurface of the carti-
lage to hydrodissect the vestibular skin away from
the lateral crura. Converse scissors are used to dis-
sect the vestibular skin from the undersurface of
the lateral crura starting along the caudal margin
of the cartilage. When in the correct plane, the
vestibular skin can be swept away from the carti-
lage out to the sesamoid cartilages. The lateral
crural strut grafts should measure from 28 mm
to 32 mm and must be cut relatively thin (1 mm
to 1.5 mm) to avoid palpability and excess bulk
in the lateral wall. The lateral crural strut grafts
should be curved with the concave surface facing
medially or toward the airway. Native costal peri-
chondrium can be left on the undersurface of the Fig. 2. Placement of lateral crural strut grafts with angeled
concave surface of the lateral crural strut grafts to medial end and obliquely oriented dome sutures.
ensure the grafts do not bend in the opposite direc-
tion. If excessive curvature is noted, the perichon-
drium can be cross-hatched, and the grafts can be amputated and resutured to match the contralat-
splinted with slivers of cartilage. The lateral crural eral normal dome. By amputating the lateral crura
strut grafts are sutured to the undersurface of the and resuturing to the caudal septal extension graft,
lateral crura with two 5-0 polydioxanone sutures the surgeon has control over how the dome takes
and are placed 1 mm short of the domes and tri- off of the midline. The surgeon can control the ori-
angulated at the medial end to help create a favor- entation of the caudal margin of the lateral crura
able orientation of the lateral crura (Fig. 2). The in relation to the cephalic margin, as well as the
favorable orientation calls for the caudal margin level at which the domes come off of the midline.
to be more anterior than the cephalic margin pro- In unilateral cleft, the ipsilateral dome is caudally
viding maximal support to the alar margin.24 displaced and is flat and displaced laterally (less
To attain maximal symmetry of the domes, projected).2–5 By amputating the lateral crura and
the lateral crura may need to be amputated from resuturing, the surgeon can correct for the domal
the medial crura and directly sutured to the cau- displacement and create symmetric domes.
dal septal extension graft. In the patient with a In many cases, both lateral crura may need to
unilateral cleft lip, the dome on the cleft side is be amputated and resutured to attain maximal

195
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2024
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

Fig. 3. Amputating the lateral crura at the level of the medial crura and resuturing to caudal septal extension graft. (Above, left)
Amputated lateral crura. (Above, right) Lateral crural replacement grafts sutured to caudal septal extension graft. (Below, left) Lateral
crural strut grafts sutured to undersurface of lateral crural replacement grafts. (Below, right) Lateral crural strut grafts and replacement
grafts placed into caudally positioned pockets along the supra-alar groove.

symmetry and proper orientation and tilt to the can be tilted caudally to promote a higher orien-
lateral crura (Fig. 3). Amputation of the lateral tation of the caudal margin of the lateral crura
crura at the level of the intermediate crura can be in relationship to the cephalic margin of the lat-
used in cases where the orientation and symme- eral crura.24 This transition is controlled by how
try cannot be aligned simply by release and place- the medial aspect of the domes are resutured to
ment of lateral crural strut grafts (Figs. 4 and 5). the caudal septal extension graft, as well as the
This is more likely to be necessary in cases where oblique placement of the dome sutures (Fig. 6).
the domes are either deformed from previous sur- The dome sutures pass obliquely across the dome,
gery or the inherent structure of the cartilage is starting medially closer to the caudal margin and
abnormally shaped. The angulation of the caudal laterally closer to the cephalic margin (Fig. 6).
margins of the resutured tip cartilages must be The dome on the cleft side can be elevated to take
assessed carefully to avoid creating a flat infratip off of the caudal septal extension graft at the same
lobule. In many cases, an infratip lobule graft is level as the contralateral dome.
placed to create proper infralobular contour. The pockets for the repositioned lateral crura
If the domes are amputated and resutured, start at the lateral end of the marginal incision and
it is imperative to recreate the normal divergent extend down the supra-alar groove. The pocket is
contour of the middle to medial crura transition. cephalic to the marginal incision and is not posi-
Normally, the middle crura diverge off of mid- tioned in the same place as an alar rim graft.30
line as they transition from the vertically oriented After repositioning the lateral crura, a dead
medial crura to the horizontally oriented lateral space is created cephalic to the repositioned lat-
crura.24 The medial aspect of the new lateral crura eral crura. This area needs to be supported with a

196
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 153, Number 1 • Secondary Repair of Unilateral Cleft Lip
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

Fig. 4. A 22-year-old patient with a left unilateral cleft lip nasal

deformity. (Above) The lateral crura dissected from the underly-
ing vestibular skin. (Center) After amputation of the left lateral
crura medial to the dome, resuturing to the medial crura and
placement of the lateral crural strut grafts. (Below) Base view
shows left lateral crus overlapping the medial crura. Yellow
arrow points to the overlapping segment.

very thin alar batten graft. This typically triangu-

lar graft is placed over the caudal margin of the
upper lateral cartilage and corresponds to the
internal nasal valve. The lateral wall is splinted Fig. 5. Same patient as shown in Figure 4. (Left) Preoperative
with thin pieces of plastic while the cast is in place frontal, lateral, oblique, and basal views. (Right) One-year
to further support the lateral wall. postoperative views.

197
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2024
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

Fig. 6. Obliquely oriented dome suture to create favorable tilt to

lateral crura. The suture passes from caudal medially to cephalic
margin laterally. The lateral crural strut grafts are triangulated
medially, with the caudal margin extending into the dome to
promote elevation of the caudal margin of the lateral crus.

If additional nasal tip projection is needed,

one can place a horizontally oriented onlay tip
graft over the domes or place a shield tip graft
sutured to the caudal margin of the medial crura.24
If major tip projection is required and the shield
tip graft projects more than 2 mm above the
existing domes, then lateral crural grafts should
be sutured to the cephalic surface of the shield
graft, angling at 45 degrees off the cephalic sur-
face (Figs. 7 and 8). Lateral crural grafts go on top
of the lateral crura and span from the shield tip
graft to the existing lateral crura.21,24 The lateral
crural grafts are sutured to the existing domes to
provide a buttress to prevent cephalic rotation of
the shield graft. Articulated alar rim grafts can
be sutured to the lateral margins of the shield tip
graft and placed into pockets along the marginal
incisions to further camouflage the shield graft
and prevent graft visibility.30 All shield tip grafts
should be further camouflaged with soft tissue,
perichondrium, or scar tissue to prevent graft
visualization over time.
Before completion of the nasal tip surgery, the Fig. 7. A 28-year-old patient with a left unilateral cleft lip nasal
vestibular skin must be reattached to the middle deformity. (Above) Intraoperative view after release of lateral
crura adjacent to the domes with a 6-0 Monocryl crura from vestibular skin. (Center) After placement of lateral
suture.31 The nostril apex on the cleft side can be crural strut grafts measuring over 25 mm. (Below, left) Lateral
placed more anterior to create a sharper apex crura with lateral crural strut grafts repositioned into caudally
and improved nostril symmetry.30 If there is a positioned pockets. (Below, right) Shield tip graft with lateral
deficiency of vestibular skin, a composite skin crura grafts and soft tissue for camouflage.
and cartilage graft can be harvested from the
cymba concha of the ear to provide additional lin-
ing.30 Residual hooding on the cleft side can be domes to account for the differences in the soft-
improved by setting the ipsilateral dome slightly tissue envelope. Additional correction be attained
cephalic to the contralateral dome when suturing by carefully excising some of the redundant ves-
the lateral crura onto the caudal septal extension tibular skin on the cleft side. Care should be taken
graft. This creates an intentional asymmetry of the to avoid overresection, as notching can occur.

198
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 153, Number 1 • Secondary Repair of Unilateral Cleft Lip

Skeletal deficiencies on the cleft side can be

augmented with cartilage grafts placed into a
pocket under the ipsilateral alar insertion. Larger
segments of costal cartilage can be placed under
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024

the alar base on the cleft side to augment defi-

ciencies, advance the alar base anteriorly, and cor-
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

rect for a high alar insertion. This augmentation

can create abnormal curvatures in the alar margin
as it approaches the alar base. An alar rim graft
placed close to the alar base can act to recreate
a normal curvature as the alar lobule meets the
cheek.
Residual asymmetries of the nasal base can
be improved using Z-plasty maneuvers, Y-to-V
advancement flaps, or composite grafting into the
nasal base.30 If the patient has a large nostril on
the cleft side, we prefer to use a Y-to-V advance-
ment made along the nostril sill. The sill is cre-
ated by advancing a thick flap of skin where the
sill should be located and moving it medially in
a Y-to-V fashion to downsize the nostril and cre-
ate a sill.30,31 Care must be taken to avoid exces-
sively downsizing the nostril as this can create
nasal obstruction. If the patient presents with ste-
nosis of the ipsilateral nostril, it can be corrected
placing a very long lateral crural strut graft (32
to 34 mm) in combination with a composite skin
and cartilage graft placed into a vertical relaxing
incision.30

DISCUSSION
Treatment of the unilateral cleft lip nasal
deformity is complex and requires advanced
techniques to correct the significant nasal tip
asymmetries. We found that correction is more
difficult if movement of the asymmetric cartilages
is hindered by their attachments to the underly-
ing vestibular skin. Camouflaging the residual
asymmetries can be partially corrected by plac-
ing tip grafts and miscellaneous onlay grafts. The
long-term effects of scar contracture can con-
tribute to worsening of the residual asymmetries
as the underlying cartilage structures are not
symmetric and not equally supported. As with
many problems in plastic surgery, underlying tis-
sue attachments must be released to allow sup-
porting structures to be reconstructed and heal
symmetrically. In the case of the unilateral cleft
lip nasal deformity, the asymmetric vestibular
skin envelope is released from the lower lateral
cartilages to allow symmetric reconstruction. In
Fig. 8. Same patient as shown in Figure 7. (Left) Preoperative addition, the asymmetric takeoff of the domes
frontal, lateral, oblique, and basal views. (Right) One-year from the medial or middle crura may need to be
postoperative views. completely reoriented. This is accomplished by

199
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2024

amputating the ipsilateral dome from the medial extension grafts, lateral crural strut grafts, and
or middle crura and then reattaching the domes premaxillary grafts. Common reasons for failure
directly onto the caudal septal extension graft, to correct the unilateral cleft lip nasal deformity
allowing complete control of the angle and atti- are related to deficiency in grafting materials.
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024

tude of the domes as they diverge off of the mid- Patient-reported outcome measures evalu-
line. (See Figures, Supplemental Digital Content ating nasal function were collected from these
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

1, which show a patient with a unilateral cleft lip patients. We use the Nasal Obstruction Symptom
nasal deformity after undergoing multiple previ- Evaluation, or NOSE, questionnaire to assess
ous surgical procedures. Intraoperative views of function.32 The data attained over the past 10
her nasal base show asymmetries and deficient left years showed significantly improved nasal func-
premaxilla, http://links.lww.com/PRS/G362. See tion compared with preoperative measurements
Figures, Supplemental Digital Content 2, which in patients treated for unilateral cleft lip nasal
show preoperative and postoperative views of deformities.
patient, http://links.lww.com/PRS/G363.) Bilateral Potential complications associated with the use
amputation and resuturing may be necessary to of the described techniques should be discussed
attain maximal symmetry.30 Amputation of the lat- with patients preoperatively. The harvesting of
eral crura at the level of the intermediate crura costal cartilage can result in a pneumothorax if
can be used in cases where the orientation and the pleura is violated or the lung parenchyma is
symmetry cannot be aligned simply by release and damaged. Pneumothorax can be minimized by
placement of lateral crural strut grafts. [See Video harvesting the seventh rib, as it usually lies below
(online), which demonstrates the surgery of the the level of the diaphragm.33 Inability to hide the
patient shown in Supplemental Digital Content 1 lower incision in the inframammary crease neces-
and 2. The video shows the release of the lateral sitated a smaller 11-mm chest incision for rib car-
crura, amputation at the level of the medial crura, tilage harvest.30
resuturing to the caudal septal extension graft, Unfavorable warping can be minimized by
and placement of lateral crural strut grafts.] This leaving the native perichondrium on the under-
is more likely to be necessary in cases where the surface of the lateral crural strut grafts so the con-
domes are either deformed from previous surgery cave surface of the graft is facing the airway.30 This
or the inherent structure of the cartilage is abnor- maneuver will not prevent bending, but will mini-
mally shaped. mize late deformity, as the perichondrium acts to
We are able to attain excellent tip symmetry stabilize the cartilage so it is less likely to deform
with the use of LCR with or without amputation postoperatively.30 It is important to observe the
of the lateral crura. Nasal tip projection is stable tendency of the cartilage to curve and choose the
in most patients because of the stability achieved graft with proper curvature for the lateral crural
by the caudal septal extension grafts. The tradeoff strut grafts.30 Most of the cartilage grafts placed
is increased stiffness in the nasal tip upon palpa- are curved and if the curvature is noted it can be
tion and potential stiffness in the upper lip when used to one’s advantage. The caudal septal exten-
the patient smiles. These sequelae of using cau- sion graft is the only graft that must be straight. In
dal septal extension grafts and lateral crural strut many cases, curved slivers of costal cartilage are
grafts are discussed with patients preoperatively. used to splint the caudal septal extension graft
Additional tip projection can be achieved into a straight contour to help avoid warping. The
using shield tip grafts with lateral crural grafts. oblique cut method of carving the costal cartilage
Proper camouflage is required to prevent graft can be helpful to minimize cartilage warping.34
visibility.30 The grafts will still bend, but to a lesser degree,
Many patients also underwent augmentation minimizing severe deformities.
of their nasal base to help provide a more stable When elevating the vestibular skin from the
and symmetric platform for the alar insertions. undersurface of the lateral crura, it is critical to
Large cartilage grafts would frequently be placed hydrodissect the vestibular skin to allow easier
below the ipsilateral alar insertion to advance the elevation. If proper hydrodissection is performed,
alar insertion point anteriorly. This also helps the vestibular skin should easily lift off of the lat-
create symmetry of the nostrils. Such maneuvers eral crura. If the vestibular skin is perforated or
require larger amounts of grafting material and lacerated, it should be sutured. At the end of the
are why costal cartilage was chosen for most of operation, we typically place a lateral wall splint
the patients. The rib provides an abundant source onto the lateral wall of the nose to promote
of cartilage for spreader grafts, caudal septal reapproximation of the vestibular skin to the

200
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 153, Number 1 • Secondary Repair of Unilateral Cleft Lip

undersurface of the lateral crura and avoid exces- 15. Tamada I, Nakajima T, Ogata H, Onishi F. Secondary repair
sive lateral wall thickness.24,25,30 of cleft lip nose deformity using subcutaneous pedicle flaps
from the unaffected side. Br J Plast Surg. 2005;58:312–317.
16. Fujimoto T, Imai K, Hatano T, Takahashi M, Tamai M.
Follow-up of unilateral cleft-lip nose deformity after second-
CONCLUSIONS
Nt8lyPbAa8CSpgOFxLwzb79h1mSRLxEDOC1dRKgcn/CHYN5vn9wUckrv2gZdVNVMshuEJSrKPsTYyKcOJbq2t on 07/09/2024

ary repair with a modified reverse-U method. J. Plast Reconstr

LCR, or lateral crural amputation and resu- Aesthetic Surg. 2011;64:747–753.
Downloaded from http://journals.lww.com/plasreconsurg by 3Es74liTC9E7+ebyg9rpd7elgXFH7NpeI2uSzFt/p4R

turing, is an effective method for definitive cor- 17. Jeong HS, Lee HK, Shin KS. Correction of unilateral second-
ary cleft lip nose deformity by a modified Tajima’s method
rection of the unilateral cleft lip nasal deformity. and several adjunctive procedures based on severity. Aesthetic
Use of this technique requires a thorough under- Plast Surg. 2012;36:406–413.
standing of the normal nasal tip anatomy and pre- 18. Flores RL, Sailon AM, Cutting CB. A novel cleft rhinoplasty
cise execution of cartilage-grafting maneuvers. procedure combining an open rhinoplasty with the Dibbell
and Tajima techniques: a 10-year review. Plast Reconstr Surg.
Dean M. Toriumi, MD 2009;124:2041–2047.
60 East Delaware Place, Suite 1425 19. Bashir M, Malik A, Khan FA. Comparison of suture and
Chicago, IL 60611 graft techniques in secondary unilateral cleft rhinoplasty. J
dtoriumi@uic.edu Craniofac Surg. 2011;22:2172–2175.
20. Byrd HS, El-Musa KA, Yazdani A. Definitive repair of the
unilateral cleft lip nasal deformity. Plast Reconstr Surg.
DISCLOSURE 2007;120:1348–1356.
21. Gunter JP, Friedman RM. Lateral crural strut graft: tech-
Dr. Toriumi receives book royalties from DMT nique and clinical application in rhinoplasty. Plast Reconst
Solutions. No funding was received for this article. Surg. 1997;99:943–952; discussion 953.
22. Sheen JH. Aesthetic Rhinoplasty. St. Louis: Mosby;
1987:432–462.
REFERENCES 23. Constantian MB. The two essential elements for planning tip
1. Haddock NT, McRae MH, Cutting CB. Long-term effect of surgery in primary and secondary rhinoplasty: observations
primary cleft rhinoplasty on secondary cleft rhinoplasty in based on a review of 100 consecutive patients. Plast Reconstr
patients with unilateral cleft lip–cleft palate. Plast Reconstr Surg. 2004;114:1571–1581; discussion 1582.
Surg. 2012;129:740–748. 24. Toriumi DM. New concepts in nasal tip contouring. Arch
2. Sykes JM, Jang YJ. Cleft lip rhinoplasty. Facial Plast Clin North Facial Plast Surg. 2006;8:156–185.
Am. 2009;17:133–144, vii. 25. Toriumi DM, Asher SA. Lateral crural repositioning for
3. Monson LA, Kirschner RE, Losee JE. Primary repair treatment of cephalic malposition. Fac Plast Cl N Amer.
of cleft lip and nasal deformity. Plast Reconstr Surg. 2015;23:55–71.
2013;132:1040e–1053e. 26. Toriumi DM. Open structural approach to second-
4. Zbar RI, Canady JW. An evidence-based approach to ary rhinoplasty. In: Rohrich RJ, Ahmed J, eds. Secondary
secondary cleft lip nasal deformity. Plast Reconstr Surg. Rhinoplasty by the Global Masters. Boca Raton, FL: CRC Press;
2011;127:905–909. 2017:1595–1632.
5. Cutting CB. Secondary cleft lip nasal reconstruction: state of 27. Toriumi DM. Caudal septal extension graft for correc-
the art. Cleft Palate Craniofac J. 2000;37:538–541. tion of the retracted columella. Otolaryngol Head Neck Surg.
6. Chetpakdeechit W, Hallberg U, Hagberg C, Mohlin B. Social 1995;6:311–318.
life aspects of young adults with cleft lip and palate: grounded 28. Toriumi DM, Bared A. Revision of the surgically over-
theory approach. Acta Odontol Scand. 2009;67:122–128. shortened nose. Facial Plast Surg. 2012;28:407–416.
7. Shih CW, Sykes JM. Correction of the cleft-lip nasal defor- 29. Toriumi DM. Discussion: Use of autologous costal cartilage
mity. Facial Plast Surg. 2002;18:253–262. in Asian rhinoplasty. Plast Reconstr Surg. 2012;130:1349–1350.
8. Wang TD. Secondary rhinoplasty in unilateral cleft nasal 30. Toriumi DM. Structure Rhinoplasty: Lessons Learned in Thirty
deformity. Clin Plast Surg. 2010;37:383–387. Years. North Salt Lake, UT: DMT Publishing; 2019.
9. Pawar SS, Wang TD. Secondary cleft rhinoplasty. JAMA Fac 31. Kiya K, Oyama T, Taniguchi M, Hosokawa K. Simultaneous
Plast Surg. 2014;16:58–63. correction of deviated columella and wide nostril floor using
10. Gillies H, Kilner TP. Hare-lip: operations for the correction the Y-V advancement in unilateral cleft lip nasal deformities.
of secondary deformities. Lancet 1932;220:1369–1375. J Plast Reconstr Aesthet Surg. 2014;67:721–724.
11. Converse JM. Reconstructive Plastic Surgery, Vol. 1. Philadelphia: 32. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B,
WB Saunders; 1964. Hannley MT. Development and validation of the Nasal
12. Tajima S, Muruyama M. Reverse-U incision for secondary Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol
repair of cleft lip nose. Plast Reconstr Surg. 1977;60:256–261. Head Neck Surg. 2004;130:157–163.
13. Black PW, Hartrampf CR Jr, Beegle P. Cleft lip type 33. Jung D, Choi S, Moon H, Chung I, Im J, Lam S. A cadaveric
nasal deformity: definitive repair. Ann Plast Surg. analysis of the ideal costal cartilage graft for Asian rhino-
1984;12:128–138. plasty. Plast Reconstr Surg. 2004;114:545–550.
14. Lee KC, Kwon YS, Park JM, Kim S-K, Park S-H, Kim J-H. Nasal 34. Taştan E, Yücel OT, Aydin E, Aydoğan F, Beriat K, Ulusoy MG.
tip plasty using various techniques in rhinoplasty. Aesthetic The oblique split method: a novel technique for carving cos-
Plast Surg. 2004;28:445–455. tal cartilage grafts. JAMA Facial Plast Surg. 2013;15:198–203.

201
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.