BritishJcurna! of Phstic Surgery (1957).

28, 262~267

PRIMARY REPAIR OF THE BILATERAL CLEFT LIP NOSE

By HAROLDMCCOMB, F.R.C.S., F.R.A.C.S.

Princess Margaret Hospital for Children, Perth, Western Australia

SIGNIFICANTnasal deformity usually persists after repair of a bilateral cleft lip. The
nose tip is depressed and tethered to the upper lip by a short columella. Downward
rotation of the alar cartilages causes drooping of the nostril margins (McComb, 1975)
with broadening of the nose tip, and the lower edges of the alar cartilages push up
oblique ridges under the lateral walls of the nostrils. The alar bases are flared and the
perimeters of the nostril margins are flattened obliquely (Fig. I).
Subsequent lengthening of the columella restores the position of the nose tip, but
if the downward rotation of the alar cartilages is not corrected there is persistent drooping
of the nostril margins and oblique ridges remain across the lateral nostril walls. Length-
ening of the columella increases the perimeter of the nostril margins which must then
be reduced, usually by alar base excisions (Fig. 2).
The nasal deformity which is associated with cleft lip is an integral part of the total
deformity. The best chance for its correction is at the time of primary lip repair when
wide dissection and mobilisation of the soft tissues is performed. Failure to correct
the nasal deformity at the time of primary repair leaves the nasal cartilages bound in
an abnormal position, tethered by shortage and malalignment of the covering skin and
nostril lining.
Pre-surgical correction of the displaced segments of the maxillary arch has made
possible a fresh approach to complete treatment of the nasal deformity at the time of
primary lip repair. The orthodontist commences treatment as soon as possible after
birth. Having gained control of the maxillary segments, and corrected the forward
displacement of the pre-maxilla as far as possible by preliminary orthopaedic procedures,
a plate is fitted which holds the pre-maxilla in position and dispenses with restraining
strapping.

FIG. I. Typical nasal deformity with short columella and downward rotation of the alar cartikges
following primary repair of bilateral cleft lip.
FIG. 2. After lengthening of the columella there is persisting downward rotation of the alar cartilages.
262
PRIMARY REPAIR OF THE BILATERAL CLEFT LIP NOSE 263

FIG. 3. The first stage in treatment is lengthening of the columella.

FIG. 4. Lengthening of the columella by a forked flap,

264 BRITISH JOURNAL OF PLASTIC SURGERY

The first step in operative treatment is reconstruction of the columella (Fig. 3).
This is performed at about 6 weeks of age. Measurement shows that the columella
length in infants, from the base of the columella to the level of the intercrural angles of
the nostril margins, is 5 mm. This distance remains surprisingly constant until the child
is about g months old. The columella is increased to this length by a forked flap
(Millard, 1958) which is cut from the sides of the prolabium (Fig. 4). It is essential
that the prongs of the flap are quadrilateral in shape, with only triangular tips, so that
the tissue is simply advanced up into the columella from the sides of the prolabium
without causing any undue narrowing of the prolabium at the base of the columella.
If completely triangular flaps are used and advanced into the columella, the prolabium
becomes waisted and globular (Fig. 5), and is liable to post-operative oedema. Narrowing
across the columellar base then makes the subsequent lip repair tight and difficult.
At first it was thought that dissection across the base of the prolabium might damage
the blood supply to this tissue when it was incorporated in the lip repair 4 weeks later.
However, care has been taken to limit the dissection of the prolabial skin from the pre-
maxilla at the time of lip repair and no problems have been encountered. The mucosal
portion of the prolabium is completely dissected free during repair of the lip, and is
turned down between the mucosa of the lateral elements.

FIG. 5. The forked flaps (A) are essentially quadrilateral to avoid narrowing of the base of the prolabium
which occurs with triangular flaps (B).
 PRIMARY REPAIR OF THE BILATERAL CLEFT LIP NOSE 265

After reconstruction of the columella, the maxillary segments are retained by a

sucking plate, sometimes assisted with fresh elastic strapping across the recently healed
prolabium.
Combined repair of the lip and nose is then performed at 3 months of age. After
dissection of the lip flaps, all the skin of the nose is elevated, from the nose tip to the
nasion, by sharp pointed scissors introduced through the incisions in the upper buccal
sulci. Particular care is taken to elevate the skin from over the alar cartilages so that
their downward rotation and displacement can be corrected.
The first sutures which are placed in the repair are 2 mattress sutures of s/o silk
which are threaded from within the nostrils through the intercrural angles of the alar
cartilages and passed subcutaneously to emerge in the region of the nasion. Gentle
traction on these sutures corrects the downward rotation of the alar cartilages, elevates
the nostril margins and nostril lining, and restores the shape and position of the nose
tip (Fig. 6).
In this way the nostril floor is repaired with the lining and alar cartilages held in
their normal position. The lip is then repaired. Where possible alar-base flaps are
used to build up the nostril floors. A triangle of mucosa from the prolabium is incor-
porated in the centre of the lip.
At the completion of the operation the long elevating mattress sutures are tied over
small gauze bolsters. The original sutures are sometimes replaced at this stage to provide
a better direction of elevation. The alar cartilages are often quite stable alone in their
new elevated position.
Finally, a through-and-through mattress suture is placed at the level of each supra-
alar groove fixing together the nasal lining and cover to obliterate the potential dead
space in the lateral walls of the nose.
It is essential that the maxillary segments are in reasonably good alignment before
this plan of treatment can be applied. In this way it has been possible to correct the
nasal deformity at the time of repair of bilateral clefts of the lip (Fig. 7). It should

FIG. 6. Upward rotation of the alar cartilages by long elevating mattress sutures: a, Sutures pick up the
intercrural angles. b, Elevation of the cartilages by gentle traction. C, Repair with tissues in correct
alignment.
266 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 7. Results of treatment in two patients.

 PRIMARY REPAIR OF THE BILATERAL CLEFT LIP NOSE 267
be emphasised that the effects of this treatment on long-term growth and development
of the nose have yet to be judged.

REFERENCES

MCCOMB, HAROLD (1975). Treatment of the unilateral cleft lip nose. Phtic and Recon-
structive Surgery, 55, 596.
MILLARD, D. RALPH (1958). Columella lengthening by a forked flap. Plastic and Recon-
structive Surgery, 22, 454.