CLEFT NOSE CLEFT NOSE RHINOPLASTY v.pptx

CLEFT NOSE

1. CLEFT NOSE v/s NORMAL NOSE Dr S. Pritam, II (MDS), Dept. of OMFS, P.M.N.M.Dental College & Hospital, Bagalkot

2. CONTENTS Introduction Problem Embryology Relevant anatomy Treatment Timing Primary rhinoplast Intermediate rhinoplasty Secondary rhinoplasty Summary Bilateral cleft lip nose deformity Unilateral cleft lip nose deformity

3. INTRODUCTION Correction of cleft lip nose deformity  a formidable challenge. Despite early correction of cleft lip nose deformity, one is often faced with an adolescent patient who has an acceptable upper lip but has a deformed nose. The nose forms a prominent part of the face. Ironically, a masterly executed cleft lip repair directs the beholders’ eyes from the deformed lip to the deformed nose.

4. Surgery to alter the shape of the nose sometimes using tissue (skin , cartilage or bone) from elsewhere in the body or artificial implants is known as Rhinoplasty. ( Rhinos , "Nose" + Plastikos , "to shape") Blair and Brown first described the cleft nose in 1931, critically identifying the pathology.

5. Deformity may be severely asymmetric, making surgical correction difficult . Patients with cleft lip may have been previously subjected to numerous surgical interventions, leading to significant scar tissue in the operative site Conversely, the surgery may adversely compromise nasal growth

6. PROBLEMS ASSOCIATED Cosmetic problems, Impaired nasal airflow Septal deflections, atretic nostrils, turbinate hypertrophy, and cleft Lips and palates.

7. Warren et al showed that children with unilateral cleft deformity have smaller airways than children with bilateral cleft deformity . Although the cleft nose grows as the patient ages, it remains 30% Smaller than that of patients without cleft lip deformity.

8. EMBRYOLOGY During normal development, the paired median nasal processes fuse to form the premaxilla , philtrum , columella, and nasal tip. The bilateral maxillary processes form the lateral aspects of the upper lip Cleft lip deformities result from a failure of the fusion of the median nasal processes with the maxillary processes

9. Interruption of this embryonic process creates malformation of some or all of the upper lip, central alveolus, and primary palate The extent of the associated cleft nasal deformity is related to the extent of the interruption of the normal developmental fusion process Even though the nasal defects may be subtle there is always a nasal abnormality associated with cleft lips

10. RELEVANT ANATOMY

11. RELEVANT CLEFT ANATOMY The ala rests on an underdeveloped premaxilla, which partly accounts for alar base lowering and horizontal nostril seating . Bone growth is retarded on the cleft side nasal bones and the nasal process of the maxilla are underdeveloped, causing the nasal dorsum to tilt to the cleft side

12. The ala is often underdeveloped & d ome lowering on the cleft side . The columella is foreshortened and lies obliquely, with its base directed away from the cleft side . The septum may lie outside of the maxillary crest seat, and the cartilaginous portion may be buckled, both of which may cause nasal tip deviation

13. Studies have confirmed the presence of significant septal deviation in patients with bilateral cleft lip when compared to patients without bilateral cleft lip. The septum tends to deviate toward the non cleft side , with the cartilaginous base displaced off the maxillary crest toward the cleft side. This septum malposition contributes to nasal tip tilt toward the non cleft side

14. UNILATERAL CLEFT LIP NOSE DEFORMITY The maxilla on the cleft side is deficient. Because of this, the alar base on the cleft side does not fuse in the midline and is positioned more posterior, lateral, and inferior than the alar base on the non cleft side . Consequently, the lateral crus of the lower lateral cartilage on the cleft side is lengthened and the medial crura is shortened in relation to the Lower Lateral Cartilage on the non cleft side.

15. The septum is attached to the non cleft maxilla inferiorly, which causes the septum to be deviated to the non cleft side caudally, and bowing dorsally toward the cleft side The abnormal insertion of the orbicularis oris muscle causes an asymmetric pull on the caudal septum. C haracteristic anterior septal deflection to the noncleft side

16. B/L CLEFT LIP NOSE DEFORMITY The maxilla is deficient bilaterally, which allows the prolabium to have unopposed anterior growth. The alar bases are displaced in a more posterior, lateral, and inferior position The deficient skeletal base leads to longer lateral crura bilaterally and short, splayed medial crura. This creates an underprojected , b r oad, and fl a t n a s a l tip.

17. The columella is short because of the malposition of the prolabium and the shortening of the medial crura . The short columella makes the broad and snubbed nasal tip even more pronounced . Bilateral insertion of the orbicularis oris musculature into the alar base contributes to the widening of the nose and flattening of the lower lateral cartilage

18. TREATMENT Timing of the Cleft Nasal Repair The decision to perform early nasal surgery is based on several factors. The extent of the deformity and the potential scarring and impact of the procedure on nasal growth . Advantages of early surgical intervention include minimizing the deformity as the child grows, lessening asymmetries to allow optimal nasal growth, and creating favorable conditions for future surgery.

19. Historically, controversy has existed as to whether primary rhinoplasty had a positive influence on the eventual appearance of the nose in patients with clefts . Major septal work and cartilaginous dissection has been thought to negatively affect nasal growth . However, no experimental or clinical studies have ever proved that minor manipulations (without resection) of the nasal tip or nasal base interfere with future nasal growth.

20. Ideal repair of a cleft nasal deformity is performed in 2 stages . The first includes alteration in the nose at the time of lip repair (primary rhinoplasty), delaying a definitive repair until the patient has completed facial growth (secondary rhinoplasty ). In female patients, secondary rhinoplasty is generally performed around 15 to 17 years of age, and in male patients at approximately 16 to 18 years of age.

21. Primary Rhinoplasty The purpose of primary rhinoplasty is to close the anterior nasal floor, to relocate the displaced alar base, and to bring early symmetry to the nasal base and tip . This approach allows for both a functional and aesthetic improvement without affect ing nasal and facial growth . After the cleft lip incisions are made and the primary lip dissection is completed, the muscle and soft tissues of the alar base are separated from their maxillary attachments .

22. The malpositioned alar base is freed by creating an internal alotomy at the anterior head of the inferior turbinate . If adequate soft tissue dissection of the alar base is performed, the cleft alar base can be repositioned (during closure) in the optimal three dimensional position Care is taken not to violate the vestibular skin, avoiding the complication of secondary adhesions and nostril stenosis.

23. This closure is first started with reapproximation of the musculature of the nasal base, which allows the cleft alar base to be reconstructed in a manner that mirrors the non cleft alar base . It is important not to narrow the sill too much . A nasal base that is too wide is easy to narrow secondarily, whereas a stenotic sill is difficult to widen later . The other component of primary cleft rhinoplasty is to reposition the cleft nasal tip into a more projected, symmetric position . The resulting nasal tip is more s ymmetric , defined and projected

24. Intermediate rhinoplasty is defined as any nasal surgery performed between the time of initial lip repair and the time of definitive rhinoplasty when the patient reaches facial skeletal maturity . Rarely used as surgeons have become more adept at primary rhinoplasty . However, many patients have significant nasal deformities that have not been adequately repaired after their initial cleft lip procedures . In these cases, performing intermediate rhinoplasty minimizes the social stigmata associated with a more noticeable nasal deformity. Intermediate Rhinoplasty

25. Once the patient has reached facial skeletal maturity, definitive septorhinoplasty can be performed . Structural reconstruction of the cleft nose often requires cartilage grafting material from the rib or ear to achieve adequate support. Secondary / Definitive Rhinoplasty

26. Goals of Secondary Rhinoplasty The creation of symmetry Definition of the nasal base and tip Relief of nasal obstruction Management of nasal scarring and webbing.

27. SUMMARY The nose in patients with congenital cleft malformations is often the facial feature that is most noticeable to the observer . The secondary nasal deformity is variable and is affected by the extent of the original cleft, growth, and by any intervening surgery to correct the lip or nose . Repair of secondary cleft nasal deformities is challenging .

28. Successful reconstruction requires an understanding of the pathologic anatomy, adequate exposure to perform techniques, and attention to structural grafting to overcome scarring and provide support . Often, graft material from the septum, rib, and/or ear is required. Attention must be paid to both function and appearance

29. REFERENCES Definitive Cleft Rhinoplasty for Unilateral Cleft Nasal Deformity- Myriam Loyo Repair of the Unilateral Cleft Lip/Nose Deformity- J. Madison Clark Rhinoplasty in adolescent cleft patients- Deodatta V. Cleft lip nose- sykes et al. journal of clinical plastic surgery Cleft Nasal Deformity and Rhinoplasty- Yoav Kaufman ; paediatric plastic surgery journal SecondaryCleftRhinoplasty - SachinS et al ; JAMA facial plastic surgery UNILATERAL CLEET RHINOPLASTY A Review - Simon J. Madorsky ; otorhinolaryngology clinics of north america

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