Now let’s shift to a more complex deviation. Here is a patient who has a cleft lip nasal deformity. He had a cleft lip repaired when he was a child, but he still has a problem with his nose, and it is a very characteristic sort of problem, a “classic” cleft lip nasal deformity. You can see his before and his after picture here from the front. Also he had a nasal bump and a bit of a droopy nose, and we addressed those things too. The bottom view also shows the twist and how we were really able to get a wonderful improvement in the twist of his nose. This oblique view also shows aesthetically the nice improvement that was made.

When you look at his CAT scans you can see that the inside of his nose also is a bit of a jumble.

It is really deviated in a classic cleft lip nasal deformity way. There is absent maxillary and pre-maxillary bone on his left side because it is a left cleft, and then the caudal (front part) of the septum is deviated to the right – to the non-cleft side, and further back it is severely deviated to the left as you can see on the scan, in a very characteristic fashion for a cleft lip nasal deformity.

On the patient’s pre-surgical front view picture, you can appreciate the deviation of the nasal bones to the right, to the non-cleft side. You can also appreciate the deviation of the middle nasal vault. There is a “concave left” deviation. There is also the characteristic tip deformity.

I did this rhinoplasty through an open rhinoplasty approach. And when you open his nose, you can also see the very characteristic problems with tip cartilages, where the cartilage on the cleft side, which is his left, (note to the Internet reader: as you look at this it is on your right), this lower lateral cartilage is posterior, inferior and laterally displaced (note to the Internet reader: this means down, in and back) compared to the right side. The medial crural part of the tip cartilage is short and the lateral crural part is long. So we are going to have to reposition those.

These diagrams of a classic cleft lip nasal deformity are taken with permission from the textbook Rhinoplasty Dissection manual, written by Dean Toriumi and me. While this is of course not always the case, you can compare this to the the actual, intraoperative photograph and get an idea that the classic cleft lip nasal deformity can be predictable.

The following 2 slides detail the classic findings:

As you can see we also took down his bump and we are going to use that piece of material as a graft. So let me tell you what we did to fix this complex deviation.

I atraightened the septum for airway purposes, and also straightened the caudal septum to help straighten the nasal tip. (We’ll talk about the techniques to straighten the caudal septum in a few minutes). I took down the nasal hump and performed bilateral medial and lateral osteotomies, straightening the upper nasal third. I returned to the nasal tip, where I placed plumping grafts to support the base of the nasal tip cartilages and fill out the nasolabial angle. I placed domal sutures on the right and left tip cartilage, but the left domal suture was placed using the “lateral crural steal” technique, thereby lengthening the medial crus at the expense of the lateral crus. Of course, the medial crus needed lengthening as it was too short. The lateral crural steal technique is illustrated in the diagram below. In this diagram it is applied to both tip cartilages, in this patient it was applied to only one tip cartilage, the left one.

This technique creates a deficiency of the lateral crus in these patients, and in this patient’s case I used the excised nasal hump as a batten graft on the left side. This effectively reconstructed the left lateral crus of the left tip cartilage.

Finally, I addressed the middle nasal vault. After hump takedown, and after the other maneuvers I described, I carefully re-evaluated the middle nasal vault. There was some persisting deviation, and this was effectively treated with a left double layer spreader graft. The diagram below illustrates the concept that a unilateral spreader graft may be placed to address a twist of the middle vault.

It is important to emphasize that even though a classic cleft lip nasal deformity tends to be very similar from one to the other, the exact techniques that you use from patient to patient will surely differ in degree, and also the overall choice of techniques may differ due to a variety of factors, such as the severity of the deformity.

So to summarize, I think that the cleft lip nasal deformity is complicated - it includes all parts of the nose, upper, middle and lower thirds – but it is something that occurs in a repetitive way, it is sort of predictable, and so for a lecture like this on the severe or complex twisted nose, I feel this is a great starting point.

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Ask Dr. Becker a question about revision rhinoplasty or make an appointment for a consultation, by calling 856-589-NOSE (6673) or emailing us at info@revisionrhinoplasty.com.