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Repair of Soft Palate Cleft and Submucous Cleft Palate
135
6. A moist throat pack is placed under the Dingman
tongue blade. An additional towel can be placed
under the Dingman blade handle to further tilt the
head and improve operative field visibility.
7. Observe the full extent of the soft palate cleft (Fig-
ure 11–5) and infiltrate the soft tissues with local
anesthetic solution containing epinephrine. Wait at
least 7 to 10 minutes for maximal hemostatic effect.
Good visibility of the operative field is paramount
in successfully completing the technical aspects of
palatal surgery. Diligent attention to items 1 to 7
will enhance the chances of accomplishing this feat.
8. Sound the palate with a needle to establish where
the bony palate ends prior to marking your inci-
sions. Incisions are then marked with a marking
pen. This will prove most important as the cutting
of incision lines becomes technically challenging,
and the markings assist in continued orientation of
the blade. An angled blade handle improves access
to the difficult anterior aspects of the cuts. The loca-
tion of the hamulus is marked first (Figure 11–6),
followed by the marking of the medial and lateral
aspects of the flaps (Figure 11–7). The medial inci-
sion lines will cross in a “V” shape over the bony
margin of the hard palate (Figure 11–8). This allows
for improved manual control of the medial aspects
of the flaps during the dissection phase.
9. Make the medial incisions (split thickness) first by
splitting the mucosa into two layers with oral and
nasal sides. This will be done from the uvula ante-
riorly to the midline of the cleft. This is repeated on
the contralateral side. Use sharp scissors to facili-
tate the splitting of the mucosa into the two layers.
Figure 11–6.  Location of the hamulus is marked first.
Figure 11–7.  Medial and lateral aspects of the flaps are marked.
Figure 11–8.  Medial incision lines cross in “V” shape over the
bony margin of the hard palate.
Figure 11–5.  Soft palate cleft extending partially into hard
palate.

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Video Atlas of Cleft Lip and Palate Surgery
Careful, sharp dissection is needed to adequately
mobilize the nasal layer for tension-free closure
in the midline (Figure 11–9). Close the nasal layer
first with 5-0 Vicryl™ sutures in a tight, interrupted
fashion (Figures 11–10 and 11–11). Be sure not to
detach the nasal mucosa from the posterior edge
of the hard palate. If this unfortunate circumstance
occurs, utilize a sharp awl to create a small hole in
the posterior palatal bone. Place sutures through
this hole and the nasal mucosa to reattach it to the
hard palate.
10. Excise any gelatinous mucosa from the distal tip of
the uvula that would present problems holding a
suture.
11. The lateral incision begins with a small releasing
incision behind the maxillary tuberosity. This con-
tinues anteriorly as needed staying close to the
palatal gingival margin of the teeth. It is usually
carried anteriorly to the premolar or canine region.
Use a #15 blade with the incision down to bone.
12. A periosteal elevator is used to help identify the
position of the hamulus. This is an important step;
isolating and uncovering the hamulus is critical
to mobilization of the oral mucosal flaps. More
importantly, the location of the hamulus will serve
as a stop point for lateral dissection of the soft tis-
sues. No dissection lateral to the hamulus will
ever be necessary in the repair of the cleft palate
deformity. Freeing of muscle off the hamulus and
around the neurovascular bundle will achieve all
the necessary mobility of the flap. Dissection into
the tissues lateral to the hamulus will only result
in excessive bleeding and will not provide any
measure of increased mobility of the flaps. This is
a most important point and should not be taken
lightly. Lay the periosteal elevator against the pala-
tal aspect of the teeth with the point directed at the
uvula. Mark this spot with an X. You may also be
able to palpate the hamulus.
13. Raise a full thickness flap off the tuberosity using
two periosteal elevators for control and visibility.
Figure 11–10.  Nasal layer closed first with 5-0 Vicryl™ sutures
in a tight, interrupted fashion.
Figure 11–11.  Diagram of nasal layer closure.
Figure 11–9.  Careful, sharp dissection to adequately mobilize
nasal layer for tension-free closure in the midline.

Repair of Soft Palate Cleft and Submucous Cleft Palate
137
Sweep medially and posteriorly toward the previ-
ously marked hamulus point. Carefully cut any
firmly attached tissue with a #15 blade. Sweep the
tissue off the posterior maxilla before you dissect
out the hamulus. Carefully use the two periosteal
elevators to identify and isolate the hamulus. You
will see the white fascia layer covering the hamu-
lus (Figure 11–12). With the hamulus isolated, use
a #11 blade to incise up the neck of the hamulus
and across the tip in a t-shaped fashion. Sweep
up the hamulus to release all muscle and fascia
attachments; avoid fracturing the hamulus if pos-
sible. Fracturing the hamulus can negatively affect
maxillary growth. Sweep tissues from the posterior
maxilla toward the midline. You should begin to
see significant movement of the soft tissue toward
the midline. Do not dissect lateral to the hamulus,
as this will only cause unnecessary bleeding.
14. Gently elevate the flaps anteriorly to the full extent
of the lateral palatal incisions. This should continue
up to the canine/premolar region. At this point,
identify the greater palatine vessels and ensure the
attachment of the palatal mucosa anteriorly, inclu-
sive of the nasopalatine artery. A skin hook can
be helpful in elevating the mucosal flaps to better
visualize the neurovascular bundle (Figure 11–13).
15. Dissect out the levator veli palatini muscle horizon-
tally from the oral side of the flap. Gently grasp the
edge of the oral mucosa with a fine pickup and use
sharp scissors with small snips to begin the devel-
opment of the muscle layer. Stay just below the
oral mucosa and do not cut into the larger bundle
of muscle. Once the muscle has been freed from
the underside of the mucosa, continue to free it
circumferentially from around the neurovascular
bundle and off the posterior aspect of the hard pal-
ate. These steps will also facilitate mobility of the
oral mucosal flaps.
16. Carefully dissect the anterior most section of the
muscle from the previously closed nasal mucosal
layer. This should facilitate the redirection of the
muscle from a vertical to a horizontal orientation
within the newly reconstructed soft palate. The
muscle bundle should move passively toward the
midline. It can be sutured primarily with 4-0 or
5-0 PDS™ sutures in an interrupted fashion (Fig-
ures 11–14 and 11–15). This muscular reorientation
is referred to as an intravelar veloplasty.
17. Finally, the oral mucosal layer is developed for
closure in the midline. To gain mobility of the oral
mucosal flaps, dissect the flaps off the hard palate
using a curved Freer or other periosteal elevator.
Slowly elevate the flaps from one lateral incision to
the opposite side. The flaps should be completely
undermined from one side to the other. The flap
should remain attached anteriorly but be suffi-
ciently mobilized to approximate in the midline
without tension. Closure of the oral layer should be
accomplished with 4-0 Vicryl™ sutures in an inter-
rupted fashion (Figure 11–16).
Figure 11–12.  Two periosteal elevators used to identify and
isolate the hamulus.
Figure 11–13.  Identify greater palatine vessels and ensure
attachment of the palatal mucosa anteriorly, inclusive of the
nasopalatine artery.

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Video Atlas of Cleft Lip and Palate Surgery
18. During the entire surgical procedure, frequently
apply pressure to the sites for improved hemo-
stasis. At the end of the case, any continued ooz-
ing should be easily managed with pressure and
placement of small amounts of Avitene™ into the
wounds.
19. Finally, suction the oropharynx and remove the
throat pack. Place the patient in a reverse Tren-
delenburg position with the head up and remove
the shoulder/neck rolls. Keep continued pres-
sure against the palate with moist gauze until the
patient is ready for extubation.
Figure 11–14.  Diagram showing anterior region where oral flap must be raised
and intravelar veloplasty posteriorly.
Figure 11–15.  Intravelar veloplasty is performed by reorient-
ing the levator veli palatini muscle from an anterior to a medial
direction.
Figure 11–16.  Closure of oral layer accomplished with 4-0
Vicryl™ sutures in an interrupted fashion.

Repair of Soft Palate Cleft and Submucous Cleft Palate
139
Repair of Submucous Cleft Palate
Von Langenbeck Technique
At the commencement of the surgical procedure, it will
be necessary to create or convert this deformity into a
soft palate cleft.
This would be done as follows:
1. Once the Dingman retractor has been placed and
local anesthesia administered, it will be necessary
to sound the hard palate and mark the flaps. The
first incision line will transect the zona pellucida
in the midline of the soft palate up to the posterior
edge of the hard palate (Figure 11–17). This move
will essentially convert the submucous cleft into an
overt soft palate cleft, which can then be treated
with the Von Langenbeck or Furlow techniques as
described herein.
Furlow Palatoplasty (Video of Repair of Soft Palate
Cleft with Furlow Technique)
Both an overt soft palate cleft and submucous cleft pal-
ate may be repaired using this technique. Please refer
to Chapter 22 for detailed surgical steps.
1. Flaps (double Z-plasties) are marked with a mark-
ing pen (Figure 11–18).
2. Oral mucosa only flap is elevated from one side
(Figure 11–19).
3. Muscle–oral mucosa flap elevated from contralat-
eral side (Figure 11–20).
Figure 11–17.  Diagram showing incision line transecting the zona pellucida in midline of soft palate up
to posterior edge of hard palate.
Figure 11–18.  Flaps (double Z-plasties) are marked with a
marking pen.

140
Video Atlas of Cleft Lip and Palate Surgery
4. Nasal mucosa flap elevated under previously raised
muscle-oral mucosa flap.
5. Nasal side muscle–mucosa flap elevated under
previously raised oral mucosal flap.
6. Liberal mobilization of all flaps accomplished with
adequate freeing of tissue around the hamulus
and neurovascular bundle as needed. Small lateral
releasing incisions near the tuberosities can be uti-
lized for this purpose.
7. Flaps repositioned and sutured primarily with 4-0
or 5-0 Vicryl™ sutures (Figure 11–21).
Postoperative Considerations
• Airway observation in the immediate
postoperative period is important.
Swelling within the first 24 to 48 hours
could be significant, and close monitoring is
required.
• Bleeding can persist in the recovery room,
and the patient should not be discharged to a
hospital bed until all sites are dry.
• Encourage clear to full liquids for the first
2 weeks.
• Patients with teeth should be instructed in
good oral hygiene techniques.
• Steroids, antibiotics, and analgesics are
prescribed for the first 5 to 10 days.
• Close follow-up is required to assess for
vitality of all flaps and possible breakdown at
surgical sites.
• Younger patients may require arm restraints
to prevent trauma to repair.
• No straws or sippy cups for 2 weeks after
surgery.
Figure 11–19.  Oral mucosa only flap is elevated from one side.
Figure 11–20.  Muscle-oral mucosa flap elevated from con-
tralateral side.
Figure 11–21.  Flaps repositioned and sutured primarily with
4-0 or 5-0 Vicryl™ sutures.

Repair of Soft Palate Cleft and Submucous Cleft Palate
141
Complications
• A major complication can be the severance
of the greater palatine artery. This is the
major blood supply to the oral mucosal flap.
Disruption thereof of the blood supply to this
flap will result in necrosis of the flap. The flap
would then be lost with scarring and fistula
formation. Secondary repair is then rendered
more difficult.
• Postoperative bleeding may occur, which
would require return to the OR for control
of the field and investigation of the surgical
sites. Taking down flaps with appropriate
local measures to control bleeding would be
indicated. Deep sutures, cautery, or various
hemostatic agents may need to be employed.
• Inability to achieve complete tension-
free closure of all flaps. This is most
frequently seen at the junction of the hard
and soft palate. This is the greatest area
of tension resulting from the restricted
anatomy encountered at the hamulus and
neurovascular bundle. Full understanding of
the anatomy and the need for mobilization
at these sites will allow for physiologic
closure (note important details outlined in the
foregoing sections)
• Persistent velopharyngeal insufficiency.
Revision surgery may be indicated, perhaps
with a superior pharyngeal flap or sphincter
pharyngoplasty (see Section VIII).
Pearls and Pitfalls
• Good preoperative planning and assessment
of the defect.
• Proper professional staffing and equipment in
place.
• Correct positioning of patient on the OR table
and adequate securing of the endotracheal
tube.
• Proper instrumentation and adequate
experience of the operating surgeon.
Specialized instruments can greatly assist the
surgeon with the surgical challenges. Surgery
of the cleft palate is conceptually easy but
technically difficult. An experienced surgeon
understands this problem and creates an
operating kit that is designed to minimize the
surgical/technical challenges.
• Sequence surgical procedures to avoid
attempting too much at any one time.
• Never dissect lateral to the hamulus. There
is no reason to manipulate in this area, as
mobility of the flaps will not be improved by
dissection in this area. Concentrate on freeing
muscle off the hamulus and skeletonizing the
neurovascular bundle. Avoid manipulation
in the area lateral to the hamulus. These
diligences will significantly and substantially
reduce bleeding.
• Colorado needle tip electrocautery helps with
hemostasis. However, care should be taken
not to shrink the oral and nasal mucosal flaps
(as noted in the foregoing). The mucosal flaps
are elevated more carefully with Potts scissors
or a 6900 Beaver® blade.
• Leaving the delicate mucosal flaps slightly
thick prevents tearing.
• It is not necessary to completely
reapproximate the oral mucosa during flap
inset. Significant tension on the flaps risks
dehiscence or fistula.
References
1. Gosain AK, Conley SF, Marks S, Larson D. Submucous
cleft palate: diagnostic methods and outcomes of surgical
treatment. Plast Reconstr Surg. 1996;97:1497–1509.
2. Moss ALH, Piggott RW, Jones KJ. Submucous cleft palate.
Br Med J. 1988;297:85–86.
3. Stal S, Klebuc M, Taylor TD. Algorithms for the treatment
of cleft lip and palate. Clin Plast Surg. 1998;25(4):493–507.
4. Sommerlad BC, Fenn C, Harland K, Sell D, Birch MJ,
Dave R. Submucous cleft palate: a grading system and
review of 40 consecutive submucous cleft palate repairs.
Cleft Palate Craniofac J. 2004;41(2):114–123.
5. Cho BC, Kim JY, Yang JD, Lee DG, Chung HY, Park JW.
Influence of the Furlow palatoplasty for patients with
submucous cleft palate on facial growth. J Craniofac Surg.
2004;15(4):547–554.
6. Shprintzen RJ, Siegel-Sadewitz VL, Amato J, Goldberg
RB, Opitz JM. Anomalies associated with cleft lip, cleft
palate, or both. Am J Med Genet. 1985;20:585–595.
7. Lipson AH, Yuille D, Thompson PG, Vandervoord JG,
Beckenham EJ. Velocardiofacial (Shprintzen) syndrome:
an important syndrome for the dysmorphologist to rec-
ognize. J Med Genet. 1991;28:596–604.

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Video Atlas of Cleft Lip and Palate Surgery
8. Rottgers SA, Ford M, Cray J, Smith D, Kinsella C,
Grunwaldt L. An algorithm for application of furlow
palatoplasty to the treatment of velocardiofacial syn-
drome-associated velopharyngeal insufficiency. Ann
Plast Surg. 2011;66:479–484.
9. Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of
secondary velopharyngeal insufficiency in cleft palate
patients with the Furlow palatoplasty. Plast Reconstr Surg.
1994;94(7):933–941.
10. Perkins JA, Lewis CL, Gruss JS, Eblen LE, Sie KC. Furlow
palatoplasty for management of velopharyngeal insuffi-
ciency: a prospective study of 148 consecutive patients.
Plast Reconstr Surg. 2005;116(1):72–80.

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Chapter 12
Repair of Nasoalveolar Clefts
Lawrence T. Herman, Sara H. Runnels, Kyle J. Chambers, and Steven M. Roser
Abstract
A cleft of the maxillary alveolus is present in patients with
unilateral and bilateral complete cleft lip and palate deformity
and cleft lip and primary palate deformities. The alveolar cleft
deformity can result in both functional and aesthetic defects,
including reflux into the nose from the oral cavity, failure of
the permanent dentition to erupt properly, hypernasal speech,
lip and nasal base deformities, and loss of teeth adjacent to the
cleft as an adult. Repair of the alveolar cleft requires presurgi-
cal planning with regard to: timing of the surgery, adjunc-
tive orthodontic treatment, previous surgical procedures, the
source of the bone grafting material used, and the soft tissue
flaps required for the nasal and oral layer closures.
An alveolar cleft is part of the “highway” of clefting
that can occur from the nose, with extension posteri-
orly to the soft palate. It can consist of a bony and soft
tissue defect of the anterior maxilla (either unilateral or
bilateral), which extends superiorly to the piriform rim
and into the floor of the nose (Figures 12–1 and 12–2).
It is most commonly associated with a cleft lip and/or
palate and rarely, if ever, seen as an isolated defect. The
defect, embryologically, is due to a failure of fusion of
the anterior primary and secondary palates between 6
and 8 weeks in utero. The resultant defect is narrowest
at the alveolus and widens superiorly toward the floor
of the nose.
Goals of Alveolar Cleft Repair1–8
1. Stabilize and prevent collapse of the maxillary seg-
ments (and premaxilla if bilateral).
2. Provide bony support for the teeth adjacent to the
cleft and healthy periodontium with keratinized
gingiva surrounding these teeth.
3. Provide bony support to tissues of the lip and nose.
By reconstructing the alveolus up to the piriform
rim and nasal floor, this results in more aesthetic
soft tissue projection of the tissues of the alar base,
lip, and nose.
4. Allow for eruption of the permanent lateral incisor
and/or canine teeth into the cleft with good bony
support.
5. Allow bony support for an endosseous dental
implant.
6. Close residual oronasal fistulae of the palate and
vestibule; these often create problems with speech,
hygiene, and nasal/sinus reflux.
Figure 12–1.  Unilateral nasoalveolar cleft.

144
Video Atlas of Cleft Lip and Palate Surgery
7. Establish a functional nasal airway.
8. Limit buccal vestibular shortening and minimize
scarring.
Timing
When to repair the alveolar cleft is a much-debated
topic. It should be understood that in planning a repair,
one needs to balance the need for repair against the risk
of adversely affecting maxillary growth. Studies sug-
gest that as much of the permanent dentition should
be preserved as possible; the timing of repair should be
dictated by the amount of growth of the roots of teeth
adjacent to the cleft. Erupting teeth will stimulate bone
growth within the grafted tissue of the cleft.
The Three Categories of
Alveolar Cleft Grafting
1. Primary Repair
• Alveolar cleft repair at the same time as lip or
soft palate closure.
• Before 2 years of age.
• Can have a significant effect on growth
leading to alveolar restriction and dental
crossbite. This is due to the fact that the
maxilla does not complete growth in a
transverse and sagittal plane until 9 or 10
years of age.
• Less cancellous bone is available for grafting
at this young age.
2. Early Secondary Repair
• Alveolar cleft repair done after the eruption
of the permanent central incisor tooth and
following the growth of one-half to two-thirds
of the root of the lateral incisor. This is usually
seen between ages 6 to 7 years.
• The lateral incisor must be of normal
morphology.
3. Late Secondary Repair
• Grafting done during the mixed dentition
stage following one half to two thirds
development of the root of the permanent
canine tooth (ages 9 to 11 years).
• Favored approach by many institutions.
Maxillary growth is usually 80% complete
by 8 years of age; therefore, there is less of a
deleterious effect on facial growth. Patients at
this age are frequently more compliant with
orthodontic and perioperative care.
Surgical Indications
After a thorough history, physical exam, and review of
radiographs (panoramic, occlusal, periapical), consider
the following questions when formulating a surgical
treatment plan:
a. Does a residual fistula (secondary to prior palatal
surgery) exist and if so, what is the extent of the
defect? Frequently, the alveolar cleft (with exten-
sion into the palate) is very large and will therefore
require adequate soft tissue for closure. Consider
the tongue or island flap as sources of soft tissue for
closure of large oral side defects.
b. Is there arch collapse? If so, the patient may need an
orthodontic evaluation.
Figure 12–2.  Bilateral nasoalveolar cleft.

Repair of Nasoalveolar Clefts
145
c. What is the condition of the teeth in or adjacent to
the cleft? In a young patient, the root development
of the permanent lateral incisor or canine will help
guide your timing for surgery.
d. Are there supernumerary teeth present? They may
compromise your ability to close the soft tissue ade-
quately; they should be removed at least 8 weeks
prior to bone grafting. This will allow for soft tissue
healing and an improved soft tissue base prior to
definitive alveolar cleft repair.
e. What volume of bone will be required to fill the
defect? Keep in mind that the underlying bony
defect is usually much larger than the apparent soft
tissue defect. A cone-beam CT scan or stereolithic
model may provide additional information.
f. Bilateral alveolar clefts (Figure 12–3):
Must achieve nasal side closure bilaterally (Figure 12–4);
however:
• Consider staging the procedure (especially in
developing countries) by closing one side at a
time. If closing bilaterally, be sure to achieve
complete oral closure as well (Figure 12–5).
• Careful dissection of the premaxillary tissues
must be undertaken to prevent compromise
of the blood supply to the premaxilla.
• Is there traumatic occlusion against the
premaxilla? If so, consider fabricating a bite
plate. This will open the bite, preventing
occlusal forces and consequent movement of
the premaxilla. Such protection will greatly
assist graft healing and bone consolidation.
g. With medical missions in developing countries, one
must consider the following:
• Consider the reason for bone grafting. Is
the patient in active orthodontics or is this
treatment ever going to be a possibility? Will
a dental implant ever be possible?
• Is there dental and orthodontic support
available?
• Is the patient having issues related to speech,
hygiene, or reflux with regard to the alveolar
cleft and any residual fistulae?
• Is a dental prosthesis currently being worn?
In many cases, it may be better to close the alveolar
cleft and residual fistulae in two soft tissue layers with-
out a bone graft (Figures 12–6). The patient will then
be able to wear a removable prosthesis and thereby
Figure 12–3.  Photo of bilateral nasoalveolar cleft.
Figure 12–4.  Nasal side closure achieved bilaterally.
Figure 12–5.  Complete oral closure achieved bilaterally.

146
A
C
B
D
Figure 12–6.  Alveolar cleft and residual fistulae closed in two soft tissue layers without a bone graft.
E
F

Repair of Nasoalveolar Clefts
147
improve his or her quality of life. This is especially true
if no orthodontics or implants are planned or possible
in the future.
Graft Options
By far, the most predictable form of grafting is with
autogenous, cancellous bone. The choice of donor site
should be based on the volume of bone required to fill
the recipient defect. This will always be seen as larger
than the soft tissue defect.
Options
a. Ilium (most preferred site with greatest volume of
cancellous bone)
b. Proximal tibia (see Chapter 14 video on Tibial Bone
Graft)
c. Calvarium
d. Intraoral site (chin, ramus, or tuberosity)
e. Rib (if early primary grafting is necessary)
Allogeneic or xenografts are far less predictable as no
viable cells are transferred to the recipient site. With
these options, the process of graft revascularization
takes much longer. Bone morphogenic proteins (BMP)
and other growth factors are currently being evaluated
experimentally. At present, these latter options are very
expensive.
Adjunctive Orthodontics
There are advantages and disadvantages to beginning
orthodontic care prior to alveolar cleft grafting versus
commencing orthodontic care following completion of
grafting.
Presurgical (Pregrafting) Orthodontic
Care Considerations
• Allows the alveolar segments to move more
easily (and open the cleft) due to less bony
resistance.
• Creates much easier access for subsequent
surgical closure of the alveolar cleft (Figures
12–7 and 12–8).
• Allows for improved perioperative hygiene
because of ease of access to the cleft.
Figure 12–7.  Adjunctive orthodontics create much easier
access for subsequent surgical closure of the alveolar cleft.
Figure 12–8.  Film of adjunctive orthodontics in place.

148
Video Atlas of Cleft Lip and Palate Surgery
• Allows less chance of creating a fistula
postoperatively because of good visualization
of the anatomy of the cleft.
• Can eliminate traumatic occlusion in bilateral
cases.
• Improves arch form.
• Needs more bone and soft tissue because the
defect is larger.
• Try to avoid movement of pericleft teeth into
the defect as this may compromise their bone
support long term. The bone graft will only
“adhere” to bone and not the cementum of
the tooth roots.
Postsurgical (Postgrafting) Orthodontic
Considerations
• Improved bony consolidation because the
graft is subject to dynamic, distractive forces
that can help the graft mature.
Surgical Equipment and Tools
• Dingman retractor and three blades
• Leibinger side retractor and two blades
• Towel clips
• Jeter needle holder (Lorenz)
• Jeter dissectors (Lorenz)
• Long straight needle holder with fine tip
• Short snaps (one straight and one curved)
• Long snaps (one straight and one curved)
• McKesson type suction tip (4-mm tip × 7")
• Frazier tip suction (#10)
• Small double skin hook
• Small single skin hook
• Senn retractor (blunt, three prongs)
• Small retractor (Ace)
• Minnesota retractor
• Dental aspirating syringe
• Periosteal elevators
• Curved Freer elevator
• Small awl (Ace)
• Small curved Allis
• Dental mirror
• Long pickups (one with teeth, one without)
• Short Adson pickups (one with teeth, one
without)
• College pliers (curved)
• Semken tissue forcep
• #7 knife handle
• #5 round style handle with angle
• #12 Locklin scissor (16 cm)
• Iris scissor (delicate tip, curved)
• Reynold’s curved scissor
• Curved Metzenbaum scissor 14.5 cm
• 16-cm curved Kelly scissor
• Bandage scissor
• Small bite blocks (small adult and child)
• Bone file
• Pediatric extraction forcep
• Small rongeur
• Large rongeur
• Small mallet
• Set of seven small osteotomes
• Dental extraction elevator
• Olsen–Heger needle holder
• 12.5-cm Ryder vascular needle holder
• 15.5-cm Ryder vascular needle holder
• Curved probe with eye
• Joseph nasal scissors, curved
• Fine caliper (0 to 40 mm)
• Bishop–Harmon tissue forcep
Anesthesia
• An oral Rae® tube facilitates good access to
the nose and alveolar cleft itself. At times, a
nasal intubation may be considered in the
noncleft naris.
• The patient is placed in Trendelenburg
position with a shoulder or neck roll utilized
to hyperextend the head for enhanced
visualization of the defect.
Surgical Procedure
(Video of Repair of Nasoalveolar Cleft)
Key Steps
1. Closure of the nasal mucosa in a watertight fashion
with the development of a bed for the bone graft.
2. Placement of autogenous, cancellous bone graft
(Figure 12–9).
3. Closure of the oral mucosa over the graft with a
well-vascularized, tension-free flap (Figure 12–10).

Repair of Nasoalveolar Clefts
149
Procedure
1. The patient is prepped and draped simultaneously
for the intraoral and extraoral procedures. Separate
sterile fields are created for the donor and recipi-
ent sites (ie, anterior ilium and mouth). Two surgi-
cal teams work simultaneously, one to harvest the
graft and the other to prepare the recipient site.
2. The cleft surgeon positions himself or herself at the
head of the OR table and usually wears a headlight.
3. A Dingman retractor or Leibinger side retractor can
be utilized for visualization of the alveolar cleft.
4. Local anesthesia is administered containing 1:100,000
epinephrine into the buccal vestibular tissues, the
floor-of-the nose, and into the palatal tissues adja-
cent to the cleft and fistula (if present). Wait at least
7 to 10 minutes to allow for maximal vasoconstric-
tor effect.
5. Place a small gauze throat pack for airway protection.
6. While waiting for the local anesthesia, “sound” the
cleft margins with a needle and place a probe, peri-
osteal, or Freer elevator into the cleft to help deter-
mine the extent of the cleft. This will be of great
importance when designing the flaps, especially
the oral layer.
7. In developing countries (where orthodontic care
is not an option and therefore the cleft will not be
expanded or opened up prior to surgery), it is help-
ful to remove any inflamed, gelatinous, or redun-
dant soft tissue at the margins of the cleft. This is
done surgically with a #11 and/or #15 blade. This
helps visualize the entire extent of the cleft. If you
cannot visualize the full extent of the defect, you
cannot get proper two-layer closure.
8. Remove any carious, malpositioned, or supernu-
merary teeth (or tooth fragments within the cleft),
which may interfere with clean two-layer closure.
Without a tension-free watertight closure, the site is
likely to breakdown. The resultant fistula will pres-
ent greater difficulty in repair.
9. In developed countries, malformed teeth and
supernumerary teeth should be removed at least
8 weeks prior to surgery to ensure full soft tissue
healing prior to cleft repair.
Closure of Nasal Layer and
Preparation of Bed for Bone Graft
10. Mark the edges/margins of the alveolar cleft with
a marking pen. Pay close attention to the edge of
the cleft and examine to ensure you leave enough
Figure 12–9.  Placement of autogenous, cancellous bone graft.
Figure 12–10.  Closure of the oral mucosa over the graft with
a well-vascularized, tension-free flap.

150
Video Atlas of Cleft Lip and Palate Surgery
of a margin of soft tissue to roll together and suture
without tension. This will be the tissue and flaps
that form the nasal layer.
11. Once the incision is marked, use a #11 or #15 blade
(an angled blade handle is helpful) to cut the tis-
sue (Figure 12–11). The flap will be full thickness
within the alveolus and down to bone. As the cuts
move posteriorly into the previously repaired cleft
palate, a split thickness technique will be necessary
(as no bone exists within this region).
12. Care must be exercised at the palatal (distal)
limits of the surgical site as mobilization of flaps
and suturing are particularly challenging in these
areas.
13. The buccal portion of the incision should remain
superficial. Once the incision is made, the layers
can be developed with the use of fine cutting scis-
sors. The tissue in this area is more mobile; there-
fore, less dissection/undermining is needed to
approximate the margins.
14. The incisions should cover the entire extent and
anatomy of the alveolar cleft in a circumferential
manner. Any failure to accomplish this goal will
ultimately result in residual fistulae.
15. Carefully begin to roll/reflect the tissues toward
the medial portion of the alveolar cleft using a peri-
osteal or other elevator (Jeter or Woodson). Work
posterior to anterior (palatal to buccal) assuring
you have sufficient tissue to close the nasal muco-
sal layer without tension. If the tissues on one side
of the cleft are thin or deficient, you can roll the
thicker side toward the weaker side. This will often
A
B
C
D
Figure 12–11.  Closure of nasal layer and preparation of bed for bone graft.

Repair of Nasoalveolar Clefts
151
allow for compensation for friable or less than ideal
tissue on one side of the cleft. The key is establish-
ing full closure along the entire length of the cleft,
securing thereby separation of the nasal cavity
from the alveolar cleft.
16. Dissection must be carried up to the height of the
piriform rim and floor of nose for the best aesthetic
and functional results.
17. Excess tissue at the margins of the flaps may be
carefully trimmed using fine scissors. This allows
for clean, neat margins that facilitate surgical
approximation.
18. At this point the entire alveolar cleft must be well
visualized and the edges easily and passively
brought together in the midline of the defect. It is
now possible to proceed with tension-free closure
of the nasal layer. Begin closure at the palatal-most
aspect of the defect, working toward the buccal.
5-0 Vicryl™ suture on a P-2, P-3, or fishhook-type
needle works best. Sutures may be mattresses or
interrupted. The goal is to create a watertight nasal
mucosal layer at this step, prior to placement of a
bone graft. One can check this by instilling saline
with or without methylene blue into the nares on
the same side as the defect. You should not see a
leak at this point.
Bone Graft Placement into the Alveolar Defect
19. Examine the alveolar defect at this point. It should
be possible to visualize the entire defect up into the
floor of the nose once the nasal mucosal layer has
been closed and elevated superiorly.
20. Generally, a minimum of 3 to 6 mL of cancellous bone
is required for grafting into a unilateral alveolar cleft.
21. Once the bone has been harvested (see previous
section on graft site options), the cancellous bone
can be placed into a sterile 10-mL syringe and con-
densed using the syringe’s plunger or other instru-
ment. Condensing the graft within the syringe
increases cell density and thereby aids in the initial
phase of bony healing.
22. The tip of the syringe can be cut off and the con-
densed bone syringed carefully into the alveolar
defect, packing with pressure up into the floor of
the nose, piriform rim, and into the alveolar crest
area. Overpack this area slightly to allow for post-
surgical resorption and remodeling (Figure 12–12).
Covering the bone graft prior to oral layer closure
with a resorbable collagen membrane is sometimes
helpful to contain the particulate bone. It is not nec-
essary to pack the palatal area of the defect with
much bone. This is an area where bone will typi-
cally exfoliate postoperatively. Of note, if cortical
bone has also been obtained when the bone graft
is procured, you may also consider placing strips
of cortical bone into the floor-of-nose and piriform
rim area (with the cortical side against the nasal
mucosal layer) to help reconstruct these areas. The
cortical struts may be secured using small bone
graft screws prior to condensing the cancellous
graft into the alveolar defect.
A
B
Figure 12–12.  Bone graft placement into the alveolar defect.

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Video Atlas of Cleft Lip and Palate Surgery
Closure of the Oral Mucosal Layer with
Well-Vascularized Tension-Free Flaps
• Oral mucosal coverage of the bone graft
with well-vascularized flaps is paramount to
surgical success (Figure 12–13).
• Oral mucosal closure may be most easily
understood as being comprised of two
components:

(1)  The palatal component

(2)  The buccal component
• The goals are to establish keratinized tissue
over the alveolus where the permanent lateral
and canine teeth will eventually erupt and
to preserve the periodontium surrounding
the supporting teeth. It is also important to
minimize vestibular shortening and scarring.
Once developed, all mucoperiosteal flaps
should be sutured with either mattress or
interrupted sutures. Frequently, 4-0 or 5-0
Vicryl™ are used for this purpose. It is also
very important to emphasize the need to
deepithelialize any palatal mucosa upon
which the oral layer flaps will lie. This can
be achieved with the use of a #11 or #15
blade. The idea is to create a deepithelialized,
bleeding base upon which the oral layer
flaps will be resting. All oral layer flaps
will partially lie upon some of the palatal
mucosa. It is important for good healing and
adaptation of these flaps that they lay on
nonepithelialized tissue. Therefore, under
direct visualization it is important to assess
the bed upon which these flaps will lie and
to deepithelialize all palatal mucosa in these
areas. It is important to close as much of the
palatal extension of the cleft as possible prior
to creating the buccal flaps.
Closure of the Palatal Component of the
Oral Mucosal Layer
• Examine the palatal tissues carefully for
scarring and assess the full extent of the
palatal extension of the clefting defect. This
will aid your decision concerning the amount
of tissue necessary for closure of the full cleft
and the best location for harvesting of this
soft tissue.
• Look to sources of oral layer closure from
tissue available upon the palatal shelves. This
tissue, if available, will be keratinized and
prevent the need for excessively long buccal
finger and rotational type flaps. The buccal
flaps will be nonkeratinized and less than
ideal for coverage of the alveolar ridge. The
length of the buccal flaps also needs to be
addressed as violation of 1:3 base to length
ratio can result in necrosis at the tip of such
longer buccal flaps. Therefore, rotational flaps
off the palatal shelves or island flaps pedicled
of the greater palatine artery are both good
options for coverage of large alveolar clefts
that extend deep into the hard palate. These
palatal flaps, if available, will still need to be
utilized in conjunction with approximation
to smaller buccal rotational or advancement
flaps.
• For very large and anatomically difficult
palatal fistulae, oral side closure may often
only be possible with pedicled flaps from the
tongue or buccal fat pad.
Use of Lateral Palatal Flaps
• The flaps adjacent to the defect are advanced
medially (technically difficult due to scarring)
over the palatal aspect of the defect and then
sutured (Figure 12–14).
• Palatal tissues are generally more bound
down due to past surgical repair of the hard
palate. Mobility therefore may often be
gained only via delicate separation with sharp
scissors from the now closed nasal layer.
Figure 12–13.  Closure of the oral mucosal layer with well-
vascularized tension-free flaps.

Repair of Nasoalveolar Clefts
153
• Once separation from the nasal layer is
achieved (in the region of the palatal cleft),
the tissue is elevated subperiosteally from
adjacent areas where palatal bone exists. This
is achieved most efficiently with the use of a
periosteal elevator. This may be done on only
one side or both sides of the palatal defect
dependent upon the amount of tissue available
and the degree of mobility required to cover
the palatal extension of the alveolar cleft.
• When developing flaps and assessing
mobility of said flaps, lateral releasing or
posterior releasing incisions may be helpful.
These releasing incisions can be made full
thickness over the palatal bone and carefully
developed using a periosteal elevator in a
subperiosteal plane. Blood supply, however,
to any such flap must be carefully evaluated
and all efforts made to prevent necrosis.
Judicious planning of flap design prior to
incision will eliminate failure of poorly
designed oral mucosal flaps.
• The lateral releasing incision is made full
thickness over bone and close to the necks of
adjacent teeth. This is done to maximize the
breath of the flap. Often, the amount of tissue
available is limited, and therefore maximizing
the width of the flap is very important.
• Lateral releasing incisions will allow for more
medial rotation of the flap but will not aid
in anterior movement. In fact, these types of
palatal flaps will have a tendency to move
slightly posterior when rotated medially
over the alveolus. This must therefore be
accounted for when planning the design of
such a flap. As these palatal rotational flaps
move medially and posteriorly, there will be
less of the clefting defect covered anteriorly.
This will require the buccal flap to cover more
of the defect.
• Lateral releasing incisions may be extended as
far posteriorly as necessary and frequently as
far back as the tuberosity.
• Care must be taken when extending any of
these flaps posteriorly to avoid damage to the
greater palatine artery. This artery will be the
major arterial blood supply to the palatal flaps.
• A small posterior triangular releasing
incision may allow for some minimal anterior
movement of the flap as well as facilitating
medial movement (Figure 12–15).
• The defects (over bone) created by medial
movement of palatal tissue will be left to
granulate in the postoperative period. It is not
necessary to pack these defects with Surgicel®
or other hemostatic agents unless excessive
bleeding ensues.
Use of Palatal Island Flaps
• In the event that more palatal tissue is
required for oral layer closure (as is this case
with large fistulae), a palatal island flap can be
mobilized (Figure 12–16). This flap is basically
a continuation of the laterally released palatal
flap but is extended posteriorly and medially
into the midline of the palate to completely
mobilize the soft tissue on all sides of the flap.
The flap will thereby be pedicled solely off the
greater palatine artery.
• This flap is consequently dependent
upon the presence and health of an intact
greater palatine artery. This artery must be
adequately and thoroughly identified prior
to mobilization of this flap. If the artery is
not present, do not complete the cutting of
this flap as the flap will quickly devitalize
and become necrotic. The time to identify
the presence and assess the vitality of this
neurovascular bundle is at the moment of
making the lateral incision.
• At this time the flap can be elevated slightly
with a periosteal elevator, and a search via
this incision can be made for the presence
of the artery. If no viable artery is identified,
Figure 12–14.  Lateral palatal flap.

154
Video Atlas of Cleft Lip and Palate Surgery
then the island flap should not be completed.
Replace the flap into its bed and consider
other options.
• When creating the island flap, remember the
posteromedial and medial portions of the flap
are over areas where no bony palate exists. It
is necessary to dissect split thickness in these
areas. The tissue can be superficially incised
with a #15 blade and two layers developed
using sharp, curved scissors.
• More mobility of the flap can be achieved by
carefully “skeletonizing” circumferentially
around a well-visualized greater palatine
artery. Sharp scissors are most effectively
utilized for this purpose. With adequate
mobilization, the island flap may be advanced
anteriorly more than 10 mm. This movement
can be most effective in covering large
anterior alveolar clefts or large anterior
palatal fistulae.
A
B
Figure 12–15.  Lateral palatal flap with posterior triangular releasing incision.
A
B
Figure 12–16.  Palatal island flap.

Repair of Nasoalveolar Clefts
155
• The island flap should then be seated and
sutured as anteriorly as possible with 4-0 or
5-0 Vicryl™ sutures.
• Any posterior defect created can be left to
granulate. However, the laxity of tissue in the
soft palate may allow for closure of this defect
with 4-0 Vicryl™ sutures without compromise
of the now anteriorly advanced island flap.
Use of Anteriorly Based Tongue Flaps
• For extremely large palatal defects, an anteriorly
based tongue flap may be employed for closure
of the oral side. Further description of this flap
may be found in Chapter 16 regarding fistula
repair.
Closure of the Buccal Component of the
Oral Mucosal Layer
• Examine the size of the buccal extent of the
alveolar cleft to assist your decision-making
process with regard to the amount of tissue
necessary to cover the oral side of the defect.
This will allow planning for the size and type
of flap required.
• It is important to close as much of the palatal
extension of the cleft as possible prior to
creating the buccal flaps.
• All flaps need to be tension-free, have a good
blood supply, and ideally provide keratinized
tissue over the now grafted alveolus.
• Buccal flaps are not good sources of
keratinized tissue; therefore, they utilize as
much keratinized palatal tissue as possible for
oral closure of these defects.
• To gain freedom and mobility of buccal flaps,
the periosteum will need to be scored sharply
with a #15 blade.
• Once mobilized, the buccal flaps should be
sutured to the palatal flaps with 4-0 or 5-0
Vicryl™ sutures.
• Frequent dehiscence is often seen at the
incision line where palatal and buccal oral
mucosa oppose each other. Mattress type
sutures can provide strength in these areas.
• It is helpful to suture the tip of the buccal flap
to the palatal mucosa first to be certain that it
is tension-free.
Buccal Flap Options
1. Direct buccal advancement flap (Figure 12–17).
• Useful for small defects with limited palatal
extension.
A
B
Figure 12–17.  Buccal advancement flap.
C

156
Video Atlas of Cleft Lip and Palate Surgery
• Created with a broad base in lip (buccal)
mucosa. Leads to vestibular shortening and
tethering of the vermilion in this area.
• Does not provide keratinized tissue for tooth
eruption or implant placement. Secondary
soft tissue grafting may be necessary.
2. Buccal finger/rotational flap (Figure 12–18).
• Anteriorly based and elevated from the
buccal vestibule rotated up and over the
graft site.
• Length should not exceed three times the
width of the base to assure adequate blood
supply to the tip. This rule is often violated
with larger defects extending into the palate.
The longer the finger flap, the more likely
perfusion at the tip will be compromised as
well as venous return.
• Donor site in the vestibule is closed primarily,
but this may shorten the buccal vestibule.
• Does not provide keratinized tissue.
3. Lateral sliding flap (Figure 12–19).
• Broad-based, full-thickness flap extending
two or more teeth off the defect on both the
mesial and distal aspects. It will be parallel
horizontally to the gingival sulcus with a
posterior vertical release.
• Made a few millimeters away from the
sulcus to leave a cuff of keratinized tissue
and preserve the papillae around the
adjacent teeth.
• Flaps are elevated and advanced toward one
another to cover the bone graft.
• Vertical release is left to heal by secondary
intention.
• Provides keratinized tissue over the graft
and alveolus.
4. Modifications of the lateral sliding flap
• For wider clefts, modifications described
to further increase the mobility of the
buccal flap: Z-plasty can be made along
the posterior aspect of the incision line
(Figure 12–20).
• More oblique incision line can be made
(Figure 12–21).
• Cut back can be made (the Herman
modification/design) (Figure 12–22).
Special Considerations in Bilateral Cases
• In developing countries, consider closing one
side at a time. This will ensure better healing
of the treated side with a healthier base for
future closure of the other side.
• Be cautious in dissecting the palatal mucosa
from the premaxilla with special concern for
blood supply to this structure.
• Consider preoperative fabrication of
a bite plate to open the occlusion and
prevent traumatic occlusion against the
premaxilla. Any movement of the premaxilla
postoperatively greatly increases the risk of
graft failure.
Postoperative Considerations
• Oral antibiotics for 7 to 10 days.
• Meticulous oral hygiene is necessary.
Consider prescribing chlorhexidine gluconate
oral rinse bid.
• Clear liquid diet for postop week 1 advanced
to full liquids week 2. Sharp foods of any type
for the first few weeks should be discouraged
as these may traumatize the flaps.
• No palatal splint is necessary.
• No orthodontic manipulation or expansion
for 2 months while the graft is consolidating.
• Continue to wear orthodontic appliances for 2
to 3 months while the graft revascularizes, the
bone consolidates (Figure 12–23), and the soft
tissue heals.
Complications
• Graft loss/exfoliation.
• Recurrence of fistula.
• Wound dehiscence.
• Failure of canine to erupt, necessitating
surgical exposure.
• Need for additional onlay grafting prior to
dental implant placement.
Pearls and Pitfalls
• Good preoperative planning and assessment
of the defect.
• Proper professional staffing and equipment
in place.

157
A
B
Figure 12–18.  Buccal rotational/finger flap.
C
D
E
F

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Video Atlas of Cleft Lip and Palate Surgery
A
B
Figure 12–19.  Lateral sliding buccal flap.
Figure 12–20.  Z-plasty modification.
Figure 12–21.  Oblique incision line.
Figure 12–22.  Herman modification.
Figure 12–23.  Film of bone graft.
• Correct positioning of patient on the OR table
and adequate securing of the endotracheal
tube.
• Proper instrumentation and adequate
experience of the operating surgeon.
Specialized instruments can greatly assist the
surgeon with the surgical challenges. Surgery
of the cleft palate is conceptually easy but
technically difficult. An experienced surgeon
understands this problem and creates an

Repair of Nasoalveolar Clefts
159
operating kit that is designed to minimize
the surgical/technical challenges.
• Consider staging the procedure (especially in
developing countries) by closing one side at a
time. If closing bilaterally, be sure to achieve
complete oral closure as well.
• Careful dissection of the premaxillary tissues
must be undertaken to prevent compromise
of the blood supply to the premaxilla.
• In many cases, it may be better to close the
alveolar cleft and residual fistulae in two soft
tissue layers without a bone graft.
References
1. Åbyholm FE, Bardach J, Salyer KE. Correction of skeletal
deformities associated with unilateral and bilateral cleft
lip, alveolus, and palate. In: Salyer KE, Bardach J, eds.
Atlas of Craniofacial and Cleft Surgery. Philadelphia, PA:
Lippincott Williams & Wilkins; 1999:810–823.
2. Boyne PJ, Sands NR. Secondary bone grafting of residual
alveolar and palatal clefts. J Oral Surg. 1972;30:87.
3. Boyne PJ. Bone grafting in the osseous reconstruction of
alveolar and palatal clefts. Oral Maxillofac Surg Clin North
Am. 1991;3(3):589–598.
4. Hall HD, Werther JR. Conventional alveolar cleft bone graft-
ing. Oral Maxillofac Surg Clin North Am. 1991;3(3):​609–616.
5. Larsen PE. Reconstruction of the alveolar cleft. In: Miloro
M, Ghali GE, Larsen P, Waite P, eds. Peterson’s Principles
of Oral and Maxillofacial Surgery. China: PMPH-USA, Ltd.;
2012:​859–870.
6. Precious DS. Alveolar bone grafting. Oral Maxillofac Surg
Clin North Am. 2000;12(3):501–514.
7. Shafer DM. Secondary bone grafting for unilateral alveo-
lar clefts: a review of surgical techniques. Atlas Oral Max-
illofac Surg Clin. 1995;3(1):29–42.
8. Turvey TA, Ruiz RL, Tiwana PS. Bone graft construction
of the cleft maxilla and palate. In: Losee JE, Kirschner RE,
eds. Comprehensive Cleft Care. New York, NY: McGraw-
Hill Medical; 2008:837–864.

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Section V
Secondary Cleft Lip Rhinoplasty

(Trang không có chữ)

163
Chapter 13
Secondary Cleft Lip Rhinoplasty
Krishna G. Patel and Jonathan M. Sykes
Abstract
The nasal deformities associated with cleft lip malforma-
tions have been well described. Much has been written on
the timing and techniques for surgical corrections.1–3 Despite
this, the secondary cleft lip rhinoplasty remains one of the
most challenging procedures most rhinoplasty surgeons
face. Interestingly, even in the mildest forms of oral cleft-
ing such as the microform cleft lip, a significant cleft nasal
deformity exists. This anatomical asymmetry reveals how
the cleft lip deformity truly is a misnomer, and in actuality
all cleft lips have both lip and nasal components. The nasal
deformities derive from all components of the nose including
the skeletal base, vestibular lining, cartilaginous and bony
nasal framework, and external soft tissue envelope. For the
unilateral cleft lip nose, the greatest challenge is addressing
the asymmetrical appearance that mostly exists in the lower
third of the nose. For the bilateral cleft lip nose, the greatest
challenge is addressing the wide alar base, the foreshortened
columella, and ptotic tip. Because the underlying maxilla
often is deficient on the cleft side and can possess significant
bilateral hypoplasia, it is imperative that all bone grafting
and orthognathic procedures be performed prior to the sec-
ondary rhinoplasty.4 Therefore, the secondary rhinoplasty is
often the last of multiple procedures patients with cleft lip
and/or palate undergo.
Secondary rhinoplasty is ideally performed when the
patient has achieved full skeletal maturity. Typically,
the procedures are performed at 14 to 16 years of age
for females and 16 to 18 years of age for males. The
title “secondary rhinoplasty” implies that at the time
of the primary cleft lip repair, a primary rhinoplasty
was performed in an attempt to decrease the degree of
nasal alar asymmetry.5,6 The primary rhinoplasty tech-
nique is typically conservative and can greatly improve
the asymmetry; however, primary nasal repairs do
not address the associated septal deviation that often
results in a crooked nose. Additionally, growth of the
child often reaccentuates any persistent nasal tip asym-
metry. For this reason, most patients with a cleft lip
necessitate a final/secondary rhinoplasty procedure.7,8
Compared to a rhinoplasty in a noncleft patient,
there is often a greater need for cartilaginous grafting.
Because a primary (albeit conservative) rhinoplasty
procedure was performed, secondary rhinoplasty
procedures must overcome any scar tissue within the
soft tissue envelope, often necessitating sturdy graft
material. Similarly, some lengthening of the columel-
lar vestibular lining on the shorter cleft side is usually
required, which again mandates the need for strong
infrastructure. Therefore, the surgeon must have a plan
for generating sufficient graft material, whether the
source derives from the septum, ear, or rib. The authors
prefer the use of septal cartilage, and when the septum
is not sufficient costal cartilage is harvested.
Even with a superb lip repair that reveals a well-
camouflaged scar and excellent lip symmetry, the
asymmetry of the nose often gives away the diagno-
sis of oronasal clefting in the patient (Figures 13–1 and
13–2). Persistent findings that are typical for the cleft
lip nose after primary cleft repairs are listed in the fol-
lowing tables for unilateral and bilateral cleft deformi-
ties (Tables 13–1 and 13–2).
Surgical Indications
The recipe for successful rhinoplasty procedures begins
with critical systematic analysis of the nose and proper
diagnosis of the deformity. Because cleft lip deformi-
ties have such a broad range of severity, the resultant
nasal deformity will similarly vary. The best approach
is to critically evaluate all components of the nose with

164
Video Atlas of Cleft Lip and Palate Surgery
clinical external examination and thorough anterior
rhinoscopy. This will aid in completely assessing both
functional and aesthetic needs. Secondly, systematic
analysis of photographic views should be performed.
These views include: frontal, lateral, oblique, and basal
angles.
As stated previously, all orthognathic and bone
grafting procedures should precede the final rhino-
plasty. Likewise, the timing of the rhinoplasty ideally
occurs at full skeletal maturity. Preoperative counseling
should occur to set forth realistic expectations for the
aesthetic and functional outcomes.
Although this chapter focuses on the final rhi-
noplasty procedure, some patients have severe nasal
deformities that require intervention prior to full
growth. This is often labeled the intermediate rhino-
Figure 13–1.  Frontal view of a cleft lip nasal deformity classi-
cally seen after repair of a unilateral cleft lip. Deformities visu-
alized include alar rim malposition with flattening of the dome
on the cleft side, foreshortened columella on cleft side, and
deficiency of the nasal sill and floor.
Figure 13–2.  Frontal view of the cleft lip nasal deformity
classically seen after repair of a bilateral cleft lip. Deformities
visualized include tip ptosis, foreshortened columella causing
bilateral hooding of the alar rim, widened alar base, and defi-
ciency of the nasal sill and floor.

Secondary Cleft Lip Rhinoplasty
165
plasty. Like the primary rhinoplasty, usually a con-
servative approach is taken when performing an
intermediate rhinoplasty, and only deformities that
cause significant nasal obstruction or psychological
distress are usually addressed. Because most surgeons
do not violate the septum during intermediate rhino-
plasty procedures, most techniques employed at this
stage involve manipulation of the soft tissue and sutur-
ing techniques.
Surgical Equipment and Tools
• Nasal speculums (multiple lengths)
• Tissue forceps (Adson–Brown 12 cm and
Bishop Harmon 8.6 cm, Bayonet forceps)
• Nasal retractor (Aufricht or Converse)
• Scissors (curved Iris 10 cm, Stevens Tenotomy
curved 10 cm, straight Stevens)
Table 13–1.  Post-Lip Repair Nasal Deformity—Unilateral Cleft Lip
Nasal Anatomic Location
Deformity
Etiology
A.  Upper nasal third
Deviated dorsum
Deviated septum
B.  Middle nasal third
Deviated dorsum
Deviated septum
C.  Lower nasal third
Deficiency of nasal sill/floor
Deficiency of underlying bony
structures
Lack of restoring soft tissue bulk at
time of primary lip repair
Widened sill (length from the alar
base to columella)
Deficiency of underlying bony
structures
Columellar length is shorter on the
cleft side
The dome of the lower lateral cartilage
is located in a more medial point along
the crura. Although the total length
of the lower lateral cartilage is equal
on cleft and noncleft sides, the medial
crus is shorter and the lateral crus is
longer on the cleft side.
Flattening or “hooding” of the
dome on the cleft side
Secondary to the shorter domal height
on the cleft side
Alar malposition (the superior rim
and soft tissue triangle on the cleft
side is positioned more inferiorly)
Secondary to the shorter domal height
on the cleft side
Nasolabial angle is too acute
Deficiency of bony support at the
columellar base
Flattening of the dome on the cleft
side pulls the tip inferiorly
Caudal septal deviation
Attachments of the septum cause
caudal septal deviation toward the
noncleft side; the posterior septum
deviates to the cleft side
Entire alar length may be
foreshortened and deficient
If an alar base (perialar) incision was
used at the time of the primary lip
repair, it can stunt the normal growth
of the ala

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Video Atlas of Cleft Lip and Palate Surgery
• Nasal forceps (Blakesley or Takahashi)
• Needle holder (Webster)
• Elevators (Joseph periosteal elevator, Cottle
elevator, Freer elevator)
• Skin hooks (2 prong, 2 mm and 2 prong, 10 mm)
• Osteotomes (3 mm curved guarded left and
right, 2 mm straight unguarded)
• Mallet
• Nasal rasps
• No. 10 Frazier tip suction
• Cartilage crusher and carving block
Anesthesia
• 1% lidocaine with 1:100,000 epinephrine
Surgical Procedure
I. For the Intermediate Rhinoplasty
1. Unilateral nasal deformity, usually a severe alar
hooding that causes aesthetic asymmetry and nasal
obstruction.
a. Endonasal approach to the lower lateral
cartilage.
b. Exposure of the lower lateral cartilage, with
scoring and mattress sutures to correct curva-
ture deformities.
c. The inferiorly displaced caudal edge of the
lower lateral cartilage can be elevated by
suturing the cephalic edge of the lower lateral
Table 13–2.  Post-Lip Repair Nasal Deformity—Bilateral Cleft Lip
Nasal Anatomic Location
Deformity
Etiology
A.  Upper nasal third
Broad nose
Broad nasal bones
B.  Middle nasal third
Broad middle third
Broad nasal bones
Pollybeak deformity
From ptotic tip
C.  Lower nasal third
Deficiency of nasal sill/floor
bilaterally
Deficiency of underlying bony
structures
Lack of restoring soft tissue bulk at
time of primary lip repair
Wide alar base
There is a tendency for the base to
widen after the primary lip repair
even when an alar base suture was
performed to set the base. This may
be secondary to deficiency of the
underlying bony support.
Columella too short
Lack of soft tissue to re-create an
adequate columella during primary
lip repair. Nasoalveolar molding may
improve this issue
The dome of the lower lateral cartilage
is located in a more medial point along
the crura bilaterally
Ptotic tip
Too short columella
Bony deficiency at the columellar base
Nasolabial angle is too acute
Deficiency of bony support at the
columellar base
Tip ptosis

Secondary Cleft Lip Rhinoplasty
167
crus to the ipsilateral or contralateral upper
lateral cartilage (Figure 13–3).
2. Bilateral nasal deformity, usually a ptotic tip and
overly short columella.
a. V-to-Y closure of columellar incision, which
lengthens the total length of the columella
(Figure 13–4).
b. Or design bilateral chondrocutaneous flaps
of lower lateral cartilage, vestibular skin, and
lip scar tissue that are advanced superiorly to
lengthen columellar lining.
c. If grafting material is available, reinforce
the columellar lengthening procedure with
a columellar strut graft.
II. For the Secondary/Final Rhinoplasty
1. Evaluation and diagnosis of the deformity and a
surgical plan should precede all surgeries.
2. External approach via trancolumellar and bilateral
marginal incisions.
Figure 13–4.  Intraoperative photos demonstrating the designing of (A) bilateral chondrocutaneous flaps to (B) increase columel-
lar length. (Reproduced with permission from Cleft lip rhinoplasty. Sykes JM. In: Master Techniques in Rhinoplasty, ed. Azzizzadeh B
et al., Elsevier Saunders, China, 2011. Chap. 24, p. 436 Fig. 34–13.)
A
B
Figure 13–3.  A. Schematic illustrating the use of a shield graft to aid in increasing tip projection and tip definition. B. Schematic
also illustrates suturing from the cephalic edge of the lower lateral cartilage to the caudal edge of the upper lateral cartilage in
order to reposition the lateral crus in a more cephalad position to correct alar rim malposition.

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Video Atlas of Cleft Lip and Palate Surgery
Table 13–3.  Secondary Cleft Nasal Deformity Algorithm
A. Is there a dorsal hump, and is this from nasal overgrowth or from tip ptosis?
Yes →
– Nasal overgrowth →
– Reduce the nasal bones and/or cartilaginous septal hump, perform osteotomies, and
reconstitute infrastructure +/- spreader grafts.
– Tip ptosis →
– Elevate tip with columellar strut graft or caudal septal extension graft.
– Tip grafting (shield, tip, or cap graft). See Figure 13–3.
No →
No intervention
B. Define the rotation of the tip. Is there an obtuse or acute nasolabial angle?
Acute →
Is this from deficiency of the maxilla, or is this secondary to tip ptosis?
– Deficiency of the maxilla →
Premaxillary plumping graft.
– Tip ptosis →
Elevate tip with columellar strut graft or caudal septal extension graft.
Obtuse →
Placement of a septal caudal extension graft should allow from repositioning of the lower lateral cartilages to reposition
the tip.
continues
3. Nasal superficial musculoaponeurotic system
(SMAS) is carefully elevated from the cartilaginous
and bony framework.
4. Upper and lower lateral cartilages are separated
from the septum.
5. If dorsal hump exists due to overgrowth, reduc-
tion of the nasal bones and/or cartilaginous septal
hump should be performed.
6. Fully expose the septum via external approach to
address the septal deviation.
a. This may require scoring of the dorsal and
caudal struts to fully correct the deviations,
which will then require stabilization with
mattress sutures and struts.
b. Release of the septomaxillary/septospinal
ligament.
c. Excision of excess septum curving off the
maxillary spine to allow it to swing to midline
and stabilize onto the spine with 4-0 long-
acting absorbable monofilament suture.
d. Save all removed cartilage for future graft
material.
7. Employ the algorithm listed in the following to
incorporate additional techniques to complete the
rhinoplasty portion of the procedure (Table 13–3
and Figures 13–5, 13–6, and 13–7).
8. Make sure to reestablish stability to the nose via
grafting and/or suture technique.
9. Ablate any potential space with tacking sutures to
prevent unpredictable healing.
10. Meticulous closure of all incisions.
11. Protect nose and stabilize tissue with external
splinting and taping.
Cases
CASE #1:  Unilateral Cleft Lip Rhinoplasty
History of Present Illness (HPI)
17-year-old male with a history of a left unilateral cleft
lip and palate that was repaired in infancy. He had
not undergone any further nasal procedures. He had
completed alveolar bone grafting and all orthodontic
needs. He had significant septal deviation with near
total nasal obstruction posteriorly through the left
nostril.
Physical Assessment
Frontal View Revealed
• Crooked nose with middorsum deviated
to the left and associated intranasal septal
deviation.
• Flattening of the left nasal dome.
• Malposition of the left nasal ala inferiorly.
• Good nasal width.
• Creep of vermilion superiorly on the cleft/left
side.

169
C. Is the alar rim malpositioned causing alar hooding and dome flattening on the cleft side?
Yes →
– Separate the mucosal lining from the lower lateral cartilage before creating a new dome.
– Create a new dome with an intradomal mattress suture and interdomal sutures that incorporate the old dome into the
medial crus. Placement of a columellar strut or caudal septal extension graft will further reinforce the repositioning of
the dome. Lateral crural strut grafts placed between the vestibular lining and innate lower lateral cartilage may also
aid in redefining new dome. This can also be achieved through a vertical dome division. See Figure 13–5.
– If the lateral crus has significant recurvature, this may require complete division of the lateral crus and rotation of the
cartilage 180 degrees with restabilization. Alternatively, reshape lateral crus with scoring and reinforce with lateral
crural strut graft. See Figure 13–6.
– The inferiorly displaced caudal edge of the lower lateral cartilage can be elevated by suturing the cephalic edge of the
lower lateral crus to the ipsilateral or contralateral upper lateral cartilage.
– Some surgeons condone conservative soft tissue resection of the prolapsed rim.9
No →
No intervention.
D. Is the entire ala deficient?
Yes →
No →
May require composite cartilage graft at alar base
No intervention.
E.
Is the vestibular lining of the columella on the cleft side shorter compared to the noncleft side in the unilateral cleft lip nose?
Yes →
No →
Place a chondrocutaneous flap of lower lateral cartilage, vestibular skin, and lip scar tissue advanced superiorly to
lengthen columellar lining. See Figure 13–7.
No intervention.
F.
Is the columella too short in the bilateral cleft lip nose?
Yes →
– V to Y closure of columellar incision.
– Design bilateral chondrocutaneous flaps of lower lateral cartilage, vestibular skin, and lip scar tissue that are
advanced superiorly to lengthen columellar lining.
No →
No intervention.
G. Is there vestibular enlargement or stenosis?
Enlargement →
Reposition the alar base medially.
Stenosis →
Composite chondro-cutaneous graft.
H. Is the alar base too wide?
Yes →
No →
Reposition alar base with alar base suture, possibly necessitating bilateral alotomy incisions.
No intervention.
I.
Is there deficiency of the nasal floor or alar base?
Yes →
No →
Premaxillary grafting.
No intervention.
J.
Will the patient require grafting material?
Yes →
Will the septum provide adequate grafting material?
Yes →
Perform septoplasty for septal grafts.
No →
Perform septoplasty and/or in addition plan to harvest alternative graft material (conchal, costal, cadaveric,
alloplastic).
No →
No intervention.
Table 13–3.  continued

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Video Atlas of Cleft Lip and Palate Surgery
Lateral View
• Good nasal projection.
• Rotation approximately 90 degrees and
acceptable.
• Cleft side had less columellar show.
• Slight deficiency of the columellar base.
Base View
• Alar base and nasal sill deficiency on cleft/left
side.
• Columellar length on cleft side is shorter.
• Flattening of the dome on the cleft side.
Procedure (Figures 13–8 and 13–9)
The patient had asymmetry of his cupid’s peaks and
needed more intranasal lining for lengthening the colu-
mella on the cleft side. A combined procedure with lip
revision and rhinoplasty was performed that allowed
for the design of a chondrocutaneous flap, involving
the lower lateral medial crus, vestibular skin, and lip
scar tissue that was advanced superiorly.
1. Lip revision was performed to address the vermil-
ion creep. As part of the technique, the lip scar was
incorporated in the chondrocutaneous flap that was
superiorly based. The most medial aspect of the flap
communicated with the nasal columellar incision.
2. External approach for the rhinoplasty via transcol-
umellar and bilateral marginal incisions.
3. Nasal SMAS was carefully elevated from the carti-
laginous and bony framework.
4. Upper and lower lateral cartilages were separated
from the septum.
5. The septum was exposed via external approach to
address the septal deviation.
a. Septoplasty was performed, and all cartilage
was saved for grafts.
b. Scoring of the dorsal and caudal struts was
performed to fully correct the deviations. The
weakened struts required stabilization with
mattress sutures and a polydioxanone (PDS™)
plate positioned on the left side of the septum
and unilateral spreader graft placed on the
right side.
c. The septomaxillary/septospinal ligament was
released.
d. The excess septum that was curving off the
maxillary spine was excised, and the septum
was allowed to swing to midline and be stabi-
lized onto the spine with 4-0 PDS™ suture.
6. Bilateral medial and lateral osteotomies were per-
formed to correct the crooked nasal deformity.
7. Deeper lip scar was rolled upward to create bulk at
the nasal sill.
Figure 13–5.  Schematic illustration of a bilateral cleft nasal
deformity showing the use of a vertical dome division to
increase tip projection. The new dome is created at a more lat-
eral point along the lower lateral cartilage, and the lengthened
medial crus is stabilized to a columellar strut graft and the
contralateral medial crus. (Reproduced with permission from
Sykes JM and Jang YJ. Cleft lip rhinoplasty. Facial Plast Surg Clin
N Am. 2009;17(1):133–144. Figure 15, p. 141.)
Figure 13–6.  Schematic illustration depicting recurvature
of the lateral crus. Isolating the lower lateral crus from the
underlying vestibular mucosa, then dividing the lateral crus and
rotating it 180 degrees creates a more functional and proper
alignment. (Reproduced with permission from Cleft lip rhi-
noplasty. Sykes JM. In: Master Techniques in Rhinoplasty, ed.
Azzizzadeh B et al., Elsevier Saunders, China, 2011. Chap. 24,
p. 439 Fig. 34–16.)

171
A
B
Figure 13–7.  A. Schematic illustrating the design of a chrondocutaneous flap that will allow for lip revision while (B) length-
ening the columellar lining on the affected side. C. The flap is rotated in a superior position and secured to a columellar strut
graft. (Reproduced with permission from Wang TD. Secondary rhinoplasty in unilateral cleft nasal deformity. Clin Plast Surg. Apr
2010;37(2):383–387. Fig. 1, p. 124.)
C

172
Video Atlas of Cleft Lip and Palate Surgery
8. There was significant lower lateral cartilage asym-
metry, and the dome on the cleft side was lower.
A lateral steal technique of borrowing from the lat-
eral crura and creating a new dome was performed
to create a higher dome. The new dome was stabi-
lized through placement of a caudal septal extension
graft and placement of inter- and intradomal sutures.
9. A rim graft was placed to maintain the new sym-
metry of the nasal ala.
10. Meticulous closure of all incisions was performed.
11. The nose was stabilized with internal and external
splinting and taping.
CASE #2:  Bilateral Cleft Lip Rhinoplasty
HPI
18-year-old Russian-American female who underwent
bilateral single stage cleft lip repair at 2 years of age.
A
B
C
Figure 13–8.  Preoperative photos of a patient with a history of a left unilateral cleft lip and palate repair preparing for a second-
ary rhinoplasty. Views: (A) frontal, (B) lateral, and (C) base. Postoperative photos of the same patient after the rhinoplasty. Views:
(D) frontal, (E) lateral, and (F) base.
D
E
F

173
Figure 13–9.  Gunter diagram illustrating the techniques employed to improve septal-dorsum deviation,
nasal sill hooding, and nasal sill deficiency.

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Video Atlas of Cleft Lip and Palate Surgery
She had a palatoplasty at 2.5 years of age and a bilateral
alveolar bone graft at 10 years of age.
Physical Assessment
The patient presented with maxillary hypoplasia, class
III malocclusion, and a cleft nasal deformity. The nose
had an amorphous nasal tip, poor tip projection, and a
nasal septal deformity.
Procedure (Figures 13–10, 13–11, and 13–12):
The patient underwent a Le Fort I maxillary osteotomy
with placement of a rigid external distractor (RED
A
B
C
Figure 13–10.  Preoperative photos of a patient with a history of a bilateral cleft lip and palate repair preparing for a secondary
rhinoplasty. She had significant maxillary hypoplasia that required distraction prior to her rhinoplasty. Images: (A) frontal and
(D) lateral views prior to either distraction or rhinoplasty. (B) Frontal and (E) lateral views after maxillary distraction osteogenesis
via an external device and prior to her rhinoplasty. (C) Frontal and (F) lateral views after her final rhinoplasty.  continues
D
E
F

Secondary Cleft Lip Rhinoplasty
175
device). After 4 weeks of advancement and 6 weeks of
bony consolidation, the distractor was removed and
the maxilla plated into its new position.
Three months after the rigid fixation, the patient
underwent septorhinoplasty (SRP).
1. External approach for the rhinoplasty via transcol-
umellar and bilateral marginal incisions.
2. Nasal SMAS was carefully elevated from the carti-
laginous and bony framework.
3. Upper and lower lateral cartilages were separated
from the septum.
4. The septum was exposed via external approach to
address the septal deviation.
a. Septoplasty was performed, and all cartilage
was saved for grafts.
5. A PDS™ plate/septal cartilage septal extension
graft was used to reconstruct the caudal septum.
A lateral steal technique of borrowing from the lat-
eral crura and creating a new dome was performed
to create a higher dome. The new dome was stabi-
lized through suturing the medial crura to the cau-
dal septal extension graft.
6. The temporalis fascia was harvested and rolled to
create a tube that was filled with morselized con-
chal cartilage. The fascia-conchal cartilage graft
was placed as an onlay graft over the dorsum to
increase dorsal height.
7. Tip projection was increased with a tip cartilage graft.
8. Bilateral lateral osteotomies were performed to
narrow the nose.
9. Meticulous closure of all incisions was performed.
10. The nose was stabilized with internal and external
splinting and taping.
CASE #3 
(Video of Secondary Cleft Lip Rhinoplasty)
HPI
35-year-old male with unilateral cleft nasal deformity.
Procedure (Figure 13–13):
An external septorhinoplasty approach is performed
with complete dissection of the deviated caudal nasal
septum. After harvest of a septal graft, a septal exten-
sion graft is placed to strengthen and straighten the
septum. The nasal tip is projected with a tongue-in-
groove suture, and the tip is narrowed with an inter-
domal suture. The right malpositioned noncleft alar rim
is repositioned and strengthened with alar strut graft.
The left malpositioned cleft alar cartilage is
strengthened with an alar turn under flap and repo-
sitioned with alar bolsters. Lastly, the floor of the nose
(and nasal sill) are re-created by dissecting out the orbi-
cularis oris muscle of the upper lip and reopposing the
muscle. The ala is repositioned with a perialar incision.
All of these maneuvers improve nasal base and tip
symmetry.
G
H
Figure 13–10.  continues  (G) Immediate postoperative lateral view after placement of the external distractor, and (H) lateral
view after distraction was completed. Note the improved position of the alar base and lip secondary to maxillary distraction,
emphasizing the importance of bony structural support.

176
A
C
B
D
Figure 13–11.  Intraoperative photos of the patient from Figure 13–10. A. Preoperative lateral view of patient and B. postopera-
tive lateral view of patient. Note the improvement of tip projection and dorsal height. An intraoperative view of the placement
of a caudal septal extension graft secured to a PDS™ plate, which will be stabilized to the septum. Appreciate the increased tip
height the nose will achieve once the lower lateral cartilages are secured to the caudal septal extension graft. D. Photo of the
caudal septal extension graft secured to a PDS™ plate. E. Photo of a temporalis fascial graft that has been rolled and filled with
morselized conchal cartilage that will be laid on the dorsum to increase dorsal height. The temporalis graft is wrapped around a
1 cc syringe and sutured along the length of the graft. Next the syringe is filled with morselized conchal cartilage. F. The cartilage
fills the rolled temporalis graft as the syringe is removed.
E
F

177
Figure 13–12.  Gunter diagram illustrating the techniques employed for the bilateral cleft rhinoplasty.

178
Figure 13–13.  Gunter diagram illustrating the techniques utilized for the accompanying video of a unilat-
eral cleft lip rhinoplasty.

Secondary Cleft Lip Rhinoplasty
179
Postoperative Considerations
• As with all rhinoplasty surgery, determination
of aesthetic outcomes should be assessed at
6 months postoperatively. Premature assess-
ment may be skewed by residual edema.
• For this reason, preoperative counseling should
stress the need for the patient to allow appro-
priate time for healing and edema to resolve.
• Taping postoperatively may help expedite the
resolution of edema and help decrease potential
dead space that can lead to unpredictable healing.
Complications
• Complications for cleft rhinoplasties are
similar to all secondary rhinoplasties. These
complications can include delayed aesthetic
irregularities or asymmetries.
• Although unusual, postoperative infections
are possible. The authors presoak all grafts in
antibiotic-infused saline and use intraoperative
and postoperative prophylactic antibiotics.
• Graft exposure can also be a complication,
which can be avoided by decreasing tension
on the incisions and performing meticulous
incision closure.
• Because the nasal soft tissue envelope has
significant memory, attaining complete
symmetry of the nasal tip in the unilateral
cleft lip nose can be difficult to achieve.
Pearls and Pitfalls
• Preoperative counseling is imperative in order
to set realistic expectations of the functional
and aesthetic outcomes.
• Clearly define the nasal deformities that exist
and devise an operative plan based on the
correction of these deformities.
• Use of cartilage grafting plays an important
role in secondary cleft lip rhinoplasty.
• Proper bony support plays a large role in the
appearance of the cleft lip nose.
References
1. Byrd HS, El-Musa KA, Yazdani A. Definitive repair of the
unilateral cleft lip nasal deformity. Plast Reconstr Surg.
2007;120(5):1348–1356.
2. Cutting CB. Secondary cleft lip nasal reconstruction:
state of the art. Cleft Palate Craniofac J. 2000;37(6):538–
541.
3. Sykes JM, Jang YJ. Cleft lip rhinoplasty. Facial Plast Surg
Clin North Am. 2009;17(1):133–144, vii.
4. Agarwal R, Parihar A, Mandhani PA, Chandra R.
Three-dimensional computed tomographic analysis of
the maxilla in unilateral cleft lip and palate: implica-
tions for rhinoplasty. J Craniofac Surg. 2012;23(5):1338–
1342.
5. Haddock NT, McRae MH, Cutting CB. Long-term effect
of primary cleft rhinoplasty on secondary cleft rhino-
plasty in patients with unilateral cleft lip-cleft palate.
Plast Reconstr Surg. 2012;129(3):740–748.
6. Sykes JM. The importance of primary rhinoplasty at the
time of initial unilateral cleft lip repair. Arch Facial Plast
Surg. 2010;12(1):53–55.
7. Shih CW, Sykes JM. Repair of the bilateral cleft lip defor-
mity. Facial Plast Surg. 2007;23(2):100–106.
8. Shih CW, Sykes JM. Correction of the cleft-lip nasal defor-
mity. Facial Plast Surg. 2002;18(4):253–262.
9. Thomas C. Primary rhinoplasty by open approach with
repair of unilateral complete cleft lip. J Craniofac Surg.
2009;​20(2):1711–1714.

(Trang không có chữ)

Section VI
Surgical Management of
Cleft-Related Midface Deformity

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183
Chapter 14
Orthognathic Surgery in the Cleft Patient
Shahid R. Aziz, Derek J. Rogers, and Steven M. Roser
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Army, the
Department of Defense, nor the U.S. government.
MAJ Rogers is a military service member. This work was
prepared as part of his official duties. Title 17 U.S.C.
105 provides that “Copyright protection under this
title is not available for any work of the United States
Government.” Title 17 U.S.C. 101 defines a United
States Government work as a work prepared by a mili-
tary service member or employee of the United States
Government as part of that person’s official duties.
Abstract
Although the cleft deformity itself does not always lead
to maxillary midface skeletal deficiency, the scarring that
results from lip and palate repair combined with the defect
results in some degree of midface deficiency in the cleft
patient. The surgical correction of this deficiency includes
considerations including the timing of surgery, adjunctive
orthodontic treatment, previous alveolar cleft repair, impact
of the maxillary advancement on speech, and modifications
of the soft tissue incisions.
Cleft lip with or without cleft palate is among the most
common of facial congenital anomalies, with an aver­
age incidence in the United States of approximately
1:1,000 births. These craniofacial deformities are not
limited to the soft tissue of the face. Facial clefts have
a significant impact on the growth and development
of the craniofacial skeleton. Repair of the cleft lip, spe­
cifically restoring the continuity of the orbicularis oris
muscle, restricts maxillary growth in an anterior–poste­
rior direction. Repair of the cleft palate, specifically the
scar development/healing of the gingival palatal flaps,
creates a restriction of transverse maxillary growth.
This combination results in a hypoplastic maxilla in
three dimensions. In the literature, approximately 25%
of cleft patients require orthognathic surgery, with a
range of 14 to 75% depending on the study reviewed.1
Mandibular growth in this patient population is typi­
cally normal, resulting in a pseudo class 3 malocclusion
(normal mandibular position combined with a hypo­
plastic maxilla). In some cases, the mandible may have
a steep mandibular plane angle resulting in an ante­
rior open bite. As such, cleft orthognathic patients may
require either a maxillary surgery alone or a combined
maxillary–mandibular procedure.
Surgical Indications
The goals of cleft orthognathic surgery are as
follows:
1. Restore facial symmetry.
2. Create a class 1 dental occlusion.
3. Place the components of the craniofacial skeleton
in an ideal aesthetic position.
4. Provide stability to the clefted maxilla.
Treatment planning is essential in maxillofacial
surgery, and in particular orthognathic surgery. A coor­
dinated treatment plan is typically created by the
surgeon and orthodontist. In cleft-orthognathics, addi­
tional support in surgical planning is provided by other
members of the craniofacial team — pediatric dentist,
speech pathologist, as well as psychology. Timing is
the first major consideration. In a standard treatment
plan for a cleft patient, pediatric dentistry is initiated
early in life, followed by orthodontic care (nonsurgical
maxillary expansion) by 6 to 7 years of age in prepara­
tion for alveolar bone grafting by 9 to 10 years of age.
Following bone grafting, the cleft patient undergoes
comprehensive orthodontics to level and align the
dentition in preparation for possible jaw surgery. Tim­
ing of orthognathic surgery has been debated in the lit­
erature. However, definitive studies by Wolford have