Your Questions
Your Questions
Q: Dr. Eppley, I am interested in nose reconstruction (cleft rhinoplasty) for my teenage daughter who was born with a cleft lip. She is fourteen and is looking to have surgery this coming year. I am looking for a plastic surgeon who is experienced with rhinoplasty in clefts and just want her to be comfortable with her appearance.
A: All orofacial clefts (with the exception of isolated cleft palate) has some detrimental effects on the development and appearance of the nose. While the entire nose is almost always affected, the greatest deviations from normal occur in the nasal tip. Because the tip shape is controlled by the underlying septal end and the paired lower alar cartilages, it is particularly susceptible to very noticeable and classic tip shape deformities. Most commonly the lower alar cartilage on the cleft side is weak and misshapen, resulting in it being positioned lower (slumping) and having a widened and oblong nostril. This is exaggerated as the end of the septum is deviated away from the cleft side into the opposite nasal airway. This causes the entire nasal tip to be asymmetric and have the classic slumped appearance. For reasons unknown, the vast majority of cleft noses have a thicker skin cover, an issue that has great relevance in the outcome of rhinoplasty correction efforts.
Most cleft noses need a full septorhinoplasty approach to both optimize correction of the bony cartilaginous framework but also to correct any internal airway obstructions (septum and turbinates) which are almost always present. The relevant question is always the timing of the rhinoplasty surgery given the congenital nature of the nasal problem and the sensitive psychosocial development of children and teenagers. The traditional thinking of doing any rhinoplasty is when facial development is near complete, age 16 or older. However, I have always taken an earlier approach to some rhinoplasty patients particularly the cleft patient and I don’t think age thirteen or fourteen is too young.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty. I am 50 years old and was originally born with cleft lip and palate. I have had two previous rhinoplasties for my cleft nose, the last being over a decade ago. I have never really liked the results and was hoping to have one more go at it in my older years. Just recently had a consultation about my nose with a surgeon who is basically a cosmetic surgeon. He looked me in the face and said that due to my anatomy and blood supply, his major concern was that he wasn’t sure if he could correct anything. His concern was necrosis. I have great blood supply and have never heard of that possible complication before. As a matter of fact that remark caused me to realize that I needed an expert in cleft nose deformities. Please tell me what you think.
A: While open rhinoplasty always has the potential for nasal tip skin necrosis, this would be a very rare problem. The surgeon would have been better to say ‘I am not interested in doing your nose’, ‘this is hard and not worth my effort’ or even ‘this is beyond my skill level’ but the idea that the blood supply to your nose is compromised and can’t be operated on is not a valid biologic concept. If that were true, the vast majority of revisional rhinoplasties would never be done, not withstanding the secondary cleft rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty to help with my congenital nose deformity from cleft lip and palate. I am a healthy 60 year female and my speech is fine. But my nose has never been right and until I read your writings on my problem I did not realize that it is a cartilage memory problem. This seems like it might be a magical solution and I hope you are the magician.
A: Correction of the cleft nose is a particularly challenging rhinoplasty procedure as the anatomy is far from normal. Such a nose appears deviated or twisted from the nasal bones down to the tip. The tip is most noteworthy as it is usually bulbous with thicker skin and deviated towards the non-clefted side. Part of this is due to the twisted septum internally which swings away towards the normal side pulling the tip with it. Trying to correct can be difficult and this where the role of cartilage memory comes into play. But the other major component is the nostril on the cleft side. It is deformed because it has a lack of adequate tissue support. The lower alar cartilage is slumped as it is weak and lacks the amount of cartilage on the other side. In addition the skin is deficient further contributing to the shape distortion. (which also makes it difficult to get a shape like the opposite side)
I will assume you have had some prior rhinoplasty work, perhaps years ago, and substantial efforts were made in the tip area. In my rhinoplasty experience, the cleft tip needs considerable support added including a columellar strut, spreader graft on the cleft side and an alar rim and batten graft above the cleft nostril.
If only improving the nostril shape to correct the amount of nostril retraction/asymmetry, I would just do a composite ear cartilage-skin graft to roll down the retracted nostril edge.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son was born with a bilateral cleft lip and palate. He just turned 9 years old. He is about to get his bone graft surgery in December. What is too early to have nose reconstruction? The surgeons said he would rather not touch his nose until he is age 15 or 16.
A: The nose deformity in bilateral cleft lip and palate is uniquely different from even that of a unilateral cleft. The lack of columellar skin and weak and short tip cartilages poses a significant reconstructive challenge that is present at any age that a patient undergoes any form of a rhinoplasty.
It is best to think of the nose reconstruction in bilateral clefts as done in stages. There are many variations as to how it is approached and will vary by surgeon. Fundamentally, it is divided into stages based on age and development. Under 12 years of age, the focus is on columellar lengthening, nostril narrowing and/or tip cartilage manipulation. After the age of 12, a full septorhinoplasty is done where the entire nose is reconstructed from the nasal bones down to the tip cartilages including the septal and turbinate deformity. At what age this full septorhinoplasty is done is open to debate but most plastic surgeons think more around the age of 14 or 15 years old when the face is essentially fully developed. There may be some modifications to this age based on the extent of the nasal deformity and the timing of orthognathic surgery (LeFort osteotomy) if needed.
In short, major manipulations of the septum and nasal bones should not be done under the face is more fully developed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my daughter is turning 13 next month. She had cleft lip (not palate) and had it repaired when she was 4 months old. She is very self conscious about her appearance. There is a visible scar between the upper lip and nose and a lopsided nose. I want to know about the possibilites to remove the scar and correct her nose asymmetry. Please let me know about the procedure. Thank you very much.
A: Isolated cleft lip always affects more than just the lip. The cleft defect extends to involve the nose in a very classic pattern of lower alar cartilage slumping resulting in an asymmetric tip of the nose with a widened nostril. Even in a well done cleft lip repair, the nose deformity becomes evident as the child grows manifesting itself fully by the teenage years. This always leaves two areas of potential improvement as a young adolescent, the repaired lip scar and the unrepaired nose.
Your daughter would undoubtably benefit by a cleft rhinoplasty and lip repair. Without seeing pictures of her I can not say whether she needs a complete septorhinoplasty or an isolated tip rhinoplasty procedure. Most commonly the fuller version of the rhinoplasty is needed with cartilage grafts. As for the lip, it is better to think of further scar reduction and not scar removal. Completely eliminating the cleft lip scar is virtually impossible. Please send me some pictures of her for a more analysis to determine her exact surgical needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have finally decided as an adult to have my cleft lip scar and nose asymmetry repaired. What I don’t like about my face is that I have a prominent lip scar, a downturned and twisted nose and an overall flatter face. I have attached some pictures so you can clearly see what I mean. What specific procedures do you think I will need and how are they done?
A: Thank you for sending your pictures. You have many of the very typical lip/nose/midface cleft-induced deformities that many so affected patients have. In analyzing how to make a significant improvement, I would recommend the following approach. A full septoprhinoplasty is needed to straighten out the whole nose and give the tip more projection and some narrowing. You would need a cartilage rib graft to build up the base of the nose (pyriform aperture/paranasal regions) by onlay grafting and as a columellar strut to improve tip projection and support. Your cleft lip repair is pretty good at the cupid’s bow area but I would excise the philtral scar and re-unite the underlying orbicularis muscle better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have decided that I would like to have my cleft lip scar and nose asymmetry repaired. Besides the surgeries for primary repair as a child, I have never considered surgery, so I have no experience in what to look for, how to choose the right surgeon, etc. I was very impressed by your website and the way it explains things. I am very serious about having this procedure done, I just need to figure out the logistics with scheduling, recovery time, costs involved, etc. Please let me know what my next steps should be. Thank you very much.
A: Even with the best primary cleft lip and nose repair as an infant, growth and ongoing facial development of the scarred area will result in lip and nose asymmetries. Most of these secondary deformities are quite classic and include vermilion notching, a vermilion-cutaneous mismatch, wide philtral scarring of the lip and tip asymmetry with nostril slumping and widening of the nose. As an adult, the best nose repair comes from a complete septorhinoplasty with cartilage grafting and a cleft lip revision. These usually can be done during the same surgery. Recovery largely revolves around the nose and includes the wearing of a nasal splint for a week after surgery. You should be back to work within 10 days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was born with cleft lip and palate and am now 28 years of age. I would like to have more symmetry of my profile, which could be improved by either a bigger upper lip or smaller lower lip. I just feel as though I could look better than I do now now.
A: Thank you for sending your pictures. I do believe you are correct in that there is room for further facial improvement and symmetry. You have all of the typical lip and nose manifestations that I have seen in just about every adult patient affected by a cleft. By your pictures, you had a unilateral cleft lip and palate on the right side. The one thing that you don’t want to do is to make the lower lip smaller. That is the normal lip and it is better to focus on making the upper lip (the abnormal one) larger and more aligned to match better to the lower lip. In paired facial structures, it is rarely a good idea in the pursuit of symmetry to try and make the normal half look like the abnormal half. While I don’t have a good frontal view of your face, I suspect that the upper lip needs to be taken apart along the scar lines and reassembled with emphasis on achieving a better vermilion roll and pout. (cleft lip revision) There may even be some benefit to adding some upper lip volume through a dermal-fat graft or allogeneic dermis at the same time. It would also be possible to do a complete septorhinoplasty during the same procedure to treat the nasal component of the cleft as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 37 years old and I was born with a cleft lip and palate. It has been repaired when I was a baby and child and I have had two operations, none past the age of three. I am wondering if anything further can be done to improve my appearance. I understand that due to the deformity, repair options are limited, as well as my age being a factor, causing healing times to be greater and results limiting. If possible I’d like to send pictures for a consult.
A: It is important to understand that age is not a factor in making healing times longer or in limiting the results from revisional facial cleft surgery. There is just as much that can be done for a 37 year-old as there is for a 7 year-old. The limiting factors, like in all cleft patients, is the magnitude of the original deformity and the quality and scarring of the lip, nasal, alveolar and palatal tissues. Since you have had but two surgeries that would suggest to me that there is room for improvement without even seeing your pictures yet. The influence of growth on the face makes for a lot of distorting changes around the orofacial cleft site. Even in the best of primary repairs as an infant, revisional surgery is almost always beneficial and desired in the teen years. It is very likely that there is room for visible improvement in the appearance of your external nose and lip through septorhinoplasty and a cleft lip revision.
Dr. Barry Eppley
Indianapolis, Indiana