Cleft Rhinoplasty Before & After Case 1
This beautiful woman loves her boost of confidence after a cleft rhinoplasty and revision of her lip scar.
She is seen here early in her recovery, and can already breathe much more easily.
She also said we “gave her back her smile!” after revising the notch in her cleft lip.
Cleft Rhinoplasty Before & After Case 2
This gentleman has a history of a cleft lip and nasal deviation, with severe difficulty breathing through his nostrils.
I performed a rhinoplasty to straighten a deviated septum, and used the removed cartilage from the septum to make grafts that helped to straighten and support the nasal passages.
We also chose to perform a genioplasty, moving the chin forward to balance his facial features.
Cleft Rhinoplasty Before & After Case 3
This handsome young man has a history of a unilateral cleft lip and palate.
He is seen here 7 months after jaw surgery (maxillary advancement, mandibular setback, and chin advancement), and 1 month after rhinoplasty.
His occlusion (or how his teeth fit together) is now centered and leveled, with the teeth now able to chew optimally. This will help with TMJ and dental health long-term.
The bony work also helped to balance his facial profile, giving his upper lip and chin more support.
The rhinoplasty improved his breathing by straightening the septum and supporting his nasal passages, like having a Breathe-Right strip on the inside of his nose.
His lip scar will also continue to improve after a re-repair and re-orientation of the muscle of his lip.
Cleft Rhinoplasty Before & After Case 4
Not every patient requires a rib graft, or total deconstruction and reconstruction of the nose.
Here, we used a spreader graft on just the left side of the nose, columellar strut graft, and suture techniques to unite, reorient, and reconstruct the cartilage support.
Fat was also transferred to his upper lip to provide a little more fullness to balance with his lower lip.
We look forward to seeing him back again as the swelling continues to improve over the next 12-24 months.
Cleft Rhinoplasty Before & After Case 5
However, if nasal obstruction and symptoms are severe, nasal reconstruction before jaw surgery is sometimes done, knowing that a second surgery may be needed after the maxilla is moved forward.
Here, septal deviation and airway collapse led to nasal obstruction, sleep apnea, and difficulty with daily activities.
Also, her upper lip balance had room for improvement of the skin height, white roll continuity, muscle continuity for playing a brass instrument, and rolling in of the exposed wet mucosa (which otherwise cracks, bleeds, and is painful if chronically exposed).
The lip was fully taken down and re-repaired similar to a primary cleft lip repair.
Her nose reconstruction included septoplasty (reset, and resection of cartilage and bone), spreader grafts, columellar strut, tip and alar grafts, and dermal-fat graft.
She has made tremendous progress after 5 weeks, breathing well and excited to return to playing her instrument!
Cleft Rhinoplasty Before & After Case 6
This woman had a history of a cleft palate, with severe nasal obstruction and a pharyngeal flap contributing to sleep apnea.
A septorhinoplasty and revision of her pharyngeal flap improved her breathing and refined her nasal tip, with no negative effects on her speech.
There’s nothing like being able to get a good night’s sleep!
Cleft Rhinoplasty Before & After Case 7
I thought I had sleep apnea. My wife tells me my snoring went away… I’m just sleeping a lot better. Now I feel more rested and just breathing a lot better.
Slow process of trying to actually breathe correctly for the first time in my life, through my nose instead of through the mouth.
The smile says it all! Nearly 100% of our cleft patients have difficulty breathing.”
Factors include the septum deviating away from the cleft towards the nostrils from the asymmetric pull of the orbicularis muscle and other soft tissue attachments seen with most repairs historically. Further back, the septum follows the bone deviating and collapsing towards the cleft.
Other considerations are weak and collapsed cartilage in the middle and lower thirds of the nose, and compensatory inferior turbinate hypertrophy.
Structural rhinoplasty was performed via an open approach, with spreader grafts, lower lateral cartilage repair (with reorientation of his previous surgical repair), and septal extension graft. Turbinate outfracture and ablation is used adjunctively based on palpation and exam after correcting the deviated septum.
Cleft Rhinoplasty Before & After Case 8
This beautiful patient is thrilled after her cleft rhinoplasty!
She had the normal development we see with most cleft lip patients.
Her septum was pointing to the right — away from the cleft side — causing severe nasal obstruction.
She also had slumping and weakness of the cartilage and skin on the same side as her cleft lip.
We performed a closed technique (incisions all inside the nostrils), to straighten the septum.
Cartilage grafts from the removed septum were then used to straighten and support her nose.
She is seen here 1 month after her surgery, breathing better than ever! Swelling gradually improves over the next 6-12 months.
Cleft Rhinoplasty Before & After Case 9
She also had some imbalance of her lip, with the height of the skin several millimeters shorter on the cleft side. This can be seen with very small imbalances magnified over years as a child grows. The scar tissue also usually does not grow as well as the surrounding skin, so even slight over-lengthening can still leave that side shorter over time.
Here, a cleft rhinoplasty and revision of the lip scar opened up her breathing tremendously. Her symmetry of the tip and wings of the nose is improved, with some upward rotation and tip support added.
Her lip was also revised, with a strong focus on not just the skin, but rebalancing the muscle height and direction of the muscle fibers.
As always, the scars will fade and flatten with time and care. She is seen here at 3 weeks after surgery.
Cleft Rhinoplasty Before & After Case 10
This handsome man had severe nasal obstruction and nasal asymmetry, with collapse and less growth of the left side of his nose. He also had a notch of his upper lip with some irregular scar texture.
Open rhinoplasty was performed, with release of the old scar tissue, and multiple cartilage grafts from his septum used to support his collapsed nasal passages, and to fill in the deep depression at the left alar groove.
Removing the crooked septal cartilage also helped open up his nasal airway.
The lip was re-repaired, with removal of the irregular scar tissue and improved balance of the height and width of the skin, dry mucosa, and wet mucosa, along with the underlying muscle.
Each of these components must be addressed individually, as well as all together kept in balance.
His swelling will continue to improve for at least 9-12 months, though some patients report improvement even at 18-24 months. He is seen here at 4 months.
Cleft Rhinoplasty Before & After Case 11
This man had a history of a cleft lip and a lifetime of difficulty breathing through his nose.
The septum (or wall between the two nostrils) is deviated away from the cleft, and the cartilage on the cleft side is usually smaller and weaker.
Correction of the deviated septum, and use of the cartilage for grafts to buttress the airway, helped to improve his nasal symmetry and ease of breathing.
Cleft Rhinoplasty Before & After Case 12
Septoplasty and spreader grafts, with tensioning of the upper lateral cartilages over the grafts, helped his breathing. This is like having an internal Breathe Right strip people use for snoring and nasal collapse.
His contour and projection match his face well, with his dorsum straighter and tip projection increased.
An onlay alar graft and tip graft helped to soften his alar groove, and added to his tip support.
Finally, the fat graft to his upper lip acts as a permanent filler, balancing the thinner upper lip with the more full lower lip. I generally prefer using fat over dermal fillers, as I like giving the longest-lasting results with the fewest number of procedures. Plus, insurance will cover the fat graft procedure, and fillers are paid cash out of pocket.
Cleft Rhinoplasty Before & After Case 13
This young man has a history of a cleft lip and palate, with septal deviation and nasal collapse.
I performed an open rhinoplasty, with straightening of his septum and use of the septal cartilage along with ear cartilage to straighten and support his nose.
His breathing and symmetry is already much improved at 1 week after removal of his splints.
We also repaired a small notch in his lip, and performed fat grafting to his upper lip and a bone graft to his cheeks to improve his facial harmony and balance.
Cleft Rhinoplasty Before & After Case 14
This athlete couldn’t breathe, with a history of a fractured and deviated septum, and a pharyngeal flap previously used to help speech for her cleft palate.
For patients with a history of a pharyngeal flap, these may actually be divided and revised after several years, usually with no change in speech and nasality, but with much improved breathing and speech.
In the same setting, her fractured septum was straightened, and cartilage grafts including spreader grafts and columellar grafts helped to let her breathe through her nose!
Her dorsum is now more regular, and her tip more refined and rotated up.
These are some of my favorite surgeries, tailoring surgeries to each person’s individual goals and needs, all while making sure they’re breathing like never before!
Cleft Rhinoplasty Before & After Case 15
First and foremost, he had difficulty breathing because of a deviated septum.
From the front you can see a slight deviation of the bridge of his nose extending to the tip. As it extended into his nasal passage, the deviation was more and more apparent, causing almost complete blockage of air movement on one side.
Correction of the deviated septum – and use of the septal cartilage grafts to the dorsum and cleft side of the ala – greatly improved his breathing.
He also has an improvement of his definition and symmetry, even at just 1 month after surgery with more improvement of his swelling still ahead of him.
Cleft Rhinoplasty Before & After Case 16
She also hoped for improved nasal symmetry. We performed an open cleft rhinoplasty, including release of scar tissue and reconstruction with multiple cartilage grafts (spreader, septal extension, columellar strut, lateral crural strut, and tip grafts).
MTF cadaveric cartilage was used after discussion pros and cons of using her own rib versus donor cartilage.
She is seen here at just 4 weeks, so the swelling will still go down another 50%. Fat graft was also performed for the upper lip, to add more bulk to begin balancing that with the lower lip.
Jaw surgery will be performed in the future. Cleft rhinoplasty is usually performed after jaw surgery. However, in this case, her breathing obstruction was severe enough to warrant doing the nose portion sooner.
The alar base scarring and any further refinements may be done at the time of the jaw surgery.
Cleft Rhinoplasty Before & After Case 17
There must also be enough strength to keep the walls from collapsing in.
Here, the biggest problems were blockage by a deviated septum, and scar tissue from a lifetime of previous cleft surgeries.
The scar tissue can be thick, tighten like a lasso, and even create bands that go across from the septum in the middle to the side.
Here, these scar bands were released and reconstructed with local rearrangement (Z-plasty, V-Y advancement) for the soft tissue.
The deviated septum was straightened and resected, with special attention paid to the bone that sits further back. This bone is the most common place I find continued blockage after someone has had a previous surgery, and this area was not treated.
Support was given by rib graft to the dorsum, ear cartilage grafts to the tip, and some cartilage and soft tissue along the rim to support the external nasal valve.
The central part of the lip in the dry vermilion was also re-repaired to add some bulk here and push some of the mucosa that wants to be inside the mouth, back inside. Otherwise, this mucosa can become dry, cracked, and bleed.
Cleft Rhinoplasty Before & After Case 18
“The amount of symmetry on both sides that you were able to achieve really impressed me.
“I’m very, very happy with the results.”
Cleft rhinoplasty for adults – one of the tougher surgeries we do, but also one of the most rewarding.
Here, a previous low strip of cartilage had been removed, yet he still had problems breathing.
The bony septum required resection further back. Towards the front, vertical excess and deviation of the cartilage required septal resection and reset to the midline.
Cartilage grafts included asymmetric spreader, a caudal septal extension, columellar strut, alar rim, and stacked alar base grafts. This was from a combination of native septal cartilage, and @MTFbiologics rib cartilage.
Notably, the lateral nasal sidewall was also advanced in V-Y fashion to redistribute scar tissue, and advance the lateral crus of the LLC.
Cleft Rhinoplasty Before & After Case 19
Here, the upper jaw required greater than 10mm of advancement to correct his occlusion.
Thus, we performed a Le Fort 1 internal distraction: the maxilla was mobilized, and hardware placed to gradually bring the bone and teeth forward 0.5mm at a time.
This incremental movement stretches the scar tissue, blood vessels, and nerves, giving them a chance to catch up a little bit every day and adapt. Otherwise, the advancement in a single surgery can be limited, and the maxilla is at risk of collapsing back.
Once the new bone solidifies, we return to retrieve the hardware and double-check stability of the new bone.
Here, he had continued difficulty breathing through his nose, and desired improved symmetry and contour.
Given his ongoing nasal obstruction — a closed septorhinoplasty was performed at the same time as the hardware removal.
MTF rib cartilage was used as a dorsal onlay graft, cantilevered with a septal extension graft. Tip grafts and diced cartilage helped provide some further tip definition and contour.
He is healing wonderfully at one month, with the swelling already much improved.
Cleft Rhinoplasty Before & After Case 20
A few things combine to create common complaints:
1) Inherently different/less growth potential
2) Asymmetric and/or abnormal attachments of muscles and ligaments
3) Bony asymmetries
4) Scar tissue
5) Abnormal blood and lymphatic flow
These inevitably lead to problems breathing, and often thick and scarred nasal envelopes that are difficult to restructure.
Here, septoplasty, multiple grafts (spreader, lateral crural strut, septal extension, and tip), all work together to provide a more symmetric and projected framework. The cartilage was a combination of his own septum and from MTF cadaveric rib. Other options include one’s own ear and/or rib cartilage.
He is seen here at 1 month, with swelling improving every day.