|Year : 2014 | Volume
| Issue : 2 | Page : 115-118
Surgical correction of severe bifid nose
Sinan Ozturk1, Fatih Zor2, Selcuk Isik2
1 Department of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey
2 Department of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy, Ankara, Turkey
|Date of Web Publication||2-Aug-2014|
Dr. Sinan Ozturk
Department of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy, Istanbul
Source of Support: None, Conflict of Interest: None
Craniofacial clefts cause severe facial disfigurement even in minor forms. The surgical reconstruction is imperative to restore function and appearance of facial structures. The presentation of Tessier number: 0 cleft patient may vary from minimal changes on median facial structures such lip, vermilion and nose, and nose to wide clefts dividing all median craniofacial structures. The variability of expression of the unusual orofacial clefts can be challenging for the surgeon, while reconstructing affected facial structures. In this report, we present the surgical management of the case with severe bifid nose. A 27-year-old male presented with congenital midfacial disfigurement with hypertelorism. The patient had a flat nasal dorsum and a deep groove between the two alar domes. The nose was short and bifid. The patient did not accept facial bipartition surgery. We performed de-epithelialization on the skin groove between the two alar domes. We repaired lower one-third part of the nose with native nasal tissues. We reconstructed upper two-third part of the nose with the osteocartilage frame harvested from the calvarium and the nasal septum. Two superiorly based-nasolabial flaps were designed with sufficient length to provide external cover of the osteocartilage frame. In case of the severe bifid nose, osteocartilaginous and soft tissue structures of the nose must be restored separately. Following reconstruction of the osteocartilaginous framework with nasal tissues or grafts, remaining nasal soft tissue, and local flaps can be used to cover the soft tissue.
Keywords: Bifid nose, cleft 0, surgical
|How to cite this article:|
Ozturk S, Zor F, Isik S. Surgical correction of severe bifid nose. J Cleft Lip Palate Craniofac Anomal 2014;1:115-8
| Introduction|| |
Craniofacial clefts cause severe facial disfigurement even in minor forms. The surgical reconstruction is imperative to restore function and appearance of facial structures. Orofacial clefting is a failure in embryonic facial development during the first 8 weeks of life. The cause of craniofacial clefts is not clear. However, some theories about orofacial clefting have been submitted such as failure of fusion theory and the failure of mesodermal penetration theory.  Various risk factors (radiation, infection, maternal metabolic imbalances, and drugs and chemicals) have been published.  Craniofacial clefts were classified by Tessier, according to their anatomical basis.  This classification system contains numbered clefts from 0 (midline cleft of the lip and nose) to 14 and 30 (mandibular). Presentation of median cleft may be varied from minimal changes on median facial structures such lip, vermilion, and nose to wide clefts dividing all median craniofacial structures.  The median craniofacial skeleton (crista galli, ethmoid, vomer, nasal, and premaxillary bones) and the cartilaginous septum can be affected in severe cases. Tessier number: 0-cleft may cause death if it is associated with holoprosencephaly.  Although the clinical presentation of patients has been almost always enough for a diagnosis of the craniofacial clefts, computed tomography (CT) scans help the surgeon to plan surgery. Minimal malformations on median facial structures can be corrected with local flap options such as z-plasties and v-y advancement flaps.  However, severe cases require reconstruction of midline of the craniofacial skeleton. Surgical correction of bifid nose can be challenging and requires multiple surgical procedures. A few articles related to surgical correction of this unusual malformation have been published. ,, In these articles, various surgical techniques have been described. The variability of expression of the unusual orofacial clefts can be challenging surgeons in reconstruction of affected facial structures. Here, we present the surgical management of the case with severe bifid nose.
| Case Report|| |
A 27-year-old male presented with congenital midfacial disfigurement with hypertelorism. The physical examination revealed a midfacial clefting with normal calvarial and lower facial structures. The patient had a flat nasal dorsum and a deep groove between the two alar domes. The nose was short and bifid. The width of nasal radix was increased. The nasal septum was thick and doubled. The nares were asymmetric and separate. The left nare was constricted and narrower than the right one. The phitral dimple was clefted and phitral columns were wide apart [Figure 1]a-c. CT scans revealed bony cleft lying from the anterior nasal spine to the radix of the nose. Patient did not approve the offered facial bipartition surgery. We thus focused mainly on reconstruction of the bifid nose. All the laboratory tests were in normal ranges.
|Figure 1: (a) Preoperative frontal view of the patient with severe bifid nose. (b) Preoperative lateral view of the patient with severe bifid nose. (c) Preoperative inferior view of the patient with severe bifid nose. (d) Postoperative frontal view of the patient with the acceptable functional and aesthetic outcome at 2 years of follow-up. (e) Postoperative lateral view of the patient with the acceptable functional and aesthetic outcome at 2 years of follow-up. (f) Postoperative inferior view of the patient with the acceptable functional and aesthetic outcome at 2 years of follow-up|
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| Surgical Technique|| |
Under general anesthesia, the skin groove between the 2 alar domes was de-ephitelized [Figure 2]. Following de-epithelization, dermis and the soft tissue covering the upper two-third of the nose was raised as an inferiorly pedicled single flap. The upper lateral cartilages and the lower lateral cartilages were detached from the overlying skin and subcutaneous tissues with a combination of sharp and blunt dissection. The right and left alar parts of the bifid nose were transposed to the midline and sutured by interdomal sutures.
|Figure 2: Surgical plan showing de-epithelized skin groove between the 2 alar domes|
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The septal mucosa was detached from cartilaginous skeleton of septum. The nasal septum was thick. After the septoplasty, the nasal passage was open. The hypertrophic bone segment, lying at the base of the priform aperture, was removed. Monocortical calvarial bone graft, 1.5 cm × 2.5 cm in diameter, was harvested from right parietal region. The calvarial bone graft and the septal cartilage grafts were reshaped to form the new cartilaginous and the bony nasal vault [Figure 3]. The cartilaginous and the bony frames were sutured to him each other with 5/0 polypropylene sutures. A subcutaneous tunnel was created with a dissector from the base of the columella through the de-ephitelized flap. The lateral osteotomies were completed percutaneously with a 2-mm osteotome. The lateral walls were infractured to close the roof and reshaped the nose in upper third. The inferiorly based flap was used to cover osteocartilage frame. Two superiorly based nasolabial flaps were designed with sufficient length to provide external cover of the soft tissue insufficiency of the middle one-third of the nasal dorsum [Figure 4]. The flaps were transposed to the superomedial part of the nose and inset with 5/0 polypropylene sutures. The nostrils were packed with Xeroform gauze with Vaseline. The nasal splint was applied for 2 weeks. A second procedure was performed 2 months later. In this operation, the pedicles of the nasolabial flaps were divided, and a revision of the flaps was performed. The functional and esthetic outcome was acceptable at 2 years of follow-up [Figure 1]d-f.
|Figure 3: The calvarial bone graft and the septal cartilage grafts were reshaped to form the new cartilaginous and the bony nasal vault|
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|Figure 4: The surgical steps of movement of alar flaps and superiorly based nasolabial flaps|
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| Discussion|| |
Although facial bipartition is essential for the reconstruction of the facial skeleton, sometimes patients prefer minimal surgery as our patient did. The clefts including upper lip structures (Cupid's bow, labial philtrum, vermillion, and buccal mucosa) can be reconstructed with local flaps.  When the nasal structures were affected, more complex surgical correction is needed. The hypoplastic and laterally displaced alar and upper nasal cartilages should be corrected to obtain more acceptable nasal shape. We rotated both alar cartilages medially to form cartilaginous framework of the lower one-third of the nose. With the rotation and medial advancement of lower nasal structures, nasal projection was also improved. Moreover, optimal nasal length could be obtained. Calvarial bone graft was used to augment the nasal dorsum. Our technique resembles the embryologic movement of the nasal structures.  We believe that correction of the lower one-third of the nose with native structures plays a key role in obtaining natural nasal appearance. Following medial and inferior rotation of the two lower lateral cartilages, there still was a soft tissue defect in the middle one-third of the nose. This soft tissue defect was covered with bilateral superior pedicled nasolabial flaps. Nasal septum can be duplicated in some cases.  Our patient had one, thickened nasal septum. The unilateral thickenings of the septum narrow nasal passage. Septal resections were performed to open the blockage of the nasal passages. Lateral osteotomies are usually insufficient to prevent a saddle nose appearance. We also used monocortical calvarial bone graft to augment the nasal dorsum as suggested by Jackson et al.  We think that the usage of bone graft works well for obtaining nasal projection in severe bifid nose cases. Harvesting of costal cartilages can lead donor site problems.  Skin excision from nasal dorsum is widely suggested in the literature. However, we did not perform skin excision, but de epithelized this part in order to cover the calvarial bone graft.
In case of early repair of bifid nose more conservative, surgical approaches are described. The case presented here was corrected during adulthood. We are not sure whether our technique has an adverse effect on nasal development when performed in childhood. The only disadvantage of our technique that it needs two stages. Second stage can be performed 2 months later under local anesthesia.
| Conclusion|| |
In case of severe bifid nose, osteocartilaginous and soft tissue structures of the nose must be restored separately. Besides to facial bipartition, we think that the lower one-third part of the nose, including the lower cartilages must be reconstructed by native nasal structures. Following reconstruction of the osteocartilaginous framework with nasal tissues or grafts, remaining nasal soft tissue and local flaps can be used to cover the soft tissue.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]