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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 17-23

Reconceiving the closed approach in unilateral cleft lip rhinoplasty: An objective evaluation of 64 consecutive cases

Department of Plastic and Cosmetic Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission03-Aug-2019
Date of Acceptance03-Dec-2019
Date of Web Publication20-Jan-2020

Correspondence Address:
Dr. Chirayu Parwal
Department of Cosmetic and Plastic Surgery, Room No. 2325, Sir Ganga Ram Hospital, New Delhi - 110 060
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_20_19

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Introduction: The cleft lip nose has been the classical case of an unsolved mystery in the history of plastic surgery. As Kernahan aptly stated, “a repaired cleft is revealed more by the associated nasal deformity than by the repair line.” Cleft lip nasal deformity becomes a surgical challenge due to various reasons: 1. Wide variation in clinical presentation, requiring a host of surgical techniques. 2. Deformity may be quite asymmetric, making correction difficult. 3. Patients might have undergone several previous operations, which lead to scarring. Aim: We aim to assess the surgical outcome of the closed approach of unilateral cleft lip nose deformity correction. Methodology: We perform the cleft lip nose correction with the primary cleft repair as well as a secondary rhinoplasty in preschool age group and adults depending on the esthetic concerns. Our approach is the closed (endonasal) rhinoplasty technique to dissect the slumped alar cartilage of its soft-tissue attachments and cutaneous skin flap and reshape and reposition it with the help of sutures inserted percutaneously. Results: We have evaluated our results by comparing the pre- and post-operative photographs in standard views and represented the correction of several esthetic nasal parameters with a simple numerical rating. We have compiled the overall result by taking into account the collective numerical ratings at 6 months of follow-up. Our results of primary rhinoplasty ranked in the “good” or “excellent” category in 85% of the cases while it was “fair” or “good” in 82% of the secondary rhinoplasties. Conclusion: We conclude that the closed rhinoplasty is less invasive, takes less surgical time, avoids tedious dissection, gives better on table predictability of the outcome, and shortens postoperative recovery and tissue healing, providing a stable and acceptable result.

Keywords: Cleft nose deformity, cleft rhinoplasty, closed rhinoplasty, primary rhinoplasty

How to cite this article:
Parwal C, Choudhary L, Pandey A, Saha SS, Kumar V. Reconceiving the closed approach in unilateral cleft lip rhinoplasty: An objective evaluation of 64 consecutive cases. J Cleft Lip Palate Craniofac Anomal 2020;7:17-23

How to cite this URL:
Parwal C, Choudhary L, Pandey A, Saha SS, Kumar V. Reconceiving the closed approach in unilateral cleft lip rhinoplasty: An objective evaluation of 64 consecutive cases. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2021 Oct 16];7:17-23. Available from: https://www.jclpca.org/text.asp?2020/7/1/17/276197

  Introduction Top

Cleft lip rhinoplasty is one of the right brain plastic surgery procedures. This stems from the fact that despite detailed, orderly analysis of the cleft lip nose deformity, esthetic virtues still remain vastly unexplored. Correction of the cleft lip nose includes a plethora of radical and subtle surgical interventions that work the best when customized to the presenting deformity [Figure 1] and [Figure 2]. As Kernahan aptly stated, “a repaired cleft is revealed more by the associated nasal deformity than by the repair line.”[1]
Figure 1: A classical primary unilateral cleft lip nose deformity

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Figure 2: A typical adult cleft lip nose deformity

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Cleft lip nasal deformity becomes a distinct challenge due to various reasons [Figure 3].[2],[3]
Figure 3: A deforming trans columellar scar seen following open rhinoplasty

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  1. Wide variation in clinical presentation, requiring a host of surgical techniques
  2. Deformity may be quite asymmetric, making correction difficult
  3. Patients might have undergone several previous operations leading to scarring
  4. The timing of rhinoplasty, whether staged or synchronous with a cleft lip repair.

Conventionally, cleft lip nose surgery is either the closed or open rhinoplasty, with the semi-open techniques lying somewhere in between the spectra. Over the years, the equilibrium has well and truly shifted toward open rhinoplasty as the analysis of the cleft lip nose has become more objective and the surgeries more rational.

We undertake the cleft lip nose correction with closed rhinoplasty techniques in infants, children, and adults. In the following case series, we present our method of unilateral cleft lip rhinoplasty with closed approach followed by an objective analysis of our results.


The aim is to assess the surgical outcome of the closed approach of unilateral cleft lip nose deformity correction at our institute and to achieve objectivity in the assessment of this rather subjective deformity by giving a subjective score to several esthetic parameters and do an objective analysis of that score. We also wish to give an insight into the closed approach in rhinoplasty, which factually seems to be losing the race when compared with the open technique.

  Methodology Top

After obtaining due approval from the Hospital Ethics Committee, this observational study was conducted on 64 patients presenting with unilateral cleft lip nose deformity at Sir Ganga Ram Hospital, New Delhi, India. Each patient enrolled in the study was furnished with a legible patient information sheet, and a written and informed consent was obtained.

The study was conducted on 64 consecutive patients including infants (n = 38), adults (n = 14), and children (n = 12) presenting with unilateral cleft lip nose deformity. Patients with syndromic clefts and those with a history of presurgical nasoalveolar molding or orthodontic intervention were excluded from the study.

Each patient was subjected to full history and detailed local and systemic examination.

Preoperative photography using a digital camera was taken in standard positions by the corresponding author:

  1. Frontal view
  2. Lateral/profile view
  3. Basilar/worm's view.

Camera specifications - All photos were taken from the same camera-16 MP, f/1.7, 24 mm (wide), 1/2.8“,1.12Um, phase detection auto focus (PDAF) with flash (Dual – light emitting diode [LED]) from a distance of 40 cm against a light background.

Operative details

Infants – Primary correction of cleft lip was done by the rotation advancement method with anterior palate repair and primary rhinoplasty - alar cartilage of cleft side is mobilized dissecting through lip incisions and hitching of cleft side buckled alar cartilage to opposite normal alar and or ipsilateral/contralateral upper lateral cartilage by mattress sutures exiting and reentering from the skin over the dorsum of the nose at the same point and securing the knot inside the nasal vestibule.

Children (preschool) – The technique employed was essentially the same as in primary rhinoplasty, with closed dissection of the alar cartilage from the dorsal aspect and partially from the mucosal aspect and complete release of the alar base from soft-tissue attachments. The inter-domal soft tissue was excised, and alar lift and medialization were done with suspension sutures.

Children (7–11 years) – all these patients were evaluated for alignment of alveolar arches and future dentition. Gingivoperiosteoplasty with alveolar bone grafting was done in these patients with secondary correction of the nasal deformity by the closed (endonasal approach). No additional incision was made in the nasal lining. The maneuvers for alar cartilage repositioning were similar as described above and were customized on a case-to-case basis. No dissection of the nasal septum was done.

Adults – Patients presenting for adult secondary cleft lip rhinoplasty were operated with the closed (endonasal) approach with an additional marginal incision in the nasal lining. The hypoplastic maxilla on the cleft side was augmented with cancellous bone graft. The displaced anterior nasal spine was resected, and the base of the columella was augmented. Closed dissection of the alar cartilage was done followed by alar lift and medialization with inter-crural and inter-domal sutures, and repositioning of the slumped alar cartilage was done by suspending it with the upper lateral cartilage. The alar base was advanced medially by the alar cinch suture. Septoplasty, humpectomy, and nasal osteotomy were done as required. Septal cartilage grafts were used for nasal tip/dorsum augmentation if required. Fat grafting was employed to correct the nasal contour as well as to add bulk to the upper lip vermillion if needed.

Primary rhinoplasty

In the case of primary rhinoplasty, the postoperative photographs were subjectively analyzed by all the authors of this manuscript, and an objective score was assigned to each of the esthetic parameters evaluated [Table 1]. At 6 months of follow-up, each patient was photographed using the digital camera under standard conditions, and a subjective rating between 0 (no deformity) to 3 (severe deformity) was given for each of the 13 esthetic parameters independently [Table 2].
Table 1: Esthetic parameters analyzed

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Table 2: Grading and scoring system for deformity

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Further, to grade these scores, we subjectively chose 1 or 2 of our best results and calculated the objective score range for them and likewise for the poor results. In this way, we formed the grading of our result and graded rest of our results purely on the objective scoring from the esthetic parameters to do away with the subjectivity as much as possible. The following scheme of the evaluation was adopted [Table 3].
Table 3: Grading and scoring system for primary deformity

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Secondary rhinoplasty

Preoperative photographs were taken in the standard views, and each esthetic parameter was given a preoperative deformity score as described. Postoperative photographs were taken in the same position as preoperative photographs at 6 months of follow-up and again, a score was assigned for each parameter. In cases of secondary rhinoplasty, we made a direct objective comparison by assessing the pre- and post-operative photographs taken under standard conditions and similar views to grade our result. Again a similar scheme of assessment and grading was used as in primary rhinoplasty, only this time we found it was logical to compare our results with the preexisting deformity to grade our surgical outcome.

The total pre- and post-operative deformity score for all the 13 parameters considered were summed up, and the difference was noted as the “surgical correction [Table 4].” The “correction” was, in turn, represented as percentage correction of the preoperative deformity and the results were graded as follows.
Table 4: Grading for surgical correction percentage (esthetic parameter)

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  Observations and Results Top

Of the total of 64 patients included in the study group, 59% (n = 38) of the patients were infants and had presented for primary cleft lip and anterior palate repair. Whereas, 26 patients had presented for secondary rhinoplasty which included children in preschool age group (n = 4), adolescent age group (n = 7), and adults (n = 15). The maximum age was 28 years and the minimum age was 2.5 months with a mean age of 6.2 years.

Of the patients operated for primary cleft lip and anterior palate repair with primary rhinoplasty (n = 38), the deformity score at 6 months is described in [Table 3]. Twenty-eight of the 38 primary rhinoplasty had a “good” or an “excellent” correction with no “poor” result [Figure 4].{Table 3}
Figure 4: (a) Result of primary cleft lip rhinoplasty at 6 months (frontal view). (b) Result of primary cleft lip rhinoplasty at 6 months (basal view). (c) Long-term (3 years) results of primary cleft lip rhinoplasty (frontal view)

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Of the patients presenting for secondary rhinoplasty (n = 26), the esthetic parameter most deformed on frontal view was the symmetry of alar lobule, on profile view the alar retraction and position of the alar base was most deformed, while on basilar view, the symmetry of the nostrils was the most deformed esthetic parameter noted [Figure 5], [Figure 6], [Figure 7]. At 6 months postoperative follow-up, on frontal view, the symmetry of alar lobule had 63% improvement, on profile view, the alar base retraction or the position of alar base had 75% improvement, while on the basilar or the worm's eye view, the symmetry of alar cartilage had 73% improvement as per the deformity scoring criteria previously described [Figure 8].
Figure 5: (a) Results of adult secondary cleft lip rhinoplasty via closed approach (frontal view). (b) Results of adult secondary cleft lip rhinoplasty via closed approach after 6 months (basal view). (c) Results of adult secondary cleft lip rhinoplasty via closed approach (profile view)

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Figure 6: Results of adult secondary cleft lip rhinoplasty via closed approach (frontal view – pre- and post-operative)

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Figure 7: (a) Adult cleft lip nose deformity (preoperative - frontal and basal view). (b) Adult cleft lip nose deformity (immediate postoperative - frontal and basal view) on table result

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Figure 8: Result description of various features in secondary cleft lip rhinoplasty via secondary approach

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It is noteworthy that the deformities most concerning in the frontal view had a fair correction, while the deformity most concerning on profile and the basilar view had a good correction at 6 months follow-up. We revised the lip repair scar in 22 of the 26 cases [Figure 9]. This suggests that although the lip symmetry was stable in most of the patients, they often perceive a cleft lip look and attribute it to the cleft lip repair scar. Our results in secondary rhinoplasty show a mean 62% improvement in the cases included, which is a “fair” result [Figure 5], [Figure 6], [Figure 7].
Figure 9: List of secondary procedures done

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Overall, our results are better in primary rhinoplasty [Table 5] than secondary, and certain esthetic parameters have shown a drastic improvement while some were quite resistant. We had only one poor result and that was in secondary rhinoplasty [Table 6]. Importantly, all our patients perceived improvement after surgery and were satisfied with their decision to opt for surgical correction.
Table 5: Results of primary rhinoplasty

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Table 6: Results of secondary rhinoplasty

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  Discussion Top

Primary nasal correction at the time of cleft lip repair lessens the eventual secondary cleft lip nasal deformity.[4] Primary rhinoplasty minimizes nasal asymmetry and allows the nasal cartilages to grow in a symmetric fashion and eliminates psychological ridicule for the child.

In some cases, early conservative secondary rhinoplasty may be performed in the preschool age group to avoid any social embarrassment for the child.[5] It may as well be offered when the child is being operated for any palatal fistula or at the time of alveolar bone grafting.

The closed method with the use of permanent sutures placed through the skin and fixed by bolsters has been described with success by Millard, Salyer, and McComb.[6],[7]

The closed approach, through an incision made within the nostril, provides minimally invasive access to the nasal structures. It allows accurate postoperative assessment of changes made and provides natural pockets for the placement of grafts within the nose, all without causing the prolonged postoperative swelling and trans-columellar scarring seen with the open technique.[8]

The closed rhinoplasty is not a blind operation. The operative strategy, making skeletal changes through limited incisions and judging progress by feeling the surface, is precisely the same discipline required by suction-assisted lipectomy.[9] Limited pocket dissection minimizes the need for graft fixation and simplifies the procedure.

The endonasal rhinoplasty is an operation designed around skin sleeve movement, balance changes, and the effects of reduction and augmentation, and it depends on an ability to see the undisturbed nasal surface accurately. This is the right-brain part of the operation.

Closed rhinoplasty, avoids the transcolumellar scar, which otherwise has a constricting effect on the columella and is all the more visible in the Indian skin type [Figure 3]. It also limits pocket dissection, hence reducing the graft requirement. By maintaining the skin continuity across the columella, the nasal tip support is maintained; the edema on the dorsal nasal flap is significantly reduced, making the operative assessment better, operative time shorter, postoperative recovery faster, and results predictable.

The open approach has been used conventionally for more difficult and complicated procedures, especially when working on the nasal tip. The open approach provides superior visualization and access; however, the external scar, loss of nasal tip support, interruption of columellar artery blood supply to the tip, and prolonged swelling are important downsides to this technique.[10] The dissection is slower, and postoperative morbidity may be higher. Poor scars occasionally, occur as well as secondary deformities.[11]

The art of rhinoplasty involves accurate analysis of the deformity, recognition of anatomic variants, tissue characteristics, or functional/structural interrelationships, and neat surgical execution. Most secondary deformities result from inaccurate assessment and almost none because the surgeon could not see well.[9]

In secondary rhinoplasty, we observed that the deformed alar cartilage did not readily correct on mere mobilization and release of deforming forces, suggesting that the cartilage had become permanently deformed. These cartilages were managed by either excision of severely deformed segments or by using percutaneous transdomal mattress sutures to change their convexity as required.

To summarize, the technique and approach to the cleft lip nose is best left to the surgeon's comfort and competence. We humbly concede that as cleft surgery still remains in the realm of clinical subjectivity, no standardized protocol or approach could be uniformly employed. Nevertheless, our technique, we believe is easy to inculcate and replicate, especially by young cleft surgeons.

We believe in the fact that the cleft lip nose is largely an esthetic deformity and so shall be its evaluation. It is essential to involve the patient and their family in the evaluation process apart from the surgical team. At the same time one has to objectify the findings, and hence that the inference can be made meaningful with the use of computer archive.

The evaluation of cleft rhinoplasty is a tedious process as it involves lot of technical backing apart from patient education and bias. To the best of our knowledge, such an evaluation in the Indian perspective is lacking. It can be due to the fact that follow-up in the Indian scenario is fairly irregular, patient education is low, and bias is tremendous.

  Conclusion Top

The cleft lip nose is a very resistant surgical scenario. A radical intervention does not always give a desired outcome while a subtle maneuver often might sub serve the very purpose. Our approach is endonasal or the closed rhinoplasty approach in both primary and secondary correction.

In the light of work published by eminent cleft surgeons in India and worldwide, we conclude that our approach is simple, sound, and systematic. Our method is nondestructive, and we repair only what is needed and restore what is deficient and correct what is deviated. We stick to primary rhinoplasty and nasal floor repair in infancy and abdicate from gingivo-periosteoplasty till 7 years of age (just before the eruption of the lateral maxillary incisor in the alveolar cleft) and employ osteotomy and septoplasty only after complete facial growth is completed. We avoid the use of any implant or bone/cartilage graft over the nasal tip to ensure it feels soft and supple. We essentially practice closed rhinoplasty, the results of which at least in our hands, have been stable, consistent and fairly satisfactory both esthetically and functionally. Some of our results have been followed up for up to 2 years and have proved to be stable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kernahan D. Ten year review of the Tajima technique. Plast Reconstr Surg 1984;49:178.  Back to cited text no. 1
Mulliken JB, Martínez-Pérez D. The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: Technical variations and analysis of results. Plast Reconstr Surg 1999;104:1247-60.  Back to cited text no. 2
Mokal NJ, Prabhash, Kale C. Composite correction of a unilateral cleft lip nose deformity and alveolar bone grafting. Indian J Plast Surg 2009;42 Suppl: S71-8.  Back to cited text no. 3
Berkeley WT. The cleft-lip nose. Plast Reconstr Surg Transplant Bull 1959;23:567-75.  Back to cited text no. 4
Shih CW, Sykes JM. Correction of the cleft-lip nasal deformity. Facial Plast Surg 2002;18:253-62.  Back to cited text no. 5
Vanderas AP. Incidence of cleft lip, cleft palate, and cleft lip and palate among races: A review. Cleft Palate J 1987;24:216-25.  Back to cited text no. 6
Ortiz-Monasterio F, Olmedo A. Corrective rhinoplasty before puberty: A long-term follow-up. Plast Reconstr Surg 1981;68:381-91.  Back to cited text no. 7
Kim HC, Jang YJ. Columellar incision scars in Asian patients undergoing open rhinoplasty. JAMA Facial Plast Surg 2016;18:188-93.  Back to cited text no. 8
Mark BC. Closed technique rhinoplasty. In: Neligan PC, editor. Plastic surgery. 3rd ed. London: Elsevier Saunders; 2013. p. 414-5.  Back to cited text no. 9
Spörri S, Simmen D, Briner HR, Jones N. Objective assessment of tip projection and the nasolabial angle in rhinoplasty. Arch Facial Plast Surg 2004;6:295-8.  Back to cited text no. 10
Constantian MB. Nasal tip surtures part II. Plast Reconstr Surg 2002;4:444-51.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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