Hello, this is Dr. Cha-Young Kang, head surgeon at Nose Lab Clinic.
Today, I would like to introduce a rhinoplasty case for a patient with a history of cleft lip and palate. Cleft lip and palate patients often present with congenital asymmetry, making correction challenging, and achieving perfect symmetry may not always be possible.
Let's take a closer look at this case.
1. Patient Medical History
The patient had undergone multiple surgeries over the years:
5 months old: Cleft lip closure surgery at a university hospital.
4-5 years old: Revision cleft lip closure surgery at a university hospital.
5th grade (elementary school): Pelvic bone graft to the palate.
Middle school: Lip asymmetry correction.
14 years ago: Nasal ala (nostril) reshaping using silicone and ear cartilage (left nostril reduction, right ear cartilage graft).
2. Patient's Requests
Improvement of the deepening and pinched appearance on the right side of the nasal tip.
Correction of the nasolabial angle (the angle between the nose and upper lip).
Enhancement of midfacial projection by elevating the nose.
Creation of a nose shape that harmonizes with the rest of the face.
Asymmetry correction (acknowledging limitations due to nostril length discrepancy).
3. Design Consultation
Pre-surgery photos showed that the right nostril was pinched, the nasal tip was crooked, and the columella was depressed. Additionally, the nasolabial angle was less than 95 degrees, which required correction to improve the overall appearance and balance of the nose.
Pre-Surgery Design Consultation: Frontal, Left Oblique, and Left Profile Views
Pre-Surgery Design Consultation: Right Oblique, Right Profile, and Nostril Views
4. Surgical Plan
Facial CT Images (Original Images)
Facial 3D CT Images (Original Images)
CT imaging revealed a deficiency in the right maxilla (upper jaw), as well as nasal cavity asymmetry.
The yellow line in the image outlines the shape of the septal cartilage, while the red line indicates the height of the nostril floor. The left side of the image corresponds to the patient’s right side, showing that the right nostril floor is significantly lower than the left.
The blue line shows how autologous rib cartilage was used to correct the asymmetry. By reconstructing the deviated septal cartilage and using rib cartilage to fill the low area of the right nostril floor, the asymmetry was improved.
The left image shows a defect in the right maxilla as seen on a 3D CT scan, and the right image demonstrates how this area will be corrected through reconstruction.
5. Surgical Procedure
a) Septal Cartilage Reconstruction:
The patient’s septal cartilage was severely damaged due to previous surgeries, where the nasal tip had been fixed to the septum without considering the septal deviation.
Autologous rib cartilage was used to reconstruct the septum, shifting it to the right and stabilizing it through a partial septal reconstruction procedure.
b) Right Alar Cartilage Reconstruction:
The right alar cartilage was almost entirely missing.
Autologous rib cartilage was used to reconstruct the right alar cartilage.
The newly reconstructed cartilage was symmetrically anchored to the extended septum, helping to correct the nostril asymmetry.
c) Nostril Correction:
Due to prior surgeries, the right alar base had been shortened significantly.
Since cartilage reconstruction alone could not fully correct the nostril shape, a composite graft (cartilage-skin graft) was performed inside the nostril to improve its contour.
This procedure greatly enhanced the symmetry of the nostrils.
d) Reinforcement of the Right Nostril Floor:
The depressed right nostril floor was a major factor contributing to the nostril asymmetry and overall nasal deviation.
The defect in the maxilla (upper jaw bone) was filled with autologous rib cartilage to support and balance the nostril floor.
This significantly improved the overall symmetry of the nostrils and nasal base.
6. Before and After Photo Comparison
Frontal view before surgery (left) after surgery (right)
Frontal View:
Significant improvement in nostril asymmetry, alar base asymmetry, and the crooked nasal tip.
The bulbous appearance of the nasal tip was reduced, creating a more refined look.
Side profile view before surgery (left) after surgery (right)
Profile View:
The nasal tip projection has been enhanced, providing a more defined and elevated tip.
The starting point of the nasal bridge has been lowered naturally, improving the overall balance between the bridge and the tip, resulting in a more three-dimensional appearance.
A natural, straight dorsal line (straight nose) was created.
The columella has been lowered slightly, resulting in a more natural nasolabial angle.
45-degree angle view before surgery (left) after surgery (right)
Oblique View:
The nasal bridge line appears more harmonious and natural.
Nostrils before surgery (left) after surgery (right)
Nostril View:
The previously collapsed right nostril has been significantly restored.
The shape of the nostrils now appears more symmetrical and balanced.
The previously tilted columella has been straightened.
The nostril floor, which was previously sunken, has been reinforced, significantly improving the overall asymmetry.
7. Final Evaluation
Cleft lip and palate rhinoplasty is often a battle against asymmetry. It is an extremely challenging and complex surgery, but understanding the deep desire for improvement in these patients makes it a surgery that we cannot give up on.
For cleft lip and palate patients, the differences in cartilage development between the two sides, combined with asymmetry in the nasal structure itself, require more than just soft tissue corrections. Simply addressing the skin of the nasal tip without reconstructing the nasal framework will not provide a long-lasting solution.
At Nose Lab Clinic, we approach cleft lip and palate rhinoplasty by reinforcing the underlying bone structure and performing septal reconstruction, which involves shifting and repositioning the septum. We also focus on improving alar cartilage asymmetry through alar cartilage reconstruction to achieve the most balanced result possible.
However, in patients who have undergone multiple surgeries or experienced significant tissue damage from previous operations, there are limitations. For example, in cases with reduced skin elasticity and scar tissue from past procedures, elevating the nose height significantly may not be possible. The nasal dorsum height must often match the limitations of the skin and soft tissue, so we must carefully manage expectations regarding major changes in nasal height.
In this case, the patient was realistic about the limitations of asymmetry correction, and their primary goal was to improve the appearance of their nose. Although the pinching on the right side of the nasal tip improved, it was explained that achieving a completely smooth appearance like the opposite side might require further refinement or secondary corrections in the future.
8. Closing Remarks
Cleft lip and palate rhinoplasty is a complex and difficult challenge, but it offers the opportunity to provide patients with new hope and confidence. Although achieving perfect symmetry and an ideal nasal shape may not always be feasible, our goal at Nose Lab Clinic is to create the most natural and harmonious nose possible.
We continuously research and develop new techniques to improve our outcomes for patients with cleft lip and palate. For those dealing with nasal deformities from cleft lip and palate, we hope this case provides some hope. We encourage you to consult with a specialist to find the most suitable surgical approach for your specific case.
At Nose Lab Clinic, we remain committed to helping patients achieve beautiful and healthy noses.
This has been Dr. Cha-Young Kang, head surgeon at Nose Lab Clinic.
Thank you.
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