The Cleft Nose and Its Repair

On Mateo's cleft side (the left), the nostril is flattened and widened, the rim of the nostril (the ala) is pulled down and outward, and the columella (the strip of skin and cartilage between the two nostrils) is short and leans toward the non-cleft side. This is the classic cleft nasal deformity, present from birth because the same failed fusion that split the lip also unbalanced the nose. Three-dimensional measurement studies confirm this and add a caveat: in unilateral cases the columella and tip are wider and the nasolabial angle is reduced, and the normal target shape differs by ancestry, so the surgeon should not use a single universal ideal.

A cone-beam CT scan looks inside the nose. In a 100-patient CBCT study, the nasal septum (the wall dividing the two nasal passages) was deviated in 92 percent of CL/P patients versus 80 percent of non-cleft controls, and abnormal conchae (the curled bones along the side wall) were also significantly more common in the cleft group. A second CBCT study found cleft groups had significantly higher rates of septal deviation and maxillary sinus mucosal thickening, plus smaller sinuses, than controls.

Repair has two phases. A primary cleft rhinoplasty is often done at the time of lip repair to reposition the alar cartilage, but the cartilage tends to relapse. The definitive septorhinoplasty (straightening the septum and refining the nose) is usually deferred until nasal growth is complete in the teen years, so the repair is not undone by later growth.