Rhinoplasty in Cleft Care

Whenever we think of cleft lip, we always think of the little baby with an obvious cleft in the lip. As I had mentioned before, the lip is the most obvious, but the cleft affects others things too, including the nose.  It may not be obvious, since we are so distracted by looking at the lip, but the nose is almost always asymmetric and I feel, like a lot of the cleft surgeons out there, that this is also just as important in the initial repair. But as much as we would like to hit a home run, the unpredictability of growth will most likely require a revision later in life. Rhinoplasty is a perfect example of this.  Those cute kids eventually, and inevitably grow up to be teenagers, and a lot of times they want their nose done.

It isn’t all about looks though. Nasal obstruction is very common since the septum and turbinates are usually obstructing a clear nasal passage with a cleft lip.  Many times my patients are more happy with being able to breathe through their nose than they are with the visual changes.

Rhinoplasty, aka nose jobs, are integral to cleft care.  Traditionally we have waited until 14 to 16 years old, but I think now with cleft care being more aggressive, 10 to 12 years old is reasonable depending on the child’s maturity and wants and wishes.

Below are some examples of the subtle, and not so subtle changes possible with cleft rhinoplasty.

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cleft care at UK HealthCare

Favorite Surgery?

I often get the question, what surgery is your favorite?  That is like asking, what is your most favorite book or movie.  Better yet, if you were stuck on a desert island, which would be your only food.  Although as adults, we kinda write off these questions as being silly, but the 1st question is a pretty legitimate one.

But just like favorite books and movies, there is no favorite, but usually a couple.  And of those, there are very different reasons why they are favorites.  So with that in mind, I figured I’d go through the list of cleft care surgeries and list why they are ALL my favorites.

1st surgery (cleft lip)

There is a reason why mission groups love to put up pics of repaired cleft lips.  This is the most dramatic part of cleft care…this is the face of cleft care, no pun intended.  And I won’t pretend to lie to you and say this isn’t one of my favorites for the same reason.  Changing a child’s appearance and making things whole is obviously very rewarding.  It’s the 1st surgery that will influence the course of this child’s cleft care.  A “bad” lip repair can be difficult to overcome with later surgeries.  Because of this, those experienced in cleft care take a dim view of those who do not routinely do these surgeries, yet tout themselves as cleft surgeons.

From a surgical point of view, this is where technical finesse merges with the “artistic” part of surgery.  Each cleft is different and requires analysis to give a complete idea or plan, on how the lip is supposed to look like at the end.  After this “artistic part”, you have to have the technical ability to complete the plan.  As you can imagine, pulling these two elements together is never the same no matter how many cleft you do, and will continuously challenge as I feel the same way as my mentors.  When you stop trying to reach for perfect, you will stop making each cleft lip repair the best you have done.

2nd surgery (cleft palate)

This is probably the most important surgery.  Without a palate, a child cannot talk and be understand. And a child who cannot be understood will have a very difficult life.  Since there is not much “worry” about the aesthetic part of surgery, it allows me to focus on the technical part of the surgery.  There is a level of technical expertise required and for this part alone I enjoy the surgery.  Add on the fact that a good repair is allowing a child to have normal speech and be able to socialize normally with their peers, is truly gratifying.  My fistula rate is 5%, which is below the national average, and something I’m proud of.

3rd surgery (bone grafting)

This is another technically satisfying surgery.  A lot of resources go into this surgery in terms of planning with orthodontics and dentistry.  Another thing I like about this surgery is that it epitomizes, or is an example, of the philosophy of cleft care.  One way to look at it, is this surgery is about saving a tooth, which is erupting into the cleft bone.  In other countries where I do mission trips, the population is usually worrying more about food, shelter, and human rights.  Worrying about a saving a tooth with a bone graft, and establishing a normal dental arch is a luxury they usually don’t have.  Plus they don’t have an orthodontist and dentist to plan out the pre care needed for this surgery.  However the way I look at it is different and I don’t think this is a “silly” or “vain” surgery.  I see it as another reason to be grateful we live in a country with the resources and social stability to make this standard of care.  The fact that we are dedicating these resources to making sure we achieve normalcy is one of the main points of cleft care.

4th surgery (cleft rhinoplasty)

By now, these children have grown up and developed their own personalities, their lives, and for better or worse, are usually in the midst of their peers with all the social pressures.  This is where I really listen to the child and parents in what THEY want…not what I think looks good.  Also, there is a large functional part of this surgery as we are able to correct their breathing out of the nose. Many patients tell me this is the best part of the surgery, not the “looks” part of it.

As for the “looks” part, I’ve found that no matter how slight or how dramatic the change, my patients tend to be quite happy with their results.  This constantly remind me that its’ the patient who this surgery is for, and not for anyone else.

5th surgery (jaw surgery)

I’m a little hesitant to put this in here, since jaw surgery is NOT always indicated.  The main reasons are usually to move the upper jaw forward and this tends to happen more in children with bilateral cleft lip and palates.  It can be for both functional issues, as well as aesthetic.  The upper jaw movement can help open up the airway and improve overall breathing.  Aesthetically, it helps correct an “underbite” look.  The planning required and timing can be complex and involved dentistry as well as orthodontists.  We can make large changes in this surgery, however we need a lot of planning and coordination with these kinds of surgeries.

Although this is sort of a general blueprint of surgeries, by no means is this meant to be an extensive list or a “for definite” plan.  This is why I’m here! to help decipher, discuss, and plan out what is needed.