The nasal cantilever technique in children undergoing primary cleft lip surgery: novel concepts and review

Approach to the lip

It was interesting to learn from a mentor like Dr. Hugh Thompson. This seems to be the norm; there is nothing wrong in doing a hybrid operation for the cleft lip, and nobody would object to an expert of being innovative [6].

Our first mentor, Dr. Miroslaw Stranc, who has extensively worked on lip function studies [7], is a strong believer in the rotation advancement technique and has often expressed, “If you end up by doing clefts, your mistakes are going to grow with you!”

Later on, as the first fellow with Dr. D. Fisher, I was influenced by his concept of the anatomic subunit principle, which was undergoing a prospective study at that time [8]. Later, with close to 20 years of performing cleft repairs, we found ourselves having adopted a few modifications from here and there as well. When we decide to perform rotation advancement, we usually use Noordhoff’s modification [9], [10].

Regarding a bilateral cleft, we tend to use a few concepts from both, the Millard and Mulliken techniques, but without narrowing the philtrum to near normal dimensions at the primary surgery. We disagree on discarding skin in infancy.

Historic review of approaches to the nose

It is interesting that not too long ago surgeons began giving more serious consideration to the early cleft nose repair approach [11].

Historically, different suturing techniques have been suggested and described to secure the cartilages surgically dissected and freed at the dome area as well as cephalically [12].

Mattress sutures were used by Tajima and Masaru [13] in 1977 to secure the repositioned lower lateral cartilages, holding the lower lateral cartilages to the triangular cartilages as part of their described approach to secondary correction of the cleft nose. Kernahan et. al. [3] presented their results using the same technique as Tajima, who then presented the long-term results of the original approach with some additions [14].

After undermining the nasal skin, McComb [15] used mattress sutures to reposition the nasal cartilages, securing them externally with bolster sutures. The mattress sutures depend on dermal resistance to maintain their traction and need to be removed in approximately 5 days. They demonstrated the technique initially in UCLND [15] and later presented their long-term follow-ups in both unilateral and bilateral clefts [16], [17].

Besides the rim incisions, Stenstrom [18] added a small external incision on the dorsum to lift the affected alar cartilages and to secure them to the septal cartilage with nonabsorbable sutures.

Current literature on cleft nasal deformity

Major authorities on cleft care and craft in the current era indicate that nasal deformity is the stigma that most likely remains clearly visible despite vigorous and repeated attempts at correction [4]. Due to several factors involved in the nasal cleft pathoanatomy, the deformity is not amenable to correction at the index operation [2]. It is easier to obtain results in the symmetric bilateral cleft lip compared to unilateral, and the latter requires more revisions [4]. Cleft lip repair is primarily a nasal surgery [1].

With all due respect, the old message or classic teaching that successful treatment of the bilateral complete cleft and palate can be the most difficult task [19], [20] is a misconception; reconstructing a double defect is not challenging. The tilted tripod theory applicable specifically to unilateral clefts makes them far more challenging from the nasal point of view and over the long term [5].

Our technique, the NCT

The Nasal Cantilever (or Nasal lift technique) described here repositions the cartilages and soft tissues in a desired and overcorrected position after they have been completely freed, and holds that position internally to a fixed base, the periosteum (Figures 4c, 6b, 5b, 5d, 11b). The choice of the loop suture material was based on it being somewhat elastic and braided with good knot quality and absorbable within a reasonable time. We did not want to use a thread that would tear the tissues and defeat the purpose. Most of the suspension techniques or cable sutures anywhere depend on the creation of fibrous bands that would eventually replace the suture, similar to a scaffold.

Early in our practice, we were exclusively trained in open tip rhinoplasty. However, when dealing with infants, preschool children, and teenagers, one should logically aim for interceptive procedures.

Almost all of these children will someday consider definitive rhinoplasty with a proper open technique. The presence of columellar scars and fibrosis from early life would hinder definitive long-term rhinoplasty. Therefore, we had to acquire technical skills in the closed technique. With a learning curve, it is possible to reshape the nose with entirely closed techniques [4], [22]. The procedure presented here barely utilizes the infracartilaginous incisions and two tiny needle-induced openings in the skin.

The lip and nose “tug of war phenomenon”

The fact that primary correction requires simultaneous repair of the lip and nose raises a question: will one of them need to be compromised?

Many surgeons would have good lip results but less than average nose results and vice versa. This is also why secondary “cleft rhinoplasty” in adults is not combined with lip revision. The nasal and lip units share borders and when there is clefting, it acts very much like a malformation.

Parameters such as presurgical orthopedic manipulation, strict collaborative programs, and compliance play a major role in the outcomes of cleft repairs. [2], [4], [21]. Cleft nose deformity correction, whether primary or secondary, has been a daunting task for many cleft surgeons to the extent that one author very humbly admitted that it has been impossible in their hands to correct this deformity [23].

In fact, very few “esthetic rhinoplasty” surgeons would like to deal with cleft noses. When an adult patient with this congenital anomaly consults a rhinoplasty surgeon, they would have very high expectations, simply because they consulted a cosmetic surgeon. The surgeon in turn knows that they would be unable to reach a result anywhere close to their average cosmetic rhinoplasties [2], [25].

When one is working with opposite vectors, it is difficult to reach optimum harmony, and a compromise on either side is expected. Tissues do their best to return their original state while combating the fibrosis created by the surgical intervention; hence, our analogy, “tug of war”, best explains the situation with primary or secondary corrections to the nose or lip (Figure 20).

Figure 12:

Case 2: (a) Used as an example for technique demonstration in UCLND at 4 months. (b) Five-month postoperative follow-up picture; the nose is maintaining its reconstructed shape. Lip outcome was somewhat expected. Some scar hypertrophy is noted at the nasal sill. UCLND, unilateral cleft lip nasal deformity.

Figure 13:

Case 3: (a) BCLND, severe and significant asymmetry, operated at 6 months. (b) One-year postoperative follow-up is shown. Although we use some maneuvers of Mulliken’s methods, we save most of the philtral skin at this age. BCLND, bilateral cleft lip nasal deformity.

Figure 14:

Case 4: (a) BCLND, like many other cases, the columella here has not formed; the was patient operated at the age of 8 months. (b) Follow-up picture at 2 years postoperatively. As usual, we do not discard any philtral skin at this age. Although the original anomaly is severe but also quite symmetric, the long-term esthetic outcome in this case can be predicted to be very good. This is contrary to older beliefs on BCLND. BCLND, bilateral cleft lip nasal deformity.

Figure 15:

Case 5: (a) UCLND, this child was operated at 18 months as a single stage for cleft palate and UCLND. (b) Follow-up picture at 6 years postoperatively. UCLND, unilateral cleft lip nasal deformity.

Figure 16:

Case 6: (a) UCLND, operated at 11 months. (b) Follow-up picture at six years postsurgery. UCLND, unilateral cleft lip nasal deformity.

Figure 17:

Case 7: (a) UCLND, operated at 5 months. (b) Follow-up picture at 10 years postsurgery. UCLND, unilateral cleft lip nasal deformity.

Figure 18:

Case 8: (a) UCLND, “form fruste” type, was operated at two years. (b) Follow-up picture at 10 years postsurgery. UCLND, unilateral cleft lip nasal deformity.

Figure 19:

Case 9: (a) UCLND, operated at 8 months. (b) Follow-up picture at 10 years postsurgery; the lip has mild shortening, which might require revision. The Patient also has nevus of Ota, right orbit. UCLND, unilateral cleft lip nasal deformity.

Figure 20:

The nasal and lip units share borders; when there is a cleft, it tends to act as a malformation. Simultaneous repair of both, whether in childhood or secondarily, means attempting to recruit tissues with opposite vectors. Tissues will resist due to their inherent memory, and compromise of results on either side is probable. Hence, the analogy “Tug of War” phenomenon.

The cantilever concept in the nose is well known, originally of Converse and Millard, where they described a cantilever bone graft secured to the radix in reconstructing the dorsum [24].

Cleft lip nasal deformity has unique pathology [2]. The cartilages and skin tend to maintain their memory, and it falls mostly under the domain of reconstructive surgeons who are used to facing challenges and are expected to be creative [25], [26].

We believe the NCT method that lifts the whole nasal collapsing “tent” and holds it onto a fixed base (the nasion) is a new concept and promises to be the ultimate corrective approach to the nasal “pathoanatomy” in children with cleft nose and lip deformity.