PRESURGICAL NASOALVEOLAR MOLDING

The difficulty with the correction of the nasal deformity associated with cleft lip and palate, and the correction of wide cleft lip and palate, has remained a challenging aspect of cleft surgery. Generally, the wider, more extensive clefts are associated with more significant nasolabial deformity. Although functionally and esthetically good results of lip closure have been obtained in recent years owing to more sophisticated surgical techniques, primary correction of the nose is often less satisfactory. In fact, the following quote by Sir Harold Gillies still rings true today:

“A well mended harelip would pass unnoticed at a cocktail party were it not for the nose.”

Nasal conformers have been used for some time for improvement of the preconditions of primary nasoplasty during primary surgery by several providers. More recently, a nasoalveolar molding appliance has been popularized by Grayson; it is adjustable by removing or adding acrylic and manipulating protrusive elements that attempt to mold the nasal cartilages. This device attempts to align the alveolar segments, lip structures, and nasal cartilages to optimize repair.

THE NASAL DEFORMITY

The specific patterns of dysmorphology seen in patients with unilateral and bilateral clefts are varied and are listed in Table 38-1 . Controversy persists regarding whether a deficiency of tissue is present on the cleft side or whether an imbalance exists in the arrangement of the tissue. Whether the cause is an intrinsic deficiency or the condition is secondary to normal structures being distorted has yet to be resolved. Farkas described the downward displacement of the alar bases in patients without clefts and in those with minimal nasal deformities. He attributed these changes to a lack of mesoderm. This syndrome characterizes the cleft nasal deformity and is likely caused by a combination of tissue deficiency and abnormal mechanical factors.

Histologic studies by Atherton show the cartilage on the cleft side to be similar to the cartilage on the noncleft side. The difference appears to be in the form and anatomy rather than in their failure to develop. Facial cartilage in fetuses with clefts demonstrates distortion rather than an overall deficiency of tissue.

After studying facial clefts in adults, Huffman and Lierle proposed that the deformity results from tissue malposition of the cleft half and not from a relative size discrepancy. However, this does not seem to be true for bilateral clefts. In these situations the opinion exists that a definitive lack of tissue is found in the columella.

Some surgeons believe that early nasal surgery interferes with growth, resulting in nasal hypoplasia; introduces scars, making secondary correction difficult; damages infantile cartilage; and makes repair technically harder because of the small size of the nose and immature cartilage.

Reconstructive surgeons have been reluctant to perform rhinoplasty on a growing nose; however, the use of new operative techniques has created growing acceptance for correcting some nasal deformities before puberty.

THE NASAL DEFORMITY

The specific patterns of dysmorphology seen in patients with unilateral and bilateral clefts are varied and are listed in Table 38-1 . Controversy persists regarding whether a deficiency of tissue is present on the cleft side or whether an imbalance exists in the arrangement of the tissue. Whether the cause is an intrinsic deficiency or the condition is secondary to normal structures being distorted has yet to be resolved. Farkas described the downward displacement of the alar bases in patients without clefts and in those with minimal nasal deformities. He attributed these changes to a lack of mesoderm. This syndrome characterizes the cleft nasal deformity and is likely caused by a combination of tissue deficiency and abnormal mechanical factors.

Histologic studies by Atherton show the cartilage on the cleft side to be similar to the cartilage on the noncleft side. The difference appears to be in the form and anatomy rather than in their failure to develop. Facial cartilage in fetuses with clefts demonstrates distortion rather than an overall deficiency of tissue.

After studying facial clefts in adults, Huffman and Lierle proposed that the deformity results from tissue malposition of the cleft half and not from a relative size discrepancy. However, this does not seem to be true for bilateral clefts. In these situations the opinion exists that a definitive lack of tissue is found in the columella.

Some surgeons believe that early nasal surgery interferes with growth, resulting in nasal hypoplasia; introduces scars, making secondary correction difficult; damages infantile cartilage; and makes repair technically harder because of the small size of the nose and immature cartilage.

Reconstructive surgeons have been reluctant to perform rhinoplasty on a growing nose; however, the use of new operative techniques has created growing acceptance for correcting some nasal deformities before puberty.

HISTORY OF PRESURGICAL ORTHOPEDICS

To address the issues of wide cleft surgery, several nonsurgical techniques to minimize the surgical repair have been attempted for many decades. In 1686 Hoffman described the use of a head cap with arms extended to the face to retract the premaxilla and narrow the cleft. There have been many improvements to this method of using the head as extraoral anchorage, and it is used today to retract the maxilla. Intraoral presurgical orthopedic techniques have also changed significantly when compared with those described by early proponents of the technique. The most well known appliance was designed by Georgiade and Latham in 1975. This device expanded collapsed lateral segments while actively retracting the premaxilla in bilateral cleft lip and palate infants. In response to controversy associated with active retraction of the premaxilla, Hotz described the use of a passive orthopedic plate to slowly align the cleft segments. All of these appliances were designed to correct the alveolar cleft only, despite the fact that the cleft nasal deformity remains the greatest esthetic challenge.