Cleft2 pre_gerlachWhat is the appropriate timing for performing cleft nose rhinoplasty?

There has been some controversy due to differences of opinion, in our community, as to the timing for nose procedures for cleft lip and palate patients.  A rhinoplasty, or “nose job” is done for cleft patients with the goal to help with appearance and breathing.  The face continues to develop throughout the teen years and cartilage, which comprises both the ear and nose, continues to change and grow throughout life.  As a surgeon, we prefer for maturity of the body’s anatomy prior to operating for best and lasting results.  With regard to the nose specifically, most surgeons, whether ENT or plastics trained, prefer to perform nose procedures for appearance and functional improvement, in the later teenage years.  Exceptions are made, usually for poor breathing, and of course, if significant ridicule is occurring. However, these are the exceptions, as the longer one waits to perform surgery the better and more lasting the results.

In cleft lip and palate patients, early surgery in the first few years of life prior to six years of age, results in significant scarring within the nose. This fact has been discussed in many peer-reviewed articles.  This scarring once introduced cannot then easily be addressed and makes later revisions very difficult.  More importantly, the bone graft to the alveolus, the bone in the gum line that allows teeth to descend, is NOT grafted until between 6-8 years old based on x-rays and dental maturity.  Therefore, if no bone is in place in the gum line, there is no supporting floor on which to build the nose.  A nose procedure prior to the bone graft makes no sense as it defies the basic tenets of anatomical support.  The result is often the quick descent of the nose in the post-operative period as there is no underlying bone for support. Additionally, the resulting scarred nasal tissues often require challenging revisions.

When you add up all the negatives involved with early rhinoplasty based on anatomy, growth, timing, function and long-term beneficial results the answer seems quite clear. A lack of facial maturity, along with lasting and difficult nasal scarring, in addition to no underlying bone framework on which to support a nose procedure leads to a simple answer.  Cleft rhinoplasty should be condemned prior to alveolar bone grafting (6-8 years of age).  It seems to defy any basic surgical tenets with little support in the literature for long-term beneficial outcomes.  If the goal of all physicians is first “to do no harm”, one has to question why such a surgery would be entertained at so early of an age.