CME Cleft Rhinoplasty · Recognize current trends and principles of cleft nasal reconstruction. 4. Recognize differences in primary versus secondary cleft nasal correction. Reconstruction

CME

Cleft RhinoplastyAllen L. Van Beek, M.D., Agnieszka S. Hatfield, M.D., and Ellie Schnepf, B.S.N.Edina and Minneapolis, Minn.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe features of the unilateraland bilateral cleft nasal deformities and associated growth changes. 2. Assess the extent of cleft nasal deformity. 3.Recognize current trends and principles of cleft nasal reconstruction. 4. Recognize differences in primary versussecondary cleft nasal correction.

Reconstruction of the cleft nasal deformity can oftenpose a significant challenge to a rhinoplasty surgeon. Prin-cipal features of unilateral and bilateral cleft nasal defor-mities and their changes with growth are discussed. Thisarticle reviews current trends in cleft nasal rhinoplastyassociated with early and late intervention. Finally, theauthors review their own data on the applications of whatare deemed current trends in reconstructive rhinoplastyassociated with cleft deformities. (Plast. Reconstr. Surg.114: 57e, 2004.)

The three-dimensional combination of rigidskeletal, firm cartilaginous, and plastic skincover makes the nose a unique part of one’sfacial appearance. The nose has become a fre-quently adjusted, reconstructed, enhanced,and even pierced part of the human anatomy.Volumes have been scribed about the compli-cated anatomy and how it can be adjusted toenhance appearance or function. A nose al-tered radically by a congenital defect has amajor impact on both appearance and func-tion. Rhinoplasty is a challenging surgical pro-cedure, and alteration of the three-dimen-sional aspects of the nose created by congenitalchanges will challenge the surgeon’s skill andjudgment.

Features of unilateral and bilateral cleft na-sal deformities, growth changes, and assess-ment methods are discussed. We review cur-rent trends in cleft nasal rhinoplasty associatedwith both early and secondary intervention.Our data on the applications of what aredeemed current trends in reconstructive rhino-plasty of cleft deformities are reviewed.

FEATURES OF UNILATERAL AND BILATERAL CLEFT

NASAL DEFORMITIES

Infants presenting with a unilateral cleft lip(Figs. 1 and 2) have inferior and wide lateraldisplacement of the lower lateral cartilages.The nasal vestibule volume is increased on thecleft side. The often-shortened columella is dis-placed toward the cleft. The associated hori-zontal and vertical displacement of the nostril’slower lateral cartilages makes consideration ofthe lower lateral cartilages an integral part ofprimary lip repair. However, controversy existsregarding direct lower lateral cartilage manip-ulations during primary lip repair in infants.

FIG. 1. Displacement of the lower lateral cartilage and lossof skeletal foundation are the key features of the unilateralcleft deformity.

Received for publication February 3, 2003; revised May 15, 2003.

DOI: 10.1097/01.PRS.0000133424.05413.BF

57e

The bilateral cleft presents with even moredistortion of the nose. A short or near-absentcolumella, widely displaced lower lateral carti-lages, a protuberant or even horizontal premax-illa, and collapse of the maxillary arch behind thepremaxilla are all noted in Figures 3 and 4.

EFFECTS OF GROWTH ON CLEFT FEATURES

Characteristic alterations of appearance andanatomy associated with cleft nasal deformity af-ter facial growth are shown from various perspec-tives. From the frontal perspective (Fig. 5), onecan see a twisted nose, a wide nasal base, flarednostrils, oblique tip-defining points, and asym-

metrical columellar alar angles. From the lateralperspective (Fig. 6), one can see altered columel-lar show, poor tip projection, rhinion promi-nence, an obtuse nasal labial angle, and shortnasal length. From the caudal perspective (Fig.7), one can see a lateral alar web, asymmetricallower lateral cartilages and nostrils, columellarscarring, a displaced caudal septum, abnormalhair location, and blunt angulation of the inter-mediate crus lower lateral cartilage.

Columellar show may be increased or de-creased from the usual 3 to 5 mm noted inadolescents and adults. A decrease occurswhen the lower lateral cartilage is flared and

FIG. 2. Abnormalities associated with bilateral cleft nasal deformity beforethe authors’ surgical intervention when the patient was 6 years old and afterfurther correction at age 14. The Abbé flap and tip reconstruction wereperformed in the interval.

FIG. 3. Preoperative lateral views of the same patient shown in Figure 2.

58e PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2004

displaced inferiorly. An increase may occur be-cause of a buckle or notch effect on the lowerlateral cartilage from primary rhinoplasty ad-justment of the nose or if lower lateral cartilageis not modified during the acute repair. It mayeven persist despite further attempts at correc-tion (Fig. 8).

Tip projection is reduced because the lowerlateral cartilage displacement on the cleft side

results in lack of support for tip projectionagainst the shortened columellar skin envelopeand lateral displacement.

Lack of midline alignment of structures iscommon in unilateral and bilateral clefting.The central incisors, philtrum, and columellamay not be aligned in the midline and may notbe able to be aligned because of the conse-quences of the maxillary defect and lip repairqualities. This makes it difficult to put the fa-cial elements into the usual spatial alignmentthat the mind is accustomed to visualizing. Addto this dilemma a lip repair that does not havehorizontal alignment of Cupid’s bow peaks andthe task of formulating a rhinoplasty plan be-comes daunting.

DEFORMITY ASSESSMENT

Determining the most effective surgical planfor any rhinoplasty must begin with an assess-ment of the internal nasal structures and theirchanges (Fig. 9). The following are importantissues to be answered during the examination:

•Is the septum attached or displaced off thecrest of the vomer?

FIG. 4. Inferior view of a 6-year-old patient with lower lateralcartilage collapse associated with cleft nasal deformity.

FIG. 5. Inferior view of abnormalities associated with cleftnasal deformity in a 6-year-old patient. LLC, lower lateralcartilage.

FIG. 6. Diagram for documenting abnormalities, sketchplanning, and educating patients and parents.

Vol. 114, No. 4 / CLEFT RHINOPLASTY 59e

•Is the caudal septum attached to the nasalspine or is it deflected into the nostrilaperture?

•Is the middle portion of the cartilaginousquadrilateral plate deformed?

•What is the status of the inferior turbinates?Will they obstruct airflow if nasal volumedecreases?

•Is the floor of the nasal vestibule obstructedwith exophytic scar from palate closure orbone grafting?

•Has a pharyngeal flap or sphincteroplastybeen performed and does it impede airflowthrough the nose?

•Is nasal and sinus mucous drainageadequate?

•Is breathing at rest oral, nasal, or both?What occurs when exercising? Is sleep apnea aproblem?1–4

Assessment of the external appearance bymeasurements and observation is importantwhen constructing a surgical plan. To assist insurgical planning, measurements are recorded(Fig. 10) and then repeated postoperatively toassess progress, growth, and results. These nu-merical data are used to plan surgery and pro-mote thoroughness. There is an art to studyingfacial characteristics and understanding thethree-dimensional relationships that are nor-mal and attractive. Altering those relationshipswhile attempting to improve form or functionis a complex combination of the art and sci-ence of plastic surgery.5

Actual measurements help begin the processof planning. How far does the lower lateral car-tilage have to be positioned to be similar to thecontralateral side both across the base and fromthe frontal perspective? How deep is the concav-ity in the sill because of muscle paucity or skeletaldeficiency? If the septum is deflected, whereshould it be positioned and anchored? Are themedial crura of the lower lateral cartilage curvedinto the naris aperture and are they symmetrical?The measurements and answers that are ob-tained will serve as a guide in estimating how

FIG. 7. Measurements of the nasal dimensions help withperceptions and planning.

FIG. 8. When planning correction, perceive where the tip-defining points would be located on the displaced lowerlateral cartilage. This is the key to accurate suture placementin early repairs.

FIG. 9. Appearance of unilateral cleft lip deformity.


much length and tip support can be created byplicating lower lateral cartilages to each other orto a columellar strut graft (Fig. 11).

EVOLVING CONSENSUS

Many techniques1,5–8 have been advocatedfor attaching the lower lateral cartilages toeach other or to the upper lateral cartilages(Figs. 12 through 18). Results in follow-up re-ports indicate that those techniques, whileseemingly satisfactory initially, provided an in-adequate correction with growth and time andrequired additional reconstruction. The com-mon feature seemed to be tip definition and

lower lateral cartilage collapse because of alack of persistent tip support.9–12

Plication of the medial and intermediate cruraof the lower lateral cartilages was advocated byConverse in 1964 (Fig. 19). Converse was surelyattempting to gain symmetry and support. Rigidcolumellar support was not provided, so correc-tion relied on the contralateral lower lateral car-tilage for enough support to maintain positionand projection. Millard believed inadequate skincover was the dominant issue. In some cases,however, he must have believed that lower lateralcartilage support was also insufficient to maintain

FIG. 10. Skeletal and muscle deficits, a protruding max-illa, and a short columella are major abnormalities associatedwith the bilateral cleft deformity.

FIG. 11. Skoog sutured the lower lateral cartilage to theupper lateral cartilage for support of the displaced lowerlateral cartilage.

FIG. 12. Humby provided support for the displaced lowerlateral cartilage by using the cephalic “excess” of the con-tralateral lower lateral cartilage for support.

FIG. 13. Walter utilized Humby’s concept but also usedthe ipsilateral cephalic “excess” of the lower lateral cartilage(LLC) to lengthen the nasal dorsum. He realized that anexcessively obtuse nasal labial angle could be corrected bylengthening the nasal dorsum.


shape, as he advocated placing unsecured strutsof cartilage between the medial crura to providemore support for the lower lateral cartilages insome of his patients.

Another vexing issue is the web created inthe lateral vestibule of the nose (Fig. 20). It iscreated by the displaced lateral crura of thelower lateral cartilage being brought to a moremedial position and also by additional connec-tive tissue between the lower lateral cartilageand overlying skin. Z-plasties, V-Y advance-ments, and flap rotations usually do not com-pletely correct the web, and over the long termthey may constrict the nasal vestibule or nostriland require a secondary correction.13,14

With that history as the background, sur-geons realized that skin and soft-tissue alter-ations for many patients did not provide long-term correction against the relentlessresistance of deformed skeletal and cartilagi-nous structures associated with clefts. That rec-ognition heralded a new era of reconstructionin the 1990s that was initiated by many differ-ent authors within a similar time period.2,12,14–18

The concepts now applied are early interven-tion, strong columellar support for nasal tipprojection, and construction of a nasal frame-work that mimics the appearance, symmetry,and position of a normal lower lateral cartilage

(Fig. 21). After a strong framework is recon-structed, skin cover can be adjusted so that itcontours around the new lower lateral cartilageframework. That change in planning producedimproved results in the appearance of the re-constructed cleft nasal deformity.

Many authors2,16,17,19 believe that correcting thedisplaced framework structures at the time of theinitial lip repair is desirable (Figs. 22 through24). Critics were fearful that early adjustment ofnasal cartilage structures would produce growthdiscrepancies. Adequate periods of follow-uphave shown that the nose does grow normallyafter early adjustment of position and configura-tion of the cartilaginous portions of the nose.

The methods of adjusting the nose duringprimary cleft lip repair (Figs. 25 through 27)seem to have a few basic goals: (1) to providetip support by suturing the lower lateral carti-lages to each other and to the upper lateralcartilages; (2) to stabilize the abnormal lowerlateral cartilage in a more anatomic and sym-metrical position18; (3) to establish a muscleand soft-tissue sill across the nasal base20; and(4) to correct the webbed lateral alar mucosaby plicating skin and mucosa.7

Early intervention and adjustment of thelower lateral cartilages in the cleft nose is ben-

FIG. 14. Byars divided the ipsilateral medial crus and usedit to elevate the lower lateral cartilage. It also reduced supportfor the nasal tip provided by the medial crura of the lowerlateral cartilage. FIG. 15. Erich gained access to the nasal structures by

using an open rhinoplasty technique.


eficial, but this approach usually does not pre-vent secondary reconstruction when the adultcharacteristics of the nose become appar-ent.11,21 Another concern is that early interven-tion can make secondary procedures more dif-ficult because of scarring or damage to thelower lateral cartilage from dissection or su-tures associated with immediate intervention.

AUTHORS’ DATA AND RECOMMENDATIONS

We have reviewed available data from 21 cleftnasal reconstructions performed by the seniorauthor during the past 4 years. The amount ofchange achieved between preoperative and post-operative measurements and the incidence ofsome of the techniques used are listed in TablesI and II, respectively. In this series of patients,most cleft lip primary repairs were performed byother surgeons and primary adjustment of thelower lateral cartilage was not done. Often a “tip

rhinoplasty” was performed by the same surgeonwhen the patient was of preschool age. At sec-ondary rhinoplasty performed by the authors,these patients were often found to have dis-rupted intermediate crura, greatly altered anat-omy of the lower lateral cartilages, and visiblenasal scars. These circumstances significantlycomplicated their definitive nasal reconstructionand statistical assessment. In this series of pa-tients, the most definitive correction and the cal-culated mean measurements for each categoryare shown in Table I.

Presently, the principles most often appliedinvolved placing a columellar strut graft, usingspanning sutures, bone grafting the maxillarydefect, and using mucosal and skin-plicatingsutures (Fig. 27).

Because the characteristics and size of the lipand nose change in proportion to age, plan-

FIG. 16. Trott’s approach.

FIG. 17. Tajima achieved additional ipsilateral lower lat-eral cartilage elevation by suturing the lower lateral cartilageto the contralateral upper lateral cartilage.

FIG. 18. Tajima realized the asymmetry of the nostrilneeded to be addressed; the reverse-U flap added anotherdimension to planning.


ning for shape and size is essential during theages of 8 of 14 years (Fig. 28). Our surgicalcorrections usually occur at two or three differ-ent time intervals. In early infancy, adjustmentsof the lower lateral cartilages occur in conjunc-tion with the cleft lip repair. Secondary adjust-ment of the lower lateral cartilages occurs be-tween the ages of 5 and 8 years because ofsignificant distortion of the nasal tip’s shape.The final correction occurs when the nose hasreached its nearly adult shape, when the pa-tient is between 12 and 15 years of age. Thebilateral defects usually require three proce-dures, whereas unilateral deformities usuallyrequire only two adjustments of the nose.

These principles have been used to success-fully manage early and late cleft nasal deformi-ties associated with unilateral and bilateral cleftrepairs. Although controversy still persists,early intervention in skilled hands may make

secondary management of the cleft nose defor-mity easier. It is emphasized that manipulatingthe lower lateral cartilages during primary liprepair requires technical expertise, loupe mag-nification, and an understanding of the pre-maxilla segment and protection of its vascularanatomy.22

Pediatric anesthesiologists, understandingparents, patient support groups, cleft team in-volvement, and parent education about thecleft team’s long-term plans are important ad-juncts to providing parents with confidenceand satisfaction.

PRIMARY CLEFT NASAL REPAIR TECHNIQUE

We prefer to perform adjustments of thelower lateral cartilages during lip repair by us-ing a lateral rim incision patterned after a mod-ified open incision23 (Fig. 29). The lower lat-eral cartilages are visualized and the perceivedintermediate crus apices are marked withmethylene blue dye as reference points. The

FIG. 19. Converse and Millard clearly understood theneed for producing lower lateral cartilage symmetry and sup-port for tip projection. Millard added unsecured struts ofcartilage between the medial crura for lower lateral cartilagesupport.

FIG. 20. The alar web created in the cleft nose is a per-sistent problem. TDP, tip-defining point.

FIG. 21. In establishing symmetrical tip-defining points, asecured columellar cartilage graft is used for reinforced sup-port to maintain projection while skin adaptation occurs.

FIG. 22. Byrd’s technique for primary nasal intervention.


intermediate portions of the lower lateral car-tilages are then plicated together with poly-dioxanone suture to produce symmetry. A su-ture is placed joining the left and right medialcrura’s junction with the left and right inter-mediate crura. An interdomal suture is placedto bring the genu of the two intermediatecrura together. The tissue attachments to theflared ala are released, and the lateral liga-ment-like attachment and associated muscleare preserved. Byrd and Salomon20 advocatebringing some of the muscle from the laterallip segment with the lateral component of thelower lateral cartilage and attaching it to thecolumella. As an extension of Farrior’s tech-nique,18 we prefer to fix the lower lateral carti-lage lateral crura across the midline throughthe premaxilla area to the contralateral alarbase with a spanning-type suture (Fig. 26). Us-ing this maneuver, the connective tissue at-tached to the lower lateral cartilage is still su-tured to the midline but without tension.Adjusting this suture tension also supports thecleft repair and narrows the nasal base. Thisexerts pressure across the entire base of thenose rather than against the already displacedmaxillary midline components. It also tends tolevel the horizontal position of the nasal base

and has less potential of interfering with thepremaxilla’s circulation. After the released lat-eral alar ligament is reattached across the mid-line to the contralateral alar base, if bucklingor irregularity occurs in the lower lateral carti-lage, additional tip projection support or lowerlateral cartilage repositioning may be required.To reposition the lower lateral cartilages sym-metrically within the skin envelope and to holdthem in position when nasal mucosa incisionsare closed, the cartilage is included in the mu-cosal closure. Transcutaneous plicating suturescan be used to position the cartilages if posi-tioning cannot be accurately accomplishedwhen the mucosa incisions are closed.2 If nec-essary, the upper lip skin under the nostril canbe deepithelialized and the nostril can be re-inset to establish symmetry with the contralat-eral nostril. Since the lower lateral cartilageshave been found to be nearly symmetrical inshape,24 though displaced, in our opinion, re-secting or moving portions of the lower lateralcartilage should be delayed until definitive re-constructive rhinoplasty is performed.

Initial management of the lower lateral carti-lage components may decrease the need for earlysecondary surgical correction of the lower lateralcartilages in the unilateral cleft nasal deformity.However, despite early intervention in the bilat-eral cleft at the time of the lip repair, lack of tipprojection, an associated short columella, anddisplaced lower lateral cartilages often result insecondary surgical intervention when the patientreaches preschool age.

SECONDARY CLEFT NASAL REPAIR TECHNIQUE

In our experience, the most difficult of allrhinoplasties is correction of the bilateral cleftnasal deformity with short nasal projection andan obtuse nasal labial angle. Plication of theintermediate crura concomitant with the liprepair does not provide tip support to over-come the short columellar length, and plica-tion of the lower lateral cartilages does notprovide enough projection. Supporting thelower lateral cartilages by suturing them to theupper lateral cartilages has been demonstratedto have only short-term benefit; this approachdoes not provide adequate projection and con-tributes to an obtuse nasal labial angle. Second-ary columellar lengthening by manipulationsof the skin envelope of the nose fails becausethe skin cannot, over the long term, hold shapeagainst rigid distortion of the displaced under-lying lower lateral cartilages. Eventually, carti-

FIG. 23. Salyer and Kirschbaum both advocated early in-tervention with alteration of lower lateral cartilage position.Salyer realized the value of plication to prevent web formationand buckling of the lower lateral cartilage.


lage determines the skin’s shape because ofstress relaxation of the skin around the unsup-ported cartilage framework.

In tip rhinoplasty correction performed atpreschool age, a modified open technique isused to provide access (Fig. 29). The lowerlateral cartilages are adjusted with interdomaland/or intradomal sutures. In the bilateralcleft, skin is recruited from the nasal dorsumand the nostril is pushed to a new position witha rigid cartilage strut graft secured with suturesbetween the medial crura of the lower lateralcartilages. The strut is then attached to the

caudal portion of the septum as a batten-typegraft to lengthen the nose, or to the posteriorseptum in the vicinity of the nasal spine if onlyprojection is required. The strut is taken fromsources other than the septum and is used tohold the intermediate crus in a projecting po-

FIG. 24. Summation of technical points advocated by many authors.

FIG. 25. Tip grafts to the caudal area of the intermediatesegment of the lower lateral cartilage are placed for tip def-inition during the final stage of reconstruction.

FIG. 26. Three-dimensional illustration of the authors’preferred technique in the final stages of reconstruction.


sition to help adjust the nasal labial angle andnasal length. After the strut is secured, thelower lateral cartilage immediately becomes elon-gated and maintains that position long term. Tipdefinition is adjusted using domal sutures sup-ported by the columellar strut graft. Initially, theprojection will be prominent. After the adultcharacteristics and size of the nose are expressed,tip projection may be slightly inadequate. At thattime, additional tip support is provided by plac-ing septal grafts on the caudal side of the inter-mediate crura of the lower lateral cartilage.

Using this technique, no decrease in growthof the lower lateral cartilages has been noted,

but in bilateral cleft rhinoplasty patients, revi-sion and additional tip projection support arerequired when they reach the teenage years.

At present, we have not used a bioabsorbabledevice in place of cartilage, but such a devicecan be an alternative strut if it can providesupport long enough to permit the redrapingof skin to accommodate the nasal framework.25

RECOMMENDED SURGICAL MANAGEMENT AT AGE 12TO 14 YEARS

In all of our cleft patients, the final adjust-ments in nasal reconstruction occurred eitherwhen the patient was as a teenager or later inlife.26 The final rhinoplasty is done through anopen approach (Fig. 30). The lower lateralcartilages, which are often surrounded by scar,must be carefully visualized. Septal abnormali-ties are corrected. After any required adjust-ments in the nasal dorsum, septal cartilage canbe obtained for use during reconstruction ofthe nose. Other sources of graft material arethe rib, ear, skull, and ilium.27–29

The nasal labial angle can be decreased byusing a caudal tip graft or, in extreme cases,by extending the septum with batten-typegrafts fixed to the cephalic edge of the me-dial crura (Fig. 31). The cephalic portions ofthe lower lateral cartilages have also beenused for this purpose (Fig. 14). Symmetricallower lateral cartilages are created by using acombination of intradomal and interdomalsutures and spanning sutures. Direct adjust-ment of the caudal border of the lower lat-eral cartilages is occasionally helpful.30,31 Os-teotomies of the nasal pyramid will berequired to correct the crooked nose defectif the deviation begins at the nasion. Osteot-omy may not be required if the crooked nosedeflection begins at the rhinion.32 Osteotomymay be required when the nasal pyramid iswide and if the nasal dorsum is excessivelyprominent and requires reduction. The lat-eral alar web can be corrected by thinningthe thickened lateral nasal wall and plicatingthe mucosa to the skin and to the adjacentpiriform margin (Fig. 28). Repositioning ofthe nostril on the upper lips to match theposition, width, and shape of the contralat-eral lower lateral cartilage can be achieved bydeepithelializing the symmetrically deter-mined location on the skin and reinsettingthe ala. If buckling of the lower lateral carti-lage persists after columellar support hasbeen provided, it is possible to correct this using

TABLE IPreoperative and Postoperative Measurements

BeforeSurgery

AfterSurgery

Base width 38.7 35.6Columellar projection 23.4 26.6Tip width 22.2 18Nasal labial angle increase 97 10Nasal labial angle decrease �12

TABLE IIIncidence of Techniques

Technique No. of Cases

Columellar strut 20/21 (95%)Nasal tip 19/21 (90%)Spreader 5/21 (24%)Onlay/batten 4/21 (19%)Alar wedge resected 8/21 (38%)

FIG. 27. Three-dimensional illustration of the authors’preferred technique for maintaining lateral vestibule volumeand shape. BG, bone graft.


narrow strips of cartilage33 placed and suturedadjacent to the rim margin to smooth the defor-mity. Reconstruction of the cleft nasal deformity

is difficult and has the same potential complica-tions as noncleft rhinoplasty.34

SUMMARY

The principles delineated for correction ofthe cleft nasal deformity are emphasized ingreat detail. These principles apply to bothunilateral and bilateral deformities. A recon-structed, sturdy framework that has the desiredthree-dimensional qualities of a normal nosewill produce a dramatic change in the shape,function, and appearance of the nose. Nasalfunction, symmetry, projection, length, width,and tip definition are the goals of the rhino-

FIG. 28. The slow but relentless changes in proportions and structural shape during growth mustbe considered during planning.

FIG. 29. Dotted lines represent intranasal incisions and solidlines represent visualized incisions.

FIG. 30. During open rhinoplasty, a transcolumellar inci-sion is used. Planning that incision is essential. Often a priorincision may exist on the columella, and vascular compromiseof the elevated columellar skin can occur if scars compromisethe base of the flap.

FIG. 31. In severe bilateral cleft nasal deformity, the nasaldorsum and columella are short with a very obtuse nasal labialangle. Tip projection and support are essential, but to preventthe obtuse angle, the nasal dorsum must be lengthened.Expanding on Walter’s technique, batten grafts are very help-ful with correction.


plasty surgeon. Those goals are also now ob-tainable in individuals with severe cleft nasaldeformity by applying the principles developedover the past decades.5,35,36

Allen L. Van Beek, M.D.7373 France Avenue SouthEdina, Minn. 55435

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CME Cleft Rhinoplasty · Recognize current trends and principles of cleft nasal reconstruction. 4. Recognize differences in primary versus secondary cleft nasal correction. Reconstruction