Cleft Rhinoplasty in Dallas, Texas
Cleft rhinoplasty is a nasal reshaping surgery for people with an abnormal appearance of their nose due to cleft lip and palate. Cleft rhinoplasty is far more complex than a typical rhinoplasty (“nose job”) which is why it is important to find a surgeon with experience performing cleft rhinoplasty. Cleft lip revision to improve the appearance of the scars and symmetry of the upper lip is frequently performed at the time of cleft rhinoplasty.
How does a cleft lip affect the nose?
Babies born with cleft lip and palate have characteristic changes to the shape of their nose. The nostril straddles the cleft in the lip, gums and palate. The separation of the gums and palate deforms the skin and cartilage of the nose. When the cleft is on one side of the lip (unilateral cleft lip) this that creates a very uneven shape. Bilateral cleft lip creates symmetric changes in the nose, but the cartilages and skin are symmetrically abnormal in their shape. The nasal shape is frequently treated surgically during the cleft lip repair as an infant. The immediate results are usually a much more even and normal appearance to the nose. Some patients may also have a “touch up” surgery to balance the tip of the nose again between 5-10 years old.
Despite a balanced appearance to the nose in early childhood, the significant nasal growth that occurs during puberty predictably results in an uneven nasal shape when the nose is fully grown. The nasal growth is uneven due to scarring created from the previous surgeries and residual abnormal shape remaining in the nasal tip cartilages, in the shape of the nasal septum and an uneven shape of the nasal bones. Together these factors cause an abnormal shape of the nose when growth in complete, that results in an unnatural appearance.
I counsel patients and parents to expect that a definitive procedure will be needed once growth of the nose in complete, with the earliest age of intervention at age 15-16 years old. The timing of cleft rhinoplasty in teenagers is impacted by whether or not the patient requires jaw surgery to correct an abnormal bite. Patients with cleft lip or cleft lip and palate may have an underdeveloped upper jaw that results in an underbite. This is most frequently corrected by moving the upper jaw forward. It is best to do this movement of the upper jaw first, and to perform the rhinoplasty second. This sequence is important because the movement of the upper jaw forward will change the appearance of the nose. So it is best to move the upper jaw first to create a stable foundation that will not change prior to reshaping the nose. I also frequently treat adults who were born with a cleft but did not have a definitive rhinoplasty as a teenager or they may just be unhappy with the appearance of their nose after rhinoplasty. There is no reason why adults should feel that cleft rhinoplasty or cleft lip revision is not an option for them because of their age.
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Patients with unilateral cleft lip most commonly desire improved symmetry of the nostrils and nasal tip. They also commonly have difficulty breathing through the nose on the side of the cleft. Patients with bilateral cleft lip most commonly feel that their nose is wide and that the nasal tip is wide and under-projected. They will commonly have difficulty breathing on one or both side of the nose.
Cleft Rhinoplasty is widely considered to be the most difficult rhinoplasty to achieve consistently good results. Techniques used for cosmetic rhinoplasty often result in poor outcomes for patients with cleft lip nasal deformity. For that reason, it is important to find an experienced surgeon to achieve an aesthetically pleasing and natural appearance after cleft rhinoplasty. Cleft rhinoplasty is frequently combined with cleft lip revision and procedures to improve breathing through the nose such as septoplasty for deviated septum and inferior turbinate reduction.
Common Reasons Why Patients Seek Cleft Rhinoplasty include:
Improve nostril symmetry
Reshape a nasal tip that is uneven, wide and poorly defined
Increase Projection of the Nasal Tip
Straighten a crooked nose
Improve the profile by lengthening a short nose
Improve the profile by removing bumps or dips in the bridge of the nose
Change the size and shape of the nose to improve facial balance
Improve breathing through the nose
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It is best to wait 1 year from the time of the most recent nasal surgery to seek consultation for cleft rhinoplasty. This provides time for swelling to fully resolve and gives the healing process time to complete and allow the skin and soft tissue to soften. The best candidates for cleft rhinoplasty are physically and psychologically healthy, do not smoke and have realistic goals for what can be achieved from surgery.
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Dr. Derderian uses an open approach to cleft rhinoplasty because the open approach allows direct visualization of the nasal cartilages. Open rhinoplasty requires a small incision in the columella (the skin between the nostrils) through which the skin of the nose is elevated off of the underlying cartilage and bone. This incision typically heals with an imperceivable scar.
The duration of surgery varies depending on the needs of each patient. Typically the procedure takes 4-5 hours. During surgery the skin is elevated from the underlying cartilage and bone. Depending on the strength and position of the cartilage and bone, and the goals of surgery, a variety of maneuvers are used to reshape the nose and improve breathing. Graft material is needed in every cleft rhinoplasty to change the shape of the nose. Cartilage from the nasal septum is the easiest site to get cartilage grafts from, and the nasal septum usually requires straightening during the procedure. A large amount of graft material is needed to reshape the nose in cleft rhinoplasty because the skin and soft tissues are very scarred and stiff. If more cartilage is needed to support the new nasal shape, the cartilage may be harvested from the patient’s ears or ribs. Dr. Derderian frequently uses an alternative source of rib cartilage harvested from organ donors that has been treated to remove all immune markers that prevents rejection of the graft. Using donor cartilage avoids additional pain and recovery for the patient.
After the desired changes in shape are achieved, the skin of the nose is closed with fine stitches. At the end of surgery soft splints are placed inside the nose to support the nasal septum and to prevent scarring. Tapes and a splint are placed over the nasal bridge to support and protect the nose for 7 days. After recovering from anesthesia you will be taken home the same day as your surgery by the family or friends who bring you to the hospital.
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Minimal activity is recommended for the first week after surgery. Patients are advised to take at least one week off from work or school. Oral pain medication is needed for the first 2-3 days. Splints and sutures are removed after 7 days. For patients traveling from out of town, it is advised that you stay in Dallas for the first week after surgery. You may travel home as soon as the stitches and splints are remove, 7 days after surgery. No vigorous activity is allowed for 3 weeks to avoid bleeding from the nose. After 3 weeks normal cardiovascular exercise and non-contact sports may be resumed gradually. No activity restrictions are recommended after 6 weeks from surgery.
The majority of swelling subsides within the first 6 weeks after surgery. At 6 weeks from surgery, the appearance of the nose will be dramatically improved compared to the pre-operative appearance, and the breathing through the nose will be the same or better than it was before surgery. It takes one year for all of the mild residual swelling to completely resolve and show the final nasal contour. While your nose will look great at 6 weeks after surgery, if you compared photos taken at 6 weeks, 6 months and 1 year from the time of surgery, you would see subtle improvements in the contours of the nose, especially in the nasal tip. For this reason, the final result is defined as 1 year after surgery.
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The cost of a cleft rhinoplasty varies depending on the degree of complexity of the surgery and the length of the procedure. Each surgery is customized to the goals of the patient and the patient’s unique anatomy. Additional procedures such as cleft lip revision and fat grafting of the lip will impact the cost of surgery, because additional time is needed to achieve your goals. The total cost includes the fees for the surgeon, anesthesiologist and the surgical facility. In most cases additional donor cartilage will be needed that adds to the cost of the rhinoplasty. The combined cost of rhinoplasty ranges from $15,000-$24,000. After your consultation, Dr. Derderian’s staff will provide a detailed quote to you with the exact cost for your surgery, and they will assist you with payment options and scheduling your procedure.
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Dr. Derderian is board certified by the American Board of Plastic Surgery. Cleft rhinoplasty and cleft lip revision are a major focus of Dr. Derderian’s surgical practice, representing approximately half of the surgeries that he performs. He performs cleft rhinoplasty and cleft lip revision for both teenagers and adults, who travel from across the country and internationally for surgery. This website provides many before and after photos for you to judge the quality and consistency of Dr. Derderian’s results.