[Cleft rhinoplasty, from primary to secondary surgery].

Despite fifty years of statistics, congresses, publications, the cleft nose remains an enigma to the great majority of cleft specialists. Most of the published papers give recipes to camouflage the cleft deformity, very few are concerned by the functional anatomy and its relation with facial growth. The complexity of the matter, the results frequently disappointing, the lack of awareness of the necessity of early nasal breathing, and the academic condemnation of any imperfect attempt to correct the nose at the time of the first operation have led to resignation. For the last forty years, we have been involved in a careful and obstinate research about the early correction of the cleft nose deformity. We wish to present our conclusions in this chapter with at least 17 years of follow-up. They are as following: in cleft patients the nasal cartilages are only deformed. We can achieve sub periosteal and sub perichondrial dissections by 6 months of age without being harmful for facial and nasal growth. Repositioning accurately the nasal structures is enough if we are able to control the healing process and prevent endonasal wound contraction. We have not to do any compromise and favor one function with regard to the others, nasal ventilation being the most important for a good facial growth. In a word, nasal pediatric surgery is necessary at the time of the first operation from 6 months of age and should be carried on with a double demand, aesthetic and functional. To achieve this goal, we must have a sound knowledge of the cleft nose deformity, of the adequate surgical techniques and of the logic chronology to reach the best result. The nose repair cannot be limited to the nasal cartilages. The whole nasal structure is concerned especially its bony framework, the width of which at the level of the piriform orifice and the nasal floor depends on the outcomes of any surgical step that it would relate to the lip, palate or alveolar closure. Interaction of all these factors calls for an appropriate answer in adequation with the diagnosis of the deformity and a coherent answer as we know that any local action may induce an unfavorable chain reaction and should integrate a global and logic project. After the primary surgery, additional correction for aesthetic or functional purpose as well, may be useful during the period of growth. For cleft teenagers or adults, the rhinoplasty can simply be indicated for harmonization after a good primary nasal correction and optimal facial growth. On the contrary, the rhinoplasty may be more or less a complex operation for the usual and severe deformities. In the last case, the diagnosis must take into account all the residual deformities, even the labial and alveolar ones, and the treatment plan integrate all the principles and techniques of the primary surgery. What has not been done at the time of the primary surgery, should be done secondarily: all the structures are present, only deformed and embedded in scarred tissues. Primary or secondary cleft rhinoplasty must be undertaken by surgeons accustomed to cleft patients, but also trained in the other fields of nasal surgery, aesthetic and reconstructive.