THE NASAL TIP IN BILATERAL HARE LIP By J. POTTER, F.R.C.S.Ed. Plastic Surgeon, Middlesbrough General Hospital, Stockton Children's Hospital, Newcastle Regional Hospital Board IN the problem of the bilateral hare lip repair there are three main factors to consider : (r) repair of the lip; (2) the formation of the nasal tip and nasal airways; (3) the correct alignment of the alveolus. First it is essential to consider the deformity. The pre-maxilla is out of line with the rest of the alveolus ; it is anterior to its normal position projecting on to the lower FIG. I Case I. Pre-operative I959. part of the nasal septum ; it displaces forwards the central lip and the lower part of the columella. In severe cases the pre-maxilla can be shown by X-rays to be advanced on the septum anteriorly. The pre-maxilla has not correctly moulded, and it is an incorrect shape. The central point of the normal alveolus is at the anterior nasal spine, and on each side slopes backwards in a " U" shape. In bilateral hare lip the abnormal anterior pre-maxilla is horizontal and the alae of the nose are kept further apart than usual. There is very little columella formed. The problem is that before the repair I73
174 BRITISH JOURNAL OF PLASTIC SURGERY there exists a flattened nasal tip with a short columella and wide nostrils, because the pre-maxilla bulges into the nostrils. In the usual repair of these cases the aim of the nose are brought further forward than normal so that a flat horizontal type of nasal tip results. The columella is short and the columella-labial angle is webbed. The lip is repaired on each side, the central skin is retained in the lip, and this accentuates the already flattened tip and short columella. The tilted pre-maxilla further accentuates the bulging into the upper part of the lip and lower end of the columella. As a result the nostrils are forced to remain Case I. FIG. 2 1966 : bilateral lip repair in 1959 with later adjustments of the lip scars. wide ; no matter how they are placed the alto tend to slide laterally,tgivingia wide base to the arch on each side, accentuating the flattening. The nostrils are everted at the lower part, the alar cartilages are actually rotated into the nose and one looks upon the upper surface of the alar cartilages, which are covered by mucous membrane instead of lying under skin. This leads to obstruction to the airways and a chronic catarrh. Extensive work on the problems of nasal obstruction has been done by Proetz (1953). Because the air passages are distorted, deposits occur on the nasal mucosa beyond the obstruction. This causes local drying, a loss of cilia and consequent infection ; there is a chronic condition of discharge and frequent acute exacerbations. Usually these children are mouth-breathers with a chronic nasal discharge. Little attention has been paid to these abnormal airways and breathing except by Matthews in a recent paper on "Rapid Expansion of the Maxillary Arch" (Matthews and Grossmann, 1963). I have referred to the work of Dr Proetz in previous papers
THE NASAL TIP IN BILATERAL HARE LIP 175 (Potter, 1954, I955). After the usual type of repair you are left with a flattened nasal tip, wide horizontal nostrils, in which the distance between the base of each ala is wider than normal, the pre-maxilla is bulging into the nasal floor on each side and into the short columeua. The lip is usually short, bulging, rigid and does not cover the incisor teeth adequately. The first case to be considered is a girl twin who had a standard repair (Figs. I and 2). Case 2 is interesting because this was the other twin, a boy. He developed a tumour of the pre-maxilla in the first few weeks of life which was diagnosed as a sarcoma and was completely excised. A two-stage repair of the lip, bring the lateral flaps below the central portion of the lip, was carried out after a further six weeks (Figs. 3 and 4). The report on the tumour is as follows : FIG. 3 Case 2. Pre-operative 1959. " L J.--Biopsy Report. Swelling of pre-maxilla. Naked eye : Piece of tissue 25 xi 5 xio mm. mainly soft in consistency but containing spicules of bone. Histology (Professor R. Willis) : This is a typical specimen of the pigmented epulis of infancy. The upper incisor region is its commonest site ; but your specimen is of special interest in that it came from this site in a case of cleft palate. In spite of its extent and infiltration, it is essentially a benign lesion, which is readily cured by local excision and which has not metastasized in any of the reported cases. Adequate local excision is the correct treatment. In one of your sections part of a tooth rudiment is present, but this shows no direct continuity with the tumour. Further sections might possibly show its derivation from the paradental epithelium." It was interesting to see the progress of this child who had a better nasal tip, columella and lip than the child who had the usual repair ; the mother remarked that she wished the girl had had this type of repair instead of the boy. I observed this child for three years to see how this nasal tip developed ; I then felt that it was worth making further efforts in an attempt to obtain a better nasal tip at the original repair than usually results in bilateral lip cases. In the normal nasal tip the skin covering the columella shapes down and clothes the nasal spine and then passes laterally and backwards to meet the ala on each side, so that this is really like an inverted "Y ". The ala passes on each side anteriorly and slightly medially so that the shape of the nares on each side is antero-medial. If the nasal tip is considered as a triangle, the base of this triangle is the line between the lower ends of the two aim : a triangle with the base of the columella and also another triangle up to the tip of the nose. The shorter the base of this triangle the more normal the nostrils are. In the Negro races this base is wider, the nasal tip flat and the bony
176 BRITISH JOURNAL OF PLASTIC SURGERY relationship underneath is different, giving wider nostrils. An important factor in the shape of the nasal tip is the position of the nasal spine : it is at the base of the columella, the columella goes forward and the other two sides slope down to the alto from it, so that it is central. If this relationship is incorrect, complete alteration of the nasal tip results. The normal lip is of adequate length to cover the teeth and is freely mobile. FIG. 4 Case a. 1966 : repair of lip 1959, adjustment of lip scar 1966. The third case was treated by a pre-operative expansion of the alveolus, as advised by McNeil (1954) and Burston (I96O, 1964). In the first stage of the operation, the central part of the mucous membrane covering the pre-maxiua was reflected downwards, and the lateral portions were reflected laterally. The anterior plate of the pre-maxilla was exposed and removed in the upper two-thirds, the tooth sacs were removed, the central septum was levelled back, in order to get it into what was thought to be its normal relationship with the nasal spine. The lateral parts of the bone were removed so that there remained the posterior wall of the pre-maxilla and the central septum which had been shortened at the upper part in order to give a more normal relationship. The central part of the mucous membrane was resutured, the lateral parts were reflected laterally and from each side of the alveolus, and a flap was reflected medially and sutured on each side to the laterally reflected flap to give a junction with the rest of the alveolus. The central portion of the skin was left in situ, and no attempt was made to push it up into the columella ; a bagginess was found at each side of the columella, so
THE NASAL TIP IN BILATERAL HARE LIP 177 small wedges of skin were excised. The soft tissues were allowed to settle for eight weeks and then the floor of the nose and the lip were repaired in one stage. The lateral portions of the lip were rotated and brought medially and sutured below the central portion to prevent any pulling on the central portion of the lip. This gave a notching FIG. 5 Case 3. 1963 : pre-operative. in the centre due to shortage of skin and a second advance adjustment of the lateral flaps was carried out. The procedure gave a good nasal tip, good airways, and no chronic nasal discharge. The lip is good but may need an Abbe flap later, because of some shortage of tissue (Figs. 5, 6 and 7). DISCUSSION Three cases have been presented in order to tell the story leading to the ultimate development of the third case. It is important to get a good nasal tip and normal nasal airways at the primary operation. I have found that secondary correction of flattened ~ nasal tips does not give a good result as that in the second and third cases presented
178 BRITISH JOURNAL OF PLASTIC SURGERY here. Late excision of the pre-maxilla, in previous cases of bilateral lip abnormality, gave only slight improvement, because the tissues of the lip by that time are fixed by scar tissue. Photographs demonstrating cases of nasal tip deformity should give a view from below for correct comparison. In the third case the alveolus is a good shape but loss of the upper incisor teeth has occurred. Incisor teeth in these cases are rudimentary, they usually give trouble at an early age and observation has shown that they have usually been removed by the age of ro years. An explanation of the abnormality of the condition and what happens following the usual type of repair has been attempted. It is felt that correct physiological function of the nasal airways should be obtained as well as a good cosmetic result.
THE NASAL TIP IN BILATERAL HARE LIP 179 FIG. 7 Case 3. 1966 : repair of lip 1963, further adjustments of lip later. REFERENCES BURSTON, W. R. (196o). Trans. int. Soc. #last. Surg., Second Congress, London. Edinburgh : Livingstone. (I964). Br. dent. J., Ii6, Nos. 285-294. MATTHEWS, D., and GROSSMANN, W. (1963). Trans. int. Soc. plast. Surg., Third Congress, Washington. Amsterdam : Excerpta Medica. (I964). Cleft Palate J., i, 43o. MCNEIL, C. K. (1954). " Oral and Facial Deformity." London : Pitman. POTTER, J. (1954). Plastic reconstr. Surg., 13, 358. (1955). Trans. int. Soc. #last. Surg., First Congress, Stockholm. Baltimore : Williams & Williams. PROETZ, A. W. (1953). J. Lar. Otol., 67 :I.