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"After my son's initial lip repair his nose seems very flat, with no length at all to the flesh that seperates the nostrils. Right now, in profile, his lip actually extends farther out than his nose (he is almost four). My plastic surgeon assures me that he will build a tip to the nose and his profile will be more "normal" after the next surgery. How can they do that? Where do they get the tissue to build up the tip of the nose? Will he have a plastic implant or something? Will they use bone from else where in the body? What can we expect from that surgery?"
In answer to this question, children born with complete bilateral cleft lips often have the problem described above of a very short columella left after the initial lip repair. With a short columella, the tip of the nose is drawn down to the upper lip and the result is a flat profile.
At approximately five to seven years of age (varying by child and by doctor) the child may be scheduled for a procedure that will lengthen the columella. There are a number of different methods used to lengthen the columella. However, lthe most common method is one for which the surgeon has prepared for this procedure by "banking" extra tissues in the upper lip area (hence, the prominent lip) when effecting the initial lip repair.
During the initial repair, extra tissue was left in the upper lip and the prolabium area was left somewhat wide. This process, while initially possibly looking a bit "different" aesthetically, will provide much-needed tissues later that will ultimately give the child the best possible repair. When doing the actual columella lengthening, the surgeon will prepare two "fingers" of tissue, one below each nostril, primarily pulling from the existing scar tissue that was left after the initial Z-plasty repair. The bottom of the existing columella is seperated from the labial area and the two undetached "fingers" of flesh are drawn up and attached into a new columella. The labial area is then sutured on each side, leaving a smaller, more natural-looking philitrum, with the new scars left to form what will appear to be normal philitrum lines (leaving a nice cupid's bow effect). The edges of the nostrils are pulled in to decrease the spread of the nostrils and the sides of the labia are pulled together to make = the peaks of the cupid's bow.
After the surgery there will be some swelling of the lip and considerable tenderness on the nose. Immediate aftercare may consist of a soft diet for a few days, cleaning the suture line and possibly using ice-water compresses to reduce swelling. = The swelling and any bruising should be gone in about two to three weeks, with the majority of the swelling gone in the first week. This surgery may be done either as an inpatient or outpatient procedure, again, depending on the doctor and the child.
Whenever you are unsure of a procedure that your doctor plans to perform, remember that you have the right to understand the surgical plan before you agree to it. Most doctors are willing to take the time to explain their plans to a parent who is interested enough to ask questions. If you feel the doctor's explanation is confusing, ask him to sketch a picture of what he plans to do. And don't be afraid to ask your doctor to explain words and/or terms that you do not understand. You not only have a right to be told what will happen to your child, you have to right to understand. And most likely, your doctor wants nothing less!
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