You'll find hundreds of files on cleft lip, cleft palate here on

This one is about: Timing of Rhino Plastic Surgeries

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by John W Canady, MD

Like many aspects of cleft care, treatment of the cleft nasal deformity is somewhat controversial. Attempts to standardize treatment are often frustrating because of the lack of uniformity in cleft patients. Each child is an individual, with individual problems. And since no two clefts are exactly alike, each treatment plan must be unique. A useful rule is that "if all the problems are different and all the patients are treated the same, then some of the patients are likely being treated incorrectly."

Correct diagnosis and treatment of cleft nasal deformity involve treating both appearance and function. Since all surgery is carried out in a child who is still growing, certain biological factors are unavoidable. Although there are differences of opinion regarding the effects of surgery on growth, perhaps more important are the effects on the surgery. A glance at any series of school photos is proof that the face changes dramatically during the growth years and in certain patients the results obtained early in childhood may not be preserved into their late teens.

This should in no way be taken as a statement that the child should be left to suffer unnecessarily during his early school years. Certainly severe functional problems must be corrected at the earliest opportunity. Problems of appearance may be equally compelling, though, and are often inseparably integrated into functional nasal problems. A balanced decision must be made because although growth will continue and may adversely affect an initial result, if excessive functional or psychosocial pressures are present, an earlier surgery is performed, the parents must understand the possibility of later revisions.

All things being equal, however, a motivated patient is a good patient and often delaying surgery until a time when BOTH the parents and patient want it performed is the best. If the patient is mature enough to describe what parts of their nasal deformity are most upsetting to them, then these can be dealt with as a priority. Also, patients at this level of development are frequently better able to understand and comply with postoperative instructions and restrictions. Nothing is more frustrating than a good surgical repair which has been traumatically disrupted by a child who is rebelling against parental limitations.

Unfortunately, there is no single perfect time for cleft rhinoplasty in every child. Severe functional problems and children who experience very negative psychosocial interactions, in part because of their appearance, deserve consideration for early repair. On the other hand, a motivated child is generally compliant in the postoperative period and this may produce superior, longer-lasting results. Correct timing of this very important surgery is best arrived at in a discussion including (and INVOLVING) the surgeon, the parents, and the patient.

----------Dr. John W Canady is the Plastic Surgeon for University of Iowa Hospitals and Clinics, Cleft Palate Team. He is also the Medical/Surgical consultant for WIDE SMILES Magazine.

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