Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity

It was with delight that we read the article entitled "Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity."1 It reviewed nasal analysis and provided instruction on surgical management of the secondary cleft rhinoplasty. According to Rohrich et al., a rigid structural framework was the main goal of secondary cleft rhinoplasty.1 Autologous costal cartilage could provide strong structural support, with its advantages of biocompatibility, ample graft volume, and low risk of infection and extrusion.2 Although it may increase the risk of donor-site morbidity, warping, and resorption, continuous improvements in cartilage harvesting, carving techniques, and sufficient postoperative analgesia gradually reduce these complications.3,4 A flattened contour of the alar rim and wide nostril sill width on the cleft side are the most common findings with the cleft nasal deformity. In addition to the four types of alar contour grafts mentioned in the article, we prefer the circular alar contour graft, which is similar to the fixed extended alar contour graft (the third type) but wider and longer. It could form a circular nasal flange to provide structural support to the severely collapsed alar rim. Changing the diameter of the circular alar contour graft can not only adjust the size and shape of the nostril but also raise the alar base and nasal sill and shorten the nostril sill width. The circular alar contour graft, with a length of 6 to 7 cm, is carved from the concave curvature of the sixth or seventh costal cartilage. The lower lateral cartilage is released from the upper lateral cartilage, and the medial and middle crura are freed from the mucosa. The tunnel is created subcutaneously along the lacuna of the nose flange, alar base, and nasal sill for insertion of the graft. The beginning of the circular alar contour graft is fixed with a figure-of-eight suture beneath the lateral crus of the lower lateral cartilage, and the end side is fixed to the medial crus of the lower lateral cartilage on the columellar strut, with the diameter of the graft adjusted according to the contralateral alar rim. The middle crus of the lower lateral cartilage is suspended in the same manner as the noncleft side. After scar tissues of the alar base and nasal sill are released on the cleft side, a cavity is formed subcutaneously. Crescent costal cartilage could fill the cavity and further raise the alar base and nasal sill (Fig. 1). The crescent graft has been used successfully in pyriform aperture augmentation because of its crescent shape fitting closely with the edge of the aperture.5 For mild midface concavity, the horizontal or vertical limb of the crescent is used, depending on the patient's anatomy. For pyriform hypoplasia, commonly observed in cleft nasal deformity, the entire crescent is preferred. Usually, the combination of the two methods can effectively improve the collapsed alar base and nasal sill, and prevent the subsequent collapse (Fig. 2).Fig. 1.: The circular alar contour graft and crescent-shaped costal cartilage used on the cleft side (left side).Fig. 2.: Typical case of cleft rhinoplasty. (Left) Preoperative and (right) 12-month postoperative photographs of a 14-year-old girl who presented for treatment of secondary unilateral cleft rhinoplasty. Before surgery, mild vault collapse and alar displacement on the cleft side and asymmetric tip-defining points were notable on the frontal view. On the lateral view, dorsal convexity, poor tip projection, and rotation were seen. On the basal view, poor tip projection, nostril shape asymmetry, and weakened alar rims with soft-tissue triangle notching on the cleft side were noted. The patient underwent component dorsal hump reduction, septal reconstruction, tip augmentation, dorsal augmentation, alar reshaping, and paranasal augmentation through an open approach. A circular alar contour graft and a crescent-shaped costal cartilage were used for the cleft side, and a classic alar contour graft and diced costal cartilage were used for the noncleft side. Note the improvement in cleft-side nostril height and shape at 12-month follow-up.Flap transfer could also help improve the alar base and narrow the nostril sill width on the cleft side. This would involve designing a triangular flap pedicled at the alar base on the cleft side, separating and pulling the triangular flap inward and upward until the alar base is symmetrical to the noncleft side. PATIENT CONSENT The patient provided written informed consent for the use of her images. Wenfang Dong, M.D.Yihao Xu, M.D.Fei Fan, M.D.Twelfth Department of Plastic Surgery Plastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People's Republic of China