A New Design for Reconstruction of Nasal Dimensions during the Primary Repair of Unilateral Cleft Lip

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With great interest, we read the article by Knight et al. about primary cheiloplasty and rhinoplasty.1 We would like to take the opportunity to further expand on the topic with a new technique for reconstruction of nasal dimensions during the primary repair of unilateral cleft lip.
Cleft lip nasal deformity offers a unique challenge to the reconstructive surgeon.2 Among many types of nasal deformity, we just attempted to address how to modify the nasal alar rim and valve collapse. As we know, nasal alar rim and valve collapse is the main deformity in children with unilateral cleft lip, especially for Asian patients because of the external nasal morphology. Many methods have been adopted to correct the nasal alar rim and valve collapse during primary cheiloplasty.3,4 Primary cleft nasal surgery at the time of initial lip repair is the standard treatment at major cleft centers. However, we still feel confused regarding the balance of tissue between tightening of the alar base and correcting nasal alar rim and valve collapse. The results of the article by Knight et al. suggest that continued greater growth on the cleft side through early childhood may result in equal heminasal width in adolescence. The results indicated that we could incise more tissue on the nasal alar base to support and correct nasal alar rim and valve collapse. To reduce the secondary revision cleft rhinoplasty rate, especially regarding the deformity of nasal alar rim and valve collapse, we have developed a new design to balance and reconstruct the nasal alar rim and valve collapse (Fig. 1).
The distance between points 1 and 2 is measured, and an equal distance from point 1 to the right peak of the Cupid’s bow is point 3. The distance between points 2 and 9 is measured and an equal distance from point 10 to the left corner of the mouth is point 4. Theoretically, point 5 can be any point on the bisecting line of the angle 2-1-3, but we suggest marking the point medially to the philtral column; the key of this design is to ensure equalizing the distance from point 5 to point 2 and the distance from point 5 to point 3. Regarding the base of the columella (point 6), the point divides the columella base into a one-third cleft part and a two-thirds noncleft part. The distance between points 3 and 6 is measured and an equal distance from point 4 to the ala bases is point 7. Point 8 is located at the edge of cleft side. With the same description as previously, surgery continues with rotation advancement incision through the skin, maintaining the integrity of muscle and mucosa.5 After muscle relocation, we attempt to tighten the alar base and correct nasal alar rim and valve collapse by the two flaps. The C flap will be sutured to close the alar base; meanwhile, the lateral flap will be rotated to close the skin wound and correct nasal alar rim and valve collapse. The proper design and operation of cleft lip repair should be beneficial to the potential normal growth of the lip and nose, fulfil future expectations, and reduce the secondary revision rate. In this treatment, we attempt to incise more tissue on the nasal alar base by using two flaps to support and correct nasal alar rim and valve collapse based on the conclusions prosed by Knight et al. In addition, we achieved a satisfactory outcome in immediate postoperative evaluation by this treatment.
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