Reply: Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty

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After reviewing the comments by Drs. Lu and Chen with regard to our recent publication in Plastic and Reconstructive Surgery entitled “Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty,”1 we would like to respond with the following rebuttal. The purpose of primary septal cartilage graft was to prevent alar rim collapse and improve nasal symmetry in patients with unilateral complete cleft lip deformity. Cleft-side nostril width was one of the measurements made in this study to assess our postoperative outcome. The use of the alar rim graft, however, was not to decrease the cleft-side nostril width. The inquiring authors suggested malpositioning of the labial and philtral muscles as the main contributing factor of the nasal deformity described in this article. We would like to clarify that all patients included in our study had adequate muscle dissections and mobilization of the perialar and philtral musculature to reestablish appropriate muscle orientation and function. There was no significant difference in cleft-side nostril width between the two groups of patients in this study. Our techniques of primary cheiloplasty with muscle dissection and repositioning have been described in Neligan’s Plastic Surgery textbook2 and the Noordhoff Craniofacial Foundation’s instructional DVD.3
The inquiring authors also raised the concern of harvesting a 0.5 × 2-cm septal cartilage from the caudal portion of the nasal septum with regard to facial growth. They commented that a 0.5 × 2-cm septal cartilage rim graft was insufficient in size to support the nostril shape when these patients reach adulthood. The use of a primary septal cartilage rim graft was to provide better nasal symmetry and aesthetic as they grow throughout childhood and early adolescence. Whether these patients need secondary cheiloplasty or rhinoplasty as they reach adulthood is still unknown. Although a septal cartilage graft is unlikely to proliferate after being transplanted to the recipient site, cartilage graft has been shown to remain viable with minimal graft resorption based on histologic findings reported by several studies.
With regard to the donor-site defect, we performed a limited subperichondrial dissection at the caudal aspect of the septal cartilage at the time of graft harvesting. The perichondrium surrounding the donor site remains intact. Whether the donor-site defect fills in with chondral matrix that eventually matures into cartilage is still unknown. This certainly warrants a separate investigation by computed tomographic or magnetic resonance imaging studies when we follow these patients long term to evaluate their facial growth and surgical outcomes.

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