Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty

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We read with great interest the article entitled “Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty” by Ting-Chen Lu et al.1 published recently in Plastic and Reconstructive Surgery. In this article, the authors did well to compare the two groups of patient outcomes with or without nasal rim graft made by caudal septal cartilage in the longest follow-up period. The nostril could be more stereologic in the trial group, although the width was not reduced. In this communication, we would like to propose several explanations for the unsolved width, and that could be conducive for the authors’ further studies in unilateral cleft rhinoplasty.
Initially, the source of secondary nasal deformity of unilateral cleft lip is not insufficient quantity of support, but the malposition caused by local muscular dysplasia. The ectopic labral and philtrum muscles and their attachments produce biomechanical changes, such as abnormal tractive force and shear force, which lead to local tissue displacement and deformation, regardless of whether it was cartilage, subcutaneous soft tissue, or skin.2 From this point, the first step for unilateral cleft rhinoplasty should be restoring the abnormal, and then you would find what is really needed, just as Menick said.3 For detailed instruction, refer to rabbit ears, which stand up because of the strong muscles in the root of the ears rather than the cartilage itself. In addition, the cartilage has a tendency to change its inherent peculiarity according to the recipient area.4 This may also need to be taken into account. Thus, the corrected labral and philtrum muscles could prevent the nostril from widening and maintain the nostril stereology.
Also, the authors harvested the caudal septal cartilage to reduce the potential negative influence on nasal development caused by this operation. The authors’ thoughtful and exquisite consideration is worthy of praise. However, a 0.5 × 2-cm septal cartilage is not a small piece for a 3-month-old baby, and is not sufficient for an adult nostril. However, the cartilage is almost impossible to grow in both the donor site and the recipient site. Unilateral cleft rhinoplasty is different from pure rhinoplasty. Filling the blank is not an enduring solution. Inappropriately, it might be a kind of waste. We are willing to wait for longer follow-up results, although the 3- to 7-year follow-up is admirable.
In the end, we thank the authors for their study of the effect of septal cartilage on nostril shape in unilateral cleft rhinoplasty. This is definitely a tricky problem, demanding prompt solutions and innovative ideas.

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