Reply: Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty

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After reviewing the comments by Dr. Maria Cecilia C. Ono and Dr. Renato da Silva Freitas regarding 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. In 2014, we compared two nasoalveolar molding techniques in patients with unilateral complete cleft lip.1,2 The difference in nostril height between the two methods was approximately 1.01 mm, and no difference was found between those two techniques when patients reached 1 year of age. In this recent publication using primary septal cartilage graft, our average follow-up time was approximately 5 years. The nostril heights in the graft and nongraft groups were 96.5 mm and 91.6 mm, respectively. The conclusion we derived from these two studies was that the cleft-side nostril height will continue to decrease with slumping of the alar rim as the patient ages despite the use of nasoalveolar molding. Our article in 20103 compared four different techniques in achieving nasal symmetry in unilateral cleft patients. This study included patients who did not have nasoalveolar molding or nasal stents. The results clearly showed that nasoalveolar molding and nasal stents provided significant benefits for cleft lip patients in terms of improved nasal symmetry up to 5 years of age. As we follow our cleft patients over time, we see new clinical challenges such as the collapse of the cleft-side alar rim and decrease in nostril height despite preoperative use of nasoalveolar molding, overcorrection of the cleft-side nostril height at the time of primary repair, and the postoperative use of nasal stents. Our surgical protocols for cleft repair continue to evolve to meet these challenges. The use of septal cartilage graft in addition to the previously published methods to improve nasal symmetry is an effort to provide our patients with more predictable long-term surgical outcomes. We do not have data supporting the use of septal cartilage graft in patients who did not have nasoalveolar molding preoperatively, or nasal stents postoperatively. The addition of primary septal cartilage graft to the previously published methods to improve nasal symmetry, however, did show promising results. A longitudinal study is still needed to monitor the effect of septal cartilage harvesting on facial growth.

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