Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty

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Surgical correction of the nasal deformities of unilateral cleft patients is challenging and sometimes frustrating because of the limitation of postoperative long-term outcomes. The development of a displaced osteocartilaginous framework of the nose constitutes an enormous difficulty to achieving stable results, as there is always a tendency to relapse even after extensive reshaping maneuvers. Therefore, a rhinoplasty after the end of craniofacial growth is frequently needed to improve both aesthetic and functional aspects of the nose.
Lu et al.1 describe the use of a semiopen rhinoplasty, with complete release of the fibrofatty tissue between the lower lateral cartilages and the nasal tip, with the interposition of a septal graft along the alar rim, overcorrecting the projection of the cleft-side nostril. Septal cartilage is harvested from the anterocaudal portion of the nasal septum, during anterior palatoplasty,1 configuring a more invasive manipulation of this recognized facial growth center. Some concerns must be mentioned based on some relevant previous publications by Dr. Chen and the Taiwan team.
In the two articles published in 2012 and 2014, they demonstrated a large series of patients treated with presurgical nasoalveolar molding.2,3 The main principle of nasoalveolar molding is try to address the nasal deformity in addition to passively molding the alveolar segments, attempting to reduce cleft severity and improve nasal form and symmetry, improve the results, and make the primary operation a less radical, less invasive procedure.4 Their studies have shown good results with both nasoalveolar molding techniques tested, proving that they are a reliable alternative for enhancing the primary rhinoplasty outcomes. In the present article, the authors emphasize that long-term results of rhinoplasty are not stable, with progressive flattening of the nostril shape and the relapse of nostril webbing; thus far, they recommend a more radical procedure. From our point of view, this statement is conflicting: Why does a team defend the use of an orthopedic device that demands a huge amount of compromise from parents and then goes for such an extensive surgical procedure to maintain the result? Are the nasoalveolar molding results not so reliable? Also, it is not congruent for us to use nasoalveolar molding to avoid huge surgical undermining and reshaping, and perform an open rhinoplasty with cartilage graft. Evaluating the nostril, it is possible to observe that the normal side is smaller than the cleft side. We think that it is more difficult to correct it than an alar web. To date, in our center (i.e., the Assistance Center for Cleft Lip and Palate, the second largest cleft center in Brazil, 120 operations per month), we have not used nasoalveolar molding, because we believe it is possible to achieve similar results without so many manipulations.
The treatment of the nasal repercussions of unilateral cleft patients is controversial. Most surgeons have limited results, and the secondary rhinoplasty is usually indicated when the patients complete craniofacial growth. We must be very cautious when deciding between conservative and more invasive approaches. Future prospective and controlled studies to resolve this doubt are strongly advised.

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