Thus, the analysis of any cleft nose deformity at any age must include an inquiry regarding residual septal deformity, physical examination to specifically study the columellar deviation, and a computed tomographic scan to confirm these findings. The operative algorithm must take into account the septocolumellar influences on the tip aesthetics and plan to eliminate them to achieve consistent results.
The frontal and lateral postoperative views of Byrd et al.’s patients show a good result regarding nasal cartilage sculpturing and grafting procedures, but the basal view shows deviation of the columellar base toward the noncleft side and tip deviation toward the cleft side along with a deficient cleft side nose sill, although the authors do mention a septal straightening maneuver. This indicates the presence of a residual deviated nasal septum and consequent malaligned septocolumellar infrastructure.
The skeletal components of the unilateral cleft lip nose deformity thus include a deficient inferior rim of pyriform fossa, hypertrophied anterior nasal spine, and skewed vomerine groove besides the well-described feature of ipsilateral maxillary hypoplasia.
In addition, the nose sill needs to be addressed regarding the muscle and skeletal deficiency and qualifies for a place in the algorithm. The nasal sill is also deficient on the postoperative photographs. Many techniques have been described for augmenting the nose sill, and we have been using a superiorly based turnover orbicularis oris muscle flap for this purpose in addition to performing the other cartilage sculpturing and grafting procedures.3
Our recommendations for cleft lip rhinoplasty would be septoplasty with relocation of the caudal part of the septum, excision of the septospinal ligament, relocation of the anterior nasal spine, and augmentation of the nose sill in addition to the standard maneuvers for reconstructing the cartilage infrastructure of the nose.4,5
Rajiv Agarwal, M.Ch.
Ramesh Chandra, F.R.C.S.
1. Byrd, H. S., El-Musa, K. A., and Yazdani, A. Definitive repair of the unilateral cleft lip nasal deformity. Plast. Reconstr. Surg.
120: 1348, 2007.
2. Agarwal, R., and Chandra, R. The septospinal ligament in the cause of cleft lip nose deformity: Study in adult unilateral clefts. Plast. Reconstr. Surg.
120: 1, 2007.
3. Agarwal, R., Bhatnagar, S. K., Pandey, S. D., Singh, A. K., and Chandra, R. Nasal sill augmentation in adult incomplete cleft lip nose deformity using superiorly based turn over orbicularis oris muscle flap: An anatomical approach. Plast. Reconstr. Surg.
102: 1350, 1998.
4. Rohrich, R. J., and Griffin, J. R. Correction of intrinsic nasal tip asymmetries in primary rhinoplasty. Plast. Reconstr. Surg.
112: 1699, 2003.
5. Salyer, K. E., Genecov, E. R., and Genecov, D. G. Unilateral cleft lip-nose repair: A 33-year experience. J. Craniofac. Surg.
14: 549, 2003.
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