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LETTERS

A Novel Cleft Rhinoplasty Procedure Combining an Open Rhinoplasty with the Dibbell and Tajima Techniques

Agarwal, Rajiv M.D.; Chandra, Ramesh M.D.

Author Information
Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 1116-1117
doi: 10.1097/PRS.0b013e3181e6063b
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Sir:

We would like to report our experience with adult cleft lip rhinoplasty, especially unilateral cases that have certain interesting deformities that need to be recognized and addressed so that we can correct and reverse the deformity satisfactorily, based on our experience of over 25 years in treating and studying the deformity closely intraoperatively by the open approach. Flores et al. have reported a novel cleft rhinoplasty procedure by combining an open rhinoplasty with the Dibbell and Tajima techniques as a retrospective review of 10 years' duration.1 A total of 35 patients were identified, and photographs from 18 of them were analyzed. The authors report a statistically significant decrease in alar base width and an increase in columellar height and nostril apex height. The single result that has been shown also illustrates these postoperative improvements, and it is a good result by any standards; in particular, the statistical analysis comes out in strong support.

However, being plastic surgeons and not statisticians, we do need to be more critical of our results in terms of correction of specific technical deformities in unilateral cleft lip and look out for the uncorrected components of this deformity and the underlying reasons thereof. No attempt is being made to individualize and undermine the result shown in this article, which must be among the best in the entire study. On the worm's-eye view, the preoperative photograph shows basically the tip of the nose toward the right side of the midline, apparent clinically as a small projection that is made even more evident by the light reflex. In the postoperative photograph, this projection maintains the same position and situation but is more prominent. This possibly signifies an uncorrected or inadequately corrected component of the nasal deformity. Light can play a spoilsport on some views, but the situation does not change on the frontal view. There is a very clear light reflex of the nasal tip toward the right side, and this does not change in position at all in the postoperative photograph.

The key factor responsible for the deviated tip in unilateral cleft lip nose is the nasal septum. Figure 1 illustrates the extent of the septal deformity in these cases and was taken just after uncovering the skin envelope before any dissection of the cartilaginous structures has commenced. The caudal border of the nasal septum is skewed to the noncleft side in these cases because of the deforming force applied at its base by the anterior nasal spine. The nasal spine is itself deviated to the noncleft side and is hypertrophied and sometimes bifid also. The growing septum in the retrocolumellar region is restrained by the anterior nasal spine and is deflected toward the noncleft vestibule. The caudal border of the septum, once deflected off the midline, continues its advance because of the continuous forward growth of the septovomerine unit and thus after being deflected presents itself in the nostril on the noncleft side. The caudal border of the septum and the spine are not independent of each other but are connected by another structure, the septospinal ligament, which has been a constant deforming influence in our experience of treating these cases over the past two decades.2 This ligament extends from the deformed anterior nasal spine and is attached to the caudal border of the septum. This whole complex defines and deforms the nasal tip in unilateral cases, and this leads to deviation of the tip toward the noncleft side. The correction of this particular abnormal anatomy requires excision of the curved caudal portion of the nasal septum, osteotomy of the anterior nasal spine, and excision of the septospinal ligament. The straightened septum then needs to be fixed in the midline and, because the anterior curved portion has been excised, in almost all cases a columellar strut, fixed or hanging, becomes a necessity unless the deformed septum is left behind and the deviated tip is accepted as a residual deformity. At the same time, it is important to address the issue of the depressed nasal base by suitable augmentation procedures.3,4

Fig. 1.
Fig. 1.:
Intraoperative photograph of a 22-year-old woman with a left-sided secondary cleft lip nose deformity following open rhinoplasty showing the configuration and curvature of the caudal border of the septum and the alar cartilage on both sides. No dissection of the cartilage or the septum has been performed at this stage. The location of the septal angle on the right side explains the presence of the nasal tip on this side.

The cleft side alar cartilage is unique in unilateral cleft lip nose deformity. It is caudally dislocated and thus its lower border frequently presents as the alar web. This finding has also been reported by Dibbell in his drawings, but he has not reported on the relative width of the lateral crus on the cleft and noncleft sides but inadvertently has drawn the cleft lateral crus wider than the noncleft lateral crus, which correlates with our observations of increased width of cleft lateral crus when compared with noncleft lateral crus. Thus, a double-pedicle flap will not totally correct the alar cartilage abnormality at the level of the genu and the cartilaginous hooding. Also, lip and cheek incisions are not necessary for correction of the cleft lip nose deformity. The Dibbell technique per se incorporates a lot of skin incisions, and those are not well tolerated by the Asian population, as many have a tendency for hypertrophic scarring and thus the postoperative result even after a symmetrical rhinoplasty may end up with a lot of extra scarring that was previously nonexistent.5

Use of soft-tissue anthropometric landmarks may not be the ideal method for analysis of the results in secondary cases of cleft lip nose deformity, as the midline (sn) may not necessarily be in the midline in a repaired lip. Moreover, the other landmarks used by the authors appear to be “off target” as sn-al distance for alar width and sn-c for columella height. In the case of the latter, the points c and c|o: both are off the midline and are not even located over the columella and thus cannot be taken as reference points for columellar height by virtue of their not being on the columella. The best way, in our opinion, to analyze images is to use AutoCAD software, which allows the digital photographs to be readily imported, and if a scale is also incorporated alongside while clicking photographs, this becomes an objective and simple method of facial analysis.

PATIENT CONSENT

The patient provided written consent for the use of her image.

Rajiv Agarwal, M.D.

Ramesh Chandra, M.D.

Department of Plastic Surgery

Chhatrapati Shahuji Maharaj Medical University

Lucknow, India

REFERENCES

1.Flores RL, Sailon AM, Cutting CB. A novel cleft rhinoplasty procedure combining an open rhinoplasty with the Dibbell and Tajima techniques: A 10-year review. Plast Reconstr Surg. 2009;124:2041–2047.
2.Agarwal R, Chandra R. The septospinal ligament in the cause of cleft lip nose deformity: Study in adult unilateral clefts. Plast Reconstr Surg. 2007;120:1633–1640.
3.Agarwal R, Chandra R. The unrecognized skeletal components of the cleft lip nose deformity. Plast Reconstr Surg. 2008;122:313–315.
4.Agarwal R, Bhatnagar SK, Pandey SD, Singh AK, 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. 1998;102:1350–1359.
5.Dibbell D. Cleft lip nasal reconstruction: Correcting the classic unilateral defect. Plast Reconstr Surg. 1982;69:264–271.

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