We appreciate the letter by Drs. Agarwal and Chandra1 in contributing to our collective quest to reconstruct the perfect nose. We agree with the critical analysis of the persistence of the light reflex pattern seen on our operative result. Although this finding can be attributable to undercorrection of the cartilaginous framework, we incorporated an open rhinoplasty in all study patients. Under direct vision, the cephalic scroll was trimmed and lower lateral cartilages were repositioned. We frequently used columellar struts to stabilize the nasal tip construct. A more likely explanation for the observed “undercorrection” lies within the soft tissue. The nasal tip skin envelope often retains the “memory” of its prior three-dimensional form and preserves a degree of its original topography, despite reconstruction of the cartilaginous framework. In our experience, this has been one of the most challenging aspects of secondary cleft rhinoplasty and still awaits a definitive solution.2
Although plastic surgeons are not statisticians, statistical analysis is an important objective method of interpreting clinical results. We certainly could have incorporated subjective analysis in our results; however, this was not the goal of the study. We have found the use of subjective analysis in the literature to be highly variable and nearly impossible to compare from one study to another. Statistical analysis allows for an objective interpretation of results and reliable means of comparing results across studies. We perform our statistical analysis acknowledging that rhinoplasty is an operation of judgment, balance, and individualized patient planning. Our study analyzed the effectiveness of specific rhinoplasty techniques in obtaining specific and lasting results in the nose. It is the surgeon's aesthetic judgment that determines when to use this technique or other techniques in their reconstructive plan.
We wholeheartedly agree with the importance of addressing the septum during secondary cleft rhinoplasty3 to address the airway, dorsal line, and nasal tip. Our preferred technique is a radical submucous resection of the bony and cartilaginous septum as far posteriorly as the sphenoid, with direct ostectomy of the vomerine groove.4 The caudal septum is then dislocated manually from the anterior nasal spine and a suture is used to relocate the septum into anatomical position. We have not found the need to remove the septospinal ligament as advocated by Agarwal and Chandra.1,3 This may be attributable to the differing cleft populations in the United States compared with India. The great majority of the patients in our study underwent primary cleft lip and nasal repair during infancy. Many of the patients in the Indian study underwent primary cleft nasal repair at a late age, possibly contributing to the hypertrophy and significance of this ligament in the Indian cleft population.
Our use of photogrammetry and anthropometry in the analysis of cleft nasal reconstruction is well established and its limitations are clearly stated. As to our use of specific anthropometric measurements, these have been directly adopted from the Farkas anthropometric study of cleft nasal reconstruction,5 and we consider these measurements to be reliable (Figs. 1 and 2).
Roberto Luis Flores, M.D.
Court B. Cutting, M.D.
Riley Hospital for Children
1.Agarwal R, Chandra R. A novel cleft rhinoplasty procedure combining an open rhinoplasty with the Dibbell and Tajima techniques (Letter). Plast Reconstr Surg
2.Cutting C, Bardach J, Pang R. A comparative study of the skin envelope of the unilateral cleft-lip nose subsequent to rotation-advancement and triangular flap lip repairs. Plast Reconstr Surg
. 1989;84:409–417; discussion 418–419.
3.Agarwal R, Chandra R. The septospinal ligament in cleft lip nose deformity: Study in adult unilateral clefts. Plast Reconstr Surg
4.Cutting CB, Flores RL. Correcting the cleft lip nose. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery.
St. Louis: Elsevier; 2009:573–583.
5.Farkas LG, Hajnis K, Posnick JC. Anthropometric and anthroposcopic findings of the nasal and facial region in cleft patients before and after primary lip and palate repair. Cleft Palate Craniofac J
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