Does the Curvature of the Rim Graft Matter?

Abstract

Sir: We read with great interest the recent article entitled “Secondary Unilateral Cleft Rhinoplasty Using Natural Curvature of Rib Cartilage as Alar Rim Graft: A Three-Dimensional Evaluation of Long-Term Results” by Dr. Liu et al.1 The series of cases along with the quantification analysis is an exemplary demonstration of the importance of the three-dimensional quantification into objectively evaluating the outcomes of rhinoplasty surgery. More impressively, the authors managed to have recruited more than a dozen patients over a span of 6 years. However, we would like to offer some different opinions from our perspective, and we wish the authors could kindly share some insights. The very nature of “using natural curvature of rib cartilage” might be somewhat ambiguous, or even argumentative. Methodologically, the article has yet to fully validate the significance of the addition of the alar rim graft. The intraoperative photographs suggest that after insetting the rim graft, the shape and outline of the nostril appear to have inconspicuous improvements. Although the objective data from three-dimensional scanning are, by all means, impressive, they seem to not have provided enough evidence on how the result would be any different with or without the rim graft. According to the photographs and the supplemental video, it is our understanding that despite this strip being harvested from the rib’s curvature, it still appears to be no more than a classic alar rim graft. The preliminary procedure of rib processing is the decortical process,2 which renders a long warped strip; any section from this layer can be trimmed and potentially used as a curved alar rim graft. What are the significant differences between those self-warping strips and the one introduced by the authors (because they are equally too thin to apply the Young modulus)? We highly agree that secondary rhinoplasty in the unilateral cleft lip patient is a daunting challenge. It is because of the congenital tissue deficiency and previous surgical scarring that, uncompromisingly, stable graft such as a fixed columellar strut is the established method for reestablishing the nasal tip.3 Having further reviewed the authors’ previously published reports,4 we wonder whether the team can provide more information on these concerns with regard to the surgical techniques? How do the authors process the nasal spine when it is severely deviated or poorly developed? We noticed that all of the columellar struts were the floating kind. How did the authors fixate the strut to avoid postoperative deviation, rotation, or derotation? Was there any camouflage (e.g., a shield graft) to further modify the tip? In addition, the thickness of the strut in the intraoperative photographs appears to be sturdy enough for a sustainable tip support. Regarding the figures that present the mobility of the tip, is this phenomenon universal in all patients? How long did it usually take for the nasal tip to achieve such mobility? DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Jianjun You, M.D., Ph.D.Lehao Wu, M.D., Ph.D.Huan Wang, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryChinese Academy of Medical Sciences and Peking Union Medical CollegePlastic Surgery Hospital and InstituteBeijing, People’s Republic of China