Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.

Abstract

Sir: We read with great interest the article by Dr. Greives et al.1 entitled “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” We would like to acknowledge the authors for sharing with us this very comprehensive analysis, performed to provide us with a practice-based assessment of preoperative evaluation, anesthesia, surgical treatment plan, perioperative management, and outcomes. Moreover, the different techniques used for cheiloplasty and nasal repair are critically discussed, giving us a complete overview and providing us with exceptional consultation material for decision-making. However, Dr. Greives et al. did not mention in their review the use of autologous fat grafting in primary cleft lip repair, which has been recently described as a further, new and emerging technique.2 We believe that this technique needs to be considered as an option for this operation. Indeed, fat tissue transfer can be considered as an excellent tool with which to solve the lack of tissue in the nasolabial complex, which is typical for this deformity. So doing can avoid one of the detailed stigmatizing signs, which is that resulting from the low projection of the upper lip, usually found together with a similarly affected nasal columella. These two deformities are, together, responsible for an unsuitable nasolabial angle.3 Fat transfer techniques have gained worldwide acceptance for the correction of a host of deformities through soft-tissue augmentation.4 Their efficacy in providing wound healing and regeneration has been related to the evidence that fat grafts harbor stem cells, termed adipose-derived stem cells, pluripotent cells producing beneficial factors. This autologous tissue may also improve scar caliber and minimize scar burden. Most importantly, for primary treatment of cleft lip and nose, research from Wu et al.5 has revealed that infant-derived adipose-derived stem cells are more biologically robust than those obtained from adult tissue. Therefore, in our opinion, the section of the article by Dr. Greives et al. regarding the surgical techniques can be enriched by considering the recent article of Dr. Balkin et al.,2 that described their experience with autologous fat tissue transplantation for primary cleft lip and nose repair. In their retrospective analysis, Dr. Balkin et al.2 performed fat grafting to various elements of the lip and nose in a series of consecutive infants who underwent primary cleft lip and nose repair with immediate fat grafting. The results, judged with clinical examination, were reported as excellent, without complications or delays in recovery. According to these results and to the well-accepted background regarding the biophysical and biochemical properties of adipose tissue, we strongly believe that adipose tissue fat grafting for the correction of primary cleft lip and nose should be taken into consideration. Thus, prospective investigations, with long follow-up, are needed to corroborate these findings. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No external funding was received. Andrea Sisti, M.D. General and Specialist Surgery Department Plastic Surgery Division University of Siena Siena, Italy Carlo M. Oranges, M.D. Plastic, Reconstructive, and Aesthetic Surgery School Marche Polytechnic University Ancona, Italy