Reply: Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty.

Abstract

Sir: We thank Dr. Li et al. for their nice illustration of the modified rotation-advancement with nasal-base triangle flap. Similar to our approach, centralization of the columella is emphasized. A fundamental difference is the reliance on transposition flaps to construct nasolabial form. Instead, we shift the underlying foundation to “raise” existing anatomical structures.1 Although long-term outcomes of their approach are pending, the pattern of repair potentially violates borders of the columella, medial footplates, and nasal sill. Although those anatomical subunits have received little attention and the configuration of that region on the noncleft side has been largely ignored, careful examination can be revealing. Before repair (Fig. 1), on the noncleft side, the medial footplate appears prominent and the nasal sill is constricted (notice how the columellar base abuts the nasal ala). Following repair (Fig. 2), on the noncleft side, the medial footplate flattens, the nasal sill widens, and the natural contours of those structures become apparent. Rather than a straight horizontal line dividing the nose from the lip, each anatomical component has a curvilinear contour with distinctive shapes defining the philtrum, columella, medial footplate, and alar base (Fig. 2). In particular, the sill has a central valley along the mid nostril. If symmetry is the ultimate goal, repair on the cleft side should approximate the configuration of non–cleft-side structures (Fig. 2). The difficulty is that those contours are not apparent preoperatively (Fig. 1). Closure along anatomical borders is inherent in the Fisher repair2 and its modifications3 because the design is defined by opposing cleft-side and non–cleft-side landmarks. The same can be achieved with rotation-advancement; however, recognition of those structures by the surgeon and a deliberate effort to tailor the repair accordingly are required (as described by Onizuka et al.4).Fig. 1.: Preoperatively, the columella and noncleft alar base deviate away from midline (marked in blue) and the cleft alar base is retruded. The twist distorts anatomical subunits in opposing ways: the cleft dome is low, and the noncleft dome is high; the cleft sill is wide, and the noncleft sill is narrow; the cleft footplate is flat, and the noncleft footplate is prominent; the cleft ala is down, and the noncleft ala is up; and so forth.Fig. 2.: Postoperatively, cleft lip repair was combined with foundation-based primary rhinoplasty (septoplasty, lateral nasal wall reconstruction, and nasal floor closure) with no nasal tip dissection. Centralization of the columella and rebalancing of alar bases produced opposing changes. Normalization reveals the natural anatomical subunits. Rather than a simple horizontal line, the medial footplate, sill, and alar base produce a curvilinear contour with a central valley (white dotted line). Ideal treatment needs to respect anatomical borders while reproducing non–cleft-side morphology that is not apparent preoperatively. Given the dynamic interplay of opposing changes, we need to pay more attention to the non–cleft-side alterations.We pay little attention to the non–cleft-side nasal sill preoperatively and do not examine it postoperatively because many of our principles are based on erroneous dogma. Traditional conventions have considered the noncleft side as normal, the cleft alar base as laterally displaced, and correction of the deformity requiring medial advancement of the cleft alar base. Objective three-dimensional analysis of children undergoing primary repair has proven all of those concepts wrong.5 Uncoupled premaxillary growth produces a “twist” deformity with opposing changes, wherein correction requires rebalancing of both sides. The cleft alar base needs to advance (but its mediolateral position should not be altered), the columella needs to be centralized, and the noncleft alar base needs to move medial5 (Figs. 1 and 2). Alterations in subunit morphology accompany each of these shifts. As we all work to improve treatments, it will be important to assess both sides of the nose in conjunction with the changes that occur. When appropriately corrected, the noncleft side may reveal the “ideal normal,” and with the right repair, we may be able to approximate it. Much like the dualism of ancient Chinese philosophy, the key to solving the unilateral cleft lip nasal deformity may be the recognition of the “yin and yang” interconnections that exist across sides and through treatment. ACKNOWLEDGMENT Dr. Joseph Gruss was an author of our original article. He has since passed away. We appreciate how he has taught us to question what we do and to challenge dogma when the truth is otherwise. DISCLOSURE The authors have no financial interest to disclose.