To Reduce the Secondary Nose Deformity on Unilateral Cleft Lip by Lateral Nasal-Base Triangle Flap.

Abstract

Sir: With great interest, we read the recent article about rhinoplasty entitled “Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty.”1 We would like to take the opportunity to further expand on the topic with our modification, which involves reducing the secondary nose deformity of unilateral cleft lip by using the lateral nasal-base triangle flap. Cosmetic rhinoplasty is one of the most taxing aesthetic procedures in plastic surgery, especially for nasal deformity in children with cleft lip. Cleft lip nasal deformity offers a unique challenge to the reconstructive surgeon for many reasons. First, clinical presentation of cleft lip varies widely, requiring a host of surgical techniques. Second, deformity may be quite severely asymmetric, making surgical correction difficult. Third, patients with cleft lip may have been previously subjected to numerous surgical interventions, leading to significant scar tissue at the operative site. Fourth, timing of rhinoplasty, whether synchronous or staged with cleft lip repair, is controversial. Fifth, this nasal anomaly affects the pediatric population, and the patient’s growth affects surgical results. Conversely, the surgery may adversely compromise nose growth. Thus, this represents a significant reconstructive challenge for plastic surgeons, because it is very difficult to master the intricate interplay of dynamic nasal subunits. Among many types of nasal deformity, we just tried to address how to modify the collapsed nasal ala. As we know, collapsed nasal ala is the main deformity in children with unilateral cleft lip. That is because of the abnormal development of the premaxilla. Many methods have been adapted to correct the collapsed nasal ala during the primary cheiloplasty; primary cleft nasal surgery at the time of initial lip repair is the standard of treatment in major cleft centers. However, the surgeons usually repair the cleft lip and modify the nasal deformity in isolated fashion, and even use the columella incision for the downward lip peak of the Cupid’s bow, which may affect the outcome with regard to primary rhinoplasty. Dr. Tse demonstrated a new approach to primary rhinoplasty. In this article, we propose a different way of reconstructing and correcting the nasal deformity, especially with regard to collapsed nasal ala with the lateral nasal-base triangle flap. With the same description as before, surgery continues with rotation advancement incision through the skin, maintaining the integrity of muscle and mucosa. The muscle is dissected free from skin and mucosa for a distance of 3 to 4 mm.2 A horizontal cut is made through muscle under the columella to rotate the displaced muscle into a normal position, from where it attaches to the base of the columella and anterior nasal spine. Dissection of the orbicularis oris muscle from its abnormal attachment is important, so that it can be sutured on the cleft side of the columella. The muscle, subcutaneous tissue, and skin are approximated after dissection of the orbicularis oris muscles. By this technique, we relocate and fix the columella during reconstruction of the orbicularis oris muscle. Thus, we design a new nasal-base triangle flap on the lateral cleft lip for reconstructing the collapsed nasal ala and alar groove in this treatment (Fig. 1). By using this method, we achieved a satisfactory outcome immediate postoperatively and at 2-year evaluation. We need more studies to confirm this in a Chinese population.3,4Fig. 1.: (Above) Points of reference: 1, central point of Cupid’s bow; 2, right peak of Cupid’s bow on the noncleft side; 3, left peak of Cupid’s bow on the noncleft side; 4, peak of Cupid’s bow on the cleft side; 5, base of the columella; 6, junction of the line bisecting the angle 2-1-3 and the philtral column on the noncleft side; 7 and 8, end of the incision on the lip; 9, base of the ala; 10, middle point of the nostril base; and 11 and 12, corner of the mouth. (Center) Incision on both sides of cleft lip. (Below) Closure of the cleft lip and correction of the nose deformity.DISCLOSURE The authors have no conflicts of interest in relation to this communication.