A cartilaginous columellar strut in cleft lip rhinoplasties

British

j%urnal

of

Plastic

Surgery

(1976),

29,

247.250

A CARTILAGINOUS COLUMELLAR STRUT IN CLEFT LIP RHINOPLASTIES By DAVIDG. DIBBELL,M.D., F.A.C.S. Department of Plastic Surgery, Universitv of Wisconsin Hospitals, 1300 University Avenue, Madison, B%sconsin 53706, USA

CREATIONof an attractive nose for the older teenager with a cleft lip is difficult and particularly so with regard to the profile. Two reasons for this are the shortness of the columella in both unilateral and bilateral clefts, and failure of the alar cartilages to provide adequate tip support. The technique to be described was developed to correct both. TECHNIQUE Following the rhinoplasty, a strut of the shape and size shown in Figure I is prepared from septal or, preferably, costal cartilage. The concave part of the Bowie Knife shape allows the skin of the nasal bridge to slope back gracefully to the bridge line. The strut is accommodated in a pocket created in the columella and membranous septum, and the septal mucosa is advanced as required for complete cover. Usually the alar cartilages must be weakened or altered; otherwise the dome and lateral crura make the tip too broad and round. The upper portions should be excised as in a standard rhinoplasty, the dome scored and the lateral crus on the cleft side in a

FIG. I.

The

size, shape

and

siting

of the strut;

it is firmly sutures. 247

sutured

to the septum

with

figure-of-eight

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248

JOURNAL

OF PLASTIC

SURGERY

scored

alar

cartilage

remov

Strut

A

c

B

FIG. 2. Reducing the contribution of the lower lateral cartilages to tip shape: A, Usual rhinoplastic B, Lateral remnant sutured in new position. C, Dorsum excision and direction of swing of the remnant. of lower lateral scored to reduce the prominence of the dome of the arch. Right, before scoring; left, after scoring.

FIG.

3. A, C, E, preoperatively.

B, D, F,

2

years postoperatively.

CARTILAGINOUS

COLUMELLAR

STRUT

IN

CLEFT

LIP

RHINOPLASTIES

249

unilateral case relocated so that it is more normally positioned in relation to the soft tissue (Fig. 2). If the columella is only slightly short, the thrust of the strut may stretch it adequately. Alternatively, it may be lengthened with a forked flap (Millard, 1958). The latter approach provides the most accessible route for siting the strut and adjusting the lower lateral cartilages. On the precise position of the strut depends the nasolabial angle and the position of the new nasal tip. This procedure does not, of course, correct alar and nostril deformities which should be dealt with before the definitive rhinoplasty. Twenty-four of these procedures have been performed with a follow-up of 6 months to 3 years. Complications occurred in 3 cases: marked resorption and twisting of the strut occurred in a 9-year-old; fracture of the strut at the tip occurred in another because the strut was too fine; slight extrusion of a too long strut through the skin of the nasal tip occurred in the 3rd patient but healed without removal of the strut. Thus far, the rest

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FIG. 4.

JOURNAL

A, C, preoperatively.

OF

PLASTIC

SURGERY

B, D, 3 years

postoperatively.

of th le patients have maintained surprisingly good nasal contour with little Iobser 'vaable res;0r*ption or deformation of the cartilage (Figs. 3 and 4). No struts have had to be rer nc bved because of secondary infection. REFERENCE MILLARD, D. R. Reconstructive

JR. (1958). Columella Surgery, 22, 454.

lengthening

by

a forked

flap.

Plastic : and