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Author's reply incision and cartilage suspension. Our early experience Recently, reports from McComb [3] and Pigott [4] demonstrated the potential long-term downsides of re- has been, I believe, better in that we have not found the cruiting lip and nostril sill tissue for columella lengthen- need for additional columellar release and feel that this ing. Three unfavorable results were noted with the ado- gain will probably come with growth over time. The technique provides excellent early columellar lengthen- lescent growth spurt: 1) the columella was too long and the nostrils were too large; 2) the nasal tip remained ing to help minimize the stigmata of the deformity in the broad, and; 3) there was drift of the columellar base and early school years, and at the same time lends itself well the lip columellar angle was transgressed by a scar. Pig- to open rhinoplasty techniques used for the later defini- ott made the additional observation that the overlength- tive repair. ening of the columella at the expense of alar dome pro- jection resulted in an unaesthetic nose at maturity. These concerns have led many surgeons to the realization that References the "extra tissue" needed for columellar lenghtening lay 1. Tajima S, Maruyama M (1977) Reverse U-incision for sec- in the nose rather than the lip and it is through this real- ondary repair of cleft lip nose. Plast Reconstr Surg 60:256 ization that Tajima et al. applied the principles of their 2. Kernahan D, Bauer B, Harris G (1980) Experience with the unilateral cleft nasal repair to the bilateral deformity. Tajima procedure in primary and secondary repair in unilateral Our first experience with this technique as a means of cleft nasal deformity. Plast Reconstr Surg 66:46 columellar lengthening was in a patient with a rare bilat- 3. McComb H (1985) Primary repair of the bilateral cleft lip eral nasal cleft deformity in which the alar cartilage nose: a 15-year review and a new treatment plan. Plast Re- constr Surg 75:477 shape and displacement matched that to the typical bilat- 4. Pigott R (1988) Aesthetic considerations related to repair of eral deformity, yet the alar base width was narrower than the bilateral cleft lip nasal deformity. Br J Plast Surg 41:593 normal. The technique was applied with great success both in reorientation and suspension of the alar cartilag- es and gain in columellar length. An external scar was avoided and the already narrow nostril sills left un- changed. When the technique was applied to the more typical bilateral nasal deformity, columellar length was effectively gained in all cases, external nasal and lip scars were avoided, and the alar cartilages were restored to a more normal configuration. This is a technique in evolution and I am not sure that S. Tajima either these authors or ourselves have reached the opti- mal design of this procedure. In relation to the use of the Department of Plastic and Reconstructive Surgery, Osaka Medical reverse U flap, a review of our earliest cases demonstrat- College, 2-7 Daiga Ku-cho, Takatsuki, Osaka 569, Japan ed that with the reverse U incision designed in a similar fashion to the unilateral procedure resulted in excessive superior columellar width. This is less a problem in the It was our earlier experience that in some selected cases Asian nose than the Caucasian. This problem can be of incomplete bilateral clefts columella gained sufficient avoided by skewing the reverse U incision more medial- length by bilateral reverse U incisions alone. However, ly to its apex and narrowing its apex. The technique is in bilateral complete clefts, sufficient columellar length also less effective in influencing the shape of the colum- could not be achieved by bilateral reverse U incisions ellar-labial angle, but this can be addressed with a num- alone, at least during the operation. This is why we add- ber of different approaches through the medial limbs of ed columella relaxation incisions. We have no explana- the incision along the membranous septum. tions why the columella could not be lengthened enough These authors have elected to gain additional colum- by bilateral reverse U incisions in the Japanese, while re- ellar length and modify the base of the columellar with verse U incisions were enough for lengthening in the their added columellar release. While some additional Caucasians who have a more prominent nose than the length is gained, I do not believe this is the ideal answer Asians. The common observation that the nasal cartilag- either because it negates much of the positives of this es are weaker in the Orientals and also give less support- technique and returns us to the very permanent problem ive strength might be one of the explanations. The differ- of scars transgressing the lip-columellar angle. The abil- ences in the primary operation especially in the nasal ity to fully assess this effect in the cases illustrated is floor and piriform margins might be the other. somewhat difficult due to the added use of several Abb6 To answer for the fear of overgrowth after the growth flaps, but it cannot be overlooked as a potential down- spurt in our cases, a satisfactory columella in terms of side of the technique described here. length and breadth will easily be gained by the shorten- I think that Tajima and coauthors are on the right ing around the base since the original columellar struc- track as far as recognizing the benefits of their reverse U tures are left intact in our procedure. European Journal of Plastic Surgery Springer Journals

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Copyright © 1997 by Springer-Verlag
Medicine & Public Health; Plastic Surgery
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