Rebalancing the Skin Envelope Using Dorsal Preservation and Septal Extension Graft in Secondary Bilateral Cleft Rhinoplasty

Overview

Bilateral cleft noses have a short, tight skin envelope that limits how far the tip can be pushed forward with a septal extension graft. The Japanese authors propose "rebalancing" the existing skin instead of adding flaps or grafts: a push-down or let-down preservation technique lowers the dorsum at the rhinion, creating skin redundancy that is then used to project the tip with a rib-cartilage SEG. Two cases are reported.

Sections of note

• Two adult male patients with bilateral cleft lip and palate.
• Both had an under-projected tip and a relatively high dorsum at the rhinion; one also had a broad nose, the other a crooked nose.
• Dorsal preservation (push-down or let-down) reduced rhinion height and created skin redundancy.
• A costal cartilage SEG projected the tip; structural grafts corrected asymmetry as needed.
• At one year: improved profile, symmetry and projection; no complications.

What it means for a patient

• In a cleft nose where the skin is too tight to bring the tip forward, lowering the bridge can "lend" skin to the tip.
• The approach avoids skin grafts or lip flaps that leave extra scars.
• Two cases show feasibility only.

Why this paper matters

It applies dorsal preservation to a reconstructive problem for which it was not designed, with a clear mechanical rationale. Limits: two patients, one-year follow-up, no outcome scores.

Terms

• Bilateral cleft lip and palate: clefts on both sides, typically leaving a very short columella and flat tip.
• Rhinion: the point on the bridge where bone meets cartilage.
• Push-down / let-down: preservation methods for lowering the intact dorsum.
• Septal extension graft (SEG): cartilage fixed to the septum to project the tip.
• Skin envelope: the skin and soft tissue over the nasal framework.