Reshaping the nose in the cleft patient represents one of the more challenging of all rhinoplasty surgeries. Efforts are made a various time periods from the initial cleft lip repair to teenage years to make nose corrections. But the tissue deformities inherent in the cleft nose almost always defies a completely satisfying result.
Of the many well known anatomic problems in the cleft nose, a columellar skin deficiency is one of them. This is most manifest in the bilateral cleft patient but exists to a lesser degree in the unilateral cleft as well. This lack of columellar skin length can mar an otherwise good realignment and reshaping of the tip cartilages at the completion of an open rhinoplasty. As when the skin is closed over the reshaped tip, the lack of columellar skin will pull down on the uplifted side of the dome causing a distortion of the nostril height and shape on the cleft side.
Different surgical strategies have been used to address this issue including columellar lengthening through V-Y lengthening closure methods. But they are not always successful in more severe unilateral cleft noses.
Since lack of skin is the problem, an alternative approach would be the use of a small skin graft placed into the deficient columellar skin side. This requires a very small skin graft which can be easily harvested from the back of the ear. Like all skin grafts, take of the graft is enabled by graft immobility and compression. This is less important with such a small graft in a well vascularized area such as the nose. But the use of a nasal stent or conformer can assist in this regard.
Dr. Barry Eppley
Indianapolis, Indiana