Aesthetic Surgery Journal

http://aes.sagepub.com/ Commentary on: Correction of Cleft Lip Nose Deformity With Rib Cartilage
S. Anthony Wolfe Aesthetic Surgery Journal 2013 33: 674 DOI: 10.1177/1090820X13488134 The online version of this article can be found at: http://aes.sagepub.com/content/33/5/674

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 Commentary
Aesthetic Surgery Journal 33(5) 674 2013 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X13488134 www.aestheticsurgeryjournal.com

Commentary on: Correction of Cleft Lip Nose Deformity With Rib Cartilage
S. Anthony Wolfe, MD, FACS, FAAP
In their article, Correction of Cleft Lip Nasal Deformity Using Rib Cartilage, Hafezi et al present their preferred source of autologous graft material in the treatment of patients with cleft lip nasal deformities (CLND). They maintain that rib cartilage, harvested as recommended by Gunter et al,1 is superior to auricular cartilage (which they believe is convoluted) and to septal cartilage (which they believe is limited in amount). The authors report on a number of CLND patients they treated with rib cartilage grafts. They achieved good results in terms of obtaining adequate tip projection and a straight dorsum, but clinical photos in a worms-eye view reveal persistent postoperative nostril constriction and straight (rather than curved) alar margins in most patients. Consequently, I disagree that the use of rib cartilage solves all potential obstacles inherent to CLND treatment. A patient with a bilateral cleft and a short columella may benefit from an Abb flap, and the existing lip skin could be used for the columella, given proper cartilaginous support for the nasal tip. Many of the patients shown in the authors clinical images had underlying maxillary deformities that I would like to have seen corrected before the final lip and nasal work was undertaken. In addition, many patients in the authors series exhibited severe distortion of the nasal septum wherein airway correction would have entailed removal of a large segment of septum. Typically, this excised septal cartilage is used for reconstructive purposes, particularly for the fashioning of spreader grafts and a columellar strut. At the same time, utilizing a postauricular approach, enough conchal cartilage is harvested to construct completely new alae. In my experience, the firmness of rib cartilage in the alae sometimes results in visibility of the graft edges through the skin. Rib cartilage is more rigid than ear cartilage (but not septal, as the authors claim), but I am not sure if this is

necessarily a blessing. In older patients, the rigid cartilage may fracture. It also presents difficulty in shaving off the thin, uniform laminae required for alar construction. In addition, some young women prefer an imperceptible postauricular scar to one on their chest wall. For these reasons, I prefer septal and auricular cartilage, and only use rib cartilage when both the septum and conchae have already been harvested. These are personal preferences, however. The authors have taken some very difficult cases and have obtained substantial improvements overall, for which they should be congratulated.

Disclosures
The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

REFErENCES
1. Gunter JP, Rohrich RJ, Adams WP. Dallas Rhinoplasty: Nasal Surgery by the Masters. 2nd ed. St Louis, MO: Quality Medical Publishing; 2007. 2. Wolfe SA. A pastiche for the cleft lip nose. Plast Reconstr Surg. 2004;114(1):1-9.

Dr Wolfe is Chief of the Division of Plastic Surgery, Miami Childrens Hospital, Miami, Florida. Corresponding Author: Dr S. Anthony Wolfe, Miami Childrens Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA. E-mail: drawolfe@bellsouth.net

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