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

Sato A, Takamura N, Yusa Y, Hara K, Imai Y.

PubMed 41050978 Publisher (DOI)Free full text (PMC)

What this paper says

In two adult men with bilateral cleft lip and palate, lowering the high bridge by dorsal preservation freed enough skin to allow a rib-cartilage septal extension graft to project the tip, with marked improvement at one year and no complications.

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.

Summary written by rhinoplasty.cc from the abstract, 2026-09-08; not medical advice. The authors' own abstract follows.

Abstract

In bilateral cleft lip and palate patients, secondary rhinoplasty is often complicated by a limited skin envelope, which restricts nasal tip projection despite the use of septal extension grafts (SEGs). We proposed a technique based on the concept of rebalancing the existing skin envelope, without the use of local flaps, skin grafts, or composite grafts. We reported 2 cases of adult male patients with bilateral cleft lip and palate who underwent secondary cleft rhinoplasty. Both patients exhibited a cleft-specific configuration characterized by an underprojected nasal tip and a relatively high dorsum at the rhinion. In addition, 1 patient presented with a broad nose deformity, and the other exhibited a crooked nose. A dorsal preservation technique-either push-down or let-down-was applied to reduce dorsal height at the rhinion and create redundancy in the skin envelope. An SEG using costal cartilage was then used to reconstruct and project the nasal tip. Structural grafts were additionally used to correct nasal asymmetries when necessary. At 1-year postoperative follow-up, both patients demonstrated marked improvements in nasal profile, symmetry, and tip projection. No complications were noted. Rebalancing the skin envelope through targeted reduction at the rhinion may allow for improved tip projection in cleft rhinoplasty. This approach may expand the applicability of SEGs in challenging cleft cases and warrants further study.

Abstract as indexed by PubMed; the article is open access (PubMed Central).