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

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.