Monday, November 3, 2008 - 7:42 AM

Ten-Year Review of a Combined Open Cleft Rhinoplasty Incision Utilizing the Dibbell and Tajima Techniques

Roberto L. Flores, MD, Alexander M. Sailon, BA, and Court B. Cutting, MD.

Background: This study assesses the safety and efficacy of a novel cleft rhinoplasty incision that combines the Dibbell, Tajima and open rhinoplasty incision sets. The Dibbell technique simultaneously corrects the lateralized alar base and depressed lower lateral cartilage on the affected side. The Tajima technique corrects nostril apex overhang and creates a soft triangle. These incisions, however, provide limited access to the nasal tip, making refined adjustments and grafting in this area difficult. By combining the Dibbell, Tajima and an open-rhinoplasty incisions, the dome cartilages can be directly visualized, facilitating cartilage repositioning/grafting and tip refinement while correcting the deformities of alar base, nostril dimension and nostril apex height.

Methods: A single-surgeon, 10-year, retrospective review of 157 consecutive unilateral cleft lip rhinoplasties was done. Non-syndromic patients who underwent a combined open incision/Dibbell/Tajima approach and who had a follow-up of greater than 8 months were included. Indications for the combined approach were lateralization of the alar base associated with a depressed dome and nostril apex overhang on the affected side. A total of 35 patients were identified. Standardized patient photographs were examined in frontal and worm’s-eye view in a subset of 17 patients who had both preoperative and postoperative photographs. Farkas normal values were applied to the medial canthal distance and from this value metric measurements of changes in alar base width, nostril dimension and nostril apex height were derived.

Results: Of the 35 study patients, none experienced complications due to skin envelope ischemia or cartilage graft infection. The revision rate of alar base position was 11% (4 of 35), depressed lower lateral cartilage 3.9% (1 of 35) and nostril apex overhang 3.9% (1 of 35). Cartilage grafting was performed in 54% (19 of 35) mostly in the form of a columellar strut (n=16) with or without additional tip grafting. There was a statistically significant decrease in alar base width (19.8mm vs. 18.3mm, p<0.01) and nostril width (9.9mm vs. 7.9mm, p<0.01) after the procedure. The difference in nostril height between the affected and non-affected side decreased (1.8mm vs. 0.9mm, p<0.05) suggesting that improved nostril height symmetry is achieved. On frontal view, the difference in nostril apex height between the affected and non-affected side was decreased when related to the inferior border of the nasal tip (1.8mm vs. 1.1mm, p<0.05).

Conclusion: An open rhinoplasty incision that combines the Dibbell and Tajima techniques is safe and associated with a low revision rate. The incision provides wide exposure to the nasal tip, facilitating cartilage grafting and tip refinement in the dome area, common procedures in our series. This technique results in a statistically significant decrease in alar base and nostril width, and a greater symmetry of nostril height and nostril apex height between the affected and non-affected sides.