Aesthetic considerations related to repair of the bilateral cleft lip nasal deformity.

A study of the changing configuration of the nose tip with age shows that the columella naturally takes a greater share of nose tip projection with increasing age. In the infant and small child, when most repairs are done, nose tip projection is due more to the alar dome component than to the columella. Over-lengthening the columella at the expense of alar dome projection results in an unaesthetic nose at maturity. The nasal correction should be towards a normal proportion for age and attention must be paid to alar dome configuration. Where the inferior view shows a "tent tip" skyline, lateral crus advancement is required and can be achieved in asynchronous repairs by Pigott alar leapfrog at primary repair or by Potter V-Y advancement at the time of forked flap columella lengthening. The profile view of the nose and lip shows that the lip "drops" from a point about two-thirds of the way from nostril apex to alar base. A key stitch advancing the alar bases at the time of columella lengthening allows the philtral area to bow forwards as a prow so that it comes to lie in a normal relationship with the columella in the profile view.