Open rhinoplasty for correction of the secondary nasal deformity due to the Marcks triangular flap cleft lip repair

Almost half a century ago, Tennison (1) proposed a triangular flap cleft lip repair that for the first time preserved the existing lip elements and permitted the creation of a normal Cupid’s bow. Brauer (2) and Randall (3) are better known for improving this original concept, but Millard (4) credits Marcks for popularizing Tennison’s method while developing his own Z-plasty modification. Trevaskis et al (5) later recapitulated their design more scientifically with a mathematical solution using a 60° tip angle and standardized templates to design the Z-plasty flaps. This reflected similar independent observations by Davies (6) as revised by Lewis (7), and Jayapathy et al (8). The Marcks and Trevaskis Z-plasty version of the triangular flap cleft lip repair, when correctly performed, results in an exquisite appearance of the lip. Their legacy remains extensive throughout eastern Pennsylvania, with disciples of this technique spread throughout North America, where this method of lip repair often can be instantly discerned due to the characteristic nasal appearance that develops following correction of the more severe unilateral cleft lip. Not unlike other secondary cleft lip nasal deformities, several deficiencies exist, including that of the alar cartilage that is typically malpositioned posteriorly, laterally and inferiorly (9,10), but peculiar to this repair is buckling of the alar rim in a V-pattern due to the requisite medial transposition of the superior cleft side Z-plasty flap. Tennison (1) advocated correction of any nasal deformity at the primary operation but never entirely accomplished this. Marcks et al (11) recognized the “typical droop of the lower lateral cartilage” after his modified repair