We conducted a retrospective, single-center, non-consecutive case series involving eight patients diagnosed with cleft lip and palate (CLP) between 2019 and 2024 at a plastic reconstructive and aesthetic surgery unit. The cohort consisted of four male and four female patients. All male patients presented with unilateral CLP, while among the female patients, three had unilateral CLP and one had bilateral CLP. The patients’ ages ranged from 15 to 28 years, with a mean age of 21 years. Objective evaluations included preoperative and postoperative measurements of the tip projection ratio and alar width ratio.

Due to the retrospective nature of this study, photographs were collected from previously documented clinical records. Consequently, standardized camera settings, patient positioning, and lighting conditions were not prospectively established. Although we attempted to maintain consistency in photographic technique across patients, variations were inevitable and represent a limitation of this analysis. We acknowledge that the retrospective nature of our study precluded the establishment of prospective photographic standardization protocols, including camera settings, lighting conditions, and exact patient positioning. This limitation may contribute to measurement variability and potential bias in anthropometric analysis. To assess the reliability of landmark identification in photographic analysis retrospectively, we conducted an inter-rater reliability test using intraclass correlation coefficients (ICC). Two independent raters analyzed all photographic data, resulting in an ICC of 0.89, indicating strong reliability.

Written informed consent was obtained from all patients for the publication of their clinical data and accompanying images. For the 15-year-old patient, written informed consent was obtained from the patient’s parent/guardian. A copy of the signed consent forms is available for review by the Editor of this journal.

A 24-year-old male patient presented with a unilateral complete left cleft lip and palate (CLP), with a history of labioplasty performed 23 years prior. The patient underwent revision labioplasty in conjunction with full open rhinoplasty. Autologous rib cartilage grafts were utilized and shaped into multiple components, including a septal extension graft, spreader graft, dorsal onlay graft, perichondrium graft, Berger graft, alar graft, shield graft, and diced cartilage graft. Postoperative assessments demonstrated an increase in the tip projection ratio and a decrease in the alar width ratio, indicating improved nasal contour and symmetry (Fig. 2).

A–C A 24-year-old male patient with a unilateral complete left cleft lip and palate (CLP) underwent revision labioplasty and full open rhinoplasty. D–F Six months postoperatively, following reconstruction with autologous rib cartilage grafts. Notable improvements were observed, including an increase in tip projection ratio and a reduction in alar width ratio, contributing to enhanced nasal symmetry and definition

A 17-year-old male patient with a unilateral complete right cleft lip and palate (CLP) had previously undergone labioplasty 14 years ago and palatoplasty 12 years ago. The patient underwent revision labioplasty combined with full open rhinoplasty. Autologous rib cartilage was harvested and sculpted into a septal extension graft, spreader graft, alar graft, strut graft, alar rim graft, and diced cartilage graft. Postoperative evaluation revealed an increased tip projection ratio and a decreased alar width ratio, indicating improved nasal projection and symmetry (Fig. 3).

A–C A 17-year-old male patient with unilateral complete right cleft lip and palate (CLP) underwent revision labioplasty and full open rhinoplasty. D–F Six months postoperatively, following nasal reconstruction using autologous rib cartilage grafts. Postoperative assessment demonstrated increased tip projection ratio and decreased alar width ratio, reflecting enhanced nasal symmetry and projection.

A 22-year-old male patient with a unilateral complete left cleft lip and palate (CLP) had previously undergone labioplasty 21 years earlier. The patient underwent secondary rhinoplasty utilizing autologous rib cartilage grafts, which were fashioned into a septal extension graft, spreader graft, alar graft, dorsal onlay graft, and diced cartilage graft. Postoperative evaluation revealed an increase in the tip projection ratio and a decrease in the alar width ratio, indicating improved nasal projection and symmetry (Fig. 4).

A–C A 22-year-old male patient with unilateral complete left cleft lip and palate (CLP) underwent full open rhinoplasty. D–F Six months postoperatively, following reconstruction using autologous rib cartilage grafts. The tip projection ratio increased and the alar width ratio decreased, indicating improved nasal projection and symmetry

A 23-year-old female patient with unilateral complete left cleft lip and palate (CLP) had previously undergone labioplasty 8 years ago, followed by palatoplasty and revision labioplasty 3 months prior to the current procedure. She underwent open rhinoplasty using autologous rib cartilage grafts, which were shaped into a septal extension graft, spreader graft, alar graft, alar rim graft, Berger graft, shield graft, and diced cartilage graft. Postoperative evaluation demonstrated an increase in the tip projection ratio and a decrease in the alar width ratio, indicating improved nasal projection and contour (Fig. 5).

A–C A 23-year-old female patient with unilateral complete left cleft lip and palate (CLP) underwent open rhinoplasty. D–F Six months postoperatively, following nasal reconstruction using autologous rib cartilage grafts. The tip projection ratio increased and the alar width ratio decreased, indicating improved nasal projection and symmetry

A 21-year-old female patient with bilateral asymmetric cleft lip and palate (CLP) had previously undergone labioplasty 20 years ago and palatoplasty 19 years ago. She underwent open rhinoplasty using autologous rib cartilage grafts, which were fashioned into a septal extension graft, spreader graft, alar graft, dorsal onlay graft, Berger graft, and diced cartilage graft. Postoperative evaluation demonstrated an increased tip projection ratio and a decreased alar width ratio, indicating improved nasal projection and symmetry (Fig. 6).

A–C A 21-year-old female patient with bilateral asymmetric cleft lip and palate (CLP) underwent open rhinoplasty. D–F Six months postoperatively, following reconstruction using autologous rib cartilage grafts. The tip projection ratio increased and the alar width ratio decreased, indicating improved nasal projection and symmetry

An 18-year-old female patient with unilateral complete left cleft lip and palate (CLP) had previously undergone labioplasty 17 years ago and palatoplasty 16 years ago. Revision labioplasty and open rhinoplasty were performed using autologous rib cartilage grafts, which were fashioned into a septal extension graft, spreader graft, dorsal onlay graft, alar graft, Berger graft, and diced cartilage graft. Postoperative evaluation revealed an increase in the tip projection ratio and a decrease in the alar width ratio, indicating improved nasal symmetry and projection (Fig. 7).

A–C An 18-year-old female patient with unilateral complete left cleft lip and palate (CLP) underwent revision labioplasty and open rhinoplasty. D–F Six months postoperatively, following reconstruction using autologous rib cartilage grafts. The tip projection ratio increased and the alar width ratio decreased, indicating enhanced nasal projection and symmetry

A 28-year-old female patient with unilateral left cleft lip and palate (CLP) had previously undergone labioplasty 27 years ago and palatoplasty 26 years ago. She underwent revision labioplasty and open rhinoplasty using autologous rib cartilage grafts, which were shaped into a septal extension graft, spreader graft, alar graft, alar rim graft, Berger graft, dorsal onlay graft, and diced cartilage graft. Postoperative evaluation demonstrated an increased tip projection ratio and a decreased alar width ratio, reflecting improved nasal projection and symmetry (Fig. 8).

A–C A 28-year-old female patient with unilateral left cleft lip and palate (CLP) underwent revision labioplasty and open rhinoplasty. D–F Six months postoperatively, following nasal reconstruction using autologous rib cartilage grafts. The tip projection ratio increased and the alar width ratio decreased, reflecting improved nasal projection and symmetry

A 15-year-old male patient with unilateral right cleft lip and palate (CLP) had previously undergone labioplasty 14 years ago and palatoplasty 13 years ago. He underwent open rhinoplasty using autologous rib cartilage grafts, which were fashioned into a septal extension graft, spreader graft, dorsal onlay graft, alar graft, alar rim graft, and diced cartilage graft. Postoperative evaluation revealed an increased tip projection ratio and a decreased alar width ratio, indicating enhanced nasal projection and symmetry

All patients were followed up for 6 months postoperatively. Indirect photographic evaluations were conducted to compare preoperative and postoperative outcomes. Table 1 summarizes the detailed demographic data, previous surgical history, specific graft techniques utilized, and objective anthropometric outcomes (tip projection and alar width ratios) for each patient included in this case series. No complications were recorded during the 6-month postoperative follow-up period. The measurements demonstrated an increase in the tip projection ratio and a decrease in the alar width ratio (Table 2). None of the patients reported complaints regarding nasal appearance, lip contour or shape, or postoperative irregularities (Figs. 9 and 10).

Measurement of tip projection ration. a Tip. b Nasal base

Measurement of alar width ratio. a Alar width. b Canthal distance

Although substantial improvements in nasal symmetry were achieved, slight residual nostril asymmetry remained evident in some cases, reflecting inherent challenges in completely correcting complex nasal deformities associated with cleft lip and palate. This highlights the necessity for realistic patient expectations regarding achievable symmetry.