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The philtral unit requires symmetrical philtral columns. Another common technical error in R-A repairs is the surgeon's failure to make the rotation scar mimic the opposite, normal philtral column.

Fig. 27 shows two examples of rotation scars that are too straight.

Fig. 28 shows four examples of rotation scars that are too curved. In all of the above cases the philtral columns are asymmetric. Not one of these patients has a normal looking philtrum.

Fig. 29A shows a rotation cut with too much curve, retaining too much tissue at its junction with the columellar crease. The remaining intra-op and post-op views clearly demonstrate how this unsatisfactory result was predetermined by, and could be predicted from, the pre-op markings. How can one plan the rotation cut so it will always match the normal ridge? First, plot the normal philtral column on the non-cleft side, noting its curvilinear course. When drawing the rotation cut on the cleft side, match that same curve from the high point of cupid's bow up to the labio-columellar crease. From this point, the rotation incision is continued in the labio-columellar crease.

Sometimes this line utilizes the entire labio-columellar crease (Fig.30A and B); other times it may reach this crease closer to the mid-line of the columella (Fig.30C); rarely, it may not reach this crease until one approaches the non-cleft side of the columella (Fig.30D). Wherever this line meets the naso-columellar crease, it then continues in the crease to a point just proximal to the normal philtral column, the sight of the cut-back as described by Millard2, 10, 12. When one does this, the philtral unit symmetry is immediately obvious in the pre-op markings.

The immediate post-operative appearance (Fig.31 and Fig.32) and later post- operative scars (Fig.33 and Fig.34) confirm the effectiveness of paying careful attention to this anatomic detail:

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