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Reconstruction of the Nasal Columella
David A. Sherris, MD;
Jon Fuerstenberg, MD;
Daniel Danahey, MD, PhD;
Peter A. Hilger, MD
Arch Facial Plast Surg. 2002;4:42-46.
ABSTRACT
Objective To report techniques successful for nasal columella reconstruction.
Methods Retrospective medical chart review of patients undergoing columella
reconstruction by 2 of us (D.A.S. and P.A.H.) from January 1, 1982, to December
31, 2000. Photographs before tumor resection or trauma, after resection or
trauma, and after reconstruction were examined by facial plastic surgeons
masked to the cases and were rated on a 10-cm visual analogue scale.
Result Sixteen patients were identified, most of whom had columellar defects
repaired with forehead flaps, nasolabial flaps, or nasofacial sulcus flaps.
The mean improvement on the 10-cm visual analogue scale was 2.0 from before
tumor resection or trauma to after reconstruction, and 5.0 from tumor resection
or trauma to after reconstruction.
Conclusion Skin grafts, composite grafts, and several flaps, including nasolabial,
nasofacial sulcus, and forehead flaps, are useful in repairing defects of
the nasal columella.
INTRODUCTION
NASAL reconstruction has been performed for centuries, with the first
reconstructions occurring before 500 BC.1 In
modern times, the practice of reconstruction has been advanced by the work
of surgeons such as Burget and Menick,2 who
proposed the subunit principle of nasal reconstruction. They found that changes
in soft tissue and bony contours of the nose resulted in distinct, consistent
nasal subunits, including the dorsum, tip, columella, 2 lateral sidewalls,
2 alae, and 2 soft tissue triangles.2 These
authors found that if greater than 50% of an aesthetic subunit of the nose
were missing, it was better to resect the rest of the subunit and reconstruct
it in its entirety. This articles focuses on the reconstruction of the nasal
columellar subunit.
The nasal columella has traditionally been a difficult subunit to repair
because of its unique contours, limited availability of adjacent skin, and
tenuous vascularity. There are few reported cases in the literature.3-9
The approaches reported include the use of full-thickness skin grafts, composite
grafts from the ear, nasolabial flaps, nasofacial flaps, and forehead flaps.3-10
Nasolabial flaps, unilateral, bilateral, or bifid, are the most frequently
described.3-5
We reviewed columella reconstructions performed by 2 of us (D.A.S. and
P.A.H.). Several techniques are described, along with follow-up information
regarding the reconstructions. The long-term aesthetic and functional results
of these columella reconstructions are reported.
PATIENTS AND METHODS
This study was a retrospective medical chart review of patients who
had undergone nasal reconstruction involving the nasal columella by 2 of us
(D.A.S. and P.A.H.) between January 1, 1982, and December 31, 2000. Involvement
of the columella was determined by review of the written surgical records
and preoperative and intraoperative photographs.
The results of the surgeries were determined by reviewing operative
notes, postoperative photographs, and clinical notes detailing follow-up appointments.
A panel of experienced facial surgeons, excluding us, was shown photographs
of the nose before and after surgery and was asked to rate the nasal aesthetics
on a 10-cm visual analogue scale, with a specific focus on the columella.
A score of 0 represented the worst appearance and 10, the best.
Several techniques were used in the reconstruction of the nasal columella,
including forehead flaps, nasolabial flaps, and nasofacial sulcus flaps. A
description of these techniques follows. A more thorough description is detailed
in the literature.8, 10
FOREHEAD FLAP TECHNIQUE
The paramedian forehead flap8, 10
is centered on the supratrochlear artery contralateral to the defect; Doppler
ultrasonography can be used to identify the vessel. A foil template is used
to determine the shape of the flap, with the length determined by the distance
from the pedicle base to the distal defect site.
Nasal mucosal flaps, epidermal turn-in flaps, and septal flaps can be
used for the nasal lining.10 In some cases
involving the columella and caudal septum, the flap used for reconstruction
can be used as nasal lining for the caudal septum. The cartilaginous structure
of the nose is reconstructed with autogenous cartilage grafts. The distal
one third of the forehead flap is thinned to the subdermal layer before it
is inset. Care must be taken in smokers, as this thinning can increase the
risk of distal flap necrosis. If hair-bearing skin is harvested with the flap,
the hair follicles should be cut or plucked from below before flap inset.
The donor site is usually closed with a running W-plasty and bilateral forehead
advancement flaps. Large donor defects may be closed partially and the resulting
defect allowed to close by secondary-intention healing over several weeks.
Approximately 3 weeks later, the pedicle is divided and the rest of
the flap is thinned to the dermis and inset. If necessary, the entire nasal
unit is dermabraded approximately 4 to 6 weeks after the original reconstruction.
Occasionally, minor revision of the reconstructed area is performed 3 months
to 1 year later. If the flap grows hair on its distal-most aspect, this can
be treated with electrolysis or laser hair ablation.
NASOLABIAL FLAP TECHNIQUE
The template for the 2-staged, superiorly based nasolabial (melolabial)
flap10 is created similarly as in the forehead
flap procedure.10 The inferior border of the
flap is the nasolabial (melolabial) crease. The nasolabial flap is incised
through the skin, with the distal end elevated in the subcutaneous plane above
the facial musculature. The proximal, medial skin is left intact as a subcutaneous
pedicle. The flap is thus shaped somewhat like a banana. The donor site is
closed by advancing a cheek flap to the nasolabial groove. Two to three weeks
later, the pedicle is divided and the flap is thinned and inset. The pedicle
is excised and closed in the nasolabial crease.
NASOFACIAL SULCUS FLAP TECHNIQUE
This is a new flap technique developed by one of us (P.A.H.). An elliptical
incision is made in the nasofacial sulcus just below the medial canthus. The
incision is carried down to the periosteum medially and laterally. Inferiorly,
the incision is made into the subcutaneous tissues superficial to the muscular
plane (Figure 1). Dissection inferior
to the flap is performed in the superficial subcutaneous tissue with primarily
blunt dissection to avoid injury to the facial artery and vein. The facial
artery, vein, and investing muscular tissues are isolated as far inferiorly
as the alar crease. The superior end of the flap dissection is carried down
to the periosteum, then deep to the flap. The angular vessels at the superior
end of the flap are divided, and bipolar cautery is used for hemostasis. An
incision is then made along the ipsilateral nostril sill, and a subcutaneous
tunnel is created that connects to the tunnel adjacent to the alar crease
(Figure 2). At this point, the elliptical
skin island is pulled through the subcutaneous tunnel and into the columellar
defect. After the skin island is pulled through the nostril sill, it is wrapped
around a piece of autogenous cartilage, which is used as a columellar strut
for tip support or columellar contour, if necessary, and sutured into place.
This forms a tubed structure. The donor site is closed primarily.
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Figure 1. Drawing of the nasofacial sulcus
flap.
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Figure 2. Tunneling the nasofacial sulcus
flap into place.
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RESULTS
Sixteen patients were identified who fit the inclusion criteria. The
defects repaired ranged from isolated columellar defects to near-total rhinectomies.
Skin cancer resection was the predominant reason necessitating columella reconstruction
(Table 1). Although several patients
had small defects, most had significant defects involving multiple nasal subunits
and tissue layers (Table 2). Forehead
flaps were the most common flaps used, followed by nasofacial sulcus flaps
and nasolabial flaps (Table 3).
The results of the reconstructions were scored on a 0- to 10-cm visual analogue
scale (Table 4). Twelve of the
16 patients had postoperative photographs available for evaluation. Three
patients had no photographs, and 1 patient had a photograph only of the defect.
Of the 12 evaluated, 3 had photographs before resection and after reconstruction,
4 had photographs of the defect and after reconstruction, 4 had all 3 (before,
defect, and after) photographs, and 1 had photographs only after reconstruction.
The aesthetic results are summarized in Table 4.
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Table 1. Population Characteristics
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Table 2. Extent of Defects
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Table 3. Techniques Used for Columella Repair*
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Table 4. Aesthetic Results*
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The mean documented follow-up of the patients was 17.2 months (range,
1-30 months) following reconstruction. Complications resulting from the reconstructions
included nostril stenosis, 3; metastasis, 2; decreased function, 2; and corneal
abrasions, 1. There were no graft or flap failures. The following 2 cases
further illustrate the procedures used and the results of the columella reconstructions.
CASE 1
A 4-year-old white boy had undergone choanal atresia repair several
years previously. Bilateral stents had been tied across the base of the columella,
which resulted in pressure necrosis and eventual loss of the columellar and
septal tissue (Figure 3). He had
no nasal obstruction and no other notable medical or surgical history. Repair
of the 1.5 x 2.0-cm caudal septal perforation was deferred, but reconstruction
of the columella was recommended.
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Figure 3. A full-thickness columellar defect.
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A nasofacial sulcus flap was performed as described in the "Patients
and Methods" section. An elliptical incision was made in the nasofacial sulcus
20% longer than the columellar base (Figure
1). The incision was carried down through the muscular tissue medially
and laterally. The skin at the inferior portion of the incision was undermined
to the alar sulcus in the subcutaneous tissues. An incision was then made
along the right nostril sill, and a subcutaneous tunnel was created that connected
to the tunnel adjacent to the alar crease. At this point, the elliptical skin
island was mobilized on the angular vessel pedicle and pulled through the
subcutaneous tunnel (Figure 2).
After the skin island was pulled through the nostril sill, it was wrapped
around an auricular cartilage graft, which was used as a columellar strut.
After more than 6 months, the flap was well healed, with no contraction, and
no secondary procedures were required (Figure
4).
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Figure 4. Nine months after columella reconstruction
with the nasofacial sulcus flap.
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CASE 2
A 65-year-old man was seen 10 years after previous resection of the
columellar skin for basal cell carcinoma and full-thickness skin graft reconstruction.
He had a 2.4 x 3.0-cm basal cell carcinoma that involved the columella,
caudal septum, and upper lip (Figure 5).
He underwent a Mohs micrographic resection, which resulted in a full-thickness
defect of the anterior one third of the septum, entire nasal columella, nasal
tip, and middle one third of the upper lip (Figure 6). He underwent perialar crescentic advancement flaps and
full-thickness central lip excision (Figure
6 and Figure 7). He underwent
forehead flap nasal reconstruction. Septal cartilage was used as a combined
caudal septal reconstruction graft and a columellar strut. Conchal cartilage
was used for medial crural reconstruction and a shield-type tip graft. The
forehead flap was turned in to reconstruct the mucosal covering of the caudal
septum. The forehead flap was also used to resurface the entire nasal columella,
tip, and dorsum. The patient is pictured 1 year after surgery (Figure 8).
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Figure 5. Basal cell carcinoma of the columella.
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Figure 6. Tumor after resection. The dark
marking on the upper lip signifies the area of full-thickness resection to
close the lip defect primarily.
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Figure 7. After lip closures. Perialar crescents
have also been excised to avoid excessive nasal base narrowing.
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Figure 8. After nasal reconstruction in
the base view.
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COMMENT
To our knowledge, this study represents the largest collection of columella
reconstruction cases in the literature. The 16 well-documented cases demonstrate
that satisfactory reconstructions are possible through several techniques.
For skin-only columellar defects, skin grafts are a reasonable reconstructive
method. Some authors3, 10 support
the use of chondrocutaneous composite auricular grafts for composite columellar
defects. None are presented in this series because the defects treated were
either skin-only or involved such a significant amount of structural nasal
cartilage (medial crural feet or caudal septum) that the surgeons judged a
composite graft inadequate for structural reconstruction. In addition, the
recipient bed for the composite graft would typically be only moderately vascular,
like the caudal septum or opposite medial crural feet, and might not support
the graft. Finally, the flap techniques are simple enough and the donor site
morbidity low enough that they would be more useful in most cases.
For most composite defects of the columella, the forehead flap, superiorly
based 2-stage nasolabial (melolabial) flap, and nasofacial sulcus flap are
the best reconstruction options. All of the flaps proved useful and reliable
in repairing simple and complicated nasal defects. When the columellar and
tip nasal subunits, with or without other adjacent nasal subunits, are involved
in the defect, the forehead flap is the best reconstruction option. The forehead
flap can be used to reconstruct all of the involved nasal subunits.
In columella-only defects, the 3 mentioned flaps can be used. The forehead
flap probably has the best vascularity, with an axial supply by the supratrochlear
vascular bundle, and may be the flap of choice in smokers or in patients in
whom vascularity issues are a concern. The nasolabial flap and nasofacial
sulcus flap are random supply flaps with an axial orientation. In women or
in men with light facial hair, the nasolabial flap is excellent to reconstruct
the columella and the caudal septal mucosa. Occasionally, the columella reconstructed
with a nasolabial flap deviated to the side of the pedicle as a result of
flap contracture during the healing phase. One way to avoid this is to plan
for the flap to be 10% to 20% longer than is actually needed and then inset
it so that there is no tension from the pedicle on the columella.
The nasofacial sulcus flap is best indicated in patients with an intact
caudal septum in whom the columella alone is to be reconstructed. The medial
crura can be reconstituted with an autogenous cartilage graft wrapped within
the flap. This flap is also useful in patients for whom the 2-staged procedure
is objectionable.
Finally, although Burget and Menick2
advocate the removal of the rest of an intact subunit when 50% or more is
involved in the defect, this may not hold true in columella reconstruction.
In some cases, 50% of the subunit was resected, especially in combination
with the tip subunit, and the rest of the columellar subunit was left intact.
These cases resulted in satisfactory results, and the scar across the columella
healed adequately. Because the columella is such a sensitive, unique anatomic
structure, the preservation of the intact subunit skin is useful. Yet, when
50% or more of the tip is involved in a columellar defect, the rest of the
tip subunit should be resected and reconstructed along with the columellar
defect, all with the same flap (usually the paramedian forehead flap), if
possible.
When photographs were available, the results were judged on cosmetic
appearance. Assessment of nasal aesthetics is a subjective measurement, with
the possibility of bias. That said, the aesthetic results of these reconstructions
not only equaled the predefect appearance but also showed an apparent improvement
in the nasal aesthetics in all cases. Because of the small group size, statistical
analysis could not be accomplished in this study. In regard to function, 2
of 16 patients complained of nasal obstruction related to the reconstruction.
That group represented two thirds of the patients who had nostril stenosis
secondary to flap edema or contracture. Nostril stenosis is the most common
complication of columella reconstruction.
In conclusion, our results demonstrate that the paramedian forehead
flap, nasolabial flap, and nasofacial sulcus flap can be used to effectively
reconstruct the nasal columella. The flaps are reliable and the results are
acceptable with respect to aesthetics and function.
AUTHOR INFORMATION
Accepted for publication July 10, 2001.
We thank Denise Rogers for her help in collecting patient information
and Kelly Amunrud for manuscript preparation.
Corresponding author and reprints: David A. Sherris, MD, Division
of Facial Plastic Surgery, Department of Otorhinolaryngology, Mayo Clinic,
200 First St SW, Rochester, MN 55905 (e-mail: sherris.david{at}mayo.edu).
From the Division of Facial Plastic Surgery, Department of Otorhinolaryngology,
Mayo Clinic (Drs Sherris and Fuerstenberg), and Department of Otolaryngology,
University of Minnesota (Dr Hilger), Rochester; and the Division of Facial
Plastic Surgery, Department of Otolaryngology, University of Illinois at Chicago
(Dr Danahey).
REFERENCES
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1. Nichter LS, Morgan RF, Nichter MA. The impact of Indian methods for total nasal reconstruction. Clin Plast Surg. 1983;10:635-647.
PUBMED
2. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239-247.
ISI
| PUBMED
3. Smith V, Papay FA. Surgical options in columellar reconstruction. Otolaryngol Head Neck Surg. 1999;120:947-951.
PUBMED
4. Ozkus I, Cek DI, Ozkus K. The use of bifid nasolabial flaps in the reconstruction of the nose
and columella. Ann Plast Surg. 1992;29:461-463.
PUBMED
5. Yanai A, Nagata S, Tanaka H. Reconstruction of the columella with bilateral nasolabial flaps. Plast Reconstr Surg. 1986;77:129-131.
PUBMED
6. Dolan R, Arena S. Reconstruction of the total columellar defect. Laryngoscope. 1995;105:1141-1143.
PUBMED
7. MacFarlane DF, Goldberg LH. The nasal floor transposition flap for repairing distal nose/columella
defects. Dermatol Surg. 1998;24:1085-1086.
PUBMED
8. Quatela VC, Sherris DA, Rounds MF. Esthetic refinements in forehead flap nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121:1106-1113.
ABSTRACT
9. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Dermatol Surg Oncol. 1991;17:184-189.
PUBMED
10. Larrabee WF, Sherris DA. Principles of Facial Reconstruction. Philadelphia, Pa: Lippincott-Raven; 1995.
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