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preoperative lateral view with a total absence of distal half of the nasal columella and a boxy tip. Fig. 2. schematic drawing of technique. a, Harvesting of the cephalic portion of the lateral crura with open technique. B, Design of a V-shaped internal nasal vestibular flap in the nasal floor. C, Cartilage grafts fixed between them and sutured to the caudal septum. D, the 2 wings of the V-shaped internal nasal vestibular flap raised. e, Rotation of the wings cranially and sutured in the midline. F, Lateral view of the reconstructed columella.
Source publication
Columella is an important structure in the center of the face, and its structural integrity has an important functional, social, and psychological role. Columella reconstruction can be very challenging for surgeons and the ideal technique remains elusive. This article describes a reconstruction technique in a young woman with columella necrosis due...
Contexts in source publication
Context 1
... physical examination revealed a partial absence of the nasal columella, from the nasal tip down to the base of columella, involving the medial crura of the alar cartilages and a boxy tip. The nose and the septum were otherwise well developed (Fig. 1). The target of reconstruction was to restore the trilaminar structure in the portion where it was missing. With an open approach, a cephalic trim of the lateral crura was performed, and 2 autogenous car- tilage grafts were harvested ( Fig. 2A). This lateral crural grafts were then placed and sutured on the caudal sep- tum and fixed between them. To correct the boxy nasal tip, we also placed horizontal mattress transdomal sutures (Fig. 2C). To obtain a coverage, a V-shaped internal nasal vestibular flap was designed in the nasal floor (Fig. 2B). The flap was a random-pattern one consisting of 2 me- dial wings and a residual columella as a base (Fig. 3). The wings were raised and rotated cranially toward the midline to reconstruct the anterior surface of the newly formed columella. The flaps were sutured together with interrupted sutures (Fig. 2D-F). The patient's postopera- tive course was uneventful, with total flap survival. ...
Context 2
... physical examination revealed a partial absence of the nasal columella, from the nasal tip down to the base of columella, involving the medial crura of the alar cartilages and a boxy tip. The nose and the septum were otherwise well developed (Fig. 1). The target of reconstruction was to restore the trilaminar structure in the portion where it was missing. With an open approach, a cephalic trim of the lateral crura was performed, and 2 autogenous car- tilage grafts were harvested ( Fig. 2A). This lateral crural grafts were then placed and sutured on the caudal sep- tum and fixed between them. To correct the boxy nasal tip, we also placed horizontal mattress transdomal sutures (Fig. 2C). To obtain a coverage, a V-shaped internal nasal vestibular flap was designed in the nasal floor (Fig. 2B). The flap was a random-pattern one consisting of 2 me- dial wings and a residual columella as a base (Fig. 3). The wings were raised and rotated cranially toward the midline to reconstruct the anterior surface of the newly formed columella. The flaps were sutured together with interrupted sutures (Fig. 2D-F). The patient's postopera- tive course was uneventful, with total flap survival. ...
Context 3
... physical examination revealed a partial absence of the nasal columella, from the nasal tip down to the base of columella, involving the medial crura of the alar cartilages and a boxy tip. The nose and the septum were otherwise well developed (Fig. 1). The target of reconstruction was to restore the trilaminar structure in the portion where it was missing. With an open approach, a cephalic trim of the lateral crura was performed, and 2 autogenous car- tilage grafts were harvested ( Fig. 2A). This lateral crural grafts were then placed and sutured on the caudal sep- tum and fixed between them. To correct the boxy nasal tip, we also placed horizontal mattress transdomal sutures (Fig. 2C). To obtain a coverage, a V-shaped internal nasal vestibular flap was designed in the nasal floor (Fig. 2B). The flap was a random-pattern one consisting of 2 me- dial wings and a residual columella as a base (Fig. 3). The wings were raised and rotated cranially toward the midline to reconstruct the anterior surface of the newly formed columella. The flaps were sutured together with interrupted sutures (Fig. 2D-F). The patient's postopera- tive course was uneventful, with total flap survival. ...
Context 4
... physical examination revealed a partial absence of the nasal columella, from the nasal tip down to the base of columella, involving the medial crura of the alar cartilages and a boxy tip. The nose and the septum were otherwise well developed (Fig. 1). The target of reconstruction was to restore the trilaminar structure in the portion where it was missing. With an open approach, a cephalic trim of the lateral crura was performed, and 2 autogenous car- tilage grafts were harvested ( Fig. 2A). This lateral crural grafts were then placed and sutured on the caudal sep- tum and fixed between them. To correct the boxy nasal tip, we also placed horizontal mattress transdomal sutures (Fig. 2C). To obtain a coverage, a V-shaped internal nasal vestibular flap was designed in the nasal floor (Fig. 2B). The flap was a random-pattern one consisting of 2 me- dial wings and a residual columella as a base (Fig. 3). The wings were raised and rotated cranially toward the midline to reconstruct the anterior surface of the newly formed columella. The flaps were sutured together with interrupted sutures (Fig. 2D-F). The patient's postopera- tive course was uneventful, with total flap survival. ...
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Citations
Background:
Composite grafts have previously been reported to achieve a good outcome for nasal defect repair, but composite grafts have greater metabolic needs than simple skin. Therefore, the traditionally recommended size of a composite graft for nasal reconstruction is less than 1.5 cm in diameter. However, the distal nose is generally well supplied with blood vessels, which might support the use of larger composite grafts in such a highly vascularized recipient site. The aim of the article is to investigate whether a large skin-fat-fascia composite graft (larger than 2.0 cm) is viable for the repair of partial-thickness nasal defects.
Methods:
From October 2017 to December 2019, 13 patients with partial-thickness nasal defects underwent nasal reconstruction using a large postauricular skin-fat-fascia composite graft. Cases were followed up for 3 to 14 months postoperatively. The aesthetic outcome was evaluated in comparison with preoperative digital images.
Results:
Skin-fat-fascia composite grafts survived without graft necrosis, dermal fibrosis, or skin contraction in all cases. Favorable aesthetic outcomes were obtained in all patients, and no further revision surgery was need.
Conclusions:
A postauricular composite graft larger than 2.0 cm is a safe and effective reconstruction approach for partial-thickness nasal defects. This technique offers significant advantages in terms of no additional facial scar, no visible asymmetry on the face, no additional surgery for revision, and with mild scar in the donor site of the postauricular region.
Introduction
Despite their relatively small size, columellar defects, including both external and internal elements, are exceedingly difficult to reconstruct. Local, regional, and distant flaps have been described for reconstruction. Herein, we present a novel technique for reconstruction of the columella using vascularized free fascia lata from the anterolateral thigh with structural replacement and skin grafting.
Methods
This novel technique utilizes a small anterolateral thigh flap, formed into vascularized fascia lata without the overlying subcutaneous fat or skin. The fascia lata is inset into the columellar and caudal septal defect after a cartilage framework is constructed and is microsurgically anastomosed to either distal facial or angular vessels. A skin graft from the ALT donor site is then secured over the fascia.
Results
This technique has been applied successfully in patients with either isolated columella or in multi-subunit reconstruction following total rhinectomy with no flap or reconstructive failures. Given the low morbidity of flap harvest and minimal access incisions, this has been reliably accomplished with short (1–2 day) hospital stays.
Conclusion
Rapid and aesthetically acceptable reconstruction of total nasal columella defects in isolation or with additional nasal subunit reconstruction, is possible utilizing this novel technique. Here we discuss pearls and pitfalls of its use following surgical resection of malignancy.
The nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischaemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques.
