Columellar Reconstruction following Nasal Continuous Positive Airway Pressure Injury

Nasal Tip Vascularization and Its Application for Columellar Reconstruction

OBJECTIVE

Many studies have been published about the vascular anatomy of the nose and its utility for nasal reconstruction. Anatomic variations of the main arteries and their perforators are well described in the literature. A nasal tip perforator, not well described in the published studies, is analyzed in the present study and its utility for columellar reconstruction. This paper presents an anatomic study of the nasal tip artery and its clinical applications for columellar repair.

METHODS

This study investigated the nasal tip perforator artery during nasal tip flap surgery for columellar repair in patients with sequels after nasal continuous positive airway pressure use. A descriptive anatomic study was conducted using intraoperative vascular dissection of patients operated on for nasal columellar defects by the author between 2013 and 2018. An observational study of a group of patients operated on for columellar repair using the axial nasal tip flap is presented here.

RESULTS

The nasal tip artery was found in all the intraoperative dissections. Location and trajectory are described. Observed columellar length and width in operated patients have been nonstatistical and significantly different than controls in this study.

CONCLUSIONS

The presence and trajectory of the nasal tip artery have been consistent in all the studied cases. The nasal tip flap based on this perforator has been a useful method for columellar repair in the studied group of patients. The presence of this vessel may augment blood supply to the nasal tip skin. By confirming the preservation of this artery, the surgeon may elevate the nasal tip flap safely.

Reconstruction of the columella with interposition of nasogenian flaps: A case report

INTRODUCTION

Reconstructing large defects of the columella and upper lip is an interesting challenge in facial reconstruction due to the high visibility of this aesthetic subunit and the difficulties posed by the unique characteristics of the skin in these areas, which differs from that of the surrounding regions. Among the various techniques proposed, the use of local flaps remains the most commonly used and effective method in this type of reconstruction.

PRESENTATION OF THE CASE

A 47-year-old man in good clinical condition presented with a nodular lesion on the columella and upper lip. The lesion was excised (revealing it to be a squamous cell carcinoma) and reconstructed using two opposing nasogenian flaps, resulting in an optimal aesthetic and functional restoration.

DISCUSSION

The use of local flaps remains the most effective technique for columella defect reconstruction. However, many described techniques require multiple surgical stages or result in visible scarring. Additionally, they do not guarantee effective reconstruction in cases involving the upper lip. On the other hand, the use of free flaps, while more expensive and requiring expert teams, may not ensure optimal color and skin texture matching.

CONCLUSIONS

The use of opposing nasogenian flaps allows for a rapid and effective reconstruction of defects involving the columella and upper lip, leading to a swift return to normal life for the patient.

Rotating nasal masks with nasal prongs reduces the incidence of moderate to severe nasal injury in preterm infants supported by noninvasive ventilation

OBJECTIVE

To investigate the association between noninvasive ventilation delivery devices and the incidence of nasal septum injury in preterm infants.

METHODS

This retrospective singlecenter cohort study included preterm infants supported by noninvasive ventilation. The incidence of nasal injury was compared among three groups according to the noninvasive ventilation delivery device (G1 - nasal mask; G2 - binasal prongs; and G3, rotation of nasal mask with prongs). Nasal injury was classified according to the National Pressure Ulcer Advisory Panel as stages 1 - 4. Multivariate regression analyses were performed to estimate relative risks to identify possible predictors associated with medical device-related injuries.

RESULTS

Among the 300 infants included in the study, the incidence of medical device-related injuries in the rotating group was significantly lower than that in the continuous mask or prong groups (n = 68; 40.48%; p value < 0.01).The basal prong group presented more stage 2 injuries (n = 15; 55.56%; p < 0.01). Staying ≥ 7 days in noninvasive ventilation was associated with a higher frequency of medical device-related injuries, regardless of device (63.81%; p < 0.01). Daily increments in noninvasive ventilation increased the risk for nasal injury by 4% (95%CI 1.02 - 1.06; p < 0.01). Higher birth weight indicated protection against medical device-related injuries. Each gained gram represented a decrease of 1% in the risk of developing nasal septum injury (RR: 0.99; 95%CI 0.99 - 0.99; p < 0.04).

CONCLUSION

Rotating nasal masks with nasal prongs reduces the incidence of moderate to severe nasal injury in comparison with single devices. The addition of days using noninvasive ventilation seems to contribute to medical device-related injuries, and higher birth weight is a protective factor.

Free vascularized fascia lata flap for total columella reconstruction

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.

Facial Soft Tissue Injuries in Pediatric Patients

Soft tissue injuries of the head and neck are a common reason for medical evaluation and treatment in pediatric populations with some unique and important considerations when compared with adults. The incidence and type of injuries continue to evolve with the adoption of new safety measures, technology advancements, and education of the general population. The goal of this article is to provide the reader with a thorough understanding of the evaluation and management of pediatric soft tissue trauma including the initial workup, physical examination, appropriateness of antimicrobial therapy, and setting for surgical repair. Additionally, the pediatric anesthetic considerations for evaluation and repair in regard to local anesthesia, sedation, and general anesthesia are described in detail. There is a focus on dog bites, perinatal injuries, and child abuse as these entities are distinctive to a pediatric population and have particular management recommendations. Lastly, application of the reconstructive ladder as it applies to children is supported with specific case examples and figures. Although there are many parallels to the management of soft tissue injury in adults, we will highlight the special situations that occur in pediatric populations, which are imperative for the facial plastic and reconstructive surgeon to understand.

Nasal columella reconstruction - A comprehensive review of the current techniques

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.

A Simple Protective Splint for Infant Nasal Reconstruction

Nasal trauma is a common complication of nasal continuous positive airway pressure (NCPAP) and may range from erythema, edema, and skin breakdown to columellar necrosis. Although rare, columellar necrosis can be a devastating complication following NCPAP, and surgical repair remains challenging due to contour and color-match difficulties, tenuous vascularity, and limited available adjacent skin. In addition, because operative site protection is critical to a successful repair, many surgeons opt to delay surgical intervention from infancy until a later age so that the patient does not inadvertently injure and compromise the graft during the early postoperative period. Here, we present a case of composite nasal reconstruction in an infant following columellar necrosis secondary to NCPAP, along with the design and implementation of a simple, inexpensive, and protective nasal splint that allows for early repair at the time of infancy.

Microsurgical reconstruction of the isolated columellar defect with a prelaminated radial forearm free flap. A case report and a review of the literature

The columella is one of the smallest subunits of the nose, but the loss of this structure has important aesthetic and structural implications. Few papers in literature present microsurgical techniques for the reconstruction of an isolated columellar defect. This report describes the use of a prelaminated radial forearm free flap (RFFF) for the reconstruction of an isolated columellar defect and reviews the current literature. A 45-year-old woman presented to our Unit with a history of palate squamous cell carcinoma and severe nasal deformity with an almost complete loss of the columella. A prelaminated RFFF with the fifth rib was used for a two-staged reconstruction of the isolated columellar defect. The radial pedicle was anastomosed to the facial vessels and the postoperative course was uneventful. Complete survival of the flap was achieved and, 10 months postoperatively, the patient had bilateral nasal patency, with an increased tip projection and a good aesthetic result. A prelaminated RFFF can be considered a valuable reconstructive option in cases of a large composite defect of the columella and limited availability of adjacent tissues.