Reconstruction of a columellar defect with a nasolabial island flap

The Reconstruction of the Nasal Columella Defect Using Domino Flaps

Skin defects of the total nasal columella can significantly impact both nasal respiratory function and aesthetics. The reconstruction of total columella is a complex process and represents a significant challenge for plastic surgeons. Various factors can cause the loss of the columella. Numerous columella reconstruction procedures have been proposed, each with their own set of advantages and disadvantages. The main issues to address include the need for regional flaps from the forehead or nasofacial sulcus, a long pedicle to reach the columella, and the double angular folding that causes a risk of malnutrition or venous congestion. Additionally, using horizontal nasolabial flaps may lead to deformation of the upper lip. In this study, we present a new procedure to reconstruct the nasal columella using "Domino flaps" with two flaps (the horizontal upper lip island flap and nasocheek island flap). This new procedure ensures adequate skin for reconstruction of nasal columella and partial tip, minimizes rotation angle, reduces the angular folding of the pedicle, furthermore limits deformation of the upper lip. "Domino flaps" are a valuable option for surgeons when reconstructing the total nasal columella. However, it is important to consider whether the patient has a beard at the donor sites.

Effect of Cleft Width on the Outcome of Presurgical Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate

ABSTRACT

The purpose of this study was to investigate the short-term effects of presurgical nasoalveolar molding (PNAM) according to cleft width (CW) in patients with unilateral cleft lip and palate (UCLP). In this retrospective study, 32 newborns with nonsyndromic UCLP treated with PNAM were allocated to 2 groups based on CW (group A, CW ≤5 mm; and group B, CW >5 mm). The following measurements were carried out using standardized photographs taken before and after PNAM therapy (before primary lip surgery): nostril axis inclination of healthy (NAI-NC) and cleft sides (NAI-C), columellar angle (CA), nasal base inclination (NBI), nasal floor width ratio (NFWR), alar base height ratio (ABHR), and columellar length ratio. Before PNAM therapy, there were significant differences between the 2 groups with respect to NAI-C, NBI, NFWR, and ABHR, indicating greater deformation of the nose in group B. After PNAM therapy, CA, NAI-C, NAI-NC, NFWR, and columellar length ratio were significantly improved in both the groups, whereas NBI and ABHR significantly worsened in group B. The improvement in CA, NAI-C, and NFWR was significantly greater in group B. Although a larger CW had some negative effects on the outcome of PNAM, it was found to be advantageous for nasal symmetry, if initiated as early as possible. Nevertheless, it is important to consider those aspects of the nasolabial area that are involved in the perception of symmetry when evaluating the effect of CW on PNAM outcomes in UCLP.

Three-Dimensional Computed Tomography of the Detoured Facial Artery: Variations and Implications for Nasojugal Groove Correction

BACKGROUND

When performing filler injection procedures to the nasojugal groove, there is the risk of iatrogenic damage to the detoured facial artery.

OBJECTIVE

To determine the 3-dimensional location of the detoured facial artery.

MATERIALS AND METHODS

The branches of the facial arteries from 118 cadaveric hemifaces were scanned using computed tomography and reconstructed using the Mimics software program.

RESULTS

Detoured facial arteries were found in 47 of the 118 hemifaces (39.8%). Two main arterial patterns were identified: in Type I (29 of 47 cases), there were both detoured and nasolabial trunks where the facial artery originated, whereas in Type II (18 of 47 cases), there was only a detoured trunk. The detoured trunk originated 32.0 ± 5.3 mm from the midsagittal line, 5.0 ± 2.8 mm from the occlusion plane, and 5.9 ± 3.5 mm below the skin layer; the inflection of the detoured trunk was located 30.0 ± 5.6 mm laterally, 26.2 ± 4.4 mm superiorly, and 5.7 ± 2.6 mm deep. The meeting point with the inferior orbital rim plane was located 17.1 ± 3.4 mm laterally, 43.4 ± 3.1 mm superiorly, and 2.8 ± 1.7 mm deep.

CONCLUSION

The 3-dimensional location of the detoured facial artery as reported here will help clinicians to avoid iatrogenic damage when they are performing filler injection procedures.

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.

Nasal Columellar Reconstruction With Reverse Lateral Nasal Artery Pedicled Nasolabial Island Flap

Nasal columellar is a complex area to reconstruct due to its unique esthetic and functional characteristics. Malignancy, trauma, infection, and esthetic surgery complications can cause columellar defect. Among many surgical plans, nasolabial island flap is most commonly used. However, flap congestions occasionally occur which inevitably lead to leech therapy. The authors introduce reverse lateral nasal artery pedicled nasolabial island flap, which has lower risk of postoperative complications.

Columellar Reconstruction After Nasal Continuous Positive Airway Pressure Associated Necrosis

Though a life-saving modality in neonatal intensive care units, nasal continuous positive airway pressure (nCPAP) carries a small risk of irreversible ischemia and necrosis of the columella due to the configuration of the pressure delivery system. Iatrogenic injuries to the columella after nCPAP use result in a spectrum of disfigurement and functional airway obstruction. The authors performed a retrospective review of patients evaluated for nCPAP-related columellar deformities by the Division of Plastic and Reconstructive Surgery at the authors' institution over a 10-year period to assess reconstructive outcomes. Of 7 patients evaluated, 3 underwent reconstruction using a combination of cartilaginous framework reshaping and local tissue flaps. After a mean follow-up period of 78 months, patients had satisfactory aesthetic and functional results. Based on the authors' observations, columellar necrosis secondary to nCPAP can be divided into 3 categories: Type A demonstrates mild notching of the columella; Type B has an absent columella without notable nasal tip depression; Type C has an absent columella with nasal tip depression, with or without external nasal valve obstruction. Reconstructive needs should be individually tailored based on the degree of nasal tip depression, cartilaginous support, and soft tissue availability.

Columellar Reconstruction following Nasal Continuous Positive Airway Pressure Injury

Nasal continuous positive airway pressure is used increasingly to treat pulmonary immaturity in premature neonates. Nasal injury is common with nasal continuous positive airway pressure use, with full-thickness tissue loss at the columella among the most devastating complications. Columellar necrosis often imparts a full-thickness injury to the overlying columellar skin, the medial crura of the lower lateral nasal cartilages, the anteromedial inner nasal mucosal lining, and potentially the anterior septal cartilage. Consequently, the columella can become scarred and shortened. Although multiple techniques have been described to reconstruct the columella, no known technique has been specifically developed to treat the unique columellar defect common to severe nasal continuous positive airway pressure injury. Donor-site morbidity related to these techniques, and how growth of the reconstructed nose will proceed, are obvious concerns, especially in young children. The authors present a novel reconstruction technique that uses recreation of the defect with posteriorly based book flaps and auricular chondrocutaneous composite graft interposition. This technique has several advantages, including avoiding central facial scars, supplying well-matched skin color and texture, and facilitating robust tip support. The authors retrospectively review the use and outcomes of this technique from 1995 and 2016 on all patients with a history of nasal continuous positive airway pressure columellar necrosis at their center.