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.

Extended rotation flap for reconstruction of partial thickness defects of the tip and nasal ala region: in search of better aesthetic results

Background

Basal cell carcinoma is the most common non-melanoma skin cancer of the nose. Defects of the nasal ala and tip region are among the most difficult to repair due to their intrinsic characteristics.

Objective

To present our experience with the extended rotation flap for reconstruction of nasal ala defects and evaluate the outcome using the Patient and Observer Scar Assessment Scale (POSAS).

Methods and Materials

Twenty-two patients with partial thickness nasal ala defects reconstructed using the extended rotation flap were assessed. Final cosmetic and functional outcomes were evaluated using the POSAS.

Results

Flaps survived in all the reported cases and no major complication was recorded. Histology showed complete excision of the tumour in all cases. Using the POSAS, the mean overall evaluation for patients was 1.8/10, while the mean overall evaluation for the evaluation panel was 2.2/ 10.

Conclusion

Although similar flaps have been previously described, the extended rotation flap for nasal ala and tip reconstruction represents a functionally and cosmetically appealing wound closure option, respecting and avoiding any distortion of the alar crease.

Columellar reconstruction: a refinement of technique

The nose is an important landmark of the face and its shape and beauty is of significant concern. The columella is the subunit between the two nostrils that provides support and projection to the nasal tip and has functional role in nostrils, as well as aesthetic. Ethiology for columellar absence or deficiency is diverse, and it is one of the most complex nasal subunits to reconstruct because of its narrow horizontal dimension, its tenuous vascularity and limited availability of adjacent tissue. We present a patient with columellar, membranous septum and upper lip defect, due to oncological resection. The lip reconstruction was designed using advancement of two upper lip edges with the technique of webster perialar/nasocheek advancement. However, the perialar/nasocheek tissue which is usually discarded was used as inferiorly based skin flaps to reconstruct the membranous septum, columellar skin and nasal vestibule lining. Rib cage cartilage graft was used as columellar strut for support. At 1-year follow-up, the patient has good nasal contour and projection. Scaring of the columella is very subtle. This is a versatile way for successful reconstruction of a columella and large central facial defect in one-stage operation. It is a method which provides very satisfactory aesthetic result with minimum patient morbidity and discomfort.

Semilunar conchal cartilage graft in saddle nose reconstruction

INTRODUCTION

The saddle nose deformity is easily recognized by the loss of septal support and nasal dorsal height with adverse functional and aesthetic consequences.

TECHNIQUE

We treated a 50-year-old woman and a 54-year old man that presented with a moderate saddle nose deformity following a previous septorhinoplasty (female patient) and a posttraumatic severe saddle nose deformity (male patient). The patients were treated by open approach rhinoplasty under general anesthesia, and the saddle nose deformity was reconstructed with a semilunar conchal cartilage graft. A semilunar part of the conchal cartilage is excised, lending its name to the graft. A smaller leaf shaped cartilage part is excised and sutured upside-down with PDS 5-0 sutures on the opposite of the cartilage, so that the concave surfaces are facing each other. The newly formed graft is then sutured in its place on the nasal dorsum in the supratip saddle area over the triangular cartilages to widen the inner nasal valve angle. The lateral tips of the semilunar graft are placed below the lateral alar crura to improve external nasal valve functionality.

DISCUSSION

This modified conchal cartilage graft presents itself as an excellent reconstructive option, especially considering its low morbidity, availability and ability to retrieve an adequate amount of cartilage in the vast majority of patients. These modifications of the conchal cartilage are previously unreported, and provide the needed height and elasticity in saddle nose reconstruction without the need for additional grafting. It is important to stress that when positioned properly, a beneficial effect in peak nasal inspiratory flow may be observed, adding to its usefulness in repairing both function and aesthetics.

An alternative single-stage application of the paramedian forehead flap in reconstruction of the face

BACKGROUND

Paramedian forehead flap represents a workhorse in facial soft tissue reconstruction but always requires a second step in order to interrupt the skin bridge. Direct visualization and dissection of vascular pedicle may avoid this drawback.

METHODS

Twenty one patients were treated between January 2012 and January 2014: 6 underwent nasal reconstruction and 15 full thickness defect of medial canthus of an orbital region. The follow-up ranges between 6 months and 2 years. All procedures were carried out in a single stage.

RESULT

All flaps were performed in a single-stage procedure, survived and healed uneventfully.

CONCLUSION

The authors describe a refinement of the original technique to be reserved for cases where vessels could be identified by Doppler, consisting in the direct visualization and dissection of the initial tract of the vascular pedicle, thus providing an extremely mobile pedicle whose size allows to locate the first part of the pedicle in the nasion, tunneling under a skin bridge between the emergence of the vessels and the defect.

Total reconstruction of the nose in settings where resources are limited

We describe a series of 8 patients who had total reconstruction of the nose during 4 separate missions to Ethiopia. The aetiology was noma (n=3), assault (n=2), acid burn (n=1), squamous cell carcinoma (n=1), and a sequela of meningococcal septicaemia (n=1). Reconstruction was with forehead flaps when adequate tissue was available (n=6) and with radial forearm flaps when it was not (n=2). Some reconstructive approaches require procedures to be done in stages, and in settings where resources are limited, difficulties with the continuity of care and provision for the management of complications, must be overcome.