Reconstruction of the Nasal Columella

David A. Sherris, MD; Jon Fuerstenberg, MD: Daniel Danaher. MD, PhD; Peter A. IIilgee, MD

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 re-construction, and 5.0 from tumor resection or trauma to after reconstruction.

Conclusion: Skin grafts, composite grafts, and several flaps. including nasolabial, nasofacial sulcus, and fore-head flaps, are useful in repairing defects of the nasal columella.

Nasal reconstruction has been performed for centuries, with the first reconstructions occurring before 500 BC.' In modern times, the practice of reconstruction has been advanced by the work of surgeons such as Burget and Menick,' 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 side walls, 2 alae, and 2 soft tissue triangles! 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 tradition-ally 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.'-° The approaches re-ported include the use of full-thickness skin grafts, composite grafts from the ear, nasolabial flaps, nasofacial flaps, and fore-head flaps.'-' Nasolabial flaps, unilat­eral, bilateral, or bifid, are the most fre­quently described.

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.

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 photo-graphs, and 1 patient had a photograph only of the defect. Of the 12 evaluated, 3 had photographs before resection and

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 I , 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 re-viewing 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.

FOREHEAD FLAP TECHNIQUE
The paramedian forehead flap 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. 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 re-constructed with autogenous cartilage grafts. The distal one third of the forehead flap is thinned to the subdermal layer before it is inset. Care must he 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 per-formed 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) flap" 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 sub-cutaneous 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 do-nor 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.

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.

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, I . 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. Re-pair of the 1.5 X 2.0-cm caudal septal perforation was deferred, but reconstruction of the columella was rec­ommended.

A nasofacial sulcus flap was performed as de-scribed in the "Patients and Methods" section. A deal incision was made in the nasofacial sulcus 20% longer than the columellar base (Figure 1). The incision was car­ried clown 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).

CASE 2
A 65-year-old man was seen 10 years after previous re-section of the columellar skin for basal cell carcinoma and full-thickness skin graft reconstruction. He had a 2.4X 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 pert-alar crescentic advancement flaps and full-thickness cen­tral lip excision (Figure 6 and Figure 7). He under-went 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).

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.

 

Table 4. Aesthetic Results*
Subgroup	Before	Defect	After	Before to After	Defect to After
Size of defect Skin only	NA	NA	NA	NA	NA
Skin, cartilage	5.3	1.3	7.3	2.0	6.0
Skin, cartilage, lining	2.9	1.2	6.3	3.4	5.1
Technique used (No.) Forehead flap (8)	4.9	1.2	6.7	1.8	5.5
Nasolabial flap (1)	3.6	1.6	6.0	2.4	4.4
Nasofacial sulcus flap (3)	NA	2.2	6.3	NA	4.1
Overall	4.5	1.5	6.5	2.0	5.0

*Data are given as score between 1 and 10. NA indicates not available.

For skin-only columellar defects, skin grafts are a rea­sonable reconstructive method. Some authors 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 fore-head 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 he 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 sup-ply 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 sub-unit, and the rest of the columellar subunit was left in-tact. 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.

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.

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.

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 5590.5 (e-mail_ sherris.david@mayo. eau).

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