Internal Nasal Vestibular Skin-Mucosal Flaps

T. R. VECCHIONE

The columella is the cornerstone of naso-oral construction and is necessary for a pleasing balance. When it is destroyed by infection, trauma, or disease, its absence becomes glaringly obvious (Fig. 70.1A). The successful treatment of patients lacking the lower septum and columella with a simple one-stage flap is presented.

FIGURE 70.1 A,B: An 8-year-old boy with absent columella secondary to severe infection at age 4. The columella, membranous septum, and 0.4 × 3.0 cm of cartilaginous septum were missing. C,D: The patient 2 years after local tissue columellar reconstruction.

INDICATIONS

The difficulty in reconstructing this subtle aesthetic unit has stimulated many elaborate operative techniques requiring multiple stages (1). Various composite grafts from the ear and
lip have been described, but these are of benefit only in the partially deficient columella with sufficient surrounding tissue present for composite graft take. These grafted tissues also were noted to shrink and become “fibrotic lumps.”

FIGURE 70.2 A: The local skin-mucosal flaps are based just above the philtrum, extending out along the nasal vestibule and then upward to include mucosa lining the lateral alar cartilage. B: When the two flaps are brought together in the midline, they extend beyond the nasal tip. C: The flaps are sutured to the dissected nasal tip. The flap donor sites heal by epithelialization and wound contracture. D: On close inspection, the bucket-handle effect can be seen, but this is not readily recognized at conversational distances.

The mucosa of the upper lip followed by a split-thickness skin graft has been used, but wound contracture and fibrosis have detracted from the long-term results (2). A frontonasal flap based on the temporalis artery (3) has been refined (4) by using a median frontal flap tunneled subcutaneously to bring a pedicle to the columella. The versatile nasolabial flap has been transferred through the nasal mucosa passing between the ala and triangular cartilages in a three-staged procedure (5). The centrally based upper lip flap and an adjacent nasolabial flap have been used to reconstruct the columella in a one-stage procedure (6). The price paid is a bearded columella and facial scars.

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