Reconstruction of the nasal columella using bilateral nasolabial flaps: case report

ABSTRACT

Introduction:

The columella is an important subunit of the nose, essential for nasal architecture and facial aesthetics. The total reconstruction of the nasal columella becomes a great challenge after repairing trauma, carcinomas, and necrosis in this region. There are descriptions in the literature of numerous reconstruction techniques using different flaps, such as a frontal region flap, an infraclavicular region flap, and a unilateral and bilateral nasolabial flap.

Case Report:

A total reconstruction of the nasal columella after resection of basal cell carcinoma (BCC) using a bilateral nasolabial flap is reported.

Conclusion:

The technique proved effective for correcting the complex defect after BCC resection, with technical ease for resolution and good aesthetic and functional results.

Keywords:
Skin neoplasms; Carcinoma, basal cell; Surgical flaps; Nasal surgical procedures; Reconstructive surgical procedures

RESUMO

Introdução:

A columela é uma importante subunidade do nariz, sendo essencial para a arquitetura nasal e estética facial. A reconstrução total da columela nasal torna-se, portanto, um grande desafio após reparação de traumas, carcinomas e necroses nesta região. Há na literatura a descrição de inúmeras técnicas de reconstrução com uso de diferentes retalhos, como retalho da região frontal, retalho da região infraclavicular, retalho nasolabial unilateral e bilateral.

Relato de Caso:

Reporta-se uma reconstrução total da columela nasal pós-ressecção de carcinoma basocelular (CBC) utilizando retalho nasolabial bilateral.

Conclusão:

A técnica utilizada mostrou-se eficaz para correção do defeito complexo pós-ressecção de CBC, apresentando facilidade técnica para resolução e bom resultado estético-funcional.

Descritores:
Neoplasias cutâneas; Carcinoma basocelular; Retalhos cirúrgicos; Procedimentos cirúrgicos nasais; Procedimentos cirúrgicos reconstrutivos

INTRODUCTION

The reconstruction of a total defect in the nasal columella is a challenge for surgeons, and it is possible to perform it in one or several stages¹,². Among the alternatives for repairing the nasal columella, we can opt for local flaps, including the bilateral nasolabial flap³.

The literature reports numerous other reconstructions: the Indian flap⁴, the “U”-shaped frontal muscle flap²,⁵, and the unilateral nasolabial flap6 for repairing the nasal columella.

Seeking a surgical option after the excision of an extensive tumor (basal cell carcinoma - BCC) in the columella with oncological safety margins, we came across the bilateral nasolabial flap³, the object of the present case report, which proved to be a non-aggressive solution, with rapid resolution and performed with local anesthesia and sedation.

OBJECTIVE

This work aims to describe the reconstruction of the nasal columella using the bilateral nasolabial flap³ after a complex defect caused by resection of basal cell carcinoma.

CASE REPORT

JAS, white male, 50 years old. He had a sclerodermiform BCC in the region of the nasal columella, documented in a biopsy before surgical resection.

Subsequently, there was tumor resection with oncological criteria and anesthesia with modified Klein solution⁷ (100ml of 0.9% saline solution, 20ml of 2% lidocaine without vasoconstrictor + 1 ampoule of adrenaline 1/1000 + 4ml of sodium bicarbonate at 8 .4%) and sedation with midazolam + fentanyl, performed by the anesthesiologist.

After tumor resection with oncological safety margins, a large defect ensued in the anterior part of the nose involving the nasal columella (Figure 1).

Figure 1
Aspect of the nasal tip after resection of basal cell carcinoma.

Bilateral demarcation of the nasolabial flaps was performed based on the anterior facial artery³. In a posteriori, the flap was elevated, transposition, and sutured to the new bed. The donor area was repaired with the advancement of local flaps (Figure 2).

Figure 2
Surgical demarcation for first refining.

After 2 months, the second procedure was performed, with the refinement of the flap (Figure 3). Subsequently, there was a new refinement step in which we reached the final result (Figure 4).

Figure 3
Postoperative refining.

Figure 4
Final result.

DISCUSSION

Basal cell carcinoma is the most common non-melanoma skin tumor in our setting, with several subtypes, according to Terzian et al.8: nodular, ulcerative nodule, cicatricial plane, sclerodermiform, terebrant and pigmented. Of these subtypes, terebrant and sclerodermiform are more aggressive, the latter being the one with the highest number of recurrences. It mainly affects the face, predominantly affecting areas with greater sun exposure⁹.

Surgical treatment is preferred when the tumor has large extensions. In this case, local anesthesia with modified Klein solution⁷ associated with sedation was recommended, providing adequate analgesia and vasoconstriction to perform tumor resection with good visibility and preparing flaps for its reconstruction, thus avoiding general anesthesia. , which offers greater risks for the patient and higher costs for the institution.

The literature review showed us numerous options for columellar reconstruction nose, from flaps from the frontal region⁵ to flaps from the infraclavicular region¹⁰. However, the simplest and least aggressive ones are the unilateral nasolabial flap⁶ and the bilateral nasolabial flap³. Paletta & Van Norman¹¹, in 1962, mentioned that when a nasal defect consists of total columellar loss, the unilateral nasolabial flap provides an excellent means of reconstruction.

Ingracio et al.¹, in 2014, advocated the use of the unilateral nasolabial flap for reconstruction of the superior pedicle columella as the appropriate choice, taking into account the maintenance of the oral orbicularis musculature.

Nonetheless, the option for the bilateral nasolabial flap concerning the unilateral one was due to the greater amount of tissue for repairing an extensive defect, its positioning to simulate the columella, and greater versatility in covering a large area to be reconstructed³.

Kaplan¹², in 1972, reported this same flap as an island of skin in the nasolabial fold region, based on the facial artery with a pedicle inferior to the height of the ala and nasal dorsum. However, demarcation with a Doppler is recommended for its rotation. We did not use this option due to the execution of the same flap with the upper pedicle removed close to the lip, seeking greater skin and a lower risk of hypertrophic scars.

Lewis¹³, in 1990, demonstrated that the columella reconstruction could be performed with a bilateral lip flap, using mucosa and muscle from the intraoral region of the upper lip. We did not use this technique due to the insufficient amount of tissue that it would provide for the reconstruction.

Mendelson et al.¹⁰, in 1979, mentioned a tubular flap removed from the cervical region in four stages for the reconstruction of this nasal unit. This type of reconstruction was not performed due to the need for four or more surgical procedures. Furthermore, the scar in the donor area (infraclavicular region) becomes extensive and has a high chance of generating a hypertrophic scar.

Other flaps for columellar reconstruction were not advocated (Orticochea¹⁴ and Millard⁵) due to the need for several surgical times and, sometimes, causing partial occlusion of one eye.

CONCLUSION

The bilateral nasolabial flap, used for the columella reconstruction, proved viable, easy to perform, and with good perfusion. Furthermore, it achieved a satisfactory columellar appearance and practically imperceptible incisions in the donor area. However, it had the disadvantage of requiring two surgical refinements to present a satisfactory aesthetic result.

REFERÊNCIAS

• ¹
  Ingracio AR, Carvalho MS, Barazzetti DO, Pavan G, Martinelli A. Reconstrução parcial de nariz baseada em retalho nasogeniano após ressecção de carcinoma espinocelular envolvendo septo nasal, columela e lábio superior. Rev Bras Cir Plást. 2014;29(3):312-5.
• ²
  Gillies H. The columella. Br J Plast Surg. 1949;2(3):192-201.
• ³
  Yanai A, Nagata S, Tanaka H. Reconstruction of the columella with bilateral nasolabial flaps. Plast Reconstr Surg. 1986;77(1):129-32.
• ⁴
  Oliveira Junior FC, Figueiredo J, Piva A. Técnicas de reconstrução cutânea aplicadas às subunidades estéticas nasais. Rev Bras Cir Craniomaxilofac. 2009;12(3):105-8.
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  Millard DR Jr. Columella lengthening by a forked flap. Plast Reconstr Surg Transplant Bull. 1958;22(5):454-7.
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  Nicolai J P. Reconstruction of the columella with nasolabial flaps. Head Neck Surg. 1982;4(5):374-9.
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  Klein JA. Tumescent Technique. Philadelphia: Mosby; 2000. 470 p.
• ⁸
  Terzian LR, Nogueira VMA, Paschoal FM, Barros JC, Machado Filho CDAS. Mohs Micrographic Surgery for tissue preservation in facial oncologic surgery. Surg Cosmet Dermatol. 2010;2(4):257-63.
• ⁹
  Nigro MHMF, Brandão LSG, Coelho APCP, Motta LM, Bastazini Júnior I. Estudo epidemiológico do carcinoma basocelular no período de 2010 a 2013 em um hospital de referência em dermatologia na cidade de Bauru, São Paulo. Surg Cosmet Dermatol. 2015;7(3):232-5.
• ¹⁰
  Mendelson BC, Masson JK, Arnold PG, Erich JB. Flaps used for nasal reconstruction: a perspective based on 180 cases. Mayo Clin Proc. 1979;54(2):91-6.
• ¹¹
  Paletta FX, Van Norman RT. Total reconstruction of the columella. Plast Reconstr Surg Transplant Bull. 1962;30:322-8.
• ¹²
  Kaplan I. Reconstruction of the columella. Br J Plast Surg. 1972;25(1):37-8.
• ¹³
  Lewis JR Jr. Labial mucosal flaps for reconstruction of the columella. In: Strauch B, Vasconez LO, Hall-Findlay EH. Grabb’s Encyclopedia of Flaps. Volume 1. Boston: Little, Brown and Company; 1990.
• ¹⁴
  Orticochea M. A new method for total reconstruction of the nose: the ears as donor areas. Br J Plast Surg. 1971;24(3):225-32.

Publication Dates

• Publication in this collection
  04 Aug 2023
• Date of issue
  2023

History

• Received
  14 July 2022
• Accepted
  16 Nov 2022