A. Kruayatidee1,2, J.W. Calvert2 1California Northstate University College of Medicine, Elk Grove, CA, USA 2Roxbury Clinic and Surgery Center, Los Angeles, CA, USA
Introduction:
The columella is notoriously the most challenging nasal subunit to reconstruct. Due to its limited vascularity from the columellar branches of the superior labial artery, it is unforgivingly prone to ischemic damage caused by trauma, iatrogenic injury, and vasoconstrictive agent abuse. Reconstruction of necrotic loss of columellar skin and cartilage typically involves a nasolabial or forehead flap. These provide robust blood supply and skin and lining but at the price of highly involved flap harvesting, multiple stages including flap elevation, inset, and flap division. Also, aesthetically concerning donor site scarring is a drawback to these techniques. A focal columellar defect, without other subunit soft tissue defects, may not be worth those risks. Therefore, we implore an alternative local flap — an upper lip, transverse fork flap.
Methods:
We propose a modified and refined operative technique for a tenuously described reconstructive approach. This was the workhorse for reconstruction of total columellar loss in three patients who had isolated loss without tip subunit involvement. They similarly faced columella necrosis, two from a history of multiple rhinoplasties, one from excessive use of cocaine. Inclusionary criteria required patients to have excess philtral column length, irrespective of lip fullness. A flap is designed in analogous fashion to that of an endonasal upper lip lift. The superior markings follow the natural contour of the nasal sill and tapered down to create hemi-crescent, bilateral flaps, maintaining a 3-mm wide attachment at midline.
Results:
There was subjective aesthetic improvement for all three patients, excellent color and texture match, and no complications with donor site scarring. The flap raised on average was approximately 8-mm to the columella, providing coverage of the central and lateral columellar walls. Costal cartilage strut grafts were able to be placed simultaneously without compromising neovascularization.
Conclusion:
We were able to provide columellar lengthening, strengthening, and adequate skin coverage with satisfying aesthetics applying this technique.