Columellar Skin Research Articles

Early management of columellar skin necrosis post-revision septorhinoplasty

Background: Columellar skin necrosis is a rare complication of Septorhinoplasty procedures. However, it is more frequent in patients who undergo multiple revision procedures and have poor skin quality. Therefore, some patients require wound care immediately post-operation. Dressing of the columellar region is difficult due to the location and anatomical configuration. Case presentation: In this paper, we present a case of partial necrosis of the columellar skin following an open Septorhinoplasty procedure which was noted on the first post-operative day. Improving circulation to the affected area was the key target of the treatment approach. Conclusion: A topical hemoglobin-based oxygenating spray (Granulox, SastoMed GmbH, Georgsmarienhütte, Germany) was applied immediately on the columellar skin wound as it is a simple and easy dressing material and can lead to healing without obvious scarring. Key points Question: Would an early, minimally invasive intervention with a hemoglobin-based oxygenating spray in a patient who was diagnosed with partial columellar skin necrosis 24 hours post revision Septorhinoplasty - without the need for surgical management provide a satisfactory outcome? Finding and meaning: The treatment yielded a good aesthetic outcome in a short duration with no significant side effects and demonstrated the ease of treating a difficult complication without the need for more surgeries.

Auricular antitragus chondrocutaneous composite graft: A novel technique for reconstruction of full-thickness columella defects

Columellar necrosis often results in injury to the overlying columellar skin, the medial crura of the lower lateral nasal cartilages, the anteromedial inner nasal mucosa, and possibly the anterior septal cartilage.1 The auricular chondrocutaneous composite graft is one of the best reconstructive methods to date.2 Increasing graft size, however, increases the risk of graft failure and donor site deformity.

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.

Components of the Hanging Columella: Strategies for Refinement.

The columella is a significant factor in the aesthetic balance of the nose, particularly the lower one-third of the nose. Its position is dependent on the anatomical constituents of the columella, and neighboring anatomical structures. Six components of the hanging columella have been identified: the caudal septum, medial crura, columellar skin, membranous septum, anterior nasal spine, and depressor septi nasi muscle. Columellar refinement begins with a careful analysis and diagnosis of the contributing components, followed by surgical techniques to address these components individually. The cumulative effect of correction of individual components appropriately positions the columella and contributes significantly to the enhancement of nasal aesthetics. Refinement of the columella can be achieved through appropriately trimming the caudal septum; repositioning and reshaping the medial crura; excising redundant columellar skin, membranous septum, and nasal mucosa; appropriately contouring the anterior nasal spine; and dividing the depressor nasi septi nasi.

Columellar Reconstruction following Nasal Continuous Positive Airway Pressure Injury.

Nasal continuous positive airway pressure is used increasingly to treat pulmonary immaturity in premature neonates. Nasal injury is common with nasal continuous positive airway pressure use, with full-thickness tissue loss at the columella among the most devastating complications. Columellar necrosis often imparts a full-thickness injury to the overlying columellar skin, the medial crura of the lower lateral nasal cartilages, the anteromedial inner nasal mucosal lining, and potentially the anterior septal cartilage. Consequently, the columella can become scarred and shortened. Although multiple techniques have been described to reconstruct the columella, no known technique has been specifically developed to treat the unique columellar defect common to severe nasal continuous positive airway pressure injury. Donor-site morbidity related to these techniques, and how growth of the reconstructed nose will proceed, are obvious concerns, especially in young children. The authors present a novel reconstruction technique that uses recreation of the defect with posteriorly based book flaps and auricular chondrocutaneous composite graft interposition. This technique has several advantages, including avoiding central facial scars, supplying well-matched skin color and texture, and facilitating robust tip support. The authors retrospectively review the use and outcomes of this technique from 1995 and 2016 on all patients with a history of nasal continuous positive airway pressure columellar necrosis at their center.

Modified Endonasal Tongue-in-Groove Technique.

Achieving stable and desirable changes in tip rotation (TR) and tip projection (TP) is among the primary goals of modern day rhinoplasty. The tongue-in-groove (TIG) technique is one technique in rhinoplasty used to improve TR and/or TP. Performing TIG endonasally using a permanent suture can be quite cumbersome as the suture needs to be buried under the skin. We describe a variation of TIG technique for endonasal rhinoplasty using a permanent suture buried in small columellar skin incisions. The technique details are described and the postoperative changes in TR and TP are analyzed for the degree of change and longevity. A retrospective review of the preoperative and postoperative photographs of 12 patients treated with the endonasal TIG technique were analyzed for changes in TR and TP. Out of 12 patients, there were seven females (58.3%) and five males (41.7%), with age ranging from 17 to 49 years. The follow-up ranged from 6 months to 53 months, with mean follow-up of 12.1 months. All patients were treated by the senior author in a major New York City hospital. Postoperative changes in TR and TP were compared by measuring the nasolabial angle as well as the Goode ratio using a photo editing software. Using a t-test and a p-value criteria of 0.05, the difference between the preoperative and postoperative TR (p = 0.0069) and TP (p = 0.026) was found to be statistically significant. None of the study patients developed any complications related to the use of a permanent suture material during the follow-up period. Our modified TIG technique is a quick, reliable, and safe option in the surgical armamentarium to achieve desired changes in TR and/or TP. 4.

Columellar Incision Scars in Asian Patients Undergoing Open Rhinoplasty.

An open approach has been adopted for rhinoplasty because of its wide and undistorted exposure. The formation of a columellar incision scar is the main drawback of this approach. To evaluate the incidence and evolution of and risk factors for columellar incision scars in an Asian population. A retrospective case series of 529 patients who underwent open rhinoplasty was performed in a tertiary care referral center in South Korea from January 1, 2011, to May 31, 2014. Problematic transcolumellar incision scars were categorized into wide and depressed, notching, and hyperpigmented wound types. Follow-up was complete on January 28, 2015, and data were assessed from July 1, 2014, to May 29, 2015. The incidence of each problematic scar and the time course of erythema evolution were evaluated. Factors affecting the formation of a problematic scar were also evaluated. Of 529 patients (176 female and 353 male patients; mean age, 31 [range, 5-70] years), 234 patients with at least 6 months of follow-up underwent evaluation for a problematic scar. Fourteen of the 234 patients (6.0%) had problematic incision scarring (wide and depressed wound, 4 [1.7%]; notching wound, 3 [1.3%]; hyperpigmentation, 4 [1.7%]; marginal incision hypertrophic scar, 2 [0.8%]; and columellar skin necrosis, 1 [0.4%]). Of the 243 patients with regular follow-up who underwent evaluation for erythema evolution, erythematous wounds were found in almost all in the immediate postoperative period and had normalized by a mean (SD) of 66.7 (37.4) postoperative days. Use of costal cartilage as tip graft material was associated with a problematic incision scar (2 of 25 patients [8.0%] vs 6 of 180 patients with other graft material [3.3%]; P = .02). In this cohort of Asian patients, the incisions used for an open rhinoplasty approach had some problems. However, the low incidence of problematic scars indicates that open rhinoplasty should not be discouraged because of the incision scar. 4.

Oronasal Fistula with Palatal Involvement Secondary to Cocaine Use

Vasoconstriction is a well-known local sympathetic effect of cocaine that may lead to ischemia, inflammation, ulceration and ultimately necrosis of the nasopharyngeal structures implicated by snorting cocaine. 2 Nasal septal perforation is present in 4.8% of abusers, making it the most common complication of cocaine abuse. 3 Chronic cocaine use may contribute to larger lesions and further destruction of the surrounding osteocartilaginous structures. Specifically, the destruction of nasal and midfacial bones and soft tissues can lead to a syndrome called cocaine-induced midline destructive lesion (CIMDL). The diagnosis of CIMDL requires at least 2 of the following clinical or radiologic findings: nasal septal perforation, lateral nasal wall destruction, and hard palate involvement. 4 We describe a patient with a history of cocaine abuse and signs of CIMDL, with midfacial destruction of the nasal septum and hard palate creating an oronasal fistula. To the best of our knowledge, we believe this is the first case of CIMDL with oronasal fistula reported in Canada. case presentation A 60-year-old male was referred to us with a 1-month history of a “hole” in his hard palate that caused fluids to leak out of his nose when drinking. Prior to presentation, he had been using denture adhesive gel as a temporizing measure for the palatal defect. He also disclosed that he had a nasal deformity, which previous physicians had attributed to his long history of cocaine snorting. The oral and nasal lesions were not associated with bleeding, pain, B-symptoms, nasal obstruction or recurrent sinusitis. His past medical history was notable for asthma and hypertension. His social history revealed a lifetime of tobacco use and many years of chronic cocaine use. On physical examination, the patient looked well and was in no acute distress. The nasal vestibules were intact bilaterally with no erosion of the columellar skin. Anterior rhinoscopy revealed complete loss of the cartilaginous nasal septum, without saddle nose deformity. Flexible nasopharyngoscopy showed extensive mucosal crusting, severe atrophy of the turbinates bilaterally but no polyps or suspicious growths. Examination of the oral cavity showed normal mucosa and dentition overall, with a single 1 cm perforation at the midline of the hard palate, communicating with the floor of the nasal cavity. The hard palate was quite soft in the area surrounding the perforation, suggesting bone loss of 2‐3 cm in circumference. The soft palate was intact and the posterior pharynx was normal, with no ulcerating or fungating growths. The remainder of the head and neck examination was unremarkable. Computed tomography (CT) scan showed extensive bony erosion of the nasal septum and hard palate, with mucosal thickening of the maxillary and ethmoid sinuses. There was no evidence of orbital or intracranial extension of this disease. Nasopharyngeal swab was positive for Staphylococcus aureus. Biopsy of the nasal cavity mucosa showed non-specific granulation tissue with no evidence of malignancy or infection.

Nasal Base Narrowing of the Caucasian Nose Through the Cerclage Technique

Introduction: Several techniques can be performed to reduce the nasal base (narrowing), as skin resection vestibular columellar skin resection, resection of skin in elliptical lip narinary, sloughing of skin and advancements (VY technique of Bernstein) and the use of cerclage sutures in the nasal base. Objective: To evaluate the technique of cerclage performed in the nasal base, through endonasal rhinoplasty without delivery of basic technique, in the Caucasian nose, reducing the distance inter-alar flare and correcting the wing with consequent improvement in nasal harmony in the whole face. Methods: A retrospective analysis by analysis of clinical documents and photos of 43 patients in whom cerclage was made of the nasal base by resecting skin ellipse in the region of the vestibule and the nasal base (modified technique of Weir) using colorless mononylon ® 4 “0” with a straight cutting needle. The study was conducted in 2008 and 2009 at Hospital of Parana Institute of Otolaryngology - IPO in Curitiba, Parana - Brazil. Patients had a follow up ranging 7-12 months. Results: In 100% of cases was achieved an improvement in nasal harmony, by decreasing the inter-alar distance. Conclusion: The encircling with minimal resection of vestibular skin and the nasal base is an effective method for the narrowing of the nasal base in the Caucasian nose, with predictable results and easy to perform.

Reconstruction of a columellar defect with a nasolabial island flap.

Columellar skin defects may be caused by excision of cutaneous malignancy, trauma, or tissue necrosis associated with surgery. Although columellar skin necrosis rarely occurs following rhinoplasty, this condition might be more common when using an external approach than a closed approach. Columellar skin incision performed with exaggerated tip augmentation may cause columellar necrosis. The nasolabial island flap, used unilaterally to cover columellar skin defects, is used for a single-stage reconstruction procedure and is generally not associated with the need for secondary surgeries. This technique is well suited for repairing columellar skin defects. We experienced a patient with columellar skin necrosis occurring after rhinoplasty which was reconstructed using a unilateral single-stage nasolabial island flap.

Septocolumellar Suture in Closed Rhinoplasty

Several surgeons advise a variety of tip sutures and describe their own techniques in open approach. Septocolumellar suture is one of them and can be described as a loop suture between the medial crura and caudal septum. Although some of the articles mention that it can be applied in closed rhinoplasty, there is no description of the technical details. This paper presents indications, technical steps, and advantages of the septocolumellar suture in closed rhinoplasty. After completing the classic sequence of the endonasal extramucous technique, the medial crural cartilages are dissected from the overlying skin at the midcolumellar level, keeping the distal fibrous attachments between the anterior columellar skin and these cartilages intact. A 5/0 or 4/0 Prolene (Ethicon Ltd, UK) with a round needle is passed, penetrating both the medial crura and then the caudal septum. Depending on the penetration level of this suture, the tip projection can be increased or decreased, the tip can be rotated, and columellar show can be corrected. This suture also makes the medial crura of the alar cartilages and septum rigidly fixed together, thus providing stability. Depending on the experience gained in 433 primary and 62 secondary rhinoplasty cases since 2000, it can be claimed that this technique, presenting an alternative to the open approach in many cases and expanding the borders of closed approach, allows one to manipulate the tip and columella easily with closed rhinoplasty and provides a significant decrease in the suboptimal results and number of complications.

Comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using conchal composite grafts

Anatomical abnormalities and heterogeneous tissue deficiencies of the bilateral cleft lip nasal deformity challenges the cranio-maxillofacial plastic surgeon to create a functional, yet aesthetically pleasing nose. The authors propose a comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using composite conchal grafts. Five children with bilateral cleft lip nasal deformities had nasal reconstruction using conchal composite grafts, averaging 5 years in age at time of surgery. Patient follow-up averaged 21 months. An open tip rhinoplasty was performed using a 'V' shaped columellar incision. The conchal composite graft was obtained from the lateral aspect of the ear and was used to reconstruct the lateral alar mucosal defects. Conchal cartilage was used as a columellar strut. The columellar skin was closed in a 'V-Y' fashion, giving greater columellar length. Visual inspection confirmed that the cleft lip nasal deformity was improved in all patients. There were no postoperative complications. All patients had complete composite graft take with minimal donor site morbidity and deformity. This comprehensive rhinoplasty technique improves the abnormalities found in bilateral cleft lip nasal deformity by using the successful aspects of other methods and introducing the composite conchal graft.

Simultaneous Open Rhinoplasty and Alar Base Excision for Secondary Cases

Simultaneous open rhinoplasty and alar base excision are a very safe procedure for protecting the vascular supply of the nasal dip and the columellar skin in primary cases when surgical dissection is performed below the musculoaponeurotic layer of the nose. Major arteries of the external nose lie above the musculoaponeurotic layer. However, secondary cases may pose increased risks to the blood supply of the nasal tip and columella skin because of the decreased vascular supply and increased scar tissue from the previous rhinoplasty. We studied our secondary cases of simultaneous open rhinoplasty and alar base excision, to assess the real risk for necrosis of the nasal tip and columellar skin. A total of 12 secondary patients (6 men and 6 women) underwent simultaneous open rhinoplasty and alar base excision in the past 3 years. Their average age was 27 years (range, 21-35 years). The average follow-up period was 15 months (range, 1-35 moths). A modified grading system, originally described by Bafaqeeh and Al-Qattan, was used for assessment of the blood supply in the nasal tip and the columellar skin. Satisfactory results were obtained for our patients, with the exception of one case. Grade 3 vascular compromise to the nasal tip and the columella was observed in one case, but the patient healed well with wound care treatment. Simultaneous alar base excision and open rhinoplasty can be performed safely in secondary cases. However some surgical maneuvers such as subcutaneous pocket preparation for the tip graft in closed rhinoplasty and subdermal defatting in the first rhinoplasty as well as previous scarring on the nasal lobule can disrupt the vascular supply of the nasal tip and columella skin. Under these conditions, alar base excision should be deferred and then performed as an isolated excision procedure.

‘The columellotomy modification’ of transseptal hypophysectomy

Objective: Although the transseptal approach to the sella turcica is the most common method by which the pituitary tumors are resected, it is not suitable for the noses with narrow nostrils, precluding the placement of the neurosurgical speculum. In this paper, as a solution for this problem, ‘the columellotomy modification’ of the transseptal approach is suggested and described together with the results in five patients. Methods: In five patients, the distance between the outer edges of the two blades of the neurosurgical speculum was measured after positioning the neurosurgical speculum through the hemitransfixion incision, and after positioning the neurosurgical speculum through ‘the columellotomy’ incision. The increase in distance after hemitransfixion incision with respect to the width of the nostril was statistically compared with the increase in distance after ‘columellotomy’ incision with respect to the width of the nostril. The postoperative complaints and cosmetic results were evaluated. Results: By paired-samples t-test, the comparison between the values of increase revealed a statistically significant difference ( P=0.011). A complaint of numbness on the columellar skin was noted in three of the five patients. Cosmetic results were satisfactory. Conclusion: ‘The columellotomy modification’ offers a wide, direct and fast exposure to the sella turcica without a cosmetic disadvantage in noses with narrow nostrils.

Simultaneous open rhinoplasty and alar base excision: is there a problem with the blood supply of the nasal tip and columellar skin?

In a prospective study, 15 consecutive patients who underwent simultaneous open rhinoplasty and alar base excision were included to investigate whether there is a problem with the blood supply of the nasal tip and columellar skin. During the surgical procedure in these patients, there was transection of the columellar arteries and external nasal arteries, and frequently of the alar branches of the angular artery. Yet, none of the patients had any evidence of ischemia of the nasal tip or columellar skin, and there was primary wound healing with a thin-line transcolumellar scar in all patients. Techniques to avoid injury to the lateral nasal artery and nasal tip plexus are discussed. It was concluded that simultaneous open rhinoplasty and alar base excision is safe as long as certain surgical principles are applied.

Facial soft-tissue augmentation with injectable autologous and allogeneic human tissue collagen matrix (autologen and dermalogen).

Facial soft-tissue augmentation has become increasingly popular as an option for those patients in whom age-related changes manifest as contour defects or who desire volume enhancement for various areas of the face. A variety of agents and techniques are currently available that, when used appropriately, can improve or correct facial rhytids and regional volume depletion. Failures of some agents are due to reduced biocompatibility, inadequate administration technique, or failure to match the actual underlying defeat with the most appropriate solution. Dermal soft-tissue augmentation with human tissue collagen matrix (Autologen and Dermalogen) is physiologic, appears to be ultimately safe and effective, and has many qualities consistent with an ideal dermal filler. Several autologous, allogeneic (cadaver-derived), heterologous, and alloplastic agents will be discussed in this article with regard to rationale, patient selection, optimum administration technique, and persistence.

Muscles that act on glabellar skin: a closer look.

The coronal incision forehead lift became a component of the face-lift procedure 35 years ago and increased the cosmetic benefit for the facial aesthetic surgery patient. Later, this enhanced cosmetic effect achieved from eyebrow resuspension was complemented by treatment of the glabellar skin lines by modifying corrugator supercilii and procerus muscle function through the same coronal incision. In recent years, newer procedures for treating the corrugator supercilii and procerus muscles by using endoscopy or limited incision techniques have eliminated the need for the coronal incision. With these newer techniques has come a renewed interest in the surgical anatomy of the muscle complex that acts on glabellar skin. This study was designed to examine the current understanding of the anatomy of these muscles and to resolve misconceptions and controversy concerning them. Fresh cadaver dissections and simulated muscle action studies done on the glabellar musculature of four specimens were correlated with nerve blockade studies performed in 10 subjects on the temporal and zygomatic branches of the facial nerve. The presence of the depressor supercilii muscle as a distinct entity was confirmed. The little-appreciated oblique head of the corrugator supercilii muscle was identified. The conclusions from this study suggest that the transverse head of the corrugator supercilii muscle produces the vertical component of the glabellar skin line and also contributes to the formation of the oblique component of the glabellar skin line. The oblique head of the corrugator supercilii muscle, the depressor supercilii muscle, and the medial head of the orbital portion of the orbicularis oculi muscle all appear to depress the medial head of the eyebrow and contribute to the formation of the oblique glabellar skin line. The nerve block study provided evidence that the zygomatic branch of the facial nerve supplies the three medial eyebrow depressor muscles, which opens the possibility for future nerve ablation techniques to control the action of the medial eyebrow depressor muscle group. This nerve block study also supports the concept of "physiologic" elevation of the medial eyebrow as an effective component of foreheadplasty.

Surgical approach to the nasal valve stenosis

Nasal valve, originally defined by Mink (1903), has changed its concept and is now regarded as slit-like opening between the caudal end of the upper lateral cartilage and the septum. Contrary to Caucasians whose smallest area of the nose lies at the nasal valve, the narrowest part of Japanese nose situates at the area between the anterior portion of the inferior turbinate and the septum. Thus, we have fewer chance to experience patients with stenotic nasal valve. Six patients complaining nasal obstruction resulted from nasal valve stenosis, mainly due to dislocated or collapsed upper lateral cartilage, underwent surgery during the last 2 years and a half. Cases of septal deformity, even it it produced valve stenosis, were excluded in this study. Surgical intervention was directed toward reconstruction of normal anatomic relationships, usually by widening the nasal valve angle and preventing collapsibility. Three underwent open rhinoplasty with gull-wing columellar skin incision, whereas 3 others were operated on via transnostril approach. History of midfacial trauma caused us to choose open rhinoplasty for restoring the function and structure. Immediate postoperative result was excellent in the aspect of appearance and subjective data regardless of surgical approach. Open rhinoplasty provided a splendid long-term result without remarkable complications. On the other hand, 2 cases operated via transnostril approach complained recurrence of stuffy nose.