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Complication of a columellar strut in an edentulous patient
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY XX ( 2 0 13 ) XXX –XXX
Available online at www.sciencedirect.com
www.elsevier.com/locate/amjoto
Complication of a columellar strut in an edentulous patient☆,☆☆,★ Sanaz Harirchian, MD a , Kim P. Murray, MD a , Jean Anderson Eloy, MD, FACS a, b, c,⁎ a
Department of Otolaryngology – Head and Neck Surgery, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ, USA b Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ, USA c Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ, USA
A R T I C L E IN F O
A B S T R A C T
Article history:
The cartilaginous columellar strut is a well established, commonly used graft in rhinoplasty
Received 6 December 2012
which provides support and stability to the nasal base. The risk of such a graft is related to grafts designs, whereby the posterior aspect can cause clicking with movement across the anterior nasal spine. We present an additional unusual complication of ill-fitting maxillary dentures in an edentulous patient, previously not reported in the literature. This unique complication should alert facial plastic surgeons to use additional caution when sculpting columellar grafts in edentulous patients in order to avoid potential post-operative complications in this specific patient population. © 2012 Elsevier Inc. All rights reserved.
1.
Introduction
The columellar strut is a well established graft utilized for nasal tip support and refinement during rhinoplasty. Jack Anderson described his tripod concept of nasal tip dynamics in the 1960s [1]. While the right and left lateral crura comprise two legs of the tripod, the conjoined medial crura functions as the third leg. The columellar strut was fashioned as a medial crural strut designed to improve columellar stability, nasal base and alar symmetry, and possibly improve tip support, projection, and even rotation. Complications of columellar strut placement are rare. There have been reports of clicking of the strut against the anterior nasal spine, however no other significant complications have been reported. We describe a
rare and unreported complication of ill-fitting maxillary dentures after columellar strut placement in an edentulous patient. To our knowledge, no previous similar case has been previously reported. The protocol for this study was reviewed and approved by the institutional review board of the University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ.
2.
Report of a case
A 43-year-old female with a past surgical history significant for a wide local excision of a low grade mucoepidermoid carcinoma of the hard palate presented 5 years later with
☆ Author Contributions: Drs Harirchian, Murray, and Eloy had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Harirchian, Murray, Eloy. Acquisition of data: Harirchian. Analysis and interpretation of data: Harirchian, Murray, Eloy. Drafting of the manuscript: Harirchian. Critical revision of the manuscript for important intellectual content: Murray, Eloy. Statistical analysis: N/A. Administrative, technical, and material support: Eloy. Study supervision: Eloy. ☆☆ Financial Disclosure: None reported. ★ Presented at the American Academy of Facial Plastic and Reconstructive Surgery Meeting, COSM; San Diego, CA, April 19, 2012. ⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, UMDNJ-New Jersey Medical School, Newark, NJ 07103, USA. Tel.: +1 973 972 4588; fax: + 1 973 972 3767. E-mail address: [email protected] (J.A. Eloy).
0196-0709/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2012.12.008
Please cite this article as: Harirchian S, et al, Complication of a columellar strut in an edentulous patient, Am J Otolaryngol– Head and Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2012.12.008
2
AM ER IC AN JOURNAL OF OTOLARYNGO LOGY –H EAD AN D N E CK ME D I CI NE AN D SUR GE RY XX ( 2 0 13 ) XXX–X XX
columellar graft. She was taken back to the operating room one week later and an intraoral approach revealed that the hard lump was cartilage of the posterior-inferior aspect of the columellar strut (Fig. 2A). The inferior portion of the cartilage was trimmed (Fig. 2B), the mucosa re-approximated, and the patient subsequently did well.
3.
Fig. 1 – Intraoperative photograph of the columellar strut and tip sutures.
constant left sided nasal obstruction and external nasal deformity. She has worn upper dentures since her surgery. On anterior rhinoscopy, the patient had significant septal deviation to the left with moderate inferior turbinate hypertrophy bilaterally. Facial analysis was notable for mid and lower 1/3 nasal deviation to the right, a small dorsal hump, a flat wide bulbous tip, and a very short upper lip. Nasolabial angle was approximately 90 degrees. The patient underwent a standard open rhinoplasty via transcolumellar and bilateral marginal incisions. Dorsal hump reduction, bilateral spreader grafts, cephalic trim leaving 7 mm of lower lateral cartilage, and tip suturing were performed. A 20 mm × 3 mm × 2 mm autologous septal cartilage graft was placed as a columellar strut (Fig. 1). There were no immediate complications. On the first follow up visit one week later, the patient complained of inability to wear her upper dentures due to a bump near the upper frenulum. Intraoral examination revealed a hard prominence into the upper gingival-labial sulcus suspicious for the inferior part of the cartilaginous
Comment
Jack Anderson's tripod theory continues to be utilized in understanding nasal tip dynamics. In Anderson's theory, the tripod is formed by the lateral crus of each lower lateral cartilage and the conjoined medial crura. This tripod rests on the anterior nasal spine and is supported centrally by attachments to the caudal septum, and laterally by attachments to the upper lateral cartilages and nasal pyramid [2]. Alterations in nasal tip projection, rotation, and support can be achieved by changes to the individual components of the tripod. The columellar strut has long been utilized to provide structural support for the lower lateral cartilages [3]. Janecke described the effects of various surgical maneuvers on tip support after 20 cadaver dissections and concluded that the most critical aspect of tip support appeared to be maintenance of the support of the medial crural feet on the posterior septum [4]. Through buttressing the medial crura, the columellar strut is believed to provide structural integrity to the nasal tip. In addition, the columellar strut can correct medial crural asymmetries, refine the infratip columellalobule region, provide a scaffold for tip sutures and grafts, and may increase nasal tip rotation and projection [5]. The mechanism for increased nasal tip projection is believed to be increased medial crural strength and support [3]. A retrospective photographic analysis of patients having undergone open rhinoplasty noted a slight increase in nasal tip projection with columellar strut placement [6]. There was also a statistically significant increase in nasal tip rotation, with a mean nasolabial angle increase from 94 to 101 degrees. However it has been argued that the columellar strut merely
Fig. 2 – Intraoperative photograph depicting (A) protrusion of the columellar strut into the upper gingivolabial sulcus and (B) view of the inferior edge of the columellar strut after intraoral incision over the cartilage. Please cite this article as: Harirchian S, et al, Complication of a columellar strut in an edentulous patient, Am J Otolaryngol– Head and Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2012.12.008
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY XX ( 2 0 13 ) XXX –XXX
maintains nasal tip projection when the tip support mechanisms have been violated [7]. The columellar strut is usually designed from autogenous septal cartilage, although cadaveric costal cartilage and auricular cartilage are also utilized. The strut is typically 20– 25 mm in length and 2–4 mm in width [3,5,8,9]. It is inserted in a recipient pocket between the alar cartilages, and sutured between the medial crura [8]. The strut can be either “floating” or “fixed” based on its intended usage. The floating columellar strut is positioned 2–3 mm anterior to the nasal spine, while the fixed strut is longer and secured to the anterior maxilla. Rohrich advocates using the longer fixed strut when 3 mm or more of tip projection is needed, versus the floating strut when 1–2 mm of tip projection is needed [3,5]. In our patient, the combination of specific patient characteristics, anatomic factors, and operative technique all contributed to the etiology of this complication. The patient's previous history of wide local excision of the hard palate with subsequent need for upper dentures placed her at risk for having difficulty related to denture placement. Additionally, the patient's very short upper lip decreased the amount of space between the columellar strut and the gingivolabial sulcus. Lastly, the creation of a 20 mm long columellar strut may have been unnecessarily long. A range of 20–25 mm in length has been described [3,5,8,9], and while some authors advocate extension of the strut onto the premaxilla, others avoid this nuance in order to prevent post operative clicking of the strut. A columellar strut can have significant benefits for improving nasal base symmetry and stability. Proper graft
3
sculpturing, especially with respect to its length, can dramatically limit the few known associated risks. Our report of this unique complication should give surgeons additional caution when sculpting columellar grafts for edentulous patients in order to avoid potential post-operative complications in this patient population. REFERENCES
[1] Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol 1984;110:349–58. [2] Westreich RW, Lawson W. The tripod theory of nasal tip support revisited: the cantilevered spring model. Arch Facial Plast Surg 2008;10:170–9. [3] Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in rhinoplasty: indications and rationale. Plast Reconstr Surg 2012;129:118e–25e. [4] Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol 1971;93:458–64. [5] Ghavami A, Janis JE, Acikel C, et al. Tip shaping in primary rhinoplasty: an algorithmic approach. Plast Reconstr Surg 2008;122:1229–41. [6] Ingels K, Orhan KS. Measurement of preoperative and postoperative nasal tip projection and rotation. Arch Facial Plast Surg 2006;8:411–5. [7] Vuyk HD, Oakenfull C, Plaat RE. A quantitative appraisal of change in nasal tip projection after open rhinoplasty. Rhinology 1997;35:124–8. [8] Daniel RK. Rhinoplasty: open tip suture techniques: a 25-year experience. Facial Plast Surg 2011;27:213–24. [9] Pastorek NJ, Bustillo A, Murphy MR, et al. The extended columellar strut-tip graft. Arch Facial Plast Surg 2005;7:176–84.
Please cite this article as: Harirchian S, et al, Complication of a columellar strut in an edentulous patient, Am J Otolaryngol– Head and Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2012.12.008
Available online at www.sciencedirect.com
www.elsevier.com/locate/amjoto
Complication of a columellar strut in an edentulous patient☆,☆☆,★ Sanaz Harirchian, MD a , Kim P. Murray, MD a , Jean Anderson Eloy, MD, FACS a, b, c,⁎ a
Department of Otolaryngology – Head and Neck Surgery, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ, USA b Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ, USA c Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ, USA
A R T I C L E IN F O
A B S T R A C T
Article history:
The cartilaginous columellar strut is a well established, commonly used graft in rhinoplasty
Received 6 December 2012
which provides support and stability to the nasal base. The risk of such a graft is related to grafts designs, whereby the posterior aspect can cause clicking with movement across the anterior nasal spine. We present an additional unusual complication of ill-fitting maxillary dentures in an edentulous patient, previously not reported in the literature. This unique complication should alert facial plastic surgeons to use additional caution when sculpting columellar grafts in edentulous patients in order to avoid potential post-operative complications in this specific patient population. © 2012 Elsevier Inc. All rights reserved.
1.
Introduction
The columellar strut is a well established graft utilized for nasal tip support and refinement during rhinoplasty. Jack Anderson described his tripod concept of nasal tip dynamics in the 1960s [1]. While the right and left lateral crura comprise two legs of the tripod, the conjoined medial crura functions as the third leg. The columellar strut was fashioned as a medial crural strut designed to improve columellar stability, nasal base and alar symmetry, and possibly improve tip support, projection, and even rotation. Complications of columellar strut placement are rare. There have been reports of clicking of the strut against the anterior nasal spine, however no other significant complications have been reported. We describe a
rare and unreported complication of ill-fitting maxillary dentures after columellar strut placement in an edentulous patient. To our knowledge, no previous similar case has been previously reported. The protocol for this study was reviewed and approved by the institutional review board of the University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ.
2.
Report of a case
A 43-year-old female with a past surgical history significant for a wide local excision of a low grade mucoepidermoid carcinoma of the hard palate presented 5 years later with
☆ Author Contributions: Drs Harirchian, Murray, and Eloy had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Harirchian, Murray, Eloy. Acquisition of data: Harirchian. Analysis and interpretation of data: Harirchian, Murray, Eloy. Drafting of the manuscript: Harirchian. Critical revision of the manuscript for important intellectual content: Murray, Eloy. Statistical analysis: N/A. Administrative, technical, and material support: Eloy. Study supervision: Eloy. ☆☆ Financial Disclosure: None reported. ★ Presented at the American Academy of Facial Plastic and Reconstructive Surgery Meeting, COSM; San Diego, CA, April 19, 2012. ⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, UMDNJ-New Jersey Medical School, Newark, NJ 07103, USA. Tel.: +1 973 972 4588; fax: + 1 973 972 3767. E-mail address: [email protected] (J.A. Eloy).
0196-0709/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2012.12.008
Please cite this article as: Harirchian S, et al, Complication of a columellar strut in an edentulous patient, Am J Otolaryngol– Head and Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2012.12.008
2
AM ER IC AN JOURNAL OF OTOLARYNGO LOGY –H EAD AN D N E CK ME D I CI NE AN D SUR GE RY XX ( 2 0 13 ) XXX–X XX
columellar graft. She was taken back to the operating room one week later and an intraoral approach revealed that the hard lump was cartilage of the posterior-inferior aspect of the columellar strut (Fig. 2A). The inferior portion of the cartilage was trimmed (Fig. 2B), the mucosa re-approximated, and the patient subsequently did well.
3.
Fig. 1 – Intraoperative photograph of the columellar strut and tip sutures.
constant left sided nasal obstruction and external nasal deformity. She has worn upper dentures since her surgery. On anterior rhinoscopy, the patient had significant septal deviation to the left with moderate inferior turbinate hypertrophy bilaterally. Facial analysis was notable for mid and lower 1/3 nasal deviation to the right, a small dorsal hump, a flat wide bulbous tip, and a very short upper lip. Nasolabial angle was approximately 90 degrees. The patient underwent a standard open rhinoplasty via transcolumellar and bilateral marginal incisions. Dorsal hump reduction, bilateral spreader grafts, cephalic trim leaving 7 mm of lower lateral cartilage, and tip suturing were performed. A 20 mm × 3 mm × 2 mm autologous septal cartilage graft was placed as a columellar strut (Fig. 1). There were no immediate complications. On the first follow up visit one week later, the patient complained of inability to wear her upper dentures due to a bump near the upper frenulum. Intraoral examination revealed a hard prominence into the upper gingival-labial sulcus suspicious for the inferior part of the cartilaginous
Comment
Jack Anderson's tripod theory continues to be utilized in understanding nasal tip dynamics. In Anderson's theory, the tripod is formed by the lateral crus of each lower lateral cartilage and the conjoined medial crura. This tripod rests on the anterior nasal spine and is supported centrally by attachments to the caudal septum, and laterally by attachments to the upper lateral cartilages and nasal pyramid [2]. Alterations in nasal tip projection, rotation, and support can be achieved by changes to the individual components of the tripod. The columellar strut has long been utilized to provide structural support for the lower lateral cartilages [3]. Janecke described the effects of various surgical maneuvers on tip support after 20 cadaver dissections and concluded that the most critical aspect of tip support appeared to be maintenance of the support of the medial crural feet on the posterior septum [4]. Through buttressing the medial crura, the columellar strut is believed to provide structural integrity to the nasal tip. In addition, the columellar strut can correct medial crural asymmetries, refine the infratip columellalobule region, provide a scaffold for tip sutures and grafts, and may increase nasal tip rotation and projection [5]. The mechanism for increased nasal tip projection is believed to be increased medial crural strength and support [3]. A retrospective photographic analysis of patients having undergone open rhinoplasty noted a slight increase in nasal tip projection with columellar strut placement [6]. There was also a statistically significant increase in nasal tip rotation, with a mean nasolabial angle increase from 94 to 101 degrees. However it has been argued that the columellar strut merely
Fig. 2 – Intraoperative photograph depicting (A) protrusion of the columellar strut into the upper gingivolabial sulcus and (B) view of the inferior edge of the columellar strut after intraoral incision over the cartilage. Please cite this article as: Harirchian S, et al, Complication of a columellar strut in an edentulous patient, Am J Otolaryngol– Head and Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2012.12.008
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY XX ( 2 0 13 ) XXX –XXX
maintains nasal tip projection when the tip support mechanisms have been violated [7]. The columellar strut is usually designed from autogenous septal cartilage, although cadaveric costal cartilage and auricular cartilage are also utilized. The strut is typically 20– 25 mm in length and 2–4 mm in width [3,5,8,9]. It is inserted in a recipient pocket between the alar cartilages, and sutured between the medial crura [8]. The strut can be either “floating” or “fixed” based on its intended usage. The floating columellar strut is positioned 2–3 mm anterior to the nasal spine, while the fixed strut is longer and secured to the anterior maxilla. Rohrich advocates using the longer fixed strut when 3 mm or more of tip projection is needed, versus the floating strut when 1–2 mm of tip projection is needed [3,5]. In our patient, the combination of specific patient characteristics, anatomic factors, and operative technique all contributed to the etiology of this complication. The patient's previous history of wide local excision of the hard palate with subsequent need for upper dentures placed her at risk for having difficulty related to denture placement. Additionally, the patient's very short upper lip decreased the amount of space between the columellar strut and the gingivolabial sulcus. Lastly, the creation of a 20 mm long columellar strut may have been unnecessarily long. A range of 20–25 mm in length has been described [3,5,8,9], and while some authors advocate extension of the strut onto the premaxilla, others avoid this nuance in order to prevent post operative clicking of the strut. A columellar strut can have significant benefits for improving nasal base symmetry and stability. Proper graft
3
sculpturing, especially with respect to its length, can dramatically limit the few known associated risks. Our report of this unique complication should give surgeons additional caution when sculpting columellar grafts for edentulous patients in order to avoid potential post-operative complications in this patient population. REFERENCES
[1] Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol 1984;110:349–58. [2] Westreich RW, Lawson W. The tripod theory of nasal tip support revisited: the cantilevered spring model. Arch Facial Plast Surg 2008;10:170–9. [3] Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in rhinoplasty: indications and rationale. Plast Reconstr Surg 2012;129:118e–25e. [4] Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol 1971;93:458–64. [5] Ghavami A, Janis JE, Acikel C, et al. Tip shaping in primary rhinoplasty: an algorithmic approach. Plast Reconstr Surg 2008;122:1229–41. [6] Ingels K, Orhan KS. Measurement of preoperative and postoperative nasal tip projection and rotation. Arch Facial Plast Surg 2006;8:411–5. [7] Vuyk HD, Oakenfull C, Plaat RE. A quantitative appraisal of change in nasal tip projection after open rhinoplasty. Rhinology 1997;35:124–8. [8] Daniel RK. Rhinoplasty: open tip suture techniques: a 25-year experience. Facial Plast Surg 2011;27:213–24. [9] Pastorek NJ, Bustillo A, Murphy MR, et al. The extended columellar strut-tip graft. Arch Facial Plast Surg 2005;7:176–84.
Please cite this article as: Harirchian S, et al, Complication of a columellar strut in an edentulous patient, Am J Otolaryngol– Head and Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2012.12.008