Nasal Columella reconstruction – A comprehensive review of the current techniques

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Nasal Columella reconstruction – A comprehensive review of the current techniques Jake Nowicki MD , Jonathan R Abbas MBChB MRCS(ENT) , Danny Sudbury MBBS, BSc , Shahram Anari MD, MSC, FRCS (ORL-HNS) PII: DOI: Reference:

S1748-6815(20)30036-X https://doi.org/10.1016/j.bjps.2020.01.016 PRAS 6403

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received date: Accepted date:

13 February 2019 5 January 2020

Please cite this article as: Jake Nowicki MD , Jonathan R Abbas MBChB MRCS(ENT) , Danny Sudbury MBBS, BSc , Shahram Anari MD, MSC, FRCS (ORL-HNS) , Nasal Columella reconstruction – A comprehensive review of the current techniques, Journal of Plastic, Reconstructive & Aesthetic Surgery (2020), doi: https://doi.org/10.1016/j.bjps.2020.01.016

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

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Nasal Columella reconstruction – A comprehensive review of the current techniques Jake Nowicki1 MD, [email protected] Jonathan R Abbas 2 MBChB MRCS(ENT) Danny Sudbury 3 MBBS, BSc Shahram Anari 4 MD, MSC, FRCS (ORL-HNS)

Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia 1

Royal Preston Hospital

2

Salford Royal NHS Foundation Trust

3

Department of Otolaryngology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, UK 4

Corresponding author. Jake Nowicki, 31 Cadell Street, Seaview Downs, Adelaide, SA, 5049. *

+61 425 706 925

Abstract The nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques.

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Keywords Columella, Reconstruction, Facial plastic surgery, Review Introduction Modern surgical techniques typically are based on the subunit principle introduced by Burget and Menick in 1985 for nasal reconstruction.[1] The nasal columella is often described as being a difficult subunit to reconstruct with satisfactory aesthetic outcome. [2]

The challenge arises due to a scarcity of adjacent tissue available for reconstruction,

as well as the columella’s distinctive contour and discrete border. [3,4] There are a wide range of medical conditions causing columella defects requiring reconstruction. Among these are ischemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. [5] Skin colour, subcutaneous bulk, columella width, and transition zones at the base of the nasal columella, nasal tip, and nasal floor, are each aesthetic properties of the normal columella anatomy that are important to address when reconstructing columella defects. [6] It is unsurprising that a myriad of different techniques exist from a variety of donor sites. [5,7-9] As can be expected, these techniques vary in complexity and required surgical skill. This article aims to describe the aesthetic properties of the columella subunit and the reconstructive techniques present in existing literature, including the circumstances under which they are indicated as well as their advantages and disadvantages. Methods A literature search was completed using PubMed, Medline and the Cochrane Database. Search dates were from January 1947 to June 2018. Key search terms included ‘columella’ and ‘reconstruction’. Where more information was required for a particular surgical technique, a further literature search was conducted for that particular

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technique. Papers that presented nasal reconstruction techniques but did not include nasal columella reconstruction were excluded. The reference list in selected articles was additionally searched for relevant papers. Only English language papers were included. Surgical techniques were organised into grafts, local random pattern flaps, regional flaps, and free flaps. Similar techniques presented by different authors were grouped according to the anatomical region of the flap donor site (e.g. nasolabial flaps). Results Overall, 655 papers were obtained from the initial literature search. 71 articles were deemed relevant based on their title and abstract. A further 21 relevant articles were found from the reference lists of these articles. The various techniques found, including grafts, local flaps, regional flaps and free tissue transfer flaps, are shown in Table 1. Discussion Columella anatomy and aesthetics The nasal columella is an important aesthetic unit of the face that determines the projection of the nasal tip, defines the nasolabial angle, and influences the relationship between the nasal base and alar rims. [10] It is composed of skin and a cartilage layer in a trilaminar structure. Functionally, aside from providing support to the nasal tip, the columella marks the transition from nonkeratinizing squamous epithelium to respiratory ciliated columnar epithelium. [10] There is a paucity in the literature on columella aesthetics. Firstly, it is important to appreciate that the columella shape ideally achieves symmetry between both the nostrils.11 The columella starts at the apex of the nostrils with an approximate width equal to that of the tip defining points.11 It then tapers reaching its narrowest point at

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the junction of the middle third and lower third.11 At the base its width should be slightly wider than at the apex. The divergence of the medial crural footplates determines the width of the columella. Crural splaying not only widens the columella but also changes the shape of the nostrils. The columella height should approximately be two-thirds the height of the base, and therefore twice the height of the lobule.11 The columella shape and dimensions differ among racial groups.12 In Caucasian patients, the inferior-most point of the columella usually lies on the same horizontal plane as the inferior extent of the ala. Patients of Asian Descent often have a retracted columella, which is apparent from the frontal view as a short columella that terminates superior to the ala.13 Only two-four millimetres of columellar show should be present below the alar margins from a profile view.13 Greater show than this is termed a ‘hanging columella’ and lesser show is termed ‘columella retraction.’13 Defects of the nasal columella may result in significant aesthetic and functional deformities. The surgical approach to reconstruction of columella defects is influenced by the local anatomy, the patient’s health, the extent and depth of the defect as well as the character of the remaining tissue that surrounds the defect. [3,14]This is particularly relevant with respect to assessing the integrity of the cartilaginous framework of the columella, as defects involving this may require cartilage grafts during reconstruction. Historically, there has been a large focus on columella lengthening techniques for bilateral cleft lip repair. However, since the anthropometric work by Mulliken15 it is widely accepted that there is not usually a columella defect that needs to be repaired, rather separate, divergent and flattened medial crura, as well as abnormally placed alar cartilage, that both need to be addressed to lengthen the columella and project the nasal tip.

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There are a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. The techniques are generally grouped into two broad categories of 1) grafts and 2) flaps. These include the use of full thickness skin grafts (FTSG), composite grafts, local random pattern flaps, regional flaps, and free flaps. Each of these has surgical pearls and pitfalls, as well as advantages and disadvantages that will be discussed in this review.

Grafts Full thickness skin grafts FTSGs can make for a simple and aesthetically acceptable columella reconstruction. They should be considered for superficial defects involving the skin and subcutaneous tissue only. Deeper defects involving the medial crura usually necessitate flap and/or composite graft coverage. [16,17] Skin grafts may also be considered for comorbid patients who cannot undergo a more extensive reconstruction. FTSGs have been used in creating prelaminated upper lip soft tissue flaps in a staged columellar reconstruction. [18,19]

They have also been used in lengthening the short columella in bilateral cleft nose

deformities. [20] To design a FTSG, a foil pattern template can be used for creating a construct that matches the defect contour, size and length. This also takes into account the contours of the surrounding tissue. The pre-auricular region, post auricular sulcus and melolabial fold are suitable donors for columella defects. [16,18,21] The donor-site markings are extended beyond the template to form an ellipse and avoid dog-ears from the incision.

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For all donor sites, care must be taken to avoid any hair bearing areas. Contact between the graft dermis and the recipient bed is also critical for graft survival. This can be assisted with meticulous defatting and the use of a bolster. [16] The advantages of FTSG reconstruction include multiple donor site options, minimal scarring and ease of shaping the skin graft to match the defect thus achieve a satisfactory aesthetic result. [22] A notable disadvantage is the potential for colour and contour mismatching, which yields a patch like appearance. Contouring irregularities may occur if the surgeon does not take FTSG contraction into account. This may be avoided by insetting grafts at appropriate tension. Patients will also rarely experience full sensation at the recipient site even after prolonged periods. [16,22] Composite grafts For correction of full thickness columella defects, it is important to reconstruct the cartilage layer to provide structural and functional integrity and prevent columella shortening. [23] A composite graft may be defined as ‘any graft which carries one or more germinal layers.’ [24] Composite grafts have been used for reconstruction of columella defects secondary to nasal positive airway pressure injury, [25] trauma, [26] burns, [23] skin cancer excision[23] and short columella associated with bilateral cleft lip. [27] Like FTSG’s, an important factor when using composite grafts is donor site selection. The chondrocutaneous tissue of the helix, antihelix, concha and ear lobe have been used for columella reconstruction. [23,25,28] The ear is similar to the columella in colour and texture and has components with various shapes and curves. [23] Graft selection from the ear can therefore be individualised according to the three dimensional configuration of the recipient defect. [23] Burm also described using a fasciocutaneous composite graft

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from the mastoid region for reconstruction of a nasal tip and columella defect, however this was only a partial thickness defect and did not require cartilaginous strut support. [26]

The posterior surface of the concha is the most commonly used composite graft donor site. [23] Chang et al. published a case series on posterior auricular chondrocutaneous composite graft reconstruction in children with columella defects secondary to nasal continuous positive airway pressure injury. [25] The technique involves preparing the columella defect by making transverse incisions at the superior and inferior edge of the defect and connecting them with a vertical midline incision. This creates two small ‘book’ flaps that are reflected laterally. The dimensions of the defect are transferred to the posterior auricle and an ellipse marked. The chondrocutaneous graft is then harvested and inset into the defect, with the book flaps then re-sutured to the skin of the graft (Figure 1). Another important consideration with composite grafts is the size of the graft that can be harvested without risk of graft failure. Traditionally, the upper limit of this has been a width of 10-15mm. [28,29] Recent studies have used larger grafts with widths up to 19mm. [23,30] Key principles to increasing composite graft survival include: proper preparation of the wound with minimal bipolar thermal injury, avoiding adrenaline mixed local anaesthetic, accurate approximation of the graft to the recipient bed and avoiding dead space, keeping the subcutaneous vessels in the graft, and maintaining a wound moisture balance. [31] The advantages of using composite grafts for columellar reconstruction are that it is a single stage simple procedure, with a shorter surgery time than several other methods. There is minimal contracture after graft healing because of the included cartilage

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graft.[23] They are also particularly well suited in children, where graft take is commonly better and donor scars from local, regional or free flaps are more difficult to conceal. Size limitation is an important disadvantage, with increased risk of graft failure and donor site deformity when larger grafts are harvested. [23]

Local flaps Local facial flaps for columella reconstruction were first presented by Blair and Byars in 1946. [32] A variety of techniques have since been reported in the literature, and they are commonly named after their donor site. Despite this expansion in the local facial flap repertoire, the ideal technique still remains elusive. [5] Local facial flaps are often indicated for isolated full thickness columella defects too large for composite graft reconstruction. Nasolabial flap The nasolabial flap, or melolabial flap, is a small and robust flap that is useful in nasal alar, sidewall, columella and intraoral reconstruction. [33-36] It is a random pattern flap that usually has arterial supply from the angular artery, superior labial artery, and dorsal nasal artery. [37] It has been described by several authors through a variety of techniques to be the preferred method for reconstructing composite, isolated columellar defects.[4,37-41] It can be used for reconstructing defects greater than 20mm in size. However, multi subunit defects that are larger than 25mm usually require alternate techniques, such as a forehead flap. Most commonly, the reconstruction involves two stages and is either a superiorly-based or inferiorly-based unilateral flap. [17] If there is total cartilage loss, then cartilage grafting may be required prior to flap reconstruction. [4] The base of the flap is the

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nasolabial crease, with the distal end of the flap elevated in the subcutaneous plane and inserted into the base of the remaining columella. It is important to not inset the flap under excessive tension, otherwise as it heals, the columella will deviate to the flap side. The base of the flap is initially left intact as a subcutaneous pedicle, and the donor site closed directly. The pedicle is divided three weeks later. Musculocutaneous nasolabial flaps (MNLF) have also been used for columella reconstruction. [39] Incorporating underlying mimetic musculature is stated to enhance the flap reliability and durability, allowing it to be transposed greater distances of up to 50mm. [39,42] The MNLF described by Dolan et al. was able to reconstruct a columella, membranous septum and caudal septum defect in a single stage. [39] However, they did experience problems with flap congestion and distal nasal collapse. It is important that when using this flap for reconstructing a full thickness columella defect that cartilage grafting be incorporated, otherwise the patient will experience nasal drooping. Hagan and Walker published a series on 20 MNLFs for naso-oral reconstruction with satisfactory results and no cases of flap loss. [42] Facial dynamics were preserved in each case. It was noted that MNLFs often have a bulky pedicle and limited arc of motion. [42] The advantages of the nasolabial flap are that it is not a bulky flap, and the skin colour and texture of the nasolabial area closely matches the normal columella anatomy. The donor site scar is also hidden in the nasolabial fold. Disadvantages include that it may provide insufficient columella projection[43] or have columellar deviation due to flap contracture during the healing phase. [4] Nasofacial sulcus flap

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Nasofacial sulcus flaps have historically been used for reconstruction of upper lip defects. [44] Columella reconstruction using this donor site has been described in two reports. [2,45] It is an axial pattern transposition flap, not a tunnelled island flap like the nasofacial island sulcus flap. [17] Bilateral flaps were used in both studies to reconstruct large defects with satisfactory functional and aesthetic results. [2,3,45] The flap architecture is illustrated in Figure 2. Dimensions are approximately 10mm wide and 15mm long. The flaps are both elevated over the facial musculature from medial to lateral and further undermined laterally to facilitate advancement. The incision must involve the alar groove to release the alar lobules and allow adequate flap advancement. After advancement of both flaps, they are inset into the midline with the medial sides of the flap forming the columella and the lateral sides the membranous septum. The donor sites are closed directly. The advantage of the nasofacial sulcus flap is that it is a single-stage procedure that can be used to reconstruct large columella defects without loss of adjacent tissue. [45] It also has a satisfactory colour and texture match. The main disadvantage of this technique is the prominent position of the donor site scar. Perinasal island flaps 1. Nasolabial island flaps This technique differs from the standard nasolabial flap by subcutaneous tunnelling of the flap directly to the columella defect, with the buried part of the flap devoid of dermis (Figure 3). [4,38] Unilateral and bilateral flap reconstructions have both been demonstrated for columella reconstruction. [4,38] Pedicle lengths of up to 25mm have

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been used. [4] It is imperative that the subcutaneous tunnel is not too narrow or pedicle compression and flap congestion may occur, as experienced by Kang et al. [4] 2. Nasofacial sulcus island flap The nasofacial sulcus island flap is similar to the nasolabial island flap technique described by Kang et al. It was first reported by Sherris et al. in 2002 and has subsequently been used for extensive reconstruction in cases with loss of the columella, membranous septum, medial aspect of the nasal sill, and medial aspect of the upper lip. [2,45]

It may be considered in patients for whom a two-stage procedure is objectionable.

The technique involves an elliptical incision in the nasofacial sulcus. We would recommend making the ellipse 20% longer than the columella defect to avoid a contracture and columella deviation. The depth of the incision is to the periosteum medially and laterally, and to the subcutaneous tissues inferiorly. A subcutaneous tunnel is created using blunt dissection towards the alar crease, and a small incision then made along the ipsilateral nasal sill. The flap is raised superiorly above the periosteum and pulled through the tunnel and nasal sill into the columellar defect. The donor site is closed directly. As with the other techniques described, cartilage grafts can be used to help contour the columella and reconstruct the medial crura. Nasal Vestibule flaps 1. Internal nasal vestibular flap Vecchione first described the use of an internal nasal vestibular flap to reconstruct a post-infectious defect of the nasal columella. [46] It has subsequently been used to reconstruct a congenitally absent columella and an iatrogenic partial thickness columella defect. [47,48] It is an important technique to consider in younger patients with

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a partial thickness, superficial columella defect where minimal external scarring is desired. The flap is a random pattern flap in a V shaped with two medially based wings which can include nasal alar lining. [46] If the medial crura is involved a cartilage strut should be placed first. The technique involves raising bilateral flaps anchored on the nasal sill that extend laterally around the alar rim (Figure 4). The flaps are approximately 6mm in width and 15mm long. Importantly, a small flap should be elevated anteriorly under the nasal tip to provide a raw surface to insert the flaps into and form the columella. Flaps can be raised slightly shorter than conventional designs to avoid compromising nasal mucosa and disfigurement with healing contracture. The donor site is left to heal by secondary intention to avoid alar deformity. The advantages of the nasal vestibular flap are that it is a one-staged procedure which provides a well-vascularised composite tissue and importantly, minimal external facial scarring. A disadvantage is that wound contracture and disfigurement may occur secondary to re-epithelialisation of the vestibular donor site. This technique can also only be used for smaller columella defects. 2. Subnasale flaps The subnasale flap technique is similar to the internal nasal vestibular flap, however the flaps are raised off the nasal floor and do not extend laterally around the alar. Jung et al published a case series using a subnasale flap for columella reconstruction in 20 patients, 12 of which were columella defects and the remainder either columella deviation or width correction. [49] The majority of the columella defects were full thickness defects requiring cartilage strut insertion. Tanini and Russo published a

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report illustrating subnasale flap reconstruction for a partial columella defect secondary to nasal continuous positive airway pressure in a neonate. The incision for the subnasale flap starts at the subnasale point and extends along the nasal floors until an adequate length is reached to cover the entire columella defect. The width at the flap base should overlie the footplate region. [49] The two flaps created bilaterally are rotated into the midline and inset into the defect. The donor site may be closed directly after undermining of the adjacent tissue or left to heal by secondary intention. If the donor site closure is under high tension, deformity of the nasal floor may occur. The advantages of this flap are that the scar is inconspicuous, donor site closure does not greatly change the contours of the nose, the short length of the flap gives high survival probability and it is a single stage procedure. The disadvantages include a potential sensation of upper lip retraction and nasal hair may be transferred with the flap and require later removal. Alar rim flaps Columella reconstruction with alar rim flaps was first described by Gillies in 1949. [50] There have since been other variant alar flaps techniques reported for columella reconstruction. [51-53] Obodbescu et al. described a technique reported to be particularly suitable for reconstruction of the shorter columella commonly seen in patients of African descent. [52] The standard alar rim flap reconstruction involves marking bilateral alar margin flaps medially based on the nasal tip. The flap length should correspond roughly to the desired columella length. The flaps are raised with a wedge of subcutaneous tissue

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leaving a thin fish-mouthed edge. The flaps are then pivoted and sutured together in the midline, except at their distal ends which are inset into the upper lip to emulate a nostril sill. [53] Odobescu’s modification is designed by placing an incision in the alar-facial groove and continuing out to the most lateral extent of the ala and then into the nasal vestibule. This creates a triangular shaped full thickness alar flap (Figure 5). The flap is then rotated on its pedicle and the distal end sutured to the nasal tip. Three weeks later, the part of the flap that is to become the columella is divided and shaped, while the remaining flap, constituting most of the ala, is transposed to its original location to recreate the alar-facial groove. This technique avoids damage to the nasal soft tissue triangle that occurs with the original technique. Margulis et al. described a separate alar rim flap technique which utilised a costal cartilage graft and Kischner wire for columella reconstruction after resection of a soft tissue mass in a four-year-old female.51 Alar rim techniques have inherent advantages and disadvantages. Overall, they provide a satisfactory skin colour and texture match and do not require dissection of a vascular pedicle. The primary disadvantage is that they may cause some degree of aesthetic distortion to the ala. This is particularly relevant in children where the tissues are more elastic and there is less laxity. If a unilateral flap is used, such as that described by Obodbescu et al., the contralateral ala will usually require adjustments as a second operation to prevent asymmetry. Peri-alar hatchet flap

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This technique was described by Gupta in 2015. It is indicated for partial or total columella defects with or without an associated nasal tip defect. It cannot be used if there are additional nasal subunit involved or if there is an associated injury to the upper lip. [43] The hatchet-shaped flap is marked on the nasolabial and sub-alar area, usually with 25x25mm dimensions and a 7 mm wide skin pedicle. The flap is dissected at the level of the muscular plane to the pedicle. It is important that the skin pedicle extends to near the midpoint of the nostril sill to allow for flap transposition into the defect. Once it is inset into the defect, the donor defect can be closed directly. The flap should be inset with minimal tension to avoid distorting the nasal tip anatomy as it heals. The pedicle is divided after two to three weeks, suturing its divided end to the remnant of the columellar base (Figure 6). The advantages of this flap are excellent aesthetic results with skin colour and texture matching. It can be used bilaterally for complete columellar and nasal tip defects and provides enough volume to reconstruct the columella without the need for a cartilage strut. The disadvantages are that it is a two-staged procedure and the authors suggest it may be unsuitable if scarring is present around the upper lip, alar or nasal sill. [43] Upper lip flaps 1. Philtrum flaps Di Santo et al. described an inferiorly based advancement philtrum flap for a full thickness columella reconstruction secondary to cocaine abuse. [54] The superior third of the columella was still intact, therefore this flap may not be appropriate for total columella loss defects. Additionally, flaps that are raised from the nasal floor, such as

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vestibular flaps, were considered but cannot be used in patients with a history of cocaine abuse, as there is excessive vestibular scarring. [54] The flap incision starts in the subnasale region and extends 10mm inferiorly on both sides of the philtrum. The width of the flap should be approximately 10mm. Laterally to the flap, two Burrow’s triangles are defined to allow for flap advancement. The flap is raised and folded in a hemi-tubular structure to reconstruct the infero-posterior columella. An antero-superiorly based random mucosal flap is then dissected from the mucosa covering the remaining aspect of the columella and folded with the philtrum flap to reconstruct the posterior columella. The anterior margin of the skin flip is then sutured to the remaining columella skin (Figure 7). The advantages of this flap are that it can be elevated from the same visual field of the defect itself and has satisfactory colour matching with minimal donor morbidity. Disadvantages are that it can only be used for lower subtotal columella defects and may shorten the philtrum remnant on the upper lip. The senior author of this paper (SA) described a philtrum flap in a four-step technique that was used for reconstructing a composite nasal columella defect. [7] The defect was full thickness involving anterior nasal floor and caudal septal defect secondary to a squamous cell carcinoma resection. The technique was employed to allow a staged reconstruction of columella with adequate nasal tip support but without reconstructing the caudal septum. The nasal vestibular floor is firstly reconstructed with bilateral transposition flaps from the upper lip (stage 1). Six weeks later, a pedicle flap is lifted from the cuboid bow of the upper lip to the tip of the nose (stage 2). Three weeks later, the flap from stage 2 is then

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divided and inserted into the base of the columella with the defect in the upper lip repaired using a full thickness skin graft harvested from pre-auricular skin (stage 3). Finally, a columella strut graft is formed from the caudal cartilaginous septum and inserted into the neo-columella, attached to the anterior nasal spine (stage 4). The advantage of this technique is that leaves minimal scarring and avoids distant flaps being raised. A significant disadvantage is the requirement for four separate procedures. 2. Medially based upper lip flaps This technique was described by Pincus and Bukachevsky on two full thickness traumatic columella defects. It was labelled as a bilateral horizontal nasolabial flap technique, however the donor sites are based on the upper lip at the nasal sill, alar base and extending out to the nasolabial creases. Flap width can be tailored to the amount of tissue required. Both flaps are undermined in full thickness fashion until they can be moved into the defect without tension on their medial pedicles. Once the flaps are raised, they are rotated 90 degrees and sutured together in the midline to reconstruct the columella. [41] The donor sites are then closed directly restoring the nasal sill and nasolabial groove. The aesthetic results of this technique are very acceptable, as there is no disfigurement of the nasoalar folds or distortion of the philtrum contour. There may be an initial postoperative shortening of the nasal labial distance, however this usually returns to normal after healing has occurred. The flap may be less suitable in men with upper lip hair bearing skin being transferred and therefore the patient may require subsequent depilation.

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Regional flaps Regional flaps, including the pedicled forehead flap, [17,55,56] the Washio flap, [57] the submental flap, [58] the Abbe flap[59] and tubed flaps[60] have been proposed as alternative techniques for columella reconstruction. These flaps are particularly warranted in patients with composite defects that are larger in size and may involve other nasal subunits. Forehead flap The forehead is multilaminar, consisting of skin, subcutaneous tissue, frontalis muscle, and a thin areolar layer. [61] The forehead flap is considered the first option and workhorse of nasal reconstruction for multi-subunit defects, as it provides the best aesthetic results. Other regional and free tissue flaps should need only to be considered if the forehead is not available as donor site or for other individual patient reasons. Forehead flaps have been used for columella reconstruction as islanded, paramedian and oblique flaps. [17,55,56,61] It is a myocutaneous flap, based on the supratrochlear vessels which pass over the supraorbital rim. [17,61] Traditionally, the reconstruction occurs in two stages, with the pedicle being divided three to four weeks after the first stage. The island forehead flap can be used as a single stage technique. [56] The difficulty with the island forehead flap, is the excessive bulk of the pedicle passing under intact glabellar skin jeopardises the blood supply and can cause flap congestion, as experienced by Vulvoic et al. [55] The flap is developed by making parallel incisions from the level of the eyebrow to superiorly near the hairline. For oblique forehead flaps, the incisions curve gently laterally in an oblique fashion. The superior incision should not cross the hairline in patients who do not have receding hairlines. The width of the forehead flap base is

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usually 25-35mm.[17] From the level of the eyebrow downward, the incisions are through skin only to a point just lateral to the root of the nose. The lower portion of the flap is dissected bluntly to prevent injury to supratrochlear vessels. The distal one third of the flap is thinned to the level of subdermal layer to closely match the native thickness of the columella and then inset into the recipient bed. The donor site may be closed primarily after wide undermining in the subgaleal plane. Any gap that cannot be approximated may be allowed to heal secondarily or closed with a split skin graft. Approximately three weeks later the pedicle is divided and the remainder of the flap thinned to the dermis and inset. The senior author of this paper (SA) uses significantly narrower pedicles (i.e. 12 mm) in designing the paramedian forehead flap. In cases of patients with a short forehead, he rarely uses the oblique design; instead, he extends the incision lower into the eyebrow and in his experience, the forehead flap will reach the nasal tip and columella if the forehead height is not less than 5 cm. In cases with a short forehead, he may also temporarily lift the nasal tip or upper lip to reach the short forehead flap. The tip and lip are then returned to their original position after the forehead flap is divided in the second stage. The senior author rarely uses a skin graft for large forehead donor sites. In these cases, he makes sure that some subcutaneous tissue fat is left in place to increase the chance of healing by secondary intention. In his opinion and experience, the secondary intention results in a much better aesthetic outcome than the skin graft. The forehead flap is an excellent flap choice, as it allows for reconstruction of columella defects with or without involvement of other nasal subunits regardless of size or depth. The blood supply is robust, making it especially helpful for smokers with whom vascularity is a concern. [17,61] Disadvantages are that multiple stages are necessary.

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Washio flap The Washio flap is an axial pattern retroauricular temporal flap that relies upon rich anastomoses between the superficial temporal and posterior auricular vessels of the ipsilateral side. [62] It provides both skin and ear cartilage for nasal reconstruction. Motamed et al. described its use in reconstruction of a short and retracted columella in an 8 year-old female previously operated on for correction of bilateral cleft lip. [57] The technique involves raising retroauricular, glabrous skin according to a conventional Washio flap, preparing the recipient area and then transferring the distal end of the flap to the prepared recipient site. Washio originally suggested dividing the pedicle after two weeks, however most authors now suggest waiting three weeks. The unused portion of the flap is returned to the bare donor area. The Washio flap is notable in comparison with other techniques in that it avoids any visible scar on the face by hiding the donor site in the retroauricular area. [62] It is also thin and can provide cartilage support. Disadvantages of the procedure are that it is two staged, requires shaving of the patient’s hair and marginal necrosis of the flap tip can be experienced. [63] Submental flap The submental island flap is a myocutaneous flap based on the submental artery, which consistently arises 50-65mm from the origin of the facial artery. [64 Tan et al. demonstrated its use for columella reconstruction in a 73 year old with a large, full thickness columella defect after excision of a papilloma. [58] The technique described by Tan et al. is a variant to the standard technique described. It is a two-stage procedure and a reverse flow flap, which allows further extension of the pedicle.

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The first stage involves harvesting and inserting of a 3cm costal cartilage graft into a pocket created between the skin and platysma muscle at the distal site of the flap. One month later, the flap is raised as per the conventional submental flap technique. To check perfusion by reverse flow, the facial vessels are clamped proximal to the original of the submental branches. If satisfactory perfusion is observed, the facial vessels are tied and divided proximally. The flap is then trimmed to the shape of the columella and transferred to the defect through a subcutaneous tunnel, with the cartilage inset first for columellar support. The advantages of this flap are that it has a constant and safe pedicle, wide pivotal movement, a well-hidden scar and can be completed without the need for microsurgery. The disadvantages are that that flap can be bulky and require a subsequent debulking procedure. It can also be hairy in male patients. [58] Free flaps Although not commonly considered as the first choice, free tissue transfer techniques are also feasible options for columella reconstruction. They are particularly helpful in poorly accessible defects where local tissue transfer cannot be used. [65] There are various free flap techniques that have been described for columella reconstruction. These include: the retro auricular chondrofasciocutaneous flap with a superficial temporal artery pedicle, [66,67] the root of the auricular helix chrondocutaneous free flap with a superficial temporal artery pedicle, [68] the first web space of the foot fasciocutaneous free flap with a dorsalis pedis and long saphenous vein pedicle, [65] and a prelaminated radial forearm free flap.[69] The recipient vessels for each one of these free flaps are the facial artery and vein.

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The advantages of free tissue transfer reconstruction are that there is freedom in the flap design to closely match the columella defect, the donor scar is usually off the face and hidden, cartilage may be included to provide columella support and it is usually a single stage procedure. The disadvantages are that the flaps can be excessively bulky and require subsequent debulking, it is technically difficult to perform and the complication profile is wider. [65,66,68] Conclusion In this article, we have presented and described the aesthetics of the columella as well as the surgical methods that have been published in the literature for columella defect reconstruction. It is clear that there is not one technique that may be considered superior above the rest. The choice of technique depends on the extent of the defect, the patient’s choice as well as the surgical expertise at hand. As a guide: 

FTSGs should be considered for superficial defects involving the skin and subcutaneous tissue only.



Composite grafts may be used for smaller full thickness defects. They are traditionally not used in defects greater than 15 millimetres in size.



Local flaps should be considered in larger full thickness defects 15-25 millimetres in size. They are an excellent option for isolated columella defects without involvement of other nasal subunits.



For larger defects exceeding 25millietres and/or those that involve multiple nasal subunits, regional and free tissue flaps should be used. Microsurgical experience is required if considering free tissue flap reconstruction.

23

This article therefore provides reconstructive clinicians with a collection of the methods including guidelines for their use, that they can add to their armamentarium of surgical techniques when treating columella defects.

Acknowledgements We would like to acknowledge Joshua Abbas for his help in producing some of the schematic figures used in this review. Conflict of Interest There are no conflicts of interest to declare. For this review study no patient consent was required. Permission for reproduction was obtained for each figure. References 1.

2. 3. 4. 5. 6.

7. 8. 9.

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Margulis A, Bauer BS, Han H, Patel PK. Reconstruction of the columella in a pediatric patient. Plast Reconstr Surg. 2003;112(7):1948-1949. Odobescu A, Servant JM, Danino IW, Danino MA. Nostril alar rim threshold flap for columellar reconstruction. J Plast Reconstr Aesthet Surg. 2011;64(7):929-933. Saad MN, Barron JN. Reconstruction of the columella with alar margin flaps. Br J Plast Surg. 1980;33(4):427-429. Di Santo D, Trimarchi M, Galli A, Bussi M. Columella reconstruction with an inferiorlybased philtral advancement flap in a cocaine abuser. Indian J Plast Surg. 2017;50(1):96-99. Vulovic D, Stepic N, Pavlovic A, Milicevic S, Piscevic B. [Reconstruction of the columella and the tip of the nose with an island-shaped forehead flap]. Vojnosanit Pregl. 2011;68(3):277-280. Baker SR, Swanson NA. Oblique forehead flap for total reconstruction of the nasal tip and columella. Arch Otolaryngol. 1985;111(7):425-429. Motamed S, Kalantar-Hormozi AJ. Columella reconstruction with the Washio flap. Br J Plast Surg. 2003;56(8):829-831. Tan O, Kiroglu AF, Atik B, Yuca K. Reconstruction of the columella using the prefabricated reverse flow submental flap: A case report. Head Neck. 2006;28(7):653-657. Okazaki M, Ueda K. The long Abbe flap combined with periosteally-vascularised mandibular bone for the simultaneous reconstruction of the upper lip and supportive columella. Scand J Plast Reconstr Surg Hand Surg. 2003;37(5):296-299. Abbenhaus JI. The use of an abdominal pedicle flap in reconstructing nasal tip avulsion. Laryngoscope. 1980;90(3):399-402. Menick FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002;109(6):1839-1855; discussion 1856-1861. Morrison CM, Bond JS, Leonard AG. Nasal reconstruction using the Washio retroauricular temporal flap. Br J Plast Surg. 2003;56(3):224-229. Maillard GF, Montandon D. The Washio tempororetroauricular flap: its use in 20 patients. Plast Reconstr Surg. 1982;70(5):550-560. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg. 1993;92(5):867-873. Benito-Ruiz J, Raigosa M, Yoon TS. Columella reconstruction using a free flap from the first web space of the foot. Ann Plast Surg. 2012;69(3):279-282. Gucer T. Retroauricular prefabricated chondrofasciocutaneous flap for reconstruction of the columella. Plast Reconstr Surg. 2002;109(3):1090-1093. Bajec J GR. The chondrocutaneous ear helical free flap for the reconstruction of the defects of the nasal tip, columella and/or ala. European Journal of Plastic Surgery. 1997;20:4. Ozek C, Gundogan H, Bilkay U, Alper M, Cagdas A. Nasal columella reconstruction with a composite free flap from the root of auricular helix. Microsurgery. 2002;22(2):53-56. Maruccia M, Elia R, Nacchiero E, Giudice G. Microsurgical reconstruction of the isolated columellar defect with a prelaminated radial forearm free flap. A case report

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and review of the literature. Microsurgery. 2019;1-6. https://doi.org/10.1002/micr.30472

Figure legends: Table 1. Columella reconstruction techniques organised into grafts, local flaps, regional flaps, and free tissue transfer Grafts

Local flaps

Regional

Free tissue transfer

flaps Full thickness skin

Nasolabial flap

grafts

Pedicled forehead

Retro-auricular

flap

chondrofasciocutaneous flap

Composite grafts

Nasofacial sulcus flap

Washio flap

Root of the auricular helix chondrocutaneous flap

Perinasal island flaps 1.

Nasofacial island flaps

2.

Nasolabial island flaps

Nasal vestibule flaps 1.

Internal vestibular flap

2.

Subnasale flap Alar rim flap Peri-alar hatchet flap Lip flaps

1.

Philtrum flaps

2.

Medially based upper lip flaps

Abbe flap

First web space of the foot fasciocutaneous flap

Submental flap

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Figure 1. Schematic of the columellar construction technique described by Chang et al. The dashed line denotes a midline vertical incision. Book flaps are reflected laterally and a composite graft is taken from the posterior ear. The cartilage is then contoured to match the defect and includes a central cartilaginous strut and two lateral skin extensions. It is then inset into a pocket at the base of the columella and the residual medial crura, and the skin flaps of the composite graft sutured to the book flaps.

Figure 2. a. Preoperative markings for the bilateral nasofacial sulcus advancement flap b. Post operative results one year later.

29

Figure 3. Nasolabial island flap as described by Kang et al. a. The flap is created and extended through a subcutaneous tunnel b to the columella defect. Permission was obtained to reproduce this figure.

Figure 4 – Schematic of the nasal vestibular flap described by Vecchione. The local flaps are based at the nasal sill and extend out along the lateral vestibule. The flaps are sutured to the dissected nasal tip; the donor site is left to heal by secondary intention. Permission was obtained to reproduce this figure.

30

Figure 5. Diagrammatic representation of the alar rim threshold flap described by Odobescu. The flap is raised by incising the alar-facial groove into the nasal vestibule. It is then pivoted on its medially based pedicle and rotated such that the distal end of the flap becomes the highest point of the columella. Subsequently the neo-columella is divided and the remaining pedicle re-inserted on the alar base. Permission was obtained to reproduce this figure.

Figure 6. Peri-alar hatchet flap described by Gupta for reconstruction of a columella and nasal tip defect. a raising of the hatchet flap for columella defect b dividing the flap pedicle after three weeks c post-operative result 20 days after pedicle division

31

32

33

Figure 7 –Intraoperative photos of the philtrum flap described by Di Santo et al. Two Burrow’s triangles were excised laterally to the 1x1cm philtrum based advancement flap. An anterosuperiorly based mucosal flap was dissected from the mucosa covering the remaining portion of the columellar septum (dotted line). The philtral flap is folded together with the mucosal flap in a tubular structure to reconstruct the posterior aspect of the flap. Permission was obtained to reproduce this figure.

34