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Columella Rotation Flap Techniques for Correction of Columellar Deviations

Jung, Dong-Hak M.D., Ph.D.; Joshi, Anil M.S., D.O.H.N.S., F.R.C.S.(O.R.L.-H.N.S.); Chang, Guen-Uck M.D.; Hyun, Sang-Min M.D.; Setty, Ravi M.S., M.Ch.

Author Information
Plastic and Reconstructive Surgery: August 2014 - Volume 134 - Issue 2 - p 336e-338e
doi: 10.1097/PRS.0000000000000330
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Sir:

There are several reasons for columellar deviations,1 such as congenital causes, deviations caused by bony and cartilaginous deformities, cases of cleft lip and nose, trauma, and previous operations. Correction of each of these factors is often required to achieve a straight columella. If the deviation is only skeletal, it is easy to correct only this to achieve the right result. The skin and soft-tissue envelope can then be replaced. However, in cases where deviation is complex and is both skeletal and involves skin and the soft-tissue envelope, correcting only the skeletal deviation is not enough. Repair of skin and the soft-tissue envelope along with this is also required.

Several techniques have been described in the literature to reconstruct the columella when there is a defect or deviation.2,3 Most of these can be quite difficult to perform and may not be appealing cosmetically and are mainly used for columellar defects, with very few flaps described specifically for deviations. We have thus designed inferior and superior columellar rotation flap techniques based on where the deviation is and have named them columellar rotation flap technique type 1 and type 2, respectively (Fig. 1).

Fig. 1
Fig. 1:
Schematic representation of type 1 and type 2 columellar rotation flap technique designs. (Above) Type 1 columellar rotation flap technique: (left to right) midline perpendicular is marked initially and the deviation is noted. A superiorly based flap is raised and rotated to the midline. This is sutured after excising any excessive soft tissue. (Below) Type 2 columellar rotation flap technique: (left to right) A perpendicular line is drawn to the midcolumellar point and deviation of the tip is noted. An inferiorly based flap is then raised and rotated to the midline to meet the perpendicular. This is then sutured with 6-0 nylon. (Above and below) Note the change in the shape of the nostrils from being asymmetrical before the procedure to symmetrical at the end of the procedure.

The design is initially marked with ink (Fig. 2). A curvilinear incision is made either inferiorly (type 1) or superiorly (type 2), depending on the where the columellar deviation is. However, we make a Z-plasty incision if the columella is more than 1 cm wide or in revision of scars. The flap is raised and skeletal deviation is initially corrected. The flap is then rotated to the other side to correct the skin and soft-tissue envelope deviation. Any excess tissue is excised. The flap is sutured with 6-0 nylon.

Fig. 2
Fig. 2:
Operative steps in type 2 columellar rotation flap technique. (Above, left) Preoperative photograph demonstrating superior deviation. (Above, center) The midline is drawn from the 12-o’clock position perpendicular to the base. Deviation is marked at the 11-o’clock position. Skin marking for incision is made. (Above, right) A columellar flap is raised and (below, left) rotated to the midline. A small area is marked in the left nostril for the extra tissue that is then excised. (Below, center) The flap is then closed with nylon. (Below, right) Postoperative result.

Columellar deviation repair is challenging to the surgeon in terms of both correcting the deviation and improving cosmesis. There are inherent factors apart from the ones mentioned earlier within the columella itself for it to be deviated. These include changes in skin and the soft-tissue envelope, weakness within the underlying cartilages, and bony changes.4 Thus, all these factors need to be addressed to achieve a satisfactory result. In particular, cases of cleft lip and nose can be quite difficult because of the complicated nature of the varied anatomy.

Both type 1 and type 2 columellar rotation flap techniques are easy to design and available in the same operating field, and enable quick reconstruction. With these, there is only a small but very well-healed line visible on the columella, with the rest of the lines hidden within the nostrils. Type 1 is the more common of the two, and we have used it on 80 patients. The commonest indications for these flaps were cases with cleft lip and in revision rhinoplasty procedures. At present, we have used type 2 designs on nine cases.

Along with columellar deviation, there would be asymmetrical nostrils that need to be addressed. Therefore, during repair, care should be taken to keep them symmetrical after rotating and suturing the flap. Sometimes during the procedure, a small raw surface can persist because of rotation of the flap. This is not a problem, as it heals quite quickly without any sequelae. Also, occasionally, as seen in three of our cases, the small scar on the columella can be visible, and can be addressed with an operation for scar correction.

Revision cases can pose problems during repair, as the soft tissue underneath is often scarred and the columella may be retracted, which makes surgery difficult.5 However, with these flaps, such deviations can be well addressed and, if required, additional support to the tip can be provided at the same time.

PATIENT CONSENT

The patient provided written consent for use of the patient’s images.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Dong-Hak Jung, M.D., Ph.D.

Anil Joshi, M.S., D.O.H.N.S., F.R.C.S.(O.R.L.-H.N.S.)

Guen-Uck Chang, M.D.

Sang-Min Hyun, M.D.

Ravi Setty, M.S., M.Ch.

Shimmian Rhinoplasty Clinic

Seoul, Republic of Korea

REFERENCES

1. Stal S, Hollier L. Correction of secondary deformities of the cleft lip nose. Plast Reconstr Surg. 2002;109:1386–1392; quiz 1393
2. Sherris DA, Fuerstenberg J, Danahey D, Hilger PA. Reconstruction of the nasal columella. Arch Facial Plast Surg. 2002;4:42–46
3. Kiya K, Oyama T, Taniguchi M, Hosokawa K. Simultaneous correction of deviated columella and wide nasal floor using Y-V advancement in unilateral cleft lip nasal deformities. J Plast Reconstr Aesthet Surg. 2014;67:721–724
4. Jung DH, Chang GU, Baek SH, Lee YK, Choi JY. Subnasale flap for correction of columella base deviation in secondary unilateral cleft lip nasal deformity. J Craniofac Surg. 2010;21:146–150
5. Jung DH, Lansangan LJ, Choi JM, Jang TY, Lee JJ. Subnasale flap for correction of columellar deformity. Plast Reconstr Surg. 2007;119:885–890

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