Question: What is the optimal one-stage reconstructive technique for patients with columellar defect concomitant with a philtrum scar?
Findings: In these patients, we opted for the Kalender (fasciocutaneous philtrum) flap for the columellar reconstruction. None of the patients experienced intraoperative or postoperative complications, and they were satisfied with the aesthetic outcome. The patients also did not need a revision/second surgery or laser hair removal.
Meaning: The Kalender flap allows for the removal of the philtrum scar while reconstructing the columella. Additionally, it is a one-staged and technically simple surgery, which can be used as an alternative in a select group of patients.
Because the unique contour of the nose makes reconstruction challenging, different algorithms have been suggested to guide nasal reconstruction.1 Among six nasal subunits, columellar reconstruction is complicated, especially due to its dimensions, negligible blood supply, convex contour, and paucity of adjacent tissues.1 The columellar reconstruction ideally should provide excellent color match and adequate subcutaneous bulk while creating transition points at the nasal tip, columella base, and nasal floor.2 Currently, many techniques are available for columellar reconstruction. Nonetheless, the gold standard for nasal reconstruction is local/regional flaps. However, some of these flaps should be performed in two stages.3–5
One of the previously described flaps is the philtrum flap, which was first introduced to the literature by Sanvenero-Roselli in 1931.6 Subsequently, New and Figi proposed a new variant of this flap.6 Nevertheless, due to the availability of better reconstructive options, it was not applied broadly. In this article, the authors present a modification of this flap called the Kalender (fasciocutaneous philtrum island) flap.
PATIENTS AND METHODS
From March 2017 to March 2019, we operated on nine patients with total columellar defects. Preoperative evaluations of patients showed an absence of the columella with a prominent philtrum scar (Fig. 1). Six of nine patients were men (male-to-female ratio = 2:1). Patient ages ranged from 14 to 28 (mean age, 22). Two of them had electrical burn injuries. The remainder developed postoperative scarring after hemangioma treatment. Patients with hemangioma underwent an average of four courses of sclerotherapy.
Information about the patients’ age, gender, and operative and postoperative complications was obtained from patient charts retrospectively. Patient satisfaction and complications were assessed at follow-ups (scheduled at 2 weeks, 6 weeks, 6 months, and 1 year) using a five-point Likert scale (0: not satisfied and 5: very satisfied). Patients gave verbal and written consent to publish their information and pictures.
If scar tissue looks extensive, a Doppler ultrasound can be used to verify the patency of the nourishing artery. We start the incision from the vermillion border using a 15-blade. It is carried up to the columellar base. Skin, subcutaneous tissues, and deep fascia are cut to the orbicularis oris muscle with the second cut. We prepare the flap symmetrically, involving the entire scar tissue. (See Supplemental Digital Content 1, which describes the surgical steps. https://links.lww.com/PRSGO/C512.) Care must be taken not to damage the orbicularis oris muscle as it is not included in the flap design. Going backward, we thicken the flap. The island flap is created by cutting the skin and subcutaneous tissues bilaterally (Fig. 2). Meticulous tissue handling preserves the blood supply from the nasal arcade formed by the columellar and the philtral branches of the superior labial and the subnasal artery. The edges of the wound are undermined to minimize the tension and to close the wound on the philtrum. The skin is repaired via 5-0 Prolene stitches.
After the incision is made, we elevate the mucosa of the septum. After that, the flap is rotated 180 degrees and placed in, forming the anterior wall of the septum (Fig. 3). To repair subcutaneous tissues, 3-0 or 4-0 Vicryl can be used. The skin is stitched with interrupted 5-0 Prolene sutures. The result is a nice-looking columella with a convex contour (Fig. 4). (See Supplemental Digital Content 2, which displays the comparison of the preoperative and postoperative lateral view. https://links.lww.com/PRSGO/C513.) The inherent quality of the scar tissue provides adequate support and eliminates the need for cartilage transfer.
We report the successful application of our method on nine patients. Our patients usually presented after burn injury (electrical or thermal) or sclerotherapy for hemangioma treatment. Patients were pleased with the aesthetic outcome with a mean score of 4.4. No postoperative hair growth was noticed, and, therefore, no postoperative laser hair removal was needed. Moreover, no other complications were observed. We did not note any deformities in the upper lip nodule or Cupid bow. Additionally, no patient complained of changes in tip projection/columellar projection or required secondary/revision surgery within the first year of surgery. Unfortunately, due to the inability to follow-up with the patients, long-term outcomes are unavailable.
The central position of the nose makes it an essential component of facial aesthetics. The nasal skin is divided into three zones, which differ due to skin quality and thickness. The columella is a part of zone 3, characterized by fixed, thinner, less sebaceous, and less mobile skin than others.3 Its absence can be congenital or acquired due to skin cancer resection, postoperative stent use, bilateral cleft lip, trauma, cocaine abuse, noma (cancrum oris), and burns related to steam inhalation therapy.7,8
Unsurprisingly, according to the statistics released by the American Society of Plastic Surgeons in 2018, nose reshaping is the third most commonly performed cosmetic surgery.9 In addition to technical and anatomical difficulties, the need for a superior aesthetic outcome complicates the surgery.10 Abundant nasal blood supply via three arterial anastomotic arcades allows for several local flaps.1 Therefore, though grafts are also available, local flaps are the preferred option for columellar reconstruction. However, the majority of them require cartilage placement for adequate support. Having said that, auricular cartilage is sparse, and the use of costal cartilage requires advanced surgical skills.
Additionally, the use of these flaps is usually complicated by the bulkiness of the flap, color mismatch, hypertrophic scar, nostril stenosis, fistula formation, cancer metastasis, decreased function, transient narrowing of the nasal base, and decreased tip projection, which we did not observe while using the novel approach.3
With our technique, the proximity of the donor site to the columella, one-staged surgery, removal of the conspicuous scar, no need for strut placement, and advanced microsurgical training made it the surgical approach of choice. However, this method has limitations, and we only use it in cases of an established scar on the philtrum. The reason for this is that the philtrum scar provides adequate support for the reconstructed columella. Therefore, only patients with mature scars with adequate texture on palpation were selected for this operation. Additionally, the Kalender flap can only be used if the philtrum scar spares the muscle and mucosa, as full-thickness scars are more frequently associated with damage to the nourishing artery. Thus, patient selection should be performed diligently. Otherwise, postoperative complications, such as flap loss and scar atrophy can develop. Therefore, in equivocal cases, intraoperative Doppler ultrasound can be used to verify the presence of reliable arterial flow.
In patients with undamaged philtrum, the postoperative midline scar can be unpleasant. Additionally, the use of the cartilage graft is mandatory. Hence, alternative techniques are usually preferable in this scenario.
Antibiotics are administered postoperatively due to the closeness of the surgical site to the mouth, which makes patients prone to developing infections. Talking and facial movements should be minimized for 2–3 days. Straws should be avoided for a week.
The philtrum flap is an acceptable reconstructive option for patients with a preexisting philtrum scar. Moreover, it is a one-staged and technically simple surgery. Use of the excised philtrum scar tissue to reconstruct the columella makes one-stage surgery possible and efficient. Furthermore, hair follicles were damaged due to previous burns or iatrogenic injury, and no hair growth was observed on the reconstructed columella. As no additional donor area was needed, patient morbidity was reduced. Therefore, we could discharge patients on postoperative day 1 and achieve satisfactory aesthetic results without complications.
The authors have no financial interest to declare in relation to the content of this article.
The patient provided written consent for the use of his image.
The study was performed according to the guidelines of the Helsinki Declaration.
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