Columella Reconstruction Using a Bilateral Nasolabial Flap: A Case Report

Introduction

The columella has many fundamental functions, such as nasal breathing and support to the nasal tip, as well as having aesthetic significance. The columella is also one of the most difficult nasal subunits, both from the point of view of disease control and from that of reconstruction. Lesions involving the columella can be difficult to control, and malignancies can spread to the septum, subcutaneous tissues of the lip, and floor of the nasal cavities. Therefore, lesions of this region have a poorer prognosis than other nasal subunits. To obtain free surgical margins, the excision of tumors often leads to large losses of substance that are very difficult to repair, because of the limited availability of adjacent tissue, trilaminar structure (comprising the skin and the alar cartilage), and functions that need to be guaranteed. The goal of the reconstruction is to recreate an anatomy and respiratory physiology that is as normal as possible, allow sufficient nasal breathing, and provide adequate support to the nasal tip and an aesthetically appropriate result, with attention to the shape and symmetry of the nostrils.

Many columella reconstruction methods have been proposed, including local nasal flaps, skin grafts, regional flaps [1,2], and free flaps (such as fascia lata free flap, radial forearm free flap, first dorsal metacarpal artery free flap) [3–6], sometimes with the support of cartilaginous grafts. The choice depends on multiple factors, such as size of the defect [7], age and general condition of the patient, experience and preferences of the surgeon, duration and number of surgeries required by the chosen strategy, and patient’s wishes regarding the aesthetic consequences of the reconstruction. Most studies we considered underline, on one hand, the broad variety of possibilities for columellar reconstruction and, on the other hand, the intrinsic difficulty of the reconstruction in terms of aesthetic results, scarring, skin retraction, and functionality.

The reconstruction technique of the columella using nasolabial flaps was first described by Da Silva in 1964, when he described a case of columellar reconstruction using a single naso-labial flap lined with a skin graft [8]. The use of bilateral nasolabial flaps was reported in 1982 by Nicolai [9] and in 1986 by Yanai et al [10], and more recently by Krogerus et al in 2022 [11] and Faenza et al in 2024 [12]. As shown in our patient and in the few reported cases, this type of reconstruction is safe and guarantees good functional and aesthetic results, with reduced operating and healing times.

Case Report

An 82-year-old woman with type II diabetes mellitus, atrial fibrillation, and chronic renal failure presented to our department with concerns of a large neoformation originating from the skin of the right side of the columella (Figure 1). The lesion infiltrated the cartilage, arriving to the skin of the columella on the left side and extending to the mucosa of the nasal septum bilaterally for 5 mm. Nasal endoscopy highlighted preservation of the floor of the nasal cavities, turbinates, and other endo-nasal structures. The overall dimension of the neoplasm was about 1.5 cm in diameter. The rest of the ENT clinical examination, including neck palpation, was unremarkable.

Biopsy of the lesion confirmed squamous cell carcinoma (G2 grading). The patient underwent a contrast-enhanced computed tomography scan of head and neck (Figure 2), which confirmed the neoplasm: the lesion originated from the right side of columella and from the right vestibule, infiltrating the nasal septum and arriving to the left side of columella; the scan did not show neck metastasis nor any other relevant findings.

After an appropriate discussion with the patient and her family about the possible therapeutic strategies and their complications, the patient opted to undergo tumor resection and reconstruction with bilateral nasolabial flaps. Radiotherapy was thoroughly discussed but discarded as a primary treatment, considering the high probability that surgery could be a viable and sustainable option for our patient, in order to obtain onco-logical radicality and a good aesthetic outcome. Other reconstruction techniques were discussed, such as the transverse forked flaps [13], but inclusion of the upper part of the lip in the safety margin and the relatively large size of the defect precluded its usage; moreover, the aesthetic result was supposedly better with the proposed technique. Free flaps were not discussed, as the patient’s comorbidities (type II diabetes mellitus, atrial fibrillation, vascular disease, and chronic renal failure) could have affected the success of this kind of surgery, which also requires a longer operative time.

Intraoperative frozen section biopsies of surgical margins after tumor resection did not reveal neoplastic cells. The surgical defect included the entire columella, with a portion of nasal septum and the floor of the nasal vestibule bilaterally (Figure 3).

Two superiorly based nasolabial flaps were prepared bilaterally, considering a possible reduction in their size due to flap retraction during the postoperative period; the flaps were positioned at the level of the defect after having introduced them under an incision of the lateral nasal wall, without de-epithelization of the pedicle. Then they were sutured medially in their most distal portion with 4/0 silk, to form a neocolumella on the midline, and to recreate the floor of the vestibule bilaterally (Figure 4).

The postoperative course was normal, with good healing of the surgical wound and without dehiscence or bleeding. The patient was discharged from the hospital on postoperative day 3.

The traditional approach would recommend a second surgical time to proceed to autonomization of pedicled flaps and completely close the wounds at the donor site level. This should be scheduled during the following weeks; however, the second surgery was not necessary, as the donor site was adequately closed by its own and the patient was satisfied with the aesthetic result.

Histological examination confirmed the presence of ulcerated squamous cell carcinoma, which measured 1.5 cm, infiltrated the quadrangular cartilage, and did not involve the resection margins. The grading of the tumor was G2. The stage of disease was pT2 Nx according to the TNM Classification of Malignant Tumours, 8th edition, and pT2b according to the Bussu and Wang staging system [14].

At the 6-month follow-up (Figure 5), the patient was free of disease, the flaps were well integrated, and the patient was satisfied with both the aesthetic appearance and nasal breathing. There was no drop in the tip or tendency of flap retraction. No further corrective surgery was necessary.

Discussion

The nasolabial flap is one of the reconstructive options for defects of the tip of the nose, columella, or nasal ala. The nasolabial flap is versatile and safe and relatively easy to perform. The double, bilateral nasolabial flap seems to be much less frequently used, as it is described less in the literature. In our case, having used a double flap led the reconstruction to a degree of symmetry that a single nasolabial flap could not guarantee; moreover, the traction lines, which could have led to retraction of the flap itself in the postoperative period, were significantly reduced by suturing the 2 flaps together.

In our case, considering the age and concomitant pathologies of the patient (type II diabetes mellitus, atrial fibrillation, vascular disease, and chronic renal failure), it was important to choose a reconstructive option that would guarantee good aesthetic and functional results but with reduced operating times and little risk of graft failure or slow postoperative wound healing. Therefore, we decided to use the bilateral nasolabial flap technique, favoring it over the choice of a microvascular free flap.

Cartilaginous support is often necessary to ensure support of the tip; when residual septum cartilage is not adequate, a sample of concha cartilage or cartilage from the helical root is often sufficient for defects of the columella and the closest portion of the nasal septum [15]. Sometimes, it could be necessary to harvest costal cartilage, at the price of additional comorbidity [1]. Nevertheless, in our case, as in the one previously described by Krogerus et al [11], that was not necessary, as we obtained good support for the tip and adequate nostril patency and air passage. A cartilaginous graft should be taken into consideration in patients with better general health conditions; however, the solution used in our patient is feasible, guarantees a reasonable aesthetic and functional result, and can be considered in patients who are elderly or have compromised health.

In our case, similar to cases previously described in the literature reporting the use of bilateral nasolabial flap, possible surgical procedures were discussed with the patient during follow-up in order to improve the aesthetic appearance of the nasal vestibule via debulking and de-epithelization of the base of the flap. Our patient was not interested, however, declaring that she was satisfied with the aesthetic result. Additionally, the use of subcutaneous tunnels at the lateral aspect of the nasal sidewall greatly reduces the aesthetic impact of the flap pedicle in its rotation toward the inside of the nose, making it less visible and less disturbing on the profile of the face and reducing the probability of a second debulking operation. In our case, a second, corrective surgery was not necessary, different from the case reported by Krogerus et al.

Conclusions

Our case demonstrates that the bilateral nasolabial flap is a very effective and safe solution for reconstructing the columella, with good support of the tip even without a cartilaginous graft. The flap is especially feasible in elderly patients and in those with concomitant pathologies, who benefit from a rapid healing of the wound. This can make it possible to avoid other subsequent corrective/debulking surgical interventions.