An Innovative Method for Nasal Injury Repair after Use of Continuous Positive Airway Pressure in Newborns
Author(s)
Date Issued
13 de octubre de 2020
Type
Article
Volume
147
Issue
1
Start Page
179e
End Page
180e
Abstract
Nasal continuous positive airway pressure is used in intensive care units as respiratory support for newborns. One of the reported complications is columellar necrosis. The mechanism seems to be the pressure generated by the prongs. The sequela is characterized by absent columella with nasal tip depression and sometimes external nasal valve obstruction. Different authors have reported this complication in their studied samples; however, treatment strategies are not well documented.1,2 Jayaratne et al.,3 in a case report, described a technique based on the principle of the Cronin columellar lengthening method. However, unnatural appearance of the nostrils and visible subnasal scars seem to be limitations of this method. Auricular chondrocutaneous composite grafts have been reported in the literature. Chang et al.4 published a case series using these grafts. The main advantages are avoidance of nasal scars and provision of tip support. However, different color and skin texture of the graft and risk of composite graft loss are reported complications of this technique. The bilateral reverse-U technique described by Tajima and Maruyama5 has been described before only for bilateral primary cleft lip nose repair. This article describes a personal surgical technique for nasal repair in patients with columellar necrosis caused by nasal continuous positive airway pressure treatment. The columella is repaired using tissues from the tip of the nose. This method is based on bilateral inverted-U incisions described by Tajima and currently used for primary bilateral cleft lip nose repair. The patient is operated on under general anesthesia. Initially, the scar tissue from the nasal septum and remaining borders of the columella is trimmed. Then, bilateral inverted-U nasal and marginal incisions are performed and finally connected, as in Figure 1.Fig. 1.: Preoperative view showing the nasal tip flap technique for columellar reconstruction.The distance from the top of the incision to the nostril rim should be the same as the length of the columellar defect (approximately 4 mm). The area of skin between these incisions (soft triangle area) is resected, as in Figure 1. The nasal flap is dissected using fine scissors at the level of the cartilages of the nose and elevated like an open rhinoplasty. The subcutaneous tissue including the nasal superficial musculoaponeurotic system and fat compartments of the nose provides volume for improvement of the nasocolumellar angle. Finally, the cutaneous flap is mobilized down and sutured to the base of the columella and the caudal septum and nostril rims using fine absorbable sutures (Fig. 2). Structural support of the repaired columella may be provided (if necessary) at later age because cartilages are too thin to be used at an early age.Fig. 2.: Postoperative view of the nasal tip flap technique for columellar reconstruction.The technique described here provides good aesthetic and functional outcomes using local tissues. [See Figure, Supplemental Digital Content 1, which shows the preoperative view of a 1-year-old patient with severe columellar injury after using nasal continuous positive airway pressure (nasal incisions in blue), https://links.lww.com/PRS/E302. See Figure, Supplemental Digital Content 2, which shows the postoperative front view of the patient after surgery illustrating cosmetic improvement of the nose after 1 year, https://links.lww.com/PRS/E303.] The main limitations of this technique are as follows: bilateral nasal soft triangle resection, lack of structural support during primary repair, and turned-up appearance of the nose. The innovative technique presented here may be useful to improve columellar appearance and external nasal valve function in patients with nasal injury caused by continuous positive airway pressure treatment. DISCLOSURE The author has no financial interest to declare in relation to the content of this article.
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