A Graded Approach to Repairing the Stenotic Nasal Vestibule

ORIGINAL ARTICLE A Graded Approach to Repairing the Stenotic Nasal Vestibule Steven Marc Daines, MD; Grant S. Hamilton III, MD; Steven Ross Mobley, MD Objective: To describe a graded approach to repairing Results: Two patients had their nostrils repaired in a vestibular stenosis that involves restoring structural sup- single stage and the others required 2 stages. In all pa- port to the ala. tients, significant improvement in nostril diameter was maintained. The patients were satisfied with the func- Methods: Retrospective review of 5 nostrils in 4 pa- tional and aesthetic results. Stenting averaged 13 days af- tients who presented to the senior author with vestibu- ter surgery and was well tolerated. No wound compli- lar stenosis. The cause was burn injury in 3 patients and cations occurred. congenital in 1 patient. The cornerstone is a batten graft to restore strength to the ala. A short-term thermoplas- Conclusions: In patients with vestibular stenosis, we use tic stent helps the nostril assume its natural shape. When a graded approach that addresses the inherent weakness an obstructing cicatrix is present, it is excised in a sec- of the nasal ala to achieve long-term vestibular patency. ond stage followed by full-thickness skin grafting. The This technique restores form and function to the ste- patients were evaluated up to 16 months postopera- notic vestibule while avoiding long-term stenting. tively. Vestibular patency was documented using high- resolution photographs, and medical records were reviewed for complications. Arch Facial Plast Surg. 2010;12(5):332-338 ASAL VESTIBULAR STENO- injured, the vestibule has a tendency to res- sis is a relatively uncom- car and contract despite seemingly well- mon deformity with sig- designed surgical maneuvers to excise the nificant aesthetic and offending cicatrix and create a new vestibu- functional effects on the lar lining.7 From a pathophysiologic stand- Npatient.1 Trauma, infection, iatrogenic in- point, stenosis of the anterior nares can be sults, and congenital lesions have all been caused by direct injury to the delicate lobule- 2-5 described in the literature as causes of ves- ala-columella complex, loss of healthy vestibular stenosis. Traumatic injury to the ala tibular lining, or both.8,9 Direct injury to the or vestibular lining is typically secondary 2,4,5 ala, such as chemical burns, leads to tissue to burns or complex lacerations. Infec- loss and scar contracture, which effec- tions that involve the anterior nasal mu- tively sucks in and flattens the ala.10 Partial cosa, including syphilis, tuberculosis, or circumferential scarring within the ves- smallpox, chickenpox, systemic lupus ery- tibule contributes additional contractive thematosus, rhinoscleroma, and leprosy can forces that tend to obliterate the cephalic and lead to scarring within the vestibule and con- 2-5 lateral portions of the vestibule and distort tracture of the ala. Iatrogenic trauma to 9 the nostril resulting in narrowing of the na- the flaccid alar wing. The medial aspect of sal aperture can include prolonged nasal the vestibule tends to be less affected by Author Affiliations: Division of packing, chemical cauterization, and poorly these distorting forces given the inherent Otolaryngology–Head & Neck executed surgical maneuvers that sacrifice support mechanism of the juxtaposed me- 9 Surgery, University of Utah the lining membrane of the vestibule.2,3 Con- dial crura and caudal septum. In addi- School of Medicine, Salt Lake genital vestibular stenosis is less common tion to tissue loss and scar contracture, the City (Drs Daines and Mobley), and is typically seen in conjunction with a constant negative pressure generated by and Department of cleft lip or nose deformity.4,6 inspiratory forces on the nostril further Otolaryngology–Head & Neck Stenosis of the nasal vestibule can be a adds to the tendency for the injured ves- Surgery, Division of Facial 11 Plastic and Reconstructive vexing deformity for the facial reconstruc- tibule to contract. Surgery, University of Iowa tive surgeon to successfully repair. Like The same factors that initiate and per- Hospitals and Clinics, Iowa City other hollow orifices in the human body (eg, petuate vestibular stenosis also serve to frus- (Dr Hamilton). lacrimal ducts, urethra, and ear canals), once trate surgical attempts to correct the defor- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 5), SEP/OCT 2010 WWW.ARCHFACIAL.COM 332 ©2010 American Medical Association. All rights reserved. Figure 1. Cadaver dissection showing a sagittally degloved nose. Note the lack Figure 2. Foil template of contralateral ala. A foil template of the unaffected of cartilaginous support at the caudal aspect of the ala overlying the vestibule. ala is designed preoperatively, which will be used to carve a batten graft. mity. A photograph of the ala in a cadaver dissection gical failure, the senior author (S.R.M.) uses a custom- demonstrates that the lower lateral cartilage does not sup- fashioned, limited-duration, thermoplastic stent that port the entire ala (Figure 1). The most caudal and lat- spares the patient the discomfort and cosmetic draw- eral portion of the ala, which overlies the vestibule, is in- backs of prolonged stent use. The custom-molded stent stead supported by easily injured fibrofatty or fibromuscular also contributes to establishing a more natural nostril con- tissue. Once injured, the lack of cartilage prevents the ala tour. We share the senior author’s experience in using a from withstanding the irresistible forces of postoperative graded approach for repairing congenital and acquired scar contracture. Furthermore, when trying to rearrange stenosis of the nasal vestibule. and/or excise the intravestibular cicatrix, the dictum “scar begets scar” holds true. Complicated intravestibular re- METHODS pairs often lead to a vicious cycle of new scar formation and recurrent stenosis of the nostril.4,12 Many different strategies have been described in the lit- All patients were evaluated by the senior author and diag- erature to address stenosis of the nasal vestibule. The com- nosed as having stenosis of the nasal vestibule based on physi- cal examination findings. Routine digital photographs were taken mon theme in each approach is the need to excise the ob- before and after surgery. A graded approach was used to re- structing cicatrix, replace the scar tissue with a new, healthy pair the deformity based on the following algorithm. In pa- lining, and stent the nostril postoperatively to prevent re- tients whose anterior nasal stenosis was secondary to direct in- stenosis. The use of cartilage grafts has been advocated by jury to the ala with resultant alar in-drawing and contracture, several authors as a means to combat restenosis. Egan and a single-stage operation was performed for placement of an alar Kim11 describe using a composite conchal graft to stent the batten graft and fitting of a short-term thermoplastic stent. In region of the nasal sill, and Karen et al6 advocate the use of patients with a significant intravestibular cicatrix, a second- an auricular composite graft to replace the intravestibular stage operation was performed to excise the offending scar and scar and to stiffen the repair. These approaches address iso- create a neovestibular lining with a full-thickness skin graft, lated stenosis within the vestibule owing to scar tissue, but again followed by short-term stent placement. they do not correct for alar collapse. Copcu13 reports using a gingivobuccal mucosal flap in conjunction with a carti- SINGLE-STAGE REPAIR lage graft to strengthen the weakened ala, but he does not provide details on the exact placement of the graft or ex- For patients with alar collapse without an obstructive cicatri- plain how he obtains a natural internal nostril contour. Blan- cial component contributing to their vestibular stenosis, the re- dini et al12 describe the theoretical use of cartilage grafts in pair is performed in a single stage. First, a foil template of the contralateral (unaffected) ala is meticulously designed conjunction with other techniques for relining the in- (Figure 2), and a thermoplastic stent is fashioned with the jured vestibule, but they did not use cartilage grafts in their goal of achieving slight overcorrection, again using the con- series. tralateral nostril as a model (Figure 3). Then a generous con- We reviewed the literature extensively using the key- chal cartilage graft is harvested, typically through a postau- words nostril stenosis and nasal vestibular stenosis.Toour ricular incision (Figure 4). knowledge, no reports in the literature have described a Second, attention is directed to the nose. A rim incision is technique for reestablishing the inherent structural sup- made along the stenotic nostril with a No. 11 blade scalpel, and port of the ala in patients with vestibular stenosis while a tight subcutaneous pocket is created with a 6900 Beaver blade allowing for a graded surgical approach via an optional (Beaver Surgical Instrument Company, Waltham, Massachu- second stage for excision of scar and creation of a neoves- setts). A teardrop-shaped cartilage graft is carved (using the foil template designed at the beginning of the procedure) and in- tibular lining with a full-thickness skin graft. Further- serted into the subcutaneous pocket (Figure 5). The rim in- more, the technique described in this article makes cision is then closed. progress in the use of postoperative stenting methods. Finally, the limited-duration thermoplastic stent is in- Although other techniques have almost uniformly re- serted in the vestibule and secured in place with 4-0 nylon su- quired months of postoperative stenting to prevent sur- ture over polytetrafluoroethylene (PTFE) tie-over pledget bol- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 5), SEP/OCT 2010 WWW.ARCHFACIAL.COM 333 ©2010 American Medical Association. All rights reserved. Figure 3. Molding of thermoplastic stent. A custom vestibular stent is Figure 5. Insertion of cartilage graft.

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