INTRODUCTION
The reconstruction of a total defect in the nasal columella is a challenge for surgeons,
and it is possible to perform it in one or several stages1,2. Among the alternatives for repairing the nasal columella, we can opt for local flaps,
including the bilateral nasolabial flap3.
The literature reports numerous other reconstructions: the Indian flap4, the “U”-shaped frontal muscle flap2,5, and the unilateral nasolabial flap6 for repairing the nasal columella.
Seeking a surgical option after the excision of an extensive tumor (basal cell carcinoma
- BCC) in the columella with oncological safety margins, we came across the bilateral
nasolabial flap3, the object of the present case report, which proved to be a non-aggressive solution,
with rapid resolution and performed with local anesthesia and sedation.
OBJECTIVE
This work aims to describe the reconstruction of the nasal columella using the bilateral
nasolabial flap3 after a complex defect caused by resection of basal cell carcinoma.
CASE REPORT
JAS, white male, 50 years old. He had a sclerodermiform BCC in the region of the nasal
columella, documented in a biopsy before surgical resection.
Subsequently, there was tumor resection with oncological criteria and anesthesia with
modified Klein solution7 (100ml of 0.9% saline solution, 20ml of 2% lidocaine without vasoconstrictor + 1
ampoule of adrenaline 1/1000 + 4ml of sodium bicarbonate at 8 .4%) and sedation with
midazolam + fentanyl, performed by the anesthesiologist.
After tumor resection with oncological safety margins, a large defect ensued in the
anterior part of the nose involving the nasal columella (Figure 1).
Figure 1 - Aspect of the nasal tip after resection of basal cell carcinoma.
Figure 1 - Aspect of the nasal tip after resection of basal cell carcinoma.
Bilateral demarcation of the nasolabial flaps was performed based on the anterior
facial artery3. In a posteriori, the flap was elevated, transposition, and sutured to the new bed.
The donor area was repaired with the advancement of local flaps (Figure 2).
Figure 2 - Surgical demarcation for first refining.
Figure 2 - Surgical demarcation for first refining.
After 2 months, the second procedure was performed, with the refinement of the flap
(Figure 3). Subsequently, there was a new refinement step in which we reached the final result
(Figure 4).
Figure 3 - Postoperative refining.
Figure 3 - Postoperative refining.
DISCUSSION
Basal cell carcinoma is the most common non-melanoma skin tumor in our setting, with
several subtypes, according to Terzian et al.8: nodular, ulcerative nodule, cicatricial
plane, sclerodermiform, terebrant and pigmented. Of these subtypes, terebrant and
sclerodermiform are more aggressive, the latter being the one with the highest number
of recurrences. It mainly affects the face, predominantly affecting areas with greater
sun exposure9.
Surgical treatment is preferred when the tumor has large extensions. In this case,
local anesthesia with modified Klein solution7 associated with sedation was recommended, providing adequate analgesia and vasoconstriction
to perform tumor resection with good visibility and preparing flaps for its reconstruction,
thus avoiding general anesthesia. , which offers greater risks for the patient and
higher costs for the institution.
The literature review showed us numerous options for columellar reconstruction nose,
from flaps from the frontal region5 to flaps from the infraclavicular region10. However, the simplest and least aggressive ones are the unilateral nasolabial flap6 and the bilateral nasolabial flap3. Paletta & Van Norman11, in 1962, mentioned that when a nasal defect consists of total columellar loss, the
unilateral nasolabial flap provides an excellent means of reconstruction.
Ingracio et al.1, in 2014, advocated the use of the unilateral nasolabial flap for reconstruction
of the superior pedicle columella as the appropriate choice, taking into account the
maintenance of the oral orbicularis musculature.
Nonetheless, the option for the bilateral nasolabial flap concerning the unilateral
one was due to the greater amount of tissue for repairing an extensive defect, its
positioning to simulate the columella, and greater versatility in covering a large
area to be reconstructed3.
Kaplan12, in 1972, reported this same flap as an island of skin in the nasolabial fold region,
based on the facial artery with a pedicle inferior to the height of the ala and nasal
dorsum. However, demarcation with a Doppler is recommended for its rotation. We did
not use this option due to the execution of the same flap with the upper pedicle removed
close to the lip, seeking greater skin and a lower risk of hypertrophic scars.
Lewis13, in 1990, demonstrated that the columella reconstruction could be performed with
a bilateral lip flap, using mucosa and muscle from the intraoral region of the upper
lip. We did not use this technique due to the insufficient amount of tissue that it
would provide for the reconstruction.
Mendelson et al.10, in 1979, mentioned a tubular flap removed from the cervical region in four stages
for the reconstruction of this nasal unit. This type of reconstruction was not performed
due to the need for four or more surgical procedures. Furthermore, the scar in the
donor area (infraclavicular region) becomes extensive and has a high chance of generating
a hypertrophic scar.
Other flaps for columellar reconstruction were not advocated (Orticochea14 and Millard5) due to the need for several surgical times and, sometimes, causing partial occlusion
of one eye.
CONCLUSION
The bilateral nasolabial flap, used for the columella reconstruction, proved viable,
easy to perform, and with good perfusion. Furthermore, it achieved a satisfactory
columellar appearance and practically imperceptible incisions in the donor area. However,
it had the disadvantage of requiring two surgical refinements to present a satisfactory
aesthetic result.
1. Hospital de Câncer de Campo Grande Alfredo Abrão, Campo Grande, MS, Brazil.
2. Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil.
3. Universidade Estadual de Mato Grosso do Sul, Campo Grande, MS, Brazil.
Corresponding author: Marcelo Rosseto Rua Raul Pires Barbosa, 1477, Chácara Cachoeira, Campo Grande, MS, Brazil Zip code:
79040-150 E-mail: marcelorosseto@yahoo.com.br