Abstract
Introduction
Nasal stenosis is an uncommon burn scar deformity which can result in breathing obstruction. The reconstruction of nasal stenosis secondary to burns can be challenging due to the limitation of localized tissue, rate of recurrence, and burn injury to the surrounding areas. A vascularized composite flap of local composite tissue (forked flap) from the lip can reliably reconstruct the nasal vestibule and nasal sill diminishing the risk of recurrent nasal stenosis. We describe our use of a modified Millard forked flap, a cleft lip repair technique.
Methods
A 52-year-old female presented with complete stenosis of the right nares secondary to burn contracture of the nostril, vestibule, and upper lip. She had suffered a flash burn to her face while smoking on home oxygen requiring prolonged ventilatory support and only received topical dressings. Three months after her burn injury she was referred for the reconstruction of her contractures.
A lateral rhinotomy was performed to define the nasal floor defect. Scar release of the remaining vestibule and ala and the aesthetic units of the lip were defined. A supple unburned area of the upper lip was harvested as a vascularized composite forked flap and rotated into the vestibule defining the vestibule floor. The ala was rotated outward and full-thickness skin grafts was used to resurface the vestibular portion. The lateral aesthetic subunit of the lip was then resurfaced as a complete unit with a full-thickness skin graft. She later required fabricated nasal splint for nighttime stenting and serial daytime nostril dilatation with Hegar dilators.
Results
At nine months post-reconstruction, the patient maintains a patent nasal airway with limited vertical lip contraction, resolution of her initial symptoms of sinus congestion, and no further difficulty breathing.
Conclusions
In 1955, Ralph Millard presented the rotation-advancement technique for cleft lip repair. The Procedure was designed to create a softer, more natural-looking reconstructed lip. In the cleft lip repair, he suggested preserving the prolabial tissue lateral to the central segment as forked flaps that were rotated and banked on the nasal vestibule floor. Had that principle not been appreciated, that tissue might have been discarded in order to respect the aesthetic unit of the lip. The surgeon must utilize reliable principles to restore and retain form and function. The use of this modified forked flap incorporated composite vascularized tissue for the nostril floor reconstruction while respecting the subunit reconstruction of the lip.
Applicability of Research to Practice
Reconstruction of the injury needs to restore both functional and aesthetic deformities. Utilization of a local vascularized composite graft, taken from an area to be discarded within the upper lip subunit, provided quality tissue that significantly reduces the risk of secondary nasal contracture.
Cleft Lip Repair: Technical Refinements for the Wide Cleft
