77e Cleft Palate-Craniofacial Jourttal 49{6) pp.

753-758 November 2012

Copyright 2012 American Cleft Palate-Craniofacial Association

CASE REPORT

Repair of Nostril Stenosis Using a Triple Flap Combination: Boomerang,

Nasolabial, and Vestibular Rotation Flaps
Mehmet Bozkurt, M.D., Emin Kapi, M.D., Samet Vasfi Kuvat, M.D., Caferi Tayyar Seluk, M.D.

Tissue losses within the nose due to various reasons result in the loss of normal anatomy and
function. The external nasal valve area is one of the most important functional components of the
nose. The coiumella, lobule, nostril, and alar region are among the components forming the external
nasal valve area. Deformities of the nostrils are among the most frequently observed features that
interfere with the functional anatomy of the nose. Malformations of the nostrils often emerge
subsequent to cleft lip repairs. Stenoses are a common type of pathology among nostril defor-
mities. In cases where a stenosis has formed, breathing problems and developmental anomalies
may occur. In the patient with nostril stenosis presented in this report, there was a serious alar
collapse and contracture subsequent to a cleft lip repair. In order to repair the nostril stenosis, a
"boomerang flap" was chosen. This boomerang flap was used in combination with a nasolabial
flap, a vestibular rotation flap, and a conchal cartilage graft to achieve a satisfactory repair.

KEY WORDS: boomerang flap, local fiap, nostril stenosis, reconstruction

The nose is the most prominent feature of the face and

carries great importance both aesthetically and functionally
(Hafezi et al, 2005; Gawrych and Janiszewska-OIszowska,
2010; Heller et al., 2010). Located at the very center of the
face, the nose may suffer losses caused by trauma and burns
as well as for oncologic and congenital reasons (Rose et al.,
1996; Meyer et al., 1996; Bernard, 2000; Hafezi et al., 2002;
Hafezi et al., 2005). One of the most important types of
funcfional losses occurs in the internal or external valve
structures (Egan and Kim, 2005). The internal nasal valve
region is described as the area comprising the nasal septum,
the caudal edge of the upper lateral cartilage, the inferior
turbinate region, and the pyriform aperture with the
nasal base (Kern, 1978). The anatomical defects in these
structures cause an internal nasal dysfunction. In general,
such dysfunctions occur due to a collapse caused by
previous operations or scar contractures.
Another valvular structure of the nose, the external nasal
valve, is composed of the nostril, the lobule-columella, and
the alar complex. The importance of this area of the nostril,
of which the size and shape depend on age and ethnicity,
stems from its function as the entrance for the air passage
(Daya, 2009). Stenoses of the nostril arc observed much more

Dr. Bozkurt, Dr. Kapi, Dr. Kuvat, and Dr. Seluk are Medical Faculty,
Department of Plastic Reconstructive and Aesthetic Surgery, Dicle
University, Diyarbakir, Turkey.
Submitted February 2011; Revised March 2011; July 2011; Accepted FIGURE 1 Preoperative view of the patient with nostril stenosis.
August 2011.
Address correspondence to: Dr. Mehmet Bozkurt, Dicle University
Medical Faculty, Department of Plastic Reconstructive and Aesthetic
Surgery, 21280 Diyarbakir, Turkey. E-mail drmbozkurt@yahoo.com.
DOI: 10.1597/11-021

753
754 Cleft Palate-Craniofacial Journal, November 2012, Vol. 49 No. 6

FIGURE 2 A: Opening of the stenosis through incisions made on the edge of the nostril and the preparation of the boomerang-shaped transposition flap based
on the superior side of the expanded lower lip. B: Transposition of the boomerang-shaped flap. C: Preparation of the superior pedicied nasolabial flap for the
repair of the lateral defect. D: Preparation of the mucosal rotation flap from the inner side of the vestibule for the repair of the medial defect. E: Placement of the
cartilage graft obtained from the aural concha as a supporting feature between the lateral flap (nasolabial flap) and the medial flap (vestibular rotation flap) usiug
a 5.0 polypropylene suture. F: Closure of the skin and the mucosa with 5.0 polypropylene and 5.0 polyglactin sutures and the conclusion of the surgical procedure.

rarely than internal nasal valve collapses. Nostril stenoses in
the vestibular line may be either congenital or acquired. The
reasons for an acquired nostril stenosis include infection,
trauma, burns, tumors, chemical agents, nasal tampons that
exert long-term pressures, and surgery to the vestibular line
(al-Oattan and Robertson, 1991; Daya, 2009). The most
important congenital reason for nostril stenosis is cleft lip and
nasal defects. However, the nostril stenosis observed
following a cleft lip operation can be classified as a stenosis
of both congenital and iatrogenic (subsequent to surgical
intervention) origins. Actually, nasal stenosis is a rarely
observed complication after a competently perfonned cleft
lip surgery. There are various techniques and combinations
defined for the repair of this deformity. Positive functional
results may be obtained through the reconstruction of the
anatomical integrity of the external nasal valve during the
repair.
This paper discusses the triple-flap (boomerang, nasola-
bial, and vestibular rotation flaps) combination method
applied in order to repair a nostril stenosis that developed
secondary to cleft lip surgery.
CASE REPORT
A 9-year-old girl who presented to our clinic with a nostril
stenosis was evaluated, and the patient's history revealed that
she had undergone a cleft lip operation at 3 months of age.
Scar areas consistent with a Millard repair were detected
during the physical examination. However, when the
dimensions of the vermilion line, cupid's bow, and the
medial and lateral lip elements were measured, it was
observed that in line with the shortcomings in the planning
and application of the cleft surgery, the lateral lip flap was
wider on the left side in the horizontal plane compared with
the right. In addition the lateral advancement flap on the left
side was shorter on the vertical plane compared with the
medial flap, and the vermilio-cutaneous border was not
formed in a linear plane. A mild whistling deformity was
present; the nasal alar cartilage was not reorganized, and the
left alar cartilage had collapsed. Furthermore, the left alar
base was placed too close to the midline. As a result, a serious
(approximately 80%) left nostril stenosis had developed
(Fig. 1). A two-stage operation was planned for the patient.

FIGURE 3 Views of the elevated flaps. A: Boomerang-shaped flap. B:
Triple flap.
Surgical Technique
Stage 1
The first phase comprised placement of the osmotic
tissue expander. Considering the overgrowth of the lateral
lip flap in the horizontal plane, this approach was chosen
for the nasal base construction under general anesthesia.
In order to bring the existing overgrown tissue to the
necessary width, it was decided to primarily place a
cylindrical osmofic tissue expander of 0.7 mL volume
below the vertical scar area. A 5-mm horizontal incision
was made through the vcrmilio-cutaneous border in order
to reach under the boomerang-shaped transposition flap,
which was concave toward the left side. A tunnel reaching
the lower left border of the columella was formed with
blunt dissection. The osmofic tissue expander was placed
after the irrigation of the tunnel-shaped pocket with saline.
Bozkurt et al., TRIPLE FLAP FOR NOSTRIL STENOSIS 755
FIGURE 4 Placement of the conchal cartilage graft into the alar region.
The incision was primarily closed, and the first stage of the
surgery was completed.
Stage 2
Lifting of ttie Boomerang Flap (Repair of Nostril Base).
After a 20-day waiting period for the fissue expander to
reach the desired size, the second stage of the surgery
began. The nostril base was separated laterally from the
nostril and the collapsed part of the alar basis was released.
The incision was extended along the alar base toward the
lateral and superior sides, and the left inferior third of the
nasal part was completely separated. A bootnerang-shaped
flap in the exact dimensions to fit the formed nostril base
defect was planned and lifted from the lateral tissue element
adjacent to the scar area as a random pedicle flap (Fig. 2A).
The lifted flap is transposed to the nostril base defect, and
the defect is closed (Fig. 2B). The incision is primarily
repaired with the help of an allograft placed on the left
nostril base and the vermilion line.
Lifting of the Nasolahial Flap (Repair of Lateral Side).
The defect in the lateral base of the nasal alar region was
closed with the superior pedicled nasolabial flap lifted from
the left nasolabial area (Fig. 2C). The nasolabial donor
area was repaired primarily.
Lifting of the Mucosal Rotation Flap and Placement of the
Cartilage Graft (Repair of Medial Side). Aiming to cover
the medial (mucosal) part of the left alar base defect, a
mucosal rotation flap was elevated from inside the vestibule
(Fig. 2D). The elevated fiap was advanced to the alar
rim, and the inner margin of the nostril was formed. The
756 Cleft Palate-Craniofacial Journal, November 2012, Vol. 49 No. 6
FIGURE 5 A and B: View of adaptations of the elevated triple flaps to
the defect.
operation was concluded after placing the cartilage graft
obtained from the aural concha between the medial and
lateral edges (Figs. 2E through 5).
The patient underwent placement of a nostril retainer and
observed closely for infection. The nostril retainer was
maintained for 3 months and then removed. No restenoses
have been observed during the short-term and long-term
follow-up. Scarring at the operation sites was negligible.
The patient could breathe freely through both nostrils. The
outcome obtained was satisfactory for both the patient and
the surgeon (Fig. 6).
DISCUSSION
When present, nostril stenosis causes oral breathing and
reduces the quality of life in these patients. It may be caused
by tissue loss, scarring, and/or contracture for numerous
reasons, representing single or multiple deformities of the
lobule-columella-ala complex. The aim of the reconstruction
of the nostril stenosis is a permanent repair of the lobule-
columella-ala complex (Daya, 2009).
In reconstructive surgery, repair options that are both
aesthetically and functionally convenient are chosen for
nasal reconstructions. Still, various difficulties may be faced
during the operations in patients where skin contractions or
scar tissue is present. These problems include the loss of the
normal anatomic integrity caused by tissue deformations
and tissue deficiency in the contraction area. These irre-
gularities and deformities of contracted alar margins are
difficult to repair and usually necessitate multiple operations
(Gawrych and Janiszewska-Olszowska, 2010; Heller et al.,
2010).
The basic surgical repair methods applied to nostril
stenoses in the literature are the W-plasty or Z-plasty, full-
or partial-thickness skin grafts, composite chondrocuta-
neous grafts, or nasolabial fiaps obtained from the ear or
locally from the perialar region (Stallings and Sessions, 1971;
Blandini et al, 1995; Constantian, 1998; Daya, 2009). The
mucous membrane graft-flaps (Tipton, 1970; Copcu, 2005);
intranasal local flaps, para-alar crescentic subcutaneous
pedicled flaps (Suzuki, 1989; Yamawaki, 2006); double cross
plasty (Naasan and Page, 1992); upper lip flap (Mavili and
Akyiirek, 1999); alar transposition flap (Aydogdu et al.,
2006); and galea-including forehead flap (Bruschi et al.,
2009) are among the other nasal stenosis repair methods.
Nasolabial flap application is known to be a useful method
in nostril stenosis, and it is one of the first methods of choice.
This fiap is usually used to cover the distal lateral alar wall
and nasal base defects. When used this way, however, the
two anatomically different components of the nostril, the
lateral wall and the basis, are covered as a single unit. This
may cause a deficiency in the normal anatomical and
functional integrity of the nostril. Therefore, in our case, we
have combined the classical nasolabial fiap method with the
mucosal rotation fiap and the C-shaped flap called the
boomerang flap. This way, the repair of the nostril in three
different vectors and planes is possible.
The basis of the nasal valve insufficiency or nasal stenosis
surgery is the expansion and support of the contracted
tissue. There are different repair methods used for supra-
alar indentations and supra-alar lateral wall weaknesses.
Even if the nasal alar integrity is present in the natural
structure, a wall support maneuver using fibroadipose
tissue or nonanatomic cartilage grafts may still be needed.
These grafts are usually obtained from septal or conchal
cartilage (Egan and Kim, 2005). They are placed into the
contracture areas in order to expand the nasal opening or
tune down the effects of scar formation, but this is a
supportive method in patients with normal alar function
and, therefore, not solely efficient in tissue defects in the
alar wings (nostril stenosis). For this reason, three flaps
have been combined for three defect levels in our case
where the target was to form a strong framework using a
cartilage graft.
One of the authors (Daya, 2009) has applied nasal stents
subsequent to surgery in 14 patients with nostril stenosis
who have undergone repairs using flaps obtained through

FIGURE 6 Views of the patient in the eighth postoperative month. A: Anterior. B and C: Laterals. D: Superior. E: BasaL
skin grafts, spontaneous epithelizadon, Z-plasty, local
nasolabial fiaps, and local scar tissue and reported rather
sadsfactory outcomes. This study is the largest one related
to nasal stenosis repairs in the literature. Various chnicians
have used nasal stents or retainers in padents with nostril
stenoses in order to prevent contracture formation and
postoperadve constrictions (Egan and Kim, 2005; Tan
et al., 2006; Saglam and Kuvat, 2009). These are helpful to
prevent nostril constrictions due to primarily congenital
cleft lip surgeries as well as the postoperative ones or those
occurred due to burns (Johnson et al., 1992; Tan et al.,
2006). However, it is obvious that the benefits of nasal
stents or retainers are limited in cleft lip cases where serious
tissue deficiency is present. We also used nostril retainers
postoperatively with our patient and believe that the
method prevents the development of restenoses. Still,
this point seems to necessitate further research through
comparadvc studies on the efficiency of these apparatuses.
The most important disadvantage of the boomerang fiap
technique obtained from the old scar tissue in the upper lip
is that it necessitates two operations due to the need for
dssue expansion. Still, considering that the repair of nostril
stenoses is rather difficult and often requires multiple
surgeries, the first stage needed to prepare the boomer-
ang fiap seems to be acceptable. However, we are aware
that this technique needs further study on larger patient
groups.
Bozkurt et al., TRIPLE FLAP FOR NOSTRIL STENOSIS 757
In conclusion, we can claim that the combinadon of
boomerang, nasolabial, and vestibular rotadon naps in
nostril stenosis patients observed subsequent to cleft lip
surgery is a useful alternative for three-dimensional repair
of the nostril.
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