Nostril stenosis secondary to a laser burn injury: correction with a composite graft.

A 15-year-old girl presented with a history of right nostril stenosis secondary to a surgical laser burn injury that she had incurred during choanal atresia repair when she was 1 year old. The ensuing scar in the nasal sill and columella created an elevation of the nostril floor, resulting in a narrowing of the nostril aperture to approximately 30% of the cross-sectional area of her normal left nostril (figure 1). The scar extended 1 cm posteriorly into the nasal floor. This deformity caused considerable right-sided nasal obstruction and retention of nasal secretions.

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Two main considerations guided surgical planning:

* First, given that dense scar tissue occupied approximately 50% of the total inner circumference of the nostril opening, any method of surgical expansion would be followed by significant postoperative contracture, which might lead to restenosis. The surgical team had entertained two options: (1) we could make a simple incision and place a retaining stent or (2) we could excise the scar and line the defect with a skin graft or local rotation flap. Given the anticipated forces of postoperative scar contracture, our concern about restenosis prompted us to discard both of these options. Instead, we decided to use a composite graft of cartilage and skin. Our belief was that the structural support of the cartilage would provide resistance against the cicatricial forces.

* The second consideration was that the sizable surface area of the scar would make excision problematic because a composite graft that was large enough to cover the ensuing raw surface would be unlikely to survive. We elected to incise the scar and interpose a graft as a spacer to expand the nostril opening. The surrounding surface scar would be incorporated into the reconstruction of the nostril rim, allowing us to use a smaller composite graft that had a greater likelihood of survival.

A composite graft of skin and cartilage was harvested from the cymba concha of the right ear (figure 2). After 1 cm of the superior and inferior skin flaps were undermined, primary closure of the donor site was performed easily. A bolster fashioned from a dental roll and Xeroform gauze was sutured into the cymba concha and maintained for 7 days. The elliptical graft measured 20 x 9 mm. Next, 5 mm of skin was removed from each end of the graft along its long axis, leaving a 10 x 9-mm central rectangular portion of skin and cartilage flanked by tapering 5-mm flanges of cartilage (figure 3).

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A vertical incision was made perpendicular to the nasal floor through the midpoint of the scar in the medial aspect of the nasal sill. The incision was carried down to the desired level of the nasal floor. Narrow tunnels were then sharply dissected at the deepest point of the incision, laterally toward the alar base and medially toward the columella. The cartilaginous flanges of the graft were then inserted into these tunnels. This cartilage foundation served to support the central island of skin. After conservative debulking of the deep scar tissue, the edges of the surface scar on each side of the incision were sutured to the skin island. External suturing was done with 5-0 nylon, and intranasal suturing was done with 5-0 chromic catgut. Because the cartilage was placed in a position corresponding to the original nasal floor and stabilized into snug pockets, insetting the skin island had the effect of pushing the scar edges into this corrected position and restoring the nostril aperture (figure 4).

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Postoperatively, aretainer of Xeroform gauze was placed to stent the nostril for 7 days; thereafter, the patient used an intranasal rubber stent at night for several months. At the 4-month follow-up, the patient had a normal nostril opening, and its size and shape were similar to those of the opposite side (figure 5). Her nasal obstruction and secretion retention had completely resolved. Residual scar tissue on the columella will be treated with serial triamcinolone injections. If objectionable scar remains after 1 year, we will consider excision of this small area followed by primary closure or skin grafting.

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Acknowledgment

The author would like to recognize Dean M. Toriumi, MD, who taught him the technique described in this article.