Stenosis of the Nasal Vestibule and Its Treatment

Annette Kotzur, M.D., Wolfgang Gubisch, M.D., and Rodolphe Meyer, M.D.

Stuttgart, Germany

Abstract. From our own experience and a review of the litera-ture, we present a few techniques which, in our eyes, give thesurgeon the possibility to treat most encountered cases of ste-nosis of the nasal vestibule. During 1991 to 1998 the author inStuttgart (W.G.) performed simple z-plasty combined with lo-cal flaps in 6 patients and composite grafts only in 12 cases, tocorrect nasal vestibule stenosis. The author in Lausanne (R.M.),who first described the paranasal myocutaneous flap to correctnot only nasal vestibule stenosis but also alar base malpositionhas treated over 50 patients with this technique and with com-posite grafts during the last 20 years.

Key words: Vestibular nose stenosis—Myocutaneous flap—Composite graft

Stenosis of the nasal vestibule is not only an aesthetic,but also a functional problem for the patient. It can showall degrees of narrowing, from slight stenosis to completeatresia. It can occur unilaterally or bilaterally. Basicallythere are three locations: at the entrance of the nasalvestibule, at the nasal vestibule itself, and at the transi-tion between the nasal vestibule and the nasal cavity.Another very rare form of anterior or posterior nasalvestibule stenosis is the congenital one, which is usuallyseen at the lateral angle of the interior nose as a synechia.More frequent are nasal vestibule stenoses after trauma,infections, or aesthetic and reconstructive operations.Basically they can be a result of ulcerous processes at therim of the nostril or after infections such as syphilis orlupus. Scar tissue is responsible for forming nasal vesti-

bule stenosis in burn patients and after total nasal recon-struction, tumor removal, and correction of cleft lipnoses. There exists an enormous variety of techniques forvestibular nose stenosis treatment. This article concen-trates on a few techniques which, in our eyes, give thesurgeon the possibility to treat most encountered vestib-ular nose stenoses safely and reliably.

Surgical Treatment

Unilateral or bilateral stenosis of the nasal vestibule hasto be corrected not only for aesthetic reasons, but also forfunctional ones. If the stenosis is encountered in chil-dren, early surgery plays an important role. The surgicalprocedure depends upon the location of the stenosis, thethickness of the obstructing wall, and the condition of theala.

Usually scarring and retraction in the vestibule are dueto the lack of nasal lining, sometimes combined with aloss of cartilage. Incisions for rhinoplasty which reachthe lateral angle of the vestibular floor at the alar bordermay also cause cicatricial stenosis of the nasal vestibule.We saw five real nasal vestibular stenoses after nasaltube operations where tubes or nasal packing (leadstring) had been inserted for a prolonged time. The leadstring can produce a small incision on the lateral angle ofthe nostril, which can cause an inflammation by repeatedirritation and lead to a scar resulting in a real nasal ste-nosis.

The techniques described below were used in 18 casesduring 1991 to 1998 by the second author (in Stuttgart).Of these, 12 patients received a composite graft and 6patients received local flaps for treatment of vestibularnose stenosis. The third author (in Lausanne) has usedthe paranasal flap and composite grafts in more than 50patients over the last 20 years.

Correspondence to Wolfgang Gubisch, M.D., Clinic for PlasticSurgery, Marienhospital Stuttgart, Boeheimstr. 37, 70199 Stutt-gart 7, Germany

Aesth. Plast. Surg. 23:86–92, 1999

© 1999 Springer-Verlag New York Inc.

Lateral-Angle Stenosis or Stenosis of theAnterior Dome

We usually treat smaller lateral-angle stenosis or stenosisof the anterior dome by simple incision or excision of thescar as proposed by Fomon [4] (Fig. 1). After excisionthe posterior membrane is removed and the anteriormembrane is placed inward and sutured. If a defect re-mains, we use a composite graft from the ear to close it.The nostril is packed afterward with an antibiotic foamfor 5 days. During this time the foam is wetted daily witha cold antibiotic solution, with the aim of reducing themetabolism of the transplant by reducing the tempera-ture.

In severe vestibular nose stenosis we combine z-plastywith a full-thickness skin graft or a composite graft torepair the scarring tissue retraction and to replace the lostskin (Figs. 2 and 3).

Vestibular Stenosis

In vestibular stenosis we usually find a soft tissue defi-ciency at the vestibular floor.

A technique used at the beginning in cleft lip patientsconsists of a laterally based septal flap transposed for-ward and grafting of the donor site with a full-thicknessskin graft. Based on this technique, the third author de-

veloped a paranasal myocutaneous flap for treating ac-quired vestibular stenosis in adults. It can be used to linethe vestibular floor (Fig. 4B), and in severe cases ofvestibular stenosis where an enlargement of the vestibu-lar floor is insufficient, the paranasal flap can be com-bined with an auricular composite graft (Fig. 4B). Com-bined with a skin graft, it also can be used after anteriormarginal web resection to line the lateral aspect of thevestibular floor. The septocolumellar defect is lined by askin graft or a composite ear graft (Fig. 6B).

Vestibular stenosis due to an obstructing membrane isgenerally insufficiently treated by excision only. Theringlike scar resulting from the excision will alwaysshow a tendency to form an occlusion again. We preferto cut a laterally and inferiorly based flap, which then isswung to the nasal floor and vestibular wall and, finally,is anchored at its alar attachment by mattress sutures.This method can also be combined with a compositegraft from the ear so that the nostril again gets a carti-laginous support.

Case Reports

Case 1 (Lausanne)

A 52-year-old female patient presented an iatrogenic na-sal vestibular stenosis after multiple rhinoplasties (Fig.

Fig. 1. 52-year-old female with leftnasal vestibular stenosis aftermultiple rhinoplasties (A,C).Postoperative results 2 years later(B,D) after large marginal bilateralresection at the columella andthinning of both allae by removalof scar tissue. (C) Preoperativeprofile. (D) Postoperative profile.

87A. Kotzur et al.

Fig. 3. 18-year-old cleft lip patientwith circular scars around thenostrils as well as scars crossingcolumella with contraction of thenasal vestibule (A). Treated byexcision of scar tissue and use ofcomposite grafts for the ear toreopen the nasal vestibule, withpostoperative results seen 2 yearslater (B).

Fig. 2. 48-year-old female withtotal necrosis of septum, ulcers atthe nostrils with shift of the nostrillocation caused by subsequent scarcontraction (A,B). Treated byexcision of scar tissue and use ofcomposite ear grafts to reopen thenasal vestibule, with satisfactorypostoperative results (C,D).

88 Stenosis of the Nasal Vestibule

1A). She was treated with large marginal bilateral resec-tion at the columella and thinning of both alae by re-moval of scar tissue. Figure 1B shows the postoperativeresult 2 years later. Figures 1C and D show the preop-erative and postoperative view in profile.

Case 2 (Stuttgart)

A 48-year-old female patient had undergone a rhino-plasty elsewhere, with massive postoperative bleeding.She obtained a packing which was removed after 4 days.She then showed total necrosis of the septum, ulcera atthe nostrils, and a subsequent scar contraction which ledto a shift of the nostrils. She was treated by scar excisionand split-thickness skin grafting, which produced a totalcicatricial stenosis and deformity of the nasal tip (Figs.2A and B). She presented to us for the first time in 1982.We excised the scar tissue again and used compositegrafts from both ears to reopen the vestibule of the nose.Figures 2C and D shows the postoperative result 2 yearslater.

Case 3 (Stuttgart)

An 18-year-old cleft lip patient presented at our clinicafter an attempt to correct the cleft lip and the cleft lipnose deformity with a one-stage operation (Fig. 3A). Onexamination he showed circular scars around the nostrilsas well as scars crossing the columella. This led to de-formation and contraction of the nasal vestibule. Wetreated the patient by excising the scar tissue and usingcomposite grafts from the ear to reopen the vestibule ofthe nose. Figure 3B shows the postoperative result 2years later.

Case 4 (Lausanne)

An 8-year-old male patient presented at the clinic of thethird author with a traumatic stenosis of the right nasalvestibule (Fig. 4A). He was treated with a paranasal flaptransferred into the nasal vestibule by alatomy combinedwith an auricular composite graft (Figs. 4B–D). Figure4E shows the postoperative result 1 year later.

Case 5 (Stuttgart)

A 40-year-old male patient presented at our clinic aftertwo operations elsewhere for correction of a cleft lipnose deformity. On examination he showed stenosis ofthe nasal vestibule due to massive rotation of the nasalala (Figs. 5A and B). We operated on him using a para-nasal flap described by the third author. The flap waspedicled on a nasal muscle and then pulled through thebase of the nasal ala. Figures 5C and D show the post-operative result 2 years later.

Case 6 (Lausanne)

An 18-year-old boy presented with practically completestenosis of the vestibule as a unilateral recurrence of abilateral stenosis he had at a few months of age, pro-duced by the strings of a Belloc packing following sur-gery on a choanal atresia.

On the left closed vestibule a flap is outlined whichwill be folded laterally to form the lining of the ala andthe lateral floor of the vestibule (Fig. 6A). The figureshows the technique used for the correction. The stenos-ing external skin is already folded laterally for the lining.The raw surface of the lateral aspect of the columella andof the membraneous septal site is covered with an earconchal composite graft (Fig. 6B). The end of the opera-tion corresponds to the figure 6C in which the alar for-mation is achieved and in which transalar sutures knottedon a plastic sheet ensure the adherence of the lining skin.Behind the columellar border, the composite graft su-tured all around is visible (Fig. 6C). The late result in theaxial view is shown in Fig. 6D.

Discussion

Fortunately nasal vestibular stenosis very seldom devel-ops after aesthetic rhinoplasty. It may result as a com-plication of multiple lacerations leaving a loss of softtissue in the region of the nasal tip or a scar from arhinoplasty incision, marginal or intercartilaginous,reaching the lateral angle of the vestibule.

Only minimal stenoses of the lateral angle or the an-terior dome can be simply incised, as proposed by Fo-mon [4]; otherwise, z-plasty with or without a skin or,rather, a composite graft is more favorable in these cases.We prefer composite grafts because they give the nostrila cartilaginous support. There are different experiencesreported in the literature concerning the size of the com-posite graft [1,6,9,10]. In our experience, no part of thegraft should be more than 1 cm away from the edge ofthe repaired defect, in order to assure blood flow withinthe first 3–6 h posttransplantation. The perichondriumshould always be taken with the graft in order to assuregood blood flow. Shrinkage of the graft should be takeninto consideration. We take a graft 1 mm thicker, longer,and broader than the defect is. Gentle handling of thecomposite graft is mandatory. The recipient area shouldbe cleared of scar tissue as far as possible to ensure agood transplant bed. According to an idea of Schmid’s[11], we often remove the central part of the cartilagegraft in order to improve the nutrition of the graft withoutharming its stability. In addition, postoperative dailycooling with an antibiotic solution for 5 days, accordingto our experience, reduces the metabolism of the graftand therefore increases the chance of graft survival.

In cases of real nasal vestibular stenosis or in cleft lippatients, these minor procedures are often insufficient. Ifwe have a broad incision as usually encountered in cleftlip noses, we have to line the vestibular wall with acomposite graft to avoid vestibular stenosis. Jablon and

89A. Kotzur et al.

Hoffman [7] recently reported a case of complete nasalstenosis after birth in which he used a hard palate mu-cosal graft to correct the vestibular stenosis. A mucosalgraft, as well as a composite graft, is tough, resistant, andeasy to harvest. The basic idea of both is that they resistpostoperative contracture better than skin grafts do. Wehave no experience with mucosal grafts by vestibularstenosis treatment, but we often use them for lower lidreconstruction and they certainly represent a good alter-native to composite grafts. In cases of a remaining minorvestibular nose stenosis in cleft lip patients, we also usethe triple-swing technique described by Gubisch [5] toobtain large, symmetric nostrils. We find a situationsimilar to that in cleft lip noses after excision of fibro-cicatricial tissue producing stenosis of the vestibularfloor. The arising defect can be covered with a paranasalmyocutaneous flap which was first described by Meyerand Kesselring in 1977 [8] and subsequently by Conleyet al. in 1982 [2], who renamed it the mini alar base

myocutaneous flap. The flap is transferred to the vestib-ular floor, either through a tunnel under the alar base(Fig. 4B,C) or with the help of a complementary alotomy(Fig. 2) [8,9]. This method can be combined with a com-posite auricular graft to increase the height of the ala orfor expansion of the lateral vestibular wall (Fig. 4B) afterexcessive removal of the lower lateral cartilage (pinchednose). We prefer to take the composite graft from theinner aspect of the crus helicis because the skin in thisregion is extremely adherent to the cartilage, which per-mits easy taking of the graft. Constantian [3] recentlyshowed that, in vestibular stenosis combined with alarbase malposition, a composite graft plus a paranasal flapnot only improves the shape and symmetry of the nosebut also increases the mean nasal airflow demonstratedin anterior, active rhinomanometry. Constantian [3] alsoshowed that, even in patients with burned or scar tissuearound the ala, the paranasal flap of Meyer proved to besafe and reliable in 29 secondary rhinoplasties.

Fig. 4. 8-year-old male patient with traumatic stenosis of right nasal vestibule (A). Treated with paranasal flap transferred into thenasal vestibule by alatomy combined with an auricular composite graft (B–D). (E) Postoperative result 1 year later.

90 Stenosis of the Nasal Vestibule

Fig. 6. 18-year-old boy born withchoanal atresia with almostcomplete stenosis of the leftvestibule (A), following anattempt to correct bilateralstenosis at a few months of age.Treated by folding the stenoticexternal skin laterally to supplythe lining (B). Raw surface of thelateral aspect of the columella andmembranous septal site coveredwith a composite graft taken fromthe ear concha (C). The late resultof these surgeries can be seen inthe axial view (D).

Fig. 5. 40-year-old male patientshowing stenosis of nasalvestibule caused by massiverotation of the nasal ala after twoattempts to correct cleft lipdeformity (A,B). Treated with aparanasal flap pedicled on a nasalmuscle and then pulled throughthe base of the nasal ala, withpostoperative results seen 2 yearslater in C and D.

91A. Kotzur et al.

In vestibular stenosis where we have to perform ananterior marginal web resection, we can use the parana-sal flap for the new lining of the vestibular floor and thelateral aspect of the vestibule. The remaining septocolu-mellar defect is closed by a skin or composite graft (Fig.6B).

Summary

We conclude that composite grafts from the ear, alone orcombined with techniques such as simple z-plasty or theparanasal myocutaneous flap with its different describedvariations, are a safe and reliable method to correct ves-tibular stenosis encountered not only in cleft lip nosesbut also after trauma or failed aesthetic and functionalrhinoplasties.

References

1. Avelar JM, Psillakis JM, Viterbo F: Use of large compositegrafts in reconstruction of deformities of the nose and ear.Br J Plast Surg37:55, 1984

2. Conley JJ, Sachs ME, Donovan DT: The mini alar base

myocutaneous flap. Meeting, American Academy Headand Neck, New Orleans, LA, 1982

3. Constantian MB: An alar base flap to correct nostril andvestibular stenosis and alar base malposition in rhino-plasty. Plast Reconstr Surg101(6):1666, 1998

4. Fomon S: Rhinoplasty. A fine art. Arch Otolaryngol85(6):685A, 1967

5. Gubisch W: The triple swing flap technique to correct theasymmetry of unilateral cleft lip nose deformities. Scand JPlast Surg32(3):287, 1998

6. Gloster HM, Brodland DG: The use of perichondrial cu-taneous grafts to repair defects of the lower third of thenose. Br J Dermatol136(1):43, 1997

7. Jablon JH, Hoffman JF: Birth trauma causing vestibularstenosis. Arch Otolaryngol Head Neck Surg123(9):1004,1997

8. Meyer R, Kesselring UK: Functional plastic surgery of thenose. Laryngol Rhinol Otol62(5):179, 1983

9. Meyer R: Secondary Rhinoplasty—The Difficult Nose.W.B. Saunders: Philadelphia, 1988

10. Portuese WF, Stucker W, Grafton W, Shockley L: Gage-white: Perichondrial cutaneous graft. Arch OtolaryngolHead Neck Surg115:705, 1989

11. Schmid E: Personal communication

92 Stenosis of the Nasal Vestibule