Bilateral Intraoral Mucosal Flaps for Repair of Vestibular Stenosis Following Rhinoplasty & Airway Reconstruction: A Case Report

Vestibular stenosis of the nasal airway is a challenging problem for both the nasal surgeon and the patient [14]. Typically, a repair of vestibular stenosis is the result of previous trauma, burn, or congenital cleft lip and palate [5-8]. These stenotic vestibular wound beds are frequently associated with signifi cant scarring. In order to repair these defects, either vascular lining and/or structural support is necessary to prevent scar contracture from recurring [2-8]. Additional donor sites are often more accepted by patients who have Abstract

aggressive reduction rhinoplasty techniques. These aggressive reductions have the potential for more scarring and possibly obstructing the airway. We present here a simple method to repair bilateral vestibular stenosis following cosmetic rhinoplasty using a cleft rhinoplasty repair technique. The technique is not frequently used in the aesthetic rhinoplasty population, but is easily reproducible and safe.

Methods
A photographic chart review was conducted on a patient who iatrogenically acquired bilateral vestibular stenosis after a revision rhinoplasty and airway operation. The intraoperative photographs were analyzed and placed into a step-by-step method to repair vestibular stenosis in the aesthetic rhinoplasty and airway patient.

Results
A 25-year-old Middle Eastern female patient wished to have a smaller nose and underwent septorhinoplasty. The patient healed well, but returned with a complaint that the nasal tip was droopy and desiring an even smaller nose. In a second revision operation, the lower lateral cartilages were cephalically rotated with both a tip rotation suture and tongue in groove technique, and a nostril sill excision was conducted.
The patient was happy with the aesthetic result, but returned several months later with bilateral airway obstruction worse than the symptoms of the deviated septum [ Figure 1].
To limit more manipulation of the nasal airway and additional scarring without the need for additional grafts, we utilized a cleft rhinoplasty technique from the oral mucosa to repair the bilateral vestibular stenosis. The fi gures most appropriately explain the markings and technique for repair.
The patient was brought to the operating room under general anesthesia and the following steps were taken: Step 1: The nose and maxillary oral mucosa were injected with 0.25% marcaine with epinephrine for anesthetic and hemostatic control [ Figure 2].
Step 2: An incision was made along the fl oor of the nose with a number 15 blade scalpel. A nasal speculum was then inserted to dilate the fl oor of the nose and create a fl oor of nose defect [ Figure 3]. The width of the defect created was measured with calipers.
Step 3: Double hooks were placed in the upper lip to expose the oral mucosa. Bilaterally, a medially based oral mucosal fl ap was drawn stopping within 1 cm from the upper lip frenulum.
The width of the mucosal fl ap drawn was wider than the defect created into the nose [ Figure 4].
Step 4: The mucosal fl aps were then incised with Bovie electrocautery on cut and incised using full thickness mucosa [ Figure 5].
Step 5: Tunnels were then created from the oral side to the nasal side using mosquito clamps to protect the mucosal fl ap from being damaged [ Figure 6].
Step 6: One the tunnel was safely created, the mosquito clamp was then passed from the nose to the mouth to grasp the mucosal fl ap and deliver it into the nose [ Figure 7].
Step 7: The oral mucosal fl ap once delivered, was then inset in the fl oor of the nose. The freely mobile end of the mucosal fl ap was placed most posteriorly in the nose and sutured with a 4.0 chromic suture [ Figure 8].   Step 8: Doyle splints were then sutured into the nose using chromic suture to serve as a bolster for the graft and prevent motion [ Figure 9].
The patient was given Kefl ex for 5 days postoperatively for surgical prophylaxis. Hyperbaric oxygen therapy was initiated on post-operative day one and the patient received 5 treatments of one hour duration. The Doyle nasal stents remained in place for three days postoperatively prior to being removed. The patient was instructed to wear nasal stents for the remaining 11 days day and night. After that the nasa stents were worn nightly for one month. The patient was seen postoperatively once a week for six weeks.       we understood that the problem is not always related to support, but rather the forces of scar contracture on a "weaker" cartilage construct [2][3][4][5][6][7][8].

Discussion
The technique presented is a cleft rhinoplasty technique which can be accomplished in a small amount of time with a minimal amount of healing and swelling. The technique does not require re-opening the nose, which would risk the possibility of damaging the already weak lower lateral cartilages. It also does not require dissection to create nasal mucosal fl aps to nourish cartilage grafts, which may not survive in the scarred nose or possibly obstruct the nose even more. This technique can be helpful in the re-operative aesthetic patient who has an acceptable aesthetic result and would like an improvement in the airway.

Conclusion
Aesthetic and airway surgery of the nose can be very rewarding and humbling at the same time. Planning surgery with the intention to help patients understand the process and the possibility of airway obstruction late post-operatively is prudent. Preservation rhinoplasty techniques seem promising to reduce unpredictable scarring. An understanding of a few techniques to repair vestibular stenosis can be helpful to the young rhinoplasty surgeon early in practice.