Columellar reconstruction with chondrocutaneous graft after injury caused by CPAP

Introduction: Continuous positive pressure in the nasal airways (CPAP) is a non-invasive form of ventilation used in premature newborns in intensive care units. However, it can affect the nose of these patients, even evolving with ischemia and columellar necrosis. Several techniques are described to reconstruct the columella, such as skin grafts, composite grafts, local flaps, and free flaps, but the atrial chondrocutaneous graft has stood out. This study aims to describe a case of columella necrosis using CPAP with reconstruction using posterior atrial chondrocutaneous grafting. Case Report: A brown, female patient, with a history of prematurity and prolonged use of CPAP when she was born due to hyaline membrane syndrome, developed columella necrosis. The patient underwent posterior auricular chondrocutaneous grafting to reconstruct the columella. She presented a satisfactory surgical result, evolving with 100% graft vitality. Discussion: Columellar necrosis associated with the use of CPAP can be aesthetically and functionally debilitating, and represents a reconstructive challenge. The options for obtaining acceptable results are limited. However, the use of ear grafts is technically straightforward, uses structurally similar donor tissues, does not cause additional scarring on the nose, is performed in a surgical period, and generally has an excellent result. Posterior auricular composite grafting for columellar reconstruction proved safe, with satisfactory aesthetic and functional results and minimal morbidity in the donor area. ■ ABSTRACT

local flaps, and free flaps 7 . Among these various procedures, the auricular chondrocutaneous graft is one of the most advantageous methods, as it allows the reconstruction of the structural cartilage together with the skin, in a single surgical time, in addition to the ear being considerably similar in shape, curve, color and texture to the columela 1,7 .
The objective of this study is to report a case of an atrial chondrocutaneous graft for columellar reconstruction after necrosis using CPAP.

CASE REPORT
Female patient, 4 years old, brown, with a history of prematurity (gestational age 31 weeks and 4 days) and fetal distress due to placental abruption, developed hyaline membrane syndrome, requiring mechanical ventilation for 16 days and continuous positive pressure in the nasal airways for another 8 days. As a result of using CPAP, he presented a columella lesion with local necrosis. On physical examination, a patient with no columella, with a consequent drop in the tip of the INTRODUCTION Continuous positive airway pressure (CPAP) is a non-invasive form of ventilation used as a method of respiratory support in premature newborns in intensive care units as an alternative to endotracheal intubation and tracheostomy 1-6 . However, due to immaturity, the nose of these patients can be easily affected 6 . Nasal injury is a relatively common consequence secondary to CPAP, with an incidence of around 13.2% to 50% 1,5 , and can vary from edema and erythema to columellar laceration and necrosis 3,5 . Less than 1% of these patients develop irreversible ischemia and necrosis, resulting in a spectrum of nasal disfigurement 2 .

DISCUSSION
Although nursing initiatives have sought to reduce the incidence, nasal injury remains a common problem in preterm newborns who receive noninvasive respiratory support, especially in preterm infants born less than 30 weeks of gestation 2,3,5,6 . Columellar necrosis associated with CPAP use can be aesthetically and functionally debilitating and represents a reconstructive challenge 2 . The options for obtaining acceptable functional and cosmetic results are limited in the reconstruction of this delicate subunit, but the use of composite grafts is consistent with many fundamentals of plastic surgery 8 .
Nasal reconstruction requires the management of several layers simultaneously in a three-dimensional shape 7,8 . The practice has shown advances since in 1985 9 , surgeons Burget and Menick, proposed the principle of subunits of the nose 10 . Nasal columella has traditionally been a subunit that is difficult to repair due to its unique contours, limited availability of adjacent skin, and tenuous vascularization 10 . The simplicity and elegance of using compound ear grafts to repair such defects were already recognized in 1896 8 . The procedure is technically straightforward, uses structurally similar donor tissues, does not cause additional scarring on the nose, performs in a surgical procedure, and usually has a very satisfactory result 8 .
Posterior auricular composite grafting for columella reconstruction proved safe and had little technical difficulty in repairing the described lesion. The aesthetic and functional result was satisfactory, with minimal morbidity in the donor area.