Nostril Stenosis Repair Using the Indwelling Flap

Summary:

Nasal vestibule stenosis is a rare deformity that can be either congenital or acquired. Various surgical techniques for reconstruction have been described, including the use of skin grafts, composite grafts, and local tissue rearrangement. We present a novel approach using 2 V-Y indwelling advancement flaps. The flaps are raised from the columella and the nostril sill, using local nasal tissue adjacent to the stenotic area. This technique provides sufficient elongation of the nostril diameter on the stenotic site, ensures well-vascularized tissue (flap-only reconstruction) that prevents restenosis, and achieves aesthetically pleasing results. Follow-up at 12 and 24 months postoperatively showed no restenosis with a satisfactory aesthetic result and patient satisfaction.

The nose is one of the most prominent facial features, serving both aesthetic and functional purposes. The nasal vestibule plays a critical role as the primary entry point for air passage. Deformities in this region can result in both functional and aesthetic problems, including nasal obstruction, mouth breathing, and discomfort.

Nostril stenosis, either congenital or acquired, presents a significant reconstructive challenge. Acquired causes include trauma, infections, burns, iatrogenic interventions (eg, nasal packing or electrocautery), and prolonged nasal intubation in premature infants. Managing this condition is complex due to the intricate anatomy of the nasal vestibule and its surrounding structures. The primary surgical goal is to reconstruct anatomically appropriate nostrils while maintaining long-term patency and preventing restenosis, ensuring both functional and aesthetic outcomes.

Several surgical techniques have been described for treating nostril stenosis, including split-thickness and full-thickness skin grafts,^1,2 composite grafts,^3–5 local flaps,^6,7 and techniques such as Z-plasty, W-plasty,⁸ and star-plasty.⁸ Postoperative stenting is often supplemented to prevent restenosis. This case report presents our experience with nostril stenosis reconstruction using 2 V-Y flaps located on opposite sides of the deformity, based on the available tissues (hence referred to as “indwelling flaps”), with an emphasis on their advantages in achieving long-term patency and aesthetic restoration.

CASE PRESENTATION

A healthy 16-year-old girl presented with left nostril stenosis of lifelong duration, resulting from prolonged nasal intubation at the involved site as a premature infant. Her medical or surgical history was otherwise unremarkable. On examination, a moderate-to-severe degree of stenosis of the left nostril was noted, involving both the alar rim and the nostril sill. Her nasal breathing on the involved side was compromised. The right nostril and septum were normal (Fig. 1).

Fig. 1.

Preoperation nostril stenosis (worms’-eye view).

Surgical Technique

The patient was operated on by the senior author (A.M.). The procedure was performed under general anesthesia. Two V-Y advancement flaps were marked. The first extended from the columellar base through the columellar pillar to the scarred soft triangle on the stenotic part, and the second extended from the nostril sill to the alar sidewall (Figs. 2, 3). After marking, a small volume of 0.5% lidocaine with 1:200,000 epinephrine was used to locally infiltrate the nasal vestibule.

Fig. 2.

Planning of the V-Y advancement flaps: columellar flap, from the columellar base to the scarred soft triangle of the stenotic area; sill flap, from the nostril sill to the alar sidewall.

Fig. 3.

Intraoperative planning using premade drawings of the flap.

Using a no. 11 blade, the flaps were incised and advanced in a V-Y manner. Careful insetting of all the skin flaps was followed by closure of the wounds with a few subcutaneous 5-0 Monocryl and cutaneous interrupted Nylon 6.0 sutures. (See figure, Supplemental Digital Content 1, which displays the final operative result following nostril stenosis repair using V-Y advancement flaps, demonstrating restored contour and airway patency, https://links.lww.com/PRSGO/E390.) A Xeroform nasal pack was lightly inserted into the nasal cavity. Mupirocin ointment was applied twice daily for 10 days. The sutures were removed at the end of this period.

Follow-up

The postoperative course of the patient was uneventful. The patient wore a nostril retainer for 6 months. A satisfactory correction of the deformity was achieved, with the result being stable during 2 years, even after cessation of the use of the nostril retainer (Fig. 4).

Fig. 4.

Postoperative follow-up at 12 months (worms’-eye view).

DISCUSSION

The rarity of nostril stenosis creates a certain difficulty in standardizing its management, as the literature describes various surgical techniques^2–8 aimed at restoring the normal nasal vestibule shape. Small modification to the nasal base can yield significant functional and aesthetic improvements. Among the most commonly reported techniques in the literature are composite grafts combined with Z-plasty. Our technique, using 2 V-Y advancement flaps, offers a novel solution for correcting nasal stenosis in cases where the columellar and nostril areas are not scarred.

This approach uses exclusively flap-based techniques, eliminating the need for skin or composite grafts. This approach leverages well-vascularized tissues from surrounding healthy areas, facilitating optimal healing, reducing the risk of necrosis or restenosis, and ensuring both functional and aesthetic outcomes. By preserving the natural contour of the nasal vestibule, the technique maintains biomechanical stability, which contributes to sustained nasal patency and improved symmetry. The dimensions of the flaps are tailored to the size of the tissue defect, which correlates with the severity of the stenosis. This technique is particularly advantageous in cases of stenosis involving both the alar rim and nostril sill, as demonstrated in our case; however, its application in more extensive or recurrent cases—where scar tissue or compromised vascularity may pose challenges—requires further evaluation. Cartilage support was not needed in this case but can be added, if necessary, for example, using a columellar strut placed deep to the columellar flap. Long-term follow-up at 2 years demonstrated both functional improvement in nasal breathing and a stable aesthetic result, suggesting the durability of this approach.

CONCLUSIONS

Nostril stenosis is a rare and challenging condition to treat with a single, reliable, and long-lasting procedure. We described a novel technique in which 2 V-Y advancement flaps from both the columellar and alar sidewall are brought together to reconstruct the nostril. The advantages of this technique include being a single-stage, all flap-based procedure that is tailored to the deformity. By avoiding grafts, the procedure reduces the risk of restenosis and provides long-lasting functional and aesthetic benefits.

PATENT CONSENT

Informed consent was obtained from the patient’s legal guardian for the publication of this case and the accompanying images. Any detail that might disclose the patient’s identity has been omitted.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

The diagram of the surgical technique (Fig. 2) was created by the author Katya Chapchay.

ETHICAL APPROVAL

This report describes a single clinical case and adheres to ethical standards for case reporting.