Surgical pearl: A disposable syringe barrel is a better alternative to a Foley’s catheter for intraoperative nasal ala stabilization

To the Editor: The nasal ala is one of the most frequent surgical sites for Mohs surgeons and for cosmetic surgeons. To perform accurate and elegant surgery over the ala, the skin surrounding the lesion needs to be stretched and fixed.^1,2 Stretching the skin around skin lesions on the nasal ala is problematic because it lacks underlying bony and or fibrous tissue. There are several techniques, such as insertion of the tip of the finger into the nasal antrum, insertion of the back of the scalpel or the back of the forceps, and insertion of gauze and a Foley catheter, that are used to stretch and stabilize the ala.^1,2 The use of a Foley catheter is a bit better and safer but it is expensive and the site cannot be manipulated during the operative procedure, which is sometimes desired by surgeons and dermatologists to get an optimum stretch at a particular site of the ala. Secondly, in making a deep incision in the case of skin cancers over the nasal ala, the catheter can get nicked, which may be a cause for hindrance during the operation. In addition, the catheter cannot be used at the same time for both nostrils due to air passage blockage. These drawbacks of the Foley catheter can be minimized by inserting the inexpensive and readily available barrel of a disposable syringe into the nasal antrum during excision, in cosmetic as well as reconstructive surgery of the nasal alae.

I take different sizes of disposable syringes (1, 3, 5 or 10 mL) and then measure the outer diameters of the barrels from the piston side of the syringe. Their respective diameters are 8 mm, 12 mm, 17 mm, and 18 mm, but there are slight variations by manufacturer. The nostril diameter is measured tentatively, for a better assessment of the optimum size of the barrel, with the help of a fine forceps or calipers after stretching the hands gently in the nostril in the antero-posterior and in vertical to antero-posterior direction. The calipers or forceps are inserted in the nostril outwardly and the distance between two hands in the stretched state is measured in millimeters. The average diameter in each direction is the effective diameter of the nostril. Thus, the size of the barrel should be chosen according to the diameter of the nostril. Following this, the size of the lesion and its excision line are marked and anesthesia is obtained by injection xylocaine (1% with adrenaline 1:200 000) at the operative site over the ala for localized and small lesions or by general anesthesia for major reconstructive surgery on the alae. Then the barrel is inserted into the nostril from the needle hub side of the syringe, after removing the needle, by a gentle screwing movement until the site of operation becomes stretched, and the piston of the syringe is removed (Figure 1). If the patient is feeling unease during insertion of the barrel particularly, which is rarely needed, in case of operative surgery under local anesthesia, then xylocaine can be sprayed with the help of the same syringe or by a spray unit, or jelly can be applied over the barrel surface before inserting the barrel of the syringe. For better air passage, if needed, the distal portion of the syringe with its needle hub can be cut before insertion of the barrel.

Fig 1.

Barrel of disposable syringe inserted into the nasal antrum for its stabilization

For peri-operative stabilization and manipulation of the nasal ala, the barrel of a disposable syringe is a simple, readily available and inexpensive instrument. It can be manipulated during the operation according to needs, which is difficult with the catheter.^1,2