One-Stage Reconstruction of Nasal Defects: Evaluation of the Use of Modified Auricular Composite Grafts

ABSTRACT

Complex nasal defects in the distal regions of the nose are cosmetically difficult to repair. In 70 patients over a period of 10 years, defects of the nasal ala and the soft triangle, nasal tip, columella, and columellar-lobular junction were reconstructed with modified auricular composite grafts. A randomized group of 40 of these patients was assessed after a mean of 55.5 months to evaluate the method's functional and cosmetic long-term results. The majority of the patients (60%, n = 48) had been treated primarily for basal cell carcinoma. Of all defects, 57% (n = 46) measured 2 to 3 cm in width and 43% (n = 34) 1 to 2 cm. Seventy-five percent (n = 60) of all defects were composite lesions involving skin, cartilage, and vestibular mucosa, in contrast to 25% (n = 20) involving skin and cartilage with intact vestibular skin. Two crucial technical modifications seemed to have improved survival for larger grafts: first, the use of hinge flaps from the margins of the defect to obtain a well-vascularized recipient bed and optimization of the raw contact surface; second, postoperative gentle scarification of the graft in combination with a constantly applied heparin solution decongests venous stasis normally seen in such grafts. This maneuver establishes a stable and early blood supply enhancing graft take. With this type of treatment, 67 (84%) grafts healed well without further complications, whereas 13 (16%) grafts developed complications, resulting in partial (n = 9) and total (n = 4) necrosis of the transplant. Six of these patients underwent a secondary reconstruction using another auricular composite graft. Long-term results of this method have turned out to be very satisfying in terms of functional and cosmetic outcome and patient acceptance.

Nasal defect - composite graft - hinge flap - cosmetic outcome

REFERENCES

• 1 Frank R. Defectus marginis alae nasi.  Jahrb Wien KK Krankenanst. 1896;  5 258
• 2 König F. On filling defects of the nostril wall.  Berl klin Wochenschr. 1902;  39 137
• 3 Gillies H D. Plastic Surgery of the Face. London, UK: Oxford Medical Publication; 1920
• 4 Brown J B, Cannon B. Composite free grafts of the skin and cartilage from the ear.  Surg Gynecol Obstet. 1946;  82 253
• 5 Dufourmentel C, LePesteur I. [Composite auricular graft in reconstruction of the lower part of the nasal pyramid. Apropos of 43 grafts].  Ann Chir Plast. 1973;  18 199-212
• 6 Sherris D A, Fuerstenberg J, Danahey D, Hilger P A. Reconstruction of the nasal columella.  Arch Facial Plast Surg. 2002;  4 42-46
• 7 Symonds F C, Crikelair G F. Auricular composite grafts in nasal reconstruction: a report of 36 cases.  Plast Reconstr Surg. 1966;  37 433-437
• 8 McLaughlin C R. Composite grafts and their blood supply.  Br J Plast Surg. 1955;  7 274-278
• 9 Chandawarkar R Y, Cervino A L, Wells M D. Reconstruction of nasal defects using modified composite grafts.  Br J Plast Surg. 2003;  56 26-32
• 10 Davenport G, Bernard F D. Improving the take of composite grafts.  Plast Reconstr Surg Transplant Bull. 1959;  24 175-182
• 11 Ratner D, Katz A, Grande D J. An interlocking auricular composite graft.  Dermatol Surg. 1995;  21 789-792
• 12 Conley J J, Vonfraenkel P H. The principle of cooling as applied to the composite graft in the nose.  Plast Reconstr Surg (1946). 1956;  17 444-451
• 13 Nichter L S, Morwood D T, Williams G S, Spence R J. Expanding the limits of composite grafting: a case report of successful nose replantation assisted by hyperbaric oxygen therapy.  Plast Reconstr Surg. 1991;  87 337-340
• 14 Burget G C, Menick F J. Nasal reconstruction: seeking a fourth dimension.  Plast Reconstr Surg. 1986;  78 145-157
• 15 Burget G C, Menick F J. Nasal support and lining: the marriage of beauty and blood supply.  Plast Reconstr Surg. 1989;  84 189-202
• 16 Menick F J. A 10-year experience in nasal reconstruction with the three-stage forehead flap.  Plast Reconstr Surg. 2002;  109 1839-1855 discussion 1856-1861
• 17 Spear S L, Kroll S S, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects.  Plast Reconstr Surg. 1987;  79 915-920