Composite grafts have advantages for small nasal defect coverage. However, if the the outer skin defect and the inner skin defect have a different location, conventional composite grafts encounter considerable limitations. Therefore, we devised a 4-limbed graft to overcome this limitation by use of soft tissue transposition.
Over the course of 5 years, this auricular composite graft was used in 10 cases of reconstruction. We harvested skin and cartilage from the helix. The composite graft had 2 limbs of soft tissue to cover the nasal defect and another 2 limbs of cartilage to support nasal framework. The cartilage limbs extended 3 to 5 mm beyond the margin of the skin. The direction of each limb was modified according to defect position.
All 10 composite grafts survived completely. All composite grafts shrank by a small percentage of their bulk. Nonetheless, the nasal framework was maintained to an acceptable extent because of the cartilage limbs.
This technique was capable not only of covering defects in the alar and columellar area, but also of maintaining a satisfactory external appearance, because the 2 limbs of cartilage included in the graft strengthened the nasal framework and provided modest support to the nostril margin. The 2 limbs of soft tissue covered the defect area. Our 4-limbed auricular chondrocutaneous composite graft is reliable option for the reconstruction of alar and columellar defects in a single-stage procedure.
The nose has a dominant position on the face, and is of great importance in the context of facial aesthetics [
Reconstruction is not easy if defects occur in the lower third of the nose, because the lower third of the nose is a single subunit and has limited mobility [
Many methods have been developed for covering nasal defects. The most basic method is primary closure, but this method encounters limitations because alar asymmetry is unavoidable due to the intrinsic tissue defects. In addition, forehead flaps have been developed. However, forehead flaps are likewise not suitable for relatively young patients because they involve a multi-stage technique that is inconvenient for the patient. Local or regional flaps have the disadvantage of causing visible midfacial scars [
Auricular chondrocutaneous composite grafts are relatively commonly used for reconstructing nasal defects. The helix, antihelix, concha, and lobule are often used as the donor sites [
For the above reasons, the chondrocutaneous composite graft began to be harvested from the ear helix. However, all grafts have some degree of shrinkage, and even slight shrinkage can cause prominent aesthetic effects on the nose. For this reason, Qing et al. [
Soft-triangle defects on the nose are more difficult to correct than dorsal defects. This is because the soft triangle may have different defect directions in the inner mucosa and outer skin when defects occur. For example, the inner mucosa can form a defect vector of 3 o’clock, while the outer skin may have a defect vector of 9 o’clock. To overcome these problems, a 4-limbed ear helix chondrocutaneous composite graft was proposed. Our study reports an improvement of the previous auricular composite graft. The 4-limbed composite graft consisted of 2 soft-tissue limbs and 2 cartilage limbs. The 2 soft-tissue limbs were intended to cover the soft-tissue defect of the nostril lining, and the 2 cartilage limbs were intended to cover the nasal framework. This structure may be able to effectively cover the nostril defect with a convex curvature and with different layers for the inner mucosa and outer skin.
Therefore, a composite graft with 4 limbs was devised, with 2 limbs (the soft-tissue/cartilage portion) cross-linked with each other. This technique adequately covered the nostril defect site. The purpose of this article is to introduce a series of patients in whom a 4-limbed auricular chondrocutaneous composite graft was used to reconstruct the defects of the ala and soft triangle.
Ten patients who underwent nasal reconstruction using a chondrocutaneous composite graft were analyzed. The indications for the chondrocutaneous composite graft included notching or defect of the ala and stricture of the nostril. Their preoperative and postoperative photographs, office charts, and hospital records were reviewed retrospectively.
The helical rim and root were used as donor sites for all grafts. To make each defect site normal, we analyzed the size, shape, contour and components of the defect site after releasing of the scar. A similar portion of the ear was used for the graft, and was harvested. When the incision line was considered, the helical crus of the ear was used to retain the cartilaginous portion of the graft beyond the margins of the overlying skin graft to serve as stabilizing limbs once the graft was inserted in the recipient site (an “inter-locking graft”) [
The incision line of the donor site was marked on either side, following the curvature of the helical crus. The donor site was anesthetized with 1% lidocaine with diluted epinephrine. The donor site was incised using a No. 15 blade, and cutting was done perpendicular to the posterior surface of the auricular skin. Composite grafts are more often harvested from the anterior surface of the auricular concha than from the posterior surface [
The composite graft was inserted into the soft-triangle defect in the nostril area. The 2 cartilage limbs were inserted in the nostril lining (
We took care to preserve the vascular components, to remove all devitalized tissue, and to increase the contact surface not only of the wound edge, but also of the wound bed. Using curved Metzenbaum scissors, the skin was trimmed to expose the underlying cartilage 3 to 5 mm beyond the margin of the skin portion. The 2 remaining soft-tissue limbs were used to cover the nostril soft-tissue defect. Once the cartilage had interlocked, the external skin of the graft was approximated using No. 6-0 non-absorbable sutures. To minimize vessel strangulation and to enhance the anastomoses between the 2 vascular beds, subcutaneous tissue suturing was not performed. The cartilage itself was not sutured on any nasal surface. After the suture, a wet dressing was placed on the graft site to improve the success rate, using an antibiotic ointment but not using an immobilized compression (e.g., Merocele® packing). We did not use any foam dressing or occlusive dressing. The patients did not use an extra pillow because the soft-tissue limb of the composite graft could maintain the appropriate nostril lining. Additionally, if the graft is compressed by a pillow, it may interfere with skin graft success by affecting the vascular circulation.
After the operation, the graft site manifested swelling and a reddish skin color. Then, within 1 to 2 days, the color of the graft became cyanotic purple due to venous congestion, which remained approximately until week 2, until adequate venous drainage developed. The stitches were removed after 15 days. The patients visited the hospital every month for postoperative monitoring.
Over a 5-year period, 10 patients underwent nasal reconstruction using the chondrocutaneous composite graft. All 10 grafts completely survived, and none of the patients showed a noticeable contour deformity on the donor site. Throughout the long-term follow-up period, however, all the composite grafts shrank by a small percentage, and the patients presented varied degrees of pigmentation. Nonetheless, the shrinkage was minimized by the 3 to 5 mm extension of the cartilage over the skin, and we performed laser treatment to correct discoloration.
Thus, satisfactory results were obtained from the nostril reconstruction procedures, and deformities of the donor sites of large defects were minimized via the 2-limb soft-tissue portion and the other 2-limb cartilage portion of the composite graft from the ear and open ointment moisture balance dressing. Two typical cases are presented below.
A 43-year-old man was referred to our plastic surgery unit due to a human bite. On examination, the patient exhibited a definite defect (approximately 1×0.5 cm) in the soft triangle of the left alar area, with a collapsed left-nostril lining (
After meticulous dissection of the graft recipient site, minimal debridement was carefully performed at the recipient site, and the composite graft was sutured at the nostril lining.
After the operation and the serial follow-up, complete coverage of the defect with excellent wound healing results was obtained from both the aesthetic and functional viewpoints (
A 53-year-old man had a soft-tissue triangle defect at the anterior nostril site and a columellar vestibule defect at the posterior nostril site due to a traffic accident. Additionally, he had an asymmetric nostril lining, with the right part larger than the left part (
Koreans have smaller noses than Caucasians [
The difference between our operation and the conventional composite graft is that our method involved 2 soft-tissue limbs and 2 cartilage limbs. It is also noteworthy that each of the 2 limbs had a 4-limb structure that intersected with that of the other. In particular, the 2 soft-tissue limbs contained a certain portion for forming a transposition flap, which was useful for covering defects of the alar and columellar areas that had various vector directions. Due to the flexibility of the soft-tissue portion, a transposition flap with a rotation arc was possible. As the rotation arc functioned independently in the 2 soft-tissue limbs, the inner and outer surfaces of the nostril could be covered in different anatomical areas (
As this graft contained 2 cartilage limbs with a solid character, there was no need for an inner retainer to hold the nostril or device in place to compress it. This promoted the patients’ comfort. Moreover, the cartilage limbs were useful for strengthening the nasal framework, minimizing potential future scar contracture, and maintaining the nostril shape. Finally, as 2 layers of skin were harvested from the donor site, the full-layer nostril defect could be reconstructed in a single stage, making the procedure convenient, cost-effective, and less invasive.
Nonetheless, this study has several potential limitations. First, composite grafts are not frequently used in large defects because of the reduced survival rate [
The 4-limbed auricular chondrocutaneous composite graft is a reliable option for the reconstruction of alar and columellar defects in a single stage. It is a simple and superior method for reconstructing the ala and columella compared to other operations in terms of color, shape, flexibility, and structural support. Relatively large alar and columellar defects can be reconstructed successfully with this composite graft, without donor site morbidity.
This work was supported by the Soonchunhyang University Research Fund.
No potential conflict of interest relevant to this article was reported.
Patients provided written consent for the use of their images.
Cartilage harvested from the helical rim had a horizontal length of about 15 mm and a vertical length of about 7 to 8 mm. We obtained 2 limbs of proper soft tissue and 2 limbs of cartilage.
The 2 limbs composed of soft tissue (red portion) could be flexibly transposed at the desired angle and could cover the defect of the soft triangle 3-dimensionally.
Preoperative photographic findings of case 1: a worm’s eye view.
Change of the left nostril lining in an oblique view. During the follow-up period, complete coverage of the defect with excellent wound healing was obtained, with good results from the functional and aesthetic point of aureus. OP, operation.
Change of left nostril lining in a worm’s eye view during the follow-up period. OP, operation; POD, post operative days.