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Correspondence to Rajiv Y. Chandawarkar MD, Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Box 443, 1515 Holcombe Boulevard, Houston, TX 77030, USA
Affiliations
Crystal Plastic Surgeons, Crystal Clinic and, Division of Plastic Surgery, Akron General Medical Center, Summa Health System and, North Eastern Ohio Universities College of Medicine, Akron, OH, USA
Crystal Plastic Surgeons, Crystal Clinic and, Division of Plastic Surgery, Akron General Medical Center, Summa Health System and, North Eastern Ohio Universities College of Medicine, Akron, OH, USA
Crystal Plastic Surgeons, Crystal Clinic and, Division of Plastic Surgery, Akron General Medical Center, Summa Health System and, North Eastern Ohio Universities College of Medicine, Akron, OH, USA
Nasal defects in certain areas such as the columellar–lobular junction, the alar rim and the soft triangle are cosmetically challenging to reconstruct. This paper describes a technique that enables the use of composite grafts for these specific nasal defects. Termed modified composite grafts (MCG), they involve creation of a dermal pedicle on the graft that enlarges the surface area of contact between the graft and the recipient bed. In addition, we used postoperative surface cooling for grafts larger than 1.5 cm. Both these modifications allow reconstruction of defects larger than 1.5 cm, improve graft survival and yield a better cosmetic outcome. Using representative cases from our series of 50 patients, we demonstrate that MCGs provide a simple, single-staged alternative to otherwise complex reconstruction of specific areas of the nose. They offset the need for local flaps, avoid donor-site scars and yield excellent long-term results.
They are readily available and easy to perform and can provide a good cosmetic outcome. When placed over cartilage in the distal portion of the nose, their survival depends on revascularization from the periphery.
The sidewalls of the defect have to be of sufficient depth to ensure good tissue contact and the graft must be limited in size. Even with partial take, a good result can still be obtained after secondary contraction.
In certain critical areas of the nose, however, the elements for graft survival are missing. Specifically, defects at the columellar–lobular junction, alar rim and the soft triangle are most challenging (Fig. 1A) . Characteristically, these areas have a thin skin cover directly under which is the supporting cartilage (Fig. 1B). Any surface excision here exposes cartilage and leaves a defect with only a very thin rim of 1–2 mm of soft tissue at the periphery. These wounds will seldom support a skin graft, much less a composite graft. Even if a conventional composite graft were technically feasible, even a minor loss of the graft in these areas would result in notching and a compromise of the final result. A partial loss of a composite graft in these areas seems to be the rule rather than the exception.
Figure 1A. Anatomic subunits treated using MCG. B. Areas of thin skin on the lower margin as well as the dorsum of the nose. C. The plane of dissection of the pocket depends upon the location of the nasal defect and its specific anatomy. Shaded areas and arrows show the possible directions in which the dissection pocket can be created. D. Defects in the soft triangle are dissected to create a pocket in an oblique plane along the alar rim.
To avoid these problems and assure greater reliability we have used an extended dermal pedicle attached to the composite graft. This pedicle provides a broad contact surface for early graft survival. When combined with surface cooling for larger grafts, a near 100% survival can be achieved.
1. Materials and methods
We studied 50 patients with composite tissue defects who met the following inclusion criteria. Demographic data was collected.
Site. The defects were confined to the columellar–lobular junction, the alar rim and the soft triangle (Fig. 1A). Patients with defects spanning combinations of these areas were also included. Nasal-tip defects were excluded.
Size. All defects sizes up to 2.0 cm were included. Defects larger than 2 cm were treated with strict adherence to the subunit principle, which mandates the replacement of the entire subunit rather than reconstruction of its part.
Nature. By definition, these defects were composite wounds involving skin, cartilage and, in some cases, vestibular skin. In addition, the surrounding skin was inadequate to support and nourish a composite graft.
Past medical or surgical history. Patients with compromised recipient beds from either radiation therapy or previous surgery were specifically included.
1.1 Operative technique
1.1.1 Preparation of recipient site
Prior to obtaining the graft, the recipient site is measured and a subcutaneous pocket is created at the base of the defect. The size of the pocket is dependent upon the size of the defect. We recommend a pocket size at least twice the area of the defect.
The plane of dissection of the pocket varies according to the location of the nasal defect and its specific anatomy (Fig. 1C).
The alar rim shows internal keratinized skin in close contact with alar cartilage.
External to the cartilage there is thin subcutaneous layer beneath a thick skin cover and at the alar margins where the dermis of the outer skin abuts the dermis of the vestibular skin.
In this situation the pocket is created in a subdermal plane of the outer skin (Fig. 1C).
In the region of the columellar–lobular junction the pocket is within the subcutaneous fat in both directions along the axis of the columella. This bi-axial pocket allows for a better anchorage of the composite graft.
Defects in the soft triangle are dissected to create a pocket in an oblique plane along the alar rim (Fig. 1D) or proximally over the nasal tip.
1.1.2 Graft harvest
Grafts are planned depending upon the need for tissue type for the defect. In patients requiring cartilage for skeletal support we used auricular grafts harvested from the root of the superior helix. A generous amount of preauricular skin (not less than twice the size of the graft) is harvested in continuity with the graft to create the dermal pedicle. The dermal extension is planned to allow the final scars to lie in lines of skin crease. In areas where the extension is limited, pedicles are created bilaterally. All grafts are harvested without the use of epinephrine.
1.1.3 Graft preparation
The pedicled portion of the graft is de-epithelized and debulked by excising excess fat but preserving the subdermal plexuses. In addition, the pedicle is tapered and thinned out distally to allow for a smooth inset without an obvious step at the edge.
1.1.4 Inset
After careful hemostasis, the recipient pockets are retracted and the MCG is gently placed into the defect with the dermal pedicle fitting snugly into the pocket. Figure 2 shows a defect of the alar rim and soft triangle defect (Fig. 2A), which was reconstructed using a modified composite graft (MCG). The MCG was carefully measured (Fig. 2B and C) and debulked (Fig. 2D). The inset is shown in Figure 2E and the final postoperative result in Figure 2F. Care is taken to prevent undue tension on the pedicle or create a pocket that is too large and allows seroma or hematoma to develop. The edges of the graft are then carefully approximated with simple fine interrupted sutures, and the whole wound is immobilized with steristrips.
Figure 2A. Preoperative view of a patient with an alar rim and soft triangle. B. MCG is carefully measured. C. The potential pocket for inset is marked. D. The graft is debulked and de-epithelialised. E. The flap is inset into the defect. F. Postoperative view at 8 weeks.
Postoperatively, MCGs larger than 1.5 cm were subjected to surface cooling. Continuous use of icepacks over the steristrip dressing for 24 h after surgery ensured adequate cooling. The patients were kept at the treatment facility for extended observation during this time.
2. Results
This single-staged reconstructive procedure was well tolerated by all patients. Preoperative, intraoperative and postoperative views of patients with lobular–columellar junction, alar rim and soft triangle are shown in Figure 3, Figure 4, Figure 5, Figure 6. It may be argued that these defects could be reconstructed using a composite graft alone. However, there is risk of loss of such a graft, which, even if incomplete, would cause a visible cosmetic deformity. The restoration of contour achieved in each of the three areas using a MCG is remarkable. Long-term results demonstrate that the cosmetic appearance is stable and there is no late scarring or retraction. Two patients experienced a partial loss that manifested with surface blistering which healed well without any secondary surgical intervention. One patient developed recurrent inclusion cysts in the nasal skin overlying the dermal pedicle. We had harvested the dermal pedicle from the temporal hairline, and speculate that small hair follicles may be the cause. We have since changed our placement of the dermal pedicle so as to avoid this area. None of the patients suffered any donor-site complications.
Figure 3A. Defect following resection of a basal cell carcinoma at the lobular–collumellar junction. B. MCG with the extended de-epithelized dermal pedicle. C. The flap is inset into the defect. D. Postoperative view at 6 months.
Figure 4A. Preoperative appearance following an incisional biopsy of lesion (performed elsewhere). B. Defect following resection of a basal cell carcinoma at the alar rim. C. The composite graft includes the helical root. The arrow indicates the extension of the incision along the preauricular crease. D. This incision allows upward mobilisation and primary closure of the donor-site defect. E. The flap is inset into the defect. F. Appearance of the reconstructed site 10 months postoperatively. G. The donor-site scar.
Figure 5A. Preoperative view. B. Defect following resection of a basal cell carcinoma at the soft triangle. C. The composite graft includes the helical root. D. Anterior and E. oblique views of the reconstructed site 12 months postoperatively.
Figure 6A. Preoperative view. B. Defect following resection of a basal cell carcinoma at the soft triangle. C. The MCG is designed with a biaxial dermal pedicle. D. MCG prior to inset; note the bilateral dermal pedicles. E. The graft is inset into the defect. F. Lateral and G. anterior views 10 months postoperatively.
The long-term results were cosmetically very pleasing. There was minimal scarring and virtually no distortion of the anatomic features that characterize these ‘difficult-to-reconstruct’ areas of the nose. Both the contour from the skeletal support and the skin surface were well preserved. Patients were very pleased with the outcome of the MCG procedure due to several reasons. It was a single-staged procedure; there were no mid-face donor scars from local or regional flaps; and there was good restoration of contour.
3. Discussion
When repairing nasal defects, one must recognize and accurately replace missing elements. In addition to skin one must frequently provide soft tissue for restoration of contour and cartilage for structural support. These are especially necessary in the distal third of the nose. Although local or regional flaps have been well described, they are particularly difficult to adapt to critical areas such as the alar rim, soft triangle or the columellar–lobular junction. Here, the soft tissues are quite thin and closely adherent to underlying cartilage. Unless one is replacing an entire nasal subunit most flaps are too bulky and fail to provide the fine contour of adjacent tissue.
A disadvantage of these methods include the need to use multiple tissues for reconstructing lining, support and cover. This adds significantly to the bulk thereby affecting cosmesis. Many of these patients need secondary debulking to restore contour. Donor-site morbidity, including septal perforation and nasal and facial scars, further add to their morbidity. Conventional composite grafts can be very useful, but are frequently unreliable in these areas. The shallow defect fails to provide sufficient contact for revascularization, and the usually exposed cartilage. Partial loss, with residual notching or contour deformity is common.
Composite grafts, especially from the ear, were first described by Konig
These grafts depend upon early inosculation from the surrounding tissue and subsequent revascularization from the recipient margin for their survival. Consequently, they are limited in size and have a high failure rate if greater than 1.5 cm.
Besides size, there are three factors that directly affect graft survival. The first is the relative degree of contact between the graft and its recipient bed. The presence of fat or cartilage on the undersurface of the composite graft acts as a barrier to inosculation and revascularization. Ways of overcoming the cartilage barrier have been described and include perforating the cartilage at several places to allow through-and-through contact.
Secondly, the quality of the recipient site can dictate survival. A scarred or irradiated site compromises early graft nutrition and result in its failure.
Thirdly, metabolic modifiers can decrease the nutritional requirement of the grafted tissue or increase the vascularity via biochemical agents. Conley and vonFraenkel advocated cooling of composite grafts, theorizing that lowering the metabolic rate of the grafted tissue would slow autolysis and, consequently, protect the graft until revascularization occurred.
Transactions of the Third International Congress of Plastic and Reconstructive Surgery. Transactions of the Third International Congress of Plastic and Reconstructive Surgery. Excerpta Medica,
Washington1963
Cooling allowed the survival of grafts larger than 2.8 cm×3.0 cm. All our MCGs that were larger than 1.5 cm were treated with postoperative cooling for 24 h. Whether cooling is essential in combination with MCGs warrants investigation. How much cooling, how it can be controlled and how long is optimal remain unanswered questions.
Studies using angiogenic growth factors with penetrance enhancers and methylpredisone
have revealed a better survival of composite grafts in animal models.
We have found that modifying the composite graft with an extended pedicle has greatly enhanced survival. This addition has been particularly useful in critical areas of the distal nose where surface contact is inadequate and failure is frequent. It offers the advantage of reconstructing three tissue types, lining, support and cover, in one stage. Using MCGs avoids the morbidity associated with other reconstructive methods, which may include facial scars, septal perforation, vestibular webbing or scarring of the mucosal lining causing retraction. This procedure used with surface cooling for larger grafts has allowed nearly complete survival of composite grafts as large as 2.0 cms. We have not tested grafts larger than 2.0 cm, although it is conceivable that this technique may improve survival of larger composite grafts. In our opinion, larger defects consisting of more than half the subunit warrant complete excision and reconstruction of the subunit with a locoregional flap, as recommended by Burget.
For smaller critical defects in these areas, our reconstructive methods provide a good and durable result.
In conclusion, the use of MCGs to reconstruct specific cosmetically challenging areas of the nose is a useful addition to the reconstructive armamentarium. While retaining all the advantages of conventional composite grafts, MCGs ensure better survival and improve the final outcome. They do so by increasing potential revascularization by expanding the relative tissue contact between the extended dermal pedicle and its recipient pocket.
References
Raghavan U
Jones N.S
Use of the auricular composite graft in nasal reconstruction.
Transactions of the Third International Congress of Plastic and Reconstructive Surgery. Transactions of the Third International Congress of Plastic and Reconstructive Surgery. Excerpta Medica,
Washington1963
Crystal Plastic Surgeons, Crystal Clinic and Division of Plastic Surgery, Akron General Medical Center, Summa Health System and North Eastern Ohio Universities College of Medicine, Akron, Ohio, USA
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