(A) Canthal bowl
(B) Columella
(C) Glabella
(D) Sidewall
(E) Tip

The correct response is Option E.

If allowed to heal by second intention, the appearance of the tip of the nose is most likely to be unacceptable aesthetically. This is because of its prominent position and high visibility. During healing by second intention, contraction of the skin typically limits the acceptability of the result, as it leads to distortion of the underlying cartilaginous skeleton. According to the results of one study of 282 patients, an acceptable outcome was reported in only 32% percent of patients who had wounds of the tip subunit that were allowed to heal by second intention. In contrast, 100% reported acceptable results at the glabella and columella, 90% at the canthal bowl, and 85% at the nasal sidewalls.

References
1. Becker GD, Adams LA, Levin BC. Nonsurgical repair of perinasal skin defects. Plast Reconstr Surg. 1991;88:768.
2. Herford AS, Zide MF. Reconstruction of superficial skin cancer defects of the nose. J Oral Maxillofac Surg. 2001;59:760-767.

A 15-year-old girl has an 8 ( 8-mm traumatic, full-thickness defect of the right ala that extends to the alar margin. Which of the following is most appropriate for reconstruction of the defect?

(A) Split-thickness skin graft from the thigh
(B) Full-thickness skin graft from the retroauricular area
(C) Composite graft from the ear
(D) Forehead flap
(E) Nasolabial flap
The correct response is Option C.

Reconstruction of this patient’s defect is best accomplished using a small composite graft from the ear. When reconstructing deep defects of the nasal ala, the primary goals are re-establishing the structural support of the nose and matching the skin color and texture for an optimal aesthetic result. In addition, lining, support, and cover are required because the defect is full thickness. A small auricular composite graft will provide appropriate structural support, soft-tissue vascularity, an excellent color match, and the necessary lining and cover for the nose. The donor site of the auricular composite graft is inconspicuous.

Because nasal reconstruction without cartilage grafting for structural support typically results in notching of the alar margin, split-thickness and full-thickness skin grafts are inadequate. Forehead and nasolabial flaps provide an excellent color match but no support and leave obvious scars on the face, which is unacceptable aesthetically in a 15-year-old girl.

References
1. Kobayashi S, Haramoto U, Ohmori K. Correction of the hypoplastic nasal ala using an auricular composite graft. Ann Plast Surg. 1996;37:490-494.
2. Weisberg NK, Becker DS. Repair of nasal ala defects with conchal bowl composite grafts. Dermatol Surg. 2000;26:1047-1051.
3. Rohrich RJ, Barton FE, Hollier LJ. Nasal aesthetics. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:513.