Inservice Exam 2005
Nasal Reconstruction

A 52-year-old woman has a full-thickness defect of the left nasal ala with a diameter of 8 mm after undergoing Mohs’ micrographic surgery for removal of a basal cell carcinoma. On physical examination, the defect involves the skin and a portion of the lower lateral cartilage, including the free border of the ala. Which of the following methods of reconstruction is most likely to prevent vestibular notching and narrowing?

(A) Composite grafting of skin and cartilage from the ear
(B) Coverage with a bilobe flap rotated from the nasal dorsum
(C) Coverage with a pedicled nasolabial groove flap
(D) Excision of the lining and primary closure
(E) Full-thickness skin grafting with pretragal skin


The correct response is Option A.


Nasal defects in the alar rim are challenging to reconstruct. Thin skin coverage, cartilage support, and thin lining are needed to replace this cosmetically prominent site. Complications of alar rim reconstruction include notching, scarring, and nostril obstruction and narrowing. Several choices are available for this region, but the best cosmetic result will be obtained with a composite full-thickness graft from the ear. This site gives the best match of the missing tissue in thickness and structure. Composite cartilage grafts are limited by their ability to revascularize. Inosculation occurs within 18 hours and vessel ingrowth sustains the graft over the long term. Grafts greater than 1.5 to 2 cm are more precarious and may not attain adequate perfusion to live. This 8-mm defect is well within the limits of expected take of a composite graft. Some authors advocate adjunctive measures to increase the take of a composite graft, such as cooling, hyperbaric oxygen therapy, or increasing the surface area of contact between the graft and recipient site.


A forehead flap gives thick tissue without lining. It would have to be folded on itself or skin grafted. It also requires two stages. Both nasolabial and bilobed flaps are local options but are bulky if folded. If skin grafted, they can contract and notch. These flaps also give additional scarring on the face. A skin graft on a local lining flap is too thin and lacks cartilage support.


References:
1. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis, MO: Mosby-Year Book; 1994.
2. Menick F. Reconstruction of the nose. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Vol 2. Philadelphia: Lippincott Williams & Wilkins; 1994:883-905.
3. Chandawaskar RY, Cervino AL, Wells MD. Reconstruction of nasal defects using modified composite grafts. Br J Plast Surg. 2003;56:26-32.
4. Rapley JH, Lawrence WT, Witt PD. Composite grafting and hyperbaric oxygen therapy in nasal tip reconstruction. Ann Plast Surg. 2001;46:434-438.