Aesthetic management of the ear as a donor site

Considerations for Optimal Grafting in Rhinoplasty

A wide variety of grafting materials and techniques can be used to create functional and aesthetic changes in rhinoplasty. Choosing the optimal grafting approach is critical to achieving an optimal patient outcome. We present a review of autografts, allografts, and alloplasts used in primary and revision rhinoplasty and discuss factors that impact graft choice. Autologous grafts serve as the pillar for grafting material in rhinoplasty given their reliable long-term outcomes, low rates of infection, resorption, and extrusion, and ability to provide structural scaffolding as well as contour. Cadaveric allografts can be utilized as a source of grafting material in certain clinical scenarios including revision rhinoplasty and have been shown to be equally safe and effective as autologous grafts while avoiding donor-site morbidity. Alloplasts can prove useful in rhinoplasty in cases of iatrogenic nasal deformities or revision cases. Careful consideration of clinical scenario, patient factors, and outcome goals is necessary to choose the appropriate grafting approach to address functional and cosmetic outcomes.

Reducing Risks of Graft Failure for Composite Skin–Cartilage Grafts

Facial skin defects pose unique challenges for the reconstructive surgeon. Aesthetically complex areas involving a free margin-such as the ear, eyelid, columella, columella-lobule interface, soft tissue triangle, alar rim, and internal nasal lining-are particularly demanding, as secondary soft tissue contracture in these locations can lead to a very poor cosmetic outcome. In these cases, composite grafts offer an ideal combination of soft tissue coverage and structural rigidity, all accomplished in a single-stage surgery. Composite grafts are often underused in facial reconstructive surgery due to the tenuous blood supply and high reported rates of graft failure.

A Simple Dressing Fixation Method Following Harvest of the Ear Cartilage Graft

ABSTRACT

Auricular cartilage is a common autologous graft material for rhinoplasty. Even though surgical techniques for the harvest of cartilage graft are well established, the management of the postoperative dressing fixation is still limited. Therefore, the authors propose a simple dressing fixation method in which gauze strips instead of gauze block or wet cotton, the suture of tie-over dressing fixed just through the cartilage rather than the full thickness of the auricle, a vaseline gauze interposed between the stitch knot and the skin and no additional pressure dressings postauricularly. No case of hematoma, infection and skin necrosis of the donor site was observed. This simple and reproducible technique provides perfect and homogeneous adhesion of the dressing all over the conchal cartilage while decreasing the risk of postoperative hematoma and discomfort.

Reconstruction of the Isolated Columellar Defect: A Novel 2-Stage Technique and Review of the Literature

The importance of the nasal complex cannot be overstated from a functional, social, and psychological perspective. The goal of reconstruction is to restore the trilaminar composition of the nose. This is accomplished by recreating the nasal lining and providing a cartilaginous framework to simultaneously support a patent airway and project the defining features to the overlying soft tissue. The columella is one of the smallest subunits of the nose, but the loss of this structure has important esthetic and structural implications. The ideal operation for an isolated defect of the columella remains elusive. The ideal reconstruction would match the pigmentation and texture of the surrounding nasal skin and provide a convex contour with underlying structural support. In addition, the donor site would not create a secondary deformity by disrupting normal anatomy. This report describes a novel 2-stage technique for reconstruction of the columella and reviews the current literature.

Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience

INTRODUCTION

Composite grafts for nasal reconstruction have been around for over a century but the opinion on its virtues and failings keeps vacillating with a huge difference on the safe size of the graft for transfer. Alar margin and columellar defects are more distinct than dorsal nasal defects in greater difficulty in ensuring a good aesthetic outcome. We report our series of 19 consecutive patients in whom a composite graft was used to reconstruct a defect of alar margin (8 patients), alar base (7 patients) or columella (4 patients).

PATIENTS AND METHODS

Patient ages ranged from 3-35 years with 5 males and 14 females. The grafts to alar margin and base ranged 0.6-1 cm in width, while grafts to columella were 0.7-1.2 cm. The maximum dimension of the graft in this series was 0.9 mm x 10 mm. Composite grafts were sculpted to be two layered (skin + cartilage), three layered wedges (skin + cartilage + skin) or their combination (two layered in a portion and three layered in another portion). All grafts were cooled in postoperative period for three days by applying an indigenous ice pack of surgical glove. The follow up ranged from 3-9 months with an average of 4.5 months.

RESULTS

All of our 19 composite grafts survived completely but they all shrank by a small percentage of their bulk. Eleven patients rated the outcome between 90-95% improvement. We noticed that composite grafts tended to show varied pigmentation in our patients, akin to split skin grafts.

CONCLUSION

In our opinion, most critical to graft survival is its size and the ratio of the marginal raw area to the graft bulk. We recommend that graft width should not exceed 1 cm to ensure complete survival even though larger sized grafts have been reported to survive. We recommend cooling of the graft and justify it on the analogy of 'warm ischemia time' for a replantation, especially in warmer climes like ours in India. We have outlined several considerations in the technique, with an analysis of differing opinions that should facilitate a surgeon in making an informed choice.

Evaluation of the use of auricular composite graft for secondary unilateral cleft lip nasal alar deformity repair

The purpose of this study is to evaluate the surgical outcome after using composite grafts for secondary cleft lip nasal deformities. A retrospective cohort study of one surgeon's outcome of 35 consecutive performed secondary cleft lip nasal deformity repair. Thirty-five patients with secondary nose deformity related to unsatisfactory cleft lip repair were operated using the proposed surgical technique since 2008. All these patients met the study criterion of having anthropometric measurements performed at least one year postoperatively. Measurement of nostril size was performed at the right and left side of the nose, preoperatively and at least one year postoperatively. The study found statistically significant differences between the preoperatory and postoperatory nose measurements. In addition, we have not found statistically significant differences between the cleft and noncleft nostril sizes measured at least one year postoperatively. The findings suggest that the proposed technique is a good alternative to address secondary nose deformity related to cleft lip primary repair.

Large auricular chondrocutaneous composite graft for nasal alar and columellar reconstruction

BACKGROUND

Among the various methods for correcting nasal deformity, the composite graft is suitable for the inner and outer reconstruction of the nose in a single stage. In this article, we present our technique for reconstructing the ala and columella using the auricular chondrocutaneous composite graft.

METHODS

From 2004 to 2011, 15 cases of alar and 2 cases of columellar reconstruction employing the chondrocutaneous composite graft were studied, all followed up for 3 to 24 months (average, 13.5 months). All of the patients were reviewed retrospectively for the demographics, graft size, selection of the donor site and outcomes including morbidity and complications.

RESULTS

The reasons for the deformity were burn scar (n=7), traumatic scar (n=4), smallpox scar (n=4), basal cell carcinoma defect (n=1), and scar contracture (n=1) from implant induced infection. In 5 cases of nostril stricture and 6 cases of alar defect and notching, composite grafts from the helix were used (8.9×12.5 mm). In 4 cases of retracted ala, grafts from the posterior surface of the concha were matched (5×15 mm). For the reconstruction of the columella, we harvested the graft from the posterior scapha (9×13.5 mm). Except one case with partial necrosis and delayed healing due to smoking, the grafts were successful in all of the cases and there was no deformity of the donor site.

CONCLUSIONS

An alar and columellar defect can be reconstructed successfully with a relatively large composite graft without donor site morbidity. The selection of the donor site should be individualized according to the 3-dimensional configuration of the defect.

Alar batten cartilage graft: treatment of internal and external nasal valve collapse

BACKGROUND

The aim of this study was to describe the efficacy of alar batten graft in correcting internal and external nasal valve collapse (i.n.v. and e.n.v.) and evaluate the functional and aesthetic results.

METHODS

From July 2006 to September 2008, 80 patients (54 females and 26 males) underwent alar batten cartilage grafting. The patients were divided into three groups: (1) 55 patients with iatrogenic nasal valve collapse (80% i.n.v., 20% e.n.v.), (2) 15 patients with posttraumatic nasal valve collapse (45% i.n.v., 55% e.n.v.), and (3) 10 patients with congenital nasal valve collapse (100% e.n.v.). Patients were evaluated at 6, 12, 24, and some at 36 months after surgery. The final follow-up was at least 24 months.

RESULTS

The results of this study revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of alar batten grafts. All the patients noted improvement in their nasal airway breathing and in their cosmetic appearance. No major complication was observed.

CONCLUSION

The alar batten graft is a simple, versatile technique for long-term reshaping, repositioning, and reconstruction of the nasal valve collapse.