The placement of structural cartilage grafts under full-thickness skin grafts: a case series and strategies for successful outcomes

Surgical Techniques Following Free Cartilage Grafting

BACKGROUND

Reconstruction of surgical defects with free cartilage grafts poses unique challenges.

OBJECTIVES

To characterize surgical techniques following free cartilage grafting.

MATERIALS AND METHODS

A literature review was performed using the Embase, PubMed Medline, Cochrane Library, ClinicalTrials.gov, and Web of Science databases from inception to May 21, 2021. Studies describing free cartilage grafts harvested from the ear or nose under local anesthesia, specifically for reconstruction of facial surgical defects, were selected for inclusion. Only surgical defects resulting from tumor resection were included.

RESULTS

In total, 34 studies involving 713 patients with 723 surgical defects met inclusion criteria. The mean age of patients was 63.3 ± 10.4 years. Free cartilage grafts were most commonly harvested from the ear (93.1%). The most common recipient site was the nose (90.3%), followed by the lower eyelid (6.7%) and ear (3.0%).

CONCLUSION

Free cartilage grafts are an effective reconstructive option for patients with deep or cartilaginous defects that have compromised structural support on the nose, ear, or eyelid.

Association of Skin and Cartilage Variables With Composite Graft Healing in a Rabbit Model

Importance

Composite grafting in nasal reconstruction involves transplanting auricular chondrocutaneous grafts, but the optimal design of these grafts is unknown.

Objectives

To investigate the ideal ratio of skin to cartilage as well as study the importance of the perichondrial attachment for graft survival.

Design, Setting, and Participants

A New England white rabbit model was used in this study, performed at the Laboratory for Animal Research at University of Kansas Medical Center from January 25 to March 18, 2016. Four varying designs of chondrocutaneous auricular grafts were transplanted to dorsal back defects, with a total of 10 grafts per treatment arm completed. The following 4 chondrocutaneous circular grafts were designed: group A, 1.5-cm diameter graft of equal skin to cartilage ratio; group B, 2.0-cm diameter skin and 1.5-cm diameter cartilage; group C, 1.5-cm diameter skin and 2.0-cm diameter cartilage; and group D, 1.5-cm diameter skin and cartilage separated and placed back together in a layered fashion. Grafts were observed until postoperative day 21, harvested, and evaluated with visual observation as well as histopathologic assessment.

Main Outcomes and Measures

Visually graded areas of survival were marked by 2 blinded academic facial plastic surgeons and calculated for approximate survival. Hematoxylin-eosin-stained, paraffin-embedded 5-μm slides were evaluated for overall survival rate, rate of cartilage necrosis, and mean vessel density per high-power field. In both cases, observers were blinded as to the study group.

Results

Visual assessments of the 5 female rabbits showed significant agreement between surgeons and consistency, with a Spearman coefficient of 0.84 and an intraclass correlation of 0.98. Group D (skin and cartilage separation) was visually graded to have significantly decreased mean survival (45.4%; 95% CI, 23.3%-67.4%) compared with group A (mean survival, 97.4%; 95% CI, 94.8%-99.9%; P < .001), group B (mean survival, 87.6%; 95% CI, 69.9%-100%; P = .004), and group C (mean survival, 82.1%; 95% CI, 66.0%-98.1%; P = .008). Histopathologic assessment revealed that group D again showed significantly inferior overall survival, increased cartilage necrosis, and decreased mean vessel density compared with group A. Group C additionally showed significantly decreased cartilage survival compared with group A (65% vs 0%; P < .001) and group B (65% vs 35%; P = .02).

Conclusions and Relevance

These results represent preliminary evidence that the attachment of skin to perichondrium in a composite graft plays an important role for graft survival. Clinicians performing nasal reconstruction with chondrocutaneous composite grafts should consider preserving attachments at this junction to improve graft survival.

Levels of Evidence

NA.

Skin graft survival on subcutaneous hinge flaps: an algorithm for nasal reconstruction

OBJECTIVES/HYPOTHESIS

To assess the survival of full-thickness skin grafts and perichondrial cutaneous grafts when placed on subcutaneous soft tissue flaps used in nasal reconstruction.

STUDY DESIGN

Retrospective case series from a secondary-care cutaneous cancer practice.

METHODS

Twenty-eight patients with nasal defects secondary to basal cell carcinoma excision were included. Clinical information, including case notes and photography, was obtained and analyzed. Graft survival was assessed in relation to type of graft and subcutaneous soft tissue flap employed for the reconstruction.

RESULTS

Overall graft survival was 79%, with 89% and 74% for perichondrial cutaneous graft and full-thickness skin grafts, respectively. Anecdotally, procerus and nasalis flaps were found to yield higher graft survival than cheek fat flaps.

CONCLUSIONS

The combination of subcutaneous soft tissue flap and skin graft cover offers a valuable addition to the treatment algorithm for nasal reconstruction following cutaneous malignancy excision.