Nasal Sesamoid Cartilages: Fact or Fiction? An Anatomical Study of the Lateral Nasal Ala

OBJECTIVES

To evaluate the presence of cartilage in the lateral nasal ala (LNA) via histological analysis of alar Mohs surgical specimens. An accurate understanding of nasal anatomy is essential to optimize esthetic and reconstructive surgical outcomes. LNA anatomy is typically pictured to include discreet accessory and sesamoid cartilages; however, the authors debate the actual presence of these structures.

METHODS

A blinded reviewer analyzed 101 lateral nasal alar histologic specimens from 362 tissue blocks using a Hematoxylin and Eosin (H&E) stain to assess for the presence of cartilage.

RESULTS

Out of the 362 tissue blocks histologically analyzed, only 1 included cartilaginous components.

CONCLUSIONS

We conclude that the presence of sesamoid and accessory cartilages in the LNA within our sample set is exceedingly rare.

The Navicular Graft for Reconstructing Deep Alar Defects

The reconstruction of deep nasal ala defects can be challenging. The often thick, sebaceous skin of the nose provides structural support helping maintain the ala shape and nasal patency; loss of this support may result in ala deformity and nasal vestibule collapse. Traditional full-thickness skin grafts of deep alar defects may result in depressed scars. We present a variation of the full-thickness skin graft to repair deeper alar defects, sculpting the graft into a boat-shaped or “navicular” form. This allows for sufficient volume restoration and good cosmesis while avoiding more extensive surgical repairs of the nasal ala. The navicular graft offers several advantages: the avoidance of more extensive procedures involving cartilage grafts and/or flaps, appropriate color/texture match, and volume restoration without pitting, notching, or retraction of nasal structures. In addition, no struts or bolsters are needed.

Gaining Large Coverage With Small Island Pedicle Flaps in Tight Cosmetic Subunits: Taking Advantage of Rotation and Pincer Principles on the Nasal Ala

BACKGROUND

Island pedicle flaps (IPFs) are widely used in reconstructive surgery due to their versatility, tissue efficiency, and excellent clinical outcomes. While IPF rotations and 'pincer flap' modifications have previously been sparsely described, they are not often discussed in the literature.

OBJECTIVE

We demonstrate the use of both rotating IPFs and pincer techniques for defects traditionally considered too large for classic IPF design on the nasal ala.

METHODS

Forty-four patients underwent alar repair using the rotation or combined rotation with pincer modification to the standard IPF technique from August 2014 to May 2017. Our technique is described and case examples are presented with photographs.

RESULTS

Forty-four patients with an average alar defect size of 1.2 cm underwent repair using rotation only or rotation with pincer modification of the classic IPF approach.

CONCLUSIONS

Reconstruction of large defects in small facial cosmetic subunits such as the nasal ala can be performed using principles of both rotating IPFs and the 'pincer flap' technique. The degree of rotation is directly related to the length of coverage. Modifications to the flap are straightforward to perform. Using these techniques, larger defects that previously would have been reconstructed using flaps that cross cosmetic boundaries can now be reconstructed within the same cosmetic unit, thus, improving aesthetic outcomes.

Second intention healing of nasal ala and dorsum defects in Asians

BACKGROUND

Reconstruction of defects of nasal ala and dorsum after surgical excision presents a substantial challenge to dermatologic surgeons. Second intention healing is a simple and extremely useful method to optimize cosmesis after skin cancer removal.

OBJECTIVES

This study reported the cosmetic outcomes after second intention healing of nasal ala and dorsum defects in Asians, and estimated the time to epithelialization and complete healing.

MATERIALS AND METHODS

Fifteen defects (<1 cm in diameter) of the nasal ala and dorsum in 10 patients were allowed to heal by secondary intention. Cosmetic results were evaluated and the time to epithelialization and complete healing were recorded.

RESULTS

Cosmetic outcomes were good to excellent in 80% of the defects; defects of the dorsum showed poorer cosmetic results than defects of the ala. The wounds needed 5-17 days (mean 11.3; SD ± 4.18) to complete epithelialization and 10-24 days (mean 17.7; SD ± 4.85) to heal completely.

CONCLUSIONS

Second intention healing of small nasal ala and dorsum defects (<1 cm in diameter) in Asians produces satisfactory cosmetic results with a low complication rate.

Comprehensive Algorithm for Nasal Ala Reconstruction: Utility of the Auricular Composite Graft

Defects of the nasal ala are challenging to reconstruct, given its complex three-dimensional structure. Successful repair of these defects needs to provide aesthetic symmetry and preserve nasal function. A wide variety of reconstructive options have been described for nasal ala defects, ranging from skin grafts to locoregional flaps, and also includes the auricular composite graft. However, there are currently no comprehensive guidelines for nasal ala repair, and the versatile role of the auricular composite graft has not been well defined. In this review, we aim to provide a comprehensive algorithm to guide repair of nasal ala defects. Additionally, we compare our experience using the auricular composite graft with the available literature to better define its utility in nasal ala repair.

Single stage turn in perforator infraorbital artery island flap for nasal ala reconstruction

Background:

The reconstruction of fullthickness nasal alla defects is challenging procedure. Use of local flaps is acceptable approach. Flap based on infraorbital artery could be used for primary reconstruction of nasal ala defects.

Methods:

The prospective study include consecutive series of 15 patients with advanced skin carcinoma of the nasal ala and medial cheek staged T4 by TNM, in whom the turn in infraorbital flap was used. The patient characteristics, type of carcinoma and complications were analyzed.

Results:

The turn in infraorbital flap was used mostly in male patients (80%), mean age 64 years. The basal cell skin carcinoma was found in 60%. Skin layer was skin grafted. All flaps survived, but in one case a partial wound dehiscence in one partial skin graft loss was found, and in two patients partial nasal obstruction occurred. These three complications were solved as secondary procedures under local anesthesia.

Conclusion:

Full-thickness defect of the nasal ala can be properly reconstructed using flap based on infraorbital artery providing exceptional esthetic and functional results, as single stage procedure.

Trigeminal trophic syndrome: report of 2 cases

OBJECTIVE

We present 2 cases of trigeminal trophic syndrome treated by surgery.

METHODS

We performed reconstruction of the ala nasi using a nasolabial flap or paramedian forehead flap in combination with an auricular chondrocutaneous composite graft.

RESULTS

One case was successfully treated. However, ulceration recurred intermittently in the other case.

CONCLUSIONS

Although trigeminal trophic syndrome is rare, we believe that plastic surgeons should have a raised awareness of this entity and familiarity with the treatment options.