Nasal Reconstruction With Skin Grafts and Composite Grafts

Steven M. Levine

Daniel C. Baker

DEFINITION

Nasal defects are frequently not amenable to primary closure without distortion of the underlying cartilaginous structure or obvious repositioning of the nasal tip or ala.¹
Nasal defects are commonly treated with the local flaps or local regional flaps.
The ideal reconstruction is skin of similar color, thickness, and texture.
One-stage reconstruction is an attractive option to both patient and surgeon.
Full-thickness skin grafts, for the purposes of this text, include the epidermis, dermis, and often adipose tissue.
Composite grafts include both a component of skin as well as cartilage.

ANATOMY

Nasal anatomy is often divided into aesthetic subunits.
- These subunits are a useful guide but quite frequently can be ignored when reconstructing the nose with full-thickness skin grafts or composite grafts.
Maximizing surface area for graft take is of primary concern when using full-thickness skin grafts or composite grafts.

PATIENT HISTORY AND PHYSICAL FINDINGS

Skin/subcutaneous defects on the nose may be treated in many cases with a full-thickness skin graft. However, if the defect includes missing cartilage or would benefit from extra-anatomical cartilage (such as an alar rim or tip), a composite graft should be considered.
The defect must have an appropriate graft recipient bed to accept either graft.
- This means if the wound has been heavily cauterized during the resection portion of the procedure, excisional debridement and local wound care should be performed until a suitable bed is present.
- If the defect is contaminated as in the case of a dog bite or motor vehicle accident, debridement and local wound care should be performed until a clean recipient bed is present.
Care should be taken to note the length, width, and depth of the defect.

SURGICAL MANAGEMENT

Full-thickness skin grafting or composite grafting can be performed under local anesthesia, sedation, or general anesthesia, depending on the preference of the surgeon and the patient.

Preoperative Planning

The primary consideration for preoperative planning is to define the extent of the defect and identify a suitable donor site.
In general, color match is improved by selecting a donor site that is anatomically close to the nose (eg, the ear, preauricular skin).
- These grafts have better color and texture match to the nose.
The preauricular region is an ideal donor site and usually heals with an inconspicuous scar. Strong preference is given to this site vs the retroauricular site despite the natural inclination to use the more “hidden” skin behind the ear.
Occasionally, the supraclavicular skin is good color and texture match for the nose.
The surgeon should identify the components of the donor tissue required to optimize the aesthetic outcome.
- Frequently, a thin layer of adipose tissue should be harvested with the grafts to allow for appropriate depth matching between the graft and the recipient site.
- It is important to avoid overthinning of full-thickness skin grafts as this may result in late contracture or a cobblestone appearance of the graft that is difficult to address.
The two most common donor sites for composite grafts used for nasal reconstruction are the anterior helical rim, which can be harvested along with a pennant of preauricular skin, and the conchal bowl, which can be harvested with either conchal skin or retroauricular skin.

Positioning

The patient is either supine if under sedation or full anesthesia or sitting reclined or supine in an exam chair if performing the graft on an awake patient.

Approach

The approach to the graft can be varied from surgeon to surgeon with a consistent emphasis on delicate handling of the graft both at the time of harvest and when securing it to the recipient site.