Thursday, April 1, 2010

Skin Grafting in Lower Third Nasal Reconstruction

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Skin grafts for the lower third nasal defects should not be overlooked as an option.  The article listed below  (first one)reminds us that  skin grafts can give a better cosmetic results than a local flap in certain situations.  
The lower third of the nose is defined by its margins, which include the alar rims inferiorly, the nasolabial grooves laterally, and the alar groove, which forms the junction with the upper two-thirds of the nose.
Classically, the lower third of the nose is composed of six subunits: bilateral ala and soft triangles, the central tip, and columella. (photo credit)
The skin in this area is thick, richly populated with sebaceous glands, often stiff and difficult to rotate and form into local flaps.
Criteria given for selecting lower third nasal defects that can be acceptably treated with full-thickness grafts
include defect location; size smaller than 1 cm; and a partial-thickness defect with underlying dermis, subcutaneous tissue, or perichondrium.
Rather than increasing the small defect to a larger defect (whole subunit size), the authors achieved acceptable cosmetic results using full-thickness skin grafts to reconstruct lower third defects smaller than 1 cm in diameter.
Any defects larger than 1 cm were reconstructed more successfully with entire subunit reconstructions using more standard reconstruction techniques (local or adjacent flap techniques).  Defects that involve cartilage or deeper are by definition complex nasal defects that will require onlay cartilage grafting for satisfactory reconstruction.  These are not appropriate for skin grafting.
Donor site selection is important to try to match “like with like.”   Best choices include:
The senior author prefers preauricular and more preferably forehead skin for lower third nasal reconstruction. Forehead sites offer thicker skin, with a relatively sebaceous, oily texture, and they suffer the same degree of daily sun exposure and actinic damage as the lower third of the nose.
Other donor sites available to the reconstructive surgeon include the nasolabial fold, postauricular skin, and supraclavicular skin.
Poor donor site choices:
Postauricular donor sites suffer very little (if any) daily sun exposure and have much thinner skin than the nasal lobule. Therefore, they are prone to pigmentation changes and do not provide a good contour match for reconstructing the lower third of the nose.
Likewise, the skin of the supraclavicular region contains very few sebaceous elements and is often hyperpigmented before harvest.
Any distortion of the alar rim or obliteration of the nasolabial groove is exceedingly noticeable and difficult if not impossible to correct secondarily so care must be taken regardless of technique used in these area.

Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?; Plast Reconstr Surg. 124(3):826-835, September 2009; McCluskey, Paul D.; Constantine, Fadi C.; Thornton, James F.
Nasal Reconstruction, Principles and Techniques: Multimedia; eMedicine article, August 28, 2008; Joseph Fata, MD
Nasal Reconstruction-Beyond Aesthetic Subunits: A 15-Year Review of 1334 CasesPlast Reconstr Surg. 2004;114:1405-1416; discussion 1417-1419; Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK.

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