Posterior Auricular Perichondrial Cutaneous Graft Combined With Cartilage Strip in Nostril Reconstruction

CASE REPORT

A 72-year-old female patient presenting with morphoeic basal cell carcinoma of the right ala underwent 1-stage tumor resection and defect reconstruction (Fig 1). The defect measured 13 mm × 16 mm and included about 50% of the right alar rim (Fig 2). For defect reconstruction, a PCCG including a strip of cartilage was harvested from the posterior auricular surface (Fig 3). To prevent alar rim notching, the cartilage strip was set in a pocket created into the intact portion of the alar rim (Figs 4 and 5). The donor site was closed with a local flap and it healed by primary intention.

Figure 5. Perichondral graft applied on the nostril defect.

Figure 6. Zoomed view of the result after 1 year.

Postoperative course was uneventful with primary healing and a 100% graft uptake. Follow-up after 1 year showed a nice alar rim contour with barely noticeable notching at the posterior border to the alar base (Figs 6–9). Although the graft itself had an excellent color match and was only slightly contracted, the scars still showed some signs of activity.

Figure 7. Complete frontal view of the patient (post–1 year).

DISCUSSION

Depending on size and site, different reconstructive options, such as primary closure, FTSG, local flaps, and composite grafts are available to cover defects of the lower third of the nose. Because the skin is often thick, sebaceous, and particularly stiff,^1,7 an elliptic incision with primary closure yields poor results with a depressed scar, which can considerably contract and distort the topography of the aesthetic unit.⁷ Therefore closure with FTSGs and local flaps are mostly employed. However, in the lower third of the nose, cosmetic appearance of FTSGs is often suboptimal in terms of thickness, rim contour with scar contraction and notching, color match, and poor graft survival over the exposed cartilage.^7,3 When compared with FTSGs, local flaps are subject only to minimal contraction and provide a better color match; furthermore, flaps have higher survival rates than grafts.³ Despite these advantages, local flaps are associated with extra incisions that cross aesthetic subunits,^1,3 and are delicate in terms of thickness, notching, and tip distortion by flap rotation or transposition because of the relative mobility of the nasal tip. The human eye can easily detect any difference in nostril rim contour after flap surgery despite the best design.¹ Results with flap coverage are frequently less than satisfactory, requiring secondary debulking and scar revision procedures.^1,7

Figure 8. Complete lateral right view of the patient with graft tissue in site (post–1 year).

Figure 9. Complete lateral left view of the patient, as control.

Composite skin grafts for nostril rim reconstruction, which include epidermis, dermis, superficial layers of subcutaneous tissue, fat, or cartilage segments, have been extensively described in the literature.^1,7,8 Particularly, composite chondrocutaneous auricular grafts harvested from the conchal cavity⁹ or the helix can provide the required thickness for both inner nasal lining and nostril rim.^8,10 Even if providing good cosmetic outcomes when placed over cartilage in the distal portion of the nose, their survival, depending on revascularization from recipient bed and defect periphery, might be critical.^1,10 To improve vascularization, coverage by skin flaps,¹⁰ attached dermal pedicles,¹¹ and modified composite grafts have been described.

Encouraged by the results obtained with PCCGs in terms of stability, color match, and graft take, we modified the graft for this case that involved about 50% of the alar rim. Nevertheless, PCCGs are limited in size and are better sized below 20 mm in diameter; therefore, we did not resect the whole aesthetic unit of the ala but dissected only the posterior part that is important for the stability of the nostril and where the tumor site was. The inclusion of a small strip of cartilage did not affect graft take in contrast to our previous experiences with composite grafts, including cartilage for nostril rim reconstruction, usually harvested from the base of the helix. The stability provided by the PCCG in combination with the strip of cartilage used mainly to prevent notching and collapsing was sufficient to withstand forced inspiration. The caudal part of the PCCG overlapping the cartilage strip could be nicely contoured to reconstruct the alar rim and the lateral cartilage strip extension was positioned into a small pocket of the intact alar rim to prevent retraction resulting in alar notching.

In conclusion, this case of a PCCG from the posterior auricular surface including a strip of cartilage resulted in a nicely contoured reconstruction of the alar rim. In our case this modified composite graft was superior in graft take and alignment to previously described grafts that include a higher percentage of full thickness cartilage.