1 The British Association of Plastic Surgeons (2004) 57, Aesthetic reconstruction of the nasal tip using a folded composite graft from the ear Yong Oock Kim*, Beyoung Yun Park, Won Jae Lee Institute of Human Tissue Restoration, Department of Plastic Surgery, College of Medicine, Yonsei University, 134 Shinchon-dong, Seodaemoon-ku, C.P.O. Box 8044, Seoul, South Korea Received 8 May 2003; accepted 9 December 2003 KEYWORDS Composite graft; Folding; Nasal tip Summary Defects of the nasal tip, the alar, and the columella were treated with composite grafts from the postauricular area. The graft was folded into a threedimensional shape, which provided a three-layered reconstruction of skin, cartilage and nasal lining. This procedure preserved the shape of the reconstruction for a longer time and yielded a good aesthetic result. Moreover, although this method was simple and was carried out in one stage, it left minimal morbidity of the donor site, and produced satisfying results. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Defects of the nasal tip, the alar, or the columella represent significant aesthetic deformity. The reconstruction of these defects needs the addition of tissue, but should produce minimal donor morbidity. If the defect is located on the tip area involving the columellar and the alar and is larger than 10 mm in size, it frequently affects the nasal air passage. Primary closure is not adequate for two-layered defects of the nasal tip, because it destroys the natural contour of the tip. For a larger defect, the reconstruction can be accomplished by local flap or distant flap, although these methods have donor site morbidity and may need several stages. For a moderate defect, however, it is more difficult to choose an appropriate treatment method. The composite graft of auricular skin and cartilage has been used for a long time. Without *Corresponding author. Tel.: þ ; fax: þ address: careful aesthetic consideration, however, the reconstructed nose will show unnatural bulkiness or flatness on the nasal tip area. The risk of a partial or total loss of a graft is also a reason for reluctance in using composite grafts. We used composite grafts in patients who had defects involving the tip, the alar, and the columella areas. We successfully reconstructed the tip projection and the contour of the alar and columella by folding one piece of the composite graft. Material and method Patients One patient had a human bite to her nasal tip. The soft triangle, the tip, and the columella were lost. The tip was abruptly cut, and the deficiency of the tip was clearly apparent in the lateral view (Fig. 1). S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps
2 Aesthetic reconstruction of the nasal tip using a folded composite graft from the ear 239 Figure 1 Case 1. (Above) Preoperative views of the patient. (Below) Two years postoperative. This defect was reconstructed by a composite graft of mm 2 in size. Another patient had an infectious disease on her nose from childhood. After controlling the infection, she lost her nasal tip contour. The defects were located on the tip, the soft triangle, and both alars. Both nostrils showed sharp triangular shapes (Fig. 2). After the release of the contracted scar, the defect was reconstructed by a composite graft of mm 2. Operative procedures In order to estimate the tissue requirement for the reconstruction, the following procedures were conducted. A piece of construction paper was folded in the shape of the nose to measure the size of the defected area. Then, we marked the size of the defect on the piece of paper. After marking the size of the defect, we unfolded the paper and cut it guided by the marked line. The size of the piece of paper showed the size of the defect (Fig. 3). We then marked the approximate size of the defect on the postauricular area using the piece of paper. Then, we harvested the composite graft in one piece from the postauricular area. Following this procedure, we removed a part of the cartilage in the line of a Y-shape, because the cartilage is not soft enough for it to be folded like a piece of paper. This removal took place before the actual construction or the folding of the composite graft (Fig. 4, above, right). Then, we folded the composite graft into the three-dimensional shape of the nose as we did with the paper, and grafted it on the defected area. The final shape of folded graft was a pyramid shape with four legs. The graft was sutured with fine silk on the recipient site after debridement of the wound (Fig. 4, below). A dressing was applied with no pressure. All stitches were removed on the seventh day after operation.
3 240 Y.O. Kim et al. Figure 2 Case 2. (Above) Preoperative views of the patient. (Below) Four months postoperative.
4 Aesthetic reconstruction of the nasal tip using a folded composite graft from the ear 241 Figure 3 Diagram (A and B) shows pre-operative status and expected status after reconstruction (dotted line). (C) Three quarter and frontal views of folded paper after fitting the raw surface are demonstrated. (D) Raw surface after release of scar tissue on the nasal tip is shown. (E) Diagram shows the reconstructed nose using the folded composite ear graft. Dotted lines show layers of cartilage.
5 242 Y.O. Kim et al. Figure 4 (Above, left) Harvested composite graft. (Above, right) After removal of the cartilage strip in a Y-shape for three-dimensional folding. (Below) Antero-posterior and worm s eye views after insetting of the folded graft.
6 Aesthetic reconstruction of the nasal tip using a folded composite graft from the ear 243 Result The composite grafts survived without losing the initial reconstructed shape. The nasal tip projections and the framework of the columellar and the alar were reconstructed successfully, and they were maintained well during the follow-up period (Figs. 1 and 2, below). There was a partial loss of the superficial skin of the graft on the columellar area in one patient. The area was healed without any additional procedures. By adding the tissue, the nostrils were wide enough and the soft triangle, the alar, and the columella were aesthetically acceptable. The scars along the boundaries of the composite graft became less obvious. Discussion The nose is a prominent structure in the face. When a plastic surgeon reconstructs the nose, the restoration of its subtle contours and highlights is as important as wound closure. The coverage of skin and nasal lining and the contour of the shape created by the cartilage graft are essential for superior aesthetic results. In the past, there have been many reports of the use of composite ear grafts for the repair of nasal defects, 1 4 ever since Dupertuis first reported a nasal tip reconstruction that used earlobe composite grafts in Composite grafts from the ear have been effectively used in reconstructions of smaller sized defects of the columella and alar. 6 When the defect involved the tip, the soft triangle, the alar, and the columella, local flaps may be preferred, because they can provide an adequate amount of tissue. However, the local flap, such as the forehead flap, needs subsequent operations to detach and to revise in order to sculpt and debulk for a more satisfactory result. Generally speaking, for the survival of the composite graft, 5 mm maximum distance from the point of vascular contact is preferred, even if the maximal size of a graft were arbitrarily determined Many composite grafts follow this guideline regardless of graft shape: wedge, elliptical, or rectangular shape. The three-dimensional tip projection, however, is difficult to reconstruct adequately with a two-dimensional composite graft. The tip projection following the procedure involving the two-dimensional composite graft can often be cosmetically unpleasant, due to its flatness. This outcome may occur because even if the thickness of the composite graft were added to the amount of tissue at the tip, the thickness of the composite tissue can be insufficient in creating adequate tip projection. 11,12 The patients in this report had unique deformities in the subunit areas of the nasal tip and the soft triangle. The deformities involved having a tissue deficiency in the nasal lining, the cartilage, and the skin cover. Using the composite ear graft in these patients would have obliged us to overcome two obstacles: the survivability of the composite graft and the aesthetically acceptable shape of the reconstructed tip and soft triangle. To overcome these obstacles, we devised a new design, the folding method, for the composite graft. This folding method produces the composite graft in a shape that is near to that of a three-dimensional pyramid. When we fold the composite graft in a threedimensional pyramid shape, we can ensure the survivability of the composite graft because the distance from the vascular margin is not more than 5 mm, although the original width of the graft before folding was 15 mm. This occurrence is due to the fact that when we fold an object once, the distance from its outer margin to the folding line is normally half of the original distance, but in a three-dimensional pyramid shape, the distance from the vascular margin to the center is decreased more than half. Moreover, folding effectively pushes the soft tissue to the apex of the pyramid from all directions, resulting in having sufficient amount of soft tissue to shape the tip and in having three buttresses of cartilage in the graft tissue to maintain the shape. Although this folding method ensures the survivability of the composite graft and the aesthetically acceptable form of the nose, there are some disadvantages, which is why this method must be used carefully. One patient showed superficial skin epidermal necrosis. However, all the skin was not affected, and it healed without a noticeable scar. We think the removal of the strip of cartilage in the Y-shape was what could have possible caused this necrosis. Because a strip of cartilage is removed, the blood circulation in the columellar area is a bit damaged, and this removal of cartilage may have caused the superficial skin epidermal necrosis. Thus in removing the cartilage and using the folding method, one must be careful and must be aware of the circumstances this method may yield. In conclusion, the tip projections of the patients after the operations proved to be aesthetically more acceptable than the resultant projections that used simple coverage of flaps or one-layer composite grafting. The results of these cases clearly present some of the beneficial features and outcomes of using the technique of three-dimensional
7 244 Y.O. Kim et al. folding of composite grafts as a treatment of choice in defects requiring reconstructive surgery. Acknowledgements The authors thank Hyun Jin Kim for her help in revising the English. This work was supported by grant No. R from the Basic Research Program of the Korea Science and Engineering Foundation. References 1. Converse JM. Reconstruction of the nasolabial area by composite graft from the concha. Plast Reconstr Surg 1950;5: Meade RJ. Composite ear grafts for reconstruction of the columella. Plast Reconstr Surg 1959;23: Symonds FC, Crikelair GF. Auricular composite grafts in nasal reconstruction: a report of 36 cases. Plast Reconstr Surg 1966;37: Breach NM. Repair of a full-thickness nasal defect with an ear lobe sandwich graft. Br J Plast Surg 1979;32: Dupertuis SM. Free earlobe grafts of skin and fat. Plast Reconstr Surg 1946;1: Lehman Jr JA, Garrett Jr WS. Earlobe composite grafts for the correction of nasal defects. Plast Reconstr Surg 1971;47: Barton Jr FE, Byrd HS. In: McCarthy JG, editor. Acquired deformities of the nose. Plastic Surgery, vol. 3. Philadelphia: WB Saunders; p Chapter Nagel F. Reconstruction of a partial auricular loss. Plast Reconstr Surg 1972;49: Rees TD. The transfer of free composite grafts of skin and fat: a clinical study. Plast Reconstr Surg 1960;25: Davenport G, Bernard FD. Improving the take of composite grafts. Plast Reconstr Surg 1959;24: Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78: Barton FE. Aesthetic aspects of partial nasal reconstruction. Clin Plast Surg 1981;8:177.