Nasal Ala Reconstruction With a Crus Helix Composite Graft: A Stepladder Approach

March 2012 | Volume 11 | Issue 3 | Original Article | 376 | Copyright © March 2012


Isaac Zilinsky MD,a,b,c* Nimrod Farber MD,b,c* Josef Haik MD,b,c Oren Weissman MD,b,c Hadar Israeli MD,b,c Eyal Winkler MDb,c

aMohs Micrographic Surgery Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel
bDepartment of Plastic and Reconstructive Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel
cThe Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
*I. Zilinsky and N. Farber contributed equally to this work.

Abstract
Background: Defects of the nasal ala present a complex reconstructive challenge. Composite grafts comprise all layers required to successfully reconstruct these full thickness deformities making them the ideal reconstructive method, yet they are usually avoided because of unjustified disreputable failure rates.
Objective: The authors introduce a stepladder approach for alar reconstruction with a crus of helix composite graft according to the severity and complexity of the defect.
Methods: Data from 25 patients who underwent correction of full thickness alar defects with composite grafts was collected and reviewed.
Results: There were no complete graft failures in any of the cases. Ten patients (40%) had partial graft necrosis ranging from 5 to 50% (average 18%); two of them (20%) were heavy smokers.
Conclusions: Composite grafts should be considered for reconstruction of full thickness nasal ala defects, given the correct surgical technique is implemented.

J Drugs Dermatol. 2012;11(3):376-381.

INTRODUCTION

Full thickness defects of the nasal ala involve lining, structure and coverage of the nasal cavity. Albeit many published techniques these complex defects remain among the most difficult challenges faced by the reconstructive surgeon.1-17 While composite grafts essentially provide a complete solution for such defects by addressing all missing layers18-19 they have not been widely adopted, because of high failure rates attributed to the scarce blood supply from the periphery of the defect.20 Over the years several techniques have successfully enhanced blood supply to the graft, improving its survival and expanding its use to larger defects.21-25

Surgical Technique

Surgery is usually performed under local anesthesia with solutions containing a mixture of epinephrine and either lidocaine or bupivacaine.26 When a forehead flap is indicated it is better to operate under general anesthesia. The entire face is prepped with an antiseptic solution and draped with sterile covers. It is important to maintain visibility of all relevant facial features to ensure maximum symmetry when drawing the operative plan. After surgery we recommend complete bed rest for 24 hours regardless of the reconstructive technique, and cooling the reconstructed ala with ice packs. Sutures are removed between 7-14 days postoperative. All patients receive a short course of oral antimicrobial prophylaxis and are treated locally with an antibiotic ointment. Minor scar revisions, if necessary, may be done 12 months after surgery as office-based touch-ups (i.e., dermabrasion).27
Composite Crus of Helix Graft Over a Partial Alar Defect
The existing defect and affected side are measured and assessed for size, shape, and contour irregularities. The desired new ala is planned according to the contralateral (healthy) ala and the proposed outline is then copied to both the recipient site and donor site on the contralateral crus helix with a tissue marker. The recipient site is prepared by denudation of the defect edges and de-epithelialization of the surface to accommodate the new ala. The crus helix is then harvested and implanted in a single stage reconstruction. (Figure 1)
Composite Crus of Helix Graft Over a Hinged Nasal Sidewall Turnover Flap
A skin flap from the nasal sidewall above the defect is hinged down and stitched to the denuded margins of the defect. The new
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