CASE REPORT
Reconstructive ConundrumA 94-year-old man with biopsy-proven nodular, pigmented basal cell carcinoma of the right nasal ala was referred for Mohs micrographic surgery for definitive surgical treatment. The tumor was completely removed after two stages, resulting in a right nasal alar full-thickness defect to the level of the mucosa. The wound diameter measured 1.8 cm x 1.8 cm and included a small through-and-through defect near the inferior portion of the wound (Figure 1). How would you repair this defect?ResolutionThe goal of the lateral alar wound repair is to maximally camouflage the scar, avoid blunting of the alar crease, and to minimize elevation of the alar rim due to cicatricial retraction.1Reconstructive options include various flap procedures (eg, bilobed flaps, V-Y advancement flaps, or forehead pedicle flaps), full-thickness and composite grafting, second intention healing, or a combination of techniques.2For a full-thickness deep alar defect, second intention healing presents several caveats, including poor cosmesis with anatomic distortion of the alar rim, as well as a large open wound that would be difficult for the patient to care for. Given the proximity of the defect to the alar free margin and the depth of missing subcutaneous tissue, a cartilage strut was considered necessary to prevent alar retraction and maintain the nasal aperture. Though free cartilage grafts coupled with second intention can do well, we thought the prolonged wound care necessary with this type of repair would be undesirable in a nonagenarian patient living on his own with no assistance. Full-thickness skin grafts placed over cartilage grafts have been reported in the past, but with such a deep wound, the high probability of graft failure steered us away from this option. A staged melolabial interpolation flap along the nasolabial fold was also considered; despite the advantage of simplicity, it was rejected due to the patient’s desire for a single stage procedure.3 To simplify the repair into a one-stage technique and to decrease the chance of alar retraction, a cheek interpolation flap with a cartilage Batten graft was performed.ProcedureThe free cartilage Batten graft offers an architectural advantage by providing immediate volumetric filling, allowing for less wound contraction and anatomic distortion.4 Conchal cartilage was harvested from the right ear through an anterior approach. First, the area was tumesced by injecting anesthetic (0.5% lidocaine with 1:200,000 epinephrine) in the perichondrial plane. Then, the appropriately sized cartilage was harvested from the right conchal bowl after perichondrial elevation of a rectangular skin flap. The harvested cartilage was placed immediately in sterile saline solution. The skin flap was laid back and sutured in place with absorbable simple running suture. A single basting suture was placed to prevent seroma formation, and to assure adherence and proper healing of the skin flap.The right nasal alar defect was minimally undermined. The through-and-through defect at the ala was repaired with a
