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Alar batten cartilage grafting in nasal reconstruction: Functional and cosmetic results
DERMATOLOGIC
SURGERY
Alar batten cartilage grafting in nasal reconstruction: Functional and cosmetic results David R. Byrd, MD, Clark C. Otley, MD, and Tri H. Nguyen, MD Rochester, Minnesota Background: Alar batten cartilage grafts can restore form and function to a compromised ala, prevent stenosis of the nasal valve, and maintain unrestricted air movement. Soft tissue reconstructive options can be combined with alar batten grafts. Objective: Our purpose was to analyze functional and cosmetic outcomes in a series of patients undergoing alar batten cartilage grafting. Methods: We analyzed the functional and cosmetic outcomes of 25 patients in whom reconstruction involved alar batten cartilage grafts. Assessment included defect characteristics, function and cosmesis (rated by physician and patient), and complications. Results: Eighty-three percent of patients had good to excellent functional and cosmetic results by patient and physician assessment. Three patients were rated as having poor cosmetic results by the physician; all 3 patients graded these results as good. One episode of graft failure occurred, and recipient and donor site complications were minor. Conclusion: Alar batten cartilage grafts appear to be an excellent option for reconstruction of substantial alar defects. (J Am Acad Dermatol 2000;43:833-6.)
S
everal soft tissue reconstructive options are available for surgical defects of the nasal ala.1-17 Consideration must be given to functional and aesthetic restoration, or suboptimal results will occur (Fig 1). We describe our experience using alar batten cartilage grafts as a technique to restore cosmesis and function in nasal alar reconstruction. An alar batten graft is defined as a rectangular or elongated oval graft of cartilage placed as a structural support across an alar defect before soft tissue reconstruction.
PATIENTS AND METHODS Twenty-five patients with significant nasal alar defects identified after excision of basal cell carcinoma (n = 22), basosquamous cell carcinoma (n = 2), and squamous cell carcinoma (n = 1) underwent cartilage grafting between July 1996 and April 1999. Follow-up was based on at least one of the following: telephone call, progress note, and photographs. Patients and physicians rated cosmetic and functionFrom the Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester. Reprint requests: Clark C. Otley, MD, Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/1/107740 doi:10.1067/mjd.2000.107740
Fig 1. Postoperative view of collapsed ala after deep alar defect was closed with a nasolabial transposition flap without cartilage grafting.
al outcomes as poor, good, or excellent. Functional outcome was assessed by the patient simply by the subjective assessment of air passage through the nostril compared with preoperative function. Functional outcome as assessed by the physician was determined by viewing the reconstructed alar contour and nasal aperture from beneath the nose. Cosmetic outcome was assessed by patients simply by asking their subjective assessment. Cosmetic out833
834 Byrd, Otley, and Nguyen
A
J AM ACAD DERMATOL NOVEMBER 2000
B
C
Fig 2. A, Donor site and alar batten cartilage graft. B, Placement of cartilage graft into surgical defect. C, One week postoperatively, after cartilage grafting and nasolabial transposition flap placement.
come was assessed by physician subjective assessment, taking into account restoration of contour, presence or absence of distortions, as well as the aesthetic quality of the overlying flap or graft coverage. Although these assessments were subjective by nature, we believe that subjective assessment of aesthetic outcome by two observers, patient and physician, is the standard. Functional assessment likewise was subjective, but formal rhinomanometric testing was not available. Time from surgery to follow-up ranged from 0.25 to 30 months (mean, 10.8 months). The defect diameter ranged from 0.6 to 5.0 cm (mean, 1.9 cm). Twelve defects were located on the right ala and 13 on the left. Eleven of the patients were men and 14 were women. Ages ranged from 38 to 92 years (mean, 76 years). Cutaneous closures included nasolabial transposition flap (n = 15), fullthickness skin graft (n = 4), rotation flap (n = 1), bilobed transposition flap (n = 1), mucosal hinge and nasolabial transposition flap (n = 2), and twostage nasolabial interpolation flap (n = 2). Our indications for performing cartilage grafting included collapse of the ala/valve on examination after tumor removal, collapse of the ala/valve on inspiration, or a prediction of distortion or collapse of the ala/valve when subjected to the contractural phase of wound healing. Graft harvesting Auricular cartilage is the donor site of choice for alar batten grafts because conchal cartilage is elastic
and has a high degree of memory. Conchal cartilage also has varied contours that can be matched to the desired contour of the ala.16,17 Antihelical or helical donor sites accessed either anteriorly or posteriorly are viable options. The entire conchal base can be removed without significant risk of auricular distortion. Subtotal resection of antihelical cartilage leaving a complete rim of intact cartilage is necessary to prevent distortion. The cartilage graft size is determined by adding 4 to 5 mm to the defect measured across the axis of cartilage placement. Graft width can vary from 3 to 8 mm. For an anterior conchal bowl donor site, a cutaneous hinge flap is created, exposing the underlying cartilage and perichondrium. A cartilage strut with perichondrium is harvested and placed in sterile saline (Fig 2, A). The donor site is closed with simple interrupted sutures, and the batten graft is trimmed to fit the defect, removing excess soft tissue but preserving perichondrium. The edges of the cartilage graft can be beveled with a scalpel to smooth them. Graft placement Recipient pockets are made with a No. 15 scalpel blade in the medial and lateral aspects of the defect (Fig 2, B). The cartilage graft is carefully set into these pockets using forceps. Two or three absorbable wraparound tacking sutures are placed to stabilize the graft (Fig 3). With insertion of the cartilage graft, nasal valve patency should be achieved and can be seen by viewing the alar contour from below. Occasionally, the surgeon must realign the
Byrd, Otley, and Nguyen 835
J AM ACAD DERMATOL VOLUME 43, NUMBER 5
Table I. Functional and cosmetic results: Physician and patient assessments Outcome, No. of patients (%) Assessment
Physician (n = 18) Excellent Good Poor Patient (n = 23) Excellent Good Poor
Functional
Cosmetic
14 (78) 4 (22) 0 (0)
9 (50) 6 (33) 3 (17)
20 (87) 3 (13) 0 (0)
11 (48) 12 (52) 0 (0)
cartilage graft to allow optimal effect, but this is uncommon. Patients will subjectively detect improved nasal air passage. The remaining soft tissue defect is closed with an appropriate cutaneous flap or graft (Fig 2, C). Prophylactic antibiotics were given in the majority of cases.
Fig 3. Representation of alar batten cartilage graft secured in an alar defect. (By permission of Mayo Foundation.)
RESULTS All of our patients believed that they had good to excellent function and cosmesis (Table I). By physician assessment, however, all patients had good to excellent function, but 17% had poor cosmesis (Table I). Poor cosmesis by physician assessment was due to suboptimal outcome of cutaneous flap or graft closure rather than the use of cartilage itself. A carefully selected flap or graft type and thickness is essential. A flap that is too thick may create a trap-door phenomenon or poor cosmesis, or both. A flap that is too thin may result in protuberance of the cartilage graft. Necrosis of a full-thickness skin graft overlaying the cartilage graft occurred in one patient. Skin grafts were used sparingly, owing to concern about ischemia. Despite cartilage graft placement, postoperative stenosis of the nasal valve occurred in 5 patients, 4 of whom deemed it minimal, and 1 of whom deemed it moderate. No patient postoperatively experienced functionally significant compromise of the nasal valve. Infection occurred in one patient and resolved after a 7-day course of cephalexin. A trap-door phenomenon developed in one patient and improved after injection with triamcinolone (5 mg/mL). Five patients experienced localized tenderness at the donor site, which was relieved by oral administration of acetaminophen or ibuprofen and resolved in 2 to 6 weeks.
DISCUSSION Many factors must be taken into account when planning nasal alar reconstruction. In most instances,
a simple cutaneous flap or graft closure is all that is needed to obtain good to excellent functional and cosmetic results. However, when surgical defects result in significant nasal valve collapse, alar batten cartilage grafts are a useful and effective tool for restoration of nasal valve function and form. The major advantages to alar batten cartilage grafting are that it is autologous tissue, has a similar contour to that of the alar rim, and establishes patency of the nasal valve. The primary disadvantage to using autologous cartilage is the creation of an additional surgical wound and associated potential comorbidities such as chondritis or infection, which were rare. In patients with full-thickness alar defects or functional compromise or both, alar batten cartilage grafts serve as a useful adjunct to cutaneous closure. We have achieved good to excellent functional and cosmetic results in the majority of cases with minimal morbidity after cartilage grafting. Alar batten cartilage grafts are useful for functionally significant alar rim defects. REFERENCES 1. Baker SR, Swanson NA, Grekin RC. Moh’s surgical treatment and reconstruction of cutaneous malignancies of the nose. Facial Plast Surg 1987;5:29-47. 2. Swanson NA. Classifications, definitions, and concepts in flap surgery. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 63-74. 3. Cook TA, Brownlee RE. Rotation flaps. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 75-90.
836 Byrd, Otley, and Nguyen
4. Brown MD. Advancement flaps. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 91-108. 5. Leffell DJ. Transposition flaps. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 10928. 6. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121:617-22. 7. Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose interpolation flap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol 1997;37:614-9. 8. Johnson TM, Baker S, Brown MD, Nelson BR. Utility of the subcutaneous hinge flap in nasal reconstruction. J Am Acad Dermatol 1994;30:459-66. 9. Johnson TM, Nelson BR. Aesthetic reconstruction of skin cancer defects using flaps and grafts. Am J Cosmet Surg 1992;9:25366.
J AM ACAD DERMATOL NOVEMBER 2000
10. Zitelli JA. The nasolabial flap as a single-stage procedure. Arch Dermatol 1990;126:1445-8. 11. Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol 1992;27:151-65. 12. Fosko SW, Dzubow LM. Nasal reconstruction with the cheek island pedicle flap. J Am Acad Dermatol 1996;35:580-7. 13. Fryer MP. Subtotal nose reconstruction with a cheek flap. Plast Reconstr Surg 1974;53:436-9. 14. Climo MS. Nasolabial flap for alar defect: case report. Plast Reconstr Surg 1969;44:303-4. 15. Redman RD, Olshansky K. Anatomical alar reconstruction with staged nasolabial flap. Ann Plast Surg 1988;20:285-91. 16. Otley CC, Sherris DA. Spectrum of cartilage grafting in cutaneous reconstructive surgery. J Am Acad Dermatol 1998;39: 982-92. 17. Ratner D, Skouge JW. Surgical pearl: the use of free cartilage grafts in nasal alar reconstruction. J Am Acad Dermatol 1997; 36:622-4.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the Journal of the American Academy of Dermatology are available to subscribers (only) for the 2000 issues from the Publisher at a cost of $123.00 for domestic, $151.94 for Canadian, and $142.00 for international for volume 42 (January-June) and volume 43 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887; phone 800-654-2452 or 407-345-4000. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
SURGERY
Alar batten cartilage grafting in nasal reconstruction: Functional and cosmetic results David R. Byrd, MD, Clark C. Otley, MD, and Tri H. Nguyen, MD Rochester, Minnesota Background: Alar batten cartilage grafts can restore form and function to a compromised ala, prevent stenosis of the nasal valve, and maintain unrestricted air movement. Soft tissue reconstructive options can be combined with alar batten grafts. Objective: Our purpose was to analyze functional and cosmetic outcomes in a series of patients undergoing alar batten cartilage grafting. Methods: We analyzed the functional and cosmetic outcomes of 25 patients in whom reconstruction involved alar batten cartilage grafts. Assessment included defect characteristics, function and cosmesis (rated by physician and patient), and complications. Results: Eighty-three percent of patients had good to excellent functional and cosmetic results by patient and physician assessment. Three patients were rated as having poor cosmetic results by the physician; all 3 patients graded these results as good. One episode of graft failure occurred, and recipient and donor site complications were minor. Conclusion: Alar batten cartilage grafts appear to be an excellent option for reconstruction of substantial alar defects. (J Am Acad Dermatol 2000;43:833-6.)
S
everal soft tissue reconstructive options are available for surgical defects of the nasal ala.1-17 Consideration must be given to functional and aesthetic restoration, or suboptimal results will occur (Fig 1). We describe our experience using alar batten cartilage grafts as a technique to restore cosmesis and function in nasal alar reconstruction. An alar batten graft is defined as a rectangular or elongated oval graft of cartilage placed as a structural support across an alar defect before soft tissue reconstruction.
PATIENTS AND METHODS Twenty-five patients with significant nasal alar defects identified after excision of basal cell carcinoma (n = 22), basosquamous cell carcinoma (n = 2), and squamous cell carcinoma (n = 1) underwent cartilage grafting between July 1996 and April 1999. Follow-up was based on at least one of the following: telephone call, progress note, and photographs. Patients and physicians rated cosmetic and functionFrom the Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester. Reprint requests: Clark C. Otley, MD, Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/1/107740 doi:10.1067/mjd.2000.107740
Fig 1. Postoperative view of collapsed ala after deep alar defect was closed with a nasolabial transposition flap without cartilage grafting.
al outcomes as poor, good, or excellent. Functional outcome was assessed by the patient simply by the subjective assessment of air passage through the nostril compared with preoperative function. Functional outcome as assessed by the physician was determined by viewing the reconstructed alar contour and nasal aperture from beneath the nose. Cosmetic outcome was assessed by patients simply by asking their subjective assessment. Cosmetic out833
834 Byrd, Otley, and Nguyen
A
J AM ACAD DERMATOL NOVEMBER 2000
B
C
Fig 2. A, Donor site and alar batten cartilage graft. B, Placement of cartilage graft into surgical defect. C, One week postoperatively, after cartilage grafting and nasolabial transposition flap placement.
come was assessed by physician subjective assessment, taking into account restoration of contour, presence or absence of distortions, as well as the aesthetic quality of the overlying flap or graft coverage. Although these assessments were subjective by nature, we believe that subjective assessment of aesthetic outcome by two observers, patient and physician, is the standard. Functional assessment likewise was subjective, but formal rhinomanometric testing was not available. Time from surgery to follow-up ranged from 0.25 to 30 months (mean, 10.8 months). The defect diameter ranged from 0.6 to 5.0 cm (mean, 1.9 cm). Twelve defects were located on the right ala and 13 on the left. Eleven of the patients were men and 14 were women. Ages ranged from 38 to 92 years (mean, 76 years). Cutaneous closures included nasolabial transposition flap (n = 15), fullthickness skin graft (n = 4), rotation flap (n = 1), bilobed transposition flap (n = 1), mucosal hinge and nasolabial transposition flap (n = 2), and twostage nasolabial interpolation flap (n = 2). Our indications for performing cartilage grafting included collapse of the ala/valve on examination after tumor removal, collapse of the ala/valve on inspiration, or a prediction of distortion or collapse of the ala/valve when subjected to the contractural phase of wound healing. Graft harvesting Auricular cartilage is the donor site of choice for alar batten grafts because conchal cartilage is elastic
and has a high degree of memory. Conchal cartilage also has varied contours that can be matched to the desired contour of the ala.16,17 Antihelical or helical donor sites accessed either anteriorly or posteriorly are viable options. The entire conchal base can be removed without significant risk of auricular distortion. Subtotal resection of antihelical cartilage leaving a complete rim of intact cartilage is necessary to prevent distortion. The cartilage graft size is determined by adding 4 to 5 mm to the defect measured across the axis of cartilage placement. Graft width can vary from 3 to 8 mm. For an anterior conchal bowl donor site, a cutaneous hinge flap is created, exposing the underlying cartilage and perichondrium. A cartilage strut with perichondrium is harvested and placed in sterile saline (Fig 2, A). The donor site is closed with simple interrupted sutures, and the batten graft is trimmed to fit the defect, removing excess soft tissue but preserving perichondrium. The edges of the cartilage graft can be beveled with a scalpel to smooth them. Graft placement Recipient pockets are made with a No. 15 scalpel blade in the medial and lateral aspects of the defect (Fig 2, B). The cartilage graft is carefully set into these pockets using forceps. Two or three absorbable wraparound tacking sutures are placed to stabilize the graft (Fig 3). With insertion of the cartilage graft, nasal valve patency should be achieved and can be seen by viewing the alar contour from below. Occasionally, the surgeon must realign the
Byrd, Otley, and Nguyen 835
J AM ACAD DERMATOL VOLUME 43, NUMBER 5
Table I. Functional and cosmetic results: Physician and patient assessments Outcome, No. of patients (%) Assessment
Physician (n = 18) Excellent Good Poor Patient (n = 23) Excellent Good Poor
Functional
Cosmetic
14 (78) 4 (22) 0 (0)
9 (50) 6 (33) 3 (17)
20 (87) 3 (13) 0 (0)
11 (48) 12 (52) 0 (0)
cartilage graft to allow optimal effect, but this is uncommon. Patients will subjectively detect improved nasal air passage. The remaining soft tissue defect is closed with an appropriate cutaneous flap or graft (Fig 2, C). Prophylactic antibiotics were given in the majority of cases.
Fig 3. Representation of alar batten cartilage graft secured in an alar defect. (By permission of Mayo Foundation.)
RESULTS All of our patients believed that they had good to excellent function and cosmesis (Table I). By physician assessment, however, all patients had good to excellent function, but 17% had poor cosmesis (Table I). Poor cosmesis by physician assessment was due to suboptimal outcome of cutaneous flap or graft closure rather than the use of cartilage itself. A carefully selected flap or graft type and thickness is essential. A flap that is too thick may create a trap-door phenomenon or poor cosmesis, or both. A flap that is too thin may result in protuberance of the cartilage graft. Necrosis of a full-thickness skin graft overlaying the cartilage graft occurred in one patient. Skin grafts were used sparingly, owing to concern about ischemia. Despite cartilage graft placement, postoperative stenosis of the nasal valve occurred in 5 patients, 4 of whom deemed it minimal, and 1 of whom deemed it moderate. No patient postoperatively experienced functionally significant compromise of the nasal valve. Infection occurred in one patient and resolved after a 7-day course of cephalexin. A trap-door phenomenon developed in one patient and improved after injection with triamcinolone (5 mg/mL). Five patients experienced localized tenderness at the donor site, which was relieved by oral administration of acetaminophen or ibuprofen and resolved in 2 to 6 weeks.
DISCUSSION Many factors must be taken into account when planning nasal alar reconstruction. In most instances,
a simple cutaneous flap or graft closure is all that is needed to obtain good to excellent functional and cosmetic results. However, when surgical defects result in significant nasal valve collapse, alar batten cartilage grafts are a useful and effective tool for restoration of nasal valve function and form. The major advantages to alar batten cartilage grafting are that it is autologous tissue, has a similar contour to that of the alar rim, and establishes patency of the nasal valve. The primary disadvantage to using autologous cartilage is the creation of an additional surgical wound and associated potential comorbidities such as chondritis or infection, which were rare. In patients with full-thickness alar defects or functional compromise or both, alar batten cartilage grafts serve as a useful adjunct to cutaneous closure. We have achieved good to excellent functional and cosmetic results in the majority of cases with minimal morbidity after cartilage grafting. Alar batten cartilage grafts are useful for functionally significant alar rim defects. REFERENCES 1. Baker SR, Swanson NA, Grekin RC. Moh’s surgical treatment and reconstruction of cutaneous malignancies of the nose. Facial Plast Surg 1987;5:29-47. 2. Swanson NA. Classifications, definitions, and concepts in flap surgery. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 63-74. 3. Cook TA, Brownlee RE. Rotation flaps. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 75-90.
836 Byrd, Otley, and Nguyen
4. Brown MD. Advancement flaps. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 91-108. 5. Leffell DJ. Transposition flaps. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St Louis: Mosby; 1995. p. 10928. 6. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121:617-22. 7. Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose interpolation flap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol 1997;37:614-9. 8. Johnson TM, Baker S, Brown MD, Nelson BR. Utility of the subcutaneous hinge flap in nasal reconstruction. J Am Acad Dermatol 1994;30:459-66. 9. Johnson TM, Nelson BR. Aesthetic reconstruction of skin cancer defects using flaps and grafts. Am J Cosmet Surg 1992;9:25366.
J AM ACAD DERMATOL NOVEMBER 2000
10. Zitelli JA. The nasolabial flap as a single-stage procedure. Arch Dermatol 1990;126:1445-8. 11. Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol 1992;27:151-65. 12. Fosko SW, Dzubow LM. Nasal reconstruction with the cheek island pedicle flap. J Am Acad Dermatol 1996;35:580-7. 13. Fryer MP. Subtotal nose reconstruction with a cheek flap. Plast Reconstr Surg 1974;53:436-9. 14. Climo MS. Nasolabial flap for alar defect: case report. Plast Reconstr Surg 1969;44:303-4. 15. Redman RD, Olshansky K. Anatomical alar reconstruction with staged nasolabial flap. Ann Plast Surg 1988;20:285-91. 16. Otley CC, Sherris DA. Spectrum of cartilage grafting in cutaneous reconstructive surgery. J Am Acad Dermatol 1998;39: 982-92. 17. Ratner D, Skouge JW. Surgical pearl: the use of free cartilage grafts in nasal alar reconstruction. J Am Acad Dermatol 1997; 36:622-4.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the Journal of the American Academy of Dermatology are available to subscribers (only) for the 2000 issues from the Publisher at a cost of $123.00 for domestic, $151.94 for Canadian, and $142.00 for international for volume 42 (January-June) and volume 43 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887; phone 800-654-2452 or 407-345-4000. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.