The Challenges of Skin Graft Lining in Nasal Reconstruction: Comment on “Full-Thickness Skin Grafts and Quilting Sutures for Reconstruction of Internal Nasal Lining”

It is with delight we read the original article titled “Full-Thickness Skin Grafts and Quilting Sutures for Reconstruction of Internal Nasal Lining” and even more pleasantly an insightful comment from Dr. Menick who has further extended the discussion on such a subject. Our group has also dedicated decades to pursuing better solutions for nose reconstruction.

As the rhinoplasty and nasal reconstruction center of a tertiary referral hospital in China, our team has been dedicated to pursuing better solutions for nose reconstruction for decades. By now, the way to repair the nasal lining that would “minimize the risk and surgeons' anxieties” is to fold the forehead or nasolabial flap. The skin graft might be applied only if it were the last resort.

It is our hands-on experience that the biggest challenge of utilizing skin graft for intranasal lining is not the variable survival rate but the almost inevitable complications that ensue.

First, even with the full thickness of skin grafting, the contractions will always be threatening for the surface in the later stage. It might bring forth a series of difficulties such as narrowing nasal airway, deformed nostril, and vestibular stenosis. Releasing the contracted skin graft leads to the demand for more lining material, while another skin graft might also result in the similar result, while elevating the skin graft for zigzag flap transposition presents the risks of graft necrosis. Therefore, if any of the aforementioned complications occur, the subsequent revision will be more difficult.

When we perform a nose reconstruction, we tend to reconstruct its entire cartilaginous framework. It contains not only the dorsal onlay graft and columellar strut but also a pair of alar rim grafts that play a pivotal role in shaping and supporting the alar. Under such circumstances, skin graft is no longer an option, as there is no soft tissue bed for the skin graft, and the back-fold from the flap is the only way to go.

Even when the alar defect is small, for which a paranasal flap could be sufficient, we still tend to raise an island flap with its pedicle somewhat skeletonized to increase its mobility, which effectively renders a facial artery perforator propeller flap. The flap is also folded, if necessary, with a piece of conchal cartilage to reconstruct the full-layered alar.

All of the aforementioned perspectives are down to one principle: sustaining the possibilities. We would very much like to echo the comment by Dr. Menick that “most patients, if informed about options, choose to look normal.” Such sentiment to us, is the continuous effort to pursue for, even though not exactly perfect.

Publication History

Article published online:
01 June 2021