The composite graft from the
conchal cartilage is a graft that is often used, especially in surgery on the
nose, due to its capacity to resolve problems of cover and tissue deficit,
arising from the removal of neoplasms or as the result of trauma, burns or
following over-aggressive rhinoplasty. We have started to use
skin-perichondrium-cartilage graft from the ear to cover large areas of the nose
with very satisfying results as well as we describe in the reported clinical
case.

Methods
The operation consisted of reconstruction of the cartilaginous nasal septum,
which had previously been removed, using two vestibular labial mucosa flaps to
reconstruct the mucosa, and cartilage from the ear conch for the cartilaginous
septum. After this, the skin edges of the fistula were turned to recreate the
inner lining of the nose and form a vascular base of wide area to accept the
composite graft. The case concerns a female 74-year old patient who had
undergone several oncological surgery for a relapsing basal cell carcinoma on
the dorsum of the nose. The operation consisted of reconstruction of the
cartilaginous nasal septum using two vestibular labial mucosa flaps to
reconstruct the mucosa, and cartilage from the ear conch for the cartilaginous
septum.

Results
The perichondrial cutaneous graft has shown in this surgical case very favorable
peculiarities that make it usable even in facial plastic surgery.

Conclusions
We believe that the positive experience that we achieved in the use of composite
grafts for the reconstruction of large areas of the nose could be interesting
for others surgeons.

Introduction
The composite graft from the conchal cartilage is a graft that is often used,
especially in surgery on the nose, due to its capacity to resolve problems of
cover and tissue deficit, arising from the removal of neoplasms or as the result
of trauma, burns or following over-aggressive rhinoplasty [1-3].
Complex defects of the nose are aesthetically difficult to repair, however, the
colour, the quality and thickness of the composite-skin graft harvested from the
preauricular site compare favourably with the skin of the nose region, even
after extensive oncological surgery such as in patients affected by basal cell
carcinoma of the nose [4].
The technique for removal of the graft is very simple, leaves no trace and does
not cause any residual functional deficit [5,6]. Insertion of the graft is easy
and allows rapid solution of surgical problems that would otherwise demand more
lengthy reconstruction or the use of microsurgery.
Working from this point of view, in the last 5 years, we have started to use
skin-perichondrium-cartilage graft from the ear to cover large areas of the nose
with very satisfying results.

We would like to describe a clinical case-study which we believe can be useful
to illustrate our technique.

Case report
The case concerns a female 74-year old patient who had undergone several
oncological surgery for a relapsing basal cell carcinoma on the dorsum of the
nose. It was three years after the last operation and the patient was very keen
on a definitive covering of the affected area (Figure 1), which had been made
with an epiphysis but which she was no longer able to tolerate. Various
reconstructive surgical operations had been proposed to the patient, but she had
always refused them.

(a)	(b)
Figure 1. A preoperative image of the large defect on the dorsum of the nose.	Figure 2. The cartilaginous nasal septum reconstructed using two vestibular labial mucosa flaps to recreate the mucosa.	Figure 3. A view of the skin edges of the fistula turned to recreate the inner lining of the nose.

Figure 1. A preoperative image of the large defect on the dorsum of the nose.
The operation consisted of reconstruction of the cartilaginous nasal septum,
which had previously been removed, using two vestibular labial mucosa flaps to
reconstruct the mucosa, and cartilage from the ear conch for the cartilaginous
septum (Figure 2). After this, the skin edges of the fistula were turned to
recreate the inner lining of the nose and form a vascular base of wide area to
accept the composite graft (Figure 3,4). The post-operatory period was regular
apart from the central section of the skin graft, which presented a severe
inflammation and which was treated with local application of a ointment and with
an administration of bromeline pills in order to reduce the swelling [7], giving
complete healing within a few weeks (Figure 5).

Figure 2. The cartilaginous nasal septum reconstructed using two vestibular
labial mucosa flaps to recreate the mucosa.
Figure 3. A view of the skin edges of the fistula turned to recreate the inner
lining of the nose.
Figure 4. The surgical area covered by a graft of skin-perichondrium-cartilage
removed from the auricular concha.
Figure 5. A postoperative image after about 4 weeks from surgery.

(a)	(b)
Figure 4. The surgical area covered by a graft of skin-perichondrium-cartilage removed from the auricular concha.	Figure 5. A postoperative image after about 4 weeks from surgery.

Discussion
The perichondrial cutaneous graft is a performant and versatile composite graft
that shows useful properties for maxillofacial surgery. The graft consists of
epidermis, dermis and subcutaneous tissue, and the perichondrial layer.

The perichondrial cutaneous graft has very favorable peculiarities that make it
usable in different types of plastic surgery, in some cases we can certainly use
it even in facial plastic surgery. The auricular concha is easily accessible,
has a good tissue consistency and adaptability. Useful characteristics are that
it does not contract and we can see a low donor site morbidity [8]. However, the
color match is not really good in colored races, so we can’t suggest this graft
in all patients.

One limitation of the technique is determined by the area that can be considered
to be sure of proper establishment and revascularisation of the composite graft.

This constraint is however more a subjective limitation than an objective one,
since there are no rules that can indicate it to us. What is considered to be
important is that the graft should have the maximum possible contact with the
vascularised tissue, which can be considered to be the bed upon which the graft
is placed; postoperative gentle scarification of the graft, in combination with
a constantly applied heparin solution decongests venous stasis normally seen in
such grafts helps to establish a stable and early blood supply enhancing graft
take [1,9]. Important is then to have the consciousness that creating a
well-vascularized recipient bed with an optimization of the raw contact surface
give the chance of good result.

Conclusions
We believe that the positive experience that we achieved in the use of composite
grafts for the reconstruction of large areas of the nose could be interesting
for others surgeons and will stimulate wider application of the technique
described in this report.

Consent statement
Written informed consent was obtained from the patient for publication of this
case report and accompanying images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
FI: participated in the surgical treatment and in the follow-up of this patient,
MT: drafted the manuscript and reviewed the literature, FMA: participated in the
surgical treatment and in the follow-up of this patient, MM: participated in the
design of this case study and in the follow-up of this patient, ADI: revised the
literature sources, RC: participated in the surgical treatment and in the
follow-up of this patient, AMI: documented this case report with digital
pictures, GD: participated in the follow-up of this patient. All the authors
read and approved the final manuscript.

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