ABSTRACT
Reconstruction of defects of the nasal ala and soft triangle may pose unique challenges for the dermatological surgeon. Alar defects that extend into deep soft tissue and/or approach the free margin of the nasal ala after skin cancer resection may eventuate in a functional as well as a cosmetic deficit if not reconstructed with appropriate structural support (Figure 1A) (1). Not only is there a risk of alar retraction if the forces of wound contraction remain unopposed during healing, but, more importantly, the negative airway pressure created with inspiration may collapse the already weakened alar support structures, with resultant compromise of the nasal valve, leading to partial airway obstruction (Figure 1b-c) (1-6). Such alar collapse does not usually occur with expiration. Free cartilage grafts can be used to avert this potential problem by providing structural support for partial-thickness nasal alar rim defects (4,7-11). These grafts may be variously configured as columellar and tip struts, sidewall braces, dorsal buttresses, and alar battens to restore the natural form and appearance of the nose (4,7,8,10). Presented here is a simplified technique for the placement of free cartilage grafts as alar battens to replace the lost structural support of the nasal alar rim. These grafts may be used in conjunction with flaps or fullthickness skin grafts to maintain airway patency and to minimize the risk of
Alar batten grafts are curvilear grafts consisting of cartilage with its overlying perichondrium. These grafts are placed into soft tissue pockets situated at the points of maximum alar rim collapse to provide additional alar support (3,10,11). The intended position of alar batten grafts may be marked preoperatively on the medial and lateral aspects of the defect, and their convex surface is oriented laterally to provide lateral support for the collapsed region of the ala (3). Although these grafts may be harvested from the auricular, nasal septal, or costal cartilage, the auricular cartilage tends to be most accessible to the dermatological surgeon, and the conchal bowl and antihelix serve as the most common donor sites in the area (4,12). Although an anterior or posterior approach to the conchal bowl site may be used without alteration in the shape of the ear, the posterior approach results
II. TECHNIQUE
The length of the cartilage graft is determined by measuring the distance between the lateral and medial borders of the defect at the alar rim and adding to that measurement four or five additional millimeters. Alar batten grafts generally measure 10-20mm in length and 3-8mm in width. These grafts must be strong enough to resist the negative inspiratory forces that collapse the lateral nasal wall as well as the forces of wound contraction which could produce upward retraction of the alar rim over time (4,11).
