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17 April 2023: Articles  Italy

Chondro-Cutaneous Autograft for Reconstruction of the Nasal Ala After a Human Bite

Management of emergency care, Rare disease

Bartolo Corradino1ABCDEG, Sara Di Lorenzo1BCD, Andrea Pio Cascino1BCDEF*

DOI: 10.12659/AJCR.939242

Am J Case Rep 2023; 24:e939242

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Abstract

BACKGROUND: The nasal ala is a paired structural subunit of the nose that is functionally important in the maintenance of the nasal valve. It consists of 3 anatomically distinct layers: skin, cartilage, and mucosa, all of which need to be restored in reconstructive surgeries to maintain nasal patency. When multiple layers are involved in a defect, the reconstruction requires combining procedures to replace each layer.

CASE REPORT: We describe a peculiar case of a 58-year-old man with a full-thickness loss of substance of the right nasal ala due to a human bite. The patient came to our hospital after an altercation with another man who bit his nose off. He was initially seen at a smaller regional hospital that did not have a plastic surgery department and was soon after transferred to our facility due to the complexity of the case. To reduce the risk of infection, the patient was treated with a complete course of intravenous antibiotic therapy and the wound was medicated daily with antiseptic solutions. The loss of substance was reconstructed with a composed graft from the auricle concha and the melolabial flap.

CONCLUSIONS: Defects of the nasal ala are challenging to reconstruct, given its complex 3-dimensional structure. The successful repair of these defects provides aesthetic symmetry and preserves nasal function. A wide variety of reconstructive options have been utilized in many nasal reconstruction cases and have been documented. The combination of a chondro-cutaneous graft from the auricular concha and a melolabial flap graft allowed a good result without local or systemic complications.

Keywords: autografts, Bites, Human, Surgery, Plastic, Surgical Flaps, Male, Humans, Middle Aged, Rhinoplasty, Nose

Background

Nasal ala subunit defects are technically challenging to reconstruct due to variable skin texture, color, and similarity in thickness between the area to be reconstructed and the donor site [1]. To preserve nasal aesthetic units and symmetry, surgical reconstruction requires a delicate balance between reshaping the nasal curvatures and predicting scar contracture [2].

Regarding the nasal ala anatomy, the external skin, cartilage, and fibrofatty middle portion and the internal mucosa can be seen as 3 anatomically distinct layers that participate to ensure the nasal valve function.

Most reports of bite wounds in the literature are related to dog or cat bites, and there are few reports of human bites that are inclusive of treatments, surgical planning, or detailed reconstruction techniques [3]. Bites are usually painful and leave bruises or tooth marks on the skin. Infected bite sites are sore, red, and swollen [4]. After initial triage evaluation, the patient should be admitted, and the human bite wound should be initially washed with physiological sterile solution, then cleansed with antiseptic solution and an empiric broad-spectrum antibiotic therapy regimen should be promptly prescribed [5]. It is also important to state that a detailed history about the dynamics of the aggression and the health conditions of the aggressor need to be collected [4].

Flaps are generally preferred over skin grafts, and in this case study, a combination of both were utilized.

Case Report

We will discuss the case of a 58-year-old man who had his right nasal ala amputated by a human bite received during an altercation between said patient and the husband of his lover. The patient was transferred to our hospital after receiving initial treatments for 2 days at a small regional hospital. During the 2 days the patient received medication, tetanus prophylaxis, broad spectrum antibiotic therapy (amoxicillin – clavulanic acid 875–125 mg, 3 tablets per day). The patient provided written informed consent for the use of his photographs for data and research purposes before the procedures.

On physical examination, the patient had full-thickness loss of substance of the right nasal ala and part of the skin covering of the tip of the nose (Figure 1). The wound site was immediately swabbed for infection, and tested positive for Streptococcus and Staphylococcus, thus requiring the patient to receive a specific antibiotic therapy. At this point, the infectious disease department was consulted, and after having analyzed the result of an antibiogram, the best course of action prescribed was clindamycin 600 mg 4 times daily and vancomycin 500 mg 3 times daily. In preparation for surgery, the wound was medicated daily with betadine and sodium hypochlorite for the next several days. The soft tissue was temporarily sutured to maintain the stability of the wound after performing a debridement of the necrotic tissue. In this case the complexity of the loss of substance, which included the right nasal ala, the tip of the nose, and the underlying cartilage, led the surgeons to perform the reconstruction of all the missing components in a single step.

The reconstruction was performed using a composed graft made of cartilage and skin taken from the left auricle concha and a transposition flap from the labial nose groove of the right cheek for skin coverage. The reconstruction of the ala and the tip of the nose was performed under general anesthesia. The patient was placed in supine position.

The first surgical stage consisted of the debridement of the necrotic cartilage and skin (Figure 2). The residual skin over the tip was detached from the cartilage and an anatomical pocket under the base of the right ala was created to accommodate the graft.

The drawing of the melolabial flap was marked to include an increase of 20% over the actual loss of substance that was to be reconstructed (Figure 3). The reason why 20% additional area was marked and utilized in this procedure was due to our clinical experience with previous cases of nasal reconstruction. In these cases, we encountered skin retraction due to scarring during the healing process. This technique does not allow any skin redundancy because it is utilized to create the curvature of the ala of the nose. Operative planning and marking of the incisions for the excision of the cartilage and skin for the graft was calculated by measuring the opposite nostril and increasing its dimensions by 0.5 cm for the cartilage and by 0.2 cm for the skin component (Figures 3, 4). The graft was set in the following manner: the skin component was placed towards the nasal cavity; the cartilage portion was placed facing outward; the frontal margin of the graft was placed on the residual cartilage and sutured to the tip of the nose; and the posterior margin was placed on the newly created cavity in correspondence to the base of the right nostril (Figure 5).

After the graft was properly set, the melolabial flap was incised down to the subcutaneous plane and transposed over the graft. The flap and the skin of the donor site were sutured using 4-0 silk sutures to close the donor site. The nasal mucosa and cartilage were sutured using 5-0 Vicryl.

During the postoperative period, the patient was advised to wear a silicone device in the reconstructed nostril all day long for the first 10 days and every night for an additional 30 days to prevent scar retraction and nasal cavity obliteration.

Postoperatively, in both donor and recipient sites, no complications were reported. Furthermore, a followup examination at 24 months after surgery revealed that results remained stable, and that a good ala symmetry and an accurate color match had been successfully obtained (Figure 6).

Discussion

Bite wounds entail a high risk of infection [8]. It is important to ascertain the presence of bacteria from the human bite and provide treatment. This serves to mitigate the possible risk of failure for any reconstructive procedure [7]. Our patient received specific antibiotic therapy, and, prior to surgery and even prior to discussing options for reconstructing the nasal ala, the patient needed to first receive a negative microbiological swab. Once we obtained the greenlight to operate, the proposed reconstruction of the nasal ala, using a composed graft made of cartilage and skin with a melolabial flap, proved to be an appropriate technique with minimal scarring, no complications, accurate color match, and rapid healing. The graft mimicked the natural arch of the nasal ala, and the patient was given a nostril dilator to use for 30 days to assist with full aesthetic and functional recovery. The cartilage graft provided the support to the flap and prevented the collapse of the nasal ala. In the auricle donor site, tissue was lost due to harvesting of the graft. This site was reconstructed with the postauricular island flap, also known as Masson’s flap [9,10]. On the donor site where the melolabial skin flap was harvested, the scar that was formed mimics the natural crease of the face and is almost invisible.

The surgery was conducted according to the principle set forth by Burget and Menick in 1985 [1], in which it was stated that it is preferable to reconstruct the entire nasal subunit rather than a smaller portion that was impacted. For compound defects involving the nasal ala, reconstruction using the melolabial flap on a composite graft is an optimal option, and this should be taken into consideration when identifying treatment options.

Composite grafts are indicated for the coverage of complex full-thickness defects up to 1.5 cm in length, as grafts larger than 1.5 cm tend to retract over time and require additional followup surgery. Previous reports have indicated that grafts larger than 1.5 cm have failure rates of over 50% [6,7].

Conclusions

We describe the case of a patient whose nose was partially amputated by a human bite. The patient was subjected to surgical debridement of necrotic cartilage and skin and to an immediate reconstruction with a graft and a local flap. It is important to swab the wound site and prescribe a targeted antibiotic therapy to the patient [5]. The composed graft needs to be at least 0.5 cm larger than the lost substance in its cartilage component, due to the scar retraction phenomenon it will undergo [11]. The patient needs to be compliant and wear a stiff device in the reconstructed nostril for 40 days to get a full result.

References:

1.. Burget GC, Menick FJ, The subunit principle in nasal reconstruction: Plast Reconstr Surg, 1985; 76(2); 239-47

2.. Fisher GH, Reconstruction of a full thickness soft triangle defect: Dermatol Surg, 2009; 35(12); 2009-12

3.. Chen C, Patel R, Chi J, Comprehensive algorithm for nasal ala reconstruction: Utility of the auricular composite graft: Surg J (N Y), 2018; 4(2); e55-61

4.. Therattil PJ, Kass WS, Sood A, Datiashvili RO, Alar rim reconstruction: A case report and review of the literature: Madridge J Case Rep Stud, 2017; 1(1); 11-15

5.. Brook I, Management of human and animal bite wounds: An overview: Adv Skin Wound Care, 2005; 18(4); 197-203

6.. Cerci FB, Usefulness of the subunit principle in nasal reconstruction: An Bras Dermatol, 2017; 92(5 Suppl. 1); 159-62

7.. Bouhanna A, Bruant-Rodier C, Himy S, [Reconstruction of the nasal alar defect with the superiorly based nasolabial flap described by Burget: report of seven cases.]: Ann Chir Plast Esthet, 2008; 53(3); 272-77 [in French]

8.. Hendi A, Reconstruction of an alar rim defect: Dermatol Surg, 2006; 32(9); 1179-80

9.. McCluskey PD, Constantine FC, Thornton JF, Lower third nasal reconstruction: when is skin grafting an appropriate option?: Plast Reconstr Surg, 2009; 124(3); 826-35

10.. Nadjmi N, Vaes L, Van de Casteele E, A novel technique for nasal alar reconstruction: Plast Reconstr Surg Glob Open, 2022; 10(4); e4284

11.. Ahuja RB, Gupta R, Chatterjee P, Shrivastava P, Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience: Indian J Plast Surg, 2014; 47(03); 333-39

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923