title: Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience.
abstract: BACKGROUND
  Composite grafts for nasal reconstruction have been around for over a century but the opinion on its virtues and failings keeps vacillating with a huge difference on the safe size of the graft for transfer. Alar margin and columellar defects are more distinct than dorsal nasal defects in greater difficulty in ensuring a good aesthetic outcome. We report our series of 19 consecutive patients in whom a composite graft was used to reconstruct a defect of alar margin (8 patients), alar base (7 patients) or columella (4 patients).
  
  
  METHODS
  Patient ages ranged from 3-35 years with 5 males and 14 females. The grafts to alar margin and base ranged 0.6-1 cm in width, while grafts to columella were 0.7-1.2 cm. The maximum dimension of the graft in this series was 0.9 mm x 10 mm. Composite grafts were sculpted to be two layered (skin + cartilage), three layered wedges (skin + cartilage + skin) or their combination (two layered in a portion and three layered in another portion). All grafts were cooled in postoperative period for three days by applying an indigenous ice pack of surgical glove. The follow up ranged from 3-9 months with an average of 4.5 months.
  
  
  RESULTS
  All of our 19 composite grafts survived completely but they all shrank by a small percentage of their bulk. Eleven patients rated the outcome between 90-95% improvement. We noticed that composite grafts tended to show varied pigmentation in our patients, akin to split skin grafts.
  
  
  CONCLUSIONS
  In our opinion, most critical to graft survival is its size and the ratio of the marginal raw area to the graft bulk. We recommend that graft width should not exceed 1 cm to ensure complete survival even though larger sized grafts have been reported to survive. We recommend cooling of the graft and justify it on the analogy of 'warm ischemia time' for a replantation, especially in warmer climes like ours in India. We have outlined several considerations in the technique, with an analysis of differing opinions that should facilitate a surgeon in making an informed choice.
authors.affiliation: Department of Burns and Plastic Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College, New Delhi, India.
authors.forename: Rajeev B
authors.initials: RB
authors.lastname: Ahuja
authors.affiliation: Department of Burns and Plastic Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College, New Delhi, India.
authors.forename: Rajat
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Department of Burns and Plastic Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College, New Delhi, India.
authors.forename: Pallab
authors.initials: P
authors.lastname: Chatterjee
authors.affiliation: Department of Burns and Plastic Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College, New Delhi, India.
authors.forename: Prabhat
authors.initials: P
authors.lastname: Shrivastava
keywords: Alar defect; columellar defect; composite grafts; nose defects