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Hicks et al. Plast Aesthet Res 2022;9:2 https://dx.doi.org/10.20517/2347-9264.2021.65 Page 7 of 11

The first step in repair is optimal preparation of the defect and ensuring optimal vascularization of wound
bed. Baker advocates allowing the wound to heal by secondary intention first, followed by interval
[6]
deepithelialization and recipient bed preparation in a second stage . Other techniques, such as using a
vascular hinge flap, may also be used to optimize the vascularity of the recipient bed.

Next, the donor site is selected, and the intended graft is marked out, oversizing slightly to allow for
contracture. The graft is typically excised sharply, and judicious hemostasis is obtained. The donor site is
closed in multiple layers.

The graft is contoured as needed and placed in the recipient bed. It is important to minimize the amount of
cauterization used in this area. It is secured using the fewest number of strategically placed sutures possible,
[6]
ensuring a secure repair while minimizing trauma to the delicate graft . In general, the graft should fit well
into the defect with no appreciable tension. After the graft has been sutured in place, a gentle bolster may be
applied in select cases. If a bolster is not applied, the wound should be gently cleaned and kept moist with
antibiotic ointment while healing. Sutures are typically removed one week after surgery. In most cases,
minor revision of graft via contouring or dermabrasion may be done as early as eight to twelve weeks after
the initial surgery.

Composite grafts in nasal reconstruction
The earliest description of composite grafts in nasal reconstruction was published by Konig in 1914, who
[8]
used composite auricular grafts to repair defects of the nasal ala and reported a graft survival rate of 53%.
Since that time, understanding of graft physiology has improved, leading to a significantly higher graft
survival rate.

Due to the unique shape and construction of the auricle, composite grafts from different parts of the auricle
[1]
may be utilized to reconstruct various nasal defects [Figure 4] . For defects of the alar rim, the optimal graft
varies based on where the defect is and what tissue layers are involved. Figure 5 demonstrates a patient with
a small, full-thickness defect of the nasal ala, which was repaired with a hinge flap for the inner lining and a
composite graft from the root of the helix for structural support and cutaneous coverage. For defects that
are more lateral and contain mostly fibrofatty tissue, grafts from the lobule may be appropriate. Grafts from
the tragus and anti-tragus may be useful in covering shallow defects along the alar margin. Defects involving
the columella and soft tissue facet are often repaired with grafts from the helical root; these grafts have
suitably thin skin, and adjacent preauricular skin may be harvested if necessary. For defects of the nasal sill
or in the correction of vestibular stenosis, a sturdy graft is needed; a composite graft from the triangular
fossa is well-suited for this area .
[6]
In larger defects, in which a local flap is used in addition to a composite graft, it is beneficial to do the local
flap first, allow this to heal, and then perform the composite graft as a second stage procedure . This
[6]
practice minimizes the tension on the graft as it is healing. This method may be used in combined cheek,
lip, and nasal defects, in which a local flap is utilized to recreate the alar-facial or nasofacial junction. It is
important to “set” this boundary first, so that it is well-defined and stable prior to the placement of the
composite graft.

Composite grafts in eyelid reconstruction
In general, eyelid reconstruction is very complex, owing to the intricate aesthetic goals and functional
requirements of the eyelid. As with all reconstructions, the eyelid must be thought of in layers: anterior
lamella (skin and orbicularis muscle), septum, and posterior lamella (tarsal plate and conjunctiva).