Leave the fat, skip the bolster: thinking outside the box in lower third nasal reconstruction.

Defects of the lower third of the nose often present especially challenging reconstructive dilemmas. The surrounding skin to match is often thick, sebaceous, and sun damaged, none of which characterizes the historically ideal periauricular donor skin for grafting. The surrounding nasal skin is quite stiff, precluding very small local flaps. To avoid the "misplaced patch" appearance of most classic full-thickness grafts to this area or the depressed scar of an elliptical excision, many surgeons turn to larger local or regional flaps. These provide not only skin color and texture match but also the necessary several millimeters of subcutaneous fat necessary for proper tip aesthetics. Many defects of the lower third are small, making many surgeons reluctant to employ these larger flaps with their long scars and potential to twist or distort delicate tip or ala anatomy. The author has sought a means to transport skin and subcutaneous fat for lower third nasal defects outside of flaps. On the basis of the superiority of nasolabial fold scars and a vast positive experience in the literature utilizing skin and fat composite grafts with no bolsters, the author applied these techniques to 33 lower third nasal defects in 29 patients. Of 33 grafts varying in size from 4 mm circular to 17 mm x 16 mm and retaining 1 to 5 mm of fat, no grafts were lost. Four grafts developed a 30 percent area or less of central necrosis resulting in localized depression. Three of these four grafts were in active smokers and the fourth graft was in a former smoker. Aside from these four grafts and one with considerable excess fat early in the series, contour was good to excellent. Hypopigmentation is still common but improves with time. Easily performed composite grafts effectively carry the necessary fat for aesthetic reconstruction and do not risk long scars on the nose and twisting of the tip and ala that can result from flaps. Revisions are infrequent and extremely simple when indicated.