'Drumhead' Technique May Spare Alar Graft Depressions


PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper

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