Acta Oto-Laryngologica Case Reports

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Restoration of soft triangle of the nose using

auricular composite graft and fibrin glue

Mohamed Elsayed Mohamed Mohamed & Ahmed Fathy Mohamed Eldehn

To cite this article: Mohamed Elsayed Mohamed Mohamed & Ahmed Fathy Mohamed Eldehn
(2020) Restoration of soft triangle of the nose using auricular composite graft and fibrin glue,
Acta Oto-Laryngologica Case Reports, 5:1, 96-100, DOI: 10.1080/23772484.2020.1848433

To link to this article: https://doi.org/10.1080/23772484.2020.1848433

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Published online: 26 Nov 2020.

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ACTA OTO-LARYNGOLOGICA CASE REPORTS
2020, VOL. 5, NO. 1, 96–100
https://doi.org/10.1080/23772484.2020.1848433

CASE REPORT

Restoration of soft triangle of the nose using auricular composite graft and
fibrin glue
Mohamed Elsayed Mohamed Mohameda and Ahmed Fathy Mohamed Eldehnb
a
Plastic Surgery Department, Ahmed Maher Teaching Hospital, Cairo, Egypt; bLecturer of ENT, Department of ENT,
Kasr Al-Ainy Medical School, Cairo, Egypt

ABSTRACT ARTICLE HISTORY

The impact of fibrin glue on helical composite graft take and outcome after reconstruction of Received 18 August 2020
the soft triangle of the nose was demonstrated. A superior helical ear composite graft was har- Revised 19 October 2020
vested for the reconstruction of the soft triangle of the left nostril. Fibrin glue is used frequently Accepted 6 November 2020
with split-thickness skin grafts but not with composite grafts before. It was used intraoperatively
KEYWORDS
as a sealant, haemostatic and fixating agent, promote wound healing and prevent skin graft Soft triangle defect; nasal
contracture. The complete composite graft-take occurred along with good aesthetic outcome reconstruction; fibrin glue;
and integration. The symmetry of both nostrils was restored. No graft shrinkage or contracture composite grafts
was observed for more than 10 months follow up. In this case, fibrin glue helped the composite
graft complete take and integration with the restored good aesthetic appearance and minimal
graft contraction. The level of evidence was – Therapeutic, V.

Introduction In this current case report, fibrin glue was used to

Nasal defects are common due to a wide variety of
causes namely congenital, post-traumatic, malignancy,
infection, etc. These defects are of different sizes and
locations [1].
The soft triangle is considered one of the most
challenging nasal subunits to be reconstructed. Failure
to reconstruct these defects properly can inversely
affect both functional outcome and esthetic appear-
ance. Insufficient restoration of the normal anatom-
ical appearance will have a tremendous implication
on the psychological and physical aspects [2].
It is better to reconstruct defects using composite
grafts in defects smaller than one cm to prevent graft
necrosis and so have a more satisfactory esthetic out-
come [3].
Fibrin glue has been used in many areas of plastic
surgery, including burn surgery. These applications
make use of the hemostatic, fixation, and engraftment
advantages for split-thickness skin grafts. No available
reports were found supporting the use of fibrin glue
to improve composite grafts take in soft triangle nasal
reconstruction [4].
help in composite graft fixation, sealing, hemostasis
and total integration and decrease the possibility of
cartilage resorption and graft contracture. Restoration
of a satisfactory aesthetic result for both the patients
and the surgical team was evident.
Case report
A 9-year-old girl presented to the outpatient clinic
with loss of the left soft triangle of the nose, after
6 weeks of epistaxis operation. The defect was mostly
due to the use of electrocautery in the treatment of
recurrent attacks of epistaxis. It seems that the hand-
piece of the electrocautery was in contact with the
skin of the soft triangle. The patient complained of a
gradual loss of the soft triangle skin within 2 weeks
post-operative. The defect of the soft triangle reached
maximum dimensions after 5 weeks postoperatively.
The resultant cellulitis and infective process led to the
loss of the soft triangle of the nose with loss of its
skin, and part of the alar cartilage and inner mucosa.
On examination, the defect size was oval in shape
with 5  4 mm in dimension because of scar

CONTACT Mohamed Elsayed Mohamed Mohamed Mghabn5777@yahoo.com, m.elsayed.tajmeel@gothi.cloud.gov.eg Plastic Surgery Department,
Ahmed Maher Teaching Hospital, 341, Port said Street, Cairo 11638, Egypt
Mohamed Elsayed Mohamed Mohamed is also an international member of the American Society of Plastic Surgeons ASPS and an international member
of the American Council for Academic Plastic Surgeons.
ß 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

contracture. Margins of the defect were inflamed and
fibrotic. Medical treatment was prescribed in the form
of local antibiotic creams, and also local decongestant
nasal drops. Based on the size of the defect and its
location also the age of the patient, a reconstructive
plan was suggested to reconstruct the lost soft triangle
using composite alar cartilage graft in one-stage oper-
ation, using fibrin glue to promote the graft fixation
and integration into the recipient area.
Intra-operative examination under general anesthe-
sia revealed the site of the previous cauterization,
fibrous tissue formation replacing the mucous mem-
brane of the nasal septum at the Little’s area.
After debridement and scar excision, the defect
measured 7  6 mm. The composite graft was har-
vested from the root of the left helix. The donor site
was closed primarily after the approximation of the
cartilage with 5-0 non-absorbable prolene sutures.
Helical skin was closed using 5-0 non-absorb-
able sutures.
The composite graft was immediately sutured to
the recipient site for better opposition of the margins.
The cartilage of the composite graft was sutured to
the alar cartilage with 6-0 non-absorbable sutures.
The inner mucosal layer was sutured first to the com-
posite graft using 5-0 absorbable sutures and the skin
was sutured using a 6-0 non-absorbable interrupted
sutures. Fibrin glue was injected into the virtual space
Figure 1. Defect of soft triangle of the left nostril measuring
5  4 mm (AP view).
ACTA OTO-LARYNGOLOGICA CASE REPORTS 97
through the interrupted sutures between the graft and
the nasal margin on both skin and mucosal sides.
The nasal cavity was packed with paraffin gauze
and a small dressing was applied after applying a thin
layer of antibiotic ointment outside. The packing was
removed on the 3rd post-operative day and the skin
sutures were removed on the 9th post-operative day.
Follow-up of the patient took place minimally once
weekly, till the end of the first month, then regular
visits once monthly till after 10 months follow-up.
There is a pink color mismatch which is being treated
with a local application of silicone gel improving with
time. The donor site is healed without any incidence.
The patient and parents were very satisfied with the
results as shown in Figures 1–6.
Discussion
Defects of the soft triangle could be reconstructed
with composite grafts from the helical rim or the root
of the helix. It has many advantages as it is a one-
stage operation and gives an excellent contour correc-
tion. The disadvantages are that it is subjected to
shrinkage and limited to small defects of about
10 mm in diameter to avoid the high risk of necrosis.
The recipient site needs to be well prepared and has a
good vascular bed to maintain graft survival. Very
gentle and delicate handling and care of the graft is
Figure 2. Lateral view of the defect.
98 M. ELSAYED MOHAMED MOHAMED AND A. F. M. ELDEHN
Figure 3. Intraoperative view of the composite graft after fix-
ation into the defect.
Figure 5. Post-operative AP views after 9 months.
necessary and should be transferred to the recipient
site as soon as possible [2].
Composite grafting seems to be a simple procedure
but still requires meticulous processing to make sure
of complete graft survival with an excellent aesthetic
outcome, yet, many plastic surgeons still in doubt to
use this process for fear of failure [5].
Figure 4. Post-operative lateral view after 6 months.
Figure 6. Post-operative view of the helical donor site.
In this case, the patient complicated a loss of soft
triangle during the use of electrocautery to control
epistaxis. The resultant defect is composed of lost soft
tissue and part of the lower lateral cartilage with
fibrosis of the remaining area. In the reconstructive
plan, multiple effective measures were needed intrao-
peratively to maximize the take of the composite graft
and finally limit the graft contracture and cartilage
shrinkage. The decision was made to use fibrin glue
aided by sutures to help in graft fixation.

There are three potential advantages of fibrin glue
for skin grafting: hemostasis, graft adherence and
take, and antibacterial action [4,6].
Perez-Guisado et al. recommended the use of fibrin
glue to increase the possibility of skin graft survival
[7]. Also, Balceniuk et al. concluded that the fibrin
glue used in skin grafting techniques helps in mini-
mizing graft loss and lowers the rate of complications
[8]. Butts et al. reported significantly lower rates of
skin graft loss while using fibrin glue [9,10].
All previous studies used fibrin glue with split-
thickness skin grafts to promote graft take and wound
healing. There was no available data about the use of
Fibrin glue with composite grafts to reconstruct nasal
defects after electrocautery burn. The available reports
only utilized fibrin glue with split-thickness
skin grafts.
Fibrin glue is safe and non-hazardous to the host,
encouraging wound healing [11,12]. Fibrin glue
showed superior results compared with sutures and
had an excellent graft take rate [13,14].
In this case, fibrin glue was used to fix the com-
posite graft in place and secured by sutures to
increase the chance of graft take and prevent acciden-
tal detachment before complete graft take.
Kaufman et al. demonstrated significant improve-
ments in cartilage graft quality using fibrin sealant.
These findings may justify changes in how cartilage
grafts are prepared and delivered for facial augmenta-
tion procedures to reduce graft resorption and main-
tain the structural integrity of the cartilage [15].
Brown et al. reported a reduction in skin graft retrac-
tion if fibrin glue was applied with [16].
The fibrin glue used in this patient may have pre-
served the graft from shrinkage with decreased possi-
bilities for cartilage resorption that preserved the final
outcome during follow-up visits for more than
10 months. Total integration of the composite grafts
occurred. The esthetic results were considered very
satisfactory for both the patient and the med-
ical team.
Conclusion
In this case, using a composite graft to restore post-
traumatic defects of the soft triangle of the nose was
versatile and safe. The addition of fibrin glue could
enhance the complete take of composite graft a very
good aesthetic outcome. More studies are required to
establish the impact of fibrin glue on complete take of
composite auricular grafts in the reconstruction of
nasal defects.
ACTA OTO-LARYNGOLOGICA CASE REPORTS 99
Ethical approval
 The manuscript has not been submitted to any
other journals for simultaneous consideration.
 The manuscript has not been published previously
(partly or in full).
 No data have been fabricated or manipulated
(including images) to support our conclusions
 No data, text, or theories by others are presented
as if they were our own.
 Consent to submit has been received from all
co-authors.
 Authors whose names appear on the submission
have contributed sufficiently to the scientific work
and therefore share collective responsibility and
accountability for the results.
 Informed consent was obtained from the parent
himself for surgical intervention and also for pub-
lication of photos.
Disclosure statement
No potential conflict of interest was reported by
the author(s).
ORCID
Mohamed Elsayed Mohamed Mohamed http://orcid.org/
0000-0002-9037-0253
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