LAUSR

To the Editor: N asal reconstruction after tumor resection is indeed a daunting task that requires both a highly skilled surgeon and an artistic sense. The highly complex 3-dimensional multiplelayered structure is extremely challenging to reconstruct, even in themost experienced hands. Wewould like to congratulate Dr Jayarajan for his very important contribution in this field. The combination flap proposed in his work is truly based on sound plastic surgery principals and should definitely be considered as an option when encountering a defect in the lateral heminose. His geometrical flap design ensures a relatively simple and predictable solution for one of the most complex problems in reconstructive surgery. Moreover, his ability to achieve a satisfying result in only 1 stage might be very appealing for patients and surgeons alike. However, several issues should be discussed regarding the proposed method. First, some of the cases presented in his series are skin-only defects. In such superficial defects, many reports show excellent results with either fullthickness skin grafts or local flaps such as the bilobed or hatchet flap for these types of defects. Both these techniques can be performed in a single stage and need not extend beyond the nose. Second, reconstruction of the ala with a cheek flap almost always creates obliteration of the alar groove because the flap is pulled laterally by the cheek musculature. Quilting sutures in the alar groove, in our opinion, only partially resolve this problem. The final long-term result, as can be seen in Figure 5B in the original article, clearly demonstrates this crucial drawback. These drawbacks, in our opinion, could have been avoided by using a forehead flap (for large alar defects). Third, the author states that in defects requiring lining they used either bipedicle mucosal advancement or septal mucoperichondrial flaps or skin grafts. In our opinion, reliable lining has utmost importance in the long-term result because any shrinkage or secondary healing has the potential to distort the delicate alar curvature. Therefore, we feel that lining should be provided by robust local tissue such as in the