Full-thickness skin graft (FTSG) is a core reconstructive option for small to moderate nasal defects after oncologic resection. By providing full dermal thickness and adnexal structures, they offer durability, sensory recovery and good aesthetic potential. However traditional FTSGs often struggle with contour and colour match on the nose. The contoured composite graft refines the FTSG technique by emphasising optimal donor site selection, meticulous tissue handling, precise haemostasis, accurate inset and strict postoperative care. Limitations in traditional FTSGs frequently arise from habitual use of preauricular or supraclavicular donor sites and graft thinning, driven by concerns of graft survival. While colour match is usually considered, dermal thickness and sebaceous match, essential for nasal reconstruction, are often overlooked. We advocate for alternative donor sites such as the infraauricular and upper neck region, dog ear grafts, and the glabella, which provide superior match to nasal skin. Graft inset should focus on meticulous dermal opposition, supported with a traditional tie-over dressing and additional contouring aided by jelonet pledgets. We recommend maintaining the tie over for a full three weeks to optimise graft integration. The contoured composite graft offers a more reliable and aesthetically harmonious solution than traditional FTSGs, achieving outcomes that often surpass both standard grafts and local flaps. Techniques and examples demonstrated in this presentation.

Background: Innervated musculocutaneous flaps are often utilised in trauma reconstruction settings. Motor-innervated free or pedicled tissue-transfer following extremity soft tissue sarcoma (ESTS) resection occurs less frequently. Case: A retired right-handed 74 male presented with biopsy-proven left biceps-brachii high-grade pleomorphic sarcomatoid malignancy. MRI demonstrated a 63x31mm lobulated mass interposed between biceps and brachialis, entrapping the musculocutaneous nerve (MCN). Median nerve and brachial artery and basilic vein were spared. Functional reconstruction was planned with a pedicled LD flap. Intraoperative resection revealed a defect comprising 14cm of biceps brachii muscle belly, deltoid insertion and origin of brachialis. 13cm of MCN was also transected proximally. Distal MCN segment into brachialis was then identified and demonstrated stimulated fascicular activity. Viable proximal and distal stumps of MCN warranted intraoperative utilisation of LCNF as a cable graft, with neurolysis, veraseal and microsurgical repair. The pedicled, functional LD was inset as originally planned. The patient reports excellent 6-month postoperative functional outcome. He has no functional limitation and has unlimited left elbow flexion and extension and shoulder abduction to 75 degrees. He moves his left hand to mouth and head with ease. Conclusions: Intraoperative availability of viable MCN stumps facilitated enhanced functional reconstruction with free LCNF grafting to ameliorate elbow flexion. Our patient demonstrates favourable outcomes from what would have been an otherwise functionally-limiting resection. We encourage an adaptable, adjustable and opportunistic approach to functional reconstruction, particularly in variable ESTS resection. This versatility may confer significant improvement patient outcomes and mitigate associated morbidity.

Introduction Perilymphatic fistula (PLF) is a difficult inner ear condition which is characterized as abnormal connection between inner and middle ear and subsequent leakage of inner ear liquid (perilymph) into the middle ear. The primary manifestations of PLF are sudden or progressive fluctuations, sensorineural hearing loss or deafness and/or vestibular symptoms ranging from dizziness to rotary vertigo. We present a case of a perilymphatic fistula secondary from traumatic injury to ear presenting as conductive hearing loss conservatively managed. Case discussion A 60 year old female sustained a left tympanic membrane perforation following a mechanical fall whilst using a cotton-tip applicator.She presented with acute vertigo, imbalance and conductive hearing loss in the affected ear. Clinical examination revealed profound vertigo on rightward head movement and a large anterior tympanic membrane 50% perforation. Audiometric evaluation demonstrated moderate to profound conductive hearing loss with an underlying mild-high frequency sensorineural component. CT of temporal bones revealed a small gas locule within the left ampulla of the superior semicircular canal. The patient was managed conservatively with vestibular rehabilitation, corticosteroids and anti-vertiginous therapy. Over the subsequent follow-up, vestibular symptoms improved significantly, though residual conductive hearing loss and tinnitus persisted. Conclusion In this case, the coexistence of tympanic membrane perforation and conductive hearing loss initially suggested a middle ear pathology; however radiological presence of a perilymphatic air and mild sensorineural hearing loss on high frequencies raised suspicion of injury to labyrinths. This case underscores the importance of integrating audiovestibular testing. Although intraoperative identification of perilymph leakage remains the diagnostic gold standard, clinical judgment and noninvasive investigations play pivotal roles in guiding management and follow-up.

Introduction Parotid gland sialocele is an uncommon but challenging complication following rhytidectomy, particularly with deep plane dissection beneath the superficial musculoaponeurotic system (SMAS). Literature describing its optimal management remains limited. Iatrogenic violation of the parotid capsule can result in postoperative sialocele formation, presenting with fluctuant swelling in the early postoperative period. While traditional management includes aspiration, compression, and anticholinergics, recent reports have highlighted the role of botulinum toxin A as a minimally invasive and effective treatment. Methods We present a case of parotid sialocele following a deep plane facelift, detailing clinical presentation, diagnostic considerations, and the management employed. A literature review was conducted to identify current therapeutic strategies for parotid sialocele following rhytidectomy, including conservative, pharmacologic, and surgical options. Results Our patient achieved complete resolution following a multimodal approach involving serial aspiration and targeted botulinum toxin A injection. Literature review demonstrated success rates of 70–100% with botulinum toxin A, using doses ranging from 10 to 100 units. Preventive measures such as SMAS or platysma coverage and selective botulinum toxin A injection into exposed glandular tissue further reduced recurrence. We present a step-wise management algorithm for this rare complication. Conclusions Parotid sialocele following rhytidectomy is rare but amenable to non-surgical management. We propose a practical algorithm integrating conservative measures and early botulinum toxin A use to optimise outcomes and minimise morbidity.