Walid Sabbagh

Donor-Site Morbidity after Autologous Costal Cartilage Harvest in Ear Reconstruction and Approaches to Reducing Donor-Site Contour Deformity.

Background: Harvesting of rib as a source of cartilage can result in significant donor-site morbidity. In experienced hands, excellent results from using autologous rib cartilage are achievable for ear reconstruction, rhinoplasty, and otolaryngology. The authors report the morbidity associated with the harvest of costal cartilage in 42 patients who underwent ear reconstruction. Methods: The notes were examined retrospectively and further data were collected with a questionnaire. Patients noted their experience of pain, clicking, and satisfaction with the donor site. Fifteen patients underwent additional clinical assessments of their donor scar and contour deformity using a standardized scale. Five donor sites were reconstructed with spare cartilage left over from carving the ear framework. Results: The results showed that pain and clicking of the chest wall represented the commonest complaints. These peaked in the first week after surgery and diminished slowly over 3 months. The donor-site scar and deformity were acceptable to most patients. There was an improvement in the contour deformity of the chest wall harvest site in the five patients who underwent reconstruction of their donor site. Conclusions: To improve the outcome for patients undergoing cartilage harvest, efforts must be made to further reduce pain and donor-site morbidity. Reconstruction of the donor site with spare cartilage should be attempted where possible to improve the contour defect of the donor site. Refinements in the methods of cartilage harvest or donor-site reconstruction may achieve this in the future.

Early experience in microtia reconstruction: The first 100 cases *

Auricular reconstruction in Microtia is a challenging operation with a steep learning curve. In view its rarity attaining a high standard for new surgeons is extremely difficult. This study analyses the first 100 microtia cases looking at complications, technique, pattern of progress and aesthetic outcome. The author performed 100 autologous ear reconstructions for microtia over a period of 4 years utilizing the two stage technique popularised by Nagata and Firmin. In 11 cases a temroparietal fascial flap was utilised because of either a low hairline or scarring. Follow up ranged from 3 to 36 months. Data was collected prospectively. There were 7 cases of partial skin necrosis, 3 of which healed with conservative management. In early cases deficiencies were seen in the proportions of the reconstructed ear and the quality of definition. Better shape and definition were evident as more surgical experience was gained. This occurred as a result of increased appreciation of the ear proportions and improved framework carving. Although two stages were planned 21 cases required further procedures. The series demonstrates the early learning curve in microtia reconstruction and underlines the importance of appropriate training and case availability in achieving high quality results in autologous ear reconstruction.

Patient satisfaction and aesthetic outcomes after ear reconstruction with a Branemark-type, bone-anchored, ear prosthesis: A 16 year review

INTRODUCTIONnReconstruction of the human ear with a bone-anchored prosthesis is a widely accepted alternative when autologous reconstruction is technically impossible or declined by the individual. However, there are relatively few data in the literature documenting patient satisfaction with this form of reconstruction.nnnMETHODSnThis study examines different aspects of patient satisfaction using an eighteen-point postal questionnaire to measure patient outcomes against a Likert rating scale. The questionnaire was sent to 33 patients who completed prosthetic ear reconstruction over a 16 year period at a specialist plastic surgery unit in the United Kingdom. Medical case notes for these cases were also reviewed. Twenty completed questionnaires were returned.nnnRESULTSnThe response rate was 61%. The majority of patients were satisfied with the aesthetics, ease of handling and comfort of the bone-anchored implant and prosthesis. However, the majority of patients was only moderately satisfied or was dissatisfied with this method of reconstruction. Specifically, 15 of the respondents reported skin problems around the abutments of the bone-anchored implant with 10 patients reporting ongoing skin complications. Granulation tissue was the most common skin problem (12 cases) followed by local infection (10 cases). Interestingly, despite the chronic skin problems, most patients indicated that they would undergo the same procedure again or would recommend it to others.nnnDISCUSSIONnOur survey shows that patients fitted with a Branemark-type bone-anchored implant for ear reconstruction are pleased with the aesthetic appearance but experience multiple, chronic, skin complications and other implant related problems. These affect their satisfaction with this method of reconstruction. Our findings may have significant implications for patients and surgeons considering this form of reconstruction and for the institutions making decisions about funding this treatment.

Reconstruction following traumatic partial amputation of the ear.

Background: Reconstruction following traumatic amputation of the external ear remains a unique challenge to the plastic surgeon. The authors report a series of ear reconstructions with autologous costal cartilage in patients following traumatic partial amputation of the ear. Technical points regarding the carving of the cartilage framework and methods of skin coverage are discussed. Methods: Fifty partial ear reconstructions with autologous costal cartilage were performed over a 4-year period. All patients had suffered previous traumatic amputation of part of the external auricle due to bite injuries (n = 36), road traffic accidents (n = 6), burns (n = 5), or torture (n = 3). A two-stage technique of reconstruction with autologous cartilage graft was used based on Nagatas adaptations of Brents original technique. In nine cases, skin shortage or extensive scarring required preoperative tissue expansion (n = 4) or a temporoparietal fascial flap (n = 5) to provide adequate coverage of the cartilage framework. Results: Forty-seven patients had a successful surgical outcome without complication. Two patients developed small areas of skin necrosis resulting in exposure of the cartilage framework. These healed with conservative management with minor loss of definition. One case of wound infection resulted in significant loss of definition of the construct, which required a further surgical procedure with additional costal cartilage graft. Conclusion: Reconstruction of the external ear with autologous costal cartilage following traumatic amputation can produce high-quality auricles consistently and is becoming the treatment of choice for such injuries, given access to a specialist center with exposure to a high volume of cases.

Costal Cartilage or Conchal Cartilage for Aesthetic and Structural Reconstruction of Lower Pole Ear Defects

BACKGROUNDnLower pole defects of the ear involve loss of the ear lobule with a variable degree of cartilaginous helical rim and antihelix.nnnOBJECTIVESnThe authors describe a method of reconstructing lower pole ear defects with local skin flaps by incorporating conchal or costal cartilage grafts.nnnMETHODSnThe authors retrospectively evaluated the charts of 13 patients who presented between 1998 and 2007 with lower pole auricular defects. For defects primarily involving the earlobe (seven cases), conchal cartilage was sandwiched between an anterior transposition flap and a posterior V-Y advancement flap. For defects extending into the inferior portions of the helical rim and antihelix (six cases), a costal cartilage framework was inserted into a skin pocket and released after six months.nnnRESULTSnThe mean follow-up for the 13 patients in this series was three years. Both techniques resulted in satisfactory long-term outcomes with excellent contour of the ear. All patients were satisfied with their reconstruction. Data showed that costal cartilage reconstructions required a minimum of two stages and that construction with conchal cartilage resulted in a softer lobule but was more likely to require minor aesthetic revision.nnnCONCLUSIONSnWith appropriate preoperative planning, these cartilage graft techniques produce excellent aesthetic outcomes in reconstructing complicated defects of the lower pole of the ear.

Cryptotia correction – the post-auricular transposition flap

BACKGROUNDnCryptotia is a congenital ear deformity in which the upper pole appears buried beneath mastoid skin. Here we describe our method of cryptotia correction which we have used to good effect with minimal complications.nnnPATIENTS AND METHODSn20 patients and 24 ears were operated on. All surgery was performed by the senior authors WS and DG. Patient age range was 4-19 years and mean follow up was 2.1 years. We use a superiorly based V-shaped flap raised from the post-auricular skin. Following ear release, the flap is rotated into the defect and donor site closed directly. Our technique ensures all scars are hidden behind the ear, there are no skin grafts required.nnnRESULTSnAll patients had a satisfactory release of cryptotia, there were no cases of partial or total flap failure, none of wound dehiscence and no patients required revisional surgery.nnnCONCLUSIONSnThe post-auricular flap is a simple technique, retaining the depth of the auriculotemporal sulcus, providing a good skin colour match without the need for skin grafting and without distorting the hair line. Our results are comparable or superior to those seen with other techniques previously described.

Earfold: A New Technique for Correction of the Shape of the Antihelix: Earfold for Correction of Prominent Ears

An absent or poorly defined antihelix often plays a central role in the perception of the prominent ear. A wide variety of otoplasty techniques have been described over the last 50 years that aim to reshape, create, or enhance the definition of the antihelix, which can, in turn, help to reduce the prominence of an ear. In addition to conventional suture and cartilage‐scoring techniques, a permanent implantable clip system (Earfold®) has recently become available that is placed using a minimally invasive approach performed under local anesthesia. In this review, we summarize conventional otoplasty techniques to correct the antihelix and compare these with the Earfold implantable clip system. Laryngoscope, 128:2282–2290, 2018

Reply: Septal Cartilage Graft for Posttraumatic Ear Reconstruction

Reply: Septal Cartilage Graft for Posttraumatic Ear Reconstruction Sir: The authors describe a case of partial ear reconstruction in which nasal septal cartilage was used to reconstruct a partial auricular defect involving the middle/lower helical rim encroaching on the superior part of the lobule. We have not previously used septal cartilage for this purpose and, although the authors have achieved a satisfactory outcome, the following points are worth highlighting. Nasal septal cartilage is thin and thus it would be difficult to carve into a three-dimensional construct, which is necessary for the majority of auricular defects. The case presented shows satisfactory reconstitution of the helical rim, but there are some limitations that could be overcome by having a larger block of cartilage, as in costal cartilage. These include better definition of the rim and concavity between the helix and antihelix, improved transition between native helix and reconstructed helix, and incorporation of the portion of the missing lobule into the carving. The shape and limited availability of septal cartilage make it really suitable only for small defects confined to the helical rim. In our view, for these defects, a segment of floating rib (eighth or ninth rib) can be harvested through a 3-cm incision, with minimal muscle dissection and almost no chest deformity whatsoever. This would provide more cartilage from which to carve a more accurate reconstruction. We have not encountered significant donor-site morbidity with costal cartilage for larger defects either in partial or in total ear reconstruction. No patients have reported long-term pain or a visible contour defect. There is often a contour deformity on deep palpation of the area, but the patient is not normally aware of or concerned by this. The cases of chest wall deformities reported by Ohara et al. occurred following autologous ear reconstruction for microtia, with the majority being in young children.1 Nasal septal cartilage does not provide an alternative in these cases because of the limited quantity available. In cases of microtia, we would wait until the child is at least 7 years old before performing ear reconstruction, to ensure the costal cartilage is large and mature enough to enable adequate harvest without risking chest wall deformity. DOI: 10.1097/PRS.0b013e318230bfb2

Modification of the Postauricular Fascial Flap in Mustardé and Furnas Type Otoplasty

GUIDELINES Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.