- Email: [email protected]
Auricular cartilage: harvest technique and versatility in rhinoplasty
Available online at www.sciencedirect.com
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547 – 552 www.elsevier.com/locate/amjoto
Auricular cartilage: harvest technique and versatility in rhinoplasty Michael Lee, MDa,b , Sean Callahan, MDa , C. Spencer Cochran, MDa,c,⁎ a
Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA b Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA c Gunter Center for Aesthetics & Cosmetic Surgery in Dallas, TX, USA Received 7 August 2010
Abstract
Objectives/Hypothesis: This study aims to present an improved technique for auricular cartilage harvest that maximizes graft volume while preserving auricular cosmesis. Also discussed is the versatility of auricular cartilage utilization in rhinoplasty. Study Design: A retrospective review of a single surgeon's experience. Methods: All auricular cartilage harvest and rhinoplasty operations performed by the senior author (CSC) from December 2006 through December 2009 cartilage were reviewed. Results: Twenty-two cases were identified in which the described technique was used to harvest auricular cartilage for the purpose of functional or aesthetic rhinoplasty. There was sufficient tissue harvested in all operations, and no patients required costal cartilage harvest. Pain at the donor site after surgery was minimal and well controlled with oral medication. There were no donor-site complications and no cases of wound infection. Conclusions: The proposed technique allows for optimal auricular cartilage harvest. By applying this method, the ear retains the preoperative appearance while the surgeon is able to obtain the largest graft possible. Auricular cartilage is a versatile source of grafting material in primary and secondary rhinoplasty. © 2011 Published by Elsevier Inc.
1. Introduction Rhinoplasty often requires cartilage grafting in efforts to improve both functional and aesthetic results. From a functional perspective, grafts are frequently used to widen the internal nasal valve and to provide structural support to the external valve to correct or prevent collapse during inspiration [1]. Grafts may also be used in aesthetic rhinoplasty to augment deficiencies, improve tip definition, and increase nasal projection. Autogenous cartilage grafts may be obtained from several different sites, including the nasal septum, ear, or rib [1,2]. The septal cartilage is widely considered to be the optimal site for grafting in rhinoplasty because of both location and abundance of grafting material. Because the septal cartilage
⁎ Corresponding author. 8144 Walnut Hill Lane, Suite 170, Dallas, Texas 75231. Tel.: +1 214 369 8123; fax: +1 214 369 2984. E-mail address: [email protected] (C.S. Cochran). 0196-0709/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.amjoto.2010.11.008
can be harvested from the same operative field, its use precludes the morbidity of obtaining cartilage from an additional donor site [2,3]. The septum usually provides sufficient cartilage in primary rhinoplasty but may be depleted in those patients undergoing revision surgery, with a history of nasal trauma, or with septal perforations [3,4]. Costal cartilage harvested from the anterior chest wall is commonly used when a large volume of graft material is needed or when significant structural support is required [2]. Although the amount of tissue harvested is greater than that of the septum and ear, costal cartilage harvest exposes the patient to potential complications. Chest wall infection, hematoma, anatomic deformity, and pneumothorax have all been described [5,6]. Auricular cartilage may be used alone or to supplement other cartilage grafts. Significant considerations in auricular cartilage harvest must include maximizing the amount of grafting material acquired while maintaining preoperative appearance of the ear. Using our proposed approach, we are able to maximize the amount of conchal cartilage harvested
548
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
Fig. 2. Methylene blue is applied to the tip of a 25-gauge needle and then used to map out the planned field of resection. The needle must pass completely through the cartilage.
Fig. 1. Three key areas (shaded) of the auricular structure must be preserved: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal to maximize the size of the graft obtained (dotted line).
en bloc without compromising the ear's appearance by preserving sufficient structural cartilage in 3 key areas of the pinnae: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal (Fig. 1). This article describes our technique for auricular cartilage graft harvest and briefly discusses the versatility of ear cartilage in rhinoplasty.
aspect of the antihelical rim, a 25-gauge needle dipped in methylene blue is introduced into the skin of the anterior ear and then pushed completely through the posterior surface of the conchal cartilage (Fig. 2). Once the planned area of dissection is marked, the posterior surface of the auricular cartilage is incised, and the dissection is carried down to the level of the perichondrium. Dissection then proceeds medially to the premastoid fascia above the auricular perichondrium because leaving the perichondrium attached to the posterior surface of the cartilage helps prevent fracture of the graft during harvest. The anterior surface of the conchal bowl is then elevated in the subperichondrial plane. The previously applied methylene blue serves to map out the acceptable area of resection thereby preserving the aforementioned landmarks and maximizing the amount of cartilage obtained (Figs. 3 and 4). Once hemostasis has been achieved with
2. Technique With the patient under general anesthesia, the face and both ears are sterilely prepared into the operative field. Anteriorly, the concha cymba and concha cavum are injected with 2 to 3 mL of 1% Xylocaine with 1:100 000 epinephrine in the subperichondrial plane, using hydrodissection to facilitate the surgical dissection. Posteriorly, the same local anesthetic is injected subcutaneously along a planned 3 to 4 cm longitudinal incision overlying the lateral extent of the conchal bowl. To prevent compromising ear protrusion, 3 key areas of the auricular structure must be preserved: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posteriorinferior margin of the external auditory canal. To maximize the amount of cartilage harvested while maintaining these areas, the possible extent of conchal cartilage resection (Fig. 1, dotted line) is percutaneously tattooed every 0.5 to 1.0 cm with methylene blue. Beginning along the medial
Fig. 3. The graft is resected from a posterior approach following the previously outlined area. The posterior perichondrium is left attached to prevent cartilage fracture and aids in resection.
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
judicious use of electrocautery, the wound is irrigated, and the incision is approximated with a 4–0 plain gut suture. A bolster should be applied to the auricle to prevent hematoma formation during the postoperative period.
3. Methods Patients undergoing rhinoplasty by the senior author (CSC) between December 2006 and December 2009 in which auricular cartilage was harvested and used were included in this retrospective review. Data were collected with regard to reason for surgery, complication rate, infection rate, revision rate, pain control, donor-site cosmesis, and type of grafts used.
4. Results Twenty-two cases were identified in which auricular cartilage was harvested. Of the 22 patients, 5 underwent surgery solely for functional reasons; 5, for aesthetic reasons; and 12, for both functional and aesthetic concerns. Of the 22 patients, 19 had a history of prior nasal surgery, of which 3 of the 19 underwent prior rhinoplasty without surgery of the septum, 2 underwent a prior septoplasty alone, and 14 had undergone a prior rhinoplasty with septoplasty. Three patients had no history of prior nasal surgery but had septal perforations related to systemic lupus erythematosus (2/3) or prior cocaine use (1/3). The septum was noted to be intact in 5 of 22 cases, partially available for grafting material in 10 cases; 7 patients had no septal cartilage available for harvest. In 15 cases, septal cartilage was harvested in addition to the auricular cartilage. In 21 of 22 cases, there was sufficient cartilage harvest to fulfill the intended purpose of the operation; one patient required harvesting of the bilateral auricular cartilage grafts. No cases required the harvest of costal cartilage.
Fig. 4. The previously demarcated helical root is preserved to prevent deformity.
549
Table 1 Grafts by type, region, and number of times used Type
Region
No. of times used
Lateral crural strut graft Spreader grafts Columellar strut graft Septal perforation repair Dorsal onlay graft Alar rim graft Butterfly graft
Ala Dorsum Tip Septum Dorsum Ala Tip
13/22 patients 6/22 patients 6/22 patients 5/22 patients 3/22 patients 3/22 patients 1/22 patients
Auricular cartilage was used as lateral crural strut grafts in 13 of 22 patients, dorsal onlay grafts in 3, spreader grafts in 6, columellar strut in 6, butterfly graft in 1, alar rim grafts in 3, and to repair septal perforation in 5 (Table 1). Donor site appearance was deemed satisfactory by both the patient and surgeon in 22 of 22 cases. There were no cases of infection and auricular hematoma. No patients had hypertrophic scarring or keloid formation at the donor site. Two patients underwent revision surgery: one patient for alar notching, and one, for removal of butterfly graft that caused widening of the midvault.
5. Discussion Cartilage grafting is often required for an effective rhinoplasty to provide structural support for improvement in nasal function and aesthetics (Figs. 5 and 6). In secondary (revision) rhinoplasty, the nasal septal cartilage, which is generally the cartilage of choice, is often lacking. Thus, alternative grafting material may need to be obtained from the rib or ear [2,4]. Costal cartilage provides a large volume of material but requires a second operative field and exposes the patient to greater morbidity and complications [5,6]. Therefore, auricular cartilage is an attractive alternative when a modest amount of grafting material is needed and when nasal septal cartilage is depleted. The goal, then, is to maximize the amount of auricular cartilage harvested while limiting complications and maintaining preoperative appearances. This article describes a technique for auricular graft harvest that aims to achieve this end. Multiple techniques for auricular cartilage harvest have been previously described. As early as 1955, Adams [7] described a method that emphasized the retention of 2 mm of the superior outer rim of the concha, 3 mm of the cartilaginous rim connecting the tragus to the antitragus, and 3 mm of the external auditory canal. Falces and Gourney [8] described their approach in which they removed the entire concha while cautioning not to violate the helical apex and the antihelical ridge. We corroborate these basic assumptions with our own experience; however, we have found that the limits of their dissection may be overly conservative. These limits included the crest of the helix, lower crus of the triangular fossa, helical buttress, margin of the meatus, and inner edge of the antitragus [8]. In our
550
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
Fig. 5. A and B, Preoperative (left) vs postoperative (right) views of a patient who underwent secondary rhinoplasty with auricular cartilage grafts by the senior author (CSC). Auricular cartilage was used as spreader grafts to correct her inverted “v” deformity, a dorsal onlay graft to augment her dorsum, and a left-sided lateral crural strut graft to correct her distorted tip and alar collapse.
experience, the cartilage spanning these regions (ie, the tragus and antitragus) may be harvested more liberally if the key areas previously described are preserved. Guyuron [9], in 1986, described a technique for auricular cartilage harvest that also shares some similarities to our approach. As in our described technique, they infiltrated with local anesthetic for hydrodissection and performed a postauricular incision. The posterior perichondrium was left attached to the graft, and a subperichondrial dissection was performed anteriorly. However, preoperative demarcation with ink was not described, which we feel is a critical step, allowing for maximal en bloc cartilage harvest intraoperatively. The described area of acceptable cartilage removal is more difficult to assess once the dissection has begun, and the native, preoperative appearances have been disturbed. Bocciceri [10] describes a similar procedure but with subperichondrial dissection on both surfaces of the graft and demarcation of the dissection with 4 or 5 needles inserted into the anterior surface of the ear. The needles emerged on the posterior surface and delineated the margin of dissection of the antihelix and helical root. Our technique is an
improvement on these recommendations because (1) the layer of perichondrium left on the posterior graft provides necessary support to the harvested cartilage, (2) tattooing provides a superior degree and accuracy of demarcation, and (3) there is reduction of the risk of injury because of the removal of the cumbersome needle load in the operative field while dissecting. Han et al [11] describe harvesting the conchal cartilage in 2 separate pieces allowing a 5-mm strut to remain between the cymba concha and cavum concha. They contend that this strut is essential to maintain structural support of the donor ear and prevent collapse. In our study, we found that preservation of this region was not necessary to maintain cosmesis. Gruber et al [12,13] separately described leaving behind a portion of the ellipse removed from the concha of the ear or a 6-mm upper vertical wall of the cavum concha to prevent ear flattening. We did not find these additional support structures to be necessary for adequate postoperative appearance of the ear by our described procedure. As expressed in our results, the harvested auricular cartilage can be used for various types of rhinoplasty struts and provides sufficient cartilage for multiple grafts in a single patient. Varying graft types, as previously described by Gunter et al [1], were used in this series and included lateral crural struts, dorsal onlay grafts, spreader grafts, columellar struts, alar rim grafts, and repair of septal perforations. The curvature and softness of the conchal cartilage make it an ideal graft for areas such as the nasal tip and alar rims. However, the large en bloc harvest described by our technique also provided sufficient tissue for both larger grafts (such as dorsal onlay grafts, spreader grafts, and columellar struts) and/or multiple grafts from one large piece of cartilage. Although limited by the number of patients in this series and the required graft types needed in those patients, the auricular cartilage could be fashioned for any graft type that can be obtained from the septal or costal cartilage. The technique described in this article is the culmination of over 50 years of experience among multiple practices that allow for simple and maximal cartilage harvest without significant postoperative deformity or complication. Local injection is used to simplify the dissection, and methylene blue is introduced through the anterior ear to safely outline critical structural components that must not be violated to prevent postoperative deformity. Although some authors advocate an anterior approach for even easier dissection and visualization landmarks, we find that the postauricular incision provides better overall cosmesis and camouflage of scar without significant increase in the difficulty of dissection or complications. Preservation of attached perichondrium on one surface of the harvested cartilage provides structure and helps prevent fracture of the en bloc graft. The layer of perichondrium left on the anterior surface of the conchal bowl may also preserve the native smooth contour and allow for new cartilage formation, which would reinforce the helical buttress. Maximal concha harvest is
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
Fig. 6. A and B, Gunter diagram depicting graft locations (green) for the patient in Fig. 5A and B.
551
552
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
achieved, en bloc, without wasted potential cartilage for grafting in functional and cosmetic rhinoplasty.
6. Conclusion The method described in this article allows for maximal auricular cartilage graft harvest while preserving structures critical to maintaining preoperative appearance. Auricular cartilage is a viable option for graft material in both primary and revision rhinoplasty with versatile application. References [1] Gunter JP, Landecker A, Cochran CS. Frequently used grafts in rhinoplasty: nomenclature and analysis. Plast Reconstr Surg 2006;118: 14e-29e. [2] Moshaver A, Gantous A. The use of autogenous costal cartilage graft in septorhinoplasty. Otolaryngol Head Neck Surg 2007;137:862-7. [3] Cakmak O, Ergin T. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg 2002;4:172-6.
[4] Cochran CS, DeFatta RJ. Tragal cartilage grafts in rhinoplasty: a viable alternative in the graft-depleted patient. Otolaryngol Head Neck Surg 2008;138:166-9. [5] Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction. A long-term study. Plast Reconstr Surg 1995;95:961. [6] Tanzer RC. Microtia: a long-term follow up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61:161. [7] Adams WM. Construction of upper half of auricle utilizing composite concha cartilage graft with perichondrium attached on both sides. Plast Recontr Surg 1955;16:88. [8] Falces E, Gorney M. Use of ear cartilage grafts for nasal tip reconstruction. Plast Reconstr Surg 1972;50:147-52. [9] Guyuron B. Simplified harvesting of the ear cartilage graft. Aesthetic Plast Surg 1986;10:37-9. [10] Boccieri A. Subtotal reconstruction of the nasal septum using a conchal reshaped graft. Ann Plast Surg 2004;53:118-25. [11] Han K, Kim J, Son D, et al. How to harvest the maximal amount of conchal cartilage grafts. Journal of Plast Reconstr Aesthetic Surg 2008;61:1465-71. [12] Gruber RP, Pardun J, Wall S. Grafting the nasal dorsum with tandem ear cartilage. Plast Reconstr Surg 2003;112:1110-22. [13] Gruber RP, Peck GC. Rhinoplasty: State of the Art. St Louis: Mosby; 1973. p. 168.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547 – 552 www.elsevier.com/locate/amjoto
Auricular cartilage: harvest technique and versatility in rhinoplasty Michael Lee, MDa,b , Sean Callahan, MDa , C. Spencer Cochran, MDa,c,⁎ a
Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA b Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA c Gunter Center for Aesthetics & Cosmetic Surgery in Dallas, TX, USA Received 7 August 2010
Abstract
Objectives/Hypothesis: This study aims to present an improved technique for auricular cartilage harvest that maximizes graft volume while preserving auricular cosmesis. Also discussed is the versatility of auricular cartilage utilization in rhinoplasty. Study Design: A retrospective review of a single surgeon's experience. Methods: All auricular cartilage harvest and rhinoplasty operations performed by the senior author (CSC) from December 2006 through December 2009 cartilage were reviewed. Results: Twenty-two cases were identified in which the described technique was used to harvest auricular cartilage for the purpose of functional or aesthetic rhinoplasty. There was sufficient tissue harvested in all operations, and no patients required costal cartilage harvest. Pain at the donor site after surgery was minimal and well controlled with oral medication. There were no donor-site complications and no cases of wound infection. Conclusions: The proposed technique allows for optimal auricular cartilage harvest. By applying this method, the ear retains the preoperative appearance while the surgeon is able to obtain the largest graft possible. Auricular cartilage is a versatile source of grafting material in primary and secondary rhinoplasty. © 2011 Published by Elsevier Inc.
1. Introduction Rhinoplasty often requires cartilage grafting in efforts to improve both functional and aesthetic results. From a functional perspective, grafts are frequently used to widen the internal nasal valve and to provide structural support to the external valve to correct or prevent collapse during inspiration [1]. Grafts may also be used in aesthetic rhinoplasty to augment deficiencies, improve tip definition, and increase nasal projection. Autogenous cartilage grafts may be obtained from several different sites, including the nasal septum, ear, or rib [1,2]. The septal cartilage is widely considered to be the optimal site for grafting in rhinoplasty because of both location and abundance of grafting material. Because the septal cartilage
⁎ Corresponding author. 8144 Walnut Hill Lane, Suite 170, Dallas, Texas 75231. Tel.: +1 214 369 8123; fax: +1 214 369 2984. E-mail address: [email protected] (C.S. Cochran). 0196-0709/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.amjoto.2010.11.008
can be harvested from the same operative field, its use precludes the morbidity of obtaining cartilage from an additional donor site [2,3]. The septum usually provides sufficient cartilage in primary rhinoplasty but may be depleted in those patients undergoing revision surgery, with a history of nasal trauma, or with septal perforations [3,4]. Costal cartilage harvested from the anterior chest wall is commonly used when a large volume of graft material is needed or when significant structural support is required [2]. Although the amount of tissue harvested is greater than that of the septum and ear, costal cartilage harvest exposes the patient to potential complications. Chest wall infection, hematoma, anatomic deformity, and pneumothorax have all been described [5,6]. Auricular cartilage may be used alone or to supplement other cartilage grafts. Significant considerations in auricular cartilage harvest must include maximizing the amount of grafting material acquired while maintaining preoperative appearance of the ear. Using our proposed approach, we are able to maximize the amount of conchal cartilage harvested
548
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
Fig. 2. Methylene blue is applied to the tip of a 25-gauge needle and then used to map out the planned field of resection. The needle must pass completely through the cartilage.
Fig. 1. Three key areas (shaded) of the auricular structure must be preserved: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal to maximize the size of the graft obtained (dotted line).
en bloc without compromising the ear's appearance by preserving sufficient structural cartilage in 3 key areas of the pinnae: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal (Fig. 1). This article describes our technique for auricular cartilage graft harvest and briefly discusses the versatility of ear cartilage in rhinoplasty.
aspect of the antihelical rim, a 25-gauge needle dipped in methylene blue is introduced into the skin of the anterior ear and then pushed completely through the posterior surface of the conchal cartilage (Fig. 2). Once the planned area of dissection is marked, the posterior surface of the auricular cartilage is incised, and the dissection is carried down to the level of the perichondrium. Dissection then proceeds medially to the premastoid fascia above the auricular perichondrium because leaving the perichondrium attached to the posterior surface of the cartilage helps prevent fracture of the graft during harvest. The anterior surface of the conchal bowl is then elevated in the subperichondrial plane. The previously applied methylene blue serves to map out the acceptable area of resection thereby preserving the aforementioned landmarks and maximizing the amount of cartilage obtained (Figs. 3 and 4). Once hemostasis has been achieved with
2. Technique With the patient under general anesthesia, the face and both ears are sterilely prepared into the operative field. Anteriorly, the concha cymba and concha cavum are injected with 2 to 3 mL of 1% Xylocaine with 1:100 000 epinephrine in the subperichondrial plane, using hydrodissection to facilitate the surgical dissection. Posteriorly, the same local anesthetic is injected subcutaneously along a planned 3 to 4 cm longitudinal incision overlying the lateral extent of the conchal bowl. To prevent compromising ear protrusion, 3 key areas of the auricular structure must be preserved: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posteriorinferior margin of the external auditory canal. To maximize the amount of cartilage harvested while maintaining these areas, the possible extent of conchal cartilage resection (Fig. 1, dotted line) is percutaneously tattooed every 0.5 to 1.0 cm with methylene blue. Beginning along the medial
Fig. 3. The graft is resected from a posterior approach following the previously outlined area. The posterior perichondrium is left attached to prevent cartilage fracture and aids in resection.
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
judicious use of electrocautery, the wound is irrigated, and the incision is approximated with a 4–0 plain gut suture. A bolster should be applied to the auricle to prevent hematoma formation during the postoperative period.
3. Methods Patients undergoing rhinoplasty by the senior author (CSC) between December 2006 and December 2009 in which auricular cartilage was harvested and used were included in this retrospective review. Data were collected with regard to reason for surgery, complication rate, infection rate, revision rate, pain control, donor-site cosmesis, and type of grafts used.
4. Results Twenty-two cases were identified in which auricular cartilage was harvested. Of the 22 patients, 5 underwent surgery solely for functional reasons; 5, for aesthetic reasons; and 12, for both functional and aesthetic concerns. Of the 22 patients, 19 had a history of prior nasal surgery, of which 3 of the 19 underwent prior rhinoplasty without surgery of the septum, 2 underwent a prior septoplasty alone, and 14 had undergone a prior rhinoplasty with septoplasty. Three patients had no history of prior nasal surgery but had septal perforations related to systemic lupus erythematosus (2/3) or prior cocaine use (1/3). The septum was noted to be intact in 5 of 22 cases, partially available for grafting material in 10 cases; 7 patients had no septal cartilage available for harvest. In 15 cases, septal cartilage was harvested in addition to the auricular cartilage. In 21 of 22 cases, there was sufficient cartilage harvest to fulfill the intended purpose of the operation; one patient required harvesting of the bilateral auricular cartilage grafts. No cases required the harvest of costal cartilage.
Fig. 4. The previously demarcated helical root is preserved to prevent deformity.
549
Table 1 Grafts by type, region, and number of times used Type
Region
No. of times used
Lateral crural strut graft Spreader grafts Columellar strut graft Septal perforation repair Dorsal onlay graft Alar rim graft Butterfly graft
Ala Dorsum Tip Septum Dorsum Ala Tip
13/22 patients 6/22 patients 6/22 patients 5/22 patients 3/22 patients 3/22 patients 1/22 patients
Auricular cartilage was used as lateral crural strut grafts in 13 of 22 patients, dorsal onlay grafts in 3, spreader grafts in 6, columellar strut in 6, butterfly graft in 1, alar rim grafts in 3, and to repair septal perforation in 5 (Table 1). Donor site appearance was deemed satisfactory by both the patient and surgeon in 22 of 22 cases. There were no cases of infection and auricular hematoma. No patients had hypertrophic scarring or keloid formation at the donor site. Two patients underwent revision surgery: one patient for alar notching, and one, for removal of butterfly graft that caused widening of the midvault.
5. Discussion Cartilage grafting is often required for an effective rhinoplasty to provide structural support for improvement in nasal function and aesthetics (Figs. 5 and 6). In secondary (revision) rhinoplasty, the nasal septal cartilage, which is generally the cartilage of choice, is often lacking. Thus, alternative grafting material may need to be obtained from the rib or ear [2,4]. Costal cartilage provides a large volume of material but requires a second operative field and exposes the patient to greater morbidity and complications [5,6]. Therefore, auricular cartilage is an attractive alternative when a modest amount of grafting material is needed and when nasal septal cartilage is depleted. The goal, then, is to maximize the amount of auricular cartilage harvested while limiting complications and maintaining preoperative appearances. This article describes a technique for auricular graft harvest that aims to achieve this end. Multiple techniques for auricular cartilage harvest have been previously described. As early as 1955, Adams [7] described a method that emphasized the retention of 2 mm of the superior outer rim of the concha, 3 mm of the cartilaginous rim connecting the tragus to the antitragus, and 3 mm of the external auditory canal. Falces and Gourney [8] described their approach in which they removed the entire concha while cautioning not to violate the helical apex and the antihelical ridge. We corroborate these basic assumptions with our own experience; however, we have found that the limits of their dissection may be overly conservative. These limits included the crest of the helix, lower crus of the triangular fossa, helical buttress, margin of the meatus, and inner edge of the antitragus [8]. In our
550
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
Fig. 5. A and B, Preoperative (left) vs postoperative (right) views of a patient who underwent secondary rhinoplasty with auricular cartilage grafts by the senior author (CSC). Auricular cartilage was used as spreader grafts to correct her inverted “v” deformity, a dorsal onlay graft to augment her dorsum, and a left-sided lateral crural strut graft to correct her distorted tip and alar collapse.
experience, the cartilage spanning these regions (ie, the tragus and antitragus) may be harvested more liberally if the key areas previously described are preserved. Guyuron [9], in 1986, described a technique for auricular cartilage harvest that also shares some similarities to our approach. As in our described technique, they infiltrated with local anesthetic for hydrodissection and performed a postauricular incision. The posterior perichondrium was left attached to the graft, and a subperichondrial dissection was performed anteriorly. However, preoperative demarcation with ink was not described, which we feel is a critical step, allowing for maximal en bloc cartilage harvest intraoperatively. The described area of acceptable cartilage removal is more difficult to assess once the dissection has begun, and the native, preoperative appearances have been disturbed. Bocciceri [10] describes a similar procedure but with subperichondrial dissection on both surfaces of the graft and demarcation of the dissection with 4 or 5 needles inserted into the anterior surface of the ear. The needles emerged on the posterior surface and delineated the margin of dissection of the antihelix and helical root. Our technique is an
improvement on these recommendations because (1) the layer of perichondrium left on the posterior graft provides necessary support to the harvested cartilage, (2) tattooing provides a superior degree and accuracy of demarcation, and (3) there is reduction of the risk of injury because of the removal of the cumbersome needle load in the operative field while dissecting. Han et al [11] describe harvesting the conchal cartilage in 2 separate pieces allowing a 5-mm strut to remain between the cymba concha and cavum concha. They contend that this strut is essential to maintain structural support of the donor ear and prevent collapse. In our study, we found that preservation of this region was not necessary to maintain cosmesis. Gruber et al [12,13] separately described leaving behind a portion of the ellipse removed from the concha of the ear or a 6-mm upper vertical wall of the cavum concha to prevent ear flattening. We did not find these additional support structures to be necessary for adequate postoperative appearance of the ear by our described procedure. As expressed in our results, the harvested auricular cartilage can be used for various types of rhinoplasty struts and provides sufficient cartilage for multiple grafts in a single patient. Varying graft types, as previously described by Gunter et al [1], were used in this series and included lateral crural struts, dorsal onlay grafts, spreader grafts, columellar struts, alar rim grafts, and repair of septal perforations. The curvature and softness of the conchal cartilage make it an ideal graft for areas such as the nasal tip and alar rims. However, the large en bloc harvest described by our technique also provided sufficient tissue for both larger grafts (such as dorsal onlay grafts, spreader grafts, and columellar struts) and/or multiple grafts from one large piece of cartilage. Although limited by the number of patients in this series and the required graft types needed in those patients, the auricular cartilage could be fashioned for any graft type that can be obtained from the septal or costal cartilage. The technique described in this article is the culmination of over 50 years of experience among multiple practices that allow for simple and maximal cartilage harvest without significant postoperative deformity or complication. Local injection is used to simplify the dissection, and methylene blue is introduced through the anterior ear to safely outline critical structural components that must not be violated to prevent postoperative deformity. Although some authors advocate an anterior approach for even easier dissection and visualization landmarks, we find that the postauricular incision provides better overall cosmesis and camouflage of scar without significant increase in the difficulty of dissection or complications. Preservation of attached perichondrium on one surface of the harvested cartilage provides structure and helps prevent fracture of the en bloc graft. The layer of perichondrium left on the anterior surface of the conchal bowl may also preserve the native smooth contour and allow for new cartilage formation, which would reinforce the helical buttress. Maximal concha harvest is
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
Fig. 6. A and B, Gunter diagram depicting graft locations (green) for the patient in Fig. 5A and B.
551
552
M. Lee et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 547–552
achieved, en bloc, without wasted potential cartilage for grafting in functional and cosmetic rhinoplasty.
6. Conclusion The method described in this article allows for maximal auricular cartilage graft harvest while preserving structures critical to maintaining preoperative appearance. Auricular cartilage is a viable option for graft material in both primary and revision rhinoplasty with versatile application. References [1] Gunter JP, Landecker A, Cochran CS. Frequently used grafts in rhinoplasty: nomenclature and analysis. Plast Reconstr Surg 2006;118: 14e-29e. [2] Moshaver A, Gantous A. The use of autogenous costal cartilage graft in septorhinoplasty. Otolaryngol Head Neck Surg 2007;137:862-7. [3] Cakmak O, Ergin T. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg 2002;4:172-6.
[4] Cochran CS, DeFatta RJ. Tragal cartilage grafts in rhinoplasty: a viable alternative in the graft-depleted patient. Otolaryngol Head Neck Surg 2008;138:166-9. [5] Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction. A long-term study. Plast Reconstr Surg 1995;95:961. [6] Tanzer RC. Microtia: a long-term follow up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61:161. [7] Adams WM. Construction of upper half of auricle utilizing composite concha cartilage graft with perichondrium attached on both sides. Plast Recontr Surg 1955;16:88. [8] Falces E, Gorney M. Use of ear cartilage grafts for nasal tip reconstruction. Plast Reconstr Surg 1972;50:147-52. [9] Guyuron B. Simplified harvesting of the ear cartilage graft. Aesthetic Plast Surg 1986;10:37-9. [10] Boccieri A. Subtotal reconstruction of the nasal septum using a conchal reshaped graft. Ann Plast Surg 2004;53:118-25. [11] Han K, Kim J, Son D, et al. How to harvest the maximal amount of conchal cartilage grafts. Journal of Plast Reconstr Aesthetic Surg 2008;61:1465-71. [12] Gruber RP, Pardun J, Wall S. Grafting the nasal dorsum with tandem ear cartilage. Plast Reconstr Surg 2003;112:1110-22. [13] Gruber RP, Peck GC. Rhinoplasty: State of the Art. St Louis: Mosby; 1973. p. 168.