- Email: [email protected]
Cauliflower ear dissection
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, e279ee282
CASE REPORT
Cauliflower ear dissection Masao Fujiwara *, Ayano Suzuki, Takeshi Nagata, Hidekazu Fukamizu Department of Plastic and Reconstructive Surgery, Hamamatsu University, School of Medicine, Hamamatsu, Japan Received 2 February 2011; accepted 14 April 2011
KEYWORDS Cauliflower ear; Dissection; Histology; Magnetic resonance image; Computed tomography
Summary Cauliflower ear (CE) is caused by repeated direct trauma to the external ear. Surgical correction of an established CE is one of the most challenging problems in ear reconstruction. However, no reports have clarified the dissection of an established CE in detail. In this report, the dissection of a CE is described based on macroscopic, microscopic and imaging features. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Cauliflower ear (CE) is caused by repeated direct trauma to the external ear. It is often seen in participants in rugby, boxing, wrestling, and judo.1 Surgical correction of an established CE is one of the most challenging problems in ear reconstruction. However, no reports have clarified the dissection of an established CE in detail. From a clinical point of view, it is important to understand the dissection of an established CE. This report describes the dissection of a CE based on macroscopic, microscopic and imaging features.
Case report A 32-year-old man presented with a deformity of the entire anterior surface of the left ear, resulting from playing rugby * Corresponding Author. Department of Plastic and Reconstructive surgery, Hamamatsu University Shool of Medicine, Handayama 1-201, Hamamatsu, Shizuoka 431-3192, Japan. Tel./fax: 81534352798. E-mail address: [email protected] (M. Fujiwara).
for 18 years. He had undergone more than 10 previous fine needle aspiration procedures for traumatic auricular hematoma. In the upper three-quarters of the auricle, there was a remarkable projection of the ear (Figure 1A,B). The projected lump was inelastic and hard. The patient complained of pain in his left ear when making phone calls or wearing a mask. Magnetic resonance (MR) and computed tomography (CT) images showed similar findings. The original convoluted shape of the ear had disappeared, and the structure was indistinct and disarranged within the lump. No hematoma was clearly recognized. There were ossifications at the antitragus and helical crus (Figure 1C,D). Surgery was performed. An incision was made along the scaphoid fossa between the projected lump and the helix. The resulting skin flap was elevated off. Although the skin on the lump was very thin, subdermal vascular plexuses were abundant. A deformed white tuber, which appeared cartilaginous, was exposed (Figure 1E). The projected tuber was tangentially excised at its base, and the posterior skeleton was exposed. A ridgeline similar to the antihelix appeared (Figure. 1F). The skeleton was shaved and sculptured with
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.018
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M. Fujiwara et al.
Figure 1 (A) Preoperative appearance of the cauliflower ear. (B) A lump, which projected ahead of the deformed helix, is seen. (C) Cross-section CT image at level m. (D) Cross-section CT image at level n. (E) Abundant vascular plexuses are seen in the back of the elevated skin flap. The cartilaginous tuber is exposed. (F) The posterior skeleton was an indistinct structure, although there was a ridge line similar to the antihelix. (G) The excised tuber was cut along the solid line. (H) Lateral appearance at 1 year after the surgery. (I) Posterior appearance at 1 year after the surgery.
a scalpel to restore a normal form as much as possible. Ossified tissues at the antitragus and helical crus were removed with small forceps as much as possible. The excised tuber was cut in the longitudinal direction. Both the surface and the inside of the tuber appeared cartilaginous macroscopically (Figure 1G). The skin was re-draped and sutured. Bolster sutures were used to splint the reshaped helical groove. The bolster sutures were removed at 13 days postoperatively. The postoperative course was uneventful. The preoperative pain while making a phone call or wearing a mask disappeared. The results at 1 year after the surgery were acceptable to the patient (Figure 1H,I). Elasticaevan Gieson staining, which shows collagen fibers as pale red, elastic fibers as blueeblack to black, and nuclei as blue to black, revealed that the excised specimen was mostly occupied by fibrous connective tissues that included blood vessels. The outermost connective tissue layer, which had abundant blood vessels,
corresponded to the perichondrium. Under the perichondrium, however, some layers of divided elastic cartilage were present along the anterior surface (Figure 2).
Discussion In the anterior surface, the normal auricle consists of a skin envelope of about 0.8e1.2 mm in thickness that is firmly attached to the perichondrium.2 In the present case, the anterior skin envelope was very thin. The posterior surface bears an additional layer of fat between the skin and the perichondrium that, unlike the anterior surface, allows good mobility of the skin (1.2e3.0 mm) on the posterior surface.2 The framework of the normal auricle consists of convoluted elastic cartilage of 1.0e3.0 mm in thickness.2 There are no blood vessels within the elastic cartilage in the normal ear. In the present case, the anterior elastic
Cauliflower ear dissection
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Figure 2 (A) Longitudinal section of the surface after Elasticaevan Gieson staining (scale bar: 5 mm). (B) A magnified image (scale bar Z 100 mm) reveals the perichondrium with abundant capillaries and cartilage with dense elastic fibers.
cartilage consisted of layers of divided elastic cartilage and was 0.3e0.8 mm in thickness. Blood vessels were included in the dense fibrous connective tissues around the elastic cartilage in the CE. In an experimental study in rabbits, Pandya3 made a semblance to a CE by dropping a 10-g weight from a fixed height onto the lateral aspect of the pinna, and examined the histological features chronologically. At 2 weeks after commencing the experiment, a thin sheet of cartilage was observed on either side of the hematoma. Three weeks later, the hematoma was replaced by fibrous tissue. Eight weeks later, the fibrous tissue was replaced by cartilage. Fourteen weeks later, calcification, new bone formation, and lamination of the cartilage took place. Clinically, previous reports have described that hematomas were seen within the cartilage, and described that cartilage lamellas could be found on both the anterior and posterior borders of the hematomas.47 Regarding the posterior cartilage lamella, Vogelin et al.5 showed the presence of original cartilage on the posterior side of the auricle by hematoxylin and eosin staining. We evaluated the anterior lamella histologically in the present case. The hematoma was organized and replaced by fibrous connective tissue.4,6,7 The results confirmed that the two cartilaginous lamellas hold hematomas or fibrous connective tissues in a CE. Although elastic cartilage provides flexibility and support, it is able to maintain its shape.2 In the present CE, the flexibility of the auricle disappeared and it became hard, although the lump included sparse elastic cartilage. Ossification is seen at a later stage in old hematomas.2,5 In the present case, deep ossification was seen at the antitragus and helical crus. The skin on the lump was very thin. Careful dissection of the skin is necessary, especially at the helix-scapha transition where there is no areolar tissue between the dermis and the perichondrium.8 With an anterior skin incision,
access to the deformed tuber is easy.2,4,7e9 This incision allows wide exposure of the distorted tuber, such that its resection does not place the skin integrity at risk.8 Meanwhile, a posterior skin incision results in an inconspicuous scar on the posterior side of the ear,1,5,6,10 and permits manipulation of both the anterior and posterior sides of the cartilage.1 A posterior incision entails a very careful and gentle dissection through the helix-scapha transition to expose the distorted tuber. In the present case, we opted for an anterior incision on the scaphoid fossa, because the possibility of damaging the skin integrity was low. When the skeleton is shaved and sculptured, the posterior lamella should be left as much as possible because it includes the original cartilage. When the structural integrity is not maintained by removal of the tuber, grafting is performed to restore the structural integrity. As graft materials, the contralateral conchal or costal cartilage have been used.1,8 Schonauer et al.6 used excised lamellas of cartilaginous tissues as sources of graft materials because the excised lamellas were sufficiently hard to support the helical rim. These findings regarding CE dissection will be useful for managing an established CE.
Conflicts of interest None.
Funding None.
Acknowledgment None.
e282
References 1. Yotsuyanagi T, Yamashita K, Urushidate S, et al. Surgical correction of cauliflower ear. Br J Plast Surg 2002;55:380e6. 2. Weerda H. Surgery of the auricle. New York: Thieme; 2007. 3. Pandya NJ. Experimental production of "cauliflower ear" in rabbits. Plast Reconstr Surg 1973;52:534e7. 4. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. The wrestler’s ear. Plast Reconstr Surg 1967;40:540e6. 5. Vogelin E, Grobbelaar AO, Chana JS, et al. Surgical correction of the cauliflower ear. Br J Plast Surg 1998;51:359e62.
U.M. Rieger 6. Schonauer F, La Rusca I, Pereira JA, et al. Redefinition of the helical rim in cauliflower-ear surgery. Br J Plast Surg 2002;55:66e8. 7. Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma. Laryngoscope 2005;115:1251e5. 8. Osorno GA. 20-year experience with the brent technique of auricular reconstruction: pearls and pitfalls. Plast Reconstr Surg 2007;119:1447e63. 9. Giffin CS. Wrestler’s ear: pathophysiology and treatment. Ann Plast Surg 1992;28:131e9. 10. Harrison G, Schneiderman RN. The protruding cauli-flower ear: treatment by use of mechanical abrasion. South Med J 1962; 55:630e2.
Invited commentary Ulrich M. Rieger a,b,* a
Department of Plastic and Reconstructive Surgery, Medical University Innsbruck (MUI), Anichstrasse 35, 6020 Innsbruck, Austria b Ringgemeinschaft Hausen-Zell i.W. 1971 e.V., 79669 Zell im Wiesental, Germany Received 15 April 2011; accepted 23 April 2011 Sir,
With great interest I have read the case report “Cauliflower ear dissection” by M. Fujiwara et al.1 The authors provide an in depth description of diagnostics using MRI and CT and their surgical technique using an anterior incision for removal of fibrous connective tissue and reshaping of ear cartilage to reconstruct the characteristic shape of the auricle. As a long lasting sports physician of a German professional wrestling team as well as being a consultant at the Department of Plastic, Reconstructive and Aesthetic surgery at Innsbruck Medical University, Austria, I would like to share some of my experience in the management of cauliflower ear. In their young professional years the wrestling athletes consider their cauliflower ear or as it is called as well as “wrestler’s ear” to be an award and “wear” it with pride. Therefore they often refuse acute incision and drainage of
the hematoma to prevent secondary deformations. However, in their later “post-wrestling” years they often start a new career in civil professions, often with extensive client contact. Only then, some of them feel ashamed of their ear deformities and either try to hide the ears under long hair or seek a surgical solution for their cauliflower ears. In these cases I usually go for a posterior incision, carefully dissecting the auricle skin off the fibrotic or ossified structures and then reshape the cartilage. I admit, however, that an anterior approach described here has its place for deformities confined to the anterior auricle. The incision can be well hidden in the transitional grove between helix and scapha. Although I never used any imaging before surgery, I agree with the authors that in extensive deformities these imagining modalities have their place for detailed pre-operative planning.
Reference 1. Fujiwara M, Suzuki A, Nagata T, Fukamizu H. Cauliflower ear dissection. J Plast Reconstr Aesthet Surg 2011;64:e279e82.
DOI of original article: 10.1016/j.bjps.2011.04.018. * Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck (MUI), Anichstrasse 35, 6020 Innsbruck, Austria. Tel.: þ43 512 504 80088. E-mail address: [email protected] ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.017
CASE REPORT
Cauliflower ear dissection Masao Fujiwara *, Ayano Suzuki, Takeshi Nagata, Hidekazu Fukamizu Department of Plastic and Reconstructive Surgery, Hamamatsu University, School of Medicine, Hamamatsu, Japan Received 2 February 2011; accepted 14 April 2011
KEYWORDS Cauliflower ear; Dissection; Histology; Magnetic resonance image; Computed tomography
Summary Cauliflower ear (CE) is caused by repeated direct trauma to the external ear. Surgical correction of an established CE is one of the most challenging problems in ear reconstruction. However, no reports have clarified the dissection of an established CE in detail. In this report, the dissection of a CE is described based on macroscopic, microscopic and imaging features. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Cauliflower ear (CE) is caused by repeated direct trauma to the external ear. It is often seen in participants in rugby, boxing, wrestling, and judo.1 Surgical correction of an established CE is one of the most challenging problems in ear reconstruction. However, no reports have clarified the dissection of an established CE in detail. From a clinical point of view, it is important to understand the dissection of an established CE. This report describes the dissection of a CE based on macroscopic, microscopic and imaging features.
Case report A 32-year-old man presented with a deformity of the entire anterior surface of the left ear, resulting from playing rugby * Corresponding Author. Department of Plastic and Reconstructive surgery, Hamamatsu University Shool of Medicine, Handayama 1-201, Hamamatsu, Shizuoka 431-3192, Japan. Tel./fax: 81534352798. E-mail address: [email protected] (M. Fujiwara).
for 18 years. He had undergone more than 10 previous fine needle aspiration procedures for traumatic auricular hematoma. In the upper three-quarters of the auricle, there was a remarkable projection of the ear (Figure 1A,B). The projected lump was inelastic and hard. The patient complained of pain in his left ear when making phone calls or wearing a mask. Magnetic resonance (MR) and computed tomography (CT) images showed similar findings. The original convoluted shape of the ear had disappeared, and the structure was indistinct and disarranged within the lump. No hematoma was clearly recognized. There were ossifications at the antitragus and helical crus (Figure 1C,D). Surgery was performed. An incision was made along the scaphoid fossa between the projected lump and the helix. The resulting skin flap was elevated off. Although the skin on the lump was very thin, subdermal vascular plexuses were abundant. A deformed white tuber, which appeared cartilaginous, was exposed (Figure 1E). The projected tuber was tangentially excised at its base, and the posterior skeleton was exposed. A ridgeline similar to the antihelix appeared (Figure. 1F). The skeleton was shaved and sculptured with
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.018
e280
M. Fujiwara et al.
Figure 1 (A) Preoperative appearance of the cauliflower ear. (B) A lump, which projected ahead of the deformed helix, is seen. (C) Cross-section CT image at level m. (D) Cross-section CT image at level n. (E) Abundant vascular plexuses are seen in the back of the elevated skin flap. The cartilaginous tuber is exposed. (F) The posterior skeleton was an indistinct structure, although there was a ridge line similar to the antihelix. (G) The excised tuber was cut along the solid line. (H) Lateral appearance at 1 year after the surgery. (I) Posterior appearance at 1 year after the surgery.
a scalpel to restore a normal form as much as possible. Ossified tissues at the antitragus and helical crus were removed with small forceps as much as possible. The excised tuber was cut in the longitudinal direction. Both the surface and the inside of the tuber appeared cartilaginous macroscopically (Figure 1G). The skin was re-draped and sutured. Bolster sutures were used to splint the reshaped helical groove. The bolster sutures were removed at 13 days postoperatively. The postoperative course was uneventful. The preoperative pain while making a phone call or wearing a mask disappeared. The results at 1 year after the surgery were acceptable to the patient (Figure 1H,I). Elasticaevan Gieson staining, which shows collagen fibers as pale red, elastic fibers as blueeblack to black, and nuclei as blue to black, revealed that the excised specimen was mostly occupied by fibrous connective tissues that included blood vessels. The outermost connective tissue layer, which had abundant blood vessels,
corresponded to the perichondrium. Under the perichondrium, however, some layers of divided elastic cartilage were present along the anterior surface (Figure 2).
Discussion In the anterior surface, the normal auricle consists of a skin envelope of about 0.8e1.2 mm in thickness that is firmly attached to the perichondrium.2 In the present case, the anterior skin envelope was very thin. The posterior surface bears an additional layer of fat between the skin and the perichondrium that, unlike the anterior surface, allows good mobility of the skin (1.2e3.0 mm) on the posterior surface.2 The framework of the normal auricle consists of convoluted elastic cartilage of 1.0e3.0 mm in thickness.2 There are no blood vessels within the elastic cartilage in the normal ear. In the present case, the anterior elastic
Cauliflower ear dissection
e281
Figure 2 (A) Longitudinal section of the surface after Elasticaevan Gieson staining (scale bar: 5 mm). (B) A magnified image (scale bar Z 100 mm) reveals the perichondrium with abundant capillaries and cartilage with dense elastic fibers.
cartilage consisted of layers of divided elastic cartilage and was 0.3e0.8 mm in thickness. Blood vessels were included in the dense fibrous connective tissues around the elastic cartilage in the CE. In an experimental study in rabbits, Pandya3 made a semblance to a CE by dropping a 10-g weight from a fixed height onto the lateral aspect of the pinna, and examined the histological features chronologically. At 2 weeks after commencing the experiment, a thin sheet of cartilage was observed on either side of the hematoma. Three weeks later, the hematoma was replaced by fibrous tissue. Eight weeks later, the fibrous tissue was replaced by cartilage. Fourteen weeks later, calcification, new bone formation, and lamination of the cartilage took place. Clinically, previous reports have described that hematomas were seen within the cartilage, and described that cartilage lamellas could be found on both the anterior and posterior borders of the hematomas.47 Regarding the posterior cartilage lamella, Vogelin et al.5 showed the presence of original cartilage on the posterior side of the auricle by hematoxylin and eosin staining. We evaluated the anterior lamella histologically in the present case. The hematoma was organized and replaced by fibrous connective tissue.4,6,7 The results confirmed that the two cartilaginous lamellas hold hematomas or fibrous connective tissues in a CE. Although elastic cartilage provides flexibility and support, it is able to maintain its shape.2 In the present CE, the flexibility of the auricle disappeared and it became hard, although the lump included sparse elastic cartilage. Ossification is seen at a later stage in old hematomas.2,5 In the present case, deep ossification was seen at the antitragus and helical crus. The skin on the lump was very thin. Careful dissection of the skin is necessary, especially at the helix-scapha transition where there is no areolar tissue between the dermis and the perichondrium.8 With an anterior skin incision,
access to the deformed tuber is easy.2,4,7e9 This incision allows wide exposure of the distorted tuber, such that its resection does not place the skin integrity at risk.8 Meanwhile, a posterior skin incision results in an inconspicuous scar on the posterior side of the ear,1,5,6,10 and permits manipulation of both the anterior and posterior sides of the cartilage.1 A posterior incision entails a very careful and gentle dissection through the helix-scapha transition to expose the distorted tuber. In the present case, we opted for an anterior incision on the scaphoid fossa, because the possibility of damaging the skin integrity was low. When the skeleton is shaved and sculptured, the posterior lamella should be left as much as possible because it includes the original cartilage. When the structural integrity is not maintained by removal of the tuber, grafting is performed to restore the structural integrity. As graft materials, the contralateral conchal or costal cartilage have been used.1,8 Schonauer et al.6 used excised lamellas of cartilaginous tissues as sources of graft materials because the excised lamellas were sufficiently hard to support the helical rim. These findings regarding CE dissection will be useful for managing an established CE.
Conflicts of interest None.
Funding None.
Acknowledgment None.
e282
References 1. Yotsuyanagi T, Yamashita K, Urushidate S, et al. Surgical correction of cauliflower ear. Br J Plast Surg 2002;55:380e6. 2. Weerda H. Surgery of the auricle. New York: Thieme; 2007. 3. Pandya NJ. Experimental production of "cauliflower ear" in rabbits. Plast Reconstr Surg 1973;52:534e7. 4. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. The wrestler’s ear. Plast Reconstr Surg 1967;40:540e6. 5. Vogelin E, Grobbelaar AO, Chana JS, et al. Surgical correction of the cauliflower ear. Br J Plast Surg 1998;51:359e62.
U.M. Rieger 6. Schonauer F, La Rusca I, Pereira JA, et al. Redefinition of the helical rim in cauliflower-ear surgery. Br J Plast Surg 2002;55:66e8. 7. Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma. Laryngoscope 2005;115:1251e5. 8. Osorno GA. 20-year experience with the brent technique of auricular reconstruction: pearls and pitfalls. Plast Reconstr Surg 2007;119:1447e63. 9. Giffin CS. Wrestler’s ear: pathophysiology and treatment. Ann Plast Surg 1992;28:131e9. 10. Harrison G, Schneiderman RN. The protruding cauli-flower ear: treatment by use of mechanical abrasion. South Med J 1962; 55:630e2.
Invited commentary Ulrich M. Rieger a,b,* a
Department of Plastic and Reconstructive Surgery, Medical University Innsbruck (MUI), Anichstrasse 35, 6020 Innsbruck, Austria b Ringgemeinschaft Hausen-Zell i.W. 1971 e.V., 79669 Zell im Wiesental, Germany Received 15 April 2011; accepted 23 April 2011 Sir,
With great interest I have read the case report “Cauliflower ear dissection” by M. Fujiwara et al.1 The authors provide an in depth description of diagnostics using MRI and CT and their surgical technique using an anterior incision for removal of fibrous connective tissue and reshaping of ear cartilage to reconstruct the characteristic shape of the auricle. As a long lasting sports physician of a German professional wrestling team as well as being a consultant at the Department of Plastic, Reconstructive and Aesthetic surgery at Innsbruck Medical University, Austria, I would like to share some of my experience in the management of cauliflower ear. In their young professional years the wrestling athletes consider their cauliflower ear or as it is called as well as “wrestler’s ear” to be an award and “wear” it with pride. Therefore they often refuse acute incision and drainage of
the hematoma to prevent secondary deformations. However, in their later “post-wrestling” years they often start a new career in civil professions, often with extensive client contact. Only then, some of them feel ashamed of their ear deformities and either try to hide the ears under long hair or seek a surgical solution for their cauliflower ears. In these cases I usually go for a posterior incision, carefully dissecting the auricle skin off the fibrotic or ossified structures and then reshape the cartilage. I admit, however, that an anterior approach described here has its place for deformities confined to the anterior auricle. The incision can be well hidden in the transitional grove between helix and scapha. Although I never used any imaging before surgery, I agree with the authors that in extensive deformities these imagining modalities have their place for detailed pre-operative planning.
Reference 1. Fujiwara M, Suzuki A, Nagata T, Fukamizu H. Cauliflower ear dissection. J Plast Reconstr Aesthet Surg 2011;64:e279e82.
DOI of original article: 10.1016/j.bjps.2011.04.018. * Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck (MUI), Anichstrasse 35, 6020 Innsbruck, Austria. Tel.: þ43 512 504 80088. E-mail address: [email protected] ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.017