- Email: [email protected]
Pinnaplasty: A porcine training model
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Correspondence and communications
Plastic Surgery Service, University of Montreal Hospital Center, Montreal, Canada E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.054
Pinnaplasty: A porcine training model Dear Sir, Following the introduction of the European Working Time Directive, surgical training has been greatly limited and complementary learning alternatives must be explored.1 A novel porcine training model is presented that allows the rehearsal of the operative steps of pinnaplasty, using either suturing or scoring techniques to increase familiarity with shaping cartilage.2 Figure 2 Photograph demonstrating an antihelix created with the Mustarde ´ technique on porcine pinna.
Figure 1
Photograph demonstrating tattooing on porcine pinna.
Utilising a pig’s head purchased from the local butcher’s shop costing £12, we are able to demonstrate the sequential approach to pinnaplasty. There are anatomical difference between the porcine and human ear. These include its relation with respect to the cranium, the size and thickness of the cartilage. However despite these differences, the lack of an anti-helical fold in the porcine model and pliability of the cartilage in pigs makes this model a suitable and effective one particularly for the novice. Furthermore both the right and left sides can be practised and an understanding of the subtle morphological differences between ears that arise. Key steps include tattooing and marking the antihelical fold to be created, the marking of skin resection and the raising of the posterior flap to reveal the tattoo marks (Figure 1).4 The ear can then be used to perform either the Mustarde ´ technique of cartilage plication with a dyed suture for clarity or the anterior scoring technique for pinnaplasty e both of which can be easily done on either ear. Raising of the adipofascial flap can be practised especially taking care not to button hole the posterior skin envelope.3 To rehearse the Mustarde ´ technique, a dyed suture such as a 3/0 prolene is used. Practising placement of sutures and ensuring that the anterior skin envelope is not breached can be practised here. The accuracy of creating the fold along the marked antihelical fold can be assessed and differing suture placements explored.4
Correspondence and communications An anterior cartilage scoring technique can be practised and appreciation of the delicacy required to avoid ridges and irregularities noted.5 Resection of the concha can be performed once the antihelical fold has been created, to reduce projection of the ear.6 The amount and location of the resection can be practised to determine its precise effect on projection.7 However, the porcine model does lack a lobule and therefore we are unable to practice this important step. In summary, we present a novel method of practising pinnaplasty on a porcine model that accurately recreates the procedure performed in humans. This simulated model can aid the trainee in mastering techniques as well as allowing a degree of freedom to experiment and develop the technique that suits him best (Figure 2).
Conflict of interest The authors declare no conflict of interest.
References 1. Hallam MJ, Lo S, Mabvuure N, Nduka C. Implications of rationing and the European working time directive on aesthetic breast surgery: a study of trainee exposure in 2005 and 2011. J Plast Reconstr Aesthet Surg 2013 Feb;66(2):e37e42. http://dx.doi.org/10.1016/j.bjps.2012.09.018 [Epub 2012 Oct 4]. 2. Tan SS, Sarker SK. Simulation in surgery: a review. Scott Med J 2011 May;56(2):104e9. http://dx.doi.org/10.1258/smj.2011. 011098 [Review]. 3. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustard? And Furnas type otoplasty. Plast Reconstr Surg 2001 Nov;108(6):1487e90 [discussion 1491]. 4. Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg 1963 Apr;16:170e8 [No abstract available]. 5. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg 1963 Jul;16:268e72 [No abstract available]. 6. Stucker FJ, Christiansen TA. The lateral conchal resection otoplasty. Laryngoscope 1977 Jan;87(1):58e62. 7. Furnas DW. Correction of prominent ears with multiple sutures. Clin Plast Surg 1978 Jul;5(3):491e5.
Charles Yuen Yung Loh Eilidh Gunn David John Laurie Pennell Thanassi Athanassopoulos Plastic and Reconstructive Surgery, Ninewells Hospital, Dundee DD1 9SY, United Kingdom E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.012
869
Reconstruction of the partial pinna using autologous ear cartilage combined with a local sliding skin flap Dear Sir, Partial auricular reconstruction seems to be more difficult to achieve than total auricular reconstruction because partial ear defects are so diverse and because the reconstructed parts need to be consistent with the residual ear in terms of shape, structure, color, and texture.1 Due to the differing sizes and locations of auricular defects, different auricular cartilage materials and skin tissues can be used for tissue reconstruction.2 Therefore, there is no standard surgical method for the repair of partial ear defects. In this study, a 32-year-old man (Figure 1A) exhibited a 4.0 2.0 cm defect in the upper and middle partial ear caused by a human bite suffered during a fight. Most of the right side of the pinna was lost, and only the upper ear and lower pole remained as residuals. After 2 weeks of healing following the bite wound, an operation was performed to repair the middle partial defect of the pinna. To approximate the appearance of the healthy ear, the concha cartilage was trimmed and attached by stitching with 50 absorbable suture at the defective cartilage edge. The transplanted cartilage was covered by the sliding skin flap behind the ear, and the flap was then sutured. Under the flap, negative pressure drainage was used to ensure good pinna appearance (Figure 1BeD). Two months later, the sliding skin flap blood root was cut off behind the ear at the hairline edge to correct the ear elevation and to make the retroauricular groove (Figure 1E). The wound area was covered by a free autologous skin transplant. Across an 8-year period from 2004 to 2012, 17 patients with partial auricle defects were treated in our hospital using methods involving autologous contralateral or ipsilateral concha cartilage combined with a local ear advancement flap. 14 of these patients also received the second-stage operation for ear elevation. Following the first-stage operation, 3 patients did not require the second-stage operation because their auricular defect size had been reduced, and their auricular appearance was good (Figure 2). Drainage was blocked in 3 patients in whom a small amount of hematoma was found and cleared in a timely manner. No cases showed skin flap necroses, and all incisions healed without infection of the wounds. One month after the second-stage operation, 7 patients experienced incision scar proliferation at the skin transplant area behind the ear. Four of them were treated with Diprospan (betamethasone dipropionate); following this anti-scar treatment, the scars disappeared. For 3 patients, the scars gradually and naturally subsided after 6 months without special treatment. All patients were followed for 12 months, and all patients’ reconstructed ears showed good auricular appearance, clear structures, and slight scarring.
Correspondence and communications
Plastic Surgery Service, University of Montreal Hospital Center, Montreal, Canada E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.054
Pinnaplasty: A porcine training model Dear Sir, Following the introduction of the European Working Time Directive, surgical training has been greatly limited and complementary learning alternatives must be explored.1 A novel porcine training model is presented that allows the rehearsal of the operative steps of pinnaplasty, using either suturing or scoring techniques to increase familiarity with shaping cartilage.2 Figure 2 Photograph demonstrating an antihelix created with the Mustarde ´ technique on porcine pinna.
Figure 1
Photograph demonstrating tattooing on porcine pinna.
Utilising a pig’s head purchased from the local butcher’s shop costing £12, we are able to demonstrate the sequential approach to pinnaplasty. There are anatomical difference between the porcine and human ear. These include its relation with respect to the cranium, the size and thickness of the cartilage. However despite these differences, the lack of an anti-helical fold in the porcine model and pliability of the cartilage in pigs makes this model a suitable and effective one particularly for the novice. Furthermore both the right and left sides can be practised and an understanding of the subtle morphological differences between ears that arise. Key steps include tattooing and marking the antihelical fold to be created, the marking of skin resection and the raising of the posterior flap to reveal the tattoo marks (Figure 1).4 The ear can then be used to perform either the Mustarde ´ technique of cartilage plication with a dyed suture for clarity or the anterior scoring technique for pinnaplasty e both of which can be easily done on either ear. Raising of the adipofascial flap can be practised especially taking care not to button hole the posterior skin envelope.3 To rehearse the Mustarde ´ technique, a dyed suture such as a 3/0 prolene is used. Practising placement of sutures and ensuring that the anterior skin envelope is not breached can be practised here. The accuracy of creating the fold along the marked antihelical fold can be assessed and differing suture placements explored.4
Correspondence and communications An anterior cartilage scoring technique can be practised and appreciation of the delicacy required to avoid ridges and irregularities noted.5 Resection of the concha can be performed once the antihelical fold has been created, to reduce projection of the ear.6 The amount and location of the resection can be practised to determine its precise effect on projection.7 However, the porcine model does lack a lobule and therefore we are unable to practice this important step. In summary, we present a novel method of practising pinnaplasty on a porcine model that accurately recreates the procedure performed in humans. This simulated model can aid the trainee in mastering techniques as well as allowing a degree of freedom to experiment and develop the technique that suits him best (Figure 2).
Conflict of interest The authors declare no conflict of interest.
References 1. Hallam MJ, Lo S, Mabvuure N, Nduka C. Implications of rationing and the European working time directive on aesthetic breast surgery: a study of trainee exposure in 2005 and 2011. J Plast Reconstr Aesthet Surg 2013 Feb;66(2):e37e42. http://dx.doi.org/10.1016/j.bjps.2012.09.018 [Epub 2012 Oct 4]. 2. Tan SS, Sarker SK. Simulation in surgery: a review. Scott Med J 2011 May;56(2):104e9. http://dx.doi.org/10.1258/smj.2011. 011098 [Review]. 3. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustard? And Furnas type otoplasty. Plast Reconstr Surg 2001 Nov;108(6):1487e90 [discussion 1491]. 4. Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg 1963 Apr;16:170e8 [No abstract available]. 5. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg 1963 Jul;16:268e72 [No abstract available]. 6. Stucker FJ, Christiansen TA. The lateral conchal resection otoplasty. Laryngoscope 1977 Jan;87(1):58e62. 7. Furnas DW. Correction of prominent ears with multiple sutures. Clin Plast Surg 1978 Jul;5(3):491e5.
Charles Yuen Yung Loh Eilidh Gunn David John Laurie Pennell Thanassi Athanassopoulos Plastic and Reconstructive Surgery, Ninewells Hospital, Dundee DD1 9SY, United Kingdom E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.012
869
Reconstruction of the partial pinna using autologous ear cartilage combined with a local sliding skin flap Dear Sir, Partial auricular reconstruction seems to be more difficult to achieve than total auricular reconstruction because partial ear defects are so diverse and because the reconstructed parts need to be consistent with the residual ear in terms of shape, structure, color, and texture.1 Due to the differing sizes and locations of auricular defects, different auricular cartilage materials and skin tissues can be used for tissue reconstruction.2 Therefore, there is no standard surgical method for the repair of partial ear defects. In this study, a 32-year-old man (Figure 1A) exhibited a 4.0 2.0 cm defect in the upper and middle partial ear caused by a human bite suffered during a fight. Most of the right side of the pinna was lost, and only the upper ear and lower pole remained as residuals. After 2 weeks of healing following the bite wound, an operation was performed to repair the middle partial defect of the pinna. To approximate the appearance of the healthy ear, the concha cartilage was trimmed and attached by stitching with 50 absorbable suture at the defective cartilage edge. The transplanted cartilage was covered by the sliding skin flap behind the ear, and the flap was then sutured. Under the flap, negative pressure drainage was used to ensure good pinna appearance (Figure 1BeD). Two months later, the sliding skin flap blood root was cut off behind the ear at the hairline edge to correct the ear elevation and to make the retroauricular groove (Figure 1E). The wound area was covered by a free autologous skin transplant. Across an 8-year period from 2004 to 2012, 17 patients with partial auricle defects were treated in our hospital using methods involving autologous contralateral or ipsilateral concha cartilage combined with a local ear advancement flap. 14 of these patients also received the second-stage operation for ear elevation. Following the first-stage operation, 3 patients did not require the second-stage operation because their auricular defect size had been reduced, and their auricular appearance was good (Figure 2). Drainage was blocked in 3 patients in whom a small amount of hematoma was found and cleared in a timely manner. No cases showed skin flap necroses, and all incisions healed without infection of the wounds. One month after the second-stage operation, 7 patients experienced incision scar proliferation at the skin transplant area behind the ear. Four of them were treated with Diprospan (betamethasone dipropionate); following this anti-scar treatment, the scars disappeared. For 3 patients, the scars gradually and naturally subsided after 6 months without special treatment. All patients were followed for 12 months, and all patients’ reconstructed ears showed good auricular appearance, clear structures, and slight scarring.