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Reconstruction of an avulsed ear by constructing a composite free flap
BritishJoumalofPlastic
44.153-154
Case Report
R&construction of an avulsed ear by constructing a composite free flap D. SuCur, M. Ninkovic, S. Markovic and S. Babovii: Department of Reconstructive and Plastic Surgery, University Medical Centre, Sarajevo, Yugoslavia SUMMARY. A completely avdsed ear cartilage was swxssfdy forearm skin as a did forearm composite free flap.
replanted after bemg buried under the volar
facing the skin and the skin incision was closed. To prevent the formation of dead space and to preserve the contours, gauze was packed into the recesses of the cartilage with tieover sutures (Fig. 3). Following wound heal@ and removal of the sutures, the patient was dismissed for a period of twoand-a-half months. The next surgical procedure was to raise the cartilage and overlying skin as a composite radial forearm free flap and revascularise it using the superhcial temporal blood vessels. The skin of the flap was sutured in the place of the avulsed ear. One-and-a-half months later the bulky flap was trimmed, taking care not to damage the blood vessels, and the final trimming of the rest of the subcutaneous tissue after a further month gave a very satisfactory result (Fig.4) to the great pleasure of the patient and the surgical team. The donor site is shown in Figure 5. We believe that it should be possible to reconstruct a missing ear using this method, by implanting an acrylic moulded and perforated ear.
Although reconstructive microsurgery is an invaluable surgical technique, it has not proved to be too successful in the microvascular replantation of an avulsed ear. Only three completely successful replantations have been reported so far (Pennington et al., 1980; Mutimer et al., 1987; Tanaka and Tajima, 1989), which is a rather unimpressive total taking into consideration the number of failed attempts. Microvascular replantation of an amputated ear would be more likely to succeed if it were a part of a bigger flap with blood vessels that were easier to identify. For these reasons, we have searched for new techniques of ear replantation using microsurgery. This paper presents a case of a successful replantation of ear cartilage achieved by using a composite forearm free flap. We believe that this technique might also be used for reconstruction in other regions.
Discussion
Case report A 27-year-old girl sustained a total left ear avulsion in a motor vehicle accident and was transferred to our department immediately afterwards. We had previously used various methods for the reconstruction of a partially or completely amputated ear, but in this particular case we decided to use a new idea based on our experience in microsurgical reconstruction.
In the literature available to us we have come across only three successful microvascular replantations of an avulsed ear. The failures may be ascribed to the tiny blood vessels of the auricle and the difficulty in carrying out the microvascular anastomoses. There is therefore still a place for other ideas and techniques to overcome this, still unsolved, problem. Avulsed segments or a complete ear cartilage have been buried into subcutaneous pockets to ensure their survival until the local conditions for the formation of the skin cover are obtained at the lace of the missing ear (Pennington et al., 1980; f uhr et al., 1981; Mutimer et al., 1987). We simply adapted this old idea by burying the cartilage in a site suitable for microsurgical tissue transfer, that is, the forearm volar region.
Technique The left ear was completely avulsed except for a small part of the lobule (Figs 1 and 2). We decided to remove the skin which was crushed only on the posterior side, leaving the perichondrium investing the framework of cartilage. The prepared cartilage was buried in a subcutaneous pocket on the lower volar part of the middle third of the left forearm. The cartilage was placed in the pocket with its external side
153
British Journal of Plastic Surgery
Fig. 2
Fig. 1
Fig. 3
Fig. 4 on admission. Figure 2-The Figure l-Appearance Figure 5-Donor area-subsequently reduced.
Fig. 5 avulsed ear. Figure >Ear
cartilage implanted subcutaneously. Figure 4-Final
I
Acknowledgement
The Authors
Sincere thanks to Tanja BeniC for preparing and translating this manuscript.
Djordje&ur, MD, Specialist in Plastic and Reconstructive Surgery and General Surgery; Head of the Department of Reconstructive and Plastic Surgery, University Medical Centre, Sarajevo. Milomir Ninkovif, MD, Specialist in Plastic and Reconstructive Surgery. Siia MarkovE, MD, Specialist in Plastic and Reconstructive Surgery. Srdjan Babovik, MD, Specialist in Plastic and Reconstructive Surgery
References Mutlmer, K. L., Banis, J. C. and Upton, J. (1987’. Microsurgical reattachment of totally amputated ears. Plastic and Reconstructive Surgery, 79,535.
Pennington, D. G., Lahn, M. F. and Pelly, A. D. (1980). Successful replantation of a completely avulsed ear by microvascular anastomosis. Plastic and Reconstructive Surgery, 65,820. &~br, D., Konstantinovi6, P. and Potpar& Z. (1981). Fresh chicken leg : an experimental model for the microsurgical beginner. British Journal of Plastic Surgery, 34,488.
Tanaka, Y. and Tajima, S. (1989). Completely successful replantation of an amputated ear by microvascular anastomosis. Plastic and Reconstructive Surgery, 84,665.
Department of Recorktructive and Plastic Surgery, University Medical Centre, MoSe Pijade 25,710OOSarajevo, Yugoslavia. Requests for reprints to Dr &Cur at the above address. Paper received 10 April 1990. Accepted 16 July 1990 after revision.
44.153-154
Case Report
R&construction of an avulsed ear by constructing a composite free flap D. SuCur, M. Ninkovic, S. Markovic and S. Babovii: Department of Reconstructive and Plastic Surgery, University Medical Centre, Sarajevo, Yugoslavia SUMMARY. A completely avdsed ear cartilage was swxssfdy forearm skin as a did forearm composite free flap.
replanted after bemg buried under the volar
facing the skin and the skin incision was closed. To prevent the formation of dead space and to preserve the contours, gauze was packed into the recesses of the cartilage with tieover sutures (Fig. 3). Following wound heal@ and removal of the sutures, the patient was dismissed for a period of twoand-a-half months. The next surgical procedure was to raise the cartilage and overlying skin as a composite radial forearm free flap and revascularise it using the superhcial temporal blood vessels. The skin of the flap was sutured in the place of the avulsed ear. One-and-a-half months later the bulky flap was trimmed, taking care not to damage the blood vessels, and the final trimming of the rest of the subcutaneous tissue after a further month gave a very satisfactory result (Fig.4) to the great pleasure of the patient and the surgical team. The donor site is shown in Figure 5. We believe that it should be possible to reconstruct a missing ear using this method, by implanting an acrylic moulded and perforated ear.
Although reconstructive microsurgery is an invaluable surgical technique, it has not proved to be too successful in the microvascular replantation of an avulsed ear. Only three completely successful replantations have been reported so far (Pennington et al., 1980; Mutimer et al., 1987; Tanaka and Tajima, 1989), which is a rather unimpressive total taking into consideration the number of failed attempts. Microvascular replantation of an amputated ear would be more likely to succeed if it were a part of a bigger flap with blood vessels that were easier to identify. For these reasons, we have searched for new techniques of ear replantation using microsurgery. This paper presents a case of a successful replantation of ear cartilage achieved by using a composite forearm free flap. We believe that this technique might also be used for reconstruction in other regions.
Discussion
Case report A 27-year-old girl sustained a total left ear avulsion in a motor vehicle accident and was transferred to our department immediately afterwards. We had previously used various methods for the reconstruction of a partially or completely amputated ear, but in this particular case we decided to use a new idea based on our experience in microsurgical reconstruction.
In the literature available to us we have come across only three successful microvascular replantations of an avulsed ear. The failures may be ascribed to the tiny blood vessels of the auricle and the difficulty in carrying out the microvascular anastomoses. There is therefore still a place for other ideas and techniques to overcome this, still unsolved, problem. Avulsed segments or a complete ear cartilage have been buried into subcutaneous pockets to ensure their survival until the local conditions for the formation of the skin cover are obtained at the lace of the missing ear (Pennington et al., 1980; f uhr et al., 1981; Mutimer et al., 1987). We simply adapted this old idea by burying the cartilage in a site suitable for microsurgical tissue transfer, that is, the forearm volar region.
Technique The left ear was completely avulsed except for a small part of the lobule (Figs 1 and 2). We decided to remove the skin which was crushed only on the posterior side, leaving the perichondrium investing the framework of cartilage. The prepared cartilage was buried in a subcutaneous pocket on the lower volar part of the middle third of the left forearm. The cartilage was placed in the pocket with its external side
153
British Journal of Plastic Surgery
Fig. 2
Fig. 1
Fig. 3
Fig. 4 on admission. Figure 2-The Figure l-Appearance Figure 5-Donor area-subsequently reduced.
Fig. 5 avulsed ear. Figure >Ear
cartilage implanted subcutaneously. Figure 4-Final
I
Acknowledgement
The Authors
Sincere thanks to Tanja BeniC for preparing and translating this manuscript.
Djordje&ur, MD, Specialist in Plastic and Reconstructive Surgery and General Surgery; Head of the Department of Reconstructive and Plastic Surgery, University Medical Centre, Sarajevo. Milomir Ninkovif, MD, Specialist in Plastic and Reconstructive Surgery. Siia MarkovE, MD, Specialist in Plastic and Reconstructive Surgery. Srdjan Babovik, MD, Specialist in Plastic and Reconstructive Surgery
References Mutlmer, K. L., Banis, J. C. and Upton, J. (1987’. Microsurgical reattachment of totally amputated ears. Plastic and Reconstructive Surgery, 79,535.
Pennington, D. G., Lahn, M. F. and Pelly, A. D. (1980). Successful replantation of a completely avulsed ear by microvascular anastomosis. Plastic and Reconstructive Surgery, 65,820. &~br, D., Konstantinovi6, P. and Potpar& Z. (1981). Fresh chicken leg : an experimental model for the microsurgical beginner. British Journal of Plastic Surgery, 34,488.
Tanaka, Y. and Tajima, S. (1989). Completely successful replantation of an amputated ear by microvascular anastomosis. Plastic and Reconstructive Surgery, 84,665.
Department of Recorktructive and Plastic Surgery, University Medical Centre, MoSe Pijade 25,710OOSarajevo, Yugoslavia. Requests for reprints to Dr &Cur at the above address. Paper received 10 April 1990. Accepted 16 July 1990 after revision.