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Replantation of an avulsed ear, using a single arterial anastamosis
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 326e329
CASE REPORT
Replantation of an avulsed ear, using a single arterial anastamosis G. O’Toole*, K. Bhatti, S. Masood Salisbury District General Hospital, Odstock Road, Salisbury, UK Received 1 December 2006; accepted 14 September 2007
KEYWORDS Ear; Avulsion; Replantation
Summary Avulsion of the ear is relatively uncommon and replantation a technical challenge. A case in which an avulsed ear was successfully replanted using a single arterial anastamosis is described. The surgical difficulties encountered, the pharmaceutical approach to postoperative care and the problems which resulted from the lack of venous drainage are discussed. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A 60-year-old gentleman, fit and well and a non-smoker, suffered an injury on the golf course in which the entire right ear except the lobe was avulsed (Fig. 1). While driving a golf buggy on wet grass, the vehicle slipped down an incline and rolled over into a bunker. The patient went under the buggy as it rolled and the ear was avulsed. No other significant injury was sustained. While the patient was being assessed in the accident and emergency department, the avulsed part was taken to the operating theatre and examined under loupe magnification (Fig. 2). It was cleaned of sand and foreign matter and a minimal excision of the edge of the skin and cartilage performed. A small posterior auricular artery was identified on
* Corresponding author. Address: 1 Eastcote View, Pinner, Middlesex HA5 1AT, UK. E-mail address: [email protected] (G. O’Toole).
the ear, but no vein could be seen. Four hours following the trauma, the patient was anaesthetised and the attempt to replant the ear was begun by a single surgeon (GO). The posterior auricular artery on the scalp side was found to be of good quality, although rather small. The skin of the ear was therefore re-attached along its anterior border and cartilage sutures placed deeply to secure it in good position. The ear was then reflected forward such that the posterior auriclar artery ends remained apposed and in a normal anatomical position. An arterial anastamosis using 10/0 nylon was completed 2 h into the procedure (6 h post trauma) and ran well for 30 min before becoming obstructed with clot. The anastamosis was therefore excised, shortening the vessels by around 2 mm and the repair repeated. Unfortunately the result was the same; good flow for half an hour followed by clot formation at the anastamosis. A third repair was performed after having shortened the vessels by a further 3 mm as it was considered possible that intimal damage within the zone of trauma was precluding
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.09.017
Replantation of an avulsed ear
Figure 1
The injury at presentation.
good flow. This made the repair more difficult as the ear could not be reflected forward on itself as much as it had been previously. Verapamil and phenoxybenzamine were applied directly to the vessels to correct spasm, and heparin was used to flush the vessel ends’ lumens during their repair. Soon after the anastamosis, an i.v. heparin infusion
Figure 2
The avulsed ear.
327 was started. Since no venous repair was possible, 5000 units of heparin were injected into the ear itself and incisions made in the posterior surface of the ear to allow for bleeding. On this the third attempt at revascularisation of the ear, the repaired vessel did not clot and the ear remained well perfused (Fig. 3). The total operation time was 6 h. The first seven postoperative days proceeded without incident. Systemic heparinisation was continued throughout this period and aspirin (150 mg) taken daily. Leeches were used, continuously at first, but with decreasing frequency as the week passed. Ciprofloxacin was prescribed to reduce the risk of Aeromonas infection from leech use. The incisions made in the postauricular skin were wiped regularly with heparin to prevent clot formation and on three occasions low molecular weight heparin was injected subcutaneously into the ear. These therapies resulted in continuous slow bleeding from the ear as a replacement to venous drainage while venous revascularisation was considered to be occurring. During this first week, the ear remained well vascularised and venous congestion controlled (Fig. 4). Blood transfusions were required to maintain a satisfactory haemoglobin level, but a degree of haemodilution was allowed as it was thought that this would reduce blood viscosity and maintain good flow to the ear. On day eight, bleeding from the ear was excessive despite satisfactory activated partial thromboplastin time (APTT) levels. With high dependency nursing and medical care being unavailable the heavy bleeding and subsequent anaemia and hypovolaemia became difficult to control. The heparin was therefore stopped perhaps more abruptly than would have been preferred. Within 3 h this led to significant venous congestion of the ear (Fig. 5) and subsequent necrosis of a small area of helical rim and postauricular skin
Figure 3
The ear at day three.
328
G. O’Toole et al.
Figure 6 Figure 4
Necrosis of the helical rim, day 12.
Day seven.
(Fig. 6). Leeches were used with decreasing frequency until day 12 by which time the congestion had resolved. On day 21 a minor procedure to excise a small amount of conchal cartilage and postauricular skin was performed. At this time the patient remained on daily aspirin treatment.
He was advised not to spend long periods outside particularly in cold weather. The patient was reviewed regularly in the outpatients department. By six weeks the swelling had settled entirely and the patient stopped taking aspirin. The defect of the superior part of the helical rim and another at the junction of the lobe with the helical rim, resulted in minor cosmetic deformities which could be left untreated, however it is likely that the patient will elect to undergo a minor reconstruction procedure in due course (Fig. 7).
Discussion
Figure 5 Venous congestion, after abrupt cessation of heparin therapy, day eight.
While the elastic and pliant nature of auricular cartilage confers to the ear a capacity for strength and resilience in minor trauma, its anatomical position renders it exposed to avulsion or sharp amputation when subjected to more significant insults. As Gibson described in 1967, in his article entitled ‘Early free grafting: The restitution of parts completely separated from the body’,1 there can have been no lack of clinical material in the days when wars were fought with sharp steel. And while some successes may have been widely reported, Gibson points out that nearly all the early surgical writers mentioned such ear composite grafts, only to condemn them as impossible. Perhaps the earliest case report of a successful ear graft, of which Gibson reminds us, pertains to that of a 14-year-old boy whose ear and occipital scalp were bitten off by a horse in 1898. It is likely, of course, that with such an injury the extensive surface area provided by the scalp avulsion on its re-application allowed for the requisite revascularisation for ‘take’ of the whole composite graft. As such it differs from an avulsion of the ear alone. In more recent times, ‘banking’ of avulsed auricular cartilage in a subcutaneous pocket has been advocated.2
Replantation of an avulsed ear
Figure 7
Six weeks post revascularisation.
However this can lead to significant resorption and distortion of the cartilage and often poor cosmesis results. In cases in which microvascular anastamoses are not possible, ‘banking’ of auricular cartilage has been superseded by reconstruction with costal cartilage, where the expertise to perform this complex surgery is available. The first successful ear replantation using microvascular anastamoses of artery and vein was reported by Pennington in 1980.3 While several other similar cases have been reported since, it is not a common procedure. This is perhaps because the ear is often avulsed in road traffic accidents or bitten off in altercations rather than being sharply amputated. The vessels are thus severely damaged and unsuitable for repair. In sharp amputations in which the vessels are of good quality the anastamosis is made more difficult by the compromised access to the posterior auricular vessels. However with the patient and microscope positioned well and optimal access achieved vascular repair is made possible. While in the majority of cases reported in the literature arterial and venous anastamoses are performed, in the case described in this article, only a single arterial anastamosis was possible. Replantation without venous anastamosis has been described previously and successful cases reported.4 The lack of a venous anastamosis necessitates an alternative to venous drainage while venous
329 revascularisation occurs over the first few days. Leeches are commonly used to prevent venous congestion and were considered effective in the patient described. The use of leeches must be combined with antibiosis because of the risk of Aeromonas infection. Systemic heparin has been demonstrated in animal studies of ear replantation to be effective5 and anecdotally in case reports6 and was used in our patient. In combination, the strategies used to replace venous drainage, as new venous channels form, may lead to continuous heavy bleeding from the ear, the significance of which cannot be understated. These patients require very close monitoring of haemodynamics and haemoglobin levels. The requirement for sometimes massive transfusions while heparinisation continues makes careful monitoring of clotting function obligatory. Stopping heparinisation abruptly in the case described, led to rapidly evident venous obstruction and subsequent loss of a small area of skin on the helical rim which required surgical debridement to allow for uncomplicated healing. The necessity for heparinisation and haemodilution has been described before. In one reported case, the ear appeared dependent on heparin and venous congestion led to loss of the ear when the heparin was stopped.6 It would perhaps have been preferable in the case described in this article if the systemic heparin therapy had been more gradually reduced, but uncontrolled bleeding from the ear, despite well controlled APTT levels, necessitated a more abrupt cessation. In conclusion, successful replantation of an avulsed ear is described. Using the principles applied to free tissue transfer, in units in which microvascular surgery is performed regularly, ear replantation is possible even with a single arterial anastamosis. In cases in which venous repair is not performed, the dangers of leeches and heparinisation cannot be understated.
References 1. Gibson T. Early free grafting: the restitution of parts completely separated from the body. Br J Plast Surg 1965;18:1e11. 2. Musgrave RH, Garrett Jr WS. Management of avulsion injuries of the external ear. Plast Reconstr Surg 1967;40:534e9. 3. Pennington DG, Lai MF, Pelly AD. Successful replantation of a completely avulsed ear by microvascular anastamosis. Plast Reconstr Surg 1980;65:820e3. 4. Safan T, Ozcan G, Kecik A, et al. Microvascular ear replantation with no vein anastamosis. Plast Reconstr Surg 1993;92:945e8. 5. Vastlou C, Scott-Earle A. Intra-operative heparin in replantation surgery e an experimental study. Ann Plast Surg 1983;10: 112e4. 6. Katsaros J, Tan E, Sheen R. Microvascular ear replantation. Br J Plast Surg 1988;41:496e9.
CASE REPORT
Replantation of an avulsed ear, using a single arterial anastamosis G. O’Toole*, K. Bhatti, S. Masood Salisbury District General Hospital, Odstock Road, Salisbury, UK Received 1 December 2006; accepted 14 September 2007
KEYWORDS Ear; Avulsion; Replantation
Summary Avulsion of the ear is relatively uncommon and replantation a technical challenge. A case in which an avulsed ear was successfully replanted using a single arterial anastamosis is described. The surgical difficulties encountered, the pharmaceutical approach to postoperative care and the problems which resulted from the lack of venous drainage are discussed. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A 60-year-old gentleman, fit and well and a non-smoker, suffered an injury on the golf course in which the entire right ear except the lobe was avulsed (Fig. 1). While driving a golf buggy on wet grass, the vehicle slipped down an incline and rolled over into a bunker. The patient went under the buggy as it rolled and the ear was avulsed. No other significant injury was sustained. While the patient was being assessed in the accident and emergency department, the avulsed part was taken to the operating theatre and examined under loupe magnification (Fig. 2). It was cleaned of sand and foreign matter and a minimal excision of the edge of the skin and cartilage performed. A small posterior auricular artery was identified on
* Corresponding author. Address: 1 Eastcote View, Pinner, Middlesex HA5 1AT, UK. E-mail address: [email protected] (G. O’Toole).
the ear, but no vein could be seen. Four hours following the trauma, the patient was anaesthetised and the attempt to replant the ear was begun by a single surgeon (GO). The posterior auricular artery on the scalp side was found to be of good quality, although rather small. The skin of the ear was therefore re-attached along its anterior border and cartilage sutures placed deeply to secure it in good position. The ear was then reflected forward such that the posterior auriclar artery ends remained apposed and in a normal anatomical position. An arterial anastamosis using 10/0 nylon was completed 2 h into the procedure (6 h post trauma) and ran well for 30 min before becoming obstructed with clot. The anastamosis was therefore excised, shortening the vessels by around 2 mm and the repair repeated. Unfortunately the result was the same; good flow for half an hour followed by clot formation at the anastamosis. A third repair was performed after having shortened the vessels by a further 3 mm as it was considered possible that intimal damage within the zone of trauma was precluding
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.09.017
Replantation of an avulsed ear
Figure 1
The injury at presentation.
good flow. This made the repair more difficult as the ear could not be reflected forward on itself as much as it had been previously. Verapamil and phenoxybenzamine were applied directly to the vessels to correct spasm, and heparin was used to flush the vessel ends’ lumens during their repair. Soon after the anastamosis, an i.v. heparin infusion
Figure 2
The avulsed ear.
327 was started. Since no venous repair was possible, 5000 units of heparin were injected into the ear itself and incisions made in the posterior surface of the ear to allow for bleeding. On this the third attempt at revascularisation of the ear, the repaired vessel did not clot and the ear remained well perfused (Fig. 3). The total operation time was 6 h. The first seven postoperative days proceeded without incident. Systemic heparinisation was continued throughout this period and aspirin (150 mg) taken daily. Leeches were used, continuously at first, but with decreasing frequency as the week passed. Ciprofloxacin was prescribed to reduce the risk of Aeromonas infection from leech use. The incisions made in the postauricular skin were wiped regularly with heparin to prevent clot formation and on three occasions low molecular weight heparin was injected subcutaneously into the ear. These therapies resulted in continuous slow bleeding from the ear as a replacement to venous drainage while venous revascularisation was considered to be occurring. During this first week, the ear remained well vascularised and venous congestion controlled (Fig. 4). Blood transfusions were required to maintain a satisfactory haemoglobin level, but a degree of haemodilution was allowed as it was thought that this would reduce blood viscosity and maintain good flow to the ear. On day eight, bleeding from the ear was excessive despite satisfactory activated partial thromboplastin time (APTT) levels. With high dependency nursing and medical care being unavailable the heavy bleeding and subsequent anaemia and hypovolaemia became difficult to control. The heparin was therefore stopped perhaps more abruptly than would have been preferred. Within 3 h this led to significant venous congestion of the ear (Fig. 5) and subsequent necrosis of a small area of helical rim and postauricular skin
Figure 3
The ear at day three.
328
G. O’Toole et al.
Figure 6 Figure 4
Necrosis of the helical rim, day 12.
Day seven.
(Fig. 6). Leeches were used with decreasing frequency until day 12 by which time the congestion had resolved. On day 21 a minor procedure to excise a small amount of conchal cartilage and postauricular skin was performed. At this time the patient remained on daily aspirin treatment.
He was advised not to spend long periods outside particularly in cold weather. The patient was reviewed regularly in the outpatients department. By six weeks the swelling had settled entirely and the patient stopped taking aspirin. The defect of the superior part of the helical rim and another at the junction of the lobe with the helical rim, resulted in minor cosmetic deformities which could be left untreated, however it is likely that the patient will elect to undergo a minor reconstruction procedure in due course (Fig. 7).
Discussion
Figure 5 Venous congestion, after abrupt cessation of heparin therapy, day eight.
While the elastic and pliant nature of auricular cartilage confers to the ear a capacity for strength and resilience in minor trauma, its anatomical position renders it exposed to avulsion or sharp amputation when subjected to more significant insults. As Gibson described in 1967, in his article entitled ‘Early free grafting: The restitution of parts completely separated from the body’,1 there can have been no lack of clinical material in the days when wars were fought with sharp steel. And while some successes may have been widely reported, Gibson points out that nearly all the early surgical writers mentioned such ear composite grafts, only to condemn them as impossible. Perhaps the earliest case report of a successful ear graft, of which Gibson reminds us, pertains to that of a 14-year-old boy whose ear and occipital scalp were bitten off by a horse in 1898. It is likely, of course, that with such an injury the extensive surface area provided by the scalp avulsion on its re-application allowed for the requisite revascularisation for ‘take’ of the whole composite graft. As such it differs from an avulsion of the ear alone. In more recent times, ‘banking’ of avulsed auricular cartilage in a subcutaneous pocket has been advocated.2
Replantation of an avulsed ear
Figure 7
Six weeks post revascularisation.
However this can lead to significant resorption and distortion of the cartilage and often poor cosmesis results. In cases in which microvascular anastamoses are not possible, ‘banking’ of auricular cartilage has been superseded by reconstruction with costal cartilage, where the expertise to perform this complex surgery is available. The first successful ear replantation using microvascular anastamoses of artery and vein was reported by Pennington in 1980.3 While several other similar cases have been reported since, it is not a common procedure. This is perhaps because the ear is often avulsed in road traffic accidents or bitten off in altercations rather than being sharply amputated. The vessels are thus severely damaged and unsuitable for repair. In sharp amputations in which the vessels are of good quality the anastamosis is made more difficult by the compromised access to the posterior auricular vessels. However with the patient and microscope positioned well and optimal access achieved vascular repair is made possible. While in the majority of cases reported in the literature arterial and venous anastamoses are performed, in the case described in this article, only a single arterial anastamosis was possible. Replantation without venous anastamosis has been described previously and successful cases reported.4 The lack of a venous anastamosis necessitates an alternative to venous drainage while venous
329 revascularisation occurs over the first few days. Leeches are commonly used to prevent venous congestion and were considered effective in the patient described. The use of leeches must be combined with antibiosis because of the risk of Aeromonas infection. Systemic heparin has been demonstrated in animal studies of ear replantation to be effective5 and anecdotally in case reports6 and was used in our patient. In combination, the strategies used to replace venous drainage, as new venous channels form, may lead to continuous heavy bleeding from the ear, the significance of which cannot be understated. These patients require very close monitoring of haemodynamics and haemoglobin levels. The requirement for sometimes massive transfusions while heparinisation continues makes careful monitoring of clotting function obligatory. Stopping heparinisation abruptly in the case described, led to rapidly evident venous obstruction and subsequent loss of a small area of skin on the helical rim which required surgical debridement to allow for uncomplicated healing. The necessity for heparinisation and haemodilution has been described before. In one reported case, the ear appeared dependent on heparin and venous congestion led to loss of the ear when the heparin was stopped.6 It would perhaps have been preferable in the case described in this article if the systemic heparin therapy had been more gradually reduced, but uncontrolled bleeding from the ear, despite well controlled APTT levels, necessitated a more abrupt cessation. In conclusion, successful replantation of an avulsed ear is described. Using the principles applied to free tissue transfer, in units in which microvascular surgery is performed regularly, ear replantation is possible even with a single arterial anastamosis. In cases in which venous repair is not performed, the dangers of leeches and heparinisation cannot be understated.
References 1. Gibson T. Early free grafting: the restitution of parts completely separated from the body. Br J Plast Surg 1965;18:1e11. 2. Musgrave RH, Garrett Jr WS. Management of avulsion injuries of the external ear. Plast Reconstr Surg 1967;40:534e9. 3. Pennington DG, Lai MF, Pelly AD. Successful replantation of a completely avulsed ear by microvascular anastamosis. Plast Reconstr Surg 1980;65:820e3. 4. Safan T, Ozcan G, Kecik A, et al. Microvascular ear replantation with no vein anastamosis. Plast Reconstr Surg 1993;92:945e8. 5. Vastlou C, Scott-Earle A. Intra-operative heparin in replantation surgery e an experimental study. Ann Plast Surg 1983;10: 112e4. 6. Katsaros J, Tan E, Sheen R. Microvascular ear replantation. Br J Plast Surg 1988;41:496e9.