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Total reconstruction of an ear
Total Reconstruction of an Ear SIDNEY K . WYNN, M .D ., Milwaukee, Wisconsin
T
HIS is a case of a forty-seven year old pre-
cision machinist who was born with a bilateral deformity of the ears consisting of total absence of the right external ear and partial absence of the left. (Figs . I and 2 .) He sought aid after all these years because of his occupation and the fact that he found it impractical to wear glasses for his normal age visual deterioration without ears . The surgical procedure outlined will be restricted to the reconstruction of the total right ear in order to avoid confusion, although many of the bilateral reconstructive procedures were carried out simultaneously . On March 6, i95i, the seventh rib cartilage from the right chest cage was removed in the usual fashion . This rib cartilage was then carved to simulate the right ear cartilage and buried in the prepared pocket in the region of the right ear . This was sutured into position with interrupted No . 5-o silk suture and the usual pressure dressing was applied . A photograph
FIG . 2 .
FIG . I . American Journal of Surgery, Volume 94, October,
(Fig . 3) taken on March 12, 1951, just befoer the sutures were removed, illustrates this first stage . Within a period of two months time it was noted that the cartilage implant was completely absorbed and no sign of it could be found by palpation . There was no evidence of infection, and the cartilage was never removed . In view of this fact it was decided that a piece of shaped polyethylene plastic material would be used instead of the autogenous rib cartilage . On June 21, 1951, an incision was made in the area of reconstruction and a subcuticular pocket was dissected . Into this pocket a crescent-shaped polyethylene plastic support was placed . This support was made from a sheet of polyethylene that had been carved by knife and smoothed down with a dental burr . This area healed uneventfully . On November 13, 1951, the patient returned to surgery and the hair-bearing portion of the scalp skin over the buried polyethylene and
rps7
658
Total Reconstruction of an Ear
Tics . 3 to 6 .
a proper bed for the skin graft . At the same operation a semi-circular incision was made in the region where the right ear lobe should be, and this was elevated as a U-shaped flap about one-fourth larger than an ordinary ear lobe to allow for shrinkage . Another part of the splitthickness skin graft which was taken from the right chest was sutured into position to back this flap and complete reconstruction of the ear lobe . The skin graft was also used to cover the defect produced on the neck by elevation of the flap . The pressure dressing was sutured into position . A photograph (Fig . 4) taken at the office eight clays postoperatively shows the
immediate postauricular region was dissected out. A thin layer of tissue was left immediately over the polyethylene . With a Padgett dermatome, a split-thickness skin graft was taken from the upper region of the right chest for better skin color match . This graft was sutured into position to cover the defect produced in order to replace the hairy skin with non-hairbearing skin in this location . Before this graft was sutured in place, a small piece of the posterior polyethylene implant was found protruding . This portion was removed and tissue sutured over the remaining implant with continuous No . 4-0 plain catgut in order to produce 659
Wynn
Fic . 7 .
F G. 8
FIG . 10 .
FIG . 9 .
FIG . 11 .
skin graft and reconstructed ear lobe in position . On January 7, 1952, bilateral supraclavicular neck tubes were elevated for later use as the helix of each ear . A photograph (Fig . 5) taken ten days postoperatively shows these healed bilateral neck tubes in position . The medial end of the right neck pedicle was string-constricted ten minutes the first day, twenty minutes the second day, forty minutes the third day, sixty minutes the fourth day and
two hours the fifth day immediately preceding the next surgical procedure . On February 8, 1952, the medial end of the tube pedicle was detached and the pedicle brought up into position just above the reconstructed ear lobe of the right ear . A photograph (Fig . 6) taken on February 27, 1952, illustrates the string tying of the lower end of the pedicle in preparation for advancement of the pedicle toward the ear. On February 29, 1952, the lower end of the 66o
Total Reconstruction of an Ear
Fis . 12 .
pedicle was advanced and sutured to the proposed upper helix area . On May 7, 1972, the tube pedicle healed in position on the right ear area . (Fig . 7 .) On that same date in the office, with the patient under local anesthesia, an incision was made in the reconstructed part of the right ear corresponding to the position of the anterior helix . Anterior to this incision the deep fat was dissected out toward the ear canal in order to reconstruct what might appear to be a concha and to help enlarge the external auditory meatus . Another triangle of fat was dissected out between where the anterior crus and the posterior crus of the antihelix should be . Closure of these incisions was done with interrupted No . 5-o plastic suture and a pressure dressing applied to the entire area. A photograph (Fig. 8) taken on May 24, 1952, shows the results of this surgical procedure . On June 6, 1952, the patient returned to the hospital and the previously reconstructed right ear was elevated off the postauricular region . The tube pedicle in its posterior portion was elevated and grooved in its undersurface . The implanted polyethylene was slipped into this groove to give support to the reconstructed ear . A continuous No . 5-o chromic catgut suture was used to attach the posterior grooved tube pedicle to the center of the encapsulated fibrous polyethylene crescent . A split-thickness skin graft was taken from the left chest and used to
FIG . 13,
cover the defect produced in the reconstructed right postauricular region . This was sutured into position with interrupted and continuous No . 5-o plastic suture and held thereto with Kerr dental modeling compound . A small nasal speculum was used in the rudimentary right external ear canal for stretching and exposure in order to open the canal farther . A curved incision was made down the canal while stretching it open . A modeling compound mold was placed in the canal covered by a split-thickness skin graft to cover all raw surfaces produced . A turban type pressure dressing was applied to the entire area . A photograph (Fig. g) taken eight days postoperatively shows the patient at the time of the initial dressing after this procedure . The modeling compound mold used in the postauricular area and also the mold used within the ear canal are demonstrated . On August 31, 1953, with the patient under local anesthesia, an incision was made inside the reconstructed portion of the helix of the right ear and a piece of dissected polyethylene was inserted in the pocket of the helix in an attempt to give better support to the helix on 661
Wynn
F1c. 14 .
Fmc. 15 .
the right side . Closure of this incision was made with interrupted No. 4-o dermalon suture . On November 16, 1953, it was decided that the ear had shrunk to the point that it was too small and additional tissue should be added . With the patient under local anesthesia a pedicle was elevated in the right upper neck region . Unfortunately, no photograph is available of this procedure and a diagram (Fig . io) is substituted to illustrate the pedicle that was elevated . On January 15, 1954, the lower end of this pedicle was detached and attached to the posterior right ear area . This was sutured into position with interrupted No . 4-o dermalon . (Fig. 11 .) In March, 1954, the remaining neck attachment of this pedicle was detached and brought to a new attachment just below the anterior upper attachment of the first pedicle . A photograph (Fig. 12) taken on August 7, 1954, illustrates the one pedicle inside of the other . On August 30, 1954, the upper end of the inner pedicle was detached about inch below its upper attachment . The upper portion of this pedicle was freed toward its attachment area and moved anteriorly to an incision made in the anterior portion of the helix . The lower portion of the pedicle was freed toward the lower attachment and sutured to the lower portion of the outer pedicle which was advanced cephalad and anteriorly . This enlarged
Fin. i6 .
the car. All incisions were sutured with interrupted No . 4-o dermalon suture . (Fig . 13 .) This completed the surgery on the right ear . Final photographs (Figs . 14 to 16) were taken on December 4, 1954, to illustrate the final appearance of the patient with and without glasses which he now is able to wear . CONCLUSION
This was a case of necessity in reconstruction of ears so that the patient could wear his glasses without the use of adhesive tape and would have a better cosmetic appearance . The case illustrates not only the multiple steps necessary for the total reconstruction of an car but also the fact that a better looking ear can be reconstructed if tube pedicles are used (one from the lower neck and one from the upper neck) in order to supply enough tissue following sufficient time for shrinkage . The case also illustrates the fact that polyethylene plastic material may have to be used at times, in spite of the fact that I never like to use foreign material for support, as this patient absorbed his own cartilage . The photographic record of this case illustrates the transition from atresia to total reconstruction of an ear . With the aid of glasses the patient is able to continue his work as a precision machinist and is also extremely pleased with the cosmetic result .
3
2
T
HIS is a case of a forty-seven year old pre-
cision machinist who was born with a bilateral deformity of the ears consisting of total absence of the right external ear and partial absence of the left. (Figs . I and 2 .) He sought aid after all these years because of his occupation and the fact that he found it impractical to wear glasses for his normal age visual deterioration without ears . The surgical procedure outlined will be restricted to the reconstruction of the total right ear in order to avoid confusion, although many of the bilateral reconstructive procedures were carried out simultaneously . On March 6, i95i, the seventh rib cartilage from the right chest cage was removed in the usual fashion . This rib cartilage was then carved to simulate the right ear cartilage and buried in the prepared pocket in the region of the right ear . This was sutured into position with interrupted No . 5-o silk suture and the usual pressure dressing was applied . A photograph
FIG . 2 .
FIG . I . American Journal of Surgery, Volume 94, October,
(Fig . 3) taken on March 12, 1951, just befoer the sutures were removed, illustrates this first stage . Within a period of two months time it was noted that the cartilage implant was completely absorbed and no sign of it could be found by palpation . There was no evidence of infection, and the cartilage was never removed . In view of this fact it was decided that a piece of shaped polyethylene plastic material would be used instead of the autogenous rib cartilage . On June 21, 1951, an incision was made in the area of reconstruction and a subcuticular pocket was dissected . Into this pocket a crescent-shaped polyethylene plastic support was placed . This support was made from a sheet of polyethylene that had been carved by knife and smoothed down with a dental burr . This area healed uneventfully . On November 13, 1951, the patient returned to surgery and the hair-bearing portion of the scalp skin over the buried polyethylene and
rps7
658
Total Reconstruction of an Ear
Tics . 3 to 6 .
a proper bed for the skin graft . At the same operation a semi-circular incision was made in the region where the right ear lobe should be, and this was elevated as a U-shaped flap about one-fourth larger than an ordinary ear lobe to allow for shrinkage . Another part of the splitthickness skin graft which was taken from the right chest was sutured into position to back this flap and complete reconstruction of the ear lobe . The skin graft was also used to cover the defect produced on the neck by elevation of the flap . The pressure dressing was sutured into position . A photograph (Fig . 4) taken at the office eight clays postoperatively shows the
immediate postauricular region was dissected out. A thin layer of tissue was left immediately over the polyethylene . With a Padgett dermatome, a split-thickness skin graft was taken from the upper region of the right chest for better skin color match . This graft was sutured into position to cover the defect produced in order to replace the hairy skin with non-hairbearing skin in this location . Before this graft was sutured in place, a small piece of the posterior polyethylene implant was found protruding . This portion was removed and tissue sutured over the remaining implant with continuous No . 4-0 plain catgut in order to produce 659
Wynn
Fic . 7 .
F G. 8
FIG . 10 .
FIG . 9 .
FIG . 11 .
skin graft and reconstructed ear lobe in position . On January 7, 1952, bilateral supraclavicular neck tubes were elevated for later use as the helix of each ear . A photograph (Fig . 5) taken ten days postoperatively shows these healed bilateral neck tubes in position . The medial end of the right neck pedicle was string-constricted ten minutes the first day, twenty minutes the second day, forty minutes the third day, sixty minutes the fourth day and
two hours the fifth day immediately preceding the next surgical procedure . On February 8, 1952, the medial end of the tube pedicle was detached and the pedicle brought up into position just above the reconstructed ear lobe of the right ear . A photograph (Fig . 6) taken on February 27, 1952, illustrates the string tying of the lower end of the pedicle in preparation for advancement of the pedicle toward the ear. On February 29, 1952, the lower end of the 66o
Total Reconstruction of an Ear
Fis . 12 .
pedicle was advanced and sutured to the proposed upper helix area . On May 7, 1972, the tube pedicle healed in position on the right ear area . (Fig . 7 .) On that same date in the office, with the patient under local anesthesia, an incision was made in the reconstructed part of the right ear corresponding to the position of the anterior helix . Anterior to this incision the deep fat was dissected out toward the ear canal in order to reconstruct what might appear to be a concha and to help enlarge the external auditory meatus . Another triangle of fat was dissected out between where the anterior crus and the posterior crus of the antihelix should be . Closure of these incisions was done with interrupted No . 5-o plastic suture and a pressure dressing applied to the entire area. A photograph (Fig. 8) taken on May 24, 1952, shows the results of this surgical procedure . On June 6, 1952, the patient returned to the hospital and the previously reconstructed right ear was elevated off the postauricular region . The tube pedicle in its posterior portion was elevated and grooved in its undersurface . The implanted polyethylene was slipped into this groove to give support to the reconstructed ear . A continuous No . 5-o chromic catgut suture was used to attach the posterior grooved tube pedicle to the center of the encapsulated fibrous polyethylene crescent . A split-thickness skin graft was taken from the left chest and used to
FIG . 13,
cover the defect produced in the reconstructed right postauricular region . This was sutured into position with interrupted and continuous No . 5-o plastic suture and held thereto with Kerr dental modeling compound . A small nasal speculum was used in the rudimentary right external ear canal for stretching and exposure in order to open the canal farther . A curved incision was made down the canal while stretching it open . A modeling compound mold was placed in the canal covered by a split-thickness skin graft to cover all raw surfaces produced . A turban type pressure dressing was applied to the entire area . A photograph (Fig. g) taken eight days postoperatively shows the patient at the time of the initial dressing after this procedure . The modeling compound mold used in the postauricular area and also the mold used within the ear canal are demonstrated . On August 31, 1953, with the patient under local anesthesia, an incision was made inside the reconstructed portion of the helix of the right ear and a piece of dissected polyethylene was inserted in the pocket of the helix in an attempt to give better support to the helix on 661
Wynn
F1c. 14 .
Fmc. 15 .
the right side . Closure of this incision was made with interrupted No. 4-o dermalon suture . On November 16, 1953, it was decided that the ear had shrunk to the point that it was too small and additional tissue should be added . With the patient under local anesthesia a pedicle was elevated in the right upper neck region . Unfortunately, no photograph is available of this procedure and a diagram (Fig . io) is substituted to illustrate the pedicle that was elevated . On January 15, 1954, the lower end of this pedicle was detached and attached to the posterior right ear area . This was sutured into position with interrupted No . 4-o dermalon . (Fig. 11 .) In March, 1954, the remaining neck attachment of this pedicle was detached and brought to a new attachment just below the anterior upper attachment of the first pedicle . A photograph (Fig. 12) taken on August 7, 1954, illustrates the one pedicle inside of the other . On August 30, 1954, the upper end of the inner pedicle was detached about inch below its upper attachment . The upper portion of this pedicle was freed toward its attachment area and moved anteriorly to an incision made in the anterior portion of the helix . The lower portion of the pedicle was freed toward the lower attachment and sutured to the lower portion of the outer pedicle which was advanced cephalad and anteriorly . This enlarged
Fin. i6 .
the car. All incisions were sutured with interrupted No . 4-o dermalon suture . (Fig . 13 .) This completed the surgery on the right ear . Final photographs (Figs . 14 to 16) were taken on December 4, 1954, to illustrate the final appearance of the patient with and without glasses which he now is able to wear . CONCLUSION
This was a case of necessity in reconstruction of ears so that the patient could wear his glasses without the use of adhesive tape and would have a better cosmetic appearance . The case illustrates not only the multiple steps necessary for the total reconstruction of an car but also the fact that a better looking ear can be reconstructed if tube pedicles are used (one from the lower neck and one from the upper neck) in order to supply enough tissue following sufficient time for shrinkage . The case also illustrates the fact that polyethylene plastic material may have to be used at times, in spite of the fact that I never like to use foreign material for support, as this patient absorbed his own cartilage . The photographic record of this case illustrates the transition from atresia to total reconstruction of an ear . With the aid of glasses the patient is able to continue his work as a precision machinist and is also extremely pleased with the cosmetic result .
3
2