Reconstruction of a large defect of the ear using a composite graft following a human bite injury

Auricular avulsion injuries: Literature review and management algorithm

Traumatic ear avulsion (TEA) may have tremendous psychological consequences if not managed properly. There are no clear guidelines on the surgical management of these injuries, especially in developing countries where microsurgical facilities are lacking. We aimed to review the literature on surgical management of TEA with the main focus on direct re-attachment (DR) so as to develop a surgical management algorithm that can be applied in the absence of microsurgical facilities. We performed an extensive review of the relevant English literature on papers indexed in PubMed describing TEA repaired with DR without restriction to a specific publication time window. A total of 28 cases in 18 publications were reviewed and analyzed. Our results indicate that in the acute setting with no available microvascular expertise, DR of auricular avulsion injuries can be better than other nonmicrosurgical techniques in generating good esthetic results, especially in incomplete auricular avulsion and small segment avulsion. The operative approach depends on the clinical setting. DR of the auricular avulsion injuries is an accepted approach. It produces good cosmetic outcomes while preserving the auricular area for future reconstruction in case of re-attachment failure.

Auricular avulsion injuries and reattachment techniques: A systematic review

OBJECTIVES

Multiple surgical techniques exist in the acute management of auricular avulsion injuries, including reattachment of the tissue as a composite graft, reconstruction using local skin flaps, the pocket principle, the Baudet method, and microvascular repair. This review aimed to compare the success rates of reattachment methods in auricular avulsion injuries.

METHODS

A PubMed search systematically identified cases in which (a) an auricular avulsion injury occurred and (b) reattachment was attempted. Search results were combined with an extensive review of references from published studies. In total, 148 cases were identified. Three reviewers independently graded the final aesthetic result of each case using a 5-point scale. The average grade of each repair was compared to the reattachment method to identify successful techniques.

RESULTS

Microvascular repair was associated with a statistically significant higher success rate compared to all other reattachment methods. Composite graft reattachment also tended to generate better final aesthetic outcomes, but this difference was not statistically significant.

CONCLUSION

Microvascular repair of the avulsed segment consistently demonstrated higher success rates. Composite graft reattachment should also be considered under the right circumstances. Overall, microvascular repair and composite graft reattachment should be considered the best options in cases of auricular avulsion repair. The authors share a major concern that other methods that rely on the use of periauricular skin will compromise any future attempts for secondary reconstruction, such as staged procedures using costal cartilage grafts. Manipulation of these tissues and in particular burying of the avulsed ear cartilage is discouraged.

LEVEL OF EVIDENCE

4.

Replantation in trauma

Following the first successful digital replant in 1968, replantation after traumatic amputation of the upper limb has become the norm in carefully selected patients. With good communication between the receiving emergency department and microsurgical team, the correct patients can be given appropriate priority and managed smoothly through their complex treatment. This article reviews the indications, initial management, surgical techniques, complications and the ex pected outcomes for upper limb replantation. This will help the nonmicrosurgeon explain to patients who have had an amputation the process of replantation and what they might expect after transfer to the microsurgical team, and it gives an overview of replantation for junior trainee microsurgeons.

Avulsion of the auricle in an anticoagulated patient: is leeching contraindicated? A review and a case

Amputation of the auricle is a periodic occurrence leading to disfigurement if not treated properly. Venous stasis is a common complication in reattachments and requires decongestant and anticoagulant treatment. Today, leech therapy is the treatment of choice. Common problems are that it is not available everywhere and that it is usually contraindicated in anticoagulated patients. The peculiarities of leech therapy and the various aspects of surgical management are reviewed. A case of a partial amputation of the auricle in a patient under concomitant anticoagulation therapy with warfarin is presented. The amputated part was reattached in another hospital without microvascular anastomosis. The patient presented to our department with early signs of venous congestion. Leech therapy was started 35 hours after trauma, and the patient continued his anticoagulation therapy. With this treatment, 90% of the amputated part was rescued. The anticoagulation therapy of the patient may have played an important role in the first hours after reattachment, preventing capillary thrombosis and in consequence facilitating the minimal oxygenation necessary. The claim that anticoagulation therapy is a contraindication to leeching should be questioned in cases of reattachments in well-controllable locations without arterial anastomosis.

Totally avulsed ear: new technique of immediate ear reconstruction

INTRODUCTION

Reconstruction of the avulsed auricle remains a challenge to the plastic surgeon. Many surgeons suggest reattachment of the total or subtotal amputated ear as a composite graft, but this solution is unreliable. Some surgeons advocate the use of the retro auricular pocket to enhance survival of the reattached ear. However, this burying method entails multistage procedures with somewhat poor results due to the associated fibrosis. Microsurgical replantation can be performed but its applicability is limited due to difficulty with venous drainage. In this paper we advocate the use of a technique of total ear reconstruction using the cartilage of the avulsed ear in a single stage.

PATIENTS

Three patients with a mean age of 36 years, all of whom were heavy smokers, were operated upon between February 2006 and January 2007. Surgery involved removal of the skin of the amputated ear and immediate reattachment. The ear cartilage was then, immediately covered with an ipsilateral temporoparietal fascia flap and a split thickness skin graft.

RESULTS

Acceptable aesthetic results were obtained in all three cases. A minor complication of limited skin graft loss occurred in one case.

CONCLUSION

Our technique is simple, one stage and maintains the delicate detail of the auricular cartilage.

[Optimal result after ear reconstruction following a dog bite injury]

A case of a young woman is reported who lost a big part of the right auricle by a dog bite. An aesthetically satisfying immediate reconstruction after refixation of the deep-ithelialised amputated helical rim could be achieved with the aid of a temporal fascial island flap and full thickness skin grafts.

Management of human bites of the face in Enugu, Nigeria

BACKGROUND

Human bites of the face present to the surgeon sometimes with a dilemma as to the method and timing of surgery. Often patients present with soft tissue defects as a result of the injury sustained. Reconstruction therefore becomes absolutely necessary to avoid psychosocial complications.

OBJECTIVES

The aim of this paper is to review human bites of the face, which presented to the Plastic Surgery Department of the National Orthopaedic Hospital, Enugu, Nigeria over a 10-year period and highlight the epidemiology, presentation, management and its outcome.

METHODS

A retrospective review of the cases of human bites of the face that presented within a ten year period was carried out. Sources of information were the case notes and operation registers. Information obtained includes age, gender of the patients as well as that of the assailants and the relationship of the assailants to the patients. Sites of the injuries, management and outcome were also obtained.

RESULTS

There were 54 patients seen and treated during the period with the age range 16-54 years (Mean age, 33.8+/-2.3). The male to female ratio was 1:1.6. Various surgical procedures including wedge excision and direct closure (for the lip); midline forehead flap cover, composite auricular graft and nasolabial flaps (for the nose) were carried out. Three of the 9 noses bitten were skin grafted and 3 had primary direct closure. Few complications occurred.

CONCLUSION

We conclude that human bites still remain common in our environment. These sometimes need reconstruction due to loss of parts. Minimal debridement with primary closure/reconstruction of human bites of the face; when presented early, gives a good result.

A Comparison of Ear Reattachment Methods: A Review of 25 Years since Pennington

BACKGROUND

A failed ear reattachment tends to complicate subsequent reconstruction with autogenous rib cartilage. The various reattachment methods differ in technical demand, in the secondary damage of periauricular tissue, and in aesthetic outcome. In the past 25 years, the microsurgical method has proven to be especially successful. The aim of this work was to assess case reports of auricular trauma since the first microsurgical ear replantation by Pennington.

METHODS

An extensive review of the literature of acute ear trauma published between 1980 and 2004 was performed. For a better comparison, the type of damage, the reattachment technique, and the final outcome were categorized. Representative cases of traumatic auricular lesions, which were reconstructed with rib or conchal cartilage at the authors' hospital, were included.

RESULTS

Seventy-four cases in 56 publications were analyzed. The microsurgical replantation showed excellent aesthetic results but demanded an intensive perioperative and postoperative treatment. Pocket methods were used mainly in partial amputations. Repairs with periauricular tissue flaps made a quite inconsistent impression. Direct reattachments, such as composite grafts, were indicated only in extended lacerations.

CONCLUSIONS

To replant an avulsed auricle is still a challenge for surgeons. Microsurgically reanastomosed ear replantation appears to be the best method because a superior outcome can be achieved without jeopardizing a subsequent ear reconstruction with rib cartilage in case of failure. The pocket method and periauricular skin or fascia flaps should be abandoned. They rarely achieve such a consistently good aesthetic outcome as a secondary reconstruction with rib cartilage.