Replantation of part of an ear as an open fan composite graft

Near-Total Ear Avulsion Repaired With Primary Closure and Hyperbaric Oxygen: A Case Series and Review of the Literature

INTRODUCTION

Near-total ear avulsion is a rare and challenging problem to repair with many techniques described; primary repair is an attractive option but is not always successful. Healing may be augmented with postoperative hyperbaric oxygen therapy (HBOT), but this technique is under-reported, and an ideal regimen is not known. The study objective is to discuss the role of HBOT in the management of ear avulsion by reviewing 2 unique cases.

METHODS

Case report and review of the literature. A Pubmed search using the terms ear avulsion and postoperative hyperbaric oxygen was performed.

RESULTS

Two pediatric patients presented with near-total avulsion of the auricle after suffering a dog bite. Various management options were discussed including observation, primary repair, post-auricular cartilage banking, graft reconstruction with periauricular tissue or rib cartilage, or microsurgical replantation. The decision was made to perform primary reattachment, followed by adjuvant hyperbaric oxygen therapy (HBOT). The patients achieved favorable esthetic results and continue to maintain the function of the reattached ear. Photo documentation was obtained throughout the process.

DISCUSSION

There is no consensus on the management of near-total ear avulsion. Primary repair is ideal from a cosmetic and ease-of-operation standpoint but does not always yield viable tissue. The use of postoperative HBOT is an attractive option that may boost success rates, but the ideal HBOT regimen is unknown. These cases represent a successful application of this innovative technique in a pediatric patient.

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.

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.