Indian Journal of Otology

CASE REPORT
Year
: 2017  |  Volume : 23  |  Issue : 3  |  Page : 208--210

Reimplantation of an amputated pinna: A case report and review of literature


Brajpal Singh Tyagi, Sushant Tyagi 
 Department of ENT and Head and Neck Surgery, Harsh ENT Hospital, Ghaziabad, Uttar Pradesh, India

Correspondence Address:
Brajpal Singh Tyagi
Harsh ENT Hospital, C43, RDC, Raj Nagar, Ghaziabad - 201 002, Uttar Pradesh
India

Abstract

Management of the partial or total amputations of the external ear has always stayed a difficult problem for otolaryngologists and plastic surgeons. For successful reimplantations of these amputations, multidisciplinary approach consisting of aggressive medical therapy with broad-spectrum intravenous antibiotics, anticoagulation, and reperfusion in conjunction with efficient surgical approach is needed. The surgeon's main objective is to obtain the best cosmetic result without damaging the auricular area to allow for subsequent future ear reconstruction in case any failure occurs after replantation. To enhance the survival of a reattached ear segment, Mladick et al. have advocated the use of the retroauricular pocket. This technique involves deepithelialization of the amputated part of the avulsed cartilage, followed by reattachment to the amputation stump and then burial into a retroauricular skin pocket. This increases the surface area of the avulsed segment in contact with surrounding nutrients, maximizing the probability of graft uptake and survival. We have used this technique successfully in our case and found acceptable results with it.



How to cite this article:
Tyagi BS, Tyagi S. Reimplantation of an amputated pinna: A case report and review of literature.Indian J Otol 2017;23:208-210


How to cite this URL:
Tyagi BS, Tyagi S. Reimplantation of an amputated pinna: A case report and review of literature. Indian J Otol [serial online] 2017 [cited 2021 May 11 ];23:208-210
Available from: https://www.indianjotol.org/text.asp?2017/23/3/208/213861


Full Text

 Introduction



Reimplantation of the partial or total amputations of the external ear has always stayed as a challenging issue for otolaryngologists and plastic surgeons. For successful reimplantations of these amputations, multidisciplinary approach consisting of aggressive medical therapy with broad-spectrum intravenous antibiotics, anticoagulation, and reperfusion in conjunction with effi cient surgical approach is needed. The surgeon's main objective is to obtain the best cosmetic result without damaging the auricular area to allow for subsequent future ear reconstruction in case any failure occurs after replantation.

 Case Report



A 46-year-old male patient presented to the emergency department of our hospital with a complete amputation of his left ear following a road traffic accident [Figure 1]. The amputated auricle was brought in a plastic bag with saline, surrounded by ice [Figure 2]. The amputated stump of the ear was thoroughly cleaned with normal saline and povidone-iodine 10% and hemostasis was achieved [Figure 3]. The patient was immediately started on broad-spectrum intravenous antibiotics (ceftriaxone 2 g 12 hourly and Metronidazole 500 mg 8 hourly). The amputated segment of the auricle was cleaned thoroughly and denuded of its skin. Perichondrium was left in place. The amputated cartilage was then reattached to the auricle in its anatomical location [Figure 4]. The denuded portion was then buried in a postauricular skin pocket and left in place for 6 weeks. We also kept tissue expander in the infra-aural skin flap and inflated it with 30 ml saline for 6 weeks (5 ml/week) [Figure 5]. This allowed the cartilage to maintain its blood supply from the overlying skin cover and the tissue expander gave us ample skin cover for staged reconstruction. The lateral portion of the skin flap was left attached to the cartilage, and the posterior/medial aspect was covered with split skin grafting and allowed to reepithelialize spontaneously over several weeks [Figure 6].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 Discussion



Blood supply to the external ear and postauricular area is primarily from the branches of the external carotid arteries such as the superficial temporal and posterior auricular arteries. In the pocket technique of replantation, the mechanism of survival of the avulsed portion is by diffusion of nutrients by the skin flap and temporoparietal fascia, respectively. This is followed by the formation of vascular channels between the grafted segment and the recipient area.[1]

The first reported case of microsurgical ear replantation was reported in 1980. Since then, it has proved to be a reliable method for the management of traumatic ear amputation. Successful microsurgical revascularization requires three different techniques, namely, vein grafts, primary vascular repair, and repair by pedicled superficial vessels of head and neck region.[2],[3]

Before this popular microsurgical technique, Mladick et al., in 1971, proposed the principle of the retroauricular pocket for nonmicrosurgical ear reattachment. This method involved deepithilization of the amputated part, followed by anatomic attachment to the amputated stump and then its burial in a retroauricular skin flap pocket.[4] In this method, a larger area of insert and greater surface area of contact with the vascular bed were provided for the graft, thus improving the chances of composite graft uptake and survival.

Park et al. also described another technique for cartilage burial, by removing all skin from the graft except over the helix area. The denuded cartilage is sandwiched between a retroauricular flap anteriorly and a facial flap posteriorly.[5]

Another technique was proposed by Destro and Speranzini, in which all the skin is removed from the graft but sparing the concha. Multiple perforations are made in the cartilage before covering it with a postauricular flap. A second staged surgery is required for the elevation of the ear.[6]

The experience of Fernandes and Driscoll has shown porous polyethylene reconstruction of the pinnac to be very efficient with good cosmetic outcomes. Medpor is an excellent option for the reconstruction. Significantly good results were achieved after tissue expansion and the use of the expanded skin.[7]

In their study, Lin et al. had found that microvascular replantation is the best method for reattachment of an amputated pinna, giving excellent cosmetic results. In patients without a suitable vessel for microanastomosis, various nonmicrosurgical methods have been suggested such as a temporoparietal fascia flap, retroauricular pocket procedure, and staged costochondral cartilage reconstruction, depending on the size of the ear defect.[8]

In a review of pinna reconstruction over 25 years, Steffen et al. have found the microsurgical replantation to give excellent esthetic results, but at the same time, it also demanded an intensive perioperative and postoperative management. They also found pocket methods to be useful in partial amputations. Repairs with periauricular tissue flaps made a quite inconsistent impression. Although direct reattachments as composite grafts were indicated only in lacerations without complete avulsions.[9]

Reconstruction of amputated and lacerated auricles is also full of complications and pitfalls. Infections present as pain, inflammation, swelling, or tenderness more than 3 days postoperatively. Antibiotic treatment should be initiated promptly to avoid the development of suppurative chondritis. Chondritis appears as persistent edema, redness, and tenderness over the auricle. Hematomas are heralded by excessive pain or tenderness of the ear on the first or second postoperative day. Prompt exposure of the ear is needed. The facial nerve is at a greater risk for injury in the neonate and young child as it exits and courses more superficially due to the undeveloped mastoid process. Sutures, especially monofilament nonabsorbable sutures, may erode through the skin. Polyfilament sutures have less of a tendency for erosion but carry a higher rate of infection. Skin necrosis and loss can result from very superficial undermining of the skin flaps used in reconstruction, leading to circulatory impairment, desquamation, and atrophy. Pressure necrosis is the most disastrous complication. All sutures must be placed with care to avoid pressure necrosis. Tight ear dressing should also be avoided to prevent this complication.

 Conclusion



Microvascular replantation still stays as the best method for reattachment of an amputated ear, giving excellent esthetic results. Although in patients where suitable vessel for microanastomosis is not present, nonmicrosurgical methods are suggested, of which temporoparietal fascia flap, retroauricular pocket procedure, and staged costochondral cartilage reconstruction have given good results depending on the size of ear defect. Significantly good results were achieved after tissue expansion using expanders such as porous polyethylene and Medpor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Maloney K. Partial avulsion of the right ear treated with a pocket technique: A case report and review of the literature. J Maxillofac Oral Surg 2015;14 Suppl 1:288-92.
2Nath RK, Kraemer BA, Azizzadeh A. Complete ear replantation without venous anastomosis. Microsurgery 1998;18:282-5.
3Kind GM, Buncke GM, Placik OJ, Jansen DA, D'Amore T, Buncke HJ Jr. Total ear replantation. Plast Reconstr Surg 1997;99:1858-67.
4Mladick RA, Horton CE, Adamson JE, Cohen BI. The pocket principle: A new technique for the reattachment of a severed ear part. Plast Reconstr Surg 1971;48:219-23.
5Park C, Lee CH, Shin KS. An improved burying method for salvaging an amputated auricular cartilage. Plast Reconstr Surg 1995;96:207-10.
6Destro MW, Speranzini MB. Total reconstruction of the auricle after traumatic amputation. Plast Reconstr Surg 1994;94:859-64.
7Fernandes JR, Driscoll DN. Burn ear reconstruction using porous polyethylene implants and tissue expansion. J Burn Care Res 2015;37:e348-52
8Lin PY, Chiang YC, Hsieh CH, Jeng SF. Microsurgical replantation and salvage procedures in traumatic ear amputation. J Trauma 2010;69:E15-9.
9Steffen A, Katzbach R, Klaiber S. A comparison of ear reattachment methods: A review of 25 years since Pennington. Plast Reconstr Surg 2006;118:1358-64.