Abstract
Objectives/Hypothesis
This study aims to present an improved technique for auricular cartilage harvest that maximizes graft volume while preserving auricular cosmesis. Also discussed is the versatility of auricular cartilage utilization in rhinoplasty.
Study Design
A retrospective review of a single surgeon’s experience.
Methods
All auricular cartilage harvest and rhinoplasty operations performed by the senior author (CSC) from December 2006 through December 2009 cartilage were reviewed.
Results
Twenty-two cases were identified in which the described technique was used to harvest auricular cartilage for the purpose of functional or aesthetic rhinoplasty. There was sufficient tissue harvested in all operations, and no patients required costal cartilage harvest. Pain at the donor site after surgery was minimal and well controlled with oral medication. There were no donor-site complications and no cases of wound infection.
Conclusions
The proposed technique allows for optimal auricular cartilage harvest. By applying this method, the ear retains the preoperative appearance while the surgeon is able to obtain the largest graft possible. Auricular cartilage is a versatile source of grafting material in primary and secondary rhinoplasty.
1
Introduction
Rhinoplasty often requires cartilage grafting in efforts to improve both functional and aesthetic results. From a functional perspective, grafts are frequently used to widen the internal nasal valve and to provide structural support to the external valve to correct or prevent collapse during inspiration . Grafts may also be used in aesthetic rhinoplasty to augment deficiencies, improve tip definition, and increase nasal projection. Autogenous cartilage grafts may be obtained from several different sites, including the nasal septum, ear, or rib .
The septal cartilage is widely considered to be the optimal site for grafting in rhinoplasty because of both location and abundance of grafting material. Because the septal cartilage can be harvested from the same operative field, its use precludes the morbidity of obtaining cartilage from an additional donor site . The septum usually provides sufficient cartilage in primary rhinoplasty but may be depleted in those patients undergoing revision surgery, with a history of nasal trauma, or with septal perforations .
Costal cartilage harvested from the anterior chest wall is commonly used when a large volume of graft material is needed or when significant structural support is required . Although the amount of tissue harvested is greater than that of the septum and ear, costal cartilage harvest exposes the patient to potential complications. Chest wall infection, hematoma, anatomic deformity, and pneumothorax have all been described .
Auricular cartilage may be used alone or to supplement other cartilage grafts. Significant considerations in auricular cartilage harvest must include maximizing the amount of grafting material acquired while maintaining preoperative appearance of the ear. Using our proposed approach, we are able to maximize the amount of conchal cartilage harvested en bloc without compromising the ear’s appearance by preserving sufficient structural cartilage in 3 key areas of the pinnae: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal ( Fig. 1 ). This article describes our technique for auricular cartilage graft harvest and briefly discusses the versatility of ear cartilage in rhinoplasty.
2
Technique
With the patient under general anesthesia, the face and both ears are sterilely prepared into the operative field. Anteriorly, the concha cymba and concha cavum are injected with 2 to 3 mL of 1% Xylocaine with 1:100 000 epinephrine in the subperichondrial plane, using hydrodissection to facilitate the surgical dissection. Posteriorly, the same local anesthetic is injected subcutaneously along a planned 3 to 4 cm longitudinal incision overlying the lateral extent of the conchal bowl.
To prevent compromising ear protrusion, 3 key areas of the auricular structure must be preserved: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal. To maximize the amount of cartilage harvested while maintaining these areas, the possible extent of conchal cartilage resection ( Fig. 1 , dotted line) is percutaneously tattooed every 0.5 to 1.0 cm with methylene blue. Beginning along the medial aspect of the antihelical rim, a 25-gauge needle dipped in methylene blue is introduced into the skin of the anterior ear and then pushed completely through the posterior surface of the conchal cartilage ( Fig. 2 ).
Once the planned area of dissection is marked, the posterior surface of the auricular cartilage is incised, and the dissection is carried down to the level of the perichondrium. Dissection then proceeds medially to the premastoid fascia above the auricular perichondrium because leaving the perichondrium attached to the posterior surface of the cartilage helps prevent fracture of the graft during harvest. The anterior surface of the conchal bowl is then elevated in the subperichondrial plane. The previously applied methylene blue serves to map out the acceptable area of resection thereby preserving the aforementioned landmarks and maximizing the amount of cartilage obtained ( Figs. 3 and 4 ). Once hemostasis has been achieved with judicious use of electrocautery, the wound is irrigated, and the incision is approximated with a 4–0 plain gut suture. A bolster should be applied to the auricle to prevent hematoma formation during the postoperative period.
2
Technique
With the patient under general anesthesia, the face and both ears are sterilely prepared into the operative field. Anteriorly, the concha cymba and concha cavum are injected with 2 to 3 mL of 1% Xylocaine with 1:100 000 epinephrine in the subperichondrial plane, using hydrodissection to facilitate the surgical dissection. Posteriorly, the same local anesthetic is injected subcutaneously along a planned 3 to 4 cm longitudinal incision overlying the lateral extent of the conchal bowl.
To prevent compromising ear protrusion, 3 key areas of the auricular structure must be preserved: (1) the inferior crus of the antihelix, (2) the root of the helix, and (3) the area where the concha cavum transitions into the posterior-inferior margin of the external auditory canal. To maximize the amount of cartilage harvested while maintaining these areas, the possible extent of conchal cartilage resection ( Fig. 1 , dotted line) is percutaneously tattooed every 0.5 to 1.0 cm with methylene blue. Beginning along the medial aspect of the antihelical rim, a 25-gauge needle dipped in methylene blue is introduced into the skin of the anterior ear and then pushed completely through the posterior surface of the conchal cartilage ( Fig. 2 ).
