Simultaneous retraction and marking for maximum conchal cartilage harvest

Authors

  • Javier González-Castro MD,

    Corresponding author
    • Department of Otolaryngology–Head and Neck Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, U.S.A
    Search for more papers by this author
  • Jorge Aldrich MD

    1. Department of Otolaryngology–Head and Neck Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, U.S.A
    Search for more papers by this author

  • Presented as a poster at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting, Washington, DC, September 5–8, 2012.

  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Send correspondence to Javier González-Castro, Metro Plaza Towers, 303 Calle Villamil, Apt. 901, San Juan, Puerto Rico 00907. E-mail: javi8g@gmail.com

INTRODUCTION

The three-dimensional contour of the face is defined by the osseocartilaginous framework as well as the soft tissue that surrounds these structures. In reconstructive surgery, it is important to analyze the defect and determine which layers are deficient and need replacement. Cartilage is employed extensively in aesthetic and reconstructive surgery for its capacity to be shaped as needed, while still maintaining its strength and structural integrity. Although many synthetic options are now available, there is still a clear advantage in the use of autologous cartilage.[1, 2] The most frequently used donor sites in aesthetic and reconstructive surgery are the nasal septum, rib, and auricular conchal cartilage. With its innate convexity, conchal cartilage is particularly suited for reconstruction of the nose.[3, 4] Harvesting conchal cartilage is relatively easy and associated with minimal donor site morbidity if done correctly. Conchal cartilage can be harvested using either an anterior or posterior auricular incision as long as the structural landmarks are preserved. The antihelix is the most important of these landmarks; most authors use a measurement of 2 to 3 mm from the antihelical border as their limit of resection.[5, 6] The helical crus should also be preserved to maintain adequate shape, and 2 to 3 mm of cartilage surrounding the external auditory canal (EAC) are essential to avoid collapse of the EAC.

When an anterior approach[2, 5, 7-10] is employed, preservation of these landmarks is somewhat straightforward because the entire concha is exposed by means of an incision along the antihelix-conchal junction. The anterior skin flap is elevated, and the cartilage is incised and removed. The advantages in this technique are less time of surgery and a clear view of the area to be removed, which in theory results in a larger cartilage yield and decreased donor site structural deformity. The disadvantage of this technique is that it leaves a visible scar on the anterior surface of the auricle, particularly in those who produce hypertrophic scars.

In the postauricular approach,[3, 4, 6, 11-15] the auricle is reflected forward and the concha is isolated via a 3-cm postauricular incision. The main advantage in this technique is that the resulting scar is hidden behind the ear. The disadvantage, however, is that when the auricle is reflected forward, the antihelical landmark is distorted, which can lead to either over- or under-resection; this results in either insufficient grafting material or an auricular deformity. In attempt to maximize the size of the harvested graft while maintaining structural integrity, various techniques have been developed to mark the antihelical border and guide the resection. One such technique is tattooing, whereby the surgeon dips the tip of a small-gauge needle in methylene blue or brilliant green. After raising the posterior flap, the surgeon then introduces the needle through the lateral surface of the auricle 2 to 3 mm from the antihelical border and carries the die through and on to the posterior surface of the auricle.[6, 11] Others simply raise the posterior flap and introduce various 30-gauge needles laterally through the antihelical border to mark the limit of resection (Fig. 1).[4, 14] Some surgeons opt for not marking the antihelix before resection, which risks under- or over-resection as well as cosmetic deformities. We have developed a technique for marking the antihelical fold that avoids staining tissues with tattooing material and most importantly avoids needle prick injury to the surgical staff. Our technique not only maximizes the amount of cartilage harvested, it also provides retraction of the auricle and postauricular flap at the same time.

Figure 1.

Artist representation of needles used to mark antihelical border.

MATERIALS AND METHODS

Surgical Procedure

Under general anesthesia, the auricle is draped in sterile fashion and 1% lidocaine with epinephrine 1:100,000 injected to both the anterior and posterior surface of the conchal bowl to obtain hemostasis and hydrodissection. A 3-cm postauricular incision is made at the level of the conchal bowl. A subperichondrial flap is elevated, exposing the posterior surface of the concha. A 3-0 monofilament nonabsorbable suture is placed 2 to 3 mm from the antihelical rim leaving long tails. The procedure is repeated between seven and nine times until the entire antihelical border is marked as shown in Figures 2 and 3. The sutures are then clamped in groups of three to four sutures using a hemostat and reflected forward to expose the postauricular conchal cartilage (Figs. 4 and 5). These sutures will serve a dual purpose; they will mark the antihelical limit of resection and retract the auricle forward. The cartilaginous incision is made following the border of our sutures as seen in Figures 4 and 6. With the auricle retracted, the anterior surface of the conchal cartilage is carefully dissected in a subperichondrial plane, leaving the helical crus intact and extending to 3 mm from the cartilaginous external auditory canal (Fig. 7). The postauricular wound is closed using a 5-0 absorbable subdermal suture followed by a running-locking 5-0 monofilament nonabsorbable suture. An antibiotic soaked bolster is packed into the conchal bowl and secured with a mattress suture to a nonadhesive gauze in the postauricular region. The bolster and sutures are removed 5 days later.

Figure 2.

Artist representation of the marking/retracting sutures in place.

Figure 3.

Marking/retracting sutures in place.

Figure 4.

Artist representation of sutures retracting auricle forward for cartilage incision.

Figure 5.

Auricle retracted with suture technique.

Figure 6.

Cartilage incision made following suture marks.

Figure 7.

Dissecting anterior portion of the conchal cartilage.

DISCUSSION

Cartilaginous support is key in reconstructive surgery. Conchal cartilage is an accessible and versatile tool that all cosmetic surgeons must have in their armamentarium. Reports have shown that it can be used for multiple reconstructions, including but not limited to the nose, ears, orbit, and chin.[2-10, 12-15] With its innate convexity and structural integrity, conchal cartilage is particularly suited for reconstruction of the nose, especially when work is needed on the ala, lower lateral cartilage, or any convex surface. Cartilage harvest can be done using either an anterior or posterior auricular incision. The particular approach and technique varies among surgeons; however, all agree that to avoid structural deformity to the auricle, one must avoid damage to the antihelix. Proponents for the anterior approach have shown that with meticulous technique, postoperative scaring can be minimal and in most occasions unperceivable to the untrained eye.[5] The postauricular approach in turn produces less visible scaring, but does pose certain limitations discussed above, which have prompted surgeons to develop new techniques. Our technique is an excellent tool for removal of the greatest amount of conchal cartilage possible while providing retraction at the same time. This technique does not add time to the procedure when compared to others that employ a postauricular approach with marking of the antihelix. In addition, when compared to those techniques that use tattooing or multiple needles for marking, we find this to be a cleaner, safer, and more effective alternative.

CONCLUSION

Although the approach and technique varies among surgeons, all agree that one must avoid damage to the antihelix to avoid a structural deformity. We have developed a technique for marking the antihelical fold that avoids staining tissues with tattooing material, and most importantly avoids needle prick injury to the surgical staff. Our technique not only maximizes the amount of cartilage harvested, it also provides retraction of the auricle and postauricular flap simultaneously.

Acknowledgments

The authors thank their graphic artist, Amarilys Irizarry, for her work on the artistic representation of their procedure.

Ancillary