1. What are the considerations for auricula reconstruction?
Healthcare practitioners must be very careful in dealing with auricle trauma; the complex and unique anatomy with the cartilage that gives the auricle its shape means that suturing and wound closure techniques must be very careful to maintain the shape of the ear and avoid complications.
To determine the course of action for auricular lacerations, health practitioners need to evaluate, among other things: identify the anatomical structure of the damaged auricle, be able to recognize contraindications to laceration wound closure, and need to know what complications may occur.
Cartilage depends on the perichondrium for its vascular supply; therefore proper coverage of the exposed cartilage can prevent potential complications such as necrosis, erosive chondritis and infection.
All auricular cartilage should be covered by skin; as the cartilage derives its blood supply from the overlying skin, skin coverage is essential for a good recovery (this may include cutting the cartilage to achieve this).
Immediate repair and prevention of infection is essential to minimize cosmetic damage.
2. What are the complications that can occur in reconstruction?
Complications can be classified as early or late.
The major early complications are hematoma, pain, infection, perichondritis and cartilage necrosis. Late complications include suture problems, keloids and hypertrophic scars, hypoesthesia, susceptibility to cold, and of course unsatisfactory results.
Another complication to watch out for after cartilage reconstruction is hematoma formation. Although these hematomas are usually caused by blunt trauma without laceration, the risk can arise at any time when the ear cartilage is compromised. An auricular hematoma is a collection of blood under the perichondrium of the ear and usually occurs secondary to trauma. Auricular deformity, commonly known as "cauliflower ear" is a result of untreated or inadequately treated auricular hematoma. Persistent hematoma can lead to cartilage damage with subsequent ear deformity. To prevent hematoma from occurring, it is important to place drainage using a bolster dressing or using a simple pressure dressing to close the potential space. Treatment with layered closure during surgery and the application of bolster dressings or simple pressure dressings in patients with auricular hematomas will give good results, preventing further complications such as cauliflower ear.
Early hematoma is a significant complication that, if left untreated, can progress to infection and cartilage necrosis, or even cauliflower ear deformity. The causes of hematoma formation are improper tissue dissection, inadequate hemostasis and inadequate pressure management. The incidence rate is around 3%, with a potentially higher incidence seen in cartilage cutting techniques.41,42 If a hematoma occurs, pain is often the presenting symptom.
The build-up should be drained immediately under sterile conditions, and any active bleeding should be controlled with electrocautery. The incision should be closed through a drain or with interrupted sutures to allow additional blood to drain. The ear should be re-dressed with an appropriate dressing, and the patient should receive broad- spectrum antibiotics.
Subscribe to DeepL Pro to edit this document.
Visit www.DeepL.com/pro for more information.
Pain is often confused with the presentation of a hematoma or infection; other causes are dressing problems such as twisted ears, or even pressure-induced necrosis. In general, pain after otoplasty should be minimal. If pain is progressive, removal of the dressing is mandatory.
The risk of infection is minimized by sterile technique, intraoperative antibiotics, antibiotic wound irrigation before closure, and antibiotic ointment applied to the suture line. If infection develops, the treatment is to evacuate any collection and the use of antibiotics. The typical pathogens are Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa; these are viewed as acute or chronic infections (e.g. infected sutures, granulomas).
Perichondritis may occur after infection or hematoma. It requires treatment under sterile conditions with debridement of necrotic tissue and intravenous administration of antibiotics.
Cartilage necrosis may also occur due to infection or hematoma. In addition, improper surgical techniques, use of cautery, or even placement of dressings can lead to cartilage necrosis.
Late suture complications can occur with many types of suture materials. Chromic catgut can cause localized skin reactions and inflammation. Certain sutures (e.g., braided compared to monofilament sutures) are more reactive and have the potential to initiate foreign body granulomas; if this occurs, the granuloma and suture material should be removed. Removal can be delayed for a few months post-operatively and thus reduce the potential negative impact on the patient of the cosmetic outcome. Another suture complication is loss of correction with the suture technique.
In this technique, overcorrection is advised to account for an estimated loss of correction of up to 40%.25 This type of complication is minimized by placing an appropriate number of sutures and using cartilage weakening modalities for stiffer cartilage.
Hypertrophic scarring or keloid formation in particular may occur after a postauricular incision. Patients at risk are younger patients and those with more pigmented skin, especially blacks with a history of keloid formation.
Preventive modalities include avoiding overly aggressive skin resection and ensuring a completely tension-free closure.
Injury to the greater auricular nerve may cause hypoesthesia after otoplasty. Although bothersome, this is not clinically significant; sensory function often returns within a few weeks to months postoperatively. Impaired auricular blood supply may lead to recurrent frostbite and higher susceptibility to cold temperatures after otoplasty.
Chondritis, which can lead to disability, is a serious complication. The initial symptoms are a red, hot and painful pinna. Later, an abscess may form between the perichondrium and cartilage, along with cartilage necrosis, requiring immediate removal of the pus and necrotic cartilage. The most dire complications of earlobe laceration are chondritis and poor cosmetic outcome
The most frequently observed complications were venous congestion in 5 patients, lobule necrosis in 3 patients, and helical root necrosis in 2 patients. All cases reported in the literature have been
achieved satisfactory clinical and aesthetic results except in one patient who
3. What needs to be evaluated in determining the course of action in a case of auricular laceration?
Surgical management factors of the severed earlobe: size and location of the avulsed part, condition of the segment and surrounding tissues, ischemic time, etiology of injury, and patient condition.
Several factors influence decision-making when choosing the appropriate method of auricular avulsion repair at initial presentation in the acute care setting. These include the size and condition of the avulsed segment, the status of the surrounding skin, the mechanism of injury, patient comorbidities, availability of microsurgical techniques, and surgeon experience.
Auricular avulsions can be organized by the size (partial or total) and location (e.g. upper pole, mid pole, concha, helix) of the injury.
The size of the deformity, viability and availability of surrounding tissue and the location of the scar are important factors to consider when choosing a reconstruction method.
Several factors influence decision-making when selecting the appropriate method of auricular avulsion repair at initial presentation in the acute care setting. These include the size and condition of the avulsed segment, the status
of the surrounding skin, the mechanism of injury, the patient's comorbidities, the availability of microsurgical techniques, and the surgeon's experience.
4. What is the purpose of auricle reconstruction?
The goal of treatment lies in restoring the normal contour of the pinna and preventing infection.
The goal of total ear reconstruction is to create a contoured replacement structure, with natural proportions, ideally located and oriented on the side of the head. It will appear symmetrical in appearance and location to the opposite normal ear if the reconstruction is unilateral. It is very important to replicate the main anatomical features of the lateral ear surface. The reconstructed ear should also be elevated posteriorly away from the side of the head, to produce a symmetrical ear projection and to recreate the post-auricular sulcus.
Some of these injuries can lead to hematomas and chondritis, which cause cosmetic damage.
The main goal of wound management in ear lacerations is closure of the exposed cartilage and prevention of hematoma around the surgical wound after the procedure.
5. When is the right time for ear reconstruction?
The optimal timing is suggested as 1 month after the previous procedure, when the cartilage is fully revascularized.
In addition, preoperative cleaning and maintenance of the amputated segment and meticulous postoperative wound care are essential for survival.
6. On page 9, there is mention of Frankfort horizontal, can the presenters explain that?
FH = Frankfurt horizontal through the infraorbital rim (1) and ear canal roof (2).
The longitudinal axis of the auricle forms an angle of ca. 30° (oblique) to the frontal plane (perpendicular to FH), such that it is approximately parallel to the vertical ramus of the mandible.
The height and position of the auricle is determined by a line parallel to the FH through the supraorbitale (the most prominent part of the forehead between the eyebrows = 3) and subnasale (the junction of the columella and upper lip = 4).
The Frankfort horizontal plane (Fig. 19-5) is the standard reference point for patient positioning in cephalometric photographs and radiographs. The Frankfort plane is defined as a line drawn from the superior aspect of the external auditory canal to the inferior border of the infraorbital rim while the patient's gaze is parallel to the floor. The soft tissue definition for the inferior aspect of the infraorbital rim is the transition point between the lower eyelid and cheek skin
7. What are the indications for ear reconstruction?
Partial ear reconstruction may be indicated in congenital (e.g. lop ear deformity) and acquired deformities involving up to two-thirds of the ear. Trauma (e.g. bite wounds, avulsions and burns) and cancer are common causes of partial or complete ear loss requiring ear reconstruction.
8. What factors can affect the success of ear reconstruction?
The first is vascular patency. The survival and wound healing of the reconstructed auricle is highly dependent on sufficient arterial flow. On the other hand, venous congestion caused after partial or total amputation can lead to cartilage loss.
The second factor concerns the availability of soft tissue cover over the replanted or harvested cartilage framework.
Lack of soft tissue cover after traumatic injury may limit the options available for repair or may require more complex flap coverage.
9. What is the primary treatment for total avulsion of the earlobe?
When he experimented with earlobe replantation in rabbits.[1] Despite these early attempts, the first successful human ear replantation was not performed until 22 years later, by Pennington of Sydney. [2,3] More than 80 cases of ear replantation have been performed and reported as successful. Successful earlobe replantation has been reported even after 33 hours post avulsion
Proper care consists of wrapping the amputated part in wet gauze, and placing it in a plastic bag inside another plastic bag containing 1 part ice and 2 parts water to achieve a cooling temperature of 4°C.[15-17] However, there are frequent errors in primary care, the least of which is storage of the amputated part without cooling. A more detrimental mistake is placing the amputated part on dry ice or covering it with frozen vegetables, causing the part to freeze at 18°C. Tissue damaged by frost is not suitable for replanting.
What can we do in cases of auricle trauma?
Auricular trauma presents several diagnostic and treatment challenges for clinicians. Advanced Trauma Life Support (ATLS) protocols should be followed from the outset to ascertain airway, breathing, circulation, and neurological status.8 A thorough history is essential, and should include the time, mechanism, and events surrounding the injury.
Audiovestibular symptoms such as hearing loss, vertigo, tinnitus, otorrhea and facial weakness should also be checked.
Earlobe lacerations can be repaired with primary closure, preferably within the first 24 hours or up to 3 days after injury to prevent scar contracture
Immediate repair and prevention of infection are essential to minimize cosmetic damage Partially or totally avulsed pinna can be reattached after thorough washing and debridement.
Primary evaluation in patients with auricular trauma begins in the same way as in all trauma patients, and includes a thorough history and physical examination.
Initial management is wound toilet and administration of analgesics to reduce pain. To ensure optimal wound healing, ensure thorough wound cleansing under local anesthesia; consider tetanus booster and antibiotic prophylaxis if required.
This disorder causes the subperichondrial space to fill with blood, which is called auricular hematoma. As cartilage has no intrinsic blood supply, it relies on the perichondrial circulation as a source of blood nutrition. When this connection is broken due to injury or being compressed by a hematoma, the cartilage is at high risk of necrosis and infection. The risk of necrosis increases when anterior and posterior hematomas are present around the ear cartilage; the hematoma acts like a tourniquet and significantly increases the risk of cartilage necrosis. Excessive lacerations increase the risk of infection; therefore, it is necessary to properly decontaminate the wound and treat with antibiotics if the mechanism of injury increases the risk of infection, such as dog bites or wounds from dirty objects.
