Auricular Cartilage Grafts in Revision Rhinoplasty
Revision Rhinoplasty is a challenge from a reconstruction standpoint for the Rhinoplasty Surgeon, both in the repair technique and the selection of implant material for augmentation grafting. Patients seeking Revision or Reconstructive Rhinoplasty frequently have had Septoplasty previously, which reduced a significant amount of septal cartilage.
Patient Cartilage for Nasal Reconstruction
These situations challenge the surgeon to decide which material will be used for structural grafting. The time-tested approach of gener¬ations of Rhinoplasty Surgeons who have exclusively used the patient’s cartilage for nasal reconstruction, due to its superior long-term survival characteristics, its ample availability in the head and neck region, its resistance to infection and resorption, and its malleable nature and elasticity when implanted in the nose. Careful strategic planning must be undertaken to get the maximal and ideal benefit from the auricular cartilage. The Revision Rhinoplasty Surgeon must understand the anatomy of the external ear and must be able to manage the precious cartilage supply to get the maximum benefit in Reconstructive Rhinoplasty.
Revision Rhinoplasty has stimulated a variety of reconstructive techniques by surgeons dedicated to restoration of both nasal form and nasal function. Often, patients seeking Revision or Reconstructive Rhinoplasty have previously undergone Septoplasty while sacrificing significant amounts of septal cartilage. These circumstances challenge the surgeon to select the ideal material to be used for structural grafting.
Implant materials may be categorized as autogenous tissue (cartilage, bone, fascia, and dermis), homograft materials (preserved, irradiated cartilage or bone, preserved acellular dermis or Alloderm, and others), and alloplastic materials. Many Revision Rhinoplasty Surgeons prefer autogenous material for nasal reconstruction because of its superior sustainability, its ready availability in the head and neck region, its resistance to infection and resorption, and its bendability and elasticity when implanted in the nose).
When beginning Revision or Reconstructive Rhinoplasty requiring aesthetic and structural grafting, the surgeon should check septum for additional residual cartilage. At times ample septal cartilage can be located despite a history of a prior Septoplasty. In addition, all other cartilaginous and bone sources in the nose are preferred whenever possible.
Auricular Cartilage Anatomy
The Revision Rhinoplasty Surgeon must comprehend external ear anatomy. Among im¬portant surface features is the helix, the prominent rim of the auricle. Parallel and anterior to the helix is an-other prominence known as the antihelix or antihelical fold. Superiorly, the antihelix divides to form a superior and inferior crus, which surround the fossa triangularis. The depression between the helix and antihelix is known as the scapha or scaphoid fossa. The antihelical fold sur¬rounds the concha, a deep cavity posterior to the exter¬nal auditory meatus. The crus helicis, which represents the beginning of the helix, divides the concha into a su¬perior portion, the cymba conchae, and an inferior por¬ tion, the cavum conchae. The cavity formed by the concha on the anterior (lateral) surface of the ear corresponds to a bulge or convexity on the posterior (medial) surface of the ear known as the eminentia of the concha.
Anterior to the concha and partially covering the external auditory meatus is the tragus. The antitragus is posteroinferior to the tragus and is separated from it by the intertragic notch. Below the antitragus is the lobule that is composed of areolar tissue and fat.
Except for the lobule, the auricle is supported by thin, flexible elastic fibrocartilage. This cartilaginous framework is 0.5 to 1.0 mm thick and covered by a min¬imum of subcutaneous tissue. The skin is loosely adherent to the posterior surface and helix of the auric¬ular cartilage. The close approximation of the skin to the anterior surface of the cartilage provides the auricle with its unique topographic features.
Harvesting Auricular Cartilage
Auricular Cartilage Grafting is removal of cartilage from the ear to reconstruct the nose. Grafts are usually taken from the concha cymba and cavum of the ear to remove cartilage without altering the overall shape of the ear. The skin of the ear remains intact.
When harvesting Composite Cartilage Grafts, an incision is made anteriorly along the ear. Composite Cartilage Grafts are a composite of two different tissues, cartilage and skin. These grafts are used for a variety of purposes in nasal reconstruction and Rhinoplasty including, alar retraction, short nose patients, overly narrow nostrils, soft tissue triangle absence, etc. They are valuable grafts that Revision Rhinoplasty Surgeons often use.
Since skin is removed, the concha cymba is the preferred location for harvesting the conchal cartilage graft for several reasons. Its location facilitates easy closure, minimizes external ear changes, and the skin is tightly adhered in this location.
The majority of our grafts for Revision Rhinoplasty are harvested from the external ear. As long as the antihelical fold is not transgressed, no significant change results in the appearance of the ear, even by the removal of the entire concha cavum and concha cymba. Segments of 3.5 to 4 cm are commonly available. In most patients, the cartilage is stiff yet pliable. Warping almost never occurs.
Harvest of this cartilage may be undertaken by a pre- or postauricular approach. In the pre-auricular ap¬proach, an incision is made just inside the antihelical fold and is therefore hidden by a shadow. Although we prefer the posterior approach, others prefer the anterior approach.
If the patient has one ear that protrudes more than the other, then the cartilage should be harvested from that side. If the patient sleeps on one side of the head, then the cartilage should be removed from the opposite side.
Using 1% xylocaine solution with 1:100,000 epinephrine, the surgeon “hydrodissects” the skin of the concha cavum and cymba from the underlying cartilage. Subperichondreal injection of local anesthetic on the anterior surface of the conchal bowl facilitates dissection of the skin off the cartilage. The posterior surface is also injected with Local Anesthesia.
To proceed with the anterior approach, the Revision Rhinoplasty Surgeon may outline with a marking pen an incision that follows the outer edge of the cavum and cymba concha. This incision should be placed along the portion of the concha that is vertically oriented in relation to the lateral aspect of the skull. Then, the incision is made with a #15 blade, and the surgeon elevates the skin and perichondrium from the underlying cartilage. Dissection proceeds using ap¬propriate scissors and also bluntly with cotton-tip applicators. Care is taken not to damage the soft auricular cartilage, which can easily tear. The dissection stops short of the cartilage of the external auditory canal.
The radix helices should be preserved. If the entire conchal bowl in excised, the auricle usually settles slightly closer to the head.
In the postauricular approach, an incision is made postauricularly in the skin overlying the eminentia of the concha. The skin-soft tissue envelope is elevated over the eminetia and the cartilage is incised, being careful to preserve an adequate amount of cartilage along the antihelical fold. The anterior skin and soft tissue are raised in the subperichondrial plane and the cartilage is excised.
The Revision Rhinoplasty Surgeon dissects out the desired piece of car¬tilage and leaves the underlying muscle behind (perichondrium remains adherent to the posterior surface of the cartilage). Avoiding deep dissection into the soft tissue minimizes bleeding.
After perfect hemostasis is achieved and the wound has been irrigated, the incision is closed. Commonly a 6-0 nylon running vertical mattress suture is used, although one may also close the incision with in¬terrupted vertical mattress sutures. Special care is taken to avoid overlap of the skin edges. A bolster dressing of Telfa, dental roll, or other suitable material is placed into the concha and sutured into position to decrease the risk of hematoma. No residual deformity of the pinna is expected with this approach. In the postauricular approach, an incision is made postauricularly in the skin overlying the eminentia of the concha. The skin-soft tissue envelope is elevated over the eminentia, and the cartilage is incised, being careful to preserve an adequate amount of cartilage along the antihelical fold. The anterior skin and soft tissue are elevated in the subperichondrial plane and the cartilage is excised.
Auricular Cartilage Grafting
Although each Auricular Cartilage Graft must be custom-carved to meet the specific needs of the patient, considerable grafting requirements can be fulfilled by one piece of ear cartilage if carving of the cartilage is well planned. In this patient example, two alar batten grafts, a tip graft, a columellar strut, and additional grafting materials were available. Due to the patient’s relatively thin skin, a layer of soft tissue was left on the posterior surface. Indeed, if the patient has thin nasal skin, then the surgeon may wish to leave a portion of soft tissue on the posterior surface of the auricular cartilage. This allows some additional camouflage and also allows for faster tissue adhesion.
Ear Cartilage Graft
Ear Cartilage Grafting (AKA Auricular Cartilage Grafting) is a reliable surgical technique for Revision Rhinoplasty, especially when grafting is needed in the tip or alae (sides of nostrils). Ear cartilage is obtained from the back of the patient’s ear at the same time as the Revision. The procedure to harvest ear cartilage usually takes 10-15 minutes and requires placing an incision just over an inch on the back of the ear.
Benefits of Auricular Cartilage Grafting
- Ear Cartilage Grafts are typically available where there may be inadequate donor cartilage in the nose.
- Ear Cartilage Grafts are natural and obtained from the patient’s own body.
- Ear Cartilage Grafts are soft and pliable and make a good graft for the tip and sides of the nose.
- Ear Cartilage Grafts are much more resistant to infection and absorption than implants or Cadaver Rib Grafts.
Drawbacks of Auricular Cartilage Grafting
- Ear Cartilage Grafts require placing an incision behind the ear and the ear will be sore for several weeks.
- Ear Cartilage Grafts are not durable and typically cannot be used to rebuild the entire bridge, lengthen a short nose, and correct severe deviations in cartilage.
- Removing a significant amount of ear causes slight deformities of the ear.
Alternatives to Auricular Cartilage Grafting
Septal Cartilage and Rib Cartilage Grafts may be softened during Revision Rhinoplasty Surgery by gently crushing and morselizing the cartilage to create some of the pliability of Ear Cartilage Grafts.
Auricular Cartilage Grafting Recovery
After Ear Cartilage Grafting a compression dressing is secured around both surfaces of the ear for 1-2 days. The ear will be sore for a few weeks but the same pain medication used to treat the discomfort after Rhinoplasty is typically adequate for the ear. The incision is typically repaired with dissolving sutures and is treated in the same way as the nose incisions.
Auricular Cartilage Graft is taken from the conchal bowl.
After flap is raised and the Auricular Cartilage
Graft is harvested.
Auricular Cartilage is taken and flap placed
back into anatomic position.
Flap closed in correct anatomic position. Notice the scar on
the Scaphoid Fossa – this was the site where a previous surgeon
harvested cartilage from the wrong section of the ear,
resulting in scarring and disfigurement.
Cotton bolster dressing is held in place
for 5 days to prevent hematoma between flaps.
Auricular Cartilage is carved for
Columellar Strut and Shield Graft.