Trachea Reconstruction with Single-Stage Composite Flaps in a Rabbit Model.

BACKGROUND: Trachea reconstruction requires creation of a functional lining, semirigid support, and vascularity. We aimed to design composite flaps with these three components in a rabbit model. METHODS: Circumferential (n = 9) and partial anterior (n = 8) tracheal defects were created in rabbits. A circumferential defect was reconstructed with a tubed ear flap incorporating cartilage for support and skin for lining. This was pedicled on the posterior auricular vessels and tunneled into the neck to bridge the defect. In the second experiment, a longitudinal anterior trachea defect was patched with a pedicled rib cartilage and intercostal muscle flap based on the internal mammary vessels. The vascularized fascia over the intercostal muscles replaced the lining while the cartilage provided support. Postoperatively, the rabbits were monitored clinically and endoscopically. The tracheal constructs were examined histologically after the animals were sacrificed. RESULTS: Rabbits with circumferential defects reconstructed with the ear flap survived up to 6 months. Histology demonstrated vascularized cartilage with good integration of the flap with native trachea. However, hair growth and skin desquamation resulted in airway obstruction in the long term. In the second experiment, all the rabbits survived without respiratory distress, and the intercostal muscle fascia was completely covered by native respiratory epithelium. CONCLUSION: We described two experimental techniques using autologous composite flaps for single-stage trachea reconstruction in a rabbit model. Skin was a poor lining replacement, whereas vascularized muscle fascia became covered with respiratory epithelium. A rib cartilage and muscle flap could potentially be used for reconstruction of partial defects in humans.

[Autologous composite grafts from the cavum conchae for reconstruction of multilayer nasal defects]. / Das autologe Haut-Knorpel-Transplantat aus dem Cavum conchae zur Rekonstruktion mehrschichtiger nasaler Defekte.

BACKGROUND: Autologous transplants comprising skin and cartilage, so-called composite grafts (cgs), are an important reconstructive tool for multilayered defects of the nose. A cg from the auricular cavum conchae needs to fulfill both functional and esthetic demands. OBJECTIVE: This article illustrates the indications for and requirements of cgs, and also investigates graft healing and functional-aesthetic results. The current publication is a review article; the original data were published with the award of the 2014 APKO prize under the title "The auricle's cavum conchae composite graft in nasal reconstruction". MATERIALS AND METHODS: At the ENT department of Ulm University Medical School, multilayered defects of different nasal esthetic subunits are reconstructed with cgs. Based on these experiences, the authors report on long-term functional and esthetic results in the areas of the donor and recipient sites. CONCLUSION: Auricular cgs are versatile and reliable autologous transplants. The ease of harvesting, minimal donor site morbidity, and stable convex shape of these grafts render them ideal for reconstruction of multilayered nasal defects. Septal splints and custom-made prosthesis promote healing and prevent stenotic scarring.

Aesthetic correction of severe cicatricial upper-eyelid ectropion with a retrograde postauricular island flap.

BACKGROUND: Cicatricial ectropion of the upper eyelid is a serious problem because of the association with exposure keratitis and ulceration. Traditional surgical treatment usually requires skin grafts or local flaps depending on the severity of the defect. However, outcomes have usually been discouraging, especially in terms of cosmetic appearance. METHODS: From February 2000 to March 2012, a total of 12 upper eyelids with severe cicatricial ectropion were treated with a retrograde postauricular island flap and were included in this study. Based on the pedicle of the parietal branch of the superficial temporal artery and its choke anastomoses to the posterior auricular artery, the retrograde postauricular island flap was harvested with a supra-auricular incision down to the non-hair-bearing side skin of the postauricular region. The flap was then transferred to the upper-lid lesion by passing it through a subcutaneous tunnel between the pedicle base and the upper-lid lesion. The donor site was directly closed by advancing the postauricular scalp flap into the sulcus. The largest flap was 6.5 × 3.5 cm(2). RESULTS: After 6-12 months of follow-up, flaps survived with good color, texture, and contour. The eyelids moved freely without recurrence of ectropion. The donor site had an inconspicuous scar. No major complications occurred. CONCLUSIONS: The retrograde postauricular island flap can be a safe, simple, and effective procedure for aesthetic correction of severe cicatricial upper-eyelid ectropion with few complications and little donor-site morbidity. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An ideal composite graft donor site for postburn alar rim deficiencies: root of helix.

One of the challenging postburn face deformities is alar rim defects or deformities. Small through-and-through defects of the nasal ala may be managed with a composite graft of auricular tissue, obtained from the earlobe, the helical rim, and the root of the helix. We use usually the root of the helix for postburn alar defect correction as a composite graft donor site. The advantage of these composite grafts is that the procedure is a single-stage operation with excellent contour correction and a well toleration of donor site morbidity by the patient.

Managing the ear as a donor site for composite graft in nasal reconstruction: update on technical refinements and donor site morbidity in 110 cases.

Reconstruction of multilayer defects of the lower nose, using composite grafts from the ear is a widespread technique. Little information exists about important aspects of managing the ear as a donor site for composite grafts. In a retrospective study, patient data were worked up concerning special preoperative planning features (donor site, recipient site), defect closure techniques, donor site morbidity, and esthetic and functional long-term results. One hundred ten composite grafts from the auricle were harvested for different defects at the lower nose. Skin and soft-tissue defect reconstruction at the auricle was carried out by tissue advancement in 43 cases or local flaps in 66 cases. Donor site morbidity was low (5 cases of delayed wound healing, 1 abscess). No flap necrosis occurred. Long-term follow-up (2-5 years) revealed no esthetic or functional impairments. Composite graft harvesting from the auricle is safe with minimal donor site morbidity, proper implementation assumed.

Comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using conchal composite grafts.

INTRODUCTION: Anatomical abnormalities and heterogeneous tissue deficiencies of the bilateral cleft lip nasal deformity challenges the cranio-maxillofacial plastic surgeon to create a functional, yet aesthetically pleasing nose. The authors propose a comprehensive rhinoplasty technique to correct the bilateral cleft lip nasal deformity using composite conchal grafts. PATIENTS: Five children with bilateral cleft lip nasal deformities had nasal reconstruction using conchal composite grafts, averaging 5 years in age at time of surgery. Patient follow-up averaged 21 months. METHODS: An open tip rhinoplasty was performed using a 'V' shaped columellar incision. The conchal composite graft was obtained from the lateral aspect of the ear and was used to reconstruct the lateral alar mucosal defects. Conchal cartilage was used as a columellar strut. The columellar skin was closed in a 'V-Y' fashion, giving greater columellar length. RESULTS: Visual inspection confirmed that the cleft lip nasal deformity was improved in all patients. There were no postoperative complications. All patients had complete composite graft take with minimal donor site morbidity and deformity. CONCLUSIONS: This comprehensive rhinoplasty technique improves the abnormalities found in bilateral cleft lip nasal deformity by using the successful aspects of other methods and introducing the composite conchal graft.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant Research Procurement: A Translational Simulation Model.

BACKGROUND: Cadaveric face transplant models are routinely used for technical allograft design, perfusion assessment, and transplant simulation but are associated with substantial limitations. The purpose of this study was to describe the experience of implementing a translational donor research facial procurement and solid organ allograft recovery model. METHODS: Institutional review board approval was obtained, and a 49-year-old, brain-dead donor was identified for facial vascularized composite allograft research procurement. The family generously consented to donation of solid organs and the total face, eyelids, ears, scalp, and skeletal subunit allograft. RESULTS: The successful sequence of computed tomographic scanning, fabrication and postprocessing of patient-specific cutting guides, tracheostomy placement, preoperative fluorescent angiography, silicone mask facial impression, donor facial allograft recovery, postprocurement fluorescent angiography, and successful recovery of kidneys and liver occurred without any donor instability. Preservation of the bilateral external carotid arteries, facial arteries, occipital arteries, and bilateral thyrolinguofacial and internal jugular veins provided reliable and robust perfusion to the entirety of the allograft. Total time of facial procurement was 10 hours 57 minutes. CONCLUSIONS: Essential to clinical face transplant outcomes is the preparedness of the institution, multidisciplinary face transplant team, organ procurement organization, and solid organ transplant colleagues. A translational facial research procurement and solid organ recovery model serves as an educational experience to modify processes and address procedural, anatomical, and logistical concerns for institutions developing a clinical face transplantation program. This methodical approach best simulates the stressors and challenges that can be expected during clinical face transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant Cadaver Simulation: The Culmination of Aesthetic, Craniofacial, and Microsurgery Principles.

BACKGROUND: The application of aesthetic, craniofacial, and microsurgical principles in the execution of face transplantation may improve outcomes. Optimal soft-tissue face transplantation can be achieved by incorporating subunit facial skeletal replacement and subsequent tissue resuspension. The purpose of this study was to establish a reconstructive solution for a full face and scalp burn and to evaluate outcome precision and consistency. METHODS: Seven mock face transplants (14 cadavers) were completed in the span of 1 year. Components of the vascularized composite allograft included the eyelids, nose, lips, facial muscles, oral mucosa, total scalp, and ears; and skeletal subunits of the zygoma, nasal bone, and genial segment. Virtual surgical planning was used for osteotomy selection, and to evaluate postoperative precision of hard- and soft-tissue elements. RESULTS: Each transplant experience decreased each subsequent transplant surgical time. Prefabricated cutting guides facilitated a faster dissection of both donor and recipient tissue, requiring minimal alteration to the allograft for proper fixation of bony segments during inset. Regardless of donor-to-recipient size discrepancy, ample soft tissue was available to achieve tension-free allograft inset. Differences between virtual transplant simulation and posttransplant measurements were minimal or insignificant, supporting replicable and precise outcomes. CONCLUSIONS: This facial transplant model was designed to optimize reconstruction of extensive soft-tissue defects of the craniofacial region representative of electrical, thermal, and chemical burns, by incorporating skeletal subunits within the allograft. The implementation of aesthetic, craniofacial, and microsurgical principles and computer-assisted technology improves surgical precision, decreases operative time, and may optimize function.

A comparison of the survival of H-Y incompatible ear, tail, and body skin grafts.

In the H-Y incompatible C57BL/6 male to female system, both tail and ear skin grafts were found to persist longer than body (thorax) skin grafts of the same size and shape. Ear skin grafts of long standing did not affect the survival of subsequent body skin grafts but, in one case, a long-term tail skin graft prolonged the survival of a subsequent body skin gratf, both transplants persisting throughout the life of the host. Whereas ear skin grafts from which cartilage was removed were invariably rejected, several ear skin grafts with cartilage intact survived permanently.

Obtaining auricular cartilage for reconstructive surgery.

The cartilage in the scaphoid fossa between the helix laterally and the antihelix medially provides excellent underlying support for soft-tissue eyelid and nasal reconstruction. After subcutaneous infiltration anesthesia is administered through both the anterior and posterior auricular skin, an incision is made along the posterior rim of the helix. A dissection plane between the perichondrium and skin exposes the cartilage. The cartilage is removed without incising the anterior skin surface. This technique is particularly useful in cicatricial entropion, upper or lower eyelid retraction, eyelid reconstruction, and socket reconstruction.

The use of tragal cartilage in ossicular reconstruction.

Readily available tragal cartilage has been found to be a very beneficial autogenous graft source for construction of prostheses to correct those defects in the ossicular chain that frequently occur when the incudostapedial joint is destroyed by middle ear pathology, particularly by the retraction of the posterior, superior quadrant of the tympanic membrane against and/or around the incudostapedial connection. This is true whether there be only erosion of the incus just at the joint, or whether there is erosion of the entire long process of the incus together with the superstructure of the stapes. The various types of deformity and the particular tragal cartilage prosthesis tailored for each deformity, and designed for maximum gain in hearing, are presented together with representative pre- and postoperative audiograms for the variety of types.

Cartilage-perichondrial composite graft tympanoplasty in the treatment of posterior marginal and attic retraction pockets.

The atelectatic retraction pocket (ARP) has been implicated in the development of chronic otitis media and cholesteatoma. The ARP's tendency for persistence or recurrence despite treatment is a significant otologic problem. The purpose of this study is to define and discuss this clinical entity and the use of cartilage-perichondrium tympanoplasty as a safe and predictable method of treatment, reducing destructive complications while maintaining ear function. A retrospective analysis of 85 operated ears is presented.

Nasal reconstruction.

Congenital malformations, trauma, benign or malignant tumors may call for reconstructive surgical procedures to cover the defect. In order to establish a proper diagnosis a careful examination including X-rays and biopsies is mandatory. A close contact with with the radiotherapist is most desirable in order to combine the therapy if necessary. After the excision of scars or growth, we differentiate between three phases of treatment: 1. The immediate reconstruction either by local flaps or by free grafts. 2. The delayed excision of the tumor after the establishment of the proper diagnosis. This waiting period (two to three weeks) is used to preform the missing nasal parts in the vicinity of the lesion either on the cheek or forehead. Rib cartilage with split skin grafts or composite grafts is used for this purpose. After the excision of the tumor the nasal reconstruction is carried out during the same operation. 3. Tumor excision and coverage of the raw surface with split grafts in order to inspect the area for several months for any recurrence and the delayed reconstruction with adjacent or distant flaps. The operative techniques are described.

Perichondrial cutaneous graft. An alternative in composite skin grafting.

The perichondrial cutaneous graft (PCCG) is a composite skin graft that is an alternative to the full-thickness skin graft (FTSG). The PCCG is harvested from the ear and contains epidermis, dermis, scant subcutaneous tissue, and the perichondrial layer. This experiment examined the differences in contraction properties of PCCGs and FTSGs. Twenty FTSGs and 20 PCCGs were harvested from the ears and grafted onto the backs of seven New Zealand white rabbits. The results confirmed that the PCCG provides superior coverage to the FTSGs with regard to thickness, contraction properties, and hair retention. This graft has potential in reconstructive head and neck surgery. When skin grafting is appropriate, the PCCG may provide superior results.

Management of the paralyzed lower eyelid by implanting auricular cartilage.

The success of a procedure to reanimate paralyzed eyelids is determined by the functional and cosmetic results. When the cornea is covered during blinking and sleeping, function has been restored, while a pleasing cosmetic result has been achieved if the eyes appear symmetrical when the lids are open. Several procedures have been developed to restore closure of the paralyzed upper eyelid (implantation of gold weights or open wire springs) or to correct lower lid lagophthalmos and ectropion (lower lid tightening with a Bick procedure or insertion of a closed eyelid spring). In some cases, even a combination of the Bick procedure and insertion of a spring may be insufficient to correct lower lid droop; therefore, we developed a technique to place cartilage into the lower eyelid to correct lid droop. The procedure, suggested by one of us (D.B.S.), has been performed on 51 patients to date. This article reviews our experience with these 51 consecutive patients.

A new method for total reconstruction of the nose: the ears as donor areas.

The concha of the ear appears to be the best donor site for total nasal reconstruction, no matter what the cause of the loss of the nose. The advantages of the technique are as follows: (1) The skin is of the same color, texture, and thickness as that of a normal nose. (2) The osteocartilaginous framework is automatically provided by the conchal cartilage and a bony strut when required. (3) The lining is also an integral part of the flaps and does not require another source. (4) The nostrils are of good size and the patient breathes normally. (5) The ears from which the concha has been removed keep their normal shape, size, and appearance, and are only slightly flatter than normal. Replacement of the concha by a skin graft does not change its cosmetic appearance.

Pilot study to evaluate the efficacy of hyperbaric oxygen therapy in improving the survival of reattached auricular composite grafts in the New Zealand White rabbit.

OBJECTIVE: This investigation is a prospective, randomized, blinded study seeking to evaluate the efficacy of hyperbaric oxygen (HBO) therapy in improving the survival of the reattached auricular composite graft. STUDY DESIGN: Twenty New Zealand White rabbits were randomly assigned to control (10) and treatment (10) groups in a prospective fashion. After amputation and reattachment of measured segments of each ear, the treatment group received 14 HBO treatments for 10 days. The control group received only standard postoperative care. On postoperative day 18, the surviving composite grafts were measured, recorded, and statistically analyzed. RESULTS: The mean percentage of graft survival for the control group was 0.31% (range 0%-2.5%), and the mean for the group receiving HBO was 15.94% (range 0%-38%). A median test was used to evaluate this difference, which was found to be statistically significant (P = 0057). CONCLUSION: Our study appears to indicate a possible survival benefit for the composite grafts in those rabbits that received HBO treatments. We believe that there are several significant difficulties with the rabbit as a model for this study, but we are encouraged at this point that a limited measurable benefit was observed. Further investigations with HBO appear to be warranted at this time.

Auricular composite grafting to repair nasal vestibular stenosis.

Nasal vestibular stenosis is defined as a narrowing of the nasal inlet resulting in airway obstruction. Causes include nasal trauma, infection, and iatrogenic insults. The objectives of this article are to illustrate nasal vestibular stenosis and to analyze common causes and surgical treatments. The operative technique of the senior author (M.S.K.), will be presented. Donor site morbidity and patient outcomes will be discussed. Sixteen patients were seen during a 5-year period. Eleven women and 5 men were evaluated and found to have nasal vestibular stenosis. Three patients had stenosis as a result of nasal fracture or laceration. Stenosis developed in the remaining 13 as a result of nasal surgery. All patients underwent auricular composite grafting, and grafts took in 100%. Partial skin slough occurred in up to 50%; however, re-epithelialization was seen within 3 weeks. Complications were seen at the donor site. Immediate patient satisfaction was seen and continues during long-term follow-up.