Can MRI Replace Nasopharyngoscopy in the Evaluation of Velopharyngeal Insufficiency?

OBJECTIVE: To investigate whether flexible nasopharyngoscopy, when performed in addition to magnetic resonance imaging (MRI), influences the type of surgery selected or success of surgery in patients with velopharyngeal insufficiency (VPI). DESIGN: Cohort study. SETTING: A metropolitan children's hospital. PATIENTS: Patients with non-syndromic, repaired cleft palate presenting for management of VPI. INTERVENTIONS: MRI and nasopharyngoscopy or MRI alone for preoperative imaging of the velopharyngeal mechanism. MAIN OUTCOME MEASURES: (1) Surgical selection and (2) resolution of hypernasality. All speech, MRI, and nasopharyngoscopy measurements were performed by raters blinded to patients' medical and surgical history. RESULTS: Of the 25 patients referred for nasopharyngoscopy, 76% completed the exam. Of the 41 patients referred for MRI, the scan was successfully completed by 98% of patients. Completion of nasopharyngoscopy was significantly (p=0.01) lower than MRI. Surgical selection did not significantly differ (p=0.73) between the group receiving MRI and nasopharyngoscopy and the group receiving MRI alone, nor was there a significant difference between these groups in the proportion of patients achieving resolution of hypernasality postoperatively (p=0.63). Percent total velopharyngeal closure assessments on nasopharyngoscopy and MRI were strongly correlated (r=0.73). CONCLUSIONS: In patients receiving MRI as part of their preoperative VPI evaluation, the addition of nasopharyngoscopy did not result in a difference in surgical selection or resolution of hypernasality. Routine inclusion of nasopharyngoscopy may not be necessary for the evaluation of velopharyngeal anatomy when MRI is available.

Comparative Effectiveness of Secondary Furlow and Buccal Myomucosal Flap Lengthening to Treat Velopharyngeal Insufficiency.

Background: Secondary Furlow (Furlow) and buccal myomucosal flaps (BMMF) treat velopharyngeal insufficiency by lengthening the palate and retropositioning the levator veli palatini muscles. The criteria for choosing one operation over the other remain unclear. Methods: A single-center retrospective cohort study was conducted. Thirty-two patients with nonsyndromic, repaired cleft palate were included. All patients underwent a Furlow or BMMF. Outcome measures included (1) resolution of hypernasality 12 months postoperatively, (2) degree of improvement of hypernasality severity; and (3) change in velar length, as measured on magnetic resonance imaging scans obtained preoperatively and 12 months postoperatively. All measures were performed by raters blinded to participants' medical and surgical history. Results: Hypernasality was corrected to normal in 80% of the Furlow group and in 56% of the BMMF group. Patients receiving BMMF had more severe hypernasality during preoperative speech evaluation. Both groups had a median decrease of two scalar rating points for severity of hypernasality (P = 0.58). On postoperative magnetic resonance imaging, patients who underwent Furlow had a median increased velar length of 6.9 mm. Patients who received BMMF had a median increased velar length of 7.5 mm. There was no statistically significant difference between groups regarding increase in velar length (P = 0.95). Conclusions: Furlow and BMMF procedures increase velar length with favorable speech outcomes. The same degree of improvement for hypernasality was observed across groups, likely explained by the similar increase in velar length achieved. Anatomic changes in palate length and levator veli palatini retropositioning persist 1 year after surgery.

Preoperative Frontal and Parietal Bone Thickness Assessment to Predict Blood Loss and Transfusion During Extended Suturectomy for Isolated Sagittal Craniosynostosis.

OBJECTIVE: To predict the morbidity of sagittal suturectomy using preoperative computer tomographic measurement of frontal and parietal bone thickness in osteotomy sites. DESIGN: Retrospective analysis. SETTING: Tertiary children's hospital. PATIENTS: Fifty infants with nonsyndromic, isolated sagittal craniosynostosis who underwent extended sagittal suturectomy from 2015-2022. METHODS: Mean thickness of the frontal and parietal bone in regions of osteotomies were determined for each patient from preoperative CT images obtained within 30 days prior to suturectomy. The relationship between bone thickness (mm) and estimated blood loss (mL) was evaluated using Spearman's correlation and a multivariable model that adjusted for patient weight and surgery duration. The association between bone thickness and perioperative blood transfusion was evaluated using a multivariable logistic model controlling for patient weight and surgery duration. MAIN OUTCOME MEASURES: Estimated blood loss, perioperative blood transfusion. RESULTS: Frontal and parietal bone thickness in the region of osteotomies were positively correlated with estimated blood loss (p < 0.01). After adjusting for patient weight and duration of operation, both parietal and frontal bone thickness were associated with intraoperative blood loss (R2 = 0.292, p = 0.002 and R2 = 0.216, p = 0.026). Thicker frontal and parietal bone in the line of osteotomies resulted in significantly higher odds of blood transfusion. Bone thickness in the line of parietal osteotomies was 76% accurate at identifying patients who would require blood transfusion (p = 0.004). CONCLUSIONS: Frontal and parietal bone thickness in the line of osteotomies is associated with blood loss and perioperative blood transfusion for sagittal suturectomy operations.

Jaw Surgery Workshop: Patient Preparation for Orthognathic Surgery.

BACKGROUND: Patients undergoing orthognathic surgery may have limited information surrounding surgery. This leads to less satisfaction with surgical outcomes, anxiety surrounding surgery and difficulty following perioperative instructions. SOLUTION: Providing a multi-disciplinary pre-operative educational experience for patients and caregivers improves surgical readiness and satisfaction. WHAT IS NEW: Our team provides a "Jaw Surgery Workshop" which includes lectures from providers, previous patients, cookbooks and supplies. This allows for improved confidence and expectations surrounding jaw surgery.

Perioperative Morbidity of Secondary Frontal Orbital Advancement After Initial Frontal Orbital Advancement.

Frontal orbital advancement (FOA) is frequently performed for patients with syndromic and/or multisuture craniosynostosis. A small proportion of patients who undergo FOA have unfavorable growth and subsequently require a second FOA later in life; however, the perioperative risks associated with this second procedure are not well studied. We report results from a retrospective review of FOAs conducted from 2007 to 2022 at a single site with the same craniofacial surgeon. A total of 33 patients were included. Perioperative outcomes were compared between primary and secondary FOA procedures. The two groups were similar in regard to suture involvement and diagnosis, although the secondary FOA group was older at the time of their FOA (1.23 versus 7.07 y, P <0.001). There was no significant difference between groups in operating time, volume of blood transfusion by weight, or in the incidence of postoperative wound complications ( P >0.05). Primary FOA procedures had significantly higher weight-adjusted blood loss (28 versus 18 mL/kg, P =0.014), with a higher proportion of patients receiving a blood transfusion (95% versus 62%, P =0.025). There was no significant difference between groups in the incidence of intraoperative dural injury (50% versus 84%, P =0.067). Our findings suggest that secondary procedures appear to impose less of a surgical risk relative to primary FOA traditionally performed in infancy, likely because of the advanced age at the time of secondary FOA.

Accessory Cranial Suture Leading to Abnormal Head Shape.

ABSTRACT: Accessory cranial sutures have been described in the literature and are most commonly associated with the parietal bone. These sutures are typically identified incidentally and there have been no reported cases of accessory cranial sutures leading to abnormal head shape.The authors present the case of a 3-month-old patient with multiple congenital anomalies and an accessory parietal suture leading to abnormal head shape. The patient was successfully treated with cranial orthotic therapy. To our knowledge, this is the first reported case of an accessory cranial suture leading to abnormal head shape.

Ablepharon Macrostomia Syndrome: Rib Cartilage and Fat Grafting for Lower Lid Reconstruction.

ABSTRACT: Ablepharon macrostomia syndrome (AMS) is a rare condition with fewer than 20 cases being reported in the literature. Features of AMS include ablepharon, hypertelorism, macrostomia, dysplastic ears, sparse body hair, and ambiguous genitalia. The most significant phenotypic presentation is rudimentary eyelids resulting in exposure keratopathy, corneal abrasions, and potential blindness. Numerous methods including primary full thickness skin grafting, conjunctival sutures followed by full thickness skin grafting, and a combination of skin grafting and local flaps have been described for definitive eyelid reconstruction in these patients. The authors report the first case of autologous rib cartilage grafting and fat grafting for lower eyelid reconstruction in a patient with AMS.

The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-Analysis.

BACKGROUND: Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness. METHODS: PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale. RESULTS: Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes (P = .6572). CONCLUSIONS: Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.

Long-Term Outcomes for Adult Patients With Cleft Lip and Palate.

The purpose of this study was to evaluate a single center's experience with adult patients who had cleft lip, cleft palate, or both. The authors aimed to identify common long-term needs in this patient population and evaluated the relationship of team-based care in meeting those needs. To do so, the authors retrospectively reviewed chart records from a single private practice and tertiary referral cleft center for all patients who were ≥15 years of age and who had a history of clefts of the lip or palate, or both, from January 1, 2013, to June 30, 2014. The authors compared the concerns of the patients who received cleft-team-based care by a single, multidisciplinary cleft team; multiple multidisciplinary cleft teams; or no formal cleft team. The authors analyzed data for 142 patients. The most common patient concerns were lip aesthetics (64%), nose aesthetics (61%), septal deviations (47%), nasal obstruction (44%), malocclusion (32%), oronasal fistulas (29%), and speech (21%). Oronasal fistulas were more commonly reported in the group of patients who had care by multiple teams (42.9%; P < .001). Malocclusion was more commonly reported in the group of patients who had care by multiple teams (50%; P = .001). The authors found that adult patients who have undergone rehabilitation for cleft lip and palate appear to have a common set of long-term needs. Multidisciplinary cleft-team-based care appears to be the most effective way to address these needs.

Work-Related Musculoskeletal Discomfort and Injury in Craniofacial and Maxillofacial Surgeons.

INTRODUCTION: Long, complex surgical procedures with non-ergonomic postures, headlights, loupe magnification, and microscope use may put craniofacial and maxillofacial surgeons at an increased risk of work-related musculoskeletal discomfort (WRMD). Identifying the prevalence and impact of WRMD may guide preventive strategies to prolong well-being, job satisfaction, and career duration. METHODS: A 31-question survey was designed to evaluate WRMD. The survey was sent to American Society of Craniofacial Surgeons and American Society of Maxillofacial Surgeons members. The survey was created and distributed electronically through a private survey research center (Qualtrics Survey Software). RESULTS: There were 95 respondents (23.75% response rate): 75% male, 56% aged 31 to 50 years old, and 73% in academic practice. On a scale of 0 to 10 (0 no pain, 10 worst pain), WRMD for surgery without loupes/microscope had a median of 3, with loupes 4, and with microscope 5. Pain was most common in the neck. Pain within 4 hours of surgery was present in 55% and 38% feared pain would influence future surgical performance. Surgeon discomfort affects posture (72%), stamina (32%), sleep (28%), surgical speed (24%), relationships (18%), and concentration (17%). Medical treatment for discomfort was sought by 22%. Time off work for treatment occurred in 9%. CONCLUSION: The WRMD can affect many aspects of a craniofacial or maxillofacial surgeon's life and has the potential to shorten or end a career. Occupational health and surgical ergonomics should be emphasized during surgical training and in surgical practice.

Craniosynostosis Surgery and the Impact of Tranexamic Acid Dosing.

Consensus does not exist regarding the best dosage regimen for using tranexamic acid (TXA) for patients undergoing open calvarial vault remodeling in craniosynostosis surgery. The purpose of this study was to evaluate 2 dosing protocols, as well as the cost of using TXA. Previously, the institutional protocol was to give patients undergoing open calvarial vault remodeling a loading infusion of TXA (10 mg/kg) at the start of their procedure, after which intravenous TXA (5 mg/kg/h) was given throughout surgery and for 24 hours postoperatively. In July 2015, the protocol changed to a reduced postoperative infusion time of 4 hours. A retrospective review was conducted of records of 30 patients who had surgery before the protocol change (24-hour group) and 23 patients whose surgery occurred after the protocol change (4-hour group). The following data were collected: blood volume transfused, hemoglobin levels, estimated blood loss, and intensive care days; and costs of TXA and blood transfusion. Results showed a 4-hour infusion was as effective as a 24-hour infusion for reducing blood loss in patients undergoing craniosynostosis. Transfusion requirements, hemoglobin and hematocrit levels, and estimated blood loss were not significantly different for the groups. The cost of TXA and transfusion in the 4-hour group was significantly less (P < 0.001) than in the 24-hour group. No significant difference in cost existed for patients who received blood transfusion alone versus patients who received the 4-hour TXA infusion.

Outcomes of Titanium Mesh Cranioplasty in Pediatric Patients.

PURPOSE: Cranial defects in children have been repaired with various materials ranging from autologous bone to synthetic materials. There is little published literature on the outcomes of titanium mesh cranioplasty (TMC) in calvarial reconstruction in the pediatric population. This study evaluates a pediatric cohort who underwent calvarial defect reconstruction with titanium mesh and assesses the efficacy and outcomes of TMC. METHODS: An Institutional Review Board approved retrospective review of patients ≤18 years of age who underwent cranioplasty from 1999 to 2014 at 2 centers was performed. The cohort undergoing TMC was studied. RESULTS: A total of 159 cranioplasties were performed. Autologous reconstruction included 84 bone flap replacements and 36 split calvarial bone graft reconstructions. Six patients underwent PEEK implant reconstruction. Titanium mesh cranioplasty was performed on 33 patients. Two patients underwent 2 separate cranioplasties. The median age of patients was 6 years (19 months to 18 years). The most common underlying etiologies were congenital syndromes/craniosynostosis (13 patients), and trauma (11). The majority of patients had prior cranial surgeries (85%). Various types of titanium mesh were used with sizes ranging from 2×3 cm to 19×20 cm, with some patients requiring distinct areas of defect reconstruction. Perioperative complications were noted in 2 patients that subsequently improved. Two patients had late soft tissue problems with complications of wound infections requiring resection of a portion of the mesh. Patients were followed an average of 4 years (range 13 days to 6.8 years), with 2 patients lost to follow-up. Overall, all patients with follow-up achieved a cranial contour with good symmetry to the unaffected side, as well as effective protection to the brain. CONCLUSIONS: Titanium mesh cranioplasty is an effective option for correcting pediatric cranial defects when autologous bone availability is limited and soft tissue coverage allows placement of an implant. The interim outcome for these patients is favorable with few complications and no evidence of growth restriction in the authors' series. Follow-up will be ongoing for these patients.

Open Craniosynostosis Surgery: Effect of Early Intraoperative Blood Transfusion on Postoperative Course.

Correction of craniosynostosis can result in blood loss when the patient already has physiologic anemia. The aim of this study was to determine whether patients benefit from early blood transfusion and whether the timing of blood transfusion affects metabolic disturbances and the postoperative course. In this retrospective review, 71 patients who underwent open calvarial vault remodeling for correction of craniosynostosis were separated into 2 groups according to whether they received blood transfusions early (within the first 30 minutes of surgery) or later (after the first 30 minutes of surgery). Patients were further separated into nonsyndromic and syndromic cohorts. Tracked variables included hemoglobin, hematocrit, arterial blood gas values, lactate level, length of stay, estimated blood loss, and amount of blood transfused in the operating room, amount transfused postoperatively, and total amount transfused.Among all patients, the early transfusion group had a higher hemoglobin nadir overall and received less postoperative blood. Within the nonsyndromic cohort, the early transfusion group had a higher estimated blood loss and received more transfused blood. In the syndromic cohort, the early transfusion group had a hemoglobin nadir that was significantly higher than in the late transfusion group and a lower estimated blood loss, shorter pediatric intensive care unit stay, and less postoperative blood transfused. Syndromic patients also received significantly more blood overall. For syndromic patients undergoing open calvarial vault remodeling, transfusion within the first 30 minutes of surgery should be considered.

Tranexamic Acid Reduces Blood Loss in Craniosynostosis Surgery.

METHODS: The authors retrospectively reviewed 79 patients with craniosynostosis who underwent either bifrontal or biparietal-occipital calvarial vault remodeling before institution of tranexamic acid (TXA) administration (non-TXA group) and 35 patients after institution of TXA administration (TXA group). The patients were analyzed in 2 groups: all open calvarial vault remodeling patients (anterior and posterior) as a whole, and anterior vaults only as a subset analysis. Primary outcomes accessed were: total intraoperative blood transfused, postoperative blood transfused, and estimated blood loss (EBL). Secondary outcomes evaluated were length of stay in the pediatric intensive care unit and hospital length of stay. RESULTS: When comparing all open calvarial vault remodeling patients, patients who received TXA required significantly less total blood transfusion during their operation (264 cc TXA group versus 428 cc non-TXA, P < 0.0001). Patients who received TXA required no blood transfusions postoperatively, compared with the non-TXA group, in which 45% of patients required postoperative blood transfusion. Weight-based EBL was also significantly lower in those patients receiving TXA (25 cc/kg in the TXA group versus 34 cc/kg in the non-TXA group [P = 0.0143]). All patients required transfusion intraoperatively. Pediatric intensive care unit length of stay was shorter in the TXA group, but there was no significant difference in total hospital length of stay. These findings also reached statistical significance when comparing only the anterior vault patients. CONCLUSION: Intraoperative TXA administration has a correlation with reduced blood transfusion requirements, as well as EBL, in patients undergoing open calvarial vault remodeling. There were no adverse events related to TXA administration.

Squamosal suture synostosis: a cause of atypical skull asymmetry.

BACKGROUND: The squamosal suture is markedly different from the major calvarial sutures of the human skull. The unique properties of the suture are a result of the complex developmental biology of the temporal bone and biomechanical force exerted by surrounding structures. The dysmorphic effects of premature fusion of the suture, and possible treatment strategies in cases of synostosis, have received only brief description in the literature. METHODS: A retrospective case series was performed. The study included patients evaluated by one of the senior authors (S.P.B., R.R.R., and D.J.S.) between 1993 and 2009. All pertinent patient data including inpatient and outpatient charts, photographic records, and radiographic scans were reviewed. Any management performed under the direction of a craniofacial surgeon was documented--including orthotic helmet therapy and operative management. RESULTS: The study included 14 patients. Synostosis of the squamosal suture was noted to occur either in an isolated fashion or in the setting of other craniofacial malformations. Patients with isolated squamosal synostosis often suffered from a deformity that was mild in severity and tended to improve with time. However, when occurring in the setting of other forms of craniosynostosis, the deformity was often progressive, and transcranial surgery was frequently required. CONCLUSIONS: Synostosis of the squamosal suture can result in, or contribute to, significant craniofacial dysmorphism. The optimal form of therapy for this disorder is evolving.

Pediatric cranial vault defects: early experience with beta-tricalcium phosphate bone graft substitute.

Pediatric calvarial defects may result from numerous causes. Availability of bone is often limited because of the child's age, and bone substitutes may be needed to reconstruct the defects. A bone substitute composed of ultraporous beta-tricalcium phosphate (Orthovita, Malvern, PA) is an osteoconductive product successfully used in orthopedic surgery. However, its application in cranial vault reconstruction is largely unstudied. The purpose of this investigation was to determine the healing rate of bone defects with the use of this product.A retrospective review was performed of patients in whom beta-tricalcium phosphate was used. Patient population consisted of 23 patients. Mean surgical age was 35 months. Reconstructions consisted of 20 craniosynostosis corrections and 3 posttraumatic repairs. The average defect size was 37 cm (range, 4.6-210 cm). Average follow-up was 12.7 months.At 2 months, 19 (79%) of 23 patients achieved healing of their defect, defined as the absence of persistent bone gaps. Persistent areas of bone weakness occurred in 3 patients at 4 months and 2 patients at 6 months. By 9 months, only 1 patient had not healed. This patient had the largest original defect of 210 cm. Defects taking longer than 2 months to heal measured 83 cm, whereas healed defects were 32 cm. No patients required treatment for graft-related problems such as infection or exposure.Early experience with beta-tricalcium phosphate bone substitute shows good healing of pediatric calvarial vault defects by 2 months, with no graft-associated complications. It seems most effective in the repair of smaller defects less than 40 cm.

Mandibular deformities: single-vector distraction techniques for a multivector problem.

Single-vector distraction devices have been criticized for creating a malocclusion in an attempt to correct a three-dimensional mandibular deficiency, resulting in the evolution of a multiplanar device. Although there are indications for the use of a multiplanar device, a vast number of patients with mandibular hypoplasia can be effectively treated with a single-vector device, producing a normal occlusion and an aesthetic result while minimizing facial scarring and simplifying postoperative care. The purpose of this review was to describe surgical techniques whereby a single-vector device is effectively used in treating a multivector mandibular deficiency.A retrospective analysis of all patients who underwent mandibular distraction at the Children's Hospital of Philadelphia between 1996 and 2005 with a semiburied, uniplanar device was conducted. Charts, photographs, graphs, operative reports, computed tomography scans, and cephalometrograms were reviewed for those patients undergoing uniplanar mandibular distraction.Ten unilateral and 4 bilateral distractions were performed. In these 14 patients, causes included hemifacial microsomia, Treacher Collins syndrome, posttraumatic hypoplasia, and temporomandibular joint ankylosis with hypoplasia. The average device distraction was 29 mm (range, 18-34 mm). The average age at distraction was 8.4 years (range, 4-15 years). Surgical techniques for these patients will be described in detail. The single-vector, semiburied device can be effectively used to aesthetically correct a three-dimensional problem and to produce or maintain a class I occlusion while simplifying postoperative management and minimizing facial scarring.

Hemifacial microsomia: clinical features and pictographic representations of the OMENS classification system.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Describe the fundamental malformations defining hemifacial microsomia. 2. Distinguish hemifacial microsomia from other congenital craniofacial anomalies sharing similar features. 3. Understand the variety of systems developed to clinically classify the features of this disorder. 4. Describe the format of the OMENS clinical classification system and appreciate its possible advantages and limitations. BACKGROUND: The clinical manifestations of hemifacial microsomia comprise a spectrum that is both broad and complex. The fundamental features include unilateral hypoplasia of the craniofacial skeleton and its overlying soft tissue. Numerous schemes have been developed to classify this spectrum. One of the most recent classification systems, the OMENS system, scores five clinical manifestations of hemifacial microsomia according to dysmorphic severity on a scale from 0 to 3: orbital asymmetry, mandibular hypoplasia, ear deformity, nerve dysfunction, and soft-tissue deficiency. METHODS: The authors describe the diverse features of hemifacial microsomia and the numerous attempts at its clinical classification, with particular emphasis on the OMENS system. RESULTS: With the possible exception of the OMENS scheme, the various systems developed to classify the clinical features of hemifacial microsomia fail to possess the flexibility and versatility needed to categorize all potential phenotypes of this complex disorder. CONCLUSIONS: The OMENS system represents the most comprehensive, versatile, objective, and easily adaptable attempt at clinical classification of hemifacial microsomia to date. The authors propose a concise clinical evaluation form using a modified version of the system to promote the use of the OMENS system, to aid in the evaluation of hemifacial microsomia patients, and to assist in data sharing among academic institutions.

Aesthetic management of the ear as a donor site.

BACKGROUND: The ear is a frequently used donor site for facial reconstruction. It serves as an ideal source for skin, cartilage, and composite grafts because of its color and texture match. However, because of the prominent location of the ears, the prevention of donor-site problems such as scarring and resultant asymmetries is equally important in creating an overall aesthetic facial reconstruction. The purpose of this review was to describe surgical techniques of minimizing ear donor-site morbidity as a consequence of harvesting of composite chondrocutaneous grafts. METHODS: A retrospective analysis was performed of all patients who underwent nasal reconstruction performed by the senior surgeon (D.J.S.) between 1987 and 2003, to identify those patients in whom a composite chondrocutaneous auricular graft was used. Photographs, surgical technique, and aesthetic outcomes were reviewed for those patients identified as having donor auricular composite grafts. RESULTS: Three hundred fifty-seven nasal reconstructions were performed. Of the 357 reconstructions, 67 involved harvest of preauricular or postauricular full-thickness skin graft, and 79 involved use of auricular cartilage. Sixteen of the 79 involved harvesting of auricular composite grafts. For these 16 patients, defect size, donor site, and closure of donor site are described and indications for certain techniques are delineated. CONCLUSIONS: The harvest of composite grafts is challenging in technical design and in closure of the defect. In this patient series, the donor defects were closed primarily in one of six ways, depending on the size of the cartilage and skin graft required. These techniques allowed adequate harvest of donor tissue while preserving the aesthetics of the ear.