Armamentarium
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History of the Procedure
The use of autologous cartilage graft in reconstruction surgery has been described as early as 1896 in the German literature by Konig. Subsequently, in 1907, Sushruta Samhita in India performed cartilage grafting in the form of a composite graft. In 1946, Brown and Cannon reported the use of auricular skin and cartilage composite grafts for reconstruction of the nose. Since that time, multiple harvesting techniques for auricular cartilage have been described with variations in the location of the skin incision, location of cartilage removal, and maximal amount of cartilage that can be removed without causing donor site deformity.
History of the Procedure
The use of autologous cartilage graft in reconstruction surgery has been described as early as 1896 in the German literature by Konig. Subsequently, in 1907, Sushruta Samhita in India performed cartilage grafting in the form of a composite graft. In 1946, Brown and Cannon reported the use of auricular skin and cartilage composite grafts for reconstruction of the nose. Since that time, multiple harvesting techniques for auricular cartilage have been described with variations in the location of the skin incision, location of cartilage removal, and maximal amount of cartilage that can be removed without causing donor site deformity.
Indications for the Use of the Procedure
Due to the elastic nature, pliability, and multiple contours of the auricular cartilage, it is one of the most versatile cartilage grafts. Indications for its use are multiple and will be briefly reviewed. Detailed discussion of each indication is, however, beyond the scope of this chapter.
Nasal Reconstruction
In the aesthetic and functional reconstruction of intrinsic, traumatic, or postoncologic surgery defects of the nose, cartilage grafting is often required. Choices of donor cartilage include the nasal septal cartilage, costal cartilage, and auricular cartilage. The use of auricular cartilage is indicated (1) in pediatric patients older than 4 years of age, (2) when the nasal defect encompasses the nasal septal cartilage, (3) when the amount of cartilage required exceeds the amount that the nasal septum can provide, and (4) when a skin/cartilage composite graft is required. In addition, the ease of harvest and its ability to substitute for all the cartilaginous structures of the nose has made the auricular cartilage an ideal donor site for nasal reconstruction. The type of graft and area of nose that can be reconstructed using the auricular cartilage are listed in Table 127-1 .
| Type of Graft | Region of Nose |
|---|---|
| Lateral crural strut graft | Ala |
| Spreader grafts | Dorsum |
| Columellar strut graft | Tip |
| Septal perforation repair | Septum |
| Dorsal onlay graft | Dorsum |
| Alar rim graft | Ala |
| Butterfly graft/shield graft | Tip |
Orbital Floor/Wall Blow-Out Fracture Reconstruction
Various indications for treatment, surgical access for treatment, and reconstruction techniques of the orbital floor/wall blow-out fractures have been described in the literature. Insufficient treatment may result in diplopia, entrapment of extraocular muscle, and enophthalmos due to an increase in orbital volume. Both autologous and alloplastic material can be used to repair the fractured orbital floor/wall. Castellani and colleagues reported that for relatively small (up to 2 × 2 cm) orbital floor defects, the use of an auricular cartilage graft is comparable to other graft material reported in the literature. Similarly, Kruschewsky and colleagues concluded in a prospective, randomized study of 20 patients that there is no significant aesthetic or functional difference in orbital blow-out fractures repaired with auricular cartilage or polyacid copolymer material.
Tracheal Reconstruction
Reconstruction of tracheal window defects as a result of tumor resection or repair of the tracheoesophageal fistula requires the use of graft material that would allow for maintenance of the tracheal skeletal framework to preserve the tracheal lumen. The relatively thin and pliable elastic cartilage of the auricle allows for easier attachment to the native tracheal wall when compared with costal cartilage. Also the natural contour of the conchal cartilage prevents prolapse of the graft into the tracheal lumen and creates skeletal support for the tracheal wall.
Tympanoplasty
Middle ear pathology, including tympanic membrane perforation, cholesteatoma, and atelectatic ear, may require reconstruction of the tympanic membrane after removal of the pathology. Conchal and tragal cartilage have been used with fair results in the reconstruction of the tympanic membrane.
Eyelid Reconstruction
Partial-thickness lower eyelid defects with the loss of the tarsal plate may result in entropion and contraction. Cartilage grafts can be used to lengthen or replace the tarsal plate. Full-thickness eyelid defects should be reconstructed to prevent injury to the cornea. The auricular cartilage can be used in conjunction with the vascularized cutaneous or musculocutaneous flap for reconstruction of full-thickness eyelid loss. Composite skin/cartilage grafts can also be used but are less reliable as they are more prone to ischemia.
Contralateral Ear Reconstruction
Finally, auricular cartilage can be used to establish the framework for reconstruction of the contralateral ear.
Limitations and Contraindications
The contraindications for auricular cartilage graft harvesting include systemic diseases or conditions such as collagen vascular disease, rheumatic disease, lupus, polychondritis, sarcoid, Wegener’s granulomatosis, predilection to keloid formation, prior extensive auricular cartilage harvesting, and microtia. There might be impaired wound healing or poor quality/quantity of the donor cartilage in a patient with these conditions or systemic diseases. Also auricular cartilage harvesting should be avoided in children under the age of 4 years to prevent growth restriction of the external ear.
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