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Thursday, June 11, 2015

Reconstructing a destroyed ear almost 90 years ago


Reconstructing the intricate anatomy of the auricle, with its folds and bends of thin cartilage, isn't easy even today. (Many patients decide to opt for an ear prosthesis rather than a reconstructed ear, which can look chunky, unnatural and just plain ugly.) I was surprised to learn that back in the 1920s, when plastic and reconstructive surgery was still in its infancy, some adventurous surgeons were attempting ear reconstruction procedures. One such case is documented in California and Western Medicine - the official journal of the California Medical Association. The case report was published in 1927. The patient, a young man, had been injured in a railway accident, losing all but a small portion of his ear. 

The procedure was largely carried out on a trial-and-error basis. The surgeon, one Harrington B. Graham, writes:

"The tissues on the scalp were undamaged so that I could use the non-hairy parts for the reconstructed portion. My first step was to transplant a piece of septal cartilage the shape of the sole of a shoe to the subcuticular tissues posterior to the defect. I placed this directly behind the defect instead of above and behind, so that when I brought my tissues forward I did not have enough support to keep them high enough. Any cartilage either from the nose of rib, used to keep the soft tissues up and away from the head, should lie, by preference, in the one-third of the completed ear. It is difficult to get enough nasal septal cartilage to fill the demand, so that the lower portion of the lobe may have to be disregarded."

Despite the difficulties with obtaining enough cartilage from the nose, the author is not convinced that rib cartilage would work better. He also stresses the importance of the final cosmetic effect of the surgery, which depends largely on the operator's skill and on the technique used.

"[obtaining rib cartilage] is a difficult task and the shaping might increase the tendency to absorption. It is hard to get a piece of rib cartilage as thin as septal cartilage, and this is a very important factor, as far as the cosmetic appearance of the ear is concerned.

The thinness of the new tissue will depend to a great extent upon the position subcutaneously of the transplant. If it is buried deeply in the tissues, the result must be a thick ear. A superficial position is a difficult one to obtain, but will pay the operator for his pains. Any tissue taken from the arm or chest must be thick, looking like a piece of putty when transplanted. However, time modifies its appearance so that under certain circumstances it may be permissible to use it."

The reconstruction was carried out painstakingly in stages and involved skin grafting from the leg:

"After leaving the cartilage in place for a month, I made a circular incision to the hair line, starting at the upper anterior part of the old ear. This incision was carried to the periosteum and the skin thus outlined, including the cartilage, was raised and folded in such a way as to have the upper border of the ear covered by a continuous layer of skin. The anterior portion was now sewed down to the tragus, and the defect on the scalp remedied by the customary undermining, reduction in size of the opening, and a skin graft taken from the leg [...] Were I to do another I should not fold the upper edge back, as in this case, but would use it entire, placing a graft over the whole posterior surface. This flap, if the cartilage were properly placed, would be quite sufficient to form a new ear without any further addition.

After another month the lower part was incised, carried forward and sewed to the freshened lobule, another graft being placed posteriorly. A few minor operations were done to smooth things out, and an attempt made to stiffen the upper border somewhat by the introduction of celluloid."

Here is a picture from the initial stages of surgical work:



And the final result looked like this:

All images from: Graham (1927)

The author self-critically admits:

"The ear that I constructed is considerably smaller than the normal ear, due to the fact that I did not carry my incision high enough on the head, that I folded too much tissue back in order to get a smooth border, and that my cartilage was not placed high enough. All of these errors should be avoided in future work."

However, the final result of the reconstruction still looks quite impressive, given the times!



Source:

Graham HB. (1927) The reconstruction of a completely destroyed auricle. Case report. Cal West Med. 27(4): 518–519. 
 
 
 

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