AURICLE RECONSTRUCTION WITH ALLOGENOVS COSTAL. CARTILAGE AND AUTOGENOUS PERICHONDRIUM. Department of Otolaryngology, Institute of ...
ACTA MED. POL., 1980, 21, 1
JANINA WI:E;CKO, ANDRZEJ KUKWA AND ALEKSANDER HINEK
AURICLE RECONSTRUCTION WITH ALLOGENOVS COSTAL CARTILAGE AND AUTOGENOUS PERICHONDRIUM Department of Otolaryngology, Institute of Surgery, Me dical Academy, For reconstruction of the cartilaginous skeleton of the auricle in con genital anomalies (microtia et atresia meatus acustici externi) in chil dren aged 5-7 years allogenic costal cartilage grafts were used. The cartilage was preserved in 700fo ethyl alcohol, placed in a glass vessel with normal saline and irradiated with 3.3 mega rads of gamma ra diation of 6°Co. Allogenic cartilage was wrapped in a pedunculated flap of temporal muscle fascia and fragments of autogenous costal pesichan dsium. This method reduced the process of graft resorption. The ma terial treated in this way consists of 8 cases and the longest follow up was 5 years.
High-grade hypoplasia of the auricle and absence of the external acoustic meatus (microtia and atresia of the external acoustic meatus) spoil greatly appearance of the child. The necessity arises then of recon struction of the auricle in the shape similar to the natural ones seems to be evident. One of the greatest difficulties in carrying out plastic operations of the auricle in children is the lack of suitable material for reconstruct ion of its cartilaginous skeleton. Autogenous costal cartilage is, as yet, the best material for this purpose. However, the costal cartilage in chil dren aged 5-7 years is too small, thin and it is difficult or even quite impossible to obtain a proper shape and size for reconstruction of the auricle using this material.
Peer (1946, 1955, 1966) and Walia et al.
(1962) stressed that young autogenous cartilage is susceptible also to partial resorption.
WiE:cko et al.
88
Until now, human cartilage preserved in 0.9°/o NaCl and sterilized with
gamma
radiation '°Co
was used in
young
children if autoge
nous costal cartilage could not be applied (Wi�cko 1974). Grafts were obtained from the Central Tissue Bank of the Laboratory of Transplan tology, Medical Academy in Warsaw. Similarly preserved grafts for auricular reconstruction were used by Dingman et al (1961) who found a considerable resorption of these grafts. The grafts of cartilage sterilized with radioactive cobalt 6°Co is tolerated well causing no tissue reactions and inflammatory processes (Ostrowski et al., 1967; Wright et al., 1970). Musgrave (1966) founa preserved human cartilage as completely unsui table for permanent reconstruction of the auricle. In striving for longer maintenance of allogenous cartilage grafts in the organism of the recipient we carried out experiments on rabbits. It was found that if allogenous rabbit's rib grafts were wrapped in autogenous costal perichondrium, the resorption was lower at the site of wrapping. The surrounding connective tissue of the host penetrated less intensively into the graft (Kukwa et al., 1974). It was demonstrated also that resor ption of cartilage grafts was slower if the allogenous cartilage was fixed for 24 hours in 70°/o ethanol solution before placing it in normal saline and irradiating it with 6°Co rays (Biskupska-Wi�cko et al., 1974). Both these observations were applied in reconstruction of the auricle in chil dren.
MATERIAL AND METHODS
In eight children aged from 6 to 8 years the lacking part of the auricle was recenstructed with grafts of allogenous costal cartilage. The cartilage was fixed for 24 hours in 70fl/o ethyl alcohol, placed then in a glass vessel with normal saline and sterilized with gamma rays of 6°Co in a dose of 3.3 mega rads. The appropriately modelled cartilage was wrap ped in autogenous rib's perichondrium. The perichondrium was obtained during the same operation from the rib on the costal arch. Always whole thickness perichondrium graft was taken containing the fibrous layer as well as the layer rich in chondrogenic cells. It was usually difficult to take obtain a sufficiently large flap of perichondrium for covering the whole graft, then its peripheral parts were wrapped additionally with a pedunculated flap of temporal muscle fascia. Surgical technique Stage I -·formation of the external acoustic meatus and kofosurgical operation on the middle eat. :The external meatus was formed behind the· fragments of rudimentary auricle. The walls of the meatus are covered
Auricle reconstruction with costal cartilage
89
with a skin graft. The skin on the surface of the mastoid processes was intact as necessary for reconstruction of the auricle (Fig. 1). ',, If no indications for a kofosurgical operation were present (deep mid
dle ear hypoplasia confirmed radiologically, unilateral anomaly with the contralateral ear with normal hearing, parental consent not available) reconstruction of the auricle is started removing a part of hair-covered skin from the surface of the mastoid process, and the blind external meatus was formed in the last stage of the operation. Stage II
-
removal of the hair-covered skin from the surface of the
mastoid process where the auricle will be reconstructed, and covered this surface with a splict skin graft (Fig.
Fig. 1
2).
Fig. 2
Fig. 1. Reconstructed external acoustic meatus behind fragments of rudimentary auricle.
Fig. 2. Free skin graft in place of hair-covered skin on the head.
Stage Ill
-
a possibly thin graft modelled with a drill from one or two
connected fragments of costal cartilage was inserted under the skin on the mastoid process. In the cartilage several holes were made (Fig
3).
A pedunculated flap was made of the temporal muscle fascia in the
lower part of the muscle and the helix of the cartilaginous skeleton of the auricle was wrapped with it. The remaining surface of the graft was , covered with strips of perichondrium taken from the ribs of the patient
p
during the same o e'l-ation (Fig 4).
Wi�cko et al.
90
Fig. 3
Fig. 4
3.
Modelled cartilaginous skeleton of the reconstructed auricle. Holes in the graft are visible. Fig. 4. Modelled costal cartilage inserted under the skin on the mas toid process. Fig.
Fig. 5
Fio. 6
f'io. 5 and 6. Reconstructed auricle, five years after the operation.
Auricle reconstruction with costal cartilage
91
Stage IV - After 2-3 months the graft was cut off from the surface
of the mastoid process, and the posterior surface of the auricle and the area on the mastoid process were covered with non-full-thickness free skin graft. At the sites of the earlier made holes in the cartilage two skin flaps on the anterior and posterior aspect of the auricle come into close contact. The fine modelled cartilage and the contact of these two surfaces of skin flaps cause that the outline of the auricle is well shaped. Stage V - Displacement of the lobe of the rudimentary auricle po steriorly to the periphery of the graft. The lobe and the blind acoustic meatus were reconstructed from a fragment of the rudimentary auricle (Fig 5 and 6). The width and length of the reconstructed auricle cor respond to those which would be reached probably by the contralateral auricle at the age of 18 years. These dimensions have been established on the basis of anthropometric investigations carried out in children at different ages (Biskupska-Witicko 1972).
DISCUSSION
The above described technique of reconstruction was used in 8 cases. The longest follow up after the operation was 5 years, the shortest one 3 years. The degree of resorption of grafts was compared clinically re garding the dimensions of the reconstructed auricle during control exa minations
with
postoperative
dimensions.
Microscopic
examinations
were not done to avoid damage to the graft. In the period of follow up·. the recontructed
auricles showed only a slight deformity and the diffe
rences in their width and lenght were 2-3 mm. Doubtlessly this was due to some resorption of the devitalized graft. It may be assumed, in view of this, that the processes of resorption and chondrogenesis were in the dynamic steadystate. It seems that in the described case the cambial layer of the autogenous perichondrum may be the source of chondrogenic cells appearing within the graft as was established by Skoog et al. (1975). Resorption of the grafts of allogenous costal cartilage with autogenous perichondrium and temporal muscle fascia was much lower than in cases treated with grafts only (Kukwa et al. 1974).
CONCLUSIONS
1. Allogenous grafts of costal cartilage preserved in 70°/o ethanol, stored in 0.9°/o NaCI solution after radiation sterilization and wrapped in autogenous costal perichondrium with temporal muscle fascia healed well without reactions in the surrounding tissues of the recipient.
Wi�cko et al.
92
2. Wrapping of modelled cartilage with temporal muscle fascia and
autogenous costal penichondrium prevented resorption and made pos sible maintenance ,of unchanged size and shape of the reconstructed auricle for several years. 3. These grafts may be used as biological prostheses for reconstruc
tion of the skeleton of the hypoplastic auricle. REFERENCES 1.
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Request for reprints should be addressed to: dr hab. med. Janina Wi�cko, Klipika Otolaryngologiczna AM, ul. Banacha 1, 02-097 Warszawa.
