A L A R G E C O M P O S I T E A U R I C U L A R G R A F T

By FRANK ROBINSON, B.Sc., M.B., F.R.C.S.

From IVythenshawe Hospital, Manchester

COMPOSITE auricular grafts as described by Brown and Cannon (1946 a, b) and by Szlazak (1948) have been used to repair small defects o f the alto of the nose f rom t ime to time. In general they have been successful.

At the end o f 1954 a very large composite graft was used to restore the tip o f a nose and bo th alto. T h e result has been satisfactory.

FIG. I FIG. 2

Prior to operation.

Case Report . --Will iam H., aged 43, was originally admitted on 24th December 1952 , having fallen on to the fire while in an epileptic fit. He sustained extensive full-thickness burns of the face, forehead, neck, and right ear.

Primary treatment included slough excision, bilateral tarsorrhaphy, and free skin grafting, and the burns were healed eight weeks after admission. Each tarsorrhaphy was then released in turn, split-skin grafts being applied to the upper and lower lids at the same operation. He was discharged on 9th April 1953 and readmitted on 7th May 1953 for a dermatome graft to the upper lip and right corner of the mouth. He was an in-patient for a further three weeks.

As a result of this treatment, extending over five months, his general appearance was reasonable except for deformity of the nose and right ear. Fie went back to work.

A year later he was offered treatment for both the nose and ear, but did not wish the latter to be operated upon. As shown in Figs. I and 2, the tip of the nose and

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A LARGE COMPOSITE AURICULAR GRAFT 331

adjacent alto had been destroyed, and the septal and alar cartilages were protruding, being covered by thin scar only.

The patient was admitted on i5th November 1954 for repair of the nose by a tubed pedicle flap. Mr Randell Champion then suggested that an adequate simpler repair might be effected by shortening the septum slightly and applying a large composite graft from the left ear.

Operation (I7th November I954).--The anterior part of the septum was exposed through a submucous incision and o- 5 cm. removed. The nasal spine was also trimmed and the columella set back. The scar and underlying cartilage was then excised along the edge of each alto and over the tip of the nose, creating a defect 8 cm.

FIG. 3 Twenty-four hours after operation.

in length extending right round its upper border. A composite graft of this length was taken from the rim of the left ear, the residual defect here being closed by direct suture after excision of protruding cartilage. After excess cartilage had been trimmed the free graft was sutured into position by two rows of 4/0 silk sutures, its edges being approximated to skin and mucosa respectively. As recommended by McLaughlin (1954), it was left exposed without a dressing (Fig. 3).

Post-operative Progress.--Most of the graft, originally dead-white, became adequately vascularised and gave rise to no anxiety. After forty-eight hours, however, an area some 3 cm. in length in the right alar region had become deeply congested and appeared likely to slough. One or two sutures were removed from both superficial and deep aspects and a very small amount of fluid blood was evacuated. Wet dressings, at first of saline and later of streptomycin solution, were applied twice daily from then onwards. Chloromycetin was given by mouth for five days. Practically all the congested area survived, a small superficial crust being shed after two weeks. The patient was discharged on the eighteenth post-operative day.

P r e sen t C o n d i t i o n . - - W h e n last seen on 24th June 1955 the condition was as shown in Figs. 4 and 5. While not anatomically normal , the tip and ala: o f

332 BRITISH JOURNAL OF PLASTIC SURGERY

the nose were much improved, and the profile especially was satisfactory. The patient himself was highly pleased with the result.

The deformity of the donor ear was not marked, and he did not wish further treatment either for this or for the much more obvious deformity of the opposite burned ear.

FIG. 4 FIG. 5 Seven months after operation.

SUMMARY

A large composite auricular graft, 8 cm. in length, was used as a simple alternative to a tubed pedicle flap repair of the tip and ale of a burned nose. I t survived almost completely and gave a pleasing result acceptable to the patient.

My thanks are due to Mr Randell Champion who suggested the line of treatment in this case. The photographs are from the Department of Medical Illustration, Wythenshawe Hospital, Manchester.

REFERENCES

BaOWN, J. B., and CANNON, B. (I946 a). Ann. Surg., xz4, xIoI. (I946 b). Surg. Gynec. Obstet., 8z, 253.

McLAUGHLIN, C. R. (r954). Brit. ft. plast. Surg., 7, 274. SZLAZAK, J. (I948). Brit. J. plast. Surg., x, I76.