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Abstract
Auricular cartilage is an important source of grafts for various reconstructive procedures such as aesthetic rhinoplasty. The purpose of this
investigation was to compare tragal cartilage with auricular cartilage harvested from the concha and scapha, and describe its clinical viability,
indications, and morbidity in rhinoplasty. A total of 150 augmentation rhinoplasties with a total of 170 grafts were included. The donor sites
were tragus (n = 136), concha (n = 26), and scapha (n = 8). The time needed to harvest the grafts, the donor site morbidity, and the indications
for operation were recorded. The anthropometric changes to 4 auricular variables after the cartilage had been harvested were analysed and
compared with those on the opposite side in 48 patients using Students paired t-test. Intraobserver reliability was assessed using Pearsons
intraclass correlation. The mean (SD) harvesting time was 27 (8) min for the concha, 4.5 (1.4) min for the tragus, and 5.7 (1.6) min for the
scapha. The largest graft was taken from the concha (28 19 mm), followed by the tragus (20 12 mm), and the scapha (18 6 mm). The
grafts were placed at the following sites: tip grafts (n = 123), columella struts (n = 80), shield (n = 20), rim (n = 17), and dorsal onlay (n = 15).
Harvesting tragal cartilage is safe, simple, fast, and has a low morbidity, but it can affect the patients ability to wear earphones. Tragal cartilage
is a good alternative for nasal reconstruction if a graft of no longer than 20 mm is required.
2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Tragus; Scapha; Concha; Grafts; Rhinoplasty; Morbidity
Introduction
0266-4356/$ see front matter 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2013.04.001
864
M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867
nose, the septum, the rib, and the external auricle.2 The external ear provides a viable alternative in graft-depleted patients
when the septal cartilage had already been used, ideally for
secondary and tertiary rhinoplasties.913 Most surgeons still
prefer conchal grafts for augmentation-reconstruction rhinoplasties, but Grobbelaar et al.14 reported a morbidity of 2.2%,
mainly postoperative deformities of the ear, haematomas, and
hypertrophic scarring. The mean time needed to harvest the
conchal cartilage ranges between 25 and 30 min.2,11,13
Cochran and DeFatta9 and Kotzur and Gubitsch10 have
since introduced the tragal cartilage as a viable alternative in
graft-depleted patients. The purpose of the present comprehensive study was to compare tragal cartilage with conchal
and scaphal cartilage for augmentation rhinoplasty. We have
assessed the different clinical indications, viability, and feasibility including the time taken to harvest the graft, donor
site morbidity, and anthropometric changes of the ear for
each graft.
Fig. 2. Technique for harvesting tragal cartilage. The incision line must be
marked at the posterior border of the edge of the tragus.
contour (as shield grafts), refine the nasal tip, avoid open
roof syndrome, and prevent formation of scars between the
skin and the bone, particularly if the skin was thin. All subjects signed consent forms according to the Declaration of
Helsinki preoperatively.
Assessment of donor site morbidity and anthropometric
analysis
Donor site morbidity and harvesting time of each graft were
recorded for each patient. This included documentation of
early complaints, including haematoma and perioperative
pain that resolved within 3 weeks, and irreversible complaints including scarring, sensory disturbances, and pain at
the donor sites.
In 48 patients the anthropometric changes after cartilage had been harvested were compared with those from the
opposite unaffected ear according to the protocol described
by Weerda.15 The width, length of the auricles, the protrusion angle of the mastoidauricular plane, and the distance
between the tragus and the lateral canthus, were measured and compared with those of the unaffected side. The
anthropometric measurements were made at least 6 months
postoperatively when the swelling had completely resolved.
Grafting techniques
The scaphal and conchal cartilage grafts were harvested
according to the technique described by Nolst Trenit.16
The minimally invasive approach to the harvesting of tragal cartilage is shown in Fig. 2.10 From an incision in the
tragal rim at the inner border, we dissect subperichondrally
to the anterior and posterior of the tragal cartilage. Hydrodissection with local anaesthetic solution containing adrenaline
facilitates the preparation. The facial nerve is located about
1012 mm anterior to the lower end of the cartilage. Nearly
the whole tragus can be removed, leaving only a small rim
2 mm wide at the site of the incision for structural support.
M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867
865
Table 1
Morbidity of donor and recipient sites of external cartilage of the ear (n = 170). Data are number (%) of patients.
Variable
Tragus (n = 136)
Concha (n = 26)
Scapha (n = 8)
Total (n = 170)
Rhinoplasty
Primary
Secondary
Tertiary
Cleft nose
Recipient site
Tip/onlay graft
Dorsum onlay graft
Rim/batten graft
Columella strut
Shield graft
Donor site morbidity
Early (reversible)
Haematoma
Perioperative pain
Late (not reversible)
Scarring
Pain on pressure
Hypoaesthesia
Clicking sensation
Unable to wear earplugs
Harvesting time (min)
Dressing
Properties of cartilage
Size (mm)
Shape
Quality
126
89
30
6
1
26
9
6
2
9
150
100
5
5
10
100
4
9
60
10
17
11
6
20
10
8
8
8
2 (1)
1
1
5 (4)
1
1
1
2
5
5
4
1
6
4
1
1
27
45
7(4)
5
2
10 (7)
5
2
2
1
20 20
Thin, straight
Firm
28 19
Convex
Stiff
18 6
Straight
Flexible
123
15
17
80
20
choice for secondary and tertiary rhinoplasties when the septal cartilage had already been used.
Donor site morbidity
The early and late morbidity are shown in Table 1. One patient
whose scar retracted and who had an adhesion between the
posterior auricle and the mastoid skin required revision.
There was less early morbidity after harvest of tragal
grafts (Fig. 3, Table 1). Following tragal harvest, the scars
were nearly invisible (Fig. 3) and were of better quality
Results
The types of graft and their distribution are shown in Table 1.
It was possible to use the tragal cartilage in 136 cases (80%).
It was necessary to use conchal cartilage in 26 patients (15%)
who required extensive reconstruction of the cartilage frame
(such as a cleft nose). Grafts from the ears were our first
866
M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867
Anthropometric analysis
Four soft tissue variables were chosen to evaluate the anthropometric changes to the ears after the cartilage had been
harvested, and these did not differ significantly. Although
there was a mean difference in length of the conchal grafts,
harvesting of scaphal or tragal cartilage had no effect
(p < 0.45). The difference in width amounted to 2.3 mm
(p < 0.52). The mean difference in distance between the tragus and the lateral canthus was 1.3 mm (p < 0.341) and the
mean variation in the protrusion angle was 2.1 (p < 0.61).
The inter-observer reliability (0.814).
Fig. 4. Technique for harvesting tragal cartilage: almost the entire cartilage
can be harvested.
than the chonchal grafts (Fig. 4). The tragal cartilage also
showed superior results as far as late morbidity was concerned
(Table 1 and Fig. 5).
Harvesting time and properties of the grafts
A further focus of this study was the time taken to harvest the
graft, including the size and shape of the monolayer cartilage
(Fig. 1 and Table 1), and tragal grafts took less time, and did
not require dressing. Fig. 1 illustrates the properties of each
cartilage graft.
Fig. 5. Appearance of the almost invisible scar after harvest of the tragal
graft.
Discussion
Numerous materials have been described for grafting in
functional as well as in aesthetic rhinoplasty. Niechajev8
most recently published excellent long-term results using
high-density polyethylene implants, which have a morbidity
similar to procedures that involve autologous grafts. However, the first choice for most authors is still septal cartilage.17
Unfortunately, enough of this is not always available, particularly in secondary rhinoplasty revisions. Auricular cartilage
from different sites around the ear is the second choice.18 The
problem with conchal cartilage grafts is their irregular structure, their curvature, and the fact that the cartilage is elastic
and cannot be crushed. Some authors also combine auricular
cartilage grafts with bone grafts or cartilage from the ribs.19
The conchal cartilage is a beneficial source of cartilage when
multiple, bigger pieces of cartilage are needed, for instance in
rhinoplasties for cleft lip or nasal reconstructions after trauma
and resection of tumours.
Murrell12 reported changes in the aesthetics of the auricular framework including distortion of the auricle, changes in
the cephaloauricular angle that result in asymmetry between
the two ears, or visible scarring after harvest of the cartilage. However, our results showed that none of the external
aural grafts (tragus, scapha, or concha) showed significant
morphological differences between the operated side and the
unaffected side. Independently of the surgical intervention, it
is reasonable to assume that there is normal variation between
the ears.20
Murrell12 further stated that changes in the auricular
framework can be avoided by preserving a central strut of
cartilage between the cymba and cavum concha. In addition, the harvesting of conchal cartilage also requires the
placement of a cumbersome and often uncomfortable postoperative dressing, or bolster, to prevent a haematoma from
forming.
Tragal cartilage avoids many of these complications and
has other essential advantages, the biggest of which is that
it is both thin and straight. Harvesting from the tragus is
easier and faster than harvesting from the concha. There is no
need for special postoperative dressings, there is less risk of
haematoma, and a straight graft can be obtained that is firmer
M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867
867
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