Letter to Editor
or horizontal flips are also useful while doing final ‘touch ups’ on the reconstructed ear. We believe that this simple method can be an additional tool helping the novice as well as the experienced plastic surgeon achieve their goals in ear reconstruction.
Alexander George, Reena Alexander1 1
a
b
c
Department of Plastic Surgery, Kims Hospital, Department of Physiology, Amrita Institute of Medical Sciences, Cochin, Kerala, India Address for correspondence: Dr. Alexander George, Kims Hospital, Cochin, Kerala, India. E-mail: [email protected]
d
Figure 1: (a) Normal left ear, (b) ‘reverse print’ or ‘horizontal flip’ of the normal left ear, which in fact is the final appearance that needs to be achieved, (c) the deformed right ear with the ear landmarks and (d) the first stage of ear reconstruction using the costal cartilage
brought about by the surgeon’s knife. Digital photography and computer imaging has ushered in a new revolution and is slowly replacing the classic photography. Total ear reconstruction in burn patients poses a technical challenge in that the reconstructed ear should resemble a normal human ear in addition to being similar to the contra lateral ear. Intraoperatively, the surgeon often looks to the contra lateral normal ear, reversing the image in his mind, to visualize the final appearance that he should attain while reconstructing the deformed ear. We have used a simple technique of reverse printing to aid us during surgery. The normal contra lateral ear is first photographed and a ‘negative’ film is developed. During printing, the ‘negative’ film is reversed so that the ‘positive’ print on paper appears as that of the ear to be reconstructed. This photograph is enlarged and used intraoperatively to guide the surgeon. With the advent of digital photography and special software, this procedure has been simplified by obtaining a ‘mirror image’ or ‘horizontal flip’ of the normal ear on a computer and then printing a magnified image on paper. During the operative procedure, the surgeon can easily view the final appearance that he should achieve and the presence of the photograph helps in creating the finer details that would otherwise have been difficult to imagine by looking at the contra lateral normal ear. Figure 1 shows the reconstruction of the right ear using the ‘reverse print’ of the contra-lateral normal left ear in a burn patient. Thought the picture shown is only that of the ear, by taking the full profile picture of the face on the normal ear side and ‘horizontally flipping’ it, it is possible to review the correct site, size, direction and angle for the new ear reconstruction. Besides its use in all forms of ear reconstruction, the ‘reverse prints’, ‘mirror images’
Access this article online Quick Response Code:
Website: www.ijps.org DOI: 10.4103/0970-0358.122030
Safe and versatile variation of the surgical technique for treating the underdeveloped antihelix in otoplasty Sir, Ear deformities, especially prominent ears, are relatively common; their incidence is approximately 5% in the Caucasian population. This condition is related to an autosomal dominant gene and is usually caused by a combination of two defects: Conchal cartilage hypertrophy and a defect in the development of antihelix fold. Several surgical techniques and tactics have been described for the correction of these two major defects. For the underdevelopment of antihelix, we have used a combination technique: Mustardé with sutures, associated with a variation of the usual scoring technique (described for Stenström) that uses the principle of Gibson and Davis, to minimize the trauma and complications.[1-4] Our technical variation to create a new antihelix fold was
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
592
Letter to Editor
performed in an anterior approach. First, we marked the limits of the new antihelix fold with a needle and ink. After a small incision of 5 mm over the crus superior of antihelix [Figure 1a], just behind the helix margin, we dissected the skin of the cartilage with iris scissors [Figure 1b]. Through the space formed, we proceeded using our technique variation: With a 15° Beaver blade (Beaver-Visitec, Inc., Waltham, MA, USA) sufficiently small to be introduced in this little incision, we made three parallel incisions in the anterior perichondrium [Figure 1c and d], replacing the scrapes used in usual techniques. These incisions were made with a reverse movement after introducing the blade in the space formed. Thereafter, we closed the small incision with a simple point with 6-0 Mononylon suture (Ethicon, Inc., Somerville, NJ, USA). Finally, we associated the technique with Mustardé points with 4-0 Mononylon suture (Ethicon, Inc., Somerville, NJ, USA) on the posterior surface of the cartilage. The wounds were closed with a bandage for 7 days. Follow-up appointments were made at the end of the 1st week, 1 month, 3 months and 6 months. We analyzed the presence of edema, hematoma or epidermolysis. We used this tactic variation in six patients and found that they all had good results in the treatment of underdeveloped antihelix and no recurrence of the defect within 6 months postoperatively, nor any case of
a
b
a
b Figure 2: (a) Anterior pre-operative and post-operative evaluation at 6 months respectively; (b) lateral pre-operative and post-operative evaluation at 6 months respectively
epidermolysis and post-operative hematoma (a common complication in the scoring technique). The scar on the anterior antihelix became almost undetectable in all patients in the postoperative evaluation at 6 months [Figure 2a and b]. Thus inour hands the variation in surgical technique used in this study for the treatment of antihelix defect in patients with prominent ears has proved to be safe and with good short-term results. The Beaver blade (Beaver-Visitec, Inc., Waltham, MA, USA) is necessary as it is of small size and can be effectively used to make the perichondreal incisions. Kaul and Patil have used other instruments with a similar technique for kwwping the post operative scar to minimum and reducing per operative trauma.[5] We will continue to perform this technique in more patients and will follow the cases long-term to further show more results.
Antonio Carlos Schilling Minuzzi Filho1,2, Pedro Bins Ely1,2, Marcos Ricardo de Oliveira Jaeger1,2, Jefferson André Pires3,4, Darwin Lizot Rech1,2 Federal University of Health Sciences of Porto Alegre, Brazilian Society of Plastic Surgery, 3Brazilian College of Surgeons, 4Academic League of Plastic Surgery of Federal University of Pelotas, Brazil 1
2
c
d
Figure 1: (a) 5 mm incision; (b) dissection with iris scissors; (c) Beaver blade introduction to make three parallel incisions in the perichondrium; (d) detail in the finish of incision
593
Address for correspondence:
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Dr. Antonio Carlos Schilling Minuzzi Filho, Sarmento Leite, 245, Porto Alegre, RS, Brazil. E-mail: [email protected]
REFERENCES 1. Mustardé JC. The treatment of prominent ears by buried mattress sutures: A ten-year survey. Plast Reconstr Surg 1967;39:382-6. 2. Stenstroem SJ. A “natural” technique for correction of congenitally prominent ears. Plast Reconstr Surg 1963;32:50918. 3. Gibson T, Davis W. The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 1958;10:257. 4. Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg 2012;129:701e-16. 5. Koul AR, Patil RK. An effective technique of helical cartilage scoring for correction of prominent ear deformity. Indian J Plast Surg 2011;44:505-8. Access this article online Quick Response Code:
Website: www.ijps.org DOI: 10.4103/0970-0358.122031
18 G needle was rail roaded over it from posterior to anterior withdrawing the previous needle. Now, the ear stud was guided along the tip of the needle, which was slowly withdrawn backwards. However, we shifted to this technique of using the intravenous (IV) cannula after reading the article by van Wijk et al.[2] in Journal of Plastic Reconstructive and Aesthetic Surgery in 2008 ‘Ear piercing techniques and their effects on cartilage, a histologic study’ and have been following this technique since then with good results. The only difference is the cannula size mentioned by van Wijk et al. was 16 G, where as we commonly use 18 G. Furthermore, size of Insyte depends on the size of ear stud and ear lobule. 18 G BD Insyte-W IV catheter’s (Becton Dickinson Infusion Therapy Systems Inc., Sandy, Utah, USA) outer diameter is 1.3 and inner 0.94-1.02 mm, whereas 16 G outer diameter is 1.7 and inner 1.32-1.40 mm. In our Institute, we always prefer gold ear stud not wire or ring to maintain a proper size hole, which will not require dilatation. We recommend only gold stud after ear piercing because they are less reactive in comparison to artificial jewellery. We also feel that this method is good for every continent not only the Indian subcontinent as piercing is gaining popularity globally and the technique is easy and single staged.
A novel technique for piercing of ear lobule suited to Indian subcontinent Sir, We read with interest the Letters to Editor ‘A novel technique for piercing of ear lobule suited to Indian subcontinent’.[1] It has been rightly pointed out by the authors that the traditional methods of ear piercing using wire involved two stages. Wire technique requires dilatation of tract or hole, which is a painful process, before a proper size ear stud can be put. Furthermore, piercing gun used by jewellers didn’t gain much acceptance among the professionals as they believed it makes ear prone for infection. Over the years, we also shared similar beliefs. We were initially using the rail road technique where in a 26 G needle was used to administer local anaesthesia and the same needle was then brought out posteriorly. Then, an
Shashank Lamba, Ashish Kumar Gupta Department of Plastic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Address for correspondence: Dr. Shashank Lamba, Department of Plastic Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu, India. E-mail: [email protected]
REFERENCES 1. Tiwari VK, Misra A, Sarabahi S. A novel technique for piercing of ear lobule suited to Indian subcontinent. Indian J Plast Surg 2013;46:160-1. 2. van Wijk MP, Kummer JA, Kon M. Ear piercing techniques and their effect on cartilage, a histologic study. J Plast Reconstr Aesthet Surg 2008;61 Suppl 1:S104-9.
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Access this article online Quick Response Code:
Website: www.ijps.org DOI: 10.4103/0970-0358.122032
594
Copyright of Indian Journal of Plastic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
or horizontal flips are also useful while doing final ‘touch ups’ on the reconstructed ear. We believe that this simple method can be an additional tool helping the novice as well as the experienced plastic surgeon achieve their goals in ear reconstruction.
Alexander George, Reena Alexander1 1
a
b
c
Department of Plastic Surgery, Kims Hospital, Department of Physiology, Amrita Institute of Medical Sciences, Cochin, Kerala, India Address for correspondence: Dr. Alexander George, Kims Hospital, Cochin, Kerala, India. E-mail: [email protected]
d
Figure 1: (a) Normal left ear, (b) ‘reverse print’ or ‘horizontal flip’ of the normal left ear, which in fact is the final appearance that needs to be achieved, (c) the deformed right ear with the ear landmarks and (d) the first stage of ear reconstruction using the costal cartilage
brought about by the surgeon’s knife. Digital photography and computer imaging has ushered in a new revolution and is slowly replacing the classic photography. Total ear reconstruction in burn patients poses a technical challenge in that the reconstructed ear should resemble a normal human ear in addition to being similar to the contra lateral ear. Intraoperatively, the surgeon often looks to the contra lateral normal ear, reversing the image in his mind, to visualize the final appearance that he should attain while reconstructing the deformed ear. We have used a simple technique of reverse printing to aid us during surgery. The normal contra lateral ear is first photographed and a ‘negative’ film is developed. During printing, the ‘negative’ film is reversed so that the ‘positive’ print on paper appears as that of the ear to be reconstructed. This photograph is enlarged and used intraoperatively to guide the surgeon. With the advent of digital photography and special software, this procedure has been simplified by obtaining a ‘mirror image’ or ‘horizontal flip’ of the normal ear on a computer and then printing a magnified image on paper. During the operative procedure, the surgeon can easily view the final appearance that he should achieve and the presence of the photograph helps in creating the finer details that would otherwise have been difficult to imagine by looking at the contra lateral normal ear. Figure 1 shows the reconstruction of the right ear using the ‘reverse print’ of the contra-lateral normal left ear in a burn patient. Thought the picture shown is only that of the ear, by taking the full profile picture of the face on the normal ear side and ‘horizontally flipping’ it, it is possible to review the correct site, size, direction and angle for the new ear reconstruction. Besides its use in all forms of ear reconstruction, the ‘reverse prints’, ‘mirror images’
Access this article online Quick Response Code:
Website: www.ijps.org DOI: 10.4103/0970-0358.122030
Safe and versatile variation of the surgical technique for treating the underdeveloped antihelix in otoplasty Sir, Ear deformities, especially prominent ears, are relatively common; their incidence is approximately 5% in the Caucasian population. This condition is related to an autosomal dominant gene and is usually caused by a combination of two defects: Conchal cartilage hypertrophy and a defect in the development of antihelix fold. Several surgical techniques and tactics have been described for the correction of these two major defects. For the underdevelopment of antihelix, we have used a combination technique: Mustardé with sutures, associated with a variation of the usual scoring technique (described for Stenström) that uses the principle of Gibson and Davis, to minimize the trauma and complications.[1-4] Our technical variation to create a new antihelix fold was
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
592
Letter to Editor
performed in an anterior approach. First, we marked the limits of the new antihelix fold with a needle and ink. After a small incision of 5 mm over the crus superior of antihelix [Figure 1a], just behind the helix margin, we dissected the skin of the cartilage with iris scissors [Figure 1b]. Through the space formed, we proceeded using our technique variation: With a 15° Beaver blade (Beaver-Visitec, Inc., Waltham, MA, USA) sufficiently small to be introduced in this little incision, we made three parallel incisions in the anterior perichondrium [Figure 1c and d], replacing the scrapes used in usual techniques. These incisions were made with a reverse movement after introducing the blade in the space formed. Thereafter, we closed the small incision with a simple point with 6-0 Mononylon suture (Ethicon, Inc., Somerville, NJ, USA). Finally, we associated the technique with Mustardé points with 4-0 Mononylon suture (Ethicon, Inc., Somerville, NJ, USA) on the posterior surface of the cartilage. The wounds were closed with a bandage for 7 days. Follow-up appointments were made at the end of the 1st week, 1 month, 3 months and 6 months. We analyzed the presence of edema, hematoma or epidermolysis. We used this tactic variation in six patients and found that they all had good results in the treatment of underdeveloped antihelix and no recurrence of the defect within 6 months postoperatively, nor any case of
a
b
a
b Figure 2: (a) Anterior pre-operative and post-operative evaluation at 6 months respectively; (b) lateral pre-operative and post-operative evaluation at 6 months respectively
epidermolysis and post-operative hematoma (a common complication in the scoring technique). The scar on the anterior antihelix became almost undetectable in all patients in the postoperative evaluation at 6 months [Figure 2a and b]. Thus inour hands the variation in surgical technique used in this study for the treatment of antihelix defect in patients with prominent ears has proved to be safe and with good short-term results. The Beaver blade (Beaver-Visitec, Inc., Waltham, MA, USA) is necessary as it is of small size and can be effectively used to make the perichondreal incisions. Kaul and Patil have used other instruments with a similar technique for kwwping the post operative scar to minimum and reducing per operative trauma.[5] We will continue to perform this technique in more patients and will follow the cases long-term to further show more results.
Antonio Carlos Schilling Minuzzi Filho1,2, Pedro Bins Ely1,2, Marcos Ricardo de Oliveira Jaeger1,2, Jefferson André Pires3,4, Darwin Lizot Rech1,2 Federal University of Health Sciences of Porto Alegre, Brazilian Society of Plastic Surgery, 3Brazilian College of Surgeons, 4Academic League of Plastic Surgery of Federal University of Pelotas, Brazil 1
2
c
d
Figure 1: (a) 5 mm incision; (b) dissection with iris scissors; (c) Beaver blade introduction to make three parallel incisions in the perichondrium; (d) detail in the finish of incision
593
Address for correspondence:
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Dr. Antonio Carlos Schilling Minuzzi Filho, Sarmento Leite, 245, Porto Alegre, RS, Brazil. E-mail: [email protected]
REFERENCES 1. Mustardé JC. The treatment of prominent ears by buried mattress sutures: A ten-year survey. Plast Reconstr Surg 1967;39:382-6. 2. Stenstroem SJ. A “natural” technique for correction of congenitally prominent ears. Plast Reconstr Surg 1963;32:50918. 3. Gibson T, Davis W. The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 1958;10:257. 4. Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg 2012;129:701e-16. 5. Koul AR, Patil RK. An effective technique of helical cartilage scoring for correction of prominent ear deformity. Indian J Plast Surg 2011;44:505-8. Access this article online Quick Response Code:
Website: www.ijps.org DOI: 10.4103/0970-0358.122031
18 G needle was rail roaded over it from posterior to anterior withdrawing the previous needle. Now, the ear stud was guided along the tip of the needle, which was slowly withdrawn backwards. However, we shifted to this technique of using the intravenous (IV) cannula after reading the article by van Wijk et al.[2] in Journal of Plastic Reconstructive and Aesthetic Surgery in 2008 ‘Ear piercing techniques and their effects on cartilage, a histologic study’ and have been following this technique since then with good results. The only difference is the cannula size mentioned by van Wijk et al. was 16 G, where as we commonly use 18 G. Furthermore, size of Insyte depends on the size of ear stud and ear lobule. 18 G BD Insyte-W IV catheter’s (Becton Dickinson Infusion Therapy Systems Inc., Sandy, Utah, USA) outer diameter is 1.3 and inner 0.94-1.02 mm, whereas 16 G outer diameter is 1.7 and inner 1.32-1.40 mm. In our Institute, we always prefer gold ear stud not wire or ring to maintain a proper size hole, which will not require dilatation. We recommend only gold stud after ear piercing because they are less reactive in comparison to artificial jewellery. We also feel that this method is good for every continent not only the Indian subcontinent as piercing is gaining popularity globally and the technique is easy and single staged.
A novel technique for piercing of ear lobule suited to Indian subcontinent Sir, We read with interest the Letters to Editor ‘A novel technique for piercing of ear lobule suited to Indian subcontinent’.[1] It has been rightly pointed out by the authors that the traditional methods of ear piercing using wire involved two stages. Wire technique requires dilatation of tract or hole, which is a painful process, before a proper size ear stud can be put. Furthermore, piercing gun used by jewellers didn’t gain much acceptance among the professionals as they believed it makes ear prone for infection. Over the years, we also shared similar beliefs. We were initially using the rail road technique where in a 26 G needle was used to administer local anaesthesia and the same needle was then brought out posteriorly. Then, an
Shashank Lamba, Ashish Kumar Gupta Department of Plastic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Address for correspondence: Dr. Shashank Lamba, Department of Plastic Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu, India. E-mail: [email protected]
REFERENCES 1. Tiwari VK, Misra A, Sarabahi S. A novel technique for piercing of ear lobule suited to Indian subcontinent. Indian J Plast Surg 2013;46:160-1. 2. van Wijk MP, Kummer JA, Kon M. Ear piercing techniques and their effect on cartilage, a histologic study. J Plast Reconstr Aesthet Surg 2008;61 Suppl 1:S104-9.
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Access this article online Quick Response Code:
Website: www.ijps.org DOI: 10.4103/0970-0358.122032
594
Copyright of Indian Journal of Plastic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
