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Simultaneous retraction and marking for maximum conchal cartilage harvest

INTRODUCTION The three-dimensional contour of the face is defined by the osseocartilaginous framework as well as the soft tissue that surrounds these structures. In reconstructive surgery, it is important to analyze the defect and determine which layers are deficient and need replacement. Cartilage is employed extensively in aesthetic and reconstructive surgery for its capacity to be shaped as needed, while still maintaining its strength and structural integrity. Although many synthetic options are now available, there is still a clear advantage in the use of autologous cartilage. The most frequently used donor sites in aesthetic and reconstructive surgery are the nasal septum, rib, and auricular conchal cartilage. With its innate convexity, conchal cartilage is particularly suited for reconstruction of the nose. Harvesting conchal cartilage is relatively easy and associated with minimal donor site morbidity if done correctly. Conchal cartilage can be harvested using either an anterior or posterior auricular incision as long as the structural landmarks are preserved. The antihelix is the most important of these landmarks; most authors use a measurement of 2 to 3 mm from the antihelical border as their limit of resection. The helical crus should also be preserved to maintain adequate shape, and 2 to 3 mm of cartilage surrounding the external auditory canal (EAC) are essential to avoid collapse of the EAC. When an anterior approach is employed, preservation of these landmarks is somewhat straightforward because the entire concha is exposed by means of an incision along the antihelix-conchal junction. The anterior skin flap is elevated, and the cartilage is incised and removed. The advantages in this technique are less time of surgery and a clear view of the area to be removed, which in theory results in a larger cartilage yield and decreased donor site structural deformity. The disadvantage of this technique is that it leaves a visible scar on the anterior surface of the auricle, particularly in those who produce hypertrophic scars. In the postauricular approach, the auricle is reflected forward and the concha is isolated via a 3-cm postauricular incision. The main advantage in this technique is that the resulting scar is hidden behind the ear. The disadvantage, however, is that when the auricle is reflected forward, the antihelical landmark is distorted, which can lead to either overor under-resection; this results in either insufficient grafting material or an auricular deformity. In attempt to maximize the size of the harvested graft while maintaining structural integrity, various techniques have been developed to mark the antihelical border and guide the resection. One such technique is tattooing, whereby the surgeon dips the tip of a small-gauge needle in methylene blue or brilliant green. After raising the posterior flap, the surgeon then introduces the needle through the lateral surface of the auricle 2 to 3 mm from the antihelical border and carries the die through and on to the posterior surface of the auricle. Others simply raise the posterior flap and introduce various 30-gauge needles laterally through the antihelical border to mark the limit of resection (Fig. 1). Some surgeons opt for not marking the antihelix before resection, which risks underor overresection as well as cosmetic deformities. We have developed a technique for marking the antihelical fold that avoids staining tissues with tattooing material and most importantly avoids needle prick injury to the surgical staff. Our technique not only maximizes the amount of From the Department of Otolaryngology–Head and Neck Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, U.S.A. Editor’s Note: This Manuscript was accepted for publication October 24, 2012. Presented as a poster at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting, Washington, DC, September 5–8, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Javier Gonz alez-Castro, Metro Plaza Towers, 303 Calle Villamil, Apt. 901, San Juan, Puerto Rico 00907. E-mail: javi8g@gmail.com