Successful Replantation of a Completely Amputated Ear on a Child

INTRODUCTION

Amputation of an ear is a very rare injury. The first successful replantation of an ear was published in the literature in 1980 (1). Before 2008 the worldwide medical literature only talks about 74 amputations of an ear and not all were treated with successful replantation (2). There are two main mechanisms of this injury. The first is by motor vehicle accident, such as amputation by glass, and the second most frequent is when the ear is bitten off by an animal. The mechanism of a bite injury causes avulsion which limits the possibility to successfully complete a replantation and at the same time in cases when replantation is indicated it complicates the procedure. We present a case of an ear amputation of a seven-year old child.

CASE STUDY

On 12 June 2005 a seven-year old boy was attacked by a German shepherd while visiting his friends. The dog bit the boy’s left ear off (Fig. 1) and caused deep wounds on his right arm, in the lumbar area and stomach. The boy was evaluated by the local surgical department and was transferred with the ear for treatment to our department. He was admitted and three and half hours from the accident surgery was started. Firstly, the wounds on arm and in the lumbar were addressed and we explored the severity of these injuries. This was prior to the decision to attempt to replant the ear. The wounds did not reach important structures and did not invade the abdominal cavity. Subsequently, we inspected the amputated ear (Fig. 2) and the area of the amputation stump. The left ear was completely amputated with a small periauricular area spared. The amputated ear was damaged by avulsion and significantly soiled (Fig. 3). We had decided to attempt replantation. The amputated ear was repeatedly washed in a physiological solution and foreign bodies were removed. The ear was stitched by several stitches of Prolen 4/0 to the conchal cartilage and placed back to the original bed. Only then we initiated a search for the venous structures. After more than two hours we had found both parts of the auricular artery branches and we performed anastomosis with fiber of 11/0 thickness. The artery according to the mark on clips was less than 0.5 mm in diameter. After the release of clips the whole ear vascularized and thanks to venous bleeding we were able to find the auricular vein branch in the ear site but not in the amputation site. Accordingly we completed preparation of the occipital vein and over bridged the defect with the use of venous graft from the dorsum of the left foot. After release of the clips the replanted ear was over-vascularized and showed signs of mild stasis. Then the wound was sutured and we inserted glove drains. The surgery lasted 5 hours and 29 minutes. At the beginning of the surgery we administered 600 mg of IV Augmentin and after completion of the venous graft suture 2000 units of intravenous Heparin. After the surgery the boy admitted to the intensive care unit. In the postoperative period we administered 600 mg of intravenous Augmentin every eight hours, intravenous Tramal 50 1/2 amp every four hours and intravenous Reodextran 500 ml every eight hours for three days. Also Heparin 2000units every six hours and after four days then Fraxiparine 0.3 ml s.c. every 12 hours. In the first five days after the replantation a small source of bleeding was maintained in the conchal area, because the only reconstructed vein did not maintain sufficient draining (Fig. 4). On the sixth postsurgical day the first and only blood transfusion was administered. On the seventh postsurgical day we initiated oxygen therapy in a barometric chamber and the patient was mobilized for the first time. On the eighth postsurgical day the bleeding was very sporadic and on the 10^th postsurgical day the bleeding stopped. The patient continued oxygen therapy in a barometric chamber for two hours daily until the 13^th postsurgical day. The seventh day after the replantation the patient developed in the lower part of the helix an ischemic area 1 x 1 cm in size (Fig. 5). This ischemic area was still apparent at discharge on postsurgical day 17. The blood supply in this area normalized within the next two weeks and the patient did not develop any scar tissue (Fig. 6). All of his wounds healed without infectious complications. The antibiotic continued to be administered for 13 days. During subsequent checkups we could comment that the shape and position of the ear is optimal (Fig. 7).

RESULTS AND DISCUSSION

Several treatment procedures can be used in the treatment of ear amputation. These procedures can be divided into either microsurgical or non-microsurgical types. The non-microsurgical procedures are preferred after amputations of small parts of the ear or if replantation cannot be technically accomplished. The most successful non-microsurgical procedure is the reattachment technique (3, 4) which comprises dermabrasion of the amputated part of the auricle, its exact arrangement to the anatomical position and stitching it to the retroauricular subcutaneous pocket. In 2.5 weeks the amputated part of the ear is extracted and is left for spontaneous re-epitalization. This method is suitable in amputation within the extent of 1.5 cm or if the amputated part of the auricule contains the earlobe. The other non-microsurgical method is stitching of the cartilage into the retroauricular subcutaneous pocket where this skin cover substitutes the skin on the front of the ear and than later a reconstruction of the retroauricular space with a skin graft (5, 6). The use of the amputated part as a composite graft is a more likely method used for amputations of very small parts of the ear. The next method is a skeletonization of the amputated cartilage. After this the cartilage is stitched to the ear stump, then the temporal fascia is transpositioned and skin grafted. The retroauricular space is then created at the same time. The disadvantages of the non-microsurgical methods are more extensive scars, deformities of the ear and resorption of the cartilage. With the exception of the last described method reconstruction has to be done in several stages. Microsurgical replantation can be successful via five methods (7–15): primary vessel reconstruction– the use of the superficial temporal blood vessels– the use of a venous graft– arerio-venous shunt, and replantation without the venous anastomosis. The primary blood vessel reconstruction is best; however, it is possible only after sharp amputations when the blood vessels are not destroyed. If the superficial temporo-parietal bundle is used as a unit or individually (more often veins) it has to be prepared distally and transposed into the surgical field with a connection to the arteries and veins. Its advantage is the possibility to anastomose the blood vessels without tension; sufficient blood flow in and out is secured and only two anastomoses have to be completed. The disadvantage is then the fact that it is not possible to reconstruct the ear with the use of temporo-parietal fascia if needed. If a venous graft has to be used to bridge the defect of an artery, vein or veins, again the temporo-parietal bundle can be used. We used the occipital vein a solution we have not found in the literature. In the literature we also found one successful replantation completed with the arterio-venous anastomosis and the venous drainage was ensured by the use of leeches.

From the available literature it is obvious that need for blood transfusion usually exceeds the number 10. The time of the replantation varies between 3–10 hours according to the number of completed anastomoses. In 80% of the described replantations venous congestion occurs and leeches or bleeding usually helps to improve the venous drainage.

CONCLUSION

For our patient we used two innovations during the replantation. First we used the occipital vein for venous drainage. The advantage of this was that we did not damage the temporo-occipital bundle and therefore we did not compromise the possibility for a secondary reconstruction with the temporo-occipital fascia. To bridge the defect we did not need a longer venous graft than for the temporo-occipital bundle and we also did not have to change the position of the patient during the surgery. The second innovation was the use of a barometric chamber. It was used from post-surgical day five and may have had a positive impact on the ischemic area in the lower part of the replanted ear which healed ad intergrum.

Address for correspondence:

Vladimír Mařík, M.D.

Department of Plastic Surgery

České Budějovice Hospital

B. Němcové 54

370 01 České Budějovice

Czech Republic

E-mail: marik.vl@quick.cz