Hyperbaric oxygen treatments were begun immediately postoperatively from recovery room. A standard protocol of twice daily 90-minute dives at 2 atmospheres was followed for 14 days. She was maintained on intravenous antibiotics and intravenous ascorbic acid 1000 mg every 12 hours to minimize ischemic injury. The ears were generously lubricated with Bacitracin ointment to avoid desiccation, and ice-cold compresses were applied for the first 48 hours postoperatively and reapplied every 15 minutes by nursing staff and family who were educated on doing the same. The patient was discharged on postoperative day 5 with arrangements made for completing her 2-week course of hyperbaric oxygen therapy therapy on an outpatient basis. At 2 weeks postoperatively, the patient demonstrated 100% survival of the left ear graft and 95% survival of the right ear graft, with minor loss of a portion of the lobule which responded to topical wound care. At 4 weeks, she had entirely healed. A subsequent z-plasty several months later was performed to correct the small contour deformity of the right lobule. At 2 years, she had a stable result with no complaints except for mild hypesthesia (Figs. 6–8).
If we extrapolate from our knowledge of skin graft physiology, the initial appearance of the reattached ears was noted to be pale consistent with the imbibition phase of initial graft survival wherein the reattached part is entirely avascular. Over the ensuing 48 hours, the grafts were noted to begin demonstrating venous congestion with a bluish hue, consistent with inosculation, and by 72–96 hours, the bluish discoloration began to get replaced with the pink blush of revascularization. Keeping the reattached ears well lubricated prevented desiccation, desquamation, and de-epithelialization.
Reducing metabolic demand of nonvascularized tissues with cooling is well established and was in fact described by Conley and Vonfraenkel13 in 1956. The use of HBO in assisting both ischemic flaps, traumatized tissues, osteoradionecrosis, and even composite grafts is well established in the literature. Unfortunately, with few exceptions, most of the HBO literature consists of poorly controlled, primarily retrospective studies with an array of clinical situations from which meaningful useful clinical information is at best difficult to interpret. The experimental evidence supporting the use of HBO in composite grafts was shown in the rat model by several authors.14,15 Survival advantages in the rabbit model have also been reported by multiple authors.16–19 The anecdotal clinical evidence supporting the use of HBO in composite grafts has also been reported by multiple authors.20–22 In a single ear near-complete amputation and reattachment reported by Komorowska-Timek and Hardesty,22 their patient’s injury included 2 small skin bridges and their clinical protocol included keeping the patient extra warm in a “hot” room for the first 72 hours postoperatively, presumably to maximize vasodilation in the small soft-tissue bridge attachments that remained, unlike our use of cooling the reattached ear parts which had been completely severed. In addition, our patient’s amputations were transcartilagenous with the entire surface area contact consisting exclusively of the 3–5 mm thickness of the severed cartilaginous-cutaneous composite unit.
The known clinical effects of HBO that are virtually undisputed include the stimulation of angiogenesis and neovascularization, reduction of superoxide formation, and reduction of venous congestion.23–25 All of these properties were clearly demonstrated in our patient’s clinical postoperative course.
The justification for the clinical decision making in the care of this patient was partially patient driven, but also by the fact that few options exist in such a case wherein the loss of such vitally important aesthetic anatomic structures can only be replaced by multiple subsequent staged complex and costly reconstructive procedures. The unexpected success of the outcome in this patient suggests that there may be a more expanded clinical role for HBO therapy in a prospective fashion in our armamentarium for complex reconstructions, both in the setting of trauma and even in the setting of elective reconstructive surgery, including the reconstruction of complex composite defects of the nose and ear. Incorporating HBO therapy into our clinical protocols may allow us to potentially redefine our traditional concepts of the limits of predictable composite graft survival. With improved access to hyperbaric oxygen chambers, this may become more feasible with time.
Although controlled prospective clinical trials may be difficult to design, it is this author’s opinion that ample evidence in the literature from both animal studies and clinical case reports such as the one reported here strongly suggests that there is a potential adjunctive role for HBO therapy in ensuring enhanced composite graft survival in the clinical setting. Precise protocols in such settings remain to be established, but established guidelines exist and sound clinical decision making on an individual basis remains paramount.
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