Secondary Logo

Journal Logo

A Novel Application of Vacuum-Assisted Closure in Auricular Reconstruction

Graewe, Frank R., M.D.; Ross, Richard J., B.Sc.(Hons.); Perks, Tim, M.D.; van der Walt, Chris, M.D.; Zuehlke, Alexander E., M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 440e-442e
doi: 10.1097/PRS.0b013e3181bcf27c
VIEWPOINTS
Free

Division of Plastic and Reconstructive Surgery, Stellenbosch University, Cape Town, South Africa (Graewe)

School of Medicine, Faculty of Health Sciences, Flinders University, South Australia, Australia (Ross)

Division of Plastic and Reconstructive Surgery, Stellenbosch University, Cape Town, South Africa (Perks, van der Walt, Zuehlke)

Correspondence to Dr. Graewe, Division of Plastic and Reconstructive Surgery, Faculty of Health Sciences, University of Stellenbosch, Francie van Zyl Drive, P.O. Box 19063, Tygerberg, Western Cape 7505, South Africa, graewe@sun.ac.za

Back to Top | Article Outline

Sir:

Auricular reconstruction is a challenge for the reconstructive surgeon. In the majority of cases, autogenous costal cartilage grafts are used as scaffolds for the overlying soft-tissue envelope. Critical to all currently used techniques is adequate protection of the graft from infection and edema during the early postoperative period. Brent described a suction drainage system with two thin catheters within the tissue envelope to facilitate redraping of the skin to the underlying cartilage framework.1 The drains were attached to vacuum blood sample tubes. However, some disadvantages are evident. First, the negative pressure inside the vacuum tubes varies between tubes and is impossible to quantify. Tubes must be changed every 2 to 3 hours over the initial 3 to 4 postoperative days (i.e., 24 to 48 times in total). This leads to repeated windows for loss of vacuum pressure, each causing shear forces across the fragile graft. Changing tubes adds an unnecessary workload for already busy nursing staff. We propose a novel application of the vacuum-assisted closure protocol. This system develops the cost-effective technique designed by Brent, but uses a more reliable vacuum apparatus that requires less monitoring.

In auricular reconstruction, we follow the two-stage procedure described by Nagata2 and Firmin3 (Fig. 1). Posttraumatic cases are treated with a one-stage procedure. Two 3.2-mm-diameter Redon drainage tubes are inserted, with the first placed within the tissue envelope next to the helix of the cartilage graft, exiting the skin approximately 2 to 5 cm inferior to the lobule. An open-cell sponge is placed over the flap. The second tube rests within a pocket created in the open-cell sponge, and both tubes are connected by means of a Y-junction. The system is enclosed in an occlusive dressing (OpSite; Smith & Nephew, Columbus, S.C.) (Fig. 2). The vacuum complex is connected in the operating room to a 3.2-mm Porto-Vac drain (Stryker Instruments, Portage, Mich.) and then clamped and transferred to wall suction in the ward. Negative pressure is kept at the minimum level required to eliminate dead space inside the soft-tissue envelope (120 to 150 mmHg). The vacuum-assisted closure system is left undisturbed for 4 to 5 days on the ward before being changed to a nonvacuum dressing for an additional week.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

The proposed adaptation of the vacuum-assisted closure technique has several advantages. The contour of the reconstructed auricle is visualized in theater and maintained over the following days, facilitating coaptation. This eliminates the issue of irregular contour for flap-scaffold apposition. Second, edema is reduced, improving vascular perfusion and lymphatic flow and reducing potential bacterial load.4 These factors act in concert to improve take of the reconstructed auricle complex. Intervention required from ward staff is reduced, as vacuum systems are untouched for 4 to 5 days. As in all systems, disadvantages do exist. The primary disadvantage is increased length of ward stay, as patients must stay in proximity to the central vacuum system. In a private hospital setting, a commercially available mobile vacuum-assisted closure system (V.A.C.; KCI, Inc., San Antonio, Texas) has been tested successfully in similar patients, with the advantage of enhanced patient mobility with monitoring on an outpatient basis. Our suggested modification demonstrates a novel application of the vacuum-assisted closure technique and has been proven safe and simple to apply and provides excellent reconstructive outcomes.

Frank R. Graewe, M.D.

Division of Plastic and Reconstructive Surgery

Stellenbosch University

Cape Town, South Africa

Richard J. Ross, B.Sc.(Hons.)

School of Medicine

Faculty of Health Sciences

Flinders University

South Australia, Australia

Tim Perks, M.D.

Chris van der Walt, M.D.

Alexander E. Zuehlke, M.D.

Division of Plastic and Reconstructive Surgery

Stellenbosch University

Cape Town, South Africa

Back to Top | Article Outline

REFERENCES

1. Brent B. The correction of microtia with autogenous cartilage grafts: I. The classic deformity. Plast Reconstr Surg. 1980;66:1–12.
2. Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg. 1993;92:187–201.
3. Firmin F. Ear reconstruction in cases of typical microtia: Personal experience based on 352 microtic ear corrections. Scand J Plast Reconstr Surg Hand Surg. 1998;32:35–47.
4. Morykwas MJ, Simpson J, Punger K, Argenta A, Kremers L, Argenta J. Vacuum-assisted closure: State of basic research and physiologic foundation. Plast Reconstr Surg. 2006;117 (Suppl):121S–126S.

Section Description

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons