Microsurgical Ear Replantation Without Venous Repair: Failure of Development of Venous Channels Despite Patency of Arterial Anastomosis for 14 Days

Abstract

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.

Microsurgical ear replantation—is venous repair necessary?—A systematic review

“…For the purpose of further analysis only cases of arterial and venous reconstruction (group 1 [ N = 38]) and artery‐only anastomosis (group 2 [ N = 19]) were included. The duration of surgery was reported in 23 cases in group 1 and 9 cases in group 2 with the median duration of surgery being 6 and 4 hour in group 1 and group 2, respectively ( P < 0.005; Table ).…”

“…As such, in the setting of adequate arterial inflow, one has to ensure venous drainage only until intrinsic drainage has been established. The importance of adequate debridement of the wound bed to facilitate neovascularization cannot be overstated …”

“…A meaningful analysis of the methods of venous decongestion (including medicinal leech therapy and blood drainage through puncture wounds/small incisions), as well as postoperative anticoagulation regimen was not possible given the heterogeneous protocols employed and comparatively sparse datasets.…”

Replantation of totally amputated ears

“…Akyerek et al [1] have reported an unsuccessful replantation in spite of using medicinal leeches, but Jeng et al [5], Concannon and Puckett [2], Otto et al [10], and Talbi et al [11] describe complete healing of ears even in cases of venous insufficiency due to not suturing veins and use of leeches.…”

“…More often one can find reports on repairing the arterial system and the impossibility of repairing the veins. This is the reason why many authors have used medicinal leeches for venous drainage [1,2,10,11]. This situation is due partly to the contusion mechanism of amputations and partly to the small vessel size, which can be a limiting factor.…”