Surgical procedure
In all patients, an entire cymba-cavum concha complex was harvested from
the external ear using an anterolateral approach through an incision
several millimeters inside the contour line along the posterior conchal
wall and inferior crus. Lidocaine hydrochloride (1%) with epinephrine
(1:100,000) was injected for vasoconstriction at the harvest site.
Several dissections were used to elevate the soft tissue away from the
cymba-cavum conchal cartilage complex. All layers including cartilage,
perichondrium, and soft tissue were preserved on the graft. Both halves
of the harvested conchal cartilage were folded back-to-back with
perichondrial surfaces positioned face-to-face without any cutting or
incision. Three or four horizontal mattress sutures were then placed on
the graft to fix the folded layers and reinforce bearing capacity. The
ends of the folded transplant were intentionally left. Finally, the
large bean-shaped original cavum concha was divided into an elliptical
main piece and several smaller polygonal pieces. The elliptical main
piece produced a strong and stable caudal end graft, that resists
cephalic-rotatory tendency. The latter pieces were stacked to form a
pagoda-shaped transplant that filled the anterior space of the nasal tip
(Fig. 1). The columellar strut graft was placed in the intercrural
space, where spreader grafts were anchored to one or both sides of the
anterior part of the strut graft. Grafts were fixed to the dorsal septum
to locate the anterior end of the columellar strut graft precisely and
to prevent cephalic rotation of the dome caused by the columellar strut
graft (Fig. 2). The folded portion of the graft was directed caudal to
strengthen the strut force and maintained the entire skeleton to prevent
cephalic rotation.