846 Correspondence and communications

taught in English within modern facilities. We look forwardto the 13th International Perforator Conference.

M.S. LloydN. Niranjan

St Andrew’s Centre for Plastic Surgery & Burns,Broomfield Hospital, Chelmsford, Essex CM1 7ET, UK

E-mail address: mark.lloyd73@btinternet.com

ª 2009 Published by Elsevier Ltd on behalf of British Association ofPlastic, Reconstructive and Aesthetic Surgeons.

doi:10.1016/j.bjps.2009.02.057

Ear avulsion

Figure 1

Ibrahim et al. in their paper ‘Total avulsed ear: new tech-nique of immediate ear reconstruction’1 in an extension ofMladick’s pocket principle2 present a method of preserva-tion of auricular cartilage denuded of its skin, deep toa temporo-parietal fascia flap. The authors present threecases. Photos of two of the cases are shown with 5 and 6months’ follow up respectively, with these early resultsdescribed reasonably as satisfactory.

Since the pocket principle was described in 1971, it hasbecome apparent that the delicate auricular cartilage isunable to withstand the contractile forces of scarringwithin the pocket over the first year or so of healing. Withthe temporo-parietal fascia flap being notorious for itscontractile properties, the development described in thisarticle of using the fascia to form the pocket, must onlyincrease the risk that the contours of the auricular cartilagewill be lost in time.

The major advancements in ear reconstruction withcostal cartilage over the last thirty years, by dedicatedspecialists most notably in the USA, Japan, France and theUK had rendered the pocket principle obsolete. Central tothe principles of costal cartilage based reconstruction is anunderstanding of the importance of the temporo-parietalfascia. In a two-stage reconstruction where there is a lackof skin, the fascia may prove vital at the first stage, fortemplate cover. Where adequate skin for the first stage ispresent, the fascia may be used to allow the second stageear release to be performed. Otherwise, it remains anoption for soft tissue cover, if cartilage exposure compli-cates either stage of the reconstruction.

The use of the temporo-parietal fascia flap in combina-tion with denuded auricular cartilage following ear avulsionwill almost always preclude a subsequent costal cartilagebased reconstruction in cases in which infective orcontractile complications ensue.

The described technique may be an option in situationswhere costal cartilage reconstruction is unavailable, unaf-fordable or refused. The sacrifice of the temporo-fascialflap, in this unforgiving surgery, is however a decision not tobe taken lightly. The gold standard remains, referral toa plastic surgery unit, with surgeons experienced in theprinciples and techniques of costal cartilage based earreconstruction.

References

1. Ibrahim SMS, Zidan A, Madani S. Total avulsed ear: a newtechnique of immediate ear reconstruction. J Plast ReconstrAesthet Surg 2008;61:S29e36.

2. Mladick RA, Horton CE, Adamson JE, et al. The pocket principle:a new technique for the reattachment of a severed ear part.Plast Reconstr Surg 1971 Sep;48(3):219e23.

Greg O’TooleWalid Sabbagh

Plastic Surgery, Royal Free Hospital, Pond Street,Hampstead NW3 2QJ, UK

E-mail address: gotnw3@gmail.com

ª 2009 Published by Elsevier Ltd on behalf of British Association ofPlastic, Reconstructive and Aesthetic Surgeons.

doi:10.1016/j.bjps.2009.01.028

Midair microanastomosis madeeasier: Syringe and suture pack foilas a platform and background

A patient presented having had his right ear completelybitten off (Figure 1). Only one suitable artery and vein