Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 824e829

CASE REPORT

Delayed, bilateral, non-microvascular ear

replantation after violent amputation
E. Garcı́a-Murray*, O. Adán-Rivas, H. Salcido-Calzadilla

Plastic Surgery Department, Hospital Angeles del Pedregal, Camino a Santa Teresa 1055, Héroes de Padierna,
México City, Postal Code 10700, México

Received 16 April 2007; accepted 6 November 2007

KEYWORDS Summary Amputation of any body part is undoubtedly a traumatic experience leaving a ter-
Ear; rible deformity, especially when the part or parts involved are visible and constitute an essen-
Replantation; tial component of someone’s facial whole. Bilateral ear amputation and successful subsequent
Amputation; replantation has been reported historically, but not in the modern surgical literature. We re-
Grafting; port the case of a 27-year-old female who was abducted and suffered a bilateral ear amputa-
Delayed grafting tion at the hands of one of her captors to speed delivery of ransom money; the severed parts
were sent to the parents approximately 2 hours after the amputation had taken place, and the
girl was released some 48 hours after the ears were delivered. Microvascular replantation was
attempted immediately after admission to the hospital some 2 hours after her release, but
failed, and so a non-microvascular replantation was performed and was successful, after
approximately 54 hours of ischaemia time. We consider this the first report of a complete
bilateral, delayed, non-microvascular, successful ear replantation in a human being in the
modern literature.
ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Ear amputation is an infrequent event that may have
significant psychological consequences, and will present
the subject afflicted by it with an obvious and terrible
deformity, though, fortunately, of rare occurrence. We
know that replantation of amputated segments of the
* Corresponding author. Address: Hospital Angeles del Pedregal,
Periférico Sur 3697- 750, Héroes de Padierna, México, D.F. 10700,
México. Tel.: þ52 55 5568 8259; fax: þ52 55 5602 3584.
E-mail address: egamurray@avantel.net (E. Garcı́a-Murray).
auricle was practiced as early as the 17th Century. The
memoirs of Stafford written during the reign of King Charles
I were cited by Cocheril1 in 1894: ‘to punish Puritan and
Colonist opposition to the regime, the victim’s ear was
frequently amputated and nailed to a wooden post’. The
evolution of three such victims was later documented as
follows: ‘Burton a minister of the Government whose fate
of ears is unknown, Bartwick, a physician, whose wife
collected his amputated ears and placed them carefully
into a handkerchief, hoping to have them replanted, and

1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2007.11.005
Ear replantation after violent amputation 825

Prynne, a lawyer who had to appear before the jury for

a second time with two normally-appearing ears, but with
signs of mutilation’. All of this happened between the years
of 1630 and 1640, long before any reports of replantation of
the ear can be found. Cocheril1 cited many examples of
successful replantation of the ear in the 19th century,
though he failed to report the relative size of the severed
part.
We reviewed the literature and found that the oldest
report is by Brown2 in 1898 relating to an external ear com-
pletely bitten off by a horse and successfully replaced. In
1967 Pierer3 made a report of a simple reattachment of
a severed ear; Mladick4 and McDowell5 reattached partial
ear amputations in 1971. Glifford6 reported in 1972 a partial
auricular amputation replacement performed in 1969.
Again Mladick7 in 1973 reported the replacement of a subto-
tal amputation (75% of the ear). Baudet8 reported his per-
sonal technique in 1972. In 1979, Salyapongse et al.9 Figure 1 Right ear stump, cut border is clearly seen, patient
reported a case of replacement by means of Baudet’s tech- is already under general anaesthesia.
nique. Clemons and Connelly10 in 1973 and Potsic and Naun-
ton11 in 1974 reported successful reattachment in totally
severed ears.
Microsurgical ear replantation was first reported by
Buncke12 in 1966 in an experimental model, but the tech-
nique was not successful clinically until 1980 by Penning-
ton.13 Since that year several authors, including
Mutimer,14 Juri,15 Turpin,16 Van Beck,17 Katsaros,18
Tanaka,19 Sadovs,20 Rappaport,21 Safak et al.,22 Kind and
Buncke23 and Concannon24 have reported 18 cases of unilat-
eral microsurgical ear replantation. Pribaz et al. reported
in 1997, two cases of successful non-microvascular replan-
tation in two children by means of ‘burying’ the ears after
de-epithelialisation with further extraction and spontane-
ous epithelialisation.25 Akyurek et al.26 reported in 2001
a successful microvascular replantation without venous
repair.
Upon reviewing the English and Spanish medical literature
we have come to the conclusion that this case is the first
successful bilateral ear replantation published in the modern Figure 2 Left ear stump, less ear tissue remains, compared
medical literature, although the unilateral replantation by to contralateral side, again, cut edge is clearly seen.
microsurgical means and the unilateral simple reattachment
as composite grafts with inconsistent success is well
documented.
We present a case of major bilateral ear amputation
with successful non-microvascular replantation, performed
54 h after the violent event. Microvascular replantation was
attempted but failed due to extensive vascular damage.

Case report

A 27-year-old female was abducted in November 1996, and

held hostage for the payment of ransom money for 15 days,
she was given little food and water. On Monday November
11th, at approximately 8:00 pm, both her ears were
amputated leaving the helical root, half the concha and
90% of the lobule (Figures 1e3), and the severed parts were
sent to her parents to speed delivery of ransom money. The
ears were delivered at approximately 10:00 pm.
The ears were rinsed and kept enveloped in a moist gauze Figure 3 Both auricles are shown prior to any intervention.
sponge, inside a sterile plastic bag, which in turn was Good tissue condition may be appreciated even after 54 h of
kept inside a bucket filled with water and ice, inside separation from the body, due to proper preservation.
826
Figure 4 (a) Right amputated auricle. (b) Left amputated
auricle.
a refrigerator, to insure proper temperature maintenance,
checking several times a day for an adequate amount of
ice and water in the bucket.
Three hours before her release, on Wednesday Novem-
ber 13th 1996 at 6:30 pm, the ears were taken to the
hospital and into the operating room for examination under
the surgical microscope for proper identification and
dissection of blood vessels (Figures 3 and 4). Four small ar-
teries and four small veins were identified (0.5 mm in diam-
eter and less), though obvious endothelial damage was
detected in the proximal portions. The patient arrived at
the operating room at 9:30 pm, at which time she was ini-
tiated on a forced iv Ringer’s lactate solution for hydration
at 500 cc/h and a complete history and physical as well as
vital signs and cardiovascular assessment were obtained
to determine whether it would be wise to have the patient
anaesthetized and operated on or not, since an initial
on-route evaluation of her base condition was performed
in the ambulance and later on corroborated by the Emer-
gency Room personnel and considered adequate to proceed
to the Operating Room. The patient was anaesthetised
and thorough cleansing and debridement of the stumps
was undertaken followed by microscopic examination and
identification of vessels. Three elements were chosen and
E. Garcı́a-Murray et al.
Figure 5 (a) Area of mastoid and occipital areas undermined
bilaterally to advance flap (b) over the posterior aspect of the
replanted auricles.
isolated, one artery and two veins for each ear, and micro-
vascular replantation was attempted but unsuccessful due
to extensive endothelial damage, which led to persistent
clotting and telescoping of the arteries in the ears. At
2:00 am on the 14th of November, the microvascular at-
tempts were called off and a salvage procedure initiated
to reattach the ears by non-microvascular means. The pro-
cedure performed was as follows: since the condition of the
tissue to be replanted was at best poor, we needed to
ensure the most vascularised bed possible to apply the
composite graft in order for it to survive at least partially,
so we decided to use the remnants of the concha as the
base and to give the skin and cartilage a chance, since their
appearance and consistency were good. From these deci-
sions, the skin and perichondrium of the anterior surface
of the remaining concha, lower crus, helical root and
anti-tragus at the stump were elevated from the cartilage
1.0 cm, along the entire edge of the stump. A cervico-pari-
eto-occipital flap was elevated subcutaneously within
a 10 cm radius (Figure 5), bilaterally, and proper haemosta-
sis was ensured. Both ears were prepared removing the pos-
terior surface skin, but preserving the perichondrium
(Figure 6) as a means for prompt revascularisation and
Ear replantation after violent amputation
Figure 6 Skin was excised off the posterior surface of the
amputated auricles, leaving the perichondrium intact as
a means for better graft ‘take’.
adequate cartilage nutrition. A 1 mm resection of the cut
edge of both ear stumps was performed; so better skin
was available for suture. Then, resection of a 3 mm strip
of skin was performed along the anterior border of the am-
putated ears and apposition of the proximal 3 mm edges
upon the stump was accomplished creating a double-lay-
ered cartilage ‘sandwich’ fixed with single 5/0 nylon mat-
tress sutures applied to the cartilage only and leaving the
tied knot posteriorly (Figures 7 and 8). The next step was
to provide skin coverage for the posterior surface of the re-
planted ears and to try and obtain a well-defined sulcus at
the same time, so the flaps were advanced as much as pos-
sible and fixated to the cartilage frame at three points at
the concha with mattress sutures (Figure 8) giving just
slight tension to the base of the flap and obtaining a ten-
sion-free flap edge to work with. The skin edges were su-
tured with simple 6/0 stitches placed 6e7 mm each from
one another in the back and frontal free skin edges
Figure 7 Cross-section of overlapping fixation at the concha.
827
Figure 8 Posterior view of flap advancement and fixation to
the concha at cartilage overlap site with three mattress
sutures.
(Figure 7). A non-suction soft 2 mm tubing drainage was
placed behind each ear and removed the next day.
The patient was placed on low molecular weight dextran
solution for 2 days and wide spectrum antibiotics and
pentoxyphiline 400 mg three times a day for 1 week, and
dexametasone 2.25 mg a day for 3 days. Both ears were
covered only to give protection but no pressure bandage
was used. Both replanted ears had small blisters on the
fourth day, on the anterior surface, and no skin sloughing
and no necrosis was observed, only some petechiae and
slight bruising, which disappeared within 1 week (Figure 9).
The ears were always covered with a thick layer of the an-
tibacterial ointment ‘Neosporin’ for the first 2 weeks. At 1
month, the ears were normal in appearance, though some
pink and red discolorations were visible, but all suture lines
and cartilage unions were stable and normal shape was
apparent (Figures 10 and 11). At 12 months postoperatively,
almost normal coloration of the skin was attained (Figures 12
Figure 9 Left ear view at 10 days post-attachment. Skin
colour and condition looks adequate.
828
Figure 10 Left ear appearance at 1 month post-attachment,
colour is good, no cartilage loss is apparent.
and 13), no residual deformity is observed, a normal ap-
pearance for both ears is apparent and the scars are barely
visible. Furthermore, protective sensation was referred by
the patient: pin-prick sensation e two point discrimination
at 10 mm was present on some areas of the anterior surface
of both ears e by 18 months.
We present this case, as what we conclude is the first
complete bilateral late non-microvascular, successful ear
replantation in the literature. We also present an alterna-
tive to the various salvage techniques which have been
described by previous authors.2e24 The case presents some
unique characteristics, as follows: (1) the procedure was
performed 54 h after amputation; (2) we had a bilateral
case which is not the rule but rather the exception; (3) re-
cipient vessels were in poor condition for microvascular re-
pair but may have been useful for quick inosculation; (4)
perichondrium was preserved to speed revascularisation
by means of the flaps.
Figure 11 View of right ear at 1 month post-attachment,
some late epidermolysis can be appreciated, cartilage is
preserved.
E. Garcı́a-Murray et al.
Figure 12 Left ear at 12 months post-attachment, subcuta-
neous tissue shows some atrophy, but general appearance is
good.
We believe that even delayed replantations with pro-
longed ischaemia times should be given a chance based
upon the success of this case and the fact that not one but
both ears ‘took’ without any major problems. It is important
to notice that almost no cartilage was resorbed probably
due to the means used to preserve the ears while un-
attached, as well as the preservation of the perichondrium
at the posterior aspect of the ears, although, thinning of the
ear fat was apparent bilaterally. The fact that no surgical
revisions were needed and no noticeable scar was left in
both auricles encourages us to suggest that this technique
may be useful when no microvascular techniques are
possible or available, and that non-microvascular tech-
niques may be in some selected cases just as good an
alternative as the aforementioned procedures. Also, leaving
the replanted part outside a subcutaneous pocket allows for
natural definition of the shape and no deformation ensues,
thus, reducing the need for subsequent interventions.
Figure 13 Right ear at 12 months post-attchment, some red-
ness is apparent, but shape and contours remain.
Ear replantation after violent amputation 829

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