Here, the completed framework is being inserted into the skin pocket around the pedicle. Insertion of the helical portion should be especially gentle to prevent deformity. If there is difficulty with placement, make sure the skin pocket is completely dissected with no fibrous bands. The pedicle can also be made slightly smaller if needed. To secure the most anterior portion of the framework, a single 3-0 nylon suture is placed. An ear positioning template should be used again to outline where the helix is to ensure the framework is in the right position. After skin trimming, stitches are placed at the anterior lobule flap to bring the skin together. A 16-gauge angiocatheter is placed at the scapha fossa. The angiocatheter is connected to suction, which allows the skin to adapt to the framework. To form the bolster suture, double-armed 4-0 proline is used, starting from the scapha fossa to the outside of the framework. These bites include the framework and will ultimately keep the xeroform in place. The space between the two bites of the double-armed suture should be wide. Xeroform is then threaded underneath the proline and placed in the scapha fossa. It is held in place once the double-armed proline is tightened and secured with very gentle knots to prevent ischemia. Unused rib cartilage is placed in a solution of vancomycin. Smaller pieces are diced into 1 to 3 millimeters and then are placed in the perichondrial pocket and closed. Larger pieces are banked under the external oblique and above the perichondrium for use in future reconstruction while preventing resorption.

surgical procedure

helical framework

skin dissection

ear positioning template

cartilage storage