Two years ago, 19 year-old Army Private Shamika Burrage was driving back to her post in Fort Bliss, Texas, after visiting family in Mississippi. Her cousin, eight months pregnant, was with her.
"I was coming back from leave and we were around Odessa, Texas," Burrage said in a statement released by the Army. "We were driving and my front tire blew, which sent the car off road and I hit the brake. I remember looking at my cousin who was in the passenger seat, I looked back at the road as I hit the brakes. I just remember the first flip and that was it."
Her car skidded and flipped several times. While her cousin escaped with only minor injuries, Burrage was ejected from the car, and suffered road rash, head injuries, and compression fractures of her spine. Doctors said that without help, she would have bled to death in another 30 minutes. She also lost her left ear.
As she completed months of rehabilitation, she sought counseling to cope with the accident and considered getting a prosthetic to conceal her scarring. But plastic surgeons offered her another option: removing cartilage from her ribs, shaping it into the form of an ear, implanting it in her forearm where new blood vessels would form around it (which would take a year), then “harvesting” her newly built ear—arm skin and cartilage—and transplanting it to her head.
She was reluctant at first, and it took her two months to decide she’d try it.
“This kind of case tests the limits of every concept we know about,” says Owen Johnson III, Chief of Plastic and Reconstructive Surgery at William Beaumont Army Medical Center in El Paso, Texas. It’s not the first time a total ear reconstruction has been done—Johnson’s mentor, Patrick Byrne of Johns Hopkins University School of Medicine, pioneered the technique in 2012 in the case of a woman who lost her ear to cancer—but it’s a first for the Army.
"We use this concept"—taking cartilage, whether from the patient or from a donor, and transplanting it to shape growing tissue—"hundreds of times a year in nasal reconstruction and in ear reconstruction," says Byrne, an associate professor in otolaryngology-head and neck surgery at the Johns Hopkins University School of Medicine. What's unusual about this case, though, is "growing" the ear in the patient's arm.
Johnson and a team of doctors performed three complex procedures. Each came with its dangers and possible pitfalls—removing cartilage from her ribs, for example, meant cutting close to the lungs, risking puncture. “It was a really complicated surgery that could have easily failed at so many different checkpoints,” Johnson says. “And we only had one shot to get everything right.”
First they had to obtain the cartilage. That meant opening up Burrage’s chest and carving out long pieces of the stuff from the right side of her ribcage. No single area would provide enough cartilage, so they removed it from eight to ten ribs in a way that would minimize any chest deformities.
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Johnson compares the cartilage to soap in consistency, and once they had enough, it was like making a soap sculpture—in this case, the shape was based on Burrage’s remaining ear. (It’s a process also used for children with anotia or microtia, birth defects that lead to a missing or underdeveloped external ear.) Usually the whole thing is held together with steel wire, but in this case, Johnson says, they used a form of super glue. He compares the process of layering, shaping, and carving cartilage to a slow, manual form of 3D printing—which he says will be the next big breakthrough in transplants. Doctors have 3D-printed molds for ears, but we still can't print cartilage—yet.
They implanted the cartilage form under the skin in her arm in what’s known as a prelaminated forearm free flap. Once there it didn’t “grow” in a conventional sense; in fact, the body can sometimes reabsorb implanted cartilage, treating it like foreign matter to be disposed. But in a successful procedure, new blood vessels grow around the cartilage, which make it viable for transplant. “The cartilage is kind of getting used to its new home,” Johnson says, “And then you just move the home.”
Johnson was also careful to preserve sensory nerves in the surrounding area of her arm so that when that skin was transplanted to her head with the ear, Burrage would be able to feel through the skin around her ear. (Her hearing wasn’t damaged, though scar tissue had formed over the ear canal; doctors removed that during the transplant.)
When harvest time came a year later, doctors needed to remove the cartilage and enough skin to cover the damaged area on Burrage’s head—but they also had to prevent permanent damage to her arm. After removing the ear, Johnson covered the arm with a skin substitute called Integra. “The nice thing is you can place that over exposed tendons,” Johnson says, “and let it sit for four to six weeks, and her healing cells will enter that matrix and eventually replace it with her own tissue.”
The substitute skin helped fill in the missing tissue, which Johnson later covered with skin taken from Burrage’s thigh. Her arm is now back to full functionality, with the complete range of motion in the arm and wrist. “She healed up great,” he says.
There's some evidence that sensation can redevelop with this type of procedure, according to Byrne. He points to tongue reconstructions where patients could later feel a pinprick on their newly transplanted tongues. But it's less clear that Burrage will have feeling in her ear. "I don't believe we've ever tested it with the ear," he says, "It's my guess that some patients would develop sensation, but it's not an expectation."
While Johnson is justly proud of the technical accomplishments in this case, he thinks it’s as important to recognize how meaningful it can be for a patient. After her accident, he says, Burrage was understandably withdrawn; her mental health was tied to her loss, and the speed with which her life had changed. Today, at 21, she can see herself in a different light; she’s happier, and will soon begin studying to be a physical therapist, hoping to help others the way she’s been helped.
“I think this illustrates that skilled reconstructive surgery isn’t just about making you look better,” Johnson says. “It’s about restoring your sense of identity, and your sense of worth. It warms my heart that when I see her now, she’s always smiling.”
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