Microtia Reconstruction

Microtia and cholesteatoma: Implications for the reconstructive surgeon

Infection after reconstructive surgery for microtia is a technical challenge. This can be a sign of cholesteatoma formation by entrapment of epithelium in the middle or outer ear, specifically when the patient does not respond to first choice antibiotic therapy and debridement.

Two patients with microtia presented themselves with severe infections after ear reconstruction. In both cases cholesteatoma was diagnosed as the cause of the infection. After cholesteatoma management an additional surgical procedure was necessary to improve the esthetic outcome. The plastic surgeon should identify possible signs of cholesteatoma after reconstruction of the auricle.

Posterior auricular artery free flap reconstruction of the retroauricular sulcus in microtia repair

BACKGROUND

Autologous repair using costal cartilage grafts remains the most widely accepted method of microtia reconstruction. A major complication of current techniques is loss of ear shape caused by scarring, contracture and cartilage absorption. We present a new surgical technique utilizing the posterior auricular artery free flap in microsurgical reconstruction of the retroauricular sulcus in microtia.

METHOD

Reconstruction is performed in two stages. In the first stage, a fabricated costal cartilage framework is inserted into a skin pocket as described by Nagata. In the second stage, the ear framework is elevated from the scalp and held by an additional cartilage wedge. Following indocyanine green angiography perforator mapping, a posterior auricular artery perforator flap is harvested from the contralateral (normal) ear and used to reconstruct the posterior auricular sulcus covering the cartilage framework and elevating wedge.

RESULTS

The technique was applied to three patients aged 11-15 years with a follow-up time of 8 months to 3 years. The average flap artery diameter was 0.73 mm and the vein was 0.7 mm. Venous congestion occurred in one case and was resolved with a vein graft leading to complete flap recovery. Good ear shape, elevation, projection, skin color and texture were achieved in all the cases.

CONCLUSION

Posterior auricular artery flap reconstruction of the retroauricular sulcus in microtia repair is a useful alternative to the current skin graft and tissue expander-based techniques. It provides the ideal skin color and texture match and may improve the overall results of microtia reconstruction by enhancing vascularity.

Exploring the Experiences of Adults With Microtia: A Qualitative Study

OBJECTIVE

Microtia is a medically complex condition, with the option of surgery to address hearing and reconstruct the ear. The current study explored adults' experiences of microtia, with a particular focus on the psychosocial impact and experiences of ear reconstruction. The ultimate aim was to identify areas for support and future research that could improve patient care.

DESIGN

Fifteen adults (12 females) aged between 20 and 62 years took part in semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis.

RESULTS

Three main themes were identified in the data: microtia as an invisible difference, surgery as a welcome opportunity, and living well with microtia. Participants had incorporated microtia into their self-concept and did not report a lasting negative impact on their lives. However, some psychosocial challenges were reported, including anxiety about showing their ears (even after reconstruction), disclosing their diagnosis to romantic partners, surgical decision-making, and feeling unsupported in the work environment.

CONCLUSION

Individuals with microtia may benefit from psychosocial interventions to increase confidence, access to support for treatment decision-making, and guidance around disclosing microtia to employers.

Comparative effects of unilateral and bilateral bone conduction hearing devices on functional hearing and sound localization abilities in patients with bilateral microtia-atresia

Background: Various amplification options are available for patients with congenital bilateral conductive hearing loss. Unilateral bone conduction hearing device (BCHD) is widely used for these patients, whereas benefits of bilateral BCHDs in certain subgroups of patients require further exploration.Objectives: To evaluate functional and directional hearing in patients with unilateral Bonebridge (MEDEL) and contralateral ADHEAR (MEDEL) devices.Materials and methods: This study included 32 patients (20 males, 12 females), of mean age 11.8 years (range 7-27 years). Hearing thresholds, speech perception and sound localization were tested three months after activation of the Bonebridge under three conditions: unaided, unilateral BHCD (Bonebridge) and bilateral BHCDs (Bonebridge plus contralateral ADHEAR). Patient acceptance of these devices in daily life was evaluated by questionnaire.Results: Compared with unaided, the mean hearing thresholds (0.5, 1, 2, and 4 kHz) and speech perception with unilateral BCHD and bilateral BCHDs were improved significantly (p < .05 each). Markers of directional hearing ability, including percentages of accurate responses, bias angles and RMS errors, were significantly better with bilateral BCHDs than unilateral BHCD (p < .05 each). Questionnaire revealed high patient satisfaction with both unilateral and bilateral devices.Conclusions: Functional hearing and sound localization abilities were better with bilateral BCHDs than unilateral BCHD.

Phenotypic redifferentiation of dedifferentiated microtia chondrocytes through a three-dimensional chondrogenic culture system

Chondrocytes from microtia patients are a valuable cell source for the tissue-engineering of auricles. However, dedifferentiation of microtia chondrocytes remains an obstacle for clinical translation. Strategies, such as three-dimensional (3D) culture systems, and the use of chondrogenic growth factors, have successfully induced redifferentiation of dedifferentiated chondrocytes from healthy individuals. However, it remains unknown whether these strategies are similarly effective for microtia patient-derived chondrocytes, which may carry genomic defects. To address this issue, dedifferentiated microtia chondrocytes (DMCs) were cultured in a 3D chondrogenic culture system for 4-8 weeks to investigate their redifferentiated properties and to generate redifferentiated microtia chondrocytes (RMCs). To predict the degree and course of redifferentiation, RMCs at different time points were harvested and examined for cell morphology, cell proliferation, type II collagen expression at passaging, and chondrogenic capacity. We show that a 3D chondrogenic culture system can effectively induce DMCs to become redifferentiated, functional chondrocytes, enabling them to regenerate mature cartilage. Furthermore, RMCs achieved their full original function after culture in the chondrogenic culture system for 6-8 weeks. Interestingly, redifferentiation of microtia chondrocytes exhibited a time-dependent trend. Although the primary mechanism by which the 3D chondrogenic culture system regulated the transition of DMCs into RMCs remains unknown, the current study provides deeper insight into microtia chondrocytes and promotes clinical translation of tissue-engineered auricles.

Sound-localisation performance in patients with congenital unilateral microtia and atresia fitted with an active middle ear implant

OBJECTIVE

This study assessed the safety and sound-localisation ability of the Vibrant Soundbridge (VSB) (Med-EL, Innsbruck, Austria) in patients with unilateral microtia and atresia (MA).

METHODS

This was a single-centre retrospective research study. Twelve subjects with unilateral conductive hearing loss (UCHL) caused by ipsilateral MA were recruited, each of whom underwent VSB implantation and auricular reconstruction. The bone-conduction (BC) threshold was measured postoperatively, and the accuracy of sound localisation was evaluated at least 6 months after surgery. Horizontal sound-localisation performance was investigated with the VSB activated and inactivated, at varying sound stimuli levels (65, 70 and 75 dB SPL). Localisation benefit was analysed via the mean absolute error (MAE).

RESULTS

There was no statistical difference in mean BC threshold of impaired ears measured preoperatively and postoperatively. When compared with VSB-inactivated condition, the MAE increased significantly in unilateral MA patients in the VSB-activated condition. Besides, sound-localisation performance worsened remarkably when sound was presented at 70 dB SPL and 75 dB SPL. Regarding the side of signal location, the average MAE with the VSB device was much higher than that without the VSB when sound was from the normal-hearing ear. However, no significant difference was observed when sound was located from the impaired ear.

CONCLUSION

This study demonstrates that in patients with unilateral MA, the VSB device does not affect inner-ear function. Sound-localisation ability is not improved, but deteriorated at follow-up. Our results suggest that the VSB-aided localisation abilities may be related to the thresholds between the ears, plasticity of auditory system and duration of use of VSB.

Alloplastic Auricular Reconstruction: Review of Implant Types, Adverse Events, and Aesthetic Outcomes

IMPORTANCE

Alloplastic implants have been applied successfully in reconstruction of the external ear, either for congenital microtia or traumatic injury.

OBJECTIVE

The objective of this study was to conduct a comprehensive systematic review of alloplastic implant materials utilized in the reconstruction of the external ear stratified by indication, specific implant type, postoperative complications, and aesthetic outcomes.

EVIDENCE REVIEW

A comprehensive systematic review of published literature on alloplastic external ear reconstruction data was conducted utilizing Medline/PubMed database without timeframe limitations in June 2019. Articles were stratified by (1) indication (microtia versus trauma reconstruction) and (2) implant material type. All postoperative complications were recorded and comparatively analyzed between implant types. Aesthetic outcomes were also identified and compared between implant types.

FINDINGS

A total of 755 patients (14 case series; follow-up range = 3 months--10 years) met the criteria for this study. Overall complication rate was 12.05% across all indications and materials used. The most frequent complications reported were graft exposure (7.8%), graft explantation (1.72%), and wound dehiscence (0.8%). Of the patients requiring graft explantation (n = 13), 7 (53.85%) received Medpor implants, and the other 6 (46.15%) were identified in silicone implants. Infection was only reported in Medpor implants. The overall rate of an acceptable aesthetic outcome was 99.34%.

CONCLUSIONS AND RELEVANCE

Alloplastic implants are a reliable means of achieving an acceptable complication profile in external ear reconstruction. While there was an overall high rate of acceptable aesthetic outcomes, the studies evaluated in this systematic review differed in their criteria for final evaluation of aesthetic outcomes.

Morbidity in Patients With Separation of Cartilaginous Framework: Temporoparietal Fascia Flap and Treatment With Dermal Regeneration Template

BACKGROUND

The full creation of an ear requires 2 reconstruction stages. In the second stage of reconstruction, the cartilaginous framework placed at first stage is separated from the head creating an auriculocephalic sulcus. Then a piece of rib cartilage is placed in the sulcus to maintain this separation and is covered with tissue that allows the integration of a full-thickness skin graft.

METHODS

A descriptive study based on the pre and postoperative medical records and photographic archives of patients diagnosed with microtia who underwent separation of the cartilaginous framework from February 2010 to July 2015 in the Plastic and Reconstructive Surgery Department at Hospital General Dr. Manuel Gea González.

RESULTS

Fifty-four patients met the selection criteria. The temporoparietal fascial flap was performed on 85% (n = 46), and 8 cases with random occipito-temporal fascial flap in association to a dermal regeneration template. The average time at the operating room was 177 minutes in patients with temporoparietal fascial flap versus 84.5 minutes in dermal regeneration template. The complication rate was 25.9% (n = 14), being similar rate with both techniques.

CONCLUSIONS

Coverage with dermal regeneration template and random occipito-temporal fascia flap as an alternative use instead of temporoparietal fascial flaps, offers good postoperative results, lower operating times, and similar rate of complications, with the advantage of producing no visible scars and reserve the temporoparietal fascial flap for possible exposure of the cartilaginous framework.

Craniofacial Interventions in Children

Craniofacial interventions are common and the surgical options continue to grow. The issues encountered include micrognathia, macroglossia, midface hypoplasia, hearing loss, facial nerve palsy, hemifacial microsomia, and microtia. In addition, a unifying theme is complex upper airway obstruction. Throughout a child's life the focus of interventions may change from airway management to speech, hearing, and language optimization, and finally to decannulation and procedures aimed at social integration and self-esteem. Otolaryngologists play an important role is this arena and provide high-quality care while continuing to expand what can be done for our patients.

Reconstruction of Congenital Microtia and Anotia: Analysis of Practitioner Epidemiology and Postoperative Outcomes

BACKGROUND

Microtia refers to a congenital malformation of the external ear that is associated with a range of functional, psychosocial, aesthetic, and financial burdens. The aim of this study was to analyze the epidemiology and postoperative complication profile of microtia reconstruction.

METHODS

A retrospective review was conducted using data from the 2012-2017 the American College of Surgeons National Quality Improvement Program Pediatric databases. Patients with a diagnosis of microtia or anotia were identified using International Classification of Diseases codes. Demographics and postoperative complications were analyzed using Chi-square and t tests for categorical and continuous variables, respectively. Multivariable regression was performed to control for confounding variables.

RESULTS

A total of 466 cases were analyzed, of which 290 (62.2%) were performed by plastic surgeons and 176 (37.8%) by otolaryngologists (ear, nose, and throat physicians [ENT]). Autologous reconstruction was the predominant approach [76.2% of cases (n = 355)] in this cohort. ENT physicians operated on a significantly younger patient population (mean age 8.4 ± 3.2 years versus 10.0 ± 3.2 years, P< 0.001) and had higher rates of concurrent atresia/middle ear repair [21.0% (n = 37) versus 3.7% (n = 17)] compared with plastic surgeons. The rate of all-cause complications was 5.9% (n = 17) in the plastic surgery cohort and 4.0% (n = 7) in the ENT cohort (P= 0.372). Multivariable regression did not reveal any statistically significant predictors for all-cause complications.

CONCLUSIONS

Reconstruction of the external ear for patients with microtia/anotia is a safe procedure, with low rates of postoperative complications, readmissions, and reoperations. Autologous reconstruction remains the preferred modality for repair of the external ear and simultaneous atresiaplasty/middle ear repair does not increase the risk of complications.

Auricular reconstruction

External ear abnormalities are common. These may affect ear shape, size, prominence and degree of development. They may also be associated with hearing loss. The early identification and management of hearing loss is essential. There are several options for reconstruction of the external ear using both autologous and non-autologous techniques. The aim of this article is to outline the different reconstructive options.

[Application of three-dimensional mechanical equilibrium concept in cartilage scaffold construction for total auricular reconstruction]

Objective

To summarize clinical experience and curative effect in applying three-dimensional mechanical equilibrium concept to cartilage scaffold construction in total auricular reconstruction.

Methods

Between June 2015 and June 2017, ninety-seven microtia patients (102 ears) were treated with total ear reconstruction by using tissue expanders. The patients included 43 males and 54 females and their age ranged from 7 to 45 years with an average of 14 years. There were 92 unilateral cases (45 in left side and 47 in right side) and 5 bilateral ones. There were 89 congenital cases and 8 secondary cases. According to microtia classification criteria, there were 21 cases of type Ⅱ, 67 cases of type Ⅲ, and 9 cases of type Ⅳ. Tissue expander was implanted in the first stage. In the second stage, autogenous cartilage was used to construct scaffolds which were covered by enlarged flap. According to the three-dimensional mechanical equilibrium concept, the stable ear scaffold was supported by the scaffolds base, the junction of helix and inferior crura of antihelix, and helix rim. The reconstructed ears were repaired in the third stage operation.

Results

All patients had undergone ear reconstruction successfully and all incisions healed well. No infection, subcutaneous effusion, or hemorrhage occurred after operation. All skin flaps, grafts, and ear scaffolds survived completely. All patients received 5- to 17-month follow-up time (mean, 11.3 months) and follow-up time was more than 12 months in 61 cases (64 ears). All reconstructed ears stood upright, and subunits structure and sensory localization of reconstructed ears were clear, and the position, shape, size, and height of bilateral ears were basically symmetrical. Mastoid region scar hyperplasia occurred in 3 patients, which was relieved by anti-scar drugs injection. No scaffolds exposure, absorption, or structural deformation occurred during follow-up period.

Conclusion

Application of three-dimensional mechanical equilibrium concept in cartilage scaffold construction can reduce the dosage of costal cartilage, obtain more stable scaffold, and acquire better aesthetic outcomes.

Multidisciplinary management of oculo-auriculo-vertebral spectrum

PURPOSE OF REVIEW

Oculo-auriculo-vertebral spectrum (OAVS) is a complex disorder that is represented by wide variations in phenotypic presentation. Recent publications and systematic reviews of the available literature are presented here.

RECENT FINDINGS

Treatment strategies vary among craniofacial centers across the country. Advances in presurgical planning, virtual surgical planning, and computer-aided manufacturing have been incorporated in the treatment of patients. The psychosocial effect of OAVS with longitudinal follow-up is now being studied.

SUMMARY

Optimal evaluation and management of the OAVS patient requires an awareness of the phenotypic and genetic differences and involves a multidisciplinary team in order to effectively and appropriately diagnose and treat such patients.

Descriptive Analysis of the Arterial Supply to the Auricle in Patients with Unilateral Microtia

Background:

Microtia is a congenital auricular deformity that occurs in 1:5,000–10,000 births. It can cause severe impairment to the patient’s self-esteem and problems regarding social integration. Multiple measures have been described in attempt to better operative outcomes of these patients. We used computed tomography (CT) angiography to analyze the vascular pattern of the auricular region before surgery.

Methods:

Fourteen patients with unilateral microtia were included. All underwent CT angiogram plus tridimensional reconstruction. Both healthy and microtic auricles were analyzed descriptively in terms of main arterial supply, pattern, diameter of subbranches, and angulation. The sample was divided in 2 age groups for better understanding of the data.

Results:

Blood supply to the auricle was found to depend on 2 main vessels: temporal superficial artery (TSA) and its subbranches (superior, middle, and lower branch) and posterior auricular (PA) artery. In the microtic group, TSA was the dominant artery in 13 of 14 cases (92%). Superior, middle, and inferior branches were present in 4, 3, and 0 cases, respectively. Three of the microtic auricles presented supply from PA artery, from which in 1 case, it represented the only supply to the region.

Conclusions:

There is wide variability in the blood supply of both healthy and microtic auricles; however, we were able to identify some tendencies in our sample. Further research is needed to prove the benefit of a preoperative imaging study in these patients. Still, in our experience, we found it useful as a complement for surgical planning.

In Vitro Regeneration of Patient-specific Ear-shaped Cartilage and Its First Clinical Application for Auricular Reconstruction

Microtia is a congenital external ear malformation that can seriously influence the psychological and physiological well-being of affected children. The successful regeneration of human ear-shaped cartilage using a tissue engineering approach in a nude mouse represents a promising approach for auricular reconstruction. However, owing to technical issues in cell source, shape control, mechanical strength, biosafety, and long-term stability of the regenerated cartilage, human tissue engineered ear-shaped cartilage is yet to be applied clinically. Using expanded microtia chondrocytes, compound biodegradable scaffold, and in vitro culture technique, we engineered patient-specific ear-shaped cartilage in vitro. Moreover, the cartilage was used for auricle reconstruction of five microtia patients and achieved satisfactory aesthetical outcome with mature cartilage formation during 2.5years follow-up in the first conducted case. Different surgical procedures were also employed to find the optimal approach for handling tissue engineered grafts. In conclusion, the results represent a significant breakthrough in clinical translation of tissue engineered human ear-shaped cartilage given the established in vitro engineering technique and suitable surgical procedure. This study was registered in Chinese Clinical Trial Registry (ChiCTR-ICN-14005469).

In Vitro Regeneration of Patient-specific Ear-shaped Cartilage and Its First Clinical Application for Auricular Reconstruction

Microtia is a congenital external ear malformation that can seriously influence the psychological and physiological well-being of affected children. The successful regeneration of human ear-shaped cartilage using a tissue engineering approach in a nude mouse represents a promising approach for auricular reconstruction. However, owing to technical issues in cell source, shape control, mechanical strength, biosafety, and long-term stability of the regenerated cartilage, human tissue engineered ear-shaped cartilage is yet to be applied clinically. Using expanded microtia chondrocytes, compound biodegradable scaffold, and in vitro culture technique, we engineered patient-specific ear-shaped cartilage in vitro. Moreover, the cartilage was used for auricle reconstruction of five microtia patients and achieved satisfactory aesthetical outcome with mature cartilage formation during 2.5 years follow-up in the first conducted case. Different surgical procedures were also employed to find the optimal approach for handling tissue engineered grafts. In conclusion, the results represent a significant breakthrough in clinical translation of tissue engineered human ear-shaped cartilage given the established in vitro engineering technique and suitable surgical procedure.

This study was registered in Chinese Clinical Trial Registry (ChiCTR-ICN-14005469).

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Patient-specific ear-shaped cartilage was engineered in vitro using expanded MCs and compound biodegradable scaffold.

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The first microtia case treated with the tissue engineered ear-shaped cartilage was follow-up for 2.5 years.

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Other four cases with similar and different surgical procedures were also presented.

Microtia is a congenital external ear malformation that can seriously influence the psychological and physiological well-being of affected children. Using expanded microtia chondrocytes, compound biodegradable scaffold, and in vitro culture technique, we engineered patient-specific ear-shaped cartilage in vitro, and performed a pilot clinical trial of auricle reconstruction using the engineered ear cartilage on five patients. Satisfactory aesthetical outcome with mature cartilage formation was achieved with the longest follow-up of 2.5 years.

Otologic and Audiology Concerns of Microtia Repair

Microtia is a congenital auricular deformity that commonly presents with associated congenital aural atresia. The most acute concern in these patients is concomitant hearing loss at birth. A team-based approach by plastic surgeons and otologists is necessary to address both the otologic and audiologic concerns of microtia and atresia. Hearing rehabilitation is imperative; yet it should not compromise the aesthetic components of reconstruction and vice versa. Here, the authors propose a framework to evaluate and manage patients with microtia and atresia with the goal of optimizing functional and cosmetic outcomes.

Total Ear Reconstruction Using Porous Polyethylene

Total ear reconstruction has been approached by several techniques involving autologous graft, prosthetic implant, and alloplastic implant options. Recent studies have shown the superiority of porous polyethylene (Medpor, Porex Surgical) reconstruction over autologous reconstruction based on improved aesthetic results, earlier age of intervention, shorter surgery times, fewer number of required procedures, and a simpler postoperative recovery process. A durable and permanent option for total ear reconstruction, like Medpor, can help alleviate the cosmetic concerns that patients with auricular deformities may be burdened with on a daily basis. In this article, the authors discuss the advantages of Medpor-based ear reconstruction and discuss recent advances in the surgical techniques involved, such as harvesting a temporoparietal fascia flap and full-thickness skin graft to adequately cover the Medpor framework and decrease extrusion rates.