A novel algorithm for autologous ear reconstruction

An Alternative Posterosuperior Auricular Fascia Flap for Ear Elevation During Microtia Reconstruction

BACKGROUND

Advances in staged total auricular reconstruction have resulted in improved anterior auricular appearance; however, satisfactory postreconstruction esthetics of the retroauricular fold remain challenging. The postauricular appearance of the reconstructed ear depends largely upon optimizing the covering material. When used as the covering soft tissue for ear elevation, a flap containing primarily the upper portion of the retroauricular fascia has potential advantages over the conventional book cover-type retroauricular fascia flap.

METHODS

We developed a geometrically designed, posterosuperior auricular fascia flap to replace the conventional retroauricular fascia flap for ear elevation. During the second-stage operation, the posterosuperior auricular fascia flap is rotated downward and turned over to wrap around the inner strut and entire posterior auricular surface.

RESULTS

Compared to the conventional book cover-type retroauricular fascia flap, the novel posterosuperior auricular fascia flap was easier to harvest and the operative time significantly decreased (110.3 vs. 121.5 min, p < 0.01). The modified flap produced a thin and natural contour of the postauricular surface, as well as reduced the incidence of postauricular hypertrophic scarring (from 24.7 to 13.2%, p = 0.03) and partial skin graft necrosis (from 43.4 to 31.2%, p = 0.01).

CONCLUSION

The geometrically designed posterosuperior auricular fascia flap improves ear elevation. Compared to the conventional book cover-type retroauricular fascia flap, this covering tissue is easier to perform so the surgical time is decreased. It was highly vascularized, well defined, thinner, and yields reliable results. Thus, favorable postauricular surface results can be achieved during auricular reconstruction by using the modified fascia flap.

NO LEVEL ASSIGNED

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A Temporoparietal Fascia Pocket Method in Elevation of Reconstructed Auricle for Microtia

BACKGROUND

In two-stage procedures for reconstruction of microtia, an axial flap of temporoparietal fascia is widely used to cover the costal cartilage blocks placed behind the framework. Although a temporoparietal fascia flap is undoubtedly reliable, use of the flap is associated with some morbidity and comes at the expense of the option for salvage surgery.

METHODS

The authors devised a simplified procedure for covering the cartilage blocks by creating a pocket in the postauricular temporoparietal fascia. In this procedure, the constructed auricle is elevated from the head superficially to the temporoparietal fascia, and a pocket is created under the temporoparietal fascia and the capsule of the auricle framework. Then, cartilage blocks are inserted into the pocket and fixed. A total of 38 reconstructed ears in 38 patients with microtia ranging in age from 9 to 19 years were elevated using the authors' method from 2002 to 2014 and followed for at least 5 months. To evaluate the long-term stability of the method, two-way analysis of variance (p < 0.05) was carried out to analyze the effect on the projection angles of the method (an axial temporoparietal fascia flap method versus a temporoparietal fascia pocket method) over long-term follow-up.

RESULTS

Good projection of the auricles and creation of well-defined temporoauricular sulci were achieved. Furthermore, the sulci had a tendency to hold their steep profile over a long period.

CONCLUSIONS

The temporoparietal fascia pocket method is simple but produces superior results. Moreover, pocket creation is less invasive and has the benefit of sparing temporoparietal fascia flap elevation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Reconstructive Surgery of Auricular Defects: An Overview

Context:

Despite the ongoing advances in surgical procedures and promising progress in bioengineering techniques, auricular reconstruction remains a significant challenge in plastic surgery. There are different causes for acquired auricular defects, including trauma, tumor ablation and burns. The management options for upper, middle and lower third auricular defects are briefly reviewed in the current paper.

Evidence Acquisition:

Original research papers investigating the plastic surgeons, otolaryngologists and maxillofacial surgeons in approaching the complicated issue of auricular reconstruction published from January 1995 to December 2014 were aggregated and used in the current study.

Results:

Utilizing autologous stem cell populations to treat craniofacial defects is a promising field of ongoing investigations. Studies show that cartilage stem/progenitor cells (CSPCs) are highly chondrogenic and can produce elastic reconstructive material with long-term tissue restoration.

Conclusions:

Auricular reconstruction surgery is a challenging plastic procedure that requires great expertise and expert knowledge of the various techniques available. Novel techniques in the fields of reconstructive bioengineering and regenerative medicine are promising but further research is required before widespread clinical application.

Objective analysis of microtia reconstruction in Indian patients and modifications in management protocol

Introduction:

An ideal ear, with representation of all anatomic landmarks, is the aim of any reconstructive surgeon embarking on reconstructing the ear in a microtia patient. The literature is abundant with the description of techniques, but these have been reported mainly in Caucasian and Oriental population. There have been very few publications on results in the population belonging to the Indian subcontinent. In spite of strictly adhering to the recommended techniques of reconstruction, the results obtained in these patients have often been marred by problems that are not reported with the Oriental or Caucasian populations. This may necessitate a relook into the management strategy of these cases. Hindering the assessment of the results, their reporting and auditing the improvement obtained by such change in the management strategy, is the lack of a standardized method for assessment of the outcome. Hence, an attempt was made in a series of patients who underwent microtia reconstruction to assess the outcome using a new tool based on the attained definition of anatomical components of the reconstructed pinna. Further effort was made to document the modifications in the technical execution of the reconstruction during the period of the study.

Materials and Methods:

A retrospective review of 44 patients and a prospective analysis of 11 patients, who underwent ear reconstruction for microtia from December 2003 to September 2014 at a tertiary care teaching hospital, was undertaken. Taking a cue from Nagata's description of an ‘ideal reconstructed ear’ which should show all the anatomical components, we developed an objective grading system to assess our results. The technique had undergone several changes during these years combining the principles of three universally accepted methods, that is, those described by Nagata, Brent, and Firmin. These changes, as well as the reasons behind them, were documented.

Results:

On objectively measuring and analysing the replication of normal morphologic characteristics of the reconstructed ears, we documented progressive improvement of our results. Good or excellent results could be achieved in 70% of cases in the second group compared to a poor outcome in more than 2/3^rd of the cases carried out during the initial period. Based on these results and the changes adopted in our practice we propose suggestions for management of microtia cases in the Indian population.

Conclusions:

An objective, weighted grading system has further enabled us to critically evaluate the outcomes and to further improve upon the existing results. Our amalgamation of the salient features of the established techniques as well as changes made based on our experience has enabled us to get good results more consistently in our attempts at microtia reconstruction. We believe that the adoption of such amalgamated methods will be more suitable in Indian patients.

Subcostal Skin Graft Donor Site for Autologous Ear Construction

Autologous ear construction for microtia creates an auricle using a costal cartilage framework. To separate the construct from the mastoid, a skin graft is required to form a retroauricular sulcus. Skin graft donor sites that have been described include the inguinal area (split or full-thickness) or scalp (split-thickness). The purpose of this study is to report a novel skin graft donor site for ear construction. We harvest a full-thickness graft from the subcostal area based on the previous scar from the cartilage harvest. Unlike the inguinal donor site, this method does not place an additional scar on the child. In contrast to the scalp donor site, the technique is simpler and a full-thickness graft minimizes contraction of the retroauricular sulcus.

Auricular reconstruction of congenital microtia: personal experience in 225 cases

Microtia is a congenital disease with various degrees of severity, ranging from the presence of rudimentary and malformed vestigial structures to the total absence of the ear (anotia). The complex anatomy of the external ear and the necessity to provide good projection and symmetry make this reconstruction particularly difficult. The aim of this work is to report our surgical technique of microtic ear correction and to analyse the short and long term results. From 2000 to 2013, 210 patients affected by microtia were treated at the Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma. The patient population consisted of 95 women and 115 men, aged from 7 to 49 years. A total of 225 reconstructions have been performed in two surgical stages basing of Firmin's technique with some modifications and refinements. The first stage consists in fabrication and grafting of a three-dimensional costal cartilage framework. The second stage is performed 5-6 months later: the reconstructed ear is raised up and an additional cartilaginous graft is used to increase its projection. A mastoid fascial flap together with a skin graft are then used to protect the cartilage graft. All reconstructions were performed without any major complication. The results have been considered satisfactory by all patients starting from the first surgical step. Low morbidity, the good results obtained and a high rate of patient satisfaction make our protocol an optimal choice for treatment of microtia. The surgeon's experience and postoperative patient care must be considered as essential aspects of treatment.

Cadaveric dissection and clinical experience with 20 consecutive tunneled pedicled superficial temporal artery perforator (STAP) flaps for ear reconstruction

INTRODUCTION

Reconstruction of anterior ear defects is poorly described, but using "like" tissue provides the optimal reconstruction. We present a cadaveric dissection and our experience with the pedicled superficial temporal artery perforator (STAP) flap for reconstruction of partial ear defects.

MATERIALS AND METHODS

Two cadavers were dissected bilaterally (n = 4) following injection of latex and barium sulfate. A retrospective review of 20 consecutive patients undergoing reconstruction with the STAP flap from 2009 to 2012 was performed. Twenty patients underwent reconstruction of anterior ear defects following resection for non-melanoma skin malignancies using a tunneled pedicled STAP flap (scapha: 5, triangular fossa: 2, scapha and triangular fossa: 13).

RESULTS

Two perforators were identified in all dissections with one perforator at the level of the tragus, and the second perforator within 1 cm cephalad to the tragus. Thirteen patients underwent reconstruction following basal cell carcinoma excision and seven patients were reconstructed following excision of squamous cell carcinoma. There were no flap losses, but four flaps (20%) developed congestion at the tip of the flap that resolved without need for flap delay, leeching, or vasodilators. No patients developed complications with the donor site, and no patients underwent revisions. With a mean follow-up of 27.3 months (range: 19-38 months), all patients were pleased with their aesthetic outcomes and alive without recurrent disease.

CONCLUSION

The STAP flap is a pedicled perforator flap providing local "like" tissue that can be utilized for resurfacing of defects involving the anterior upper external ear with minimal donor site morbidity.