A single-stage two-flap method of total ear reconstruction

Total rebuilding of the ear after unsatisfactory initial microtia reconstruction: 30-year experience using autogenous costal cartilage framework

BACKGROUND

This study describes the author's experience with long-term follow-up analysis of secondary procedures in patients with unsatisfactory initial microtia reconstruction.

METHODS

A total of 134 patients who underwent secondary operations between 1992 and 2021 were reviewed by examining medical records and photographic data. A total of 110 patients followed between 6 months and 26 years (average 33.2 months) were included for evaluation of aesthetic outcomes.

RESULTS

Primary reconstruction was performed with costal cartilage in 113 patients, porous polyethylene implant in 7 patients, silicone implant in 6 patients, and others in 8 patients. The major external features at the time of the secondary reconstruction were lump (91 cases), deficient convolution (19 cases), and no framework with scarred mastoid skin (22 cases). All secondary reconstructions were performed with an autogenous costal cartilage framework. The framework was covered using temporoparietal fascia flap techniques in 118 patients, mastoid skin coverage technique in 12 patients, and others in 4 patients. One major complication (exposure of cartilage framework due to partial necrosis of fascial flap) and three minor complications (loss of moderate-sized full-thickness skin, grafted on the fascia) were recorded. The average score given for aesthetic outcomes, rated on a four-point Likert scale (i.e., 1 = poor, 2 = fair, 3 = good, and 4 = excellent) was 3.17 (median 3.00). A total of 42% of the patients were rated excellent and 36% were rated good.

Salvage of Ear Framework Exposure Following Autologous Microtia Reconstruction: Repair Strategy for Each Location of Exposure

One of the most common complications of total auricular reconstruction is exposure of the ear framework. Various reconstruction methods have been reported depending on the location and size of exposed cartilage. This report describes a safe reconstruction method for each exposed part of the grafted ear framework. From January 2019 to August 2021, 2 cases (4 areas) of framework exposure were observed following autologous microtia reconstruction. The first case developed 2 small areas of skin necrosis on the anterior helix and lower antihelix to concha. The former was reconstructed with a temporal fascia flap and the latter with a local transposition flap. The second case also developed 2 small areas of skin necrosis on the posterior helix and lower antihelix to concha. The former was sutured directly and the latter with a local transposition flap. However, both wounds recurred due to flap necrosis and the cartilage was exposed again. The 3rd operation was performed by covering both wounds with a posterior auricular turnover flap and skin graft. In both cases, the exposed framework was completely covered with the flaps, and the reconstructed ears showed well-defined convolutions. Covering exposed cartilage with a local flap with a random pattern of blood circulation is convenient because no additional skin grafts are required. However, the blood circulation of the flaps is inadequate when an elongated flap is required; consequently, flap necrosis may occur. On the other hand, a temporal fascia flap and posterior auricular flap, which have axillary pattern blood circulation, are considered to be safer. We believe that it is safe to use a temporal fascia flap for cartilage exposure in the upper half of the auricle, and a posterior auricular turnover flap for the lower half.

Quantitative Analysis on Cartilage Growth Between Ipsilateral and Contralateral Donor Sites in Microtia Patients

BACKGROUND

Costal cartilage harvest is required in patients with unilateral microtia when autologous reconstruction is being considered. However, whether an ipsilateral or contralateral donor site should be used remains controversial. This is the first study to compare cartilaginous growth between ipsilateral and contralateral donor sites in patients with unilateral microtia.

METHODS

In this retrospective study of 58 patients, the lengths of the sixth to ninth costal cartilages and 3 position-defining measurements with respect to the sixth to ninth costochondral junctions were calculated using 3-dimensional costal cartilage imaging. Patients were divided into subgroups, and the lateral differences between isolated microtia and hemifacial microsomia and between the growing and adult age groups, were compared.

RESULTS

In the isolated group, the sixth and seventh costal cartilages were longer on the contralateral side. The transverse dimension on the contralateral side, with respect to the sixth and seventh costochondral junctions, was also larger than that on the ipsilateral side in growing patients. However, no significant difference was observed between the 2 sides in the hemifacial microsomia group; there was also no difference between the age-related groups in this regard (P > 0.05).

CONCLUSIONS

These findings suggest that age- and side-related differences in donor sites should be considered in patients with isolated microtia.

Ear Reconstruction: Empirical Data of 406 Cases of Carving the Convex Structures of the Framework

OBJECTIVE

In auricular reconstruction, the convex structures of the framework determine the esthetics, and young doctors often need sufficient training to determine the best carving techniques. This study aimed to recommend optimal carving methods and provide measured data of convex structures of the carved costal cartilage framework to prevent complications, improve esthetics, and reduce the learning curve.

METHODS

From 2018 to 2021, 406 patients with microtia who underwent costal cartilage carving were enrolled. The helix is formed by the eighth costal cartilage. The complex of the antihelix was fabricated from part of the eighth costal cartilage or the ninth costal cartilage. The tragus was constructed using residual cartilage pieces from the base frame. These components were measured, and those from the new ear graded "excellent" were used for data analysis. The statistical analysis was principally processed using Excel software.

RESULTS

A total of 112 ears were graded "excellent". The following are the mean and standard deviation of each group of data: antihelix thickness, 0.31 ± 0.06 cm; antihelix width, 0.40 ± 0.06 cm; superior crus thickness, 0.18 ± 0.04 cm; superior crus width, 0.38 ± 0.09 cm; inferior crus width, 0.22 ± 0.04 cm; inferior crus thickness, 0.28 ± 0.05 cm; helix thickness, 0.31 ± 0.04 cm; the four-point height of the helix, 0.52 ± 0.08 cm/0.51 ± 0.07 cm/0.46 ± 0.06 cm/0.41 ± 0.06 cm; and tragus height, 0.98 ± 0.15 cm.

CONCLUSION

These data may help beginners in reducing the learning curve of ear reconstruction. Framework fabrication based on these data allows attaining a harmonious ear framework and satisfactory three-dimensional auricle outline, yielding acceptable results and few complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:569-575, 2023.

Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction

Despite various surgical techniques for ear elevation in autogenous cartilage microtia reconstruction, it is still challenging for plastic surgeons to obtain a satisfactory depth of the cephaloauricular sulcus and stable projection of the reconstructed ear. Here, the authors demonstrate individualized options for surgical approaches and relevant details for complication management. Between January 2014 and June 2020, a series of 895 patients who underwent the second stage of microtia reconstruction were reviewed. Complications occurred in 103 patients aged between 8 and 34 years. Recommended surgical selections, as well as appropriate strategies for complication prophylaxis and treatment, were shown to minimize the negative influence on the contour of the cephaloauricular sulcus according to individual conditions. We found that 78% of the patients were satisfied with the auricle contour with harmonious integrity. Individualized strategies for ear elevation and complication treatment contribute to symmetry and satisfactory projection of the reconstructed auricle.

Strategies for the Treatment of Auricular Complications after the First Stage of Autologous Cartilage Microtia Reconstruction

BACKGROUND

Effective handling of auricular complications after the first stage of autologous cartilage microtia reconstruction remains one of the most demanding challenges for plastic surgeons. Here, the authors discuss relevant details for treatment of such complications in various conditions.

METHODS

A total of 1739 microtia patients underwent the first stage of auricular reconstruction with autogenous costal cartilage between 2007 and 2019. Different complications occurred in 136 cases. The details of complications are described, and relevant tactics for appropriate prevention and treatment are introduced.

RESULTS

Selective methods for the management of different complications in a prompt and effective manner after the first stage of ear reconstruction have been shown to salvage and maintain the contour of the reconstructed auricle to the maximum extent.

CONCLUSION

Auricular complications can be well treated and prevented through careful preoperative preparation, meticulous intraoperative manipulation, and proper postoperative management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Facial Cartilaginous Reconstruction-A Historical Perspective, State-of-the-Art, and Future Directions

Importance: Reconstruction of facial deformity poses a significant surgical challenge due to the psychological, functional, and aesthetic importance of this anatomical area. There is a need to provide not only an excellent colour and contour match for skin defects, but also a durable cartilaginous structural replacement for nasal or auricular defects. The purpose of this review is to describe the history of, and state-of-the-art techniques within, facial cartilaginous surgery, whilst highlighting recent advances and future directions for this continually advancing specialty. Observations: Limitations of synthetic implants for nasal and auricular reconstruction, such as silicone and porous polyethylene, have meant that autologous cartilage tissue for such cases remains the current gold standard. Similarly, tissue engineering approaches using unrelated cells and synthetic scaffolds have shown limited in vivo success. There is increasing recognition that both the intrinsic and extrinsic microenvironment are important for tissue engineering and synthetic scaffolds fail to provide the necessary cues for cartilage matrix secretion. Conclusions and Relevance: We discuss the first-in-man studies in the context of biomimetic and developmental approaches to engineering durable cartilage for clinical translation. Implementation of engineered autologous tissue into clinical practise could eliminate donor site morbidity and represent the next phase of the facial reconstruction evolution.

3D printing for tissue engineering in otolaryngology

Airway and other head and neck disorders affect hundreds of thousands of patients each year and most require surgical intervention. Among these, congenital deformity that affects newborns is particularly serious and can be life-threatening. In these cases, reconstructive surgery is resolutive but bears significant limitations, including the donor site morbidity and limited available tissue. In this context, tissue engineering represents a promising alternative approach for the surgical treatment of otolaryngologic disorders. In particular, 3D printing coupled with advanced imaging technologies offers the unique opportunity to reproduce the complex anatomy of native ear, nose, and throat, with its import in terms of functionality as well as aesthetics and the associated patient well-being. In this review, we provide a general overview of the main ear, nose and throat disorders and focus on the most recent scientific literature on 3D printing and bioprinting for their treatment.

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.

The surgical anatomy of soft tissue layers in the mastoid region

Background

An understanding of the soft tissue layers in the mastoid region has become important for otologic reconstructive surgery. The objective of this study was to clarify the surgical anatomy of the soft tissue layers in the mastoid region and reveal its clinical significance.

Methods

Cadaveric study.

Results

Our dissections showed the soft tissue layers consisting of skin, subcutaneous layer, superficial and deep mastoid fasciae, and periosteum. The superficial mastoid fascia was continuous with the temporoparietal fascia cranially and the superficial cervical fascia caudally. The deep mastoid fascia could be clearly separated from the superficial mastoid fascia and has continuity to the loose alveolar layer in the temporoparietal region. However, it caudally fused with the fascia and ligament of the sternocleidomastoid.

Conclusions

A comprehensive understanding of soft tissue layers would improve otologic reconstructive surgery.

Level of Evidence

NA

Cartilage exposure following autologous microtia reconstruction: An algorithmic treatment approach✰

BACKGROUND

Successful reconstruction of microtia involves fabrication of a cartilaginous framework and provision of thin, durable, soft tissue cover. Vascular compromise of this skin envelope can lead to exposure of the underlying cartilage, resulting in cartilage resorption and distortion of the final form of the ear construct. We describe our algorithm for management of this complication.

METHODS

All patients who underwent autologous ear reconstruction by a single surgeon (NWB) from April 2006 to September 2012 were retrospectively reviewed to identify any that developed exposure of the underlying cartilage framework. Details related to timing, location, size and management of the cartilage exposure were collected.

RESULTS

From a total of 230 autologous auricular reconstructions (median age at first stage, 11.4 years), 15 exposures of the cartilage framework were identified. All exposures occurred following the first stage of reconstruction (mean of post-operative day 29, range, 7-86 days). Large areas of exposure (> 10 mm2) required surgical management, with debridement and coverage with either a cutaneous or fascial flap, depending on the location. Areas < 10 mm2 were managed conservatively. All exposures were successfully treated with no adverse effects on the final aesthetic outcome.

CONCLUSION

Cartilage exposure following autologous microtia reconstruction can be a devastating complication if not addressed in a prompt and effective manner. The management strategy we propose provides a concise algorithm to guide the treatment of cartilage exposure.

LEVEL OF EVIDENCE

Therapeutic, grade III.

Interpositional Flap Reconstruction of Temporomandibular Joint Using a Novel Anterior-Based Mastoid Flap Technique

In this report, it was aimed to use the anterior-based mastoid fascia flap as an interpositional graft in TMJ surgery. This technical report, along with this characteristic, is the first in the literature.

Anatomical and Histological Evaluation of the Retroauricular Fascia Flap for Staged Auricular Reconstruction

OBJECTIVES

The retroauricular fascia flap (RFF) is one of the most commonly used vascularized linings for auriculocephalic sulcus reconstruction in staged total auricular reconstruction. This study aims to investigate the histomorphometric features regarding the retroauricular fascia.

METHODS

Histological evaluation included qualitative observation and quantitative analysis of sections of RFF stained with hematoxylin and eosin, Masson's trichrome, Elastica van Gieson, CD31, and Lyve-1. Ultrasonographic evaluation included measurement of the thickness of the superficial layer of the retroauricular fascia (RFF origin) at three different positions in microtia patients. P < 0.05 was considered statistically significant.

RESULTS

RFF was a thin, highly organized layer with mainly collagen fibers. From its superior to inferior portions, the percentage of collagen fibers differed significantly (superior 87.57 ± 10.85%, middle 68.29 ± 29.02%, inferior 53.31 ± 33.33%, p < 0.05). The percentages of elastic fibers in the superior (4.86 ± 5.17%) and middle (5.05 ± 5.37%) areas were higher than that in the inferior (2.14 ± 2.42%, p < 0.05). RFF blood vessel density (20× magnification) decreased significantly from the superior to inferior portions (superior 6.39 ± 1.18, middle 5.17 ± 1.15, inferior 2.67 ± 0.78, p < 0.05). Lymphatic vessel density (20× magnification) also decreased significantly from the superior to inferior regions (superior 6.80 ± 0.62, middle 5.26 ± 1.17, inferior 2.11 ± 0.46, p < 0.05). Thickness of the superficial layer of retroauricular fascia increased significantly from the superior to inferior regions (superior 0.29 ± 0.06 mm, middle 0.36 ± 0.09 mm, inferior 0.53 ± 0.14 mm, p < 0.001).

CONCLUSIONS

From cranial to caudal, the RFF became thicker, less elastic, and less vascularized, and contained fewer lymphatic vessels. Therefore, when the retroauricular fascia is large enough, the superior portion would be preferred for RFF in auriculocephalic sulcus reconstruction.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modified 2-Stage Method for Auricular Reconstruction

BACKGROUND

Auricular reconstruction is one of the most challenging procedures in the field of plastic surgery. The aims of this study were to apply the modified 2-stage method to perform auricular reconstruction and to summarize the clinical experience in the past 10 years.

METHODS

Auricular reconstruction was performed in 243 patients (total 254 ears) of congenital microtia using autologous costal cartilage. The whole procedure is divided into 2 stages. Stage I: the individualized framework fabricated with autologous costal cartilage is inserted into subcutaneous pocket in the mastoid region, and then the earlobe was transposed backward to connect with the lower part of the framework. The second-stage surgery mainly includes the following main contents: ear elevation, fixing the bracket behind the reconstructed ear framework, harvesting the retroauricular fascial flap to cover the bracket, and closing the defect with free skin grafts.

RESULTS

A total of 243 patients (254 ears) of congenital microtia underwent ear reconstruction. The follow-up time ranged from 6 months to 4 years; 220 patients were satisfied with the results. Surgery-related complications such as infection, partial skin graft necrosis, flap necrosis, bad projection of the constructed auricle, and extrusion of cartilage occurred in 24 cases, and hypertrophic scars occurred in 16 patients.

CONCLUSIONS

This modified 2-stage method for auricle reconstruction can receive acceptable results and fewer complications; furthermore, it is relatively simple and easy to master. The 10-year experience validates that this modified method is an ideal method in auricular reconstruction.

Vascular Nature and Existence of Anastomoses of Extrinsic Postauricular Fascia: Application for Staged Auricular Reconstruction

A staged auricular reconstruction in microtia patients was developed by using superficial mastoid fascia (as part of extrinsic postauricular fascia) to cover the cartilagenous framework due to its highly vascularized nature. Three branches of external carotid artery (superficial temporal artery, posterior auricular artery and occipital artery) were found to supply this fascia, this study was therefore aimed to investigate the dimension of blood supply from each vessel and also to demonstrate the existence of anastomoses among these arteries. Thirty-eight pinnas and postauricular fascias from Thai fresh adult cadavers were included to document the anastomoses by showing both perfused dye connection (10 dissections) and visible anastomotic branches (8 dissections) among them. Distribution of each vessel trunk and its branches were demonstrated using superimposed illustration in the other 20 dissections with dye injection into each artery to designate 3 zones of anastomotic area between each arterial pair. Maximal size of viable postauricular fascial flap for staged reconstruction according to this vascular study was thus estimated to be at least 5 cm above and 3 cm below the Frankfurt horizontal plane and about 6 cm posterior to external acoustic meatus owing to the course of posterior auricular artery and its anastomoses. In addition, greater size of flap with dual blood supply from both superficial temporal and posterior auricular arteries can be raised by harvesting beyond 5 cm above external acoustic meatus.

Tissue Expansion Using Hyaluronic Acid Filler for Single-Stage Ear Reconstruction: A Novel Concept for Difficult Areas

BACKGROUND

Auricular reconstruction is one of the most challenging procedures in plastic surgery. An adequate skin envelope is essential for cartilage framework coverage, yet few good options exist without additional surgery. We propose a novel method for minimally invasive tissue expansion, using hyaluronic acid (HA) filler to allow for single-stage ear reconstruction.

OBJECTIVES

To introduce the novel concept of HA filler for tissue expansion in ear reconstruction, and as an alternative to traditional expansion techniques.

METHODS

Macrolane is a large particle HA gel developed for large volume restoration. Expansion of the non-hair-bearing mastoid skin was performed in our clinic weekly or every other week. Final expansion was completed one week prior to reconstructive surgery. Tissue from one patient's expanded pocket was sent for histological analysis.

RESULTS

Ten patients underwent single-stage auricular reconstruction with preoperative expansion. Injection sessions ranged from 7 to 13 (mean, 9.7). Mean injected volume per session was 2.03 mL per patient, for an average total of 19.8 mL (range, 14.5-30 mL). There were no major complications. One minor complication required removal of exposed wire from the antihelix in the office. Hematoxylin and eosin stain revealed similar histology to that seen with traditional expanders.

CONCLUSIONS

This novel expansion technique using serial HA injections allowed for optimized skin coverage in single-stage ear reconstruction. The concept of tissue expansion using HA filler is a new frontier for research that may be applicable to other arenas of reconstruction.

LEVEL OF EVIDENCE

4.

Salvage of Ear Framework Exposure in Total Auricular Reconstruction

BACKGROUND

One of the most common complications of total auricular reconstruction is delayed wound healing, which results in skin necrosis and exposure of the ear framework. Various options exist for salvage of the exposed ear framework.

METHODS

From January 2009 to May 2014, 149 patients underwent total auricular reconstruction using an autogenous cartilage framework or porous polyethylene framework (Medpor; Stryker, USA). An autogenous cartilage framework was used in 48 patients, and a Medpor framework was used in 101 cases. Three cases of framework exposure (3/48, 6.3%) were observed among the patients treated with an autogenous cartilage framework. In contrast, framework exposure took place in 11 patients who were treated with a Medpor framework (11/101, 10.9%). Depending on the method of total ear reconstruction and the location of exposure, the authors used local skin flaps, temporoparietal fascia flaps, deep temporal fascia (DTF) flaps, or mastoid fascia (MF) flaps with skin grafting.

RESULTS

Among the 11 patients who experienced framework exposure after being treated with a Medpor framework, a DTF flap with skin grafting was used in 6 patients and an MF flap with skin grafting in 6 patients; 1 patient was treated with both a DTF flap and an MF flap. All 3 cases of cartilage framework exposure were salvaged using a temporoparietal fascia flap with skin grafting, and a local skin flap was used in 1 case. In all 3 cases, the exposed framework was completely covered with the flap, and the reconstructed ears showed well-defined convolutions.

CONCLUSIONS

Salvage of framework exposure remains a challenging issue in total auricular reconstruction. However, appropriate wound management using various flaps allows the reconstructed ear to be safely preserved.

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

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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.

Modular Component Assembly Approach to Microtia Reconstruction

BACKGROUND

Current methods of microtia reconstruction include carving an auricular framework from the costal synchondrosis. This requires considerable skill and may create a substantial defect at the donor site.

OBJECTIVE

To present a modular component assembly (MCA) approach that minimizes the procedural difficulty with microtia repair and reduces the amount of cartilage to a single rib.

DESIGN, SETTING, AND PARTICIPANTS

Ex vivo study and survey. A single porcine rib was sectioned into multiple slices using a cartilage guillotine, cut into components outlined by 3-dimensional printed templates, and assembled into an auricular scaffold. Electromechanical reshaping was used to bend cartilage slices for creation of the helical rim. Chondrocyte viability was confirmed using confocal imaging. Ten surgeons reviewed the scaffold constructed with the MCA approach to evaluate aesthetics, stability, and clinical feasibility. The study was conducted from June 5 to December 18, 2014.

MAIN OUTCOMES AND MEASURES

The primary outcome was creation of a modular component assembly method that decreases the total amount of rib needed for scaffold construction, as well as overall scaffold acceptability. The surgeons provided their assessments through a Likert-scale survey, with responses ranging from 1 (disagree with the statement) to 5 (agree with the statement). Thus, a higher score represents that the surgeon agrees that the scaffold is structurally and aesthetically acceptable and feasible.

RESULTS

An auricular framework with projection and curvature was fashioned from 1 rib. The 10 surgeons who participated in the survey indicated that the MCA scaffold would meet minimal aesthetic and anatomic acceptability. When embedded under a covering, the region of the helix and antihelix of the scaffold scored significantly higher on the assessment survey than that of an embedded alloplast implant (mean [SD], 4.6 [0.97] vs 3.5 [1.27]; P = .007). Otherwise, no significant difference was found between the embedded MCA and alloplast implants (4.42 [0.48] vs 3.87 [0.41]; P = .13). Cartilage prepared with electromechanical reshaping was viable.

CONCLUSIONS AND RELEVANCE

This study demonstrates that 1 rib can be used to create an aesthetic and durable framework for microtia repair. Precise assembly and the ability to obtain thin, uniform slices of cartilage were essential. This cartilage-sparing MCA approach may be an alternative to classic techniques.

LEVEL OF EVIDENCE

NA.

A True Single-Stage Reconstruction of a Projected Auricle for Concha-Type Microtia Incorporating Endoscopically Harvested Temporoparietal Fascia

Reconstruction of microtia with autogenous costal cartilage that produces a well-projected ear in a single stage is a challenging endeavor. In this case report, we describe a single-stage, projected costal cartilage-based reconstruction of concha type mitoria. Due to the patient's low hairline, his hair-bearing scalp would encroach on the ear framework if placed subcutaneously in the standard fashion. Thus, a large TPF flap harvested with endoscopic assistance was planned to achieve both a color-matched hairless skin envelope and a well-projected ear in single stage.

Combining regenerative medicine strategies to provide durable reconstructive options: auricular cartilage tissue engineering

Recent advances in regenerative medicine place us in a unique position to improve the quality of engineered tissue. We use auricular cartilage as an exemplar to illustrate how the use of tissue-specific adult stem cells, assembly through additive manufacturing and improved understanding of postnatal tissue maturation will allow us to more accurately replicate native tissue anisotropy. This review highlights the limitations of autologous auricular reconstruction, including donor site morbidity, technical considerations and long-term complications. Current tissue-engineered auricular constructs implanted into immune-competent animal models have been observed to undergo inflammation, fibrosis, foreign body reaction, calcification and degradation. Combining biomimetic regenerative medicine strategies will allow us to improve tissue-engineered auricular cartilage with respect to biochemical composition and functionality, as well as microstructural organization and overall shape. Creating functional and durable tissue has the potential to shift the paradigm in reconstructive surgery by obviating the need for donor sites.

Periosteal Flap Technique for Elevation of the Pinna in Microtia

IMPORTANCE

For optimal aesthetic construction of the auricle in patients with severe microtia, it is important to construct an exquisite framework and place it in the correct natural position. In addition to its accurate vertical and sagittal positioning, normal elevation is of utmost importance because this determines the auricular width from the common anterior view in interpersonal communication. Many techniques have been described to stabilize the constructed auricle in the elevated position. Some of the techniques are prone to relapse (eg, simple skin transplantation), while others are intricate (eg, using cartilage, huge pedicled flaps, and free skin grafts).

OBSERVATIONS

The objective of the study was to describe a simple and reliable periosteal flap technique and present our experience in 158 patients with complete unilateral or bilateral ear deformity (with possible defects of the external auditory meatus) who were operated on between February 3, 2005, and August 27, 2012. Principles of the technique include elevating the framework from the posterior aspect, stabilizing it with autogenous rib cartilage, covering this with a novel periosteal flap, and skin grafting.

CONCLUSIONS AND RELEVANCE

The periosteal flap technique proved to be straightforward and reliable. All flaps had unrestricted microcirculation. Good and stable projection of the auricle was achieved in all patients.

Current management of microtia: a national survey

BACKGROUND

Microtia reconstruction remains one of the most challenging procedures encountered by the reconstructive surgeon. A national report on the current management of microtia has never been presented before. The purpose of this project was to survey members of the American Society of Plastic Surgeons (ASPS) to identify their preferences and practices and report their opinions regarding issues related to microtia reconstruction.

METHODS

An anonymous web-based survey consisting of 19 questions was distributed to the members of the ASPS. Questions focused on the management of microtia. The study design was descriptive, using categorical data analysis.

RESULTS

Thirty-eight percent of all respondents perform microtia reconstruction; 91 % learned the autogenous cartilage-based reconstruction technique, while only 16 % were exposed to alloplastic reconstruction. Seventy percent of all respondents learned autogenous cartilage-based ear reconstruction exclusively. Fifty percent of respondents who perform microtia reconstruction reported a steep learning curve. In the pediatric patient population, 49 % of microtia surgeons prefer performing the surgery when the patient is between 7 and 10 years of age, while 40 % of microtia surgeons prefer the patient to be 4-6 years of age. Fifty-nine percent of all respondents believe that in 15 years tissue engineering will represent the gold standard of microtia reconstruction.

CONCLUSION

Staged microtia repair using autogenous cartilage remains the heavily favored method of microtia reconstruction among plastic surgeons. Moreover, there is a deficiency in training the newer surgical techniques, such as alloplastic and osseointegrated options. This study also highlights the continuing need to elucidate the optimal timing for microtia repair in the pediatric patient to mitigate the potential psychosocial morbidity well described in the literature.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Superficial mastoid fascia as an accessible donor for various augmentations in Asian rhinoplasty

This study was designed to assess the anatomic characteristics and clinical versatility of superficial mastoid fascia as a soft-tissue donor for augmentation in Asian rhinoplasty. Dissections were performed on four fresh cadavers (eight ears) for histologic study. A 3×10 mm2-sized full layer of skin and underlying soft tissue was harvested from the postauricular area, transversely and longitudinally (cephalic and caudal directions), 5 mm apart from the midpoint of the auriculocephalic sulcus. The average fascial thickness and nerve distribution were assessed using digital microscopic images after haematoxylin and eosin (H&E) staining. In the histologic study, the average measured thickness of the superficial mastoid fascia was between 3.8 and 4.5 mm in various directions. Clinically, 33 subjects who underwent rhinoplasty using superficial mastoid fascia were assessed prospectively. When soft tissue was needed in various types of augmentations, a longitudinal incision was made on the posterior auriculocephalic sulcus and the maximum thickness of superficial mastoid fascia was harvested. The sizes of the superficial mastoid fascia used in the 33 subjects ranged from 0.4×2.5 cm2 to 1.2×4.2 cm2. The superficial mastoid fascia was grafted regionally for the nasion, tip and nasal dorsum. In two cases, hypertrophic scars developed at the donor site. Four subjects experienced transient dysaesthesia and hypoaesthesia at the donor area postoperatively. Superficial mastoid fascia may be a useful resource in rhinoplasty as a donor for various types of augmentations, allowing easy access without prominent scarring or permanent sensory nerve damage when a low-to-moderate volume of soft tissue is required.

Modification of the second stage of auricular elevation in Nagata's technique for treating microtia

The ultimate goal in treating congenital microtia is the reconstruction of an auricle with a natural appearance as close as possible to the healthy one in terms of shape, contour, size, texture, position, and projection. Here we present another option to the second stage of raising the ear in Nagata's technique for treating microtia. The first step includes implantation of a cartilaginous framework and transposition of the ear lobe. Raising the cartilage leaves a skin defect behind the auricle. Instead of using a superficial temporoparietal fascia flap as described by Nagata, we raise a simple rotation flap from the mastoid and neck to close the defect with a minimal scar. The advantages of this technique include firm elevation, good frontal projection, and a natural appearance of the auriculo-cephalic sulcus with a normal retroauricular hairline. In addition, the procedure fast and practical, creates no additional scars on the scalp, and preserves the superficial temporoparietal fascia.

Reconstruction of the retroauricular fold by 'nonpedicled' superficial mastoid fascia: details of anatomy and surgical technique

During ear reconstruction, it is often difficult to achieve a good projection of the new ear. This is due to the retraction of retroauricular tissues, and the use of a cartilage wedge and superficial temporal fascia is frequently needed to elevate the ear framework. The aim of this article is to identify, by cadaver dissection, the anatomical structures of the retroauricular and mastoid regions and also to demonstrate the possibility of increasing the size of the superficial mastoid fascia by defibrating and cutting up its structure. The cartilage wedge is then inserted into a three-dimensional fascial environment. This allows reconstruction of the retroauricular fold with 'nonpedicled' fascia and to have a firm, stable ear elevation without sacrificing the temporal fascia. Nine ear reconstructions were performed using this technique and no major complications occurred; however, one procedure was complicated by a limited necrosis of the skin graft. In all cases we obtained a good and persistent elevation of the ear, as well as a well-defined fold, with the possibility of wearing glasses. Symmetry was satisfactory and aesthetic results were pleasant for all treated patients. This simple procedure allows one to obtain a good projection of the ear without involving the use of the superficial temporal fascia, which in addition is very useful in case of eventual complications such as cartilage extrusion.

Two-stage reconstruction of the auricle in congenital microtia using autogenous costal cartilage

The current authors reconstructed the auricles of congenital microtia patients with a two-stage method using autogenous costal cartilage. In the first stage, lobule rotation, fabrication of the cartilage framework, and implantation of the framework were performed. In the second stage, elevation of the auricle using transplantation of the costal cartilage and two local transposition flaps, formation of the tragus, and deepening of the concha were performed. A total of 125 consecutive patients were treated, ranging from seven to 53 years old, from 1990 to 2003. Sixty-nine patients were males and 56 patients were females. Unilateral microtia was present in 114 patients (right 73, left 41), bilateral in 11 patients. Ninety-four cases were the classic sausage-shaped lobule type deformity; the remaining 42 cases presented concha-type deformity. The follow-up period was 6 months to 10 years. One hundred and eighteen cases presented acceptable ear contour after ear reconstruction. Unfavourable results were blunted convolution of the reconstructed ear because of thick fibrous tissue in six cases, mild absorption of carved cartilage by infection in two cases, deformation of the constructed helix occurred in four cases, less projection of the elevated ear in three cases, and hypertrophic scars in three cases. Our procedure produced acceptable contour of the reconstructed auricle with fewer complications than conventional procedures. In addition, careful meticulous manipulation is necessary to create natural contour of the ear and to reduce complications in all stages.

Satisfactory surgical option for congenital microtia with defects of external auditory meatus (EAM) and middle ear

CONCLUSIONS

Improved appearance and hearing and increased efficiency are achievable for congenital microbia with defects of external auditory meatus (EAM) and middle ear. First the site of the external auditory meatus (EAM) orifice must be located according to the results of the temporal CT scan, then the auricle can be reconstructed employing the three-stage method. At the third stage, the EAM and middle ear can be reconstructed at the same time.

OBJECTIVE

To select the best approach for reconstruction of congenital microtia with defects of the EAM and middle ear.

PATIENTS AND METHODS

This study analyzed 498 cases (528 ears) of auricle reconstruction by the three-stage method and 77 cases (91 ears operation/120 ears) of EAM and middle ear reconstruction.

RESULTS

For auricular reconstructions, the effects of reconstructed auricles were classified into four grades according to their structure verisimilitude and the bilateral symmetry. The majority of patients/families were satisfied. For 52 ears with normal movement of stapes, reconstructions of EAM and middle ear improved hearing by 15-50 dB, but long-term improvement was not ideal. In bilateral patients, 20 of 24 ears with reconstructed EAMs exhibited relapse of stenosis or atresia. For patients whose EAMs were reconstructed first, scar developed around the orifice and affected the skin flap and later auricle reconstruction, while reconstructing the auricle first sometimes resulted in the location of the EAM orifice deviating from an ideal position.

Use of an expanded temporoparietal fascial flap technique for total auricular reconstruction

BACKGROUND

The authors propose an expanded technique of the temporoparietal facial flap of sufficient size to provide complete coverage in a single-stage procedure for the projected three-dimensional autogenous cartilage framework, including the tragus or lobule.

METHODS

A temporoparietal fascial flap measuring 9 x 9 cm was prepared and wrapped around an expander. The expander was gradually infused with saline solution. Approximately 6 months after the first operation, a projected three-dimensional auricular framework was covered by the expanded temporoparietal fascial flap. Nine patients underwent total ear reconstruction using the expanded temporoparietal fascial flap technique. Of these, two cases were anotia, five were failed reconstructed microtia, and two were posttraumatic absence of ear.

RESULTS

A final aesthetic assessment of the results was analyzed subjectively. Three cases showed excellent results, four cases showed good results, one case showed a fair result, and one case showed a poor result.

CONCLUSIONS

This expansion technique is indicated in reconstruction of anotia patients who require longer and wider fascial flaps and in auricular reconstruction patients undergoing microvascular free fascial flap transfer for lessening postoperative vascular obstruction, when microvascular anastomosis is performed on the retroauricular region. The technique is also indicated in salvage auricular reconstruction for patients with an unusual vascular pattern on the temporoparietal fascial flap, or for patients showing a vascular insufficiency of the flap's distal portion after flap elevation.

Refinements in the Elevation of Reconstructed Auricles in Microtia

BACKGROUND

In the treatment of microtia, the search has been for surgical techniques that prevent postoperative complications and realize sufficient and stable projection of the constructed ear.

METHODS

Cartilage was fixed with absorbable synthetic thread instead of wire because wire has a high risk of exposure. A subcutaneous pedicle was added to the concha to prevent skin necrosis. Dead space and hematoma creation were prevented with vacuum aspiration, bolster fixation, and microdrainage with small tubes. A triangular skin flap connecting to the ear lobe was used to prevent shrinkage on the posteroinferior portion of the concha. Projection of the inferior portion of the auricle was supported with a hydroxyapatite-tricalcium phosphate ceramic.

RESULTS

Our technique was applied to 42 patients, and none of them experienced slip of the fixed cartilage, auricular deformation, skin necrosis, or infections. Shrinkage of the inferior portion of the auricle was minimal, and good projection was obtained.

CONCLUSIONS

The authors' technique prevents complications and realizes good shape and projection of the auricle in total reconstruction of the auricle. Hydroxyapatite-tricalcium phosphate ceramic is a useful material that complements the cartilage shortage.

Surgical Results of Two-Stage Reconstruction of the Auricle in Congenital Microtia Using an Autogenous Costal Cartilage Alone or Combined with Canaloplasty

BACKGROUND

The authors performed two-stage ear reconstruction using autogenous costal cartilage alone or combined with canaloplasty of the acoustic meatus to improve the functional results with minimal operative stages.

METHODS

In the first stage, lobule transposition, fabrication of the cartilage framework, and implantation of the framework were performed. In the second stage, elevation of the auricle, coverage with the mastoid fascia flap and skin graft, and concha excavation were performed. Canaloplasty was combined simultaneously in 27 patients with radiologic and audiometric evidence of cochlear function.

RESULTS

A total of 37 cases in 36 consecutive patients with microtia were treated. Results of external ear reconstruction were evaluated by ear contour, quality of detail, and projection of the ear. Thirty-three cases presented acceptable ear contour after ear reconstruction. Unfavorable results were lack of detail of the reconstructed auricle in two patients and deformation of the constructed helix in one patient. Six patients exhibited improved hearing over 30 dB pure-tone average and three patients exhibited improved hearing below 30 dB after canaloplasty in the concha type. In the lobule type, seven patients demonstrated a greater than 30-dB gain in pure-tone average, six patients demonstrated a gain below 30 dB, and there was no improvement in five patients. Complications related to canaloplasty were chronic drainage of the auditory meatus in three cases and meatal stenosis in six cases.

CONCLUSIONS

The results of the contour of the reconstructed auricle with reduced operative stages combined with canaloplasty were acceptable to the patients. However, in lobule-type deformities, meticulous manipulation is necessary to reduce complications after canaloplasty.

Vascular supply of the subcutaneous pedicle of Nagata's method in microtia reconstruction

Nagata's method is a two-stage method for total ear reconstruction in patients with microtia. In the first stage of this procedure, mastoid flap and posterior lobule flap are elevated with a subcutaneous pedicle. However, contribution to the vascular supply by this pedicle has been controversial. We investigated the presence or absence of apparent vessels in the subcutaneous pedicle in 14 primary cases of microtia in the first stage operation. In all cases some vessels were included in the pedicle. In lobular and small concha type microtia, the vessels originated from the parotid fascia or aponeurotic tissue behind the remnant cartilage. In concha type microtia, apparent vessels could be preserved by including the perichondrium of the conchal cartilage. These findings suggest that the mastoid and posterior lobule flaps or W-shaped flap in Nagata's first stage operation are actually the perforator-based flaps. The source vessel of the perforators seemed to be the posterior auricular artery because of its location although further dissection was not performed in order not to damage the vascular supply. The presence of the vessels can augment the blood supply of not only W-shaped flaps but also the skin flap cephalad to them. By confirming the preservation of the perforators in the subcutaneous pedicle the surgeon may be able to trim the covering skin more safely.

Total ear reconstruction in the devascularized temporoparietal region: II. Use of the omental free flap

Total ear reconstruction using the omental free flap technique was performed on five patients who presented with a devascularized temporoparietal region. The main indication for this technique was unavailability of the contralateral temporoparietal fascia in those requesting autogenous auricular reconstruction. There were no microvascular failures in the procedures conducted. In one case there was a partial loss of the transferred omentum, which resulted from an inadequate omental tailoring. A normal convoluted auricle was obtained after multistage debulking operations and meticulous postoperative molding. The average follow-up period was 3.4 years. Final aesthetic results were graded as satisfactory in four patients and poor in one patient.

Auricular reconstruction for microtia: Part II. Surgical techniques

Reconstruction of the microtic ear represents one of the most demanding challenges in reconstructive surgery. In this review the two most commonly used techniques for ear reconstruction, the Brent and Nagata techniques, are addressed in detail. Unique to this endeavor, the originator of each technique has been allowed to submit representative case material and to address the pros and cons of the other's technique. What follows is a detailed, insightful overview of microtia reconstruction, as a state of the art. The review then details commonly encountered problems in ear reconstruction and pertinent technical points. Finally, a glimpse into the future is offered with an accounting of the advances made in tissue engineering as this technology applies to auricular reconstruction.

Total ear reconstruction in the devascularized temporoparietal region: I. Use of the contralateral temporoparietal fascial free flap

Total ear reconstruction by the use of contralateral temporoparietal fascial free flap and autogenous costal cartilage was performed in 16 patients presenting with a devascularized temporoparietal region resulting from trauma or prior surgery. The microsurgical success rate was 87.5 percent (14 of 16 transplants). On evaluation of the final aesthetic result in 11 patients followed up for more than 3 years, nine patients were graded good-to-excellent and two patients exhibited fair-to-poor results. Despite the relatively long operating hours and the comparatively low microsurgical success rate, ear reconstruction by autogenous tissue transplantation has proved to be an encouraging and worthwhile experience. This article presents the clinical cases and discusses the technical details.

Firm elevation of the auricle in reconstruction of microtia with a retroauricular fascial flap wrapping an autogenous cartilage wedge

During conventional reconstruction of the auricle in patients with microtia, simply separating the auricle from the mastoid region with a full-thickness skin graft usually fails to create firm elevation and sufficient projection. To achieve frontal symmetry is difficult, and sometimes the normal auricle needs to be set back. We reconstructed the auricle in patients with microtia in two major stages using a modified Nagata's method. Using a wide W-incision skin flap, the first stage includes implantation of a cartilage framework and transposition of the ear lobule. Our modification lies in the second stage. Instead of using the superficial temporoparietal fascial flap, we elevated a retroauricular fascial flap from the mastoid region, turning it over to wrap an autogenous costal-cartilage wedge, and covered it with a full-thickness skin graft. Between June 1996 and May 1999, eight patients underwent this operation. All the fascial flaps and overlying full-thickness skin grafts survived well. The advantages of our technique include firm elevation, good frontal projection and a natural appearance of the posterior aspect of the ear. Additionally, by using this fast and practical procedure, we avoid creating additional scars on the scalp and preserve the superficial temporoparietal fascia and superficial temporal vessels.

Subfascial expansion and expanded two-flap method for microtia reconstruction

This article presents an improved two-flap method for microtia reconstruction. In the first stage of this method, a tissue expander is inserted in the mastoid region through a subfascial pocket, after which the overlying fascia and skin are expanded simultaneously with saline infusion for about 5 months. In the second stage, the expanded fascial and skin layers are split and prepared as anteriorly based skin and fascial flaps defined by their vascularity. An erect, three-dimensional, contour-accentuated ear framework fabricated with autogenous rib cartilage is inserted between the two flaps. The anteroauricular surface of the framework is draped with the thin, expanded skin, and the postauricular surface is draped with the thin, expanded fascia and overlying grafted skin. In the third stage, remnant auricular cartilage is removed and the crus helicis, tragus, intertragic notch, conchal floor, and a hollow mimicking the external auditory meatus are shaped. In this study, 146 microtias were reconstructed consecutively using the improved two-flap method. The final results were promising--major complications were minimal and most patients showed consistently favorable aesthetic results. This method married a two-flap procedure with a gradual tissue expansion, conveniently exploiting the advantages of both methods, but without the disadvantages.