Relocation of polyotia tissue to reconstruct the tragus and fill the preauricular depression

OBJECTIVES

The present article introduces a lingual composite tissue flap based on the tragus-like structure for correcting polyotia deformity, with the aim of providing a surgical technique that involves relocating polyotia tissue to reconstruct the tragus and fill the preauricular depression.

METHODS

The study included a total of 21 patients with polyotia who underwent lingual composite tissue flap reconstruction between January 2020 to December 2022. Patients were retrospectively assessed through a comprehensive review of their medical records and photographic data. Tragus morphology was evaluated based on the measurements of tragus length and width. The Aesthetic Outcomes Scale (AOS), modified Vancouver Scar Scale (mVSS), and Visual Analogue Scale (VAS) were employed for the assessment of surgical outcomes.

RESULTS

The follow-up period for all patients ranged from 6 to 15 months. The length and width of the normal tragus were not significantly different from those of the reconstructed tragus. The mean preoperative AOS score was 2.73 ± 0.51, while the mean postoperative AOS score increased to 7.61 ± 0.65. The mVSS yielded an average score of 1.80 ± 1.43, indicating inconspicuous scarring post polyotia surgery. The preoperative VAS satisfaction score was recorded as 1.57 ± 0.67, while the postoperative VAS score significantly increased to 8.33 ± 0.91. The flaps all successfully survived post-operation without any occurrences of flap hematoma, necrosis, infection, or wound dehiscence.

CONCLUSION

The reconstruction of the tragus should be given careful consideration when addressing polyotia. The utilization of a lingual composite tissue flap for correction can achieve excellent aesthetic results for the tragus, with high patient satisfaction and minimal complications.

Perioperative position management of 46 cases with simultaneous bilateral auricle reconstruction: A summary of experience

OBJECTIVES

The primary problem in simultaneous bilateral auricle reconstruction is the fragility of the reconstructed ear structure. Postoperative pressure is strictly prohibited to ensure the operation's effectiveness. The study aimed to summarize the experience of perioperative postural management in simultaneous bilateral auricular reconstruction.

METHOD

This study summarizes the experience of perioperative postural management, providing preoperative sleeping posture adaptability training, neck movement training, standardization of the head position angles and the head suspension time in surgery, using protective headrests, paying attention to the transfer and handover procedures, and using specially designed pillows.

RESULTS

The comprehensive nursing approach in simultaneous bilateral auricular reconstruction significantly reduced complications, improved patient comfort, and optimized postoperative adaptation. Preoperative posture training, standardized intraoperative head positions, and vigilant postoperative care played pivotal roles, demonstrating positive outcomes in 46 cases.

DISCUSSION

Perioperative position management can reduce the risk of complications and pressure injuries, improving patients' postoperative comfort, emotional state, tolerance, and adaptability.

CONCLUSION

All ears were viable and in good shape after long-term follow-up. The experiences discussed in this study can be broadly applied to technically mature ear reconstruction teams.

Retrospective study on unilateral polyotia combined with microtia utilizing the technique of preserving residual ear tissue

BACKGROUND

The presence of polyotia in individuals with microtia is a rare deformity. Due to the intricate structure of the auricle, uncertain etiology, and challenging corrective techniques, it has always been a focal point in the field of plastic surgery. The present study presents a technique for correcting the combination of polyotia and microtia by utilizing residual ear tissue as graft material.

METHODS

The retrospective study included 23 patients with polyotia and microtia from 2018 to 2022. The residual ear tissue was used to rectify auricular deformities in all patients. The patients were instructed to evaluate the satisfaction of the auricle shape using a visual analog scale (VAS) both before and 6 months after the surgical procedure. The esthetic outcomes of auricle subunits were simultaneously assessed by a senior physician pre- and postoperatively.

RESULTS

The mean duration of follow-up in this study was 8.73 months. The preoperative VAS satisfaction score was recorded as 2.26 ± 0.86, while the post-operative VAS score significantly increased to 7.86 ± 0.86. The preoperative auricle esthetic outcomes score was recorded as 9.95 ± 1.74, while the post-operative score significantly increased to 24.04 ± 2.16. The follow-up period did not present any cases of flap necrosis, hematoma, infection, or wound dehiscence.

CONCLUSION

The study demonstrates that comprehensive utilization of residual auricular tissue can lead to optimal outcomes in correcting polyotia with concha-type microtia. The utilization of residual ear tissue can be maximized to streamline the operation, minimize bodily harm, and enhance patient satisfaction.

Bioengineering Full-scale auricles using 3D-printed external scaffolds and decellularized cartilage xenograft

Reconstruction of the human auricle remains a formidable challenge for plastic surgeons. Autologous costal cartilage grafts and alloplastic implants are technically challenging, and aesthetic and/or tactile outcomes are frequently suboptimal. Using a small animal "bioreactor", we have bioengineered full-scale ears utilizing decellularized cartilage xenograft placed within a 3D-printed external auricular scaffold that mimics the size, shape, and biomechanical properties of the native human auricle. The full-scale polylactic acid ear scaffolds were 3D-printed based upon data acquired from 3D photogrammetry of an adult ear. Ovine costal cartilage was processed either through mincing (1 mm3) or zesting (< 0.5 mm3), and then fully decellularized and sterilized. At explantation, both the minced and zested neoears maintained the size and contour complexities of the scaffold topography with steady tissue ingrowth through 6 months in vivo. A mild inflammatory infiltrate at 3 months was replaced by homogenous fibrovascular tissue ingrowth enveloping individual cartilage pieces at 6 months. All ear constructs were pliable, and the elasticity was confirmed by biomechanical analysis. Longer-term studies of the neoears with faster degrading biomaterials will be warranted for future clinical application. STATEMENT OF SIGNIFICANCE: Accurate reconstruction of the human auricle has always been a formidable challenge to plastic surgeons. In this article, we have bioengineered full-scale ears utilizing decellularized cartilage xenograft placed within a 3D-printed external auricular scaffold that mimic the size, shape, and biomechanical properties of the native human auricle. Longer-term studies of the neoears with faster degrading biomaterials will be warranted for future clinical application.

Application of 3D printing in ear reconstruction with autogenous costal cartilage: A systematic review

PURPOSE

In recent years, 3D printing technology has been employed as a production method that builds materials layer upon layer, providing notable advantages in terms of individual customization and production efficiency. Autologous costal cartilage ear reconstruction has seen substantial changes due to 3D printing technology. In this context, this research evaluated the prospects and applications of 3D printing in ear reconstruction education, preoperative planning and simulation, the production of intraoperative guide plates, and other related areas.

METHODOLOGY

All articles eligible for consideration were sourced through a comprehensive search of PubMed, the Cochrane Library, EMBASE, and Web of Science from inception to May 22, 2023. Two reviewers extracted data on the manufacturing process and interventions. The Cochrane risk of bias tool and Newcastle-Ottawa scale were used to assess the quality of the research. Database searching yielded 283 records, of which 24 articles were selected for qualitative analysis.

RESULTS

The utilization of 3D printing is becoming increasingly widespread in autogenous costal cartilage ear reconstruction, from education to the application of preoperative design and intraoperative guide plates production, possessing a substantial influence on surgical training, the enhancement of surgical effects, complications reduction, and so forth.

CONCLUSION

This study sought to determine the application value and further development potential of 3D printing in autologous costal cartilage ear reconstruction. However, there is a lack of conclusive evidence on its effectiveness when compared to conventional strategies because of the limited number of cohort studies and randomized controlled trials. Simultaneously, the evaluation of the effect lacks objective and quantitative evaluation criteria, with most of them being emotional sentiments and ratings, making it difficult to execute a quantitative synthetic analysis. It is hoped that more large-scale comparative studies will be undertaken, and an objective and standard effect evaluation system will be implemented in the future.

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.

Comparative study of pre- and postauricular flaps for external auditory canal defect reconstruction

BACKGROUND

Malignancies involving the external auditory canal deserve critical evaluation due to this area's aesthetic and functional importance. Flaps can be very useful for the restoration of the external auditory canal. A variety of flaps available for the surgical treatment of external acoustic meatus defects exist, depending on the precise location and size.

OBJECTIVES

Our study aimed to compare aesthetic and functional results in the postoncological reconstruction of external auditory canal defects using a preauricular flap and postauricular revolving door flap.

METHODS

Sixteen patients treated at our plastic surgery unit for defects involving the external auditory canal between January 2014 and December 2020 were included in the study. All defects were the result of a primary or secondary skin cancer excision. Patients were divided into two groups, one receiving the preauricular flap technique and the other the postauricular revolving door flap technique.

RESULTS

Three separate visual analog scales reported excellent scores for the two procedures, though the postauricular revolving door flap had slightly better results. Both preauricular flap and postauricular revolving door flap reconstructive techniques showed good options for external auditory canal reconstruction in postexcision skin cancer patients. From an aesthetic point of view, the revolving door flap appeared to be a more elegant surgical approach in this type of reconstruction because the scar was hidden in the postauricular sulcus.

CONCLUSIONS

Reconstruction with a postauricular revolving door flap allowed for a more natural movement with no external pedicle.

EVIDENCE-BASED MEDICINE EBM LEVEL

IV.

Ear reconstruction stage I: Minor modifications in sculpting the auricle support using the 7th and 8th costal cartilages

BACKGROUND

The verisimilitude of the reconstructed auricle and its long-term stability largely depends on the framework sculpting. This study described three kinds of minor modifications based on Firmin's way of sculpting the auricle framework and reported the clinical outcomes achieved with them.

METHODS

We conducted a retrospective study of congenital microtia patients undergoing detail-improved auricular reconstruction from June 2016 to June 2020. The three kinds of minor modifications included: (1) fabricating the base frame using the 7th costal cartilage, (2) fabricating the helix and the antihelix complex using the 8th costal cartilage, and (3) fabricating the helix using the combination of the 8th and 9th costal cartilage.

RESULTS

Ninety-eight patients (aged 9-27 years, 62.2% male) were included. Ninety-five patients (97.0%) adopted minor modifications 1, 2, and 3 patients (3.0%) adopted minor modifications 1, 2, and 3. All patients achieved an excellent auricle appearance and a well-laid foundation for subsequent operations. During the follow-up period, 89 patients (90.8%) were satisfied with the reconstructed auricles, 6 (6.1%) complained of hypertrophic scars in the retroauricular sulcus or pigmentation in the skin graft area, and 3 (3.1%) developed surgery-related complications.

CONCLUSIONS

Three minor modifications of the auricle framework sculpting can make more satisfactory use of cartilage and adjust with the flexibility of the reconstructed auricle in different situations, making it similar to the contralateral auricle, thus, improving patients' satisfaction.

A modified tissue expander method for ear reconstruction in patients with excessively insufficient postauricular skin

OBJECTIVE

For microtia patients with excessively insufficient postauricular skin, it is difficult to obtain a satisfied outcome with existing strategies. In this study, we developed a modified tissue expander method for auricular reconstruction.

METHODS

The modified tissue expander method divided into 4 stages. In the first stage, a 30 ml or 50 ml kidney-shaped tissue expander was implanted in the mastoid region. A short time expansion (average 33.5 days) was conducted subsequently. In the second stage, the expander was removed and a modified cartilage framework without tragus was inserted through the same incision. A crescent-shaped cartilage pad was inserted into the incision of cartilage-harvest site at the same time. In the third stage, the reconstructed ear was elevated. Lobule rotation and remanent modification were performed in the fourth stage. The patients were followed up between half a year and 10 years. The outcomes of the reconstructed ears were scored with evaluation criteria.

RESULTS

From January 2010 to December 2019, a total of 45 microtia patients with excessively insufficient postauricular skin were performed the modified tissue expander method. Fourty-two patients showed satisfied outcomes. Complications such as hyperpigmentation in the skin graft area (3, 6.7%), scar hyperplasia (3, 6.7%) and folliculitis (1, 2.2%) were found. There were no complications related to the tissue expander.

CONCLUSION

The modified tissue expander method is an effective and safe technique for auricular reconstruction in patients having excessively insufficient postauricular skin, with satisfying medium-term results.

Firm elevation of the auricle in reconstruction of microtia with a retroauricular fascial flap wrapping two titanium plate struts

BACKGROUND

Reconstruction of the cephaloauricular sulcus in patients with microtia in ear reconstructions remains challenging. Costal cartilage and other support materials wedge were used for ear elevation. Each material has its disadvantages. To reconstruct a stable cephaloauricular sulcus and reduce costal cartilage harvesting, we used two titanium plate struts to support the costal cartilage framework.

METHODS

A titanium plate strut was designed. The angle of the strut was 60°, the arm length was 0.8 cm, and the width was 0.5 cm. The thickness was 0.6 mm. Four small pores are formed on the titanium plate. The implanted framework was separated from the underlying bed. Two titanium plate struts were fixed on the raised ear framework, tendon, and periosteum, and then wrapped with a turned-over retroauricular fascia flap. The raw surface was covered with a split-thickness skin graft, harvested from the scalp.

RESULTS

From 2019 to 2022, 51 patients underwent second-stage operations. All patients were followed up for a minimum of 6 months. The auricular projection was well-maintained, and the cephaloauricular sulcus of the constructed auricle was acceptable in 50 patients. There was one infection, and the titanium plate struts were removed, which resulted in shrinking cephaloauricular angles.

CONCLUSIONS

Titanium plate is effective as a supportive material to obtain the proper and firm projection of the constructed auricle. It provides a new option for patients whose costal cartilage volume is insufficient or who do not want to have the costal cartilage harvested again.

Fibronectin matrix assembly and TGFβ1 presentation for chondrogenesis of patient derived pericytes for microtia repair

Tissue engineered cartilage for external ear reconstruction of congenital deformities, such as microtia or resulting from trauma, remains a significant challenge for plastic and reconstructive surgeons. Current strategies involve harvesting autologous costal cartilage or expanding autologous chondrocytes ex vivo. However, these procedures often lead to donor site morbidity and a cell source with limited expansion capacity. Stromal stem cells such as perivascular stem cells (pericytes) offer an attractive alternative cell source, as they can be isolated from many human tissues, readily expanded in vitro and possess chondrogenic differentiation potential. Here, we successfully isolate CD146+ pericytes from the microtia remnant from patients undergoing reconstructive surgery (Microtia pericytes; MPs). Then we investigate their chondrogenic potential using the polymer poly(ethyl acrylate) (PEA) to unfold the extracellular matrix protein fibronectin (FN). FN unfolding exposes key growth factor (GF) and integrin binding sites on the molecule, allowing tethering of the chondrogenic GF transforming growth factor beta 1 (TGFβ1). This system leads to solid-phase, matrix-bound, GF presentation in a more physiological-like manner than that of typical chondrogenic induction media (CM) formulations that tend to lead to off-target effects. This simple and controlled material-based approach demonstrates similar chondrogenic potential to CM, while minimising proclivity toward hypertrophy, without the need for complex induction media formulations.

Repair of exposure and fracture of the porous high-density polyethylene framework after ear reconstruction

OBJECTIVE

To assess the repair method of exposure or fracture of the porous high-density polyethylene ear framework after total auricle reconstruction.

STUDY DESIGN

A prospective case study.

METHODS

From April 2018 to October 2021, 11 patients with framework exposure or fracture after total auricle reconstruction were admitted to the hospital for repair. In these 11 patients, the repair was performed using (1) a temporal muscle flap combined with free skin graft in 5 patients, (2) a mastoid fascia flap combined with free skin graft in 2 patients, (3) a simple local skin flap in 1 patient, (4) combination of a temporalis muscle flap and a mastoid fascia flap together with free skin graft in 2 patients, and (5) a Su-Por helix material combined with a temporal muscle flap and free skin graft in 1 patient.

RESULTS

After follow-up for 3-36 months, except for one patient in whom local exposure again occurred at the same site, the framework was in a good shape in the other patients, and all the skin graft survived.

CONCLUSION

The defect of the upper part of the auricle can be repaired using a temporal muscle flap combined with temporal muscle fascia and skin graft. The defect of the middle and lower part of the auricle can be repaired using a mastoid fascia flap combined with skin graft. For framework fracture, the damaged site can be first strengthened with another ear material and then combined with the adjacent fascia flap and free skin graft.

Microtia Part I: Preoperation and In-operation Lessons from 1012 Ear Reconstruction Operations

BACKGROUND

Organ reconstruction is one of the most challenging tasks in plastic and reconstructive surgery. This is particularly true of ear reconstruction, which requires enormous attention to detail.

METHODS

In the first of two articles, we set out details and precautions for each step of the preoperative and intraoperative stages of the ear reconstruction process for microtia patients. We cover preoperative screening and assessment of surgical conditions, the design of intraoperative incisions, flap separations, costal cartilage extraction, framework carving and cranial ear angle surgery.

RESULTS

Over the period Jan 2015-July 2021, our surgical team carried out 1012 microtia ear reconstructions, at the rate of 3-4 per week. This article presents the key learnings from this high volume of operations. Two typical cases involving different types of microtia are presented in order to illustrate the process of total ear reconstruction.

CONCLUSIONS

This article describes in detail the preoperative and intraoperative stages of the ear reconstruction process. We share our cumulative surgical experience gained over 20 years, especially the latest practical lessons gleaned over the last six and a half years.

LEVEL OF EVIDENCE IV

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 .

Experience of the 'Ear Glove' in children with microtia

INTRODUCTION

Microtia is a congenital condition which can be found in isolation or as part of a syndrome. The key factors to consider when treating a child with microtia are hearing, speech and language development, cosmesis, and the psychological impact on the patient as well as the family. As children age and become more self-aware, the anxiety about transition from primary to secondary school can often be a trigger for carers and child to want a cosmetic solution at a younger age. Any form of cosmetic surgery ideally requires a child with an understanding of what is involved, as well as sufficient growth and anatomy to provide soft tissue resources for surgery. An additional issue for some children with microtia is the concern about adding to their already 'different' appearance by using a bone conduction solution/hearing implant. We present the outcomes of a novel non-surgical prosthesis 'Ear Glove' offered to pediatric patients with microtia.

METHODS

Children with microtia are seen in the multidisciplinary outpatient clinic and reviewed by the team which includes an Otolaryngologist, Audiologist, Plastic surgeon and Maxillofacial prosthetist. When discussing cosmesis, all reconstruction options are explored. These include a 'no treatment' option, both adhesive and implant-retained prosthetic ears, and autologous and/or MedporⓇ ear reconstruction (age appropriate). All children who chose to undergo the adhesive non-surgical prosthetic option 'Ear Glove' for microtia were identified by our prosthetic department (n = 9), and their outcomes reviewed.

RESULTS

Nine children have been fitted with the 'Ear Glove', with all 9 achieving excellent symmetry and aesthetics. Seven patients continue to successfully use their prostheses either daily or for special occasions. Two of these patients also decided to undergo bone anchored hearing implant surgery. One patient opted to change his treatment plans and chose 'no treatment' after feeling he preferred his 'little' ears. Finally, one patient reported the daily use of adhesive to be a deterrent. No skin reactions to the adhesive were reported in any patient.

CONCLUSIONS

The 'Ear Glove' is increasingly being used by microtia patients in our department to good effect. This non-surgical alternative allows young patients to appreciate the cosmetic results of the surgical options before committing to an invasive procedure.

Cryptotia Repair Using a Modified V-Y Advancement Flap with Helix Rounding Technique

BACKGROUND

Cryptotia is a common congenital auricular malformation seen in Asian people. To date, multiple surgical procedures have been described for correcting cryptotia. However, the deformity often recurs, presenting as an unclear auriculotemporal sulcus and a malformed helix. The present study aimed to introduce a novel surgical approach to obtain a stable and aesthetic auricular correction in cryptotia patients and to acquire an understanding toward improved surgical management of cryptotia.

METHODS

Twenty-four cryptotia patients (28 ears), who were operated between April 2018 and November 2021, were included in this study. All patients underwent surgical correction for cryptotia using a modified V-Y advancement flap with helix rounding technique, performed by a senior surgeon.

RESULTS

Patients were followed for an average period of 9.4 months (6 to 18 months). Twenty-one patients (87.5%) were satisfied, three (12.5%) were partially satisfied, and none were unsatisfied. Most patients experienced temporary edema as a postsurgical complication, which resulted in a swollen auricle appearance lasting for three to four weeks postoperatively. One patient experienced skin necrosis in one ear on the anterior portion of the upper helix and this was solved by skin grafting.

CONCLUSIONS

The method of surgical correction utilizing a modified V-Y advancement flap with helix rounding technique proved to be a reliable option in cryptotia patients. It can provide stable aesthetic results after cryptotia correction in clinical practice.

LEVEL OF EVIDENCE IV

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 .

Microtia Part II: Post-Operation and Complications Management Lessons from 1012 Ear Reconstruction Operations

BACKGROUND

Ear reconstruction presents challenges for surgeons, not only during the pre-operation and in-operation stages, but also post-operation. The post-operation stage and the treatment of complications are critical to the overall success of ear reconstruction surgery.

METHODS

This article, the second of two articles setting out details and precautions for each step of the ear reconstruction process for microtia patients, covers post-operative care: negative pressure drainage, bandaging and fixing, nursing, treatment of complications and satisfaction survey.

RESULTS

Over the period Jan 2015-July 2021, our surgical team treated 77 complications in 1012 microtia ear reconstructions. This article presents the key learnings from this high volume of operations. All complications were treated promptly and the shape of the auricle was preserved as much as possible. Patients were surveyed after the operation and expressed satisfaction with the shape of the reconstructed external auricle. Three typical cases involving different types of complications are described.

CONCLUSIONS

This article deals in detail with the post-operation stage. We share our cumulative surgical experience gained over 20 years, especially the latest practical lessons gleaned over the last six and a half years.

LEVEL OF EVIDENCE II

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 .

Ultrasound Imaging Offers Promising Alternative to Create 3-D Models for Personalised Auricular Implants

Three-dimensional imaging and advanced manufacturing are being applied in health care research to create novel diagnostic and surgical planning methods, as well as personalised treatments and implants. For ear reconstruction, where a cartilage-shaped implant is embedded underneath the skin to re-create shape and form, volumetric imaging and segmentation processing to capture patient anatomy are particularly challenging. Here, we introduce 3-D ultrasound (US) as an available option for imaging the external ear and underlying auricular cartilage structure, and compare it with computed tomography (CT) and magnetic resonance imaging (MRI) against micro-CT (µCT) as a high-resolution reference (gold standard). US images were segmented to create 3-D models of the auricular cartilage and compared against models generated from µCT to assess accuracy. We found that CT was significantly less accurate than the other methods (root mean square [RMS]: 1.30 ± 0.5 mm) and had the least contrast between tissues. There was no significant difference between MRI (RMS: 0.69 ± 0.2 mm) and US (0.55 ± 0.1 mm). US was also the least expensive imaging method at half the cost of MRI. These results unveil a novel use of ultrasound imaging that has not been presented before, as well as support its more widespread use in biofabrication as a low-cost imaging technique to create patient-specific 3D models and implants.

Auricular reconstruction in microtia for soft tissue coverage: Flap pocket method versus expansion method

BACKGROUND

Auricular reconstruction is the sole therapy for external ear deformities. The flap pocket method and the expansion method are currently the two principal auricular reconstruction methods in microtia. The efficacy and safety of these two surgical techniques has long been a subject of controversy, bedeviled by a lack of objective comparative evidence.

METHODS

The authors searched the PubMed, Embase, Web of Science and Cochrane Library databases for clinical studies on auricular reconstruction in microtia updated to Jan 1, 2021. A meta-analysis was conducted to estimate the major outcomes for patient convenience, incidence of complications and postoperative patient satisfaction.

RESULTS

A total of twenty-two articles involving 7963 patients were included in this study. Nine studies involving 2475 patients concerned the flap pocket method and thirteen studies involving 5488 patients concerned the expansion method. The pooled patient satisfaction rate was higher using the flap pocket method than the expansion method (90.5% versus 83.3%, p = 0.000). Total complication incidence was lower using the flap pocket method than with the expansion method (6.8% versus 9.5%, p = 0.000). There were zero expander-related complications using the flap pocket method, but a 4% complication incidence using the expansion method. The total treatment period for the flap pocket method was 5.57 ± 1.13 months, much shorter than the 10.75 ± 3.54 months (p < 0.05) of the expansion method.

CONCLUSIONS

In microtia, the flap pocket method scores higher on patient satisfaction, while having lower post-operative complications and a shorter treatment period compared with the expansion method.

A New Method of Correcting Cryptotia by Changing Mechanical Fulcrum After Constricted Cartilage Overturned

BACKGROUND

Many techniques have been introduced to correct cryptotia. The previous methods are releasing the constricted cartilage and changing the mechanical fulcrum partly to the right position. However, some patients are still not satisfied with the treatment results, due to cryptotia recurrence and insufficient superior 1/3 width. This study aimed to develop a new method for completely changing the mechanical direction of constricted cartilage for correcting cryptotia.

METHODS

From 2007 to 2020, twenty-four cryptotia patients were treated. During surgical reconstruction, the retroauricular skin flap was elevated, the posterior aspect of the upper auricular cartilage was completely exposed, and the abnormal insertion of the auricular intrinsic muscles detached. The sharply curved antihelical cartilage was cut and overturned, and the scalp skin flap was undermined and advanced toward the postauricular sulcus. The edge of the retroauricular scalp flap is fixed on the mastoid periosteum. The incision was closed.

RESULTS

Eighteen patients had unilateral cryptotia, and six had bilateral cryptotia. Relatively favorable results were obtained in the follow-up period (range, 6-48 months). There were no cases of skin necrosis, complications, or revision surgery.

CONCLUSIONS

The main advantages of this technique are the surgically reproducible results, and that it can be applied to most cases. The method described in this paper could potentially increase the width of the upper third of the auricle and reduce recurrence rate, while also leaving an inconspicuous scar and a satisfactory auricular contour. It is suggested that this technique could be an alternative method of cryptotia correction.

LEVEL OF EVIDENCE IV

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 .

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions

BACKGROUND

There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective.

METHODS

Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties.

RESULTS

Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales.

INTERPRETATION

The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

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.

Modification of the cartilaginous framework for autologous ear reconstruction: Construction of a stable complete ring framework with grander highs and lows

BACKGROUND

Successful microtia reconstruction involves fabrication of a framework with well-defined ear subunits. Tragal definition and deep conchal bowl are key elements to produce a natural well-defined and contoured ear. We describe a modification in the cartilage framework with the purpose of increasing framework stability, tragal definition and conchal bowl depth.

METHODS

The tragus is placed on two cartilaginous bars (L-shaped), which are fixed to the framework base block creating a complete ring. These increase tragal projection and conchal depth. The tragus is carved angled posteriorly to have a shadowing effect on the absent auditory canal. Aesthetic outcome was assessed, at least 6 months after the second stage, on a 5-point ordinal scale (1-5) using the scoring system published in the UK microtia care standards and agreed on by the International Society for Auricular Reconstruction (ISAR).

RESULTS

A total of 406 auricular reconstructions were performed in 363 patients (206 right, 114 left, 43 bilateral). After excluding cases who did not have second stage and those without complete photographs, 290 cases were assessed. The described modification in the framework carving was performed in 255 ears out of these 290 ears. The mean aesthetic score before and after the modification was 2.4 and 3.09 respectively for the tragus (p < 0.001), 2.2 and 2.95 for the intertragal notch (p < 0.001) and 2.77 and 3.49 for the concha (p < 0.001).

CONCLUSIONS

This technical refinement has resulted in increased permanence and definition of the tragus and deeper and more aesthetic concha.

A novel ear elements segmentation algorithm on depth map images

The growing interest in the auricular anatomy is due to two different strands of research: 1) in the medical field it is associated with autologous ear reconstruction, a surgery adopted following trauma or congenital malformations; 2) in surveillance and law enforcement the ear is used for human detection and recognition. Alternative systems of ear analysis can be differentiated for the type of input data (two-dimensional, three-dimensional or both), for the type of acquisition tools (3D scanner, photographs, video surveillance, etc.) and finally for the adopted algorithms. Although the segmentation and recognition of the ear from the face is a widely discussed topic in literature, the detection and recognition of individual anatomical elements has not yet been studied in depth. To this end, this work lays the foundation for the identification of the auricular elements through image processing algorithms. The proposed algorithm automatically identifies the contours of the main anatomical elements by processing depth map images. The algorithm was tested qualitatively and quantitatively on a dataset composed of 150 ears. The qualitative evaluation was performed with the collaboration of medical staff and the quantitative tests were performed using manually annotated ground truth data.

A modified crescent cartilage block for improving the retroauricular contour of the reconstructed ear: A retrospective cohort study

BACKGROUND

The use of a semilunar cartilage block to elevate a reconstructed ear does not always achieve a well-defined auriculocephalic sulcus. Herein, we modified the conventional crescent cartilage block through sculpting a concavity at its posterior surface, with the aim of improving the retroauricular contour. The study aimed to verify the effectiveness and reliability of this modified cartilage block through a retrospective cohort study.

METHODS

A retrospective review of patients who underwent Nagata microtia reconstruction between October 2017 and November 2018 were conducted. The esthetic outcomes of auricular projection and cranioauricular sulcus in patients who accepted the modified semilunar block were compared with those of patients who underwent the same procedure using the traditional crescent pad.

RESULTS

A total of 163 (84 of the modified group and 79 of the traditional group) patients were included. The mean (median) esthetic scores for ear projection in the modification and traditional groups were 3.13 (3) and 3.06 (3), respectively. The rate of favorable ear projection in the modification group (83.3%) was similar with that in the traditional group (78.5%) (p = 0.550). The mean (median) esthetic scores for cranioauricular sulcus in the modification and traditional groups were 2.51 (3) and 2.90 (3), respectively. The rate of favorable retroauricular sulcus in the modification group was 75.9%, whereas that in the traditional group was 51.2%, with the differences reaching statistical significance (p = 0.001).

CONCLUSIONS

The concave crescent-shaped block can improve the contour of the auriculocephalic sulcus under the premise of ensuring the ear projection.

Clinical Results of Ear Elevations in Patients with Microtia Using Skin Grafts from Three Donor Sites: A Retrospective Study

BACKGROUND

Skin grafts, frequently used for ear elevation in ear reconstructions, may suffer from color mismatches, scar hypertrophy, secondary contraction, and auricular sulcus depth differences. To determine the most suitable donor area, we compared the contralateral postauricular area, groin, and scalp as potential donor sites.

METHODS

Since 2008, we have used three donor sites for obtaining skin grafts used in ear reconstructions. Full-thickness groin skin, split-thickness grafts from the scalp, and contralateral postauricular and groin composite full-thickness skin grafts were used in 202, 231, and 195 patients, respectively. Photographic assessments were used to assess color matching, sulcus depth, cranioauricular angle symmetry, and flatness of the skin grafts; surgical complications were also documented.

RESULTS

Among the three donor sites, there were no significant differences in the color matching scores (p = 0.456). The scalp donor scores had significantly lower mean scores for sulcus depth and symmetry and for graft flatness scores than the other donor sites. The assessment scores between the groin and postauricular donor groups were similar. Each donor site was associated with some surgical complications. However, postauricular skin, when combined with groin skin, demonstrated the best cosmetic results and the fewest complications.

CONCLUSION

All three donor sites are viable options for skin graft donor sites in ear elevation surgeries. Although the advantages and disadvantages of each site should be explained to the patient, the ultimate donor site selection may be determined according to patient and surgeon preferences.

LEVEL OF EVIDENCE IV

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 .

Evaluation of effectiveness of three-dimensional printed ear splint therapy following ear elevation surgery in microtia patients: A randomized controlled trial

AIM

This study aimed to compare the effectiveness of a 3D-printed ear splint with that of a conventional thermoplastic ear splint after microtia reconstruction.

METHODS

Patients who underwent ear elevation surgery with postauricular fascia coverage between October 2017 and October 2018 were included. They were randomly divided into the experimental group (3D-printed ear splint) and the control group (thermoplastic ear splint) and underwent routine postoperative rehabilitation and antiscar therapy. Splint therapy was initiated 4 weeks postoperatively and continued until 24 weeks postoperatively. The evaluated indices were the Vancouver scar scale score (VSS score), cranioauricular distance, patient compliance, complications (dermatitis, skin ulcers, skin necrosis), and patient satisfaction. A two-group t-test was carried out to compare all variables except patient satisfaction, which was compared using the Mann-Whitney U-test; p < 0.05 was considered significant.

RESULTS

Twenty patients were included in each group. At 4 weeks postoperatively, the VSS score (p = 0.748) and cranioauricular distance (p = 0.647) showed no significant differences between the groups. At 24 weeks postoperatively, the mean VSS scores were 4.85 ± 1.46 and 6.25 ± 1.74 (p = 0.009), the mean cranioauricular distances were 15.80 ± 1.82 mm and 13.95 ± 1.93 mm (p = 0.004), and the patient satisfaction scores were 4.5 ± 0.51 and 3.7 ± 0.47 (p < 0.001) in the experimental group and the control group, respectively, all showing significant differences. Two patients in each group exhibited skin irritation or skin ulcers, which resolved after 6 months of follow-up.

CONCLUSION

The application of 3D-printed ear splints provides better inhibition of scar contracture, better maintenance of ear projection and higher patient satisfaction than conventional ear splints following ear elevation surgery in microtia patients. Therefore, 3D-printed ear splints should be preferred over conventional ear splints whenever possible.

"Auricular reconstruction: A sociocultural, surgical and scientific perspective"

The functional and sociocultural role of the auricle has been prevalent in art, literature and history for millennia. It is no surprise, therefore, that auricular anomalies can be associated with affective disorders and impaired academic performance in children. The challenge of auricular reconstruction has captured the attention of surgical innovators for millennia with the earliest records of auricular reconstruction documented in the Edwin Smith Surgical Papyrus dating back to 3000 BCE. Since the 19th century, however, the interest in the ambition partial and total auricular reconstruction witnessed a rebirth, with refinements in frame construction, projection and skin coverage improving exponentially over the last two centuries. The gold standard auricular reconstruction practices today have their roots in these historical milestones, and form a solid foundation for the introduction of technological advancements such as 3D bioprinting and composite tissue allotransplantation into future auricular reconstruction practice. The aim of this review is to outline the sociocultural role of the auricle, the history and evolution of auricular reconstruction surgery and to provide an insight into potential future avenues of restoring auricular form and function.

The Study of Using 3D Scan Technique to Evaluate the Expanding Method of Ear Reconstruction Before Operation

PURPOSE

Three-dimensional scanning technology was used to measure the expansion of the area and size of auricular skin to meet the normal standard of the external ear before ear reconstruction among microtia patients.

MATERIALS AND METHODS

The skin surface area of microtia patients was measured by three-dimensional scanner: the surface area (S), vertical length (A), vertical curve length (B), transverse length (C), transverse curve length data (D), and then taking the average. Corresponding measurements in healthy adults were also obtained: surface area (S₀), the vertical curve length (B₀), and transverse curve length (D₀) of the normal external ear were obtained by scanning normal adult male ears with reference to the range of the vertical length and the transverse straight length. Mean surface area (S and S₀), vertical curve length (B and B₀), and transverse curve length (D and D₀) were compared between microtia patients and healthy adults.

RESULTS

The surface area, vertical curve length, and transverse curve length were statistically significantly higher among healthy adults.

CONCLUSIONS

With the amount of expanded water injection of 120-130 ml, the expanded skin still does not reach the standard of the normal external ear in terms of skin surface area and size.

LEVEL OF EVIDENCE IV

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.

[Secondary surgery of the external ear]

Secondary surgeries of the external ear can be divided into two categories: secondary otoplasties and secondary ear reconstructions. The most frequent causes of secondary otoplasties are a recurrence, an over-corrected ear, an off-center ear, a prominent lobule, and finally chronic ear pain. Recurrence of the prominence can be treated by a new posterior stitch otoplasty, an Earfold clip, or a frame stitch. The over-corrected ear can be projected either by costal cartilage grafts or by hyaluronic acids. Patients who are unsatisfied of the aesthetic result of their prominent ear correction usually complain about an off-centered ear, because the ideal ear axis is parallel to the cheek. A prominent lobule can be corrected with a posterior stitch and a VY flap. Chronic ear pain can be significantly reduced by a protocol of physiotherapy with positive sensory feedback. In ear reconstruction, it is important preserve the retroauricular skin and the superficial temporal fascia, which are the workhorses of ear reconstruction. Secondary ear reconstructions are usually very complex procedures, which should be performed by specialists.

Reconstruction of the Ear

Skin cancer is a common indication for reconstructive surgery of the ear. The unique anatomy of the external ear makes the restoration of form and function challenging for the reconstructive surgeon. This article reviews the relevant anatomy of the ear, defines the goals of reconstruction, outlines the assessment of defects based on location, and describes specific surgical techniques useful in auricular reconstruction.

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.

Ear Reconstruction Using Autologus Costal Cartilage: A Steep Learning Curve

Purpose

Ear reconstruction is a challenging operation with a steep learning curve. In view of its rarity, attaining a high standard for new surgeons is extremely difficult. This study describes the author's experience of 53 ear reconstructions using costal cartilage for congenital and post-traumatic ear deformity.

Methods

The author performed 53 autologous ear reconstructions for microtia and post-traumatic ear defect over a period of 5 years utilizing the two-stage technique popularized by Firmin in most of the cases. An assessment of complications, pattern of progress and aesthetic outcome of the reconstructed ears was carried out.

Results

There were 4 cases of partial skin necrosis. In early cases, deficiencies were seen in the proportions of the reconstructed ear and the quality of definition. Better shape and definition were evident as more surgical experience was gained. This occurred as a result of increased appreciation of the ear proportions and improved framework carving.

Conclusions

The series demonstrates the early learning curve in microtia reconstruction and underlines the importance of appropriate training and case availability in achieving high-quality results in autologous ear reconstruction.

Salvage of a cartilage framework exposure in total ear reconstruction using a retro-auricular fascia flap with double axial irrigation

Cartilage framework exposure during total ear reconstruction requires an early salvage procedure and a secure coverage. We present a case that has been successfully covered by a retro-auricular fascia flap and a skin graft. Because we were dealing with a post-traumatic ear amputation with extensive scarring, the flap was designed to include both the retro-auricular artery and the occipital artery for an enhanced vascular security. This flap design may play a more important role especially in post-traumatic ear reconstruction.

Using Four-Layer Sculpted Rib Cartilage Framework to Increase Transverse Height of the Reconstructive Ear in One Operative Stage for Microtia Patients

PURPOSE

This case study improves an operative method of ear reconstruction for microtia patients by using a four-layer rib cartilage framework to increase transverse height of the reconstructive ear to a natural level in one operative stage.

MATERIALS AND METHODS

The procedures of ear reconstruction were conducted from February 2014 to May 2016. The ear framework used in the procedures was fabricated from autologous rib cartilage into a four-layer spliced sculpture. Totally 23 patients with unilateral microtia were willing to be enrolled in this study.

RESULTS

After the operation, 23 patients achieved 2.3-2.8 cm transverse height of reconstructed ears, which was basically the same as the normal side. Both patients and their families felt satisfied with the results. Follow-up was performed at 6-16 months after the procedures. Only one case showed significantly lowered transverse height of the reconstructed ear, compared to the normal one. It was due to the sleeping position of the patient (10-year-old boy), which put the reconstructed ear under pressure and reduced the transverse height of the ear.

CONCLUSIONS

The method of four-layer sculpted autologous rib cartilage ear reconstruction has good clinical effect. It can provide a reconstructed ear that reaches normal transverse height and avoids a third operation to increase the transverse height by rib cartilage transplantation.

LEVEL OF EVIDENCE IV

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 .

Cost analysis of microtia treatment in the Netherlands

INTRODUCTION

Ear reconstruction for microtia is a challenging procedure. Although analyzing esthetic outcome is crucial, there is a paucity of information with regard to financial aspects of microtia reconstruction. This study was conducted to analyze the costs associated with ear reconstruction with costal cartilage in patients with microtia.

METHODS

Ten consecutive children with autologous ear reconstruction of a unilateral microtia were included in this analysis. All patients had completed their treatment protocol for ear reconstruction. Direct costs (admission to hospital, diagnostics, and surgery) and indirect cost (travel expenses and absence from work) were obtained retrospectively.

RESULTS

The overall mean cumulative cost per patient was €14,753. Direct and indirect costs were €13,907 and €846, respectively. Hospital admission and surgery cover 55% and 32% of all the costs, respectively.

DISCUSSION

This study analyzes the costs for autologous ear reconstruction. Hospital admission and surgery are the most important factors of the total costs. Total costs could be decreased by possibly decreasing admission days and surgical time. These data can be used for choosing and developing future treatment strategies.

[Reconstruction of the ear in the burns patient]

Face burns are a singular pathology with great functional and psychological impact in the patients suffering them. The ears play a fundamental role in personal interactions and damage to this organ results in physical and emotional distress. The reconstructive treatment of the burned ear is a challenge. Multiple procedures have been described to achieve success in the reconstruction of the burned ear; immediate reconstruction with autologous rib cartilage, secondary reconstruction, alloplastic material reconstruction, tissue expansion, skin grafts and also microvascular flaps are some of the most common procedures used in this patients. All these techniques focus on giving a natural appearance to the patient. Burns to the ears affect 30% of the patients with facial burns, they require an excellent treatment given by a multidisciplinary team.

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.

Mechanisms of ear trauma and reconstructive techniques in 105 consecutive patients

Acquired auricular deformities may diminish facial esthetics and cause psychological distress. The aim of this article is to provide an overview of the type of injuries and applied reconstructive techniques in a large academic hospital in The Netherlands. A retrospective chart review was conducted for the last 105 patients who underwent auricular reconstruction for an acquired deformity. Data concerning gender, affected side, cause of injury, anatomical region, the previous and further surgeries, type of cartilage, and skin cover used were collected and analyzed. 105 patients were included. Acquired auricular deformities were mainly caused by bite injuries (22 %), traffic accidents (17 %), burns (9.5 %), and post-otoplasty complications (9.5 %). The upper third of the auricle was most often injured (41 %), followed by the entire auricle (19 %). 70 % of cases required reconstruction with costal cartilage. The most common form of cutaneous cover was a postauricular skin flap (40 % of cases). This study gives a complete overview of causes and treatment of acquired auricular deformities. The results are comparable with the results of similar studies found in literature. Bite wounds are the leading cause of acquired auricular injuries. The upper third is most commonly affected. In the largest percentage of reconstructions, costal cartilage and a postauricular flap were used to correct the deformity.

Extended lateral thoracic fasciocutaneous biosynthetic flap for reconstruction of full-thickness partial external ear defects: an experimental study

External ear reconstruction is a controversial topic in reconstructive plastic surgery. Here, we prepared a pedicled biosynthetic flap for full-thickness, partial ear defects in rabbits. We operated on six adult female New Zealand rabbits weighing 3-4 kg. The dimensions of the lateral thoracic fasciocutaneous flap were 7 × 6 cm. The flap was elevated based on one of the bilaterally located internal thoracic arteries, which were dissected proximally. The pedicled flap was folded in two, and polypropylene mesh was sandwiched in the middle. The flap was adapted to a defect of 3.5 × 3 cm in diameter. In fact, the defect was created before elevation of the flap. Rabbits were followed up for 4 weeks, at the end of which they were killed and their ears were evaluated histopathologically. The survival rate of the rabbits was 100 %. All pedicled biosynthetic flaps were viable, but one showed partial (20 %) necrosis (1/6) and one was partially detached (1/6). Macroscopic (color, thickness, texture) and histological (polymorphonuclear leukocyte invasion in the skin, subcutaneous tissue, and at the junction between the polypropylene mesh and the flap) features of the flap were compared to the ipsilateral ear. A new technique was developed for partial external ear reconstruction with sufficient inner skeletal support and outer skin lining. Level of evidence Level NA.

Analysis of the microcirculation after soft tissue reconstruction of the outer ear with burns in patients with severe burn injuries

Reconstruction of soft tissue defects of the ear with burns remains one of the most difficult tasks for the reconstructive surgeon. Although numerous reconstructive options are available, the results are often unpredictable and worse than expected. Besides full and split skin grafting, local random pattern flaps and pedicled flaps are frequently utilized to cover soft tissue defects of the outer auricle. Because of the difficulty and unpredictable nature of outer ear reconstruction after burn injury, a case-control study was conducted to determine the best reconstructive approach. The microcirculatory properties of different types of soft tissue reconstruction of the outer ear with burns in six severely burned Caucasian patients (three men and three women; mean age, 46 years (range, 22-70)) were compared to those in the healthy tissue of the outer ear using the O2C device (Oxygen to See; LEA Medizintechnik, Gießen, Germany). The results of this study revealed that the investigated microcirculation parameters such as the median values of blood flow (control group: 126 AU), relative amount of hemoglobin (control group: 59.5 AU), and tissue oxygen saturation (control group: 73%) are most similar to those of normal ear tissue when pedicled flaps based on the superficial temporal artery were used. These findings suggest that this type of reconstruction is superior for soft tissue reconstruction of the outer ear with burns in contrast to random pattern flaps and full skin grafts regarding the microcirculatory aspects. These findings may improve the knowledge on soft tissue viability and facilitate the exceptional and delicate process of planning the reconstruction of the auricle with burns.

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.

Mechanical and biochemical mapping of human auricular cartilage for reliable assessment of tissue-engineered constructs

It is key for successful auricular (AUR) cartilage tissue-engineering (TE) to ensure that the engineered cartilage mimics the mechanics of the native tissue. This study provides a spatial map of the mechanical and biochemical properties of human auricular cartilage, thus establishing a benchmark for the evaluation of functional competency in AUR cartilage TE. Stress-relaxation indentation (instantaneous modulus, Ein; maximum stress, σmax; equilibrium modulus, Eeq; relaxation half-life time, t1/2; thickness, h) and biochemical parameters (content of DNA; sulfated-glycosaminoglycan, sGAG; hydroxyproline, HYP; elastin, ELN) of fresh human AUR cartilage were evaluated. Samples were categorized into age groups and according to their harvesting region in the human auricle (for AUR cartilage only). AUR cartilage displayed significantly lower Ein, σmax, Eeq, sGAG content; and significantly higher t1/2, and DNA content than NAS cartilage. Large amounts of ELN were measured in AUR cartilage (>15% ELN content per sample wet mass). No effect of gender was observed for either auricular or nasoseptal samples. For auricular samples, significant differences between age groups for h, sGAG and HYP, and significant regional variations for Ein, σmax, Eeq, t1/2, h, DNA and sGAG were measured. However, only low correlations between mechanical and biochemical parameters were seen (R<0.44). In conclusion, this study established the first comprehensive mechanical and biochemical map of human auricular cartilage. Regional variations in mechanical and biochemical properties were demonstrated in the auricle. This finding highlights the importance of focusing future research on efforts to produce cartilage grafts with spatially tunable mechanics.

Pre and post-operative psychological functioning in younger and older children with microtia

OBJECTIVES

Microtia ranges from a smaller ear to the absence of the external ear and has been associated with psychosocial distress. Traditional ear reconstruction takes place beginning at age six. Use of an alloplastic implant allows for earlier surgery starting at age three, which may reduce potential negative psychological effects. However, few studies have examined psychosocial outcomes of ear reconstruction with groups that include young children.

METHODS

Children (N = 23) with microtia and their parents completed two microtia-related scales, negative emotions and microtia social awareness, and the Behavioral Assessment System for Children - Second Edition (BASC-2) subscales of anxiety, depression, and social skills before surgery and one year after surgery. Participants (74% male) were three to nine years old with a mean age of 6.13 ± 2.10 years and were grouped by age at surgery, three to six years (n = 11) or seven to ten years (n = 12). The sample identified as Latino (96%) or "other" (4%).

RESULTS

Pre and postoperative scores by age group were compared using two-way repeated measures analyses of variance. Children and parents reported significantly less negative emotion and microtia social awareness following surgery, with an interaction for parental report of older children showing higher negative emotion preoperatively. Older children also had higher scores of depression and anxiety before surgery and both groups reported significant decreases following surgery, along with improved social skills. Older children showed significantly greater gains in social skills.

CONCLUSION

All participants and their parents reported improved psychological functioning postoperatively. However, older children may be at greater risk of psychological concerns given the longer time they have to cope with the impact of microtia on self-image and exposure to social stressors. Undergoing reconstructive surgery earlier may be a protective factor for children with microtia.

Modified Antia-Buch flap for the reconstruction of helical rim defects

BACKGROUND

The Antia-Buch flap is a sophisticated one-stage procedure using two chondrocutaneous flaps to reconstruct the ear helix. Because tissue laxity is largely conferred by the inferior flap, relative to the less mobile superior flap, chondrocutaneous resection of scapha is required for closure. This results in loss of ear height and limits morphologic outcome. We describe a modification of the Antia-Buch flap, which may avoid such drawbacks.

PATIENTS AND METHOD

We conducted a retrospective review of patients (n = 15), each undergoing our modified Antia-Buch flap between 2010 and 2014. All procedures were performed under local anesthesia as outpatient procedures. Data on magnitude of resections, procedure durations, related complications, and aesthetic outcomes were collected.

RESULTS

The mean size of resection was 25 mm (range, 20-30 mm). The modification improved the mobility of the upper chondrocutaneous flap, eliminating the need to resect the scapha. All wounds healed uneventfully, with no skin necrosis. The morphologic outcome was satisfactory or very satisfactory in all patients, preserving the shape, height, and width of the ear.

CONCLUSIONS

Our modification changes the upper flap from an advancement flap to a transposition flap, enhancing its mobility and preempting the resection of the scapha. Thus, anatomic landmarks, aesthetic subunits of the pinna, and ear height are maintained for highly satisfactory morphologic results.

LEVEL OF EVIDENCE

4.

A new skin flap method for total auricular reconstruction in microtia patients with a reconstructed ear canal: extended scalp and extended mastoid postauricular skin flaps

Before visiting a plastic surgeon, some microtia patients may undergo canaloplasty for hearing improvement. In such cases, scarred tissues and the reconstructed external auditory canal in the postauricular area may cause a significant limitation in using the posterior auricular skin flap for ear reconstruction. In this article, we present a new method for auricular reconstruction in microtia patients with previous canaloplasty. By dividing a postauricular skin flap into an upper scalp extended skin flap and a lower mastoid extended skin flap at the level of a reconstructed external auditory canal, the entire anterior surface of the auricular framework can be covered with the two extended postauricular skin flaps. The reconstructed ear shows good color match and texture, with the entire anterior surface of the reconstructed ear being resurfaced with the skin flaps. Clinical question/level of evidence; therapeutic level IV.

Our preferred surgical approach to cicatricial cryptotia

BACKGROUND

Adhesions between the auricle and retroauricular cranial wall and mastoid occur after burns to this area due to cicatricial contracture, leading to the distortion of the otocranial angle and obscuring the remnant auricle in the scar. A definition of cicatricial cryptotia was devised to describe the ear deformity after burn by the authors, and a novel surgical approach to cicatricial cryptotia was employed to reconstruct the auricle.

PATIENTS AND METHODS

A total of 33 ears in 26 adult patients were operated upon. As many as 19 cases of cicatricial cryptotia were unilateral, seven cases bilateral. The patients' age ranged from 19 to 31 years. Because of a lack of normal tissues surrounding the remnant ear, a periauricular cicatricial flap was designed to repair the helix and antihelix defect and a horizontal bifoliate skin flap for earlobe reconstruction. Two triangular cicatricial flaps located at the cephalic or caudal direction of the survival ear were used for shaping the otocranial angle and auriculotemporal sulci, combined with zoned transplantation of a full-thickness skin graft.

RESULTS

All cicatricial flaps demonstrated nearly 100% survival and the take rate of transplanted skin grafts was approximately 95%. The main structures were visible and cosmetically acceptable; the otocranial angle and auriculotemporal sulci were acceptably restored. The function of wearing eye glasses or a mask was regained. The patients were followed up from 3 months to 6 years after surgery; the mean follow-up period was 3.2 years. The contour of the reconstructed auricle was maintained well, and the scar contracture was acceptable.

CONCLUSION

Periauricular cicatricial flaps combined with skin grafting is a new approach to cicatricial cryptotia when auricle reconstruction after burn is limited by a scarcity of supple, elastic local skin and fascia.

A novel algorithm for autologous ear reconstruction

Sculpting a tridimensional autologous rib cartilage framework is essential to restore a natural ear shape and becomes routine with preoperative training, but management of the skin is the key to minimizing complications. Here the authors provide a classification scheme to manage auricular skin: Type 1 is a Z-plasty with transposition of the lobule; type 2 is a transfixion incision of the microtic ear; type 3 exposes the cartilage remnants through a cutaneous incision. They also explain how to choose between the three types, depending upon the auricular skin potential. With training and method, results in ear reconstruction using autologous rib cartilage are excellent and reproducible.