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

Comparison of auricle reconstruction with expanded flaps and auricle reconstruction with non-expanded flaps in patients with microtia: A meta-analysis

OBJECTIVE

We conducted this meta-analysis to compare the efficacy of these two surgical methods by comparing the incidence of major evaluation indicators.

METHODS

The databases such as PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP information databases were searched.

RESULTS

The satisfaction rate of patients with auricle reconstruction using expanded flaps was 86.5%, and the satisfaction rate of patients with auricle reconstruction using non-expanded flaps was 87.9%. The incidence of postoperative hematoma was 3.2% in patients with auricle reconstruction using expanded flaps and 18.9% in patients with auricle reconstruction using non-expanded flaps. The incidence of postoperative skin necrosis was 2.2% in patients with auricle reconstruction using expanded flaps and 4.1% in patients with auricle reconstruction using non-expanded flaps. The incidence of postoperative incision infection was 3.1% in patients with auricle reconstruction using expanded flaps and 0.9% in patients with auricle reconstruction using non-expanded flaps. The incidence of cartilage framework exposure was 2.2% in patients with auricle reconstruction using expanded flaps and 1.9% in patients with auricle reconstruction using non-expanded flaps. The incidence of postoperative scar hyperplasia was 3.8% in patients with auricle reconstruction using expanded flaps and 3% in patients with auricle reconstruction using non-expanded flaps. The publication bias of included literature was evaluated by Egger test. There was no publication bias in this Meta-analysis (P > .05).

CONCLUSION

The auricle reconstruction using non-expanded flaps is dominant in four of the six evaluation indexes. Therefore, we believe that the auricle reconstruction using non-expanded flaps has better therapeutic effect in patients with microtia. Due to the limitations of this meta-analysis, the conclusions of this meta-analysis still need to be further verified.

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.

Exploring Aesthetic Outcomes and Complications in Auricular Reconstruction Utilising Autologous Cartilage: A Systematic Review and Narrative Synthesis

Auricular reconstruction remains a challenging procedure, requiring a high degree of manual dexterity and attention to detail in order to reconstruct the complex three-dimensional geometry of the ear successfully. Most techniques will rely on autologous cartilage for auricular framework fabrication, carrying a risk of donor and recipient site morbidity. The aim of this report is to investigate the complications and aesthetic outcomes associated with autologous cartilage harvest in auricular reconstruction. A systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies for four databases were developed. Studies were screened according to the inclusion and exclusion criteria by two independent reviewers. The literature search identified 7171 articles. Filtering for relevance and duplication reduced the number of articles to 52. A total of 12,215 patients underwent auricular reconstruction utilising autologous cartilage. Indications included 11,696 patients due to microtia, 334 patients due to burns or trauma, 70 patients due to constricted ears, and 115 patients due to prominent ears. The most commonly reported donor site complications included chest wall deformities (n = 159). The most commonly reported recipient site complications included hypertrophic or keloid scars (n = 279), haematoma (n = 155), tissue expander exposure (n = 111), cartilage or framework exposure (n = 122), and cartilage framework deformation or resorption (n = 50). Although a challenging procedure, auricular reconstruction utilising autologous cartilage is possible. Exceptional aesthetic results can be achieved when performed by a skilled surgeon on appropriately selected individuals. However, the potential risks and complications associated with the procedure should be discussed with the patient and family beforehand.

The regenerative treatment of costal osteochondral graft implantation for partial growth arrest using a rabbit model

PURPOSE

To investigate the feasibility of cylindrical costal osteochondral graft transplantation as a novel regenerative treatment in growth arrest.

METHODS

The medial portion of the proximal tibial growth plate of 6-week-old male New Zealand White rabbits was resected to establish an experimental model of partial growth plate injury. The rabbits were divided into four groups: no-treatment, bone wax transplantation, costal chondral graft, and costal osteochondral graft groups. Radiographic and micro-computed tomography scan results were analyzed to evaluate angular deformity of the tibia and bony bridge formation at the injury site. In addition, repair of the injured growth plate cartilage was assessed histologically at 4, 8, and 12 weeks postoperatively.

RESULTS

Radiographic examination revealed that bone wax transplantation continuously decreased the medial proximal tibial angle (MPTA) while the costal chondral graft implantation reduced the decrease of MPTA at 12 weeks postoperatively. The costal osteochondral graft implantation recovered the MPTA, close to the normal. Histologically, the costal osteochondral grafts retained the MPTA in the injured site compared to costal chondral grafts. Additionally, hypertrophic chondrocytes were observed at the graft site in the costal osteochondral graft group at 12 weeks, suggesting that endochondral ossification may occur at the graft site similar to normal ossification. The fluorescence in situ hybridization analysis of osteochondral grafts transplanted from male to female rabbits indicated that they were replaced by cells of host origin.

CONCLUSION

The costal osteochondral graft can achieve regeneration without bony bridge formation in partial growth plate injury.

The Effect of Fixation Materials on the Long-Term Stability of Cartilage Framework for Microtia Reconstruction

Objective: To observe the effect of fixation materials on the long-term stability of the cartilage framework in auricular reconstruction. Methods: Consecutive patients who underwent the first stage of auricular reconstruction by the same surgical team from September 2018 to March 2021 were included. Those with braided absorbable suture, polypropylene suture, and titanium wire were defined as Groups A, B, and C, respectively. Six months later, when the patients underwent the second stage of surgery, absorption and deformation of the framework were assessed. Results: A total of 604 patients (622 ears) were included. The most common occurrence was spot absorption in the antihelix and was observed in 34.7%, 17.4%, and 22.8% ears in the A, B, and C groups, respectively (p < 0.05). There were also significant differences regarding severe absorption and severe deformation. The histological examination suggested that those in Group A had more T cells and macrophages around the suture than those in Groups B and C. Conclusion: Absorbable suture seems to correlate with higher risk of cartilage absorption and helix displacement. Titanium wire had the lowest rate of helix pop-out or fracture, which means the best stability.

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.

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.

Aesthetic Otoplasty: Principles, Techniques and an Integrated Approach to Patient-Centric Outcomes

BACKGROUND

Otoplasty is a century-old procedure that, through continued modifications, now has over two hundred different procedures described in the literature. In this article, we seek to describe the anatomy and principles of aesthetic otoplasty, as well as some of the key contributions to aesthetic otoplasty. This article will also outline some of the most commonly used techniques today and associated patient outcomes.

METHODS

We present a review of the literature of relevant anatomy, pathophysiology and common techniques and outcomes. We also provide a discussion of several patients with associated techniques and outcomes.

RESULTS

The treatment of prominent ear has developed through manipulation and experimentation. The outcomes are defined by the native anatomy, the surgical technique and the attention to patient-centered outcomes.

CONCLUSION

Aesthetic otoplasty remains one of the most important surgical techniques and common procedures in plastic surgery. Using an integrated approach guided by known principles as well as patient goals allows for optimal outcome in aesthetic otoplasty.

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 .

Autologous costal chondral transplantation and costa-derived chondrocyte implantation: emerging surgical techniques

It is a great challenge to cure symptomatic lesions and considerable defects of hyaline cartilage due to its complex structure and poor self-repair capacity. If left untreated, unmatured degeneration will cause significant complications. Surgical intervention to repair cartilage may prevent progressive joint degeneration. A series of surgical techniques, including biological augmentation, microfracture and bone marrow stimulation, autologous chondrocyte implantation (ACI), and allogenic and autogenic chondral/osteochondral transplantation, have been used for various indications. However, the limited repairing capacity and the potential pitfalls of these techniques cannot be ignored. Increasing evidence has shown promising outcomes from ACI and cartilage transplantation. Nevertheless, the morbidity of autologous donor sites and limited resource of allogeneic bone have considerably restricted the wide application of these surgical techniques. Costal cartilage, which preserves permanent chondrocytes and the natural osteochondral junction, is an ideal candidate for the restoration of cartilage defects. Several in vitro and in vivo studies have shown good performance of costal cartilage transplantation. Although costal cartilage is a classic donor in plastic and cosmetic surgery, it is rarely used in skeletal cartilage restoration. In this review, we introduce the fundamental properties of costal cartilage and summarize costa-derived chondrocyte implantation and costal chondral/osteochondral transplantation. We will also discuss the pitfalls and pearls of costal cartilage transplantation. Costal chondral/osteochondral transplantation and costa-based chondrocytotherapy might be up-and-coming surgical techniques for recalcitrant cartilage lesions.

Craniofacial Microsomia

Clinicians use different diagnostic terms for patients with underdevelopment of facial features arising from the embryonic first and second pharyngeal arches, including first and second branchial arch syndrome, otomandibular dysostosis, oculoauriculovertebral syndrome, and hemifacial microsomia. Craniofacial microsomia has become the preferred term. Although no diagnostic criteria for craniofacial microsomia exist, most patients have a degree of underdevelopment of the mandible, maxilla, ear, orbit, facial soft tissue, and/or facial nerve. These anomalies can affect feeding, compromise the airway, alter facial movement, disrupt hearing, and alter facial appearance.

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.

Assessment of MRI safety issues for stainless steel sutures used for microtia reconstruction

INTRODUCTION

Potential magnetic resonance imaging issues for stainless steel sutures used for microtia reconstruction could be clinically significant for safety and diagnostic yield considerations. Therefore, the purpose of this investigation was to assess magnetic resonance issues (magnetic field interactions, heating, and artifacts) for different types of stainless steel sutures used for microtia reconstruction.

METHODS

Small gauge, commonly used stainless steel sutures from four different manufacturers (5/0 Steelex, Aesculap/B, Braun Medical, Inc.; Nagata 38 Gauge Microtia Wire, Bear Medical Corporation; Auricular Reco Wire, Medicon Surgical Inc.; and 5-0 B&S 35 Surgical Steel Suture, Ethicon, Inc.) were tested using standardized ex vivo techniques to assess magnetic field interactions, heating, and artifacts at 3 Tesla. Before testing, the stainless steel sutures were configured in a manner same as that for cartilage reconstruction used to treat microtia.

RESULTS

Each stainless steel suture exhibited minor magnetic field interactions at 3 Tesla (translational attraction, deflection angle <10°, and no torque). Heating associated with a whole-body averaged specific absorption rate of 2.9 W/kg was not excessive (highest temperature changes, ≤1.8 °C). Artifacts were relatively minor in relation to the size and shape of each stainless steel suture (artifact size in relation to the size and shape of each stainless steel suture extending ≤5 mm).

CONCLUSIONS

The stainless steel sutures that underwent testing do not present additional risks to patients in a 3-Tesla or less magnetic field setting (i.e., magnetic resonance conditional). Artifacts for these sutures may only be an issue within close proximity to the reconstructed ear.

A New Classification of Helix Fabrication Methods with Autogenous Costal Cartilage in Microtia Reconstruction

BACKGROUND

Recreating the complex architecture of the auricle poses one of the most demanding challenges for the plastic surgeon. The fabrication of the prominent helix is crucial to the final contour of the constructed ear. The success of helix carving depends greatly on the complicated characteristics of the cartilage used, which is commonly the eighth costal cartilage. The authors elaborate on the relevant details for helix sculpting based on different qualities of cartilage.

METHODS

A series of 415 microtia patients underwent autogenous costal cartilage auricular reconstruction between 2012 and 2015. Because the cartilage used for helix reconstruction is always imperfect or insufficient for the fabrication of anatomical structures, they have devised perfect helix duplication by using individualized eighth rib cartilage with different cartilage lengths, widths, and flexibilities. Four possible scenarios in helix fabrication have been elaborated, and the corresponding methods were introduced.

RESULTS

Selective methods for different scenarios in helix fabrication have been shown to produce favorable results. The results reveal that a harmonious helix was achieved and provide a cohesive framework for the integrity of a reconstructed ear.

CONCLUSIONS

A new classification of helix fabrication methods with autogenous costal cartilage is elaborated, and a favorable framework with harmonious proportions is achieved by precise carving using corresponding measures for different cartilage characteristics. This approach enhances helix aesthetics and helps attain a satisfactory contour of the auricle.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Costal cartilage transplantation for treatment of growth plate injury in a rabbit model

OBJECTIVES

The purpose of this study is to evaluate the effects of allogenic costal cartilage transplantation on preventing bony bridge formation and angular deformities for the treatment of partial growth plate injury using a rabbit model.

METHODS

An experimental model of partial growth injury was created by resecting the medial part of the proximal tibial growth plate in male six-week-old New Zealand White rabbits. The rabbits were divided into four groups: no surgery; no transplantation; bone wax transplantation; and allogenic costal cartilage transplantation. The angular deformities of the tibia and bony bridge were analysed using radiographs and microcomputed tomography, and the repair of the injured growth plate cartilage and bony bridge formation rate were histologically evaluated.

RESULTS

On radiographic evaluation, the varus deformities in the costal cartilage group were significantly improved compared with the no transplantation group at four and eight weeks after operation and with the bone wax group at eight weeks after operation. Micro-computed tomography showed that the bony bridge formation was prevented in the bone wax and costal cartilage groups. Histological findings showed that the bony bridge formation in the bone wax and costal cartilage group was decreased. In addition, the growth plate was continuous and stained with safranin O and immunohistochemically stained for type II collagen.

CONCLUSION

Transplantation of costal cartilage improved angular deformities and decreased bony bridge formation in the partial growth plate injury. Costal cartilage might be a suitable graft for the treatment of growth plate injury.

Direct electrospinning of 3D auricle-shaped scaffolds for tissue engineering applications

Thirty-two poly(ε)caprolactone (PCL) scaffolds have been produced by electrospinning directly into an auricle-shaped mould and seeded with articular chondrocytes harvested from bovine ankle joints. After seeding, the auricle shaped constructs were cultured in vitro and analysed at days 1, 7, 14 and 21 for regional differences in total DNA, glycosaminoglycan (GAG) and collagen (COL) content as well as the expression of aggrecan (AGG), collagen type I and type II (COL1/2) and matrix metalloproteinase 3 and 13 (MMP3/13). Stress-relaxation indentation testing was performed to investigate regional mechanical properties of the electrospun constructs. Electrospinning into a conductive mould yielded stable 3D constructs both initially and for the whole in vitro culture period, with an equilibrium modulus in the MPa range. Rapid cell proliferation and COL accumulation was observed until week 3. Quantitative real time PCR analysis showed an initial increase in AGG, no change in COL2, a persistent increase in COL1, and only a slight decrease initially for MMP3. Electrospinning of fibrous scaffolds directly into an auricle-shape represents a promising option for auricular tissue engineering, as it can reduce the steps needed to achieve an implantable structure.

Correction of Lobule-type Microtia: Part 2: The Stage of Ear Elevation

Background:

Here, we introduce our recent operative technique for ear elevation that results in (1) minimal morbidity for patients, (2) symmetric appearance, (3) clearer 3-dimensional structure with a deep concha, (4) good aesthetic appearance by hiding the grafted area behind the ear, and (5) maintenance of deep temporoauricular sulcus and angle.

Methods:

After a skin incision, the ear is elevated with temporoparietal fascia underlying the cartilage. On the conchal area, undermining is performed just below the skin so that the deep concavity can be maintained. Scalp and neck skin behind the ear is undermined subcutaneously and lifted up cranially to hide the entire area of grafted skin behind the ear. The postauricular surface is covered by full-thickness skin from the lower abdomen. A protective splint is applied for 3 months while sleeping.

Results:

A total of 137 ears in 121 patients were corrected with our technique and followed up for at least 3 years. All of the scar tissue could be hidden behind the ear, an aesthetically excellent result.

Conclusions:

Our technique made it possible to acquire an excellent and symmetrical shape of the ear. The important points in our procedure are as follows: (1) subcutaneous posterior undermining to enlarge the conchal cavity, (2) careful arrangement of the temporoauricular angle and auriculo-earlobe angle, (3) reduction in the area of temporally grafted skin to hide all scars behind the ear, and (4) protection of the ear to maintain the shape using a postoperative splint.

A novel method of naturally contouring the reconstructed ear: modified antihelix complex affixed to grooved base frame

BACKGROUND

Prior reports of ear reconstruction have cited favorable results. Although greater attention has been devoted to fabricating a more refined cartilaginous framework, many patients still complain that the contours are unnatural. The authors' aim was to offer a new technique that resolves some lingering issues.

METHODS

To fabricate the antihelix complex optimally, the authors modified an existing method. Rather than chiseling a sharp, Y-shaped graft of cartilage for structural prominence, the superior crus is broadened, and a gentle slope is sculpted on both aspects. Simultaneously, a groove in the base frame is carved for smooth attachment. The width of the inferior crus is limited to roughly one-third that of the superior crus, and the inferior crus is maintained in high relief. A gentle slope is shaped on the antihelix, and a groove for placement of the antihelix is carved into the base frame.

RESULTS

Between 2011 and 2013, a total of 162 patients underwent reconstruction using this modified technique. Three such subjects have been selected to highlight the favorable results achieved. Given modifications confer natural contours to superior and inferior crura, antihelix, and surrounding structures, providing a cohesive framework for the integrity of a reconstructed ear.

CONCLUSIONS

The antihelix complex is critical for creating a natural auricle. Harmonious integration of superior and inferior crura and antihelix enhances the overall aesthetics, increasing procedural satisfaction for patient and surgeon alike.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Complication rate of autologous cartilage microtia reconstruction: a systematic review

Background:

Autologous cartilage has been widely accepted as the frame material of ear reconstruction for patients with microtia. Although rare, there are multiple complications related with the surgical reconstruction techniques. The authors performed a systematic review of the English literature of microtia reconstruction to determine significant surgical factors that are predictors of postoperative complications.

Methods:

A PubMed search using the terms “ear reconstruction” and “microtia” was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, surgical techniques, the incidence of all kinds of complications, and the specific postoperative morbidity. Patient cohorts were pooled, and the incidence of complications was calculated. Significant predictors such as the use of tissue expander, simultaneously mid-ear reconstruction, with/without skin graft, and different fascia coverage were analyzed by chi-square test.

Result:

Of 320 articles found, 60 met the inclusion criteria. Totally 9415 patients with microtia were analyzed in this review with 1525 cases with complications. The overall complication incidence is 16.2% in average with a range of 0–72.9%. There was no significant difference when comparing the overall complication rate between with/without preexpansion 2-stage and multiple-stage techniques or with/without mid-ear reconstruction simultaneously.

Conclusion:

Although there is little agreement in literature regarding risk factors for complications, the authors were able to demonstrate several significant predictors by systematically analyzing 60 articles. Improved knowledge of the incidence of different complications related with various surgical methods can help surgeons provide improved preoperative counseling and take measures to minimize the risk.

Craniofacial microsomia

Craniofacial microsomia (CFM) is one of the most common congenital conditions treated in craniofacial centers worldwide. This condition is variably associated with anomalies of the jaws, ears, facial soft tissue, orbits, and facial nerve function and can be associated with extracranial anomalies. The cause of this condition is unknown, though CFM has been associated withprenatalexposures and genetic abnormalities. Diagnosis, treatment, and outcome assessment in CFM is challenging due to the wide phenotypic spectrum observed in this condition. Surgical treatment requires a coordinated team approach involving multiple specialties, which can include plastic surgery, craniofacial surgery, orthognathic surgery, and microsurgery. A wide variety of surgical options exist, and individual treatment plans should be based on the patient's needs. Although CFM can be challenging to treat, successful outcomes are rewarding. We provide a review of the common craniofacial surgical treatments for individuals with CFM.

Fabrication of stable cartilage framework for microtia in incomplete synchondrosis

The synchondrosis between the sixth and seventh costal cartilage is usually used for the base frame in autogenous ear reconstruction. If the synchondrosis is loose, a variety of modifications can be devised. This report introduces new methods for these problems. In cases of incomplete synchondrosis, only the surface of the base block margin was smoothly tapered without carving for the removal of the conchal deepening. The secure fixation of the two segments (helix and antihelix) to the base block using fine wire sutures gave stability to the unstable basal frame. After confirming that all the segments were assembled in one stable piece, the remaining conchal deepening of the basal framework was removed, and the outer lower portion of the basal cartilage was trimmed along its whole length. A total of 10 consecutive patients with microtia, ranging from 8 to 13 years old, were treated from 2008 to 2009. The follow-up period was 6 months to 2 years. Despite incomplete synchondrosis, the stable frameworks were constructed using the authors' method and aesthetically acceptable results were achieved. The proposed method can provide an easy way to make a stable cartilage framework regardless of the variable conditions of synchondrosis.

An analysis of quantitative measurements of drainage exudate using negative suction in 96 microtia ear reconstructions

Negative suction drainage is commonly used for the prevention of seromas or hematomas in auricular reconstruction surgery; however, there are few reports regarding the quantitative measurement of negative suction and its relation to disposed time, patient age or microtia type. In the present study, the authors recorded the volume of suction exudate in microtia reconstruction and elaborate on the relevant details of controlling negative suction. A negative suction drainage system was applied in 96 microtia patients between 2007 and 2010. Two small polyethylene drains were inserted adjacent to the concha and the scapha, respectively. The volume of exudate was recorded for three days after surgery and was analyzed according to disposed time, patient age and microtia type. The drains were removed on the third postoperative day, when only a small amount of exudate remained. A significant change in drainage was observed over three days postoperatively, and the quantity decreased progressively on the third postoperative day. Comparison of age groups showed that the volume of drainage from adults was greater than that from children or adolescents in the first two postoperative days, regardless of whether the drains were inserted in the scapha or concha. No statistical differences were found on the third postoperative day. A comparison of drain types revealed no statistically significant differences between scapha and concha drains three days postoperatively. The analysis demonstrated that drainage quantity is related to disposed time and patient age, but not to microtia type. The authors recommend removal of suction drains on the third postoperative day. Moreover, individualized negative suction treatment according to age or microtia type provides a safe and consistent approach to achieving acceptable results and fewer complications.

Modifications of three-dimensional costal cartilage framework grafting in auricular reconstruction for microtia

BACKGROUND

Total auricular reconstruction of microtia with autogenous costal cartilage poses one of the most demanding challenges in plastic and reconstructive surgery because of the unique and complex three-dimensional shape of the auricle. Attaining an ideal result of the constructed ear depends primarily on the fabricated cartilaginous ear framework. In this article, the authors discuss the essential modifications of ear framework grafting. The authors elaborate the relevant anatomical details for a harmonious ear framework and present a favorable result of the contour of the reconstructed auricle.

METHODS

Fabricating the auricular framework corresponds roughly with Brent's method. As the cartilage framework used for reconstruction is always imperfect or insufficient for the fabrication of anatomical structures, especially the tragus and the conchal bowl, individualized framework grafting based on different patient age groups and different degrees of strength and thickness of the rib cartilages have been devised accordingly.

RESULTS

A total of 126 patients underwent reconstruction using autogenous costal cartilage between 2007 and 2008. Three cases performed with the new modification of the framework fabrication are shown. They reveal that a harmonious ear framework was achieved and presented a reconstructed auricle with a favorable result. Surgery-related complications occurred in four cases.

CONCLUSIONS

Consequently, individualized framework fabrications are useful in every case and the cartilaginous cube fastened under the constructed tragus is proving to keep the tragus in a stable and erect position. Therefore, the modifications allow one to attain a harmonious ear framework and satisfactory three-dimensional outline of the auricle.

Tissue engineering a model for the human ear: assessment of size, shape, morphology, and gene expression following seeding of different chondrocytes

This study examines the tissue engineering of a human ear model through use of bovine chondrocytes isolated from four different cartilaginous sites (nasoseptal, articular, costal, and auricular) and seeded onto biodegradable poly(l-lactic acid) and poly(L-lactide-epsilon-caprolactone) (50 : 50) polymer ear-shaped scaffolds. After implantation in athymic mice for up to 40 weeks, cell/scaffold constructs were harvested and analyzed in terms of size, shape, histology, and gene expression. Gross morphology revealed that all the tissue-engineered cartilages retained the initial human auricular shape through 40 weeks of implantation. Scaffolds alone lost significant size and shape over the same period. Quantitative reverse transcription-polymerase chain reaction demonstrated that the engineered chondrocyte/scaffolds yielded unique expression patterns for type II collagen, aggrecan, and bone sialoprotein mRNA. Histological analysis showed type II collagen and proteoglycan to be the predominant extracellular matrix components of the various constructs sampled at different implantation times. Elastin was also present but it was found only in constructs seeded with auricular chondrocytes. By 40 weeks of implantation, tissue-engineered cartilage of costal origin became calcified, marked by a notably high relative gene expression level of bone sialoprotein and the presence of rigid, nodular protrusions formed by mineralizing rudimentary cartilaginous growth plates. The collective data suggest that nasoseptal, articular, and auricular cartilages represent harvest sites suitable for development of tissue-engineered human ear models with retention over time of three-dimensional construct architecture, gene expression, and extracellular matrix composition comparable to normal, nonmineralizing cartilages. Calcification of constructs of costal chondrocyte origin clearly shows that chondrocytes from different tissue sources are not identical and retain distinct characteristics and that these specific cells are inappropriate for use in engineering a flexible ear model.