The anatomy and application of the postauricular fascia flap in auricular reconstruction for congenital microtia

Using Auricular Cartilage-fascia Composite Tissue Free Grafting Technique to Improve Cartilage Survival Outcomes

OBJECTIVES

Auricular cartilage graft has a wide range of applications in plastic and reconstructive surgery. However, there is still a risk of absorption of the grafts over time. Intrinsic postauricular fascia (IPF) with a rich vascular network may play an important role in the nutrition and repair of auricular cartilage. This study aimed to investigate the effect of IPF on the survival viability of free auricular cartilage grafts.

METHODS

24 auricular cartilages were obtained from 6 New Zealand white rabbits which were divided into the cartilage-fascia composite graft group (FC group, n=12) and the cartilage without fascia group (C group, n=12). Two groups of cartilage were implanted into each side of the subcutaneous pocket of the rabbit's dorsum. The rabbits were sacrificed after 3 months and all cartilage grafts were obtained. Macroscopic observation, histopathological staining, and biomechanical testing were performed on all specimens.

RESULTS

There were significant differences between the 2 groups regarding proliferating chondrocytes, apoptotic chondrocytes, vascularization, and matrix collagen. Compared to the auricular cartilage grafts without fascia, the auricular cartilage-fascia composite grafts had more neovascularization, proliferative chondrocytes, and type II collagen, with a homogeneous cartilage matrix and no obvious areas of heterogeneous staining. Young's modulus and ultimate tensile strength of cartilage were reduced in both groups compared to pretransplantation, but the composite graft group was superior to the fascia-free group.

CONCLUSIONS

Auricular cartilage-fascial composite tissue free graft could improve cartilage survival outcomes with higher viability and mechanical properties.

Reconstructive Techniques in Pediatric Congenital Microtia: A Systematic Review and Meta-analysis

Autografts and allografts are commonly used in microtia reconstruction. We aimed to systematically review and compare these reconstructive materials in pediatric congenital microtia reconstruction. A systematic review of the literature was performed. MEDLINE, Embase, PubMed, Web of Science, and CINAHL databases were searched for original studies on congenital microtia reconstruction in pediatric patients since database inception to 2021. Microtia grade was stratified as high or low. Meta-analysis of pooled proportions and continuous variables was performed using inverse variance weighting with a random effects model to compare between the autograft and allograft groups. Sixty-eight studies with a total of 5,546 patients used autografts (n = 5,382) or alloplastic implants (n = 164). Four other studies used prosthesis, cadaveric homografts, or tissue engineering. The allograft group was on average younger than the autograft group (8.4 vs. 11.1 years). There were no syndromic patients in the allograft group, compared to 43% in the autograft group. Patients treated with allografts had higher microtia grade than those treated with autograft (98 vs. 72%). Autografts were more commonly utilized by plastic surgeons and allografts by otolaryngologists (95 vs. 38%). No autografts and 41% of allografts were done concurrently with atresiaplasty or bone conduction implant. Satisfaction rates were similarly high (>90%) with similar complication rates (<10%). Microtia reconstruction using autografts and allografts had similar satisfaction and complication rates. Allografts were preferred for younger patients and concurrent hearing restoration. Further large-scale studies are required to evaluate the long-term efficacy of these reconstructive techniques.

Combining bioengineered human skin with bioprinted cartilage for ear reconstruction

Microtia is a congenital disorder that manifests as a malformation of the external ear leading to psychosocial problems in affected children. Here, we present a tissue-engineered treatment approach based on a bioprinted autologous auricular cartilage construct (EarCartilage) combined with a bioengineered human pigmented and prevascularized dermo-epidermal skin substitute (EarSkin) tested in immunocompromised rats. We confirmed that human-engineered blood capillaries of EarSkin connected to the recipient's vasculature within 1 week, enabling rapid blood perfusion and epidermal maturation. Bioengineered EarSkin displayed a stratified epidermis containing mature keratinocytes and melanocytes. The latter resided within the basal layer of the epidermis and efficiently restored the skin color. Further, in vivo tests demonstrated favorable mechanical stability of EarCartilage along with enhanced extracellular matrix deposition. In conclusion, EarCartilage combined with EarSkin represents a novel approach for the treatment of microtia with the potential to circumvent existing limitations and improve the aesthetic outcome of microtia reconstruction.

Long-term aesthetics, patient-reported outcomes, and auricular sensitivity after microtia reconstruction: A systematic review

BACKGROUND

Auricular reconstruction for microtia is most frequently performed using autologous costal cartilage (ACC) or porous polyethylene (PPE) implants. Short-term results are generally promising, but long-term results remain unclear. Long-term outcomes were explored in this systematic review, and minimal reporting criteria were suggested for future original data studies.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included if postsurgical follow-up was at least 1 year. Outcome reporting was split into separate publications, and results on complications were reported previously. This publication focused on long-term aesthetic, patient-reported, and sensitivity outcomes.

RESULTS

Forty-one publications reported on these outcomes. Both materials led to aesthetically pleasing results and high rates of patient satisfaction. ACC frameworks grew similarly to contralateral ears, and the anterior surface of auricles regained sensitivity. Furthermore, postoperative health-related quality of life (HRQoL) outcomes were generally good. Data synthesis was limited due to considerable variability between studies and poor study quality. No conclusions could be drawn on the superiority of either method due to the lack of comparative analyses.

CONCLUSION

Future studies should minimally report (1) surgical efficacy measured using the tool provided in the UK Care Standards for the Management of Patients with Microtia and Atresia; (2) complications including framework extrusion or exposure, graft loss, framework resorption, wire exposure and scalp/auricular scar complications and (3) HRQoL before and after treatment using the EAR-Q patient-reported outcome measure (PROM).

Long-term complications of microtia reconstruction: A systematic review

BACKGROUND

Microtia is a rare disorder characterized by malformation or even complete absence of the auricle. Reconstruction is often performed using autologous costal cartilage (ACC) or porous polyethylene implants (PPE). However, the long-term outcomes of both methods are unclear.

OBJECTIVE

This systematic review aimed to analyze long-term complications and suggest minimal reporting criteria for future original data studies.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included provided that the follow-up period was at least one year. This publication focused on long-term complications reported in patients with a postoperative follow-up period of at least one year.

RESULTS

Twenty-nine publications reported on complications during long-term follow-up. Overall long-term complication rates were not reported. The incidence of individual complications during long-term follow-up was less than 10% after ACC reconstruction and less than 15% in PPE reconstruction. Framework resorption and wire exposure were reported even after an extended follow-up of more than five years after ACC reconstruction, while reports on the extended long-term results of PPE reconstruction are limited. Data synthesis was limited due to heterogeneity and poor study quality.

CONCLUSIONS

Future studies should report on long-term complications including framework exposure or extrusion, graft loss, framework resorption, wire exposure and scalp and auricular scar complications. We recommend a surgical follow-up of at least five years.

Repair Exposure of the Postauricular Tissue Expander Using the Modified Brent Method: A 7-Year Experience

OBJECTIVES

Ear reconstruction is a challenging surgery for the complicated conditions in patients with microtia. The tissue expansion techniques were necessary and relatively safe for patients with insufficient soft tissue. However, complications such as necrosis of expanded flap and exposure of tissue expander limited the popularization of this method. This study described the use of modified Brent method to handle the exposure of the postauricular tissue expander.

METHODS

From January 2013 to December 2019, 27 ear reconstruction patients with trauma or necrosis on an expanded skin flap and subsequent exposure of tissue expander were treated with modified Brent method, which consisted of 3 stages: removal of the expander, tension-free closure of wound, and framework fabrication; elevation of reconstructed ear; lobule rotation; and minor modification.

RESULTS

Fifty-six percent of exposures occurred in the lower pole of the tissue expander. Exposure usually occurred 54.5 days after implantation. The majority of reconstructed ears had a satisfactory appearance and showed relatively stable outcomes. Only one case of cartilage exposure required revision surgery and was repaired by the temporoparietal fascia.

CONCLUSION

With reasonable distribution of expanded flap, prolonged interval, and sutures under tension-free conditions, complications like the occurrence of trauma or necrosis-induced exposure of tissue expander can be repaired efficiently by a staging modified Brent method.

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications

Background

Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances.

Methods

The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed.

Results

A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction.

Conclusions

Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

A novel two-stage strategy combing tissue expansion and Nagata`s technique for total auricular reconstruction

BACKGROUND

This study was performed to explore the clinical application of the Nagata's technique for combing tissue expansion in auricular reconstruction.

METHODS

The auricular reconstruction was performed in two surgical stages. At the first stage, an 80 ml expander was inserted in the mastoid region after preoperative evaluation. After a gradual expansion period and nearly 2-month rest time, the flap achieved the appropriate area and thickness. At the second stage, the expander was removed and a three-layer cartilage framework was inserted into the pocket through a Y-shaped lobule incision, and the earlobe and tragus were rebuild simultaneously.

RESULTS

From 2012 to 2016, 104 microtia patients underwent auricular reconstruction with this method in our hospital. Patients were followed up for between 6 months and 2 years. Ninety-six patients and their families were satisfied with the results, especially the clear outline, appropriate color, good projection, and the symmetry of bilateral ears. Complications of ischemic necrosis of the distal earlobe and skin of the concha cavity occurred in two cases, hematoma after the first stage occurred in two cases, and four patients needed further restorations.

CONCLUSIONS

A novel two-stage strategy combing tissue expansion and Nagata's technique is an effective and efficient technique for auricular reconstruction with satisfying medium-term results.

Incision and flap design during total auricular reconstruction using a 2-stage strategy

Background

Total auricular reconstruction is a challenge for plastic surgeons. Expanded flap method and Nagata’s method with autologous costal cartilage are two leading techniques for ear reconstruction. And a two-stage strategy of expanded flap method received attention. In the present study, we report the incision and flap design of this strategy.

Methods

In the first stage, an 80 mL kidney-shaped expander was inserted in the mastoid region with the larger pole superiorly. The expander pocket was dissected subcutaneously in the scalp area and subfascially in the lower third region. In the second stage, the expander was removed from a Y-shaped lobule incision on the remanent ear. Then the remnant ear was separated into three flaps: the posterior skin flap, anterior skin flap, and lobule flap. When the framework was fabricated, the base frame and the underlying pad, which enhanced the projection, were fixed together as a whole to provide a more prominent appearance. The framework was totally wrapped into the expanded single flap without free skin grafting. Lobule transposition and tragus construction were performed simultaneously instead of a third-stage surgery. The recipient bed of rotated lobule was resected only to the epidermal layer and the subcutaneous layer was preserved to avoid central necrosis.

Results

A total of 21 patients received this strategy to reconstruct ear. With 3 months to 1.5 years of follow-up, 19 patients (90.5%) were satisfied with the reconstructed ears. 3 patients (14.3%) required further modification of reconstructed ear. No serious complications occurred during the procedures.

Conclusions

With a Y-shaped incision, three-flap design of remanent ear and lobule rotation to an epidermal-removal area, tissue expander removal and modification of remanent ear can be performed effectively to avoid necrosis and an extra operation.

Complications of tissue expansion in the head and neck

BACKGROUND

The authors aim to present a comprehensive review detailing the present state of evidence with regard to complications following tissue expansion in the head and neck.

METHODS

A systematic literature search was conducted to identify all studies reporting complications of tissue expansion in the head and neck between 2000 and 2019. Subgroup comparisons based on expander locations and planes were conducted.

RESULTS

A total of 7058 patients were included. Tissue expansion was associated with an overall complication rate of 8.73% (616/7058). The most common complications were extrusion (207/7009; 3.0%) and hematoma (200/7009; 2.9%). Overall complications were highest in the scalp (65/238; 27.3%) and lowest in the mastoid (347/5688; 6.1%). Complications were more common with expansion in the non-subcutaneous plane (63/590; 10.7%).

CONCLUSION

In the absence of large clinical trials, systematic reviews such as these can help inform clinical guidelines and provide practitioners with an evidence-based reference to improve informed consent.

Dorsal Augmentation with Diced Conchal Cartilage Wrapped in Retroauricular Fascia

BACKGROUND

Dorsal augmentation is of primary importance to shape an ideal nose. Although costal cartilage is still used for this purpose, diced cartilage grafts wrapped in autogenous fascia became more and more popular in recent decades. In this paper, the authors report their experience with a new combination made by diced conchal cartilage wrapped in retroauricular fascia in primary and secondary cases.

METHODS

The clinical records of the first 19 patients to undergo dorsal augmentation with this technique were reviewed. The entire concha has been harvested and, once diced, wrapped in a sleeve of retroauricular fascia obtained using the same incision. Quilting reabsorbable sutures closed the mastoid dead space and prevented the risk of hematoma. The graft has been used in all the cases through a closed approach.

CONCLUSION

The use of diced cartilage is nowadays considered one of the best options among the available procedures for dorsal augmentation. Diced conchal cartilage wrapped in posterior auricular fascial graft is a new, simple and safe procedure that eliminates the necessity of a secondary donor site (temple or thorax), speeds up the operation and leaves a well-concealed scar behind the ear. Its main disadvantages toward costal diced cartilage wrapped in rectus abdominis fascia are the minor quantity of cartilage that can be obtained, even in case of bilateral harvest, and compared to temporal fascia a longer postoperative swelling (6-8 weeks).

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 .

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.

Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty

Over the last 100 years, more than 200 different methods have been described to correct prominent ear deformity. These techniques revolved around various combinations of postauricular incision, cartilage scoring, and strategic suture placement to reapproximate the antihelical fold and correct angular deformity. In the last two decades, fascial flap techniques have become prominent in otoplasty. This article gives a comprehensive review of the different surgical techniques employed to construct fascial flaps and their contributions to otoplasty.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

NO LEVEL ASSIGNED

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

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

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

The Versatile Posterior Auricular Fascia in Secondary Rhinoplasty Procedures

BACKGROUND

Secondary rhinoplasty often involves the addition of autogenous graft material to add volume, structure, support and to camouflage cartilage and bone grafts. A variety of fascias have been used to camouflage, wrap and give "fill" in secondary rhinoplasty. The posterior auricular fascia is a source of material ideal for such purposes, and its quantity, anatomical structure and ease of harvest with minimal donor site morbidity make it a versatile and attractive autogenous graft.

METHODS

The clinical records of patients receiving autogenous posterior auricular fascial grafts were reviewed. There were two main uses of this graft material, one was to cover the tip reconstruction in secondary rhinoplasties under thin tip skin. This is a camouflage graft. The second use is for fill and augmentation, especially for the nasal dorsum and as an interpostitional graft between the dorsum and the tip.

CONCLUSION

The posterior auricular fascial graft has many potential uses in secondary rhinoplasties and is readily harvested as a generous graft concurrent to conchal cartilage harvest and with a concealed scar behind the ear.

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 .

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.

Anatomical and Clinical Study of the Posterior Auricular Artery Angiosome: In Search of a Rescue Tool for Ear Reconstruction

Background:

The retroauricular tissues have been used for a long time for ear reconstruction, but the anatomical bases of flaps of this region are not completely clear. The aim of this study was to estimate blood supply area and location of this on the skin and fascia retroauricular dependent of posterior auricular artery (PAA) to establish safe margins to design flaps for auricular reconstruction.

Methods:

Dissection under magnification (×3.5) of the PAA through a cervical approach; injection of methylmethacrylate in the PAA as a staining technique; retroauricular approach to identify the territory of irrigation of PAA in the retroauricular skin and fascia; measuring and location of the stained area; and report of 2 cases of ear reconstruction with fasciocutaneous and fascia flaps based on PAA, designed according to the anatomical study.

Results:

In a sample of 10 cadaveric specimens, the PAA irrigated an area of the retroauricular skin and fascia of 10.7 cm length × 7.07 cm wide equivalent to 60.44 cm² (95% CI, 37.07–83.81), with a distribution posterior to external auditory canal of 7.15 cm (95% CI, 5.53–8.77) and posterior to the helix insertion of 6.12 cm (95% CI, 4.89–7.35). In the 2 patients treated with fascia and fasciocutaneous flaps based on the PAA, these were good options for ear reconstruction.

Conclusion:

A fascia or fasciocutaneous flap from the retroauricular region based on PAA within the dimensions and location found in this study will be a safe option for reconstruction of the ear.

Reconstructive Surgery of Auricular Defects: An Overview

Context:

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

Evidence Acquisition:

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

Results:

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

Conclusions:

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

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.

Implant double tissue expanders superposingly in mastoid region for total ear reconstruction without skin grafts

OBJECTIVE

To present our clinical experience in using two skin soft-tissue expanders implanted superposingly in the mastoid region and Medpor ear framework for congenital microtia reconstruction.

METHODS AND MATERIALS

The process of our technique is divided into three stages. In the first surgical stage, a 50 cm(3) and 80 cm(3) kidney-shaped expander is implanted under the fatty layer in mastoid region. Overlay the big expander on the small one. After the first surgery stage they are inflated alternately. In the second surgical stage, we remove two skin soft-tissue expanders and fix the Medpor ear framework to the fascial tissue which is covered by the expanded skin flap wholly without application of fascial flap. In the third stage, we perform the transposition of the auricular lobule to the designated position, construction of the tragus and refinement the new reconstructed ear. From January 2009 to December 2010, 27 patients were treated by this method of total ear reconstruction.

RESULTS

27 patients acquired symmetrical, subtle contour, prominent reconstructed auricles. The new reconstructed ear had a good contour and its skin color and texture were nearly the same as the normal surrounding skin. The postauricular sulcus was stable and satisfactory. The postoperative follow-up time ranged from 1 to 3 years. The expanded skin flap took well without necrosis. Exposure of the skin expander occurred in 2 patients (7.4%). The Medpor ear framework was extrused in one patient (3.7%). In addition, the hematoma was observed in 3 patients (11.1%). No other severe complications happened.

CONCLUSION

Overlying implantation of two skin-soft skin expanders solves the problem of insufficient amount of the skin flap, avoids postauricular skin grafting, simplifies the surgical procedure and shortens the operation time significantly.

Total auricular reconstruction without skin grafting

Successful ear reconstruction depends on two factors: an ear framework and the skin covering the framework. However, the relative deficiency of skin for coverage of the cartilage framework remains an issue. This new method for total auricular reconstruction is a three-stage operation and involves the use of two tissue expanders. First, two skin expanders are implanted, one underneath the scalp and the other sited behind the microtic ear. At the second stage, after lobule transposition, the two expanded skin flaps (upper and lower) and mastoid fascial flap are raised. At the same time, the autogenous rib cartilage is harvested and the framework constructed. The cartilage framework is then anchored between the upper expanded skin flap and the fascial flap with its inferior pole inserted into the rotated earlobe. The upper expanded skin flap covers the whole anterior surface of the framework and drapes over the margins of the fascial flap, which wrap the framework from beneath. The raw surface of fascial flap is covered with the lower expanded skin flap. The formation of a pseudomeatus and tragus is performed at the third stage. Deficiency of skin is the major problem encountered with the other conventional methods. Our innovations using two tissue expanders in combination with an autogenous rib cartilage framework eliminate this problem completely.

Post-traumatic ear reconstruction using postauricular fascial flap combined with expanded skin flap

INTRODUCTION

Post-traumatic ear reconstruction still remains a great challenge for plastic surgeons. In this article, we present the technique of post-traumatic ear reconstruction using a postauricular fascial flap combined with an expanded skin flap.

METHODS

From May 2007 to June 2009, 91 cases of post-traumatic ear defect were treated using a postauricular fascial flap combined with an expanded skin flap. Surgical procedure included postauricular-skin-flap expansion, removal of tissue expander, autogenous rib-cartilage-framework implantation, postauricular-fascial-flap lifting and split-thickness free-skin grafting.

RESULTS

With a follow-up duration of 6 months to 1 year, the described technique provided a nice final result, and the reconstructed ears showed good match in size, shape, colour and location to the contralateral normal ear.

CONCLUSION

Post-traumatic ear reconstruction using a postauricular fascial flap combined with an expanded skin flap is an ideal approach with good final results.