Firm elevation of the reconstructed auricle with a retroauricular fascial flap wrapping an EH (a mixture of epoxide acrylate malelic and hydroxyapatite) composite wedge

Usefulness of resorbable plate in auricular elevation in two-stage microtia reconstruction

BACKGROUND

Achieving a well-reconstructed retroauricular sulcus with satisfactory projection and a sufficiently deep retroauricular sulcus is important and at the same time challenging. The selection of the support material is crucial to obtain a sustainable, deep sulcus. The costal cartilage is the conventional material of choice. However, risk of slippage of inserted cartilage and donor site morbidity exists. Resorbable plates are durable, easy to secure and can be easily modified into desired shape. The current study aimed to demonstrate the effectiveness of using a resorbable plate for auricular elevation.

METHODS

Retrospective review of patients who received auricular elevation with resorbable plates from December 2020 to October 2022 was performed. Patients demographics, number of inserted plates and screws, postoperative complication were analyzed.

RESULTS

Of 65 patients with microtia who underwent auricular reconstruction, resorbable plates were applied to 12 patients. Mean follow up period was 198 (range, 86-360) days. Auricular elevation was performed with one plate at cavum conchae and remnant rib cartilage at the helix in 10 patients (87)%. Two patients had resorbable plate as support material at the both sites. Regarding postoperative complications, there were no hematoma, seroma, plate exposure or plate fracture. Two patients suffered wound problems. One patient recovered only with conservative management. The other healed completely after debridement and intravenous antibiotics administration without undesired change of shape of ear.

CONCLUSIONS

We suggest using resorbable plates as an ideal support material, as it can provide firm support to achieve appropriate depth of sulcus without excessive bulk.

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.

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

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

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.

Alloplastic Auricular Reconstruction: Review of Implant Types, Adverse Events, and Aesthetic Outcomes

IMPORTANCE

Alloplastic implants have been applied successfully in reconstruction of the external ear, either for congenital microtia or traumatic injury.

OBJECTIVE

The objective of this study was to conduct a comprehensive systematic review of alloplastic implant materials utilized in the reconstruction of the external ear stratified by indication, specific implant type, postoperative complications, and aesthetic outcomes.

EVIDENCE REVIEW

A comprehensive systematic review of published literature on alloplastic external ear reconstruction data was conducted utilizing Medline/PubMed database without timeframe limitations in June 2019. Articles were stratified by (1) indication (microtia versus trauma reconstruction) and (2) implant material type. All postoperative complications were recorded and comparatively analyzed between implant types. Aesthetic outcomes were also identified and compared between implant types.

FINDINGS

A total of 755 patients (14 case series; follow-up range = 3 months--10 years) met the criteria for this study. Overall complication rate was 12.05% across all indications and materials used. The most frequent complications reported were graft exposure (7.8%), graft explantation (1.72%), and wound dehiscence (0.8%). Of the patients requiring graft explantation (n = 13), 7 (53.85%) received Medpor implants, and the other 6 (46.15%) were identified in silicone implants. Infection was only reported in Medpor implants. The overall rate of an acceptable aesthetic outcome was 99.34%.

CONCLUSIONS AND RELEVANCE

Alloplastic implants are a reliable means of achieving an acceptable complication profile in external ear reconstruction. While there was an overall high rate of acceptable aesthetic outcomes, the studies evaluated in this systematic review differed in their criteria for final evaluation of aesthetic outcomes.

Hyperbaric Oxygen Therapy: An Effective and Noninvasive Therapy for Complications of Ear Reconstruction

OBJECTIVES

Although complications of ear reconstruction are rare, common salvage procedures involve invasive surgery, and final outcomes can be uncertain. In this study, the authors have successfully applied noninvasive hyperbaric oxygen therapy (HBOT) as an adjunct treatment for the complications of ear reconstruction.

METHODS

During a 2-year period, 42 patients with complications of ear reconstruction were included in the study. All patients received HBOT twice a day for 2 to 3 courses, and each course lasted for 10 days.

RESULTS

Patients suffered from 4 different complications: hematoma (15), flap venous congestion (13), frame exposure (10), and postoperative infection (4). After HBOT, 41 patients recovered without a need for additional surgical repair. One patient developed an infection and required further treatment.

CONCLUSIONS

Combined with traditional salvage procedures, HBOT effectively treated various complications of ear reconstruction.

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 .

Splinting After Ear Reconstruction

BACKGROUND

Long-term postoperative splinting plays a role in the prevention of contracture of the grafted skin after a second-stage ear reconstruction. The scar retraction could lead to an unfavorable aesthetic outcome. Splinting could play a role to overcome or prevent the loss of projection and the obliteration of the sulcus.

MATERIAL AND METHODS

We have defined the characteristics of an ideal long-term splint and present a stepwise clinical protocol for the fabrication of an ethylene-vinyl acetate splint. The splint was applied to all patients included in a prospective study on the postoperative splinting regime. Ethylene-vinyl acetate has proved its safety and longevity in dental prosthetics.

CONCLUSIONS

Patient compliance was optimal, and no allergic reactions, pressure sores, or skin necrosis were reported. The splint is self-retaining and light weight. Because of its transparent color, it can be easily camouflaged. A stepwise clinical protocol for the fabrication of a low-cost patient-specific ear splint is presented.

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.

Application of Computer-Assisted Design and Manufacturing-Fabricated Artificial Bone in the Reconstruction of Craniofacial Bone Defects

PURPOSE

The purpose of this study was to evaluate the clinical application of individual craniofacial bone fabrications using computer-assisted design (CAD)-computer-assisted manufacturing technology for the reconstruction of craniofacial bone defects.

MATERIALS AND METHODS

A total of 8 patients diagnosed with craniofacial bone defects were enrolled in this study between May 2007 and August 2010. After computed tomography scans were obtained, the patients were fitted with artificial bone that was created using CAD software, rapid prototyping technology, and epoxy-methyl acrylate resin and hydroxyapatite materials. The fabrication was fixed to the defect area with titanium screws, and soft tissue defects were repaired if necessary.

RESULTS

The fabrications were precisely fixed to the defect areas, and all wounds healed well without any serious complications except for 1 case with intraoral incision dehiscence, which required further treatment. Postoperative curative effects were retrospectively observed after 6 to 48 months, acceptable anatomic and cosmetic outcomes were obtained, and no rejections or other complications occurred.

CONCLUSIONS

The use of CAD-computer-assisted manufacturing technology-assisted epoxy-methyl acrylate resin and hydroxyapatite composite artificial bone to treat patients with craniofacial bone defects could enable the precise reconstruction of these defects and obtain good anatomic and cosmetic outcomes.

Rib Cartilage Assessment Relative to the Healthy Ear in Young Children with Microtia Guiding Operative Timing

BACKGROUND

The optimal age at which to initiate for auricular reconstruction is controversial. Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction. We developed a method to guide the timing of auricular reconstruction in children with microtia ranging in age from 5 to 10 years.

METHODS

Rib cartilage and the healthy ear were assessed using low-dose multi-slice computed tomography. The lengths of the eighth rib cartilage and the helix of the healthy ear (from the helical crus to the joint of the helix and the earlobe) were measured. Surgery was performed when the two lengths were approximately equal.

RESULTS

The preoperative eighth rib measurements significantly correlated with the intraoperative measurements (P < 0.05). From 5 to 10 years of age, eighth rib growth was not linear. In 76 (62.8%) of 121 patients, the eighth rib length was approximately equal to the helix length in the healthy ear; satisfactory outcomes were achieved in these patients. In 18 (14.9%) patients, the eighth rib was slightly shorter than the helix, helix fabrication was accomplished by adjusting the length of the helical crus of stent, and satisfactory outcomes were also achieved. Acceptable outcomes were achieved in 17 (14.0%) patients in whom helix fabrication was accomplished by cartilage splicing. In 9 (7.4%) patients with insufficient rib cartilage length, the operation was delayed. In one (0.8%) patient with insufficient rib cartilage length, which left no cartilage for helix splicing, the result was unsatisfactory.

CONCLUSIONS

Eighth rib cartilage growth is variable. Rib cartilage assessment relative to the healthy ear can guide auricular reconstruction and personalize treatment in young patients with microtia.

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.

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.

Onlay rib bone graft in elevation of reconstructed auricle: 17 years of experience

Background

A cartilage wedge block and covering flap are standard procedures for firm elevation of the ear in microtia correction. However, using costal cartilage for elevation of the reconstructed auricle can be insufficient, and the fixed cartilage wedge block may be absorbed or may slip out. Furthermore, elevating covering flaps is time-consuming and uses up fascia, a potential source of reconstruction material. Therefore, we propose an innovative method using autologous onlay rib bone graft for auricular elevation of microtia.

Methods

From February 1995 to August 2012, 77 patients received a first stage operation with a rib cartilage framework graft. In the second stage operation, a small full thickness of rib bone was harvested through the previous donor scar. The bihalved rib bone was inserted into the subperiosteal pocket beneath the cartilage framework.

Results

The follow-up time ranged from 1 month to 17 years, with a mean of 3 years. All of the patients sustained the elevation of their ears very well during the follow-up period. Donor site problems, except for hypertrophic scars, were not observed. Surgery-related complications, specifically skin necrosis, infection, or hematoma, occurred in 4 cases.

Conclusions

Onlay rib bone graft used to elevate the reconstructed auricle is a more anatomically appropriate material than cartilage, due to the bone-to-bone contact between the bone graft and the temporal bone. Postoperative minor correction of the elevation degree is straightforward and the skin graft survives better. Therefore, reconstructed auricle elevation using onlay rib bone graft is a useful and valuable method.

Reconstruction of fronto-orbital and nasal defects with compound epoxied maleic acrylate/hydroxyapatite implant prefabricated with a computer design program

The repair of fronto-orbital nasal bone defects may be a troublesome problem to plastic surgeons. This report aims to present the results of reconstruction of fronto-orbital nasal bone defects with the prefabrication of epoxied maleic acrylate/hydroxyapatite compound (EH compound) using 3-dimensional (3D) imaging data and computer-assisted manufacturing techniques, sometimes combined with autogenous bone to repair nasal defect. Helical computed tomography data were used to create a 3D model of the patient's skull. On the basis of these data, the individual shape of the implant was created by a computer-aided design/computer-aided manufacturing program. A rapid prototyping system was applied for production of the physical models. A total of 12 patients with traumatic fronto-orbital nasal defects were included in this study. The patients followed up for 1 to 24 months. The satisfactory results, such as excellent symmetry, stability, and normal fronto-orbital contours were obtained for all patients. The operating time was short without any complications. The depression of the region of fronto-orbital nasal bone defects always achieved an attractive or satisfactory prominence that was in balance and harmony with other facial features of all the patients. This method allows accurate fabrication of the implant. It improves the surgical techniques and reduces the risk of a second intervention, with improved aesthetic outcomes.