Total auricular reconstruction without skin grafting

Comprehensive analysis of donor-site chest deformities after autologous costal cartilage microtia reconstruction: A systematic review

BACKGROUND

Autologous costal cartilage has gained widespread acceptance as an important material for ear reconstruction in patients with microtia. Despite its recognition as being "worth the trade-off," attention should be directed toward donor-site deformities. This systematic review focused on existing English literature related to microtia reconstruction and aimed to reveal the incidence of chest wall deformities and assess the effectiveness of the various proposed surgical techniques aimed at reducing donor-site morbidities.

METHODS

A comprehensive search was conducted on Pubmed and OVID using the keywords "microtia," and "chest deformity" or "rib harvest." Articles were screened based on predefined inclusion and exclusion criteria. Data acquisition encompassed patient demographics, employed surgical techniques, methods for evaluating chest deformity, and incidence of associated complications.

RESULTS

Among the 362 identified articles, 21 met the inclusion criteria. A total of 2600 cases involving 2433 patients with microtia were analyzed in this review. Perichondrium preservation during cartilage harvesting led to a significant reduction in chest deformities. However, the wide incidence range (0% to 50%) and the lack of specific assessment methods suggested potential underestimation. Computed tomography revealed reduced chest wall growth in the transverse and sagittal directions, resulting in decreased thoracic area. Innovative surgical techniques have shown promising results in reducing chest deformities.

CONCLUSIONS

Although a quantitative analysis was not feasible, objective evidence of deformities was established through computed tomography scans. This analysis highlighted the need for dedicated studies with larger sample sizes to further advance our understanding of chest wall deformities in microtia reconstruction.

Application of System Nursing in the Prevention of Postoperative Nonstructural Scoliosis in Patients With Ear Reconstruction

OBJECTIVE

To evaluate whether early systematic nursing can reduce the occurrence of postoperative nonstructural scoliosis in patients undergoing ear reconstruction.

METHODS

A total of 136 patients with congenital microtia who underwent ear reconstruction surgery at the Department of Plastic Surgery, Chinese Academy of Medical Sciences from, January 2022 to July 2022 were included as study subjects. They were randomly divided into a routine nursing group and a systematic nursing group. After preoperative and postoperative education, as well as continuous follow-up intervention after surgery, spinal CT three-dimensional imaging examination was performed 6 months later to measure the Cobb angle and observe the occurrence of spinal scoliosis.

RESULTS

Compared with the routine nursing group, the incidence and severity of postoperative nonstructural scoliosis were significantly reduced in patients who received systematic nursing.

CONCLUSIONS

Systematic nursing intervention for patients undergoing ear reconstruction can help prevent the occurrence of postoperative nonstructural scoliosis and has a positive effect on improving patient prognosis. It is worth promoting in clinical treatment.

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.

Comparison of Auricle Reconstruction Using Tissue Expanders With Skin Grafting and Auricle Reconstruction Using Tissue Expanders Without Skin Grafting: A Single-Arm Meta-Analysis

OBJECTIVE

The authors conducted this meta-analysis to compare the efficacy of auricle reconstruction using tissue expanders with skin grafting and auricle reconstruction using tissue expanders without skin grafting by comparing the 6 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

By comparison, the authors found that, the satisfaction rate, the incidence of postoperative hematoma, the incidence of postoperative incision infection, and the incidence of cartilage framework exposure of patients with auricle reconstruction using tissue expanders with skin grafting were all lower than those with auricle reconstruction using tissue expanders without skin grafting. However, the incidence of postoperative skin necrosis, the incidence of leakage or exposure of expanders in patients with auricle reconstruction using tissue expanders with skin grafting were all higher than those with auricle reconstruction using tissue expanders without skin grafting.

CONCLUSIONS

Auricle reconstruction using tissue expanders with skin grafting has advantages in reducing the incidence of postoperative hematoma, the incidence of postoperative incision infection, and the incidence of cartilage framework exposure. Auricle reconstruction using tissue expanders without skin grafting has advantages in improving the satisfaction rate, reducing the incidence of postoperative skin necrosis, and the incidence of leakage or exposure of expanders. From the comparison of specific data, there is no significant difference in the treatment effect between the 2 surgical methods.

Biofabrication of a shape-stable auricular structure for the reconstruction of ear deformities

Bioengineering of the human auricle remains a significant challenge, where the complex and unique shape, the generation of high-quality neocartilage, and shape preservation are key factors. Future regenerative medicine–based approaches for auricular cartilage reconstruction will benefit from a smart combination of various strategies. Our approach to fabrication of an ear-shaped construct uses hybrid bioprinting techniques, a recently identified progenitor cell population, previously validated biomaterials, and a smart scaffold design. Specifically, we generated a 3D-printed polycaprolactone (PCL) scaffold via fused deposition modeling, photocrosslinked a human auricular cartilage progenitor cell–laden gelatin methacryloyl (gelMA) hydrogel within the scaffold, and cultured the bioengineered structure in vitro in chondrogenic media for 30 days. Our results show that the fabrication process maintains the viability and chondrogenic phenotype of the cells, that the compressive properties of the combined PCL and gelMA hybrid auricular constructs are similar to native auricular cartilage, and that biofabricated hybrid auricular structures exhibit excellent shape fidelity compared with the 3D digital model along with deposition of cartilage-like matrix in both peripheral and central areas of the auricular structure. Our strategy affords an anatomically enhanced auricular structure with appropriate mechanical properties, ensures adequate preservation of the auricular shape during a dynamic in vitro culture period, and enables chondrogenically potent progenitor cells to produce abundant cartilage-like matrix throughout the auricular construct. The combination of smart scaffold design with 3D bioprinting and cartilage progenitor cells holds promise for the development of clinically translatable regenerative medicine strategies for auricular reconstruction.

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First application of human auricular cartilage progenitor cells for bioprinting.

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Dual-printing of hybrid ear-shaped constructs with excellent shape fidelity over time.

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Strategy and design ensured adequate deposition of cartilage-like matrix throughout large auricular constructs.

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.

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.

[Improve the appearance of auriculocephalic angle in reconstructed auricular with skin flap of residual ear in patients with microtia of concha cavity]

Objective

To explore the reasonable utilization of residual ear tissue after total ear reconstruction with total expansion method in patients with microtia of concha cavity, in order to obtain the best appearance.

Methods

The clinical data of 150 patients with microtia of concha cavity between January 2012 and January 2017 were retrospectively analyzed. There were 92 males and 58 females, with an average age of 11.1 years (range, 6.5-35.0 years). The shallow upper auriculocephalic angle was found after the first stage expander embedding and the second stage total expansion, and the third stage auricular reconstruction was carried out 6-12 months later. The residual earlobe was transferred through Z-plasty to reconstruct the lobe. An arc incision was made to release and deepen the upper auriculocephalic angle. And then a skin flap pedicled on the upper part of the residual ear was formed and then transferred to cover the wound on the auriculocephalic angle. The residual ear cartilage tissue flaps with subcutaneous tissue pedicle were inserted into the lacuna under the framework to increase the height of the scaffold. The remaining residual ear skin flaps were sutured to cover the wound of concha.

Results

A epidermis blister in diameter of 0.5 cm was found in 1 patient's flap at 7 days after operation, and healed after 2 weeks of dressing change. The other patients' flaps survived well. All the patients were followed up 6-12 months, with an average of 9.6 months. The auriculocephalic angle in the upper part of the reconstructed ear was obviously deepened, the height of the reconstructed ear was increased. The symmetry of the ears was better than before. The concha was not obviously contracted and the appearance of the reconstructed ear was satisfactory. The hair on the upper surface of the reconstructed ear decreased obviously, and the hairline around the ear moved up.

Conclusion

The transfer of the upper residual auricular skin flap and residual auricular cartilage in patients with microtia of concha cavity can not only deepen the auriculocephalic angle, but also increase the height of the upper framework. The symmetry between the reconstructed auricle and the normal auricle is better than before.

Accurate Measurements of the Skin Surface Area of the Healthy Auricle and Skin Deficiency in Microtia Patients

Background:

The limited cranial skin covering auricular implants is an important yet underrated factor in auricular reconstruction for both reconstruction surgery and tissue engineering strategies. We report exact measurements on skin deficiency in microtia patients and propose an accessible preoperative method for these measurements.

Methods:

Plaster ear models (n = 11; male:female = 2:1) of lobular-type microtia patients admitted to the University Medical Center Utrecht in The Netherlands were scanned using a micro-computed tomographic scanner or a cone-beam computed tomographic scanner. The resulting images were converted into mesh models from which the surface area could be calculated.

Results:

The mean total skin area of an adult-size healthy ear was 47.3 cm², with 49.0 cm² in men and 44.3 cm² in women. Microtia ears averaged 14.5 cm², with 15.6 cm² in men and 12.6 cm² in women. The amount of skin deficiency was 25.4 cm², with 26.7 cm² in men and 23.1 cm² in women.

Conclusions:

This study proposes a novel method to provide quantitative data on the skin surface area of the healthy adult auricle and the amount of skin deficiency in microtia patients. We demonstrate that the microtia ear has less than 50% of skin available compared with healthy ears. Limited skin availability in microtia patients can lead to healing problems after auricular reconstruction and poses a significant challenge in the development of tissue-engineered cartilage implants. The results of this study could be used to evaluate outcomes and investigate new techniques with regard to tissue-engineered auricular constructs.

Auricular reconstruction using a novel three-flap technique improves the auriculocephalic angle

BACKGROUND

Skin grafting is needed for traditional auricular reconstruction. As the skin grafts contract, the postoperative framework is distorted. This leads to a decrease in the auriculocephalic angle. The objective of this study was to test a new method to cover the reconstructive framework by using three skin flaps and a larger tissue expander than that normally used. This may reduce the distortion of the reconstructed ear and create a well-shaped auriculocephalic angle.

METHODS

A large expander was inserted in the postauricular mastoid area. Three expanded flaps were then created to cover the anterior and posterior frameworks, with separate mastoid coverage. By measuring the height and angle at three different points on the reconstructed ear and comparing them with the contralateral normal ear, a system for measuring the auriculocephalic angle was established.

RESULTS

The surface of the framework and the mastoid area were covered by three flaps developed from one large tissue expander. The appearance of the reconstructed ears was similar to that of the normal side by the patient's 6- to 12-month follow-up. The difference in the distance at the three points between the reconstructed and normal sides after the three-flap reconstruction was less than that following traditional reconstruction (p < 0.05). The variation in the angle measured at these three points in the three-flap group was also much smaller than that in the traditional group (p < 0.01).

CONCLUSIONS

The three-flap technique not only improves the appearance of the reconstructed ear, but helps shape a perfect auriculocephalic angle.

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

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

An Experimental Study of Auricular Reconstruction Using a Thin Porous Silastic Frame Assisted by Tissue Expansion: An Animal Study

BACKGROUND

In the 1960s, the silastic ear frame was used for auricular reconstruction. Most surgeons abandoned the use of the silastic ear frame in the 1980s because of the high incidence of exposure. In this study, we introduce the computer-aided design and manufacture of a thin, porous silastic auricle frame and investigate the possibility of auricular reconstruction using this frame assisted by tissue expansion.

METHODS

An adult male with average sized, normal ears was selected. A spiral CT scan was performed to obtain primitive data on his external ear. Mimics-8.1 and Geomagic studio-12 were used for 3D reconstruction and image processing. A thin, porous silastic auricle frame 1.4 mm in thickness was manufactured. A 50 ml kidney-shaped tissue expander was implanted between the panniculus carnosus and the deep fascia through an incision on the back of each of 10 New Zealand white rabbits. Each week the expander was inflated with 10 ml saline to a total of 160 m1. Maintenance of the expansion lasted for a month. The expander was then removed, and the silastic auricle frame was inserted into the pocket. The reconstructed ears were observed for 6 months postoperatively.

RESULTS

The reconstructed ears remained soft and flexible, with no deformation, contracture, or extrusion observed 6 months postoperatively. The scaphoid fossa, triangular fossa, cavum, helix, and antihelix remained defined.

CONCLUSIONS

The silastic frame, 1.4 mm in thickness manufactured by computer-aided design, stood up to the contraction of the overlying expanded flap. It is possible to be used for auricular reconstruction assisted by tissue expansion.

Auricular reconstruction using biofabrication-based tissue engineering strategies

Auricular malformations, which impose a significant social and psychological burden, are currently treated using ear prostheses, synthetic implants or autologous implants derived from rib cartilage. Advances in the field of regenerative medicine and biofabrication provide the possibility to engineer functional cartilage with intricate architectures and complex shapes using patient-derived or donor cells. However, the development of a successful auricular cartilage implant still faces a number of challenges. These challenges include the generation of a functional biochemical matrix, the fabrication of a customized anatomical shape, and maintenance of that shape. Biofabrication technologies may have the potential to overcome these challenges due to their ability to reproducibly deposit multiple materials in complex geometries in a highly controllable manner. This topical review summarizes this potential of biofabrication technologies for the generation of implants for auricular reconstruction. In particular, it aims to discuss how biofabrication technologies, although still in pre-clinical phase, could overcome the challenges of generating and maintaining the desired auricular shapes. Finally, remaining bottlenecks and future directions are discussed.

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.