A new strategy for total auricular reconstruction using prelamination of an extended retroauricular flap with tissue expansion

Strategies of Total Auricular Reconstruction for Patients With Poor Skin Coverage at the Mastoid Area

OBJECTIVE

Burns and injuries can lead to massive defects in the mastoid tissues, which increase the difficulty of ear reconstruction. It is crucial to choose an appropriate surgical method for these patients. Here, we introduce strategies for auricular reconstruction in patients without satisfactory mastoid tissues.

METHODS

From April 2020 to July 2021, 12 men and 4 women were admitted to our institution. Twelve patients were severely burned, 3 patients experienced car accidents, and 1 patient had a tumor on his ear. The temporoparietal fascia was used for ear reconstruction in 10 cases, and the upper arm flap was used in 6 cases. All of the ear frameworks were made of costal cartilage.

RESULTS

The location, size, and shape of both sides of the auricles were generally the same. Two patients needed further surgical repair because of cartilage exposure at the helix. All of the patients were satisfied with the outcome of the reconstructed ear.

CONCLUSION

For patients with ear deformity and poor skin coverage in the mastoid area, we can choose the temporoparietal fascia if the patient's available superficial temporal artery is longer than 10 cm. If not, we can choose the upper arm flap. The latter needs a five-stage operation, which is more time consuming and difficult than the former. Moreover, the expanded upper arm flap is thinner and has better elasticity than the temporoparietal fascia, so the shape of the reconstructed ear is better. We need to evaluate the condition of the affected tissue and choose the appropriate surgical method to achieve a good result.

Autologous Scar-Related Tissue Combined with Skin Grafting for Reconstructing Large Area Burn Scar

BACKGROUND

This study introduced a novel method to reconstruct large areas of scarring caused by burns via combining autologous scar-related tissue with spit-thickness skin grafting (ASTCS).

METHODS

25 patients underwent reconstruction after scar resection surgeries around the joints were analyzed between Jan 2012 and Jan 2018. Patient demographics and clinical parameters were collected, autologous scar-related tissue was modified to meshed structure, and the split-thickness skin was acquired from the scalp. The scar was resected and punched by a meshing machine with a thickness of 0.3-0.5 mm at a ratio of 1:1. The secondary wounds were covered by the epidermis from a donor site. The surgical areas were bandaged for 7-10 days before the first dressing change.

RESULTS

25 patients (mean [SD] age, 26.4 [18.8] years; 16 [64%] men) underwent wounds reconstructive operations due to scar resection were reviewed. Wound location of 9 (22%), 8 (19.5%), 9 (22%), 7 (17.1%) and 8 (19.5%) cases were reconstructed in axillary, hand and wrist, popliteal fossa, elbow and neck, respectively. 39 sites of transplanted tissues survived well, and 2 sites were cured after two weeks of dressing changes. Except the analysis of injury causes, nutritional status, wound area and hospital days, patients with scar deformities in joint areas achieved satisfactory function by assessing the Vancouver Burn Skin Score and the Barthel Index Scale Scores after 12-month follow-up.

CONCLUSIONS

Combining autologous scar-related tissue with skin grafting provided a novel method for treating large areas of burn scars with better functional outcomes.

Secondary surgery for the unsatisfactory auricle after auricular reconstruction

OBJECTIVES

Complications, including framework exposure, infections, and reconstructed auricle deformation, may occur after auricular reconstruction. However, reports on surgical methods for cases with unsatisfactory outcomes after auricular reconstruction using an autologous costal cartilage are insufficient. Herein, we summarized retreatment casesfor poor ear morphology in patients who had undergone auricular reconstruction in our department for 5 years and discussed other techniques.

METHODS

Between September 2014 and September 2019, 24 ears of 24 patients with poor morphology, unsatisfactory macroscopic characteristics and anatomical structures, and unsatisfactory outcomes of local repair after auricular reconstructive surgery were treated. Patients were divided into the following three groups: type 1 (9 ears), with intact and sufficient hairless skin in the mastoid region behind the reconstructed ear; type 2 (7 ears), with intact, but insufficient, hairless skin in the mastoid region behind the reconstructed ear; and type 3 (8 ears), with hairless skin in the mastoid region behind the reconstructed ear with impaired skin integrity.

RESULTS

Twenty-two (91.6%) patients successfully completed the surgical treatment and recovered well; one experienced delayed wound healing and another developed hypertrophic scarring at the incision site at 3 months postoperatively. All patients were followed for 0.5-4 (mean, 2.8) years. The macrostructure of the reconstructed ear post-revision was stable and significantly improved in terms of morphology and structure.

CONCLUSIONS

In patients with unsatisfactory outcomes after auricular reconstruction, the appropriate technique for the revision surgery should consider the local soft tissue conditions of the reconstructed ear to obtain satisfactory results.

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.

Ear Reconstruction with the Combination of Expanded Skin Flap and Medpor Framework: 20 Years of Experience in a Single Center

BACKGROUND

In ear reconstruction, the difficulty lies in reestablishing the ear's bionic form with adequate skin coverage and an appropriate framework. Skin expansion and a porous polyethylene (i.e., Medpor) framework are often used for ear reconstruction. However, a long-term review of the combined application of the expanded skin and Medpor framework has not been reported. This article reviews ear reconstruction combining these two factors over the past 20 years in the authors' center to summarize the surgical technique and analyze the postoperative results and complications.

METHODS

A retrospective review was performed that included all patients who underwent ear reconstruction with expanded skin and Medpor framework in the authors' center between 1998 and 2018.

RESULTS

A total of 68 patients with microtia who were admitted to the authors' center for surgical ear reconstruction were included, and 70 ears were reconstructed. Fifty-seven of the patients (83.82 percent) felt satisfied with their reconstructed ear, five patients (7.35 percent) were not satisfied with the reconstructed ear, and six patients (8.82 percent) had the frameworks removed. Fifteen patients (22.06 percent) developed complications, including framework exposure (13.24 percent), infection (4.41 percent), scar hypertrophy (4.41 percent), and hematoma (2.94 percent).

CONCLUSIONS

Framework exposure limits the combined application of expanded skin flap and Medpor framework when reconstructing the ear without additional fascial interposition. Using a temporoparietal fascia or postauricular fascia flap during the operation is effective to decrease the exposure rate; however, this complication cannot be completely avoided. Using postauricular fascia and skin graft may lead to scar hypertrophy; thus, these techniques should be used with caution.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Clinical efficacy of modified total auricular reconstruction technique by using reformative inflation method and remnant ear without skin grafting

Background

As one of the most widely used methods to treat microtia, the auricular reconstruction proposed by Zhuang may have several drawbacks. This study aimed to introduce a modified Zhuang's ear reconstruction technique by using a reformative inflation method and remnant ear to shorten therapy time and avoid skin grafting in a two-stage operation for patients with microtia.

Methods

A total of 124 patients with microtia were enrolled consecutively from 2014 to 2018. Among them, 66 patients underwent a modified Zhuang's method, and the remaining patients underwent Zhuang's method. The clinical and perioperative characteristics of patients, as well as complications and esthetic outcomes were analyzed.

Results

Compared with Zhuang's group, our modified Zhuang's group had better average esthetic scores according to two plastic surgeons [11.5 (IQR, 10.5-12.5) vs. 9.5 (IQR, 7.5-11.0), P<0.001], fewer hypertrophic scar cases [0% (n=0/66) vs. 10% (n=6/58), P = 0.024], shorter whole therapy duration [2.5 (IQR, 2.4-2.6) vs. 5.0 (IQR, 5.0-5.1) days, P<0.001] and shorter hospital duration after operation [5 (IQR, 5-6) vs. 6 (IQR, 5-6) days, P=0.013].

Conclusions

Our modified Zhuang's technique is a new method to treat microtia which results in a clear contour of the reconstructed ear and matching skin color, minimal scarring, and a short treatment time.

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.

Repair of damage to the skin flap during total auricular reconstruction with tissue expansion

INTRODUCTION

Auricular reconstruction with tissue expansion has been widely used in children with microtia. Base on the experience of using tissue expander, more patients have undergone a modified auricular reconstruction using a framework wrapped by expanded skin flap without fascial and skin graft transplantation. Skin damage is a common complication that may lead to serious outcomes, such as infection and distortion. Promptly repair is particularly important when using this modified technique. This work aims to record the site and other information on damage to the expanded skin flap, and to apply various salvage methods according to the site and stage.

METHODS

From January 2017 to September 2019, 170 patients who underwent total auricular reconstruction without fascial and skin graft were followed up. All patients who had skin damage received corresponding prompt treatment. Details on the site, occurrence time, and salvage methods were noted.

RESULTS

A total of 19 patients were found to have skin damage during the follow-up period. The defect size ranged from 10 mm² to 70 mm². Four patients had skin damage in the lower part of the skin flap combined with expander exposure. The second stage of auricular reconstruction was carried out immediately. Two patients had skin flap damage in anterior 1/3rd of the helix, seven in middle 1/3rd of the helix, four in posterior 1/3rd of the helix and two in the triangular fossa. Most of the skin damage occurred within 4-9 months after auricular reconstruction. According to the site and other factors, the expanded skin flap with the exposed cartilage was repaired using local skin flap, retroauricular skin flap, and retroauricular fascia. Patients were satisfied with the outcome of the repair. Additional skin damage and other complications were not observed after the repair operations.

CONCLUSION

Skin damage is a common complication, and it should receive more attention while applying this modified auricular reconstruction using tissue expansion. The site, occurrence time, and other information provide reference to improve the reconstruction without fascial or skin graft transplantation. Salvage methods, such as retroauricular skin flap and retroauricular fascia, have been treated as highly efficient backup methods and have achieved satisfying results.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE IV

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

Total Auricular Reconstruction Using a Single Extended Postauricular Flap Without Skin Grafting in Two Stages: Experiences of 106 Cases

BACKGROUND

Postauricular fascial flap with skin grafting is popular as a solution in total auricular reconstruction, which might result in visible scars and mismatched color, especially in Asian people. Other methods using an expanded postauricular flap to avoid skin grafting often require three or more operations, which increases suffering for patients. This work aims to introduce a modified technique for auricular reconstruction using a single expanded postauricular flap without skin grafting in a two-stage operation.

METHODS

An 80-ml kidney-shaped expander was implanted in the mastoid area as the first-stage operation after preoperative evaluation. After a gradual expansion period and a 2-month rest time, the flap achieved the appropriate size and thickness. In the second stage, a three-layer cartilage framework was fabricated and inserted into the pocket through an incision at the remnant ear, and the earlobe and tragus were rebuilt simultaneously.

RESULTS

From September 2013 to October 2017, 106 microtia patients were selected for auricular reconstruction applying this method in our hospital. Patients were followed up to 6 months to 4 years. Most of them (93.4%) were satisfied with the reconstructed ears, especially with respect to suitable color and invisible scars. Complications of expander exposure or framework exposure happened in three cases, and all of them finally got a satisfactory result.

CONCLUSION

A single large expanded postauricular flap without a skin graft is an effective and efficient technique for auricular reconstruction with satisfying results. It can reconstruct an exquisite ear without a skin graft and can be finished in only two stages of operations.

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.

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.

Different Methods of Fabricating Cartilaginous Ear Framework in Children With Microtia According to the Length of the Eighth Costal Cartilage Intraoperatively

BACKGROUND

There is controversy over the optimal timing of microtia reconstruction. The eighth costal cartilage, which is used to shape the helix framework, can be one of the key factors determining surgical timing of microtia reconstruction. Nevertheless, it is difficult to predict the length of the eighth costal cartilage preoperatively. The aim of the present study was to discuss different methods of fabricating cartilaginous ear framework in children with microtia according to different lengths of the eighth costal cartilage.

METHODS

Based on the actual length of the eighth costal cartilage in microtia children, there are 2 methods to fabricate auricular framework. In method I, the eighth costal cartilage was divided into 2 parts. Part A was used to fashion the helix, while part B was used to protrude the antihelix, superior, and inferior crus. The seventh rib was used to form the main body and the sixth rib was used to form the base of the framework. In method II, the seventh costal cartilage was used to fashion the helix and extrude the antihelix, superior, and inferior crus as method I did. The sixth rib was used to form the main body and the eighth rib was used to form the base of the framework.

RESULTS

A total of 68 microtia children underwent auricular reconstruction adopting the modified techniques between 2015 and 2016. The great majority of patients (66 patients) were satisfied with the reconstructed ears. Two patients were relatively satisfied with the reconstructed ears. Three cases have been selected to illustrate the favorable result achieved. They revealed that the helix, antihelix, superior crus, and inferior crus all appeared distinct and presented a favorable result of the contour of the reconstructed auricle.

CONCLUSIONS

Based on different lengths of eighth costal cartilage in children, different methods of fabricating ear framework make full use of the autogenous costal cartilage and elevate anatomical details, demonstrating that personalized treatment is necessary.