ORIGINAL ARTICLE A 2-Stage Ear Reconstruction for Microtia · A 2-Stage Ear Reconstruction for...
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ORIGINAL ARTICLE A 2-Stage Ear Reconstruction for Microtia Haiyue Jiang, MD; Bo Pan, MD; Yanyong Zhao, MD; Lin Lin, MD; Lei Liu, MD; Hongxing Zhuang, MD Objective: To introduce our 2-stage reconstruction of microtia method, which results in a natural-looking contour of the reconstructed ears, one of the most demanding challenges in facial plastic surgery. Methods: In the first stage, the 3-dimensional carti- lage framework is fabricated. The skin flap and retro- auricular fascial flap are elevated in the mastoid area. Then the framework is wrapped by the fascial flap from behind and covered by the skin flap from front. In the second stage the crus, the tragus, and the con- chal cavity are reconstructed. So almost all of the fine structures of ear are reconstructed. Results: Sixty-eight patients ranging in age from 5 to 17 years had their ears reconstructed using our 2-stage method from January 1, 2006, to December 31, 2008. Forty-eight patients were boys, and 20 were girls. Unilateral microtia was present in 66 patients and bilateral microtia was present in 2 patients. The reconstructed ears had a 3-dimensional configuration, and the cranioauricular angle of the recon- structed ears was similar to that of the contralateral ear. Conclusions: Two-stage ear reconstruction is a simple and promising method for microtia. Furthermore, the complications are rare. Arch Facial Plast Surg. 2011;13(3):162-166 R ECONSTRUCTION OF MICRO- tia represents one of the most demanding chal- lenges in facial plastic sur- gery. A variety of surgical strategies have been devised for the re- construction of the external ear. 1-4 There has been considerable acceptance of the multistage methods of Tanzer 5 and Brent. 6 However, the lack of ear definition and ex- cessive operating stages detract from the final result. We used a 2-stage ear recon- struction method from 2006 to 2008 for 68 patients. Most of the reconstructed ears had a 3-dimensional and natural-looking contour. Herein, we describe our 2-stage technique: in the first stage, 2 flaps are cre- ated, and cartilage is fabricated; in the sec- ond stage, the tragus, crus, and conchal cavity are reconstructed. METHODS STAGE 1 In the first stage of our reconstruction proce- dure, the right costal cartilages are harvested, usually the sixth, seventh, and eighth carti- lages, individually, in children. A 10 3-cm skin excision outline is then made on the cen- ter of the seventh cartilage. The skin is ex- cised and trimmed into a skin graft of inter- mediate thickness. The costal cartilage is harvested separately, and the costochondral junction is dissected. The perichondrium is in- cised parallel to the margin of the costal car- tilage. The length between the incision and the margin of the costal cartilage is usually about 2 to 3 mm. Most of the perichondrium is left intact except for the perichondrium on the sur- face of the costal cartilage. The framework has 3 main parts: the he- lix, the base, and the pad, and these 3 parts are of different heights. The helix and partial crus helicis, which are formed from the eighth rib, are at the top of the level. The base is the most complex part and is fabricated mainly from the seventh cartilage. The scapha can be carved di- rectly from a piece of crescent-shaped carti- lage. This crescent-shaped cartilage is turned over and anchored on the interior side of the scapha to form the antihelix and superior crus (Figure 1). The inferior crus is constructed by introducing a small fragment of cartilage into the seventh cartilage. The triangular fossa is formed by the concavity between the superior and inferior crura. The helical cartilage is at- tached anterior to the base of framework. The pad is formed by the sixth cartilage and an- chored beneath the base to enhance projec- tion of the framework (Figure 2). The superior and posterior parts of the skin flap are designed along the hairline. The infe- rior part of the skin flap runs parallel to the trans- position incision of the remnant ear (Figure 3). The skin flap is elevated in the layer of subcu- Author Affiliations: Plastic Surgery Hospital, Peking Union Medical College, Beijing, China. ARCH FACIAL PLAST SURG/ VOL 13 (NO. 3), MAY/JUNE 2011 WWW.ARCHFACIAL.COM 162 ©2011 American Medical Association. All rights reserved. Downloaded From: on 07/25/2018
Transcript of ORIGINAL ARTICLE A 2-Stage Ear Reconstruction for Microtia · A 2-Stage Ear Reconstruction for...
ORIGINAL ARTICLE
A 2-Stage Ear Reconstruction for MicrotiaHaiyue Jiang, MD; Bo Pan, MD; Yanyong Zhao, MD; Lin Lin, MD; Lei Liu, MD; Hongxing Zhuang, MD
Objective: To introduce our 2-stage reconstructionof microtia method, which results in a natural-lookingcontour of the reconstructed ears, one of the mostdemanding challenges in facial plastic surgery.
Methods: In the first stage, the 3-dimensional carti-lage framework is fabricated. The skin flap and retro-auricular fascial flap are elevated in the mastoid area.Then the framework is wrapped by the fascial flapfrom behind and covered by the skin flap from front.In the second stage the crus, the tragus, and the con-chal cavity are reconstructed. So almost all of the finestructures of ear are reconstructed.
Results: Sixty-eight patients ranging in age from 5 to 17yearshadtheirears reconstructedusingour2-stagemethodfrom January 1, 2006, to December 31, 2008. Forty-eightpatients were boys, and 20 were girls. Unilateral microtiawaspresent in66patientsandbilateralmicrotiawaspresentin 2 patients. The reconstructed ears had a 3-dimensionalconfiguration, and the cranioauricular angle of the recon-structed ears was similar to that of the contralateral ear.
Conclusions: Two-stage ear reconstruction is a simpleand promising method for microtia. Furthermore, thecomplications are rare.
Arch Facial Plast Surg. 2011;13(3):162-166
R ECONSTRUCTION OF MICRO-tia represents one of themost demanding chal-lenges in facial plastic sur-gery. A variety of surgical
strategies have been devised for the re-construction of the external ear.1-4 Therehas been considerable acceptance of themultistage methods of Tanzer5 and Brent.6
However, the lack of ear definition and ex-cessive operating stages detract from thefinal result. We used a 2-stage ear recon-struction method from 2006 to 2008 for68 patients. Most of the reconstructed earshad a 3-dimensional and natural-lookingcontour. Herein, we describe our 2-stagetechnique: in the first stage, 2 flaps are cre-ated, and cartilage is fabricated; in the sec-ond stage, the tragus, crus, and conchalcavity are reconstructed.
METHODS
STAGE 1
In the first stage of our reconstruction proce-dure, the right costal cartilages are harvested,usually the sixth, seventh, and eighth carti-lages, individually, in children. A 10�3-cmskin excision outline is then made on the cen-ter of the seventh cartilage. The skin is ex-cised and trimmed into a skin graft of inter-
mediate thickness. The costal cartilage isharvested separately, and the costochondraljunction is dissected. The perichondrium is in-cised parallel to the margin of the costal car-tilage. The length between the incision and themargin of the costal cartilage is usually about2 to 3 mm. Most of the perichondrium is leftintact except for the perichondrium on the sur-face of the costal cartilage.
The framework has 3 main parts: the he-lix, the base, and the pad, and these 3 parts areof different heights. The helix and partial crushelicis, which are formed from the eighth rib,are at the top of the level. The base is the mostcomplex part and is fabricated mainly from theseventh cartilage. The scapha can be carved di-rectly from a piece of crescent-shaped carti-lage. This crescent-shaped cartilage is turnedover and anchored on the interior side of thescapha to form the antihelix and superior crus(Figure 1). The inferior crus is constructedby introducing a small fragment of cartilage intothe seventh cartilage. The triangular fossa isformed by the concavity between the superiorand inferior crura. The helical cartilage is at-tached anterior to the base of framework. Thepad is formed by the sixth cartilage and an-chored beneath the base to enhance projec-tion of the framework (Figure 2).
The superior and posterior parts of the skinflap are designed along the hairline. The infe-rior part of the skin flap runs parallel to the trans-position incision of the remnant ear (Figure3).The skin flap is elevated in the layer of subcu-
Author Affiliations: PlasticSurgery Hospital, Peking UnionMedical College, Beijing, China.
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taneous tissue. An additional 3.5- to 4.0-cm incision behind thehairline is made to form the C-shaped retroauricular fascial flap.The superior part is elevated on the surface of temporal fascia;the posterior part is on the periosteum; and the inferior part ison the musculi sternocleidomastoideus (Figure 4). Then, a ret-roauricular fascial flap measuring 7 to 8�4 to 5 cm is preparedand wrapped. The flap is based on the posterior auricular muscleand local fascia. The main vascular supply to this area is derivedfrom the posterior auricular artery and innervated by the lesseroccipital nerves.
The cartilage framework is positioned between the skin flapand the fascial flap. The rear of the framework reaches to thepedicle of the remnant ear. The retroauricular fascial flap wrapsthe framework from the back and anchors it to the helix(Figure 5). The skin flap covers the whole anterior surfaceand part of the posterior surface of the cartilage framework. Theremainder of the posterior surface of the cartilage frameworkis covered by the fascial flap. A small suction catheter is in-
serted between the framework and the skin flap. The fascial flapand the subsequent wound surface are then covered with theskin graft made from the patient’s chest skin. A tie-over dress-ing is applied to the skin graft. Suction drain is applied untilthe fifth postoperative day, and on the tenth postoperative day,the dressing is removed altogether from the reconstructed ear.
STAGE 2
A V-shaped flap, the crus flap, is formed in the superior part ofthe remnant ear. A C-shaped flap with a radius of 1 cm, thetragus flap, is designed in the conchal area. After the 2 flapsare elevated, the remnant ear cartilage is exposed and dividedinto 2 parts. The superior part is carved into a cone shape andconnected to the helix. The inferior part is trimmed into a semi-circular slice to form the lining of the tragus, which is thenwrapped by the tragus flap doubled on itself. The redundantskin is excised to form the tragus. Then the extraneous rem-
A B
C D
Figure 1. Construction of the ear framework. A, The scapha is designed onthe cartilage. B, A piece of crescent-shaped cartilage is carved. C, Thecrescent-shaped cartilage is turned over and anchored on the interior side ofthe scapha to form the antihelix and superior crus. D, The instruments usedin our method: the straight needles, blade, and steel wire.
A B C
Figure 2. The constructed ear framework. A, Front view. B, Posterior view. C, Lateral view.
Figure 3. The earlobe is transposed with the formation of the skin flap andfascial flap.
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nant cartilage tissue is excised to the mastoid periosteum todeepen the conchal floor. The cavity is lined with a full-thickness skin graft from the opposite retroauricular area orfrom the chest where the scar is obvious and repair needed(Figure 6).
RESULTS
Sixty-eight patients, ages ranging from 5 to 17 years, weretreated using the 2-stage method from January 1, 2006,to December 31, 2008 (48 boys and 20 girls). Unilateralmicrotia was present in 66 patients, and bilateral micro-tia in 2.
Follow-up ranged from 1 to 3 years (Figures 7, 8,and 9). In 66 cases, the reconstructed ears had 3-dimen-sional configurations and cranioauricular angles similarto those of the contralateral control ears. There were 5cases of conspicuous hair growth in the helix, which weretreated by 3 to 5 applications of laser therapy. No ab-sorption or distortion of cartilage framework was ob-served.
COMMENT
The remnant ear is a key factor in reconstructing theinferior structure of the ear.1 The transposition of theremnant ear is the classical technique in microtiareconstruction. However, the timing of the transposi-tion has always been controversial. Tanzer5 believesthat the transposition should be the first part of thereconstruction procedure. If the frame is inserted dur-ing the second stage, it is difficult to obtain a goodmatch with the already transposed lobule. In contrast,Brent6 proposes that the reconstruction should bestarted by placing the cartilaginous frame in the idealposition. Then lobule transposition can be correctlyadapted to the already constructed contours duringthe second stage. We perform earlobe transpositionand implantation of cartilage framework in a singlestage. Thus the operation times can be reduced.
We also practice several other innovations, based onthe fabrication technique devised by Brent.6 We usuallyharvest cartilage from the right side of the chest. We areaware that the trend among most other practitioners ismoving in the opposite direction, but we believe that the
A B
Figure 4. Ear framework placement. A, Elevation of the skin flap andretroauricular fascial flap. B, Framework is anchored between the skin flapand retroauricular fascial flap.
Figure 5. The helix of the framework is wrapped by the fascial flap.
A B C D
Figure 6. Stage 2 of ear reconstruction. A, The V-shaped crus flap and C-shaped tragus flap are designed. B, After the elevation of the crus flap and tragus flap,the remnant ear cartilage is exposed. C, The crus and tragus are formed. D, The conchal cavity is lined with a skin graft.
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A B C
Figure 7. Postoperative view after completion of stage 1 ear reconstruction in a 16-year-old patient. A, Frontal view. B, The reconstructed ear has a 3-dimensionalcontour, and the definition is clear. C, The contralateral normal ear.
A B C
Figure 8. Postoperative view after completion of stage 2 ear reconstruction in a 10-year-old patient. A, Frontal view. B, The crus, tragus, and conchal cavity areformed. C, The contralateral normal ear.
A B C
Figure 9. Preoperative (A) and postoperative (B and C) views of an 8-year-old boy who underwent 2-stage ear reconstruction. B, Two months after completion ofstage 1. C, One year after completion of stage 2.
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heart is well protected by the integrity of the left thorax.Furthermore we do not find using the cartilage in thisway to be inconvenient. In the process of cartilage fab-rication, we use the cartilage cut from the scaphoid toproduce as much contour definition of the antihelix andinferior crus as is required. Projection is the main factorin 3-dimensional contour. In Brent’s6 third stage, a blockof cartilage is inserted beneath the framework to lift thereconstructed ear. In our method, we use 3-layer frame-work, and there is no need to enhance the projection ofthe ear in another procedure.
Since local skin and fascial flaps were introduced insingle-stage ear reconstruction, the 2-flap technique hasbeen widely used.7,8 In elevating the retroauricular fas-cial flap, 3 key factors must be kept in mind. First, in thesuperior part, the principle is that the superficial tem-poral fascia and loose areolar layer are all raised whenseparated from the temporal fascia. Second, in the pos-terior part, careful hemostasis should be maintained ifthere is an emissary vein in the mastoid area. Third, inthe inferior part, the parotid gland may be abnormallypositioned, especially in patients with dysplasia of man-dible. Do not accidentally injure the parotid gland whendissecting the fascial flap.
Temporoparietal fascial flap is another widely used fas-cial flap in ear reconstruction. It has many advantages.These include pliability, good vascularity, and easy trans-location. However this type of flap leaves a conspicuousscar in the temporal region. We usually use the tempo-roparietal fascial flap as a rescue to repair exposure ofcartilage framework.
The remnant ear cartilage is in the conchal region. Itis usually excised and discarded to deepen the conchalcavity. We use partial remnant ear cartilage to recon-struct the helix crus and tragus. Thus the requirementfor cartilage framework is reduced. This method is es-pecially practical in young patients whose rib cartilageis insufficient.
Accepted for Publication: August 3, 2010.Correspondence: Yanyong Zhao, MD, Plastic SurgeryHospital, Peking Union Medical College, 33 Badachu Rd,Beijing, China ([email protected]).Author Contributions: Study concept and design: Jiang,Pan, Zhao, and Zhuang. Acquisition of data: Jiang, Pan,Zhao, Lin, Liu, and Zhuang. Analysis and interpretationof data: Jiang and Pan. Drafting of the manuscript: Jiang,Pan, Zhao, Lin, Liu, and Zhuang. Critical revision of themanuscript for important intellectual content: Jiang and Pan.Statistical analysis: Jiang, Pan, Zhao, Lin, Liu, and Zhuang.Obtained funding: Jiang, Pan, Zhao, Liu, and Zhuang. Ad-ministrative, technical, and material support: Jiang, Pan,Lin, and Zhuang. Study supervision: Jiang and Zhao.Financial Disclosure: None reported.Funding/Support: This work was supported by Vital Clini-cal Subject Foundation of China grant 2004468 and Chi-nese National Natural Science Foundation grants30500290 and 30950032.Additional Contributions: The authors thank the pa-tients for their participation.
REFERENCES
1. Pan B, Lin L, Zhao Y, Zhuang H, Lu H, Jiang H. Use of the remnant ear for recon-struction in lobule-type microtia. Arch Facial Plast Surg. 2009;11(5):338-341.
2. Pan B, Jiang H, Guo D, Huang C, Hu S, Zhuang H. Microtia: ear reconstructionusing tissue expander and autogenous costal cartilage. J Plast Reconstr AesthetSurg. 2008;61(suppl 1):S98-S103.
3. Jiang H, Pan B, Lin L, Cai Z, Zhuang H. Ten-year experience in microtia recon-struction using tissue expander and autogenous cartilage. Int J PediatrOtorhinolaryngol. 2008;72(8):1251-1259.
4. Song YG, Zhuang HX. One-stage total reconstruction of the ear with simulta-neous tympanoplasty. Clin Plast Surg. 1990;17(2):251-261.
5. Tanzer RC. Microtia--a long-term follow-up of 44 reconstructed auricles. Plast Re-constr Surg. 1978;61(2):161-166.
6. Brent B. Auricular repair with autogenous rib cartilage grafts: two decades of ex-perience with 600 cases. Plast Reconstr Surg. 1992;90(3):355-376.
7. Nagata S. A new method of total reconstruction of the auricle for microtia. PlastReconstr Surg. 1993;92(2):187-201.
8. Helling ER, Okoro S, Kim G II, Wang PT. Endoscope-assisted temporoparietal fas-cia harvest for auricular reconstruction. Plast Reconstr Surg. 2008;121(5):1598-1605.
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