Auricular reconstruction represents a difficult reconstructive and aesthetic problem to the plastic surgeon. One of the greatest challenges in facial plastic surgery is total ear reconstruction. To date, no perfect material has been found to substitute for the elastic cartilage present in the normal ear. Total auricular reconstruction remains very complex.
JOURNAL OF MEDICAL RESEARCH REPORT OF 31 CASES OF AURICULAR RECONSTRUCTION DUE TO CONGENITAL MICROTIA BY USING AUTOGENOUS COSTAL CARTILAGE Vu Duy Dung¹, Nguyen Roan Tuat¹, Le Gia Vinh² ¹Ha Noi Medical University ²Medical Military Academy Auricular reconstruction represents a difficult reconstructive and aesthetic problem to the plastic surgeon One of the greatest challenges in facial plastic surgery is total ear reconstruction To date, no perfect material has been found to substitute for the elastic cartilage present in the normal ear Total auricular reconstruction remains very complex Prosthetic restoration is not favored by most but does remain available option for many patients Tissue engineers have sought to create a precise three dimensional auricular neo-cartilage but autogenous cartilage remains the gold standard thus far This is a prospective study of thirty-one consecutive patients undergoing total auricular reconstruction for congenital microtia at the National Pediatric Hospital of Vietnam The operation had stages: In the first stage, the 6th, 7th and 8th ribs are harvested for creation and implantation of a cartilaginous frameworks In the second stage, the lobule is transposed using a z-plasty of a narrow, inferiorly-based triangular flap In the third stage, the construct is elevated and the post-auricular sulcus is covered with a split thickness skin graft in order to improve auricular projection The success rate was 78.8% with excellent, good or satisfactory results In cases (21.2%), there was infection with loss of the cartilage Our study auricular reconstruction with autogenous costal cartilaginous has 78.8% success rate with satisfactory to excellent, and cosmetic outcome and least complication results in our series support this conclusion Keywords: Microtia, congenital, auricular, reconstruction, costal cartilage I INTRODUCTION Microtia is a rare condition, it affects only in 7000 to 8000 births, though rates can vary depending on ethnic background In 90% of cases, it affects only one ear, usually the right ear, and is more common in males Microtia describes the outer ear, but is often associated with absence of the ear canal (called ear canal atresia) There are four grades of microtia: Corresponding author: Vu Duy Dung, Ha Noi Medical University Email: dungent@gmail.com Received: 27/11/2018 Accepted: 12/03/2019 JMR 118 E4 (2) - 2019 Grade I: A less than complete development of the external ear with identifiable structures and a small but present external ear canal Grade II: A partially developed ear (usually the top portion is underdeveloped) with a closed stenotic external ear canal producing a conductive hearing loss Grade III (is the most common form of microtia): Absence of the external ear with a small peanut like vestige structure and an absence of the external ear canal and ear drum (figure.1) Grade IV: Absence of the total ear or anotia Reconstruction of the outer ear malformation cannot be done right after birth 123 JOURNAL OF MEDICAL RESEARCH can be achieved at to 10 years of age, when there is a thicker, more robust rib cartilage to use from the chest Figure Grade III microtia Until the reconstruction can be done, patients and families must cope with the abnormality Total auricular reconstruction using rib cartilage grafts have been shown to be a reliable technique since the 1920’s It usually involves two to four separate surgeries done under anesthesia separated by several months to allow for healing between each stage There are several different rib cartilage graft reconstruction techniques All involve taking rib cartilage from the chest during the 1st stage and carefully sculpting it into a framework that is shaped like an ear This framework is then implanted in a skin pocket underneath the scalp on the skull where the new ear will be located The newly created cartilage framework becomes part of the patient’s live tissue, and is incorporated after to months, at which point the second stage of the surgery is performed In the 2nd stage, incisions are made behind the ear to release the ear from the scalp skin, and the cartilage framework is lifted up to give it adequate projection A skin graft is then used to help cover the backside of the newly lifted ear Sometimes, additional minor stages are performed to improve the shape of the ear, the appearance of scars, or project the ear even further Although some surgeons consider doing rib cartilage graft reconstruction in patients as young as to years of age, a much better and more detailed 3-dimensional reconstruction 124 At the National Pediatric Hospital of Viet Nam, we have begun performing microtia reconstructions using autologous costal cartilage in recent years, so that we research with aim of study is to evaluate outcomes of these surgeries in our initial patient series II METHODS Study design Prospective report thirty-one patients were operated for auricular reconstruction due to severe microtia at National Pediatric Hospital, from December 2015 to December 2017 Study process Patients selection: Patients undergoing surgery were between ages of and 18, with no prior surgery on the chest or affected temporal area, and had congenital microtia (grade III or IV) Pre-operative preparation: A thorough history and physical was performed on each patient, including attention to possible associated anomalies A psychological evaluation was also performed for each patient Preoperative design and planning of cartilage framework was performed The size, measurement and position of the ear were done by tracing an x-ray film pattern of the normal opposite ear This template pattern was later sterilized using cidex in the operating room, and positioned equidistant with the contralateral side as shown in figure.2 Figure Preoperative planning JMR 118 E4 (2) - 2019 JOURNAL OF MEDICAL RESEARCH Operative details: - First stage (creation and implantation of cartilage graft framework): elevation of a thin skin flap over the non-hair bearing auricular area through an anterior limited incision Costal cartilage is obtained through a transverse or oblique incision over the 6th intercostal space, using sub-perichondrial dissection The x-ray pattern of the opposite ear is then placed over the union between the 6th and 7th costal cartilage to form the base block in which is carved the scapha, antihelix, and triangular fossa (figure.3) Figure Framework The synchondrosis of this base is secured using - Ethibond sutures The 8th cartilage is harvested to form the helical rim and is sutured to the base using 3.0 prolene A thin skin flap is made at the affected temporal area, and abnormal cartilage is removed The framework is then implanted under this skin flap Low negative suction is then applied to position the skin flap, anchor the cartilage framework and to reduce dead space and hematoma as demonstrated in figure Figure Complete 1st stage JMR 118 E4 (2) - 2019 - Second stage (Lobule transposition): To achieve maximal safety and reliability of the lobule, it is transposed during a second stage The rotation or reposition of this displaced structure is essentially done by z-plasty transposition of narrow, inferiorly based triangular flap - Third stage (Auricular framework elevation): detachment of the constructed auricle and ear lobe positioning The post auricular sulcus is defined by elevating the constructed auricle from the scalp and by covering the undersurface with a thick split thickness skin graft Retro auricular skin is advanced into the newly created sulcus and a bolster dressing is placed to secure the graft To augment the auricular elevation a sub facial mastoid pocket is created just behind the deepest point of the detached ear to harvest the cartilage wedge, graft bank in the postauricular area as show in figure Figure Complete 2nd stage Time of follow up and assessment at least months post-op, which were studied in the patients: age, sex involved, side involved, outcomes of procedures, and complications Evaluation criteria: For aesthetic outcomes (figure.6), observers evaluated frontal, lateral photographs of all patients and rated the reconstructed ear on a scale of with the following criteria [1]: (excellent) all external ear anatomy well visualized, excellent projection, no revisions 125 JOURNAL OF MEDICAL RESEARCH necessary; (moderate)—major external ear anatomy visualized, reasonable projection, minor revisions may improve outcome; (unsatisfactory)—abnormalities in multiple anatomical components of the ear, major revisions necessary In this study thirty-one patients were underwent ear reconstruction These patients ranged in age from to 18 years old, with a mean age of 11.7 The mean length of postoperative follow-up was months, with a range of to 14 months All patients exhibited grade III or IV microtia Demographic data are summarized in table For the auricular reconstruction, cosmetic outcomes were satisfactory to excellent in 74.2% and 21.2% had unsatisfactory results Figure Outcome of microtia reconstructed For analysis of landmark on pinna, based upon Sharma et al grading system Table Mohit Sharma et al [2] grading system for microtia All patients underwent microtia reconstruction in stages, with 13 cases (41.9%) needing further work (scar revision) Anatomical attribute Score Crus of helix There were cases of flap necrosis or skin graft compromise There were no cases of framework exposure There were 11 minor complications, of which resolved with conservative management For the most part, there were sub-centimeter wound dehiscence which resulted from trauma to the region in postoperative period Upper 1/3rd Table Patient Demographics Middle 1/3 Helix rd Lower 1/3rd Superior and inferior crus Demographics Freq (n) Male 21 Female 10 Anti-helix Middle part Mean age (range) Anti-tragus Left microtia Tragus Right microtia 19 Lobule Bilateral microtia Scaphoid fossa Total patients 31 Triangular fossa Total ears 33 Cymba concha Cavum concha Total (maximum) score 13 III RESULTS 126 11.7 (7-18) There were patients with postauricular hematoma, which were aspirated in the office Complication data are summarized in table Representative preoperative and postoperative photographs are shown in figure JMR 118 E4 (2) - 2019 JOURNAL OF MEDICAL RESEARCH Table Complications of Auricular Reconstruction (33 Ears Available for Follow-up) Complications Freq (n) Skin graft necrosis Infection 10 Hair bearing skin over auricle Hypertrophic scar, keloid Framework exposure Postauricular hematoma Pneumothorax - Bleeding - Inspection of landmarks on reconstructed Ear based upon Sharma et al…grading scale (table 1) Each unit will be counted point so the between to 13, and scale of with the following criteria On table showing that 78.8% achieved satisfactory to excellent outcomes, and 21.2% were unsatisfactory most important factor affecting the aesthetic outcome of the auricular reconstruction with rib costal cartilage graft is the fabricated cartilage framework The autogenous cartilage graft is “gold standard” for the auricular reconstruction because of its availability, and durable results compared to other methods including synthetic materials and prostheses In this study we compared our results in term of final aesthetic outcome and anatomical landmark on total 33 auricular reconstructed ears were done (in 31 patients) The operation was done under general anesthesia, spending 4-6 hrs with each case The success rate was 78.8% with satisfactory to excellent but 21.2% of cases had an unsatisfactory result Meanwhile, Mohit Sharma [2] reported good or excellent results could be achieved in 70% but this difference with no significant Table Grading scale for evaluating the results Grading scale for evaluating the results Results Total scores Grade No Of ears % 12-13 Excellent 13 39.4% 9-11 Good 24.2% 6-8 Satisfactory 15.2% ≤5 Unsatisfactory 21.2% 21.2% 33 100% 100% Total IV DISCUSSION Tanzer [3] introduced total auricular reconstruction using autologous costal cartilage graft in 1959 with stages and Brent [4] in 1974 modified this to stages Their concept of multistage treatment is now the state of art solution for ear reconstruction Subsequently Nagata [5] and Firmin [6] have further refined this technique to a stage reconstruction The JMR 118 E4 (2) - 2019 Total 78.8% And the overall rate of complications was 33.3% (11/33 ears) was higher than Rachel et al (18%) Ear reconstruction in our group was performed as early as possible, after ages 7-10 years to allow the thoracic cage to be large enough to provide for an adequate size of the framework In this series we started the ear reconstruction for 45.5% in those aged 127 JOURNAL OF MEDICAL RESEARCH - 11 years old (primary school-age), in 39.4% for those 12 - 15 years old (secondary schoolage), and in 15.1% for those 16-18 years old (high school-age) V CONCLUSIONS Reconstruction of the auricle is one of the most challenging and rewarding aspects of facial plastic surgery Each patient and each ear deformity are unique, thus making the management of these patients a humbling, challenging, and perpetually stimulating problem Autogenous costal cartilaginous graft auricular reconstruction can be attempted with good long term results In fact that a majority had acceptable results however there is room for improvement with further experience REFERENCES Rachel et al., (2017) Evaluation of Outcomes Measures in Microtia Treatment: 128 Exposures, Infections, Aesthetics, and Psychosocial Ramifications PRS Global Open, september, p 1-7 Mohit Sharma et al., (2015) Objective analysis of microtia reconstruction in Indian patients and modifications in management protocol Indian J Plast Surg, May-Aug 48 (2): p 144-152 Tanzer RC., (1959) Total reconstruction of the external ear Plast Reconstr Surg Transplant Bull, 23: p 1-15 Brent B., (1980) The correction of microtia with autogenous cartilage grafts: II Atypical and complex deformities Plast Reconstr Surg, 66: p 13-21 Nagata S., (1993) A new method of total reconstruction of the auricle for microtia Plast Reconstr Surg, 92: p 187-201 Firmin F et al., (2011) A novel algorithm for autologous ear reconstruction Semin Plast Surg, 25: p 257-64 JMR 118 E4 (2) - 2019 ... the auricular reconstruction with rib costal cartilage graft is the fabricated cartilage framework The autogenous cartilage graft is “gold standard” for the auricular reconstruction because of. .. correction of microtia with autogenous cartilage grafts: II Atypical and complex deformities Plast Reconstr Surg, 66: p 13-21 Nagata S., (1993) A new method of total reconstruction of the auricle for microtia. .. auricular reconstruction using autologous costal cartilage graft in 1959 with stages and Brent [4] in 1974 modified this to stages Their concept of multistage treatment is now the state of art solution