+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e10
Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients So-Eun Han, So-Young Lim, Jai-Kyung Pyon, Sa-Ik Bang, Goo-Hyun Mun, Kap Sung Oh* The Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Received 8 December 2014; accepted 13 April 2015
KEYWORDS Aesthetic auricular reconstruction; Microtia; Rib cartilage grafts; Rib cartilage calcification
Summary Background: Cartilage calcification is an important factor in aesthetic auricular reconstruction using autologous rib cartilage grafts in adults, a technique that involves difficult manipulation and unexpected absorption. As a result, artificial implants or prosthetics are considered for auricular reconstruction in adult patients despite the limitations of artificial material. In this article, we present our experience with auricular reconstruction using autologous rib cartilage grafts in adult microtia patients with reliable aesthetic results and minimal complications. Methods: A retrospective chart review was performed for 84 microtia patients ranging in age from 21 to 56 (average: 29.9) years who underwent auricular reconstruction using autologous rib cartilage grafts from March 2001 to March 2013. To validate our acceptable reconstructive results, two independent observers performed postoperative photographic evaluation of two groups (adults and children) using non-inferiority tests in addition to patient questionnaires. Results: The mean operation time for rib cartilage grafts was 3 h and 53 min, and the follow-up time for all patients ranged from 6 months to 8 years. Surgery-related complications occurred in only three cases. On objective photographic evaluation, the adult group was not inferior to the child group in auricular shape, location, or symmetry. The subjective patient satisfaction evaluation reported a high satisfaction rate. Conclusions: As this study shows, aesthetic auricular reconstruction using rib cartilage grafts in adult microtia patients is possible even in cases with advanced cartilage calcification. Modification of the fabricating framework, well-preserved flap vascularity, and complete
* Corresponding author. Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwonro, Gangnam-gu, Seoul 135-710, Republic of Korea. Tel.: þ82 2 3410 2210; fax: þ82 2 3410 0036. E-mail address: [email protected] (K.S. Oh). http://dx.doi.org/10.1016/j.bjps.2015.04.016 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
+
MODEL
2
S.-E. Han et al. understanding of physiological aspects of rib cartilage are essential for aesthetic auricular reconstruction. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The auricular reconstruction of microtia has presented a surgical challenge to plastic reconstructive surgeons due to the highly complex three-dimensional (3D) structures of ears and the difficulty in achieving the high aesthetic demands of patients. Autologous rib cartilage grafts are widely considered a standard modality for auricular reconstruction with favorable long-term results by many professional surgeons such as Tanzer,1,2 Brent,3e5 and Nagata.6e10 The successful outcome of auricular reconstruction using autologous rib cartilage grafts depends on various factors, including the surgeon’s ability to carve cartilage, adequate size and strength of rib cartilage, and the availability of sufficient healthy normal tissue and favorable blood circulation in the auricular region. To create the 3D framework with rib cartilage, physiological aspects of rib cartilage, including sufficient amounts of costal cartilage, are important factors.11,12 In particular, calcification and the associated stiffness of cartilage with increasing age are also important factors that lead to difficult manipulation and unexpected absorption, resulting in poor surgical results.11e13 Due to this, artificial implants or prosthetics are considered an option in adult patients; however, these methods are limited by complications such as extrusion and infection and the absence of long-term follow-up results.14,15 To the best of our knowledge, there are few large published series on the use of autologous rib cartilage grafts in patients >20 years for auricular reconstruction, including objective evaluation and patient satisfaction with surgical results. In this article, we retrospectively reviewed a series of 84 adult patients (20 years) who had favorable outcomes using autologous rib cartilage grafts. An objective photographic grading system and patient questionnaires were used to validate our acceptable reconstructive results.
Patients and methods Between March 2001 and March 2013, 84 microtia patients ranging in age from 21 to 56 (mean: 29.9; standard deviation (SD): 8.7) years were transferred to our institution for auricular reconstruction. All procedures were performed by a senior surgeon (K.S.O.) using autologous rib cartilage grafts. Patient characteristics such as age, gender, cause of deformity, side of deformity, classification, type of rib cartilage combination, and procedure were noted (Table 1). The 3D reconstructed rib computed tomography (CT) was performed preoperatively using a 64-slice multidetector-row CT scanner in the same manner as a previous study.16 To measure the degree of cartilage
calcification, we analyzed the chosen rib cartilage of each patient. The proportion of calcification was measured by manually outlining the calcification area and the cartilage area of each CT section using software (Aquarius iNtuition, Terarecon, CA, USA). To evaluate the correlations for age and degree of calcification, we executed Spearman’s correlation analysis using Statistical Analysis System (SAS) version 9.3 (SAS Institute, Cary, NC, USA). The p-values were considered to be significant at a level of 0.05. Postoperative photographs were used by two independent observers to evaluate aesthetic outcomes, including auricular shape and location, symmetry, and scar formation. Each item was graded as
Table 1
Patient characteristics.
Characteristics
Adult group No. of Patients (%)
Child group No. of Patients (%)
Age at surgery
21e30 years:55 (65.4) 31e40 years:18 (21.5) 41e50 years:8 (9.5) >51 years:3 (3.6)
8e10years:72 (72) 11e20 years:28 (28)
51 (60.7) 33 (39.3)
69 (69) 31 (31)
71 (84.5) 13 (15.5)
97 (97) 3 (3)
43 (51.2) 38 (45.2) 3 (3.6)
52 (52) 47 (47) 1 (1)
16 (19.0) 67 (79.8) 1 (1.2)
30 (30) 70 (70)
75 (89.0) 9 (11.0)
54 (54) 46 (46)
47 (55.9) 1 (1.2)
69 (69)
36 (42.9)
31 (31)
Sex Male Female Cause Congenital Acquired Affected side Right Left Bilateral Classification Concha Lobule Anotia Types of rib cartilage combinations 6,7,8 th 6,7,8,9 th Procedure RCG and Elevation TEI and RCG and Elevation RCG and TEI and Elevation
RCG, rib cartilage grafts. TEI, tissue expander insertion.
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
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Aesthetic auricular reconstruction in adult microtia patients excellent (4), good (3), fair (2), or poor (1). The evaluations were categorized into high (3 or 4) or low (1 or 2) ratings. We performed a non-inferiority test to show that the postoperative results of the adult group (age >20) were not inferior to those of the child group (age 20). For this, we sampled 100 patients in the child group who underwent the same operation and evaluation procedures. The noninferiority margin was predefined as a 10% difference in success rate. The p-values were corrected by Bonferroni’s method in the case of multiple testing, and they were considered to be significant at the level of 0.05. Photographic images of the patients were taken in frontal and oblique views. A patient satisfaction questionnaire was performed at least 12 months after the surgery, which was composed of five questions that addressed size, color match, scar appearance, and overall satisfaction. Responses to individual question were rated as “very satisfied,” “satisfied,” “unsatisfied,” or “dissatisfied.” This study was reviewed and approved by the institutional review board of our institution.
3 represents the superior and inferior crus of the antihelix, was sufficiently modified to make the tail of the cartilage reach the crus helix of the main framework. We especially focused on minimizing the risk of skin-flap necrosis by preserving a subcutaneous pedicle to ensure adequate blood supply to nourish the skin flap.
Auricular elevation An incision was made along the lateral margin of the ear framework, and the framework was elevated. The superficial temporal fascia was elevated and then folded backward to cover the cartilage blocks, which were banked in the subcutaneous layer of the chest during rib cartilage grafting. The posterior raw surface of the ear framework was covered by defatted harvested skin from the groin. Sterilized glasses were used to ensure they could be worn correctly without problems.
Tissue expander insertion
Surgical procedure Autologous rib cartilage grafting To create the framework, the senior author (K.S.O.) harvested cartilage from three or four locations on the sixth to the ninth ribs depending on the size and shape of the patient’s cartilage (Figure 1). The cartilage of the sixth and seventh ribs and the synchondritic portion of the contralateral chest were used for the framework base according to the methods of Brent3 and Nagata.6 A groove was created on the outer margin of the base frame in order to stabilize the helical component and to place it at the eighth cartilage. The scaphoid fossa and the triangular fossa were obtained by sculpting the body of the base framework if the thickness of the cartilage pieces was sufficient. In order to prevent a blunted convolution in cases where the cartilage was thin, the prominent structures used were the superior and inferior crus of the antihelix, which were attached by an additional Y-shaped cartilage graft to the ninth cartilage or other residual cartilage pieces on the base frame. In many adult cases, there were enough residual cartilage pieces to reconstruct the superior and inferior crus of the antihelix without using the ninth cartilage. The major concern regarding auricular reconstruction in adults is rib cartilage calcification. Prior to the operation, we evaluated rib cartilage calcification characteristics with the aid of 3D CT images. In cases with severely calcified cartilage, we used burrs for delicate carving instead of chisels and scalpels. To reconstruct the helix component, we used the eighth cartilage for a one-piece carving without breaking. However, the rib cartilage broke during bending in cases with severely calcified cartilage. If this occurred, the broken calcified cartilage was trimmed, and then Prolene suture was used to form and fix the natural configuration. To tightly assemble the rib cartilage framework, we fixed the cartilage to the base framework using Prolene suture, or K-wire suture in some cases, taking care to avoid the severely calcified area. To create the tragus and intertragal notch, the length of the Y-shaped cartilage graft, which
In anotia cases, tissue expander insertion surgery was performed before autologous rib cartilage grafts regardless of age to obtain sufficient soft tissue. For acquired traumatic deformity cases, we inserted a tissue expander between the rib cartilage grafts and the auricular elevation to reduce scar contracture and obtain enough soft tissue. One patient did not want additional groin scarring and desired a well-matched skin color for the reconstructed ear, so we performed this procedure in that case as well. A 3-cm incision line was created on the margin of the ear framework. A 45e or a 60-ml rectangular tissue expander was inserted subcutaneously at the postauricular mastoid region in the same manner as a previous study.17 A subcutaneous pocket was dissected and extended over the scalp covering the mastoid area in order to obtain sufficient space for the tissue expander. The pocket for the port, which was connected to the prosthesis by a length of tubing, was prepared in the temporal area. Inflation with normal saline was initiated 2 weeks after tissue expander insertion, and expansion was performed at 2-week intervals over a period of 3e4 months post operatively.
Tissue expander removal and auricular elevation The expanded postauricular skin flap was advanced to the mastoid area, and it was set into the auriculo-cephalic sulcus after removing the tissue expander.17 We performed thorough capsulectomy of the expanded postauricular skin flap to make a more visually projected ear with less tension. The predicted remnant skin flap and dog-ears were marked and then excised. Auricular elevation with groin skin provides a dark-pigmented color in the postauricular area. Instead of full-thickness skin from the inguinal area, the excised skin was draped at the posterior surface for the elevation procedure.17 Despite the addition of the tissue expander insertion procedure, we obtained satisfactory aesthetic results using the expanded skin to buttress the cartilage framework, with superior skin texture and color match.17
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
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MODEL
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S.-E. Han et al.
Figure 1 (above left) On the outer margins of the sixth and seventh cartilage base frameworks, the helical component was stabilized by the eighth cartilage (above right). Broken calcified cartilage was trimmed, and then Prolene sutures were used for suitable fixation. The scaphoid fossa and the triangular fossa were produced by sculpting the base framework (middle left). Completed rib cartilage framework, middle right; tragus reconstruction, below left. Prolene sutures were used to fix the rib cartilage framework.
Results A total of 85 cases in 84 consecutive microtia patients who were older than 20 years underwent auricular reconstruction using autologous rib cartilage grafts. The mean operation time for rib cartilage grafts was 3 h and 53 min, and the follow-up time for all patients ranged from 6
months to 8 years, with an average of approximately 3 years. There were no cases of cartilage extrusion, skinflap necrosis, or infection. One case of hematoma after tissue expander insertion was caused by inadequate intraoperative hemostasis without the use of postoperative pressure dressing. Hematoma evacuation was performed after identifying the bleeding focus. With
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
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MODEL
Aesthetic auricular reconstruction in adult microtia patients Table 2 Comparison of “High Ratinga” proportions in objective photographic evaluation between the two groups.
Shape and location
Symmetry
Scar
Adult group N Z 84 (45.6%)
Child group N Z 100 (54.4%)
pvalue
Observer 1: 81(96%) Observer 2: 82(97%) Observer 1: 77(91%) Observer 2: 79(94%) formation
Observer 1: 95(95%) Observer 2: 98 (98%) Observer 1: 87(87%) Observer 2: 98(98%) Observer 1: 80(95%) 0.0042
0.0001
Observer 1: 97(97%) Observer 2: Observer 2: 76(90%) 97(97%) a
0.0000 0.0012 0.0394
0.3380
High rating means Excellent (4) or Good (3).
regard to the elevation procedure, there was one case of partial skin graft loss and one case of hypertrophic scarring. The patient with partial skin graft loss underwent an additional split-thickness skin graft. The patient who developed a hypertrophic scar in the postauricular area responded to treatment with an intralesional steroid injection. The relationship between age and degree of calcification was calculated with Spearman’s correlation analysis.
Figure 2
5 Calcification of the sixth, seventh, and eighth rib cartilages increased significantly with age (sixth rib cartilage: r Z 0.53, p-value
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e10
Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients So-Eun Han, So-Young Lim, Jai-Kyung Pyon, Sa-Ik Bang, Goo-Hyun Mun, Kap Sung Oh* The Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Received 8 December 2014; accepted 13 April 2015
KEYWORDS Aesthetic auricular reconstruction; Microtia; Rib cartilage grafts; Rib cartilage calcification
Summary Background: Cartilage calcification is an important factor in aesthetic auricular reconstruction using autologous rib cartilage grafts in adults, a technique that involves difficult manipulation and unexpected absorption. As a result, artificial implants or prosthetics are considered for auricular reconstruction in adult patients despite the limitations of artificial material. In this article, we present our experience with auricular reconstruction using autologous rib cartilage grafts in adult microtia patients with reliable aesthetic results and minimal complications. Methods: A retrospective chart review was performed for 84 microtia patients ranging in age from 21 to 56 (average: 29.9) years who underwent auricular reconstruction using autologous rib cartilage grafts from March 2001 to March 2013. To validate our acceptable reconstructive results, two independent observers performed postoperative photographic evaluation of two groups (adults and children) using non-inferiority tests in addition to patient questionnaires. Results: The mean operation time for rib cartilage grafts was 3 h and 53 min, and the follow-up time for all patients ranged from 6 months to 8 years. Surgery-related complications occurred in only three cases. On objective photographic evaluation, the adult group was not inferior to the child group in auricular shape, location, or symmetry. The subjective patient satisfaction evaluation reported a high satisfaction rate. Conclusions: As this study shows, aesthetic auricular reconstruction using rib cartilage grafts in adult microtia patients is possible even in cases with advanced cartilage calcification. Modification of the fabricating framework, well-preserved flap vascularity, and complete
* Corresponding author. Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwonro, Gangnam-gu, Seoul 135-710, Republic of Korea. Tel.: þ82 2 3410 2210; fax: þ82 2 3410 0036. E-mail address: [email protected] (K.S. Oh). http://dx.doi.org/10.1016/j.bjps.2015.04.016 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
+
MODEL
2
S.-E. Han et al. understanding of physiological aspects of rib cartilage are essential for aesthetic auricular reconstruction. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The auricular reconstruction of microtia has presented a surgical challenge to plastic reconstructive surgeons due to the highly complex three-dimensional (3D) structures of ears and the difficulty in achieving the high aesthetic demands of patients. Autologous rib cartilage grafts are widely considered a standard modality for auricular reconstruction with favorable long-term results by many professional surgeons such as Tanzer,1,2 Brent,3e5 and Nagata.6e10 The successful outcome of auricular reconstruction using autologous rib cartilage grafts depends on various factors, including the surgeon’s ability to carve cartilage, adequate size and strength of rib cartilage, and the availability of sufficient healthy normal tissue and favorable blood circulation in the auricular region. To create the 3D framework with rib cartilage, physiological aspects of rib cartilage, including sufficient amounts of costal cartilage, are important factors.11,12 In particular, calcification and the associated stiffness of cartilage with increasing age are also important factors that lead to difficult manipulation and unexpected absorption, resulting in poor surgical results.11e13 Due to this, artificial implants or prosthetics are considered an option in adult patients; however, these methods are limited by complications such as extrusion and infection and the absence of long-term follow-up results.14,15 To the best of our knowledge, there are few large published series on the use of autologous rib cartilage grafts in patients >20 years for auricular reconstruction, including objective evaluation and patient satisfaction with surgical results. In this article, we retrospectively reviewed a series of 84 adult patients (20 years) who had favorable outcomes using autologous rib cartilage grafts. An objective photographic grading system and patient questionnaires were used to validate our acceptable reconstructive results.
Patients and methods Between March 2001 and March 2013, 84 microtia patients ranging in age from 21 to 56 (mean: 29.9; standard deviation (SD): 8.7) years were transferred to our institution for auricular reconstruction. All procedures were performed by a senior surgeon (K.S.O.) using autologous rib cartilage grafts. Patient characteristics such as age, gender, cause of deformity, side of deformity, classification, type of rib cartilage combination, and procedure were noted (Table 1). The 3D reconstructed rib computed tomography (CT) was performed preoperatively using a 64-slice multidetector-row CT scanner in the same manner as a previous study.16 To measure the degree of cartilage
calcification, we analyzed the chosen rib cartilage of each patient. The proportion of calcification was measured by manually outlining the calcification area and the cartilage area of each CT section using software (Aquarius iNtuition, Terarecon, CA, USA). To evaluate the correlations for age and degree of calcification, we executed Spearman’s correlation analysis using Statistical Analysis System (SAS) version 9.3 (SAS Institute, Cary, NC, USA). The p-values were considered to be significant at a level of 0.05. Postoperative photographs were used by two independent observers to evaluate aesthetic outcomes, including auricular shape and location, symmetry, and scar formation. Each item was graded as
Table 1
Patient characteristics.
Characteristics
Adult group No. of Patients (%)
Child group No. of Patients (%)
Age at surgery
21e30 years:55 (65.4) 31e40 years:18 (21.5) 41e50 years:8 (9.5) >51 years:3 (3.6)
8e10years:72 (72) 11e20 years:28 (28)
51 (60.7) 33 (39.3)
69 (69) 31 (31)
71 (84.5) 13 (15.5)
97 (97) 3 (3)
43 (51.2) 38 (45.2) 3 (3.6)
52 (52) 47 (47) 1 (1)
16 (19.0) 67 (79.8) 1 (1.2)
30 (30) 70 (70)
75 (89.0) 9 (11.0)
54 (54) 46 (46)
47 (55.9) 1 (1.2)
69 (69)
36 (42.9)
31 (31)
Sex Male Female Cause Congenital Acquired Affected side Right Left Bilateral Classification Concha Lobule Anotia Types of rib cartilage combinations 6,7,8 th 6,7,8,9 th Procedure RCG and Elevation TEI and RCG and Elevation RCG and TEI and Elevation
RCG, rib cartilage grafts. TEI, tissue expander insertion.
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
+
MODEL
Aesthetic auricular reconstruction in adult microtia patients excellent (4), good (3), fair (2), or poor (1). The evaluations were categorized into high (3 or 4) or low (1 or 2) ratings. We performed a non-inferiority test to show that the postoperative results of the adult group (age >20) were not inferior to those of the child group (age 20). For this, we sampled 100 patients in the child group who underwent the same operation and evaluation procedures. The noninferiority margin was predefined as a 10% difference in success rate. The p-values were corrected by Bonferroni’s method in the case of multiple testing, and they were considered to be significant at the level of 0.05. Photographic images of the patients were taken in frontal and oblique views. A patient satisfaction questionnaire was performed at least 12 months after the surgery, which was composed of five questions that addressed size, color match, scar appearance, and overall satisfaction. Responses to individual question were rated as “very satisfied,” “satisfied,” “unsatisfied,” or “dissatisfied.” This study was reviewed and approved by the institutional review board of our institution.
3 represents the superior and inferior crus of the antihelix, was sufficiently modified to make the tail of the cartilage reach the crus helix of the main framework. We especially focused on minimizing the risk of skin-flap necrosis by preserving a subcutaneous pedicle to ensure adequate blood supply to nourish the skin flap.
Auricular elevation An incision was made along the lateral margin of the ear framework, and the framework was elevated. The superficial temporal fascia was elevated and then folded backward to cover the cartilage blocks, which were banked in the subcutaneous layer of the chest during rib cartilage grafting. The posterior raw surface of the ear framework was covered by defatted harvested skin from the groin. Sterilized glasses were used to ensure they could be worn correctly without problems.
Tissue expander insertion
Surgical procedure Autologous rib cartilage grafting To create the framework, the senior author (K.S.O.) harvested cartilage from three or four locations on the sixth to the ninth ribs depending on the size and shape of the patient’s cartilage (Figure 1). The cartilage of the sixth and seventh ribs and the synchondritic portion of the contralateral chest were used for the framework base according to the methods of Brent3 and Nagata.6 A groove was created on the outer margin of the base frame in order to stabilize the helical component and to place it at the eighth cartilage. The scaphoid fossa and the triangular fossa were obtained by sculpting the body of the base framework if the thickness of the cartilage pieces was sufficient. In order to prevent a blunted convolution in cases where the cartilage was thin, the prominent structures used were the superior and inferior crus of the antihelix, which were attached by an additional Y-shaped cartilage graft to the ninth cartilage or other residual cartilage pieces on the base frame. In many adult cases, there were enough residual cartilage pieces to reconstruct the superior and inferior crus of the antihelix without using the ninth cartilage. The major concern regarding auricular reconstruction in adults is rib cartilage calcification. Prior to the operation, we evaluated rib cartilage calcification characteristics with the aid of 3D CT images. In cases with severely calcified cartilage, we used burrs for delicate carving instead of chisels and scalpels. To reconstruct the helix component, we used the eighth cartilage for a one-piece carving without breaking. However, the rib cartilage broke during bending in cases with severely calcified cartilage. If this occurred, the broken calcified cartilage was trimmed, and then Prolene suture was used to form and fix the natural configuration. To tightly assemble the rib cartilage framework, we fixed the cartilage to the base framework using Prolene suture, or K-wire suture in some cases, taking care to avoid the severely calcified area. To create the tragus and intertragal notch, the length of the Y-shaped cartilage graft, which
In anotia cases, tissue expander insertion surgery was performed before autologous rib cartilage grafts regardless of age to obtain sufficient soft tissue. For acquired traumatic deformity cases, we inserted a tissue expander between the rib cartilage grafts and the auricular elevation to reduce scar contracture and obtain enough soft tissue. One patient did not want additional groin scarring and desired a well-matched skin color for the reconstructed ear, so we performed this procedure in that case as well. A 3-cm incision line was created on the margin of the ear framework. A 45e or a 60-ml rectangular tissue expander was inserted subcutaneously at the postauricular mastoid region in the same manner as a previous study.17 A subcutaneous pocket was dissected and extended over the scalp covering the mastoid area in order to obtain sufficient space for the tissue expander. The pocket for the port, which was connected to the prosthesis by a length of tubing, was prepared in the temporal area. Inflation with normal saline was initiated 2 weeks after tissue expander insertion, and expansion was performed at 2-week intervals over a period of 3e4 months post operatively.
Tissue expander removal and auricular elevation The expanded postauricular skin flap was advanced to the mastoid area, and it was set into the auriculo-cephalic sulcus after removing the tissue expander.17 We performed thorough capsulectomy of the expanded postauricular skin flap to make a more visually projected ear with less tension. The predicted remnant skin flap and dog-ears were marked and then excised. Auricular elevation with groin skin provides a dark-pigmented color in the postauricular area. Instead of full-thickness skin from the inguinal area, the excised skin was draped at the posterior surface for the elevation procedure.17 Despite the addition of the tissue expander insertion procedure, we obtained satisfactory aesthetic results using the expanded skin to buttress the cartilage framework, with superior skin texture and color match.17
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
+
MODEL
4
S.-E. Han et al.
Figure 1 (above left) On the outer margins of the sixth and seventh cartilage base frameworks, the helical component was stabilized by the eighth cartilage (above right). Broken calcified cartilage was trimmed, and then Prolene sutures were used for suitable fixation. The scaphoid fossa and the triangular fossa were produced by sculpting the base framework (middle left). Completed rib cartilage framework, middle right; tragus reconstruction, below left. Prolene sutures were used to fix the rib cartilage framework.
Results A total of 85 cases in 84 consecutive microtia patients who were older than 20 years underwent auricular reconstruction using autologous rib cartilage grafts. The mean operation time for rib cartilage grafts was 3 h and 53 min, and the follow-up time for all patients ranged from 6
months to 8 years, with an average of approximately 3 years. There were no cases of cartilage extrusion, skinflap necrosis, or infection. One case of hematoma after tissue expander insertion was caused by inadequate intraoperative hemostasis without the use of postoperative pressure dressing. Hematoma evacuation was performed after identifying the bleeding focus. With
Please cite this article in press as: Han S-E, et al., Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.04.016
+
MODEL
Aesthetic auricular reconstruction in adult microtia patients Table 2 Comparison of “High Ratinga” proportions in objective photographic evaluation between the two groups.
Shape and location
Symmetry
Scar
Adult group N Z 84 (45.6%)
Child group N Z 100 (54.4%)
pvalue
Observer 1: 81(96%) Observer 2: 82(97%) Observer 1: 77(91%) Observer 2: 79(94%) formation
Observer 1: 95(95%) Observer 2: 98 (98%) Observer 1: 87(87%) Observer 2: 98(98%) Observer 1: 80(95%) 0.0042
0.0001
Observer 1: 97(97%) Observer 2: Observer 2: 76(90%) 97(97%) a
0.0000 0.0012 0.0394
0.3380
High rating means Excellent (4) or Good (3).
regard to the elevation procedure, there was one case of partial skin graft loss and one case of hypertrophic scarring. The patient with partial skin graft loss underwent an additional split-thickness skin graft. The patient who developed a hypertrophic scar in the postauricular area responded to treatment with an intralesional steroid injection. The relationship between age and degree of calcification was calculated with Spearman’s correlation analysis.
Figure 2
5 Calcification of the sixth, seventh, and eighth rib cartilages increased significantly with age (sixth rib cartilage: r Z 0.53, p-value
