Surgical Methods Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
Elevation of the Auricle without Canal/Tympanoplasty Norio Fukuda · Yoko Fukayama
In principle, construction of the external auditory canal (EAC)/tympanoplasty is actively performed during elevation of the auricle in all patients with bilateral microtia at our department. This is because improved auditory acuity is expected and headband-type bone-conduction hearing aids can be switched to in-ear hearing aids (airconduction hearing aids to be worn inside the ear hole). However, when a patient with unilateral microtia, or his/her family, does not want reconstruction of EAC/tympanoplasty, or when improved auditory acuity is not expected with the procedure because of poor growth of the middle ear evaluated according to Jahrsdoerfer’s grading system [1], elevation of the auricle without canal/tympanoplasty is performed by the department of plastic surgery only. The advantage of this method would be reduced temporal/physical burden on patients because of a shorter operating time and fewer postoperative visits to the otolaryngologist. A disadvantage would be the necessity for another surgery if the patient wants construction of the external ear later, but we use three-dimensional CT to determine the position of ear plasty in advance, so that the cavity of concha is positioned at the optimal site even when the EAC is not constructed. After the first-stage surgery of costal cartilage transplantation, where the framework created from the costal cartilage is transplanted under the skin of the scheduled site of the auricle, auricle elevation is performed about 6 months later as the secondstage surgery. Various methods can be used for elevation depending on the individual operator, but the currently popular method is banking the extra cartilage harvested during the first-stage surgery under the chest skin, to be taken out during the secondstage surgery to create the buttress for auricular elevation. A method for elevating the temporal fascia flap (TPF) to cover the buttress cartilage for skin grafting over it [2], and a method for elevation of a fascia flap posterior to the reconstructed auricle to cover the buttress cartilage [3] have also been reported. We usually perform an easy
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Department of Plastic Surgery, Dokkyo Medical University, Tochigi, Japan
a
b
Fig. 1. a. Incision around the reconstructed auricle. b. Reconstructed auricle elevated above TPF and creating a pocket for inserting the buttress.
method using the membrane around the framework and TPF. Recently, split-thickness skin grafting from the scalp has been performed at the posterior of the reconstructed auricle.
We shave patients’ hair about 10 cm around the auricle area to prepare for surgery for fixation of tie-overs and harvesting skin from the temporal region, and also perform preparations for general anesthesia (preoperative tests, explanation to family members, etc.). During the operation, we mark an incision line around the auricle and inject epinephrine solution diluted 200,000-fold. We inject physiological saline subcutaneously to the donor site to facilitate harvesting skin of 12/1,000 inch in thickness, 5 cm in width, and 7 cm in length using an air pressure type or electronic dermatome prior to skin incision. Then, we make an incision around the reconstructed auricle, and elevate the reconstructed auricle on the layer above the TPF while preserving a layer of membrane around there constructed auricle framework. Next, we proceed with dissection up to the margin of the cavity of concha to create a window-like opening on the TPF connected to the framework. Then, we make a window at the membrane around the framework along the margin of the cavity of concha, and bind together the TPF and membrane to create a pocket for inserting the buttress cartilage (fig. 1). At the same time, we take out the costal cartilage banked under the chest skin, and create a buttress13 mm in height by arranging at least two trains of cartilage blocks in an arc shape (fig. 2). We insert the buttress cartilage into the pocket and make necessary modifications, and we suture and close the window (fig. 3). Fixation of the buttress cartilage itself with suture is not necessary.
Elevation of the Auricle Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
93
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Preparations for and Procedures of Surgery
Fig. 2. We take out the costal cartilage banked under the chest skin, and create buttress blocks in an arc shape.
Fig. 3. This shows the buttress cartilage inserted into a pocket.
We dissect the area around the elevated auricle a little wider on the TPF and suture vertically at the posterior region of the reconstructed auricle to define the elevated auricle and a groove in the temporal region and to reduce the area of skin grafting. Finally, we perform skin grafting over the framework membrane and TPF. When performing tie-over fixation, we knot the threads in the horizontal direction alone to avoid wrinkling the skin graft (fig. 4).
94
Fukuda · Fukayama Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Fig. 4. Skin grafting over the framework membrane and TPF.
Fig. 5. Three months after the operation.
Fig. 6. Twenty months after the operation.
A side from suturing of skin grafting, hang 10–13 threads around the auricle and the same number of threads at a site distant from the skin graft for use as tieovers.
We usually remove the tie-overs 2 weeks after surgery if there are no signs of infection, and after removing the sutures we observe the course on an outpatient basis. Skin grafts usually take favorably as long as excessive pressure is not applied. When skin grafts do not take well in some areas, we apply ointment and observe the course. When signs of infection are observed, the wound should be promptly lavaged. Although very rare, when exposure of the transplanted buttress cartilage cannot be prevented by conservative observation of the course, we try to cover the transplanted buttress cartilage using the skin flap from the postauricular region.
Elevation of the Auricle Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
95
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Postoperative Management and Complications
References 3 Yoshimura K, AsatoH, Nakatsuka T, Sugawara Y, Park S: Elevation of a constructed auricle using the anteriorly based mastoid fascial flap. Br J Plast Surg 1999;52:530–533.
Norio Fukuda Department of Plastic Surgery, Dokkyo Medical University 880 Kitakobayashi, Mibu-Machi, Shimotsuga-gun Tochigi 320-0293 (Japan) E-Mail [email protected]
96
Fukuda · Fukayama Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
1 Jahrsdoerfer RA, Yearkley JW, Aguilar EA, Cole RR, Gray LC: Grading system for the selection of patients with congenital aural atresia. Am J Otol 1992; 13: 6– 12. 2 Nagata S: Modification of the stages in total reconstruction of the auricle. IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 1994; 93: 254– 266.
Elevation of the Auricle without Canal/Tympanoplasty Norio Fukuda · Yoko Fukayama
In principle, construction of the external auditory canal (EAC)/tympanoplasty is actively performed during elevation of the auricle in all patients with bilateral microtia at our department. This is because improved auditory acuity is expected and headband-type bone-conduction hearing aids can be switched to in-ear hearing aids (airconduction hearing aids to be worn inside the ear hole). However, when a patient with unilateral microtia, or his/her family, does not want reconstruction of EAC/tympanoplasty, or when improved auditory acuity is not expected with the procedure because of poor growth of the middle ear evaluated according to Jahrsdoerfer’s grading system [1], elevation of the auricle without canal/tympanoplasty is performed by the department of plastic surgery only. The advantage of this method would be reduced temporal/physical burden on patients because of a shorter operating time and fewer postoperative visits to the otolaryngologist. A disadvantage would be the necessity for another surgery if the patient wants construction of the external ear later, but we use three-dimensional CT to determine the position of ear plasty in advance, so that the cavity of concha is positioned at the optimal site even when the EAC is not constructed. After the first-stage surgery of costal cartilage transplantation, where the framework created from the costal cartilage is transplanted under the skin of the scheduled site of the auricle, auricle elevation is performed about 6 months later as the secondstage surgery. Various methods can be used for elevation depending on the individual operator, but the currently popular method is banking the extra cartilage harvested during the first-stage surgery under the chest skin, to be taken out during the secondstage surgery to create the buttress for auricular elevation. A method for elevating the temporal fascia flap (TPF) to cover the buttress cartilage for skin grafting over it [2], and a method for elevation of a fascia flap posterior to the reconstructed auricle to cover the buttress cartilage [3] have also been reported. We usually perform an easy
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Department of Plastic Surgery, Dokkyo Medical University, Tochigi, Japan
a
b
Fig. 1. a. Incision around the reconstructed auricle. b. Reconstructed auricle elevated above TPF and creating a pocket for inserting the buttress.
method using the membrane around the framework and TPF. Recently, split-thickness skin grafting from the scalp has been performed at the posterior of the reconstructed auricle.
We shave patients’ hair about 10 cm around the auricle area to prepare for surgery for fixation of tie-overs and harvesting skin from the temporal region, and also perform preparations for general anesthesia (preoperative tests, explanation to family members, etc.). During the operation, we mark an incision line around the auricle and inject epinephrine solution diluted 200,000-fold. We inject physiological saline subcutaneously to the donor site to facilitate harvesting skin of 12/1,000 inch in thickness, 5 cm in width, and 7 cm in length using an air pressure type or electronic dermatome prior to skin incision. Then, we make an incision around the reconstructed auricle, and elevate the reconstructed auricle on the layer above the TPF while preserving a layer of membrane around there constructed auricle framework. Next, we proceed with dissection up to the margin of the cavity of concha to create a window-like opening on the TPF connected to the framework. Then, we make a window at the membrane around the framework along the margin of the cavity of concha, and bind together the TPF and membrane to create a pocket for inserting the buttress cartilage (fig. 1). At the same time, we take out the costal cartilage banked under the chest skin, and create a buttress13 mm in height by arranging at least two trains of cartilage blocks in an arc shape (fig. 2). We insert the buttress cartilage into the pocket and make necessary modifications, and we suture and close the window (fig. 3). Fixation of the buttress cartilage itself with suture is not necessary.
Elevation of the Auricle Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
93
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Preparations for and Procedures of Surgery
Fig. 2. We take out the costal cartilage banked under the chest skin, and create buttress blocks in an arc shape.
Fig. 3. This shows the buttress cartilage inserted into a pocket.
We dissect the area around the elevated auricle a little wider on the TPF and suture vertically at the posterior region of the reconstructed auricle to define the elevated auricle and a groove in the temporal region and to reduce the area of skin grafting. Finally, we perform skin grafting over the framework membrane and TPF. When performing tie-over fixation, we knot the threads in the horizontal direction alone to avoid wrinkling the skin graft (fig. 4).
94
Fukuda · Fukayama Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Fig. 4. Skin grafting over the framework membrane and TPF.
Fig. 5. Three months after the operation.
Fig. 6. Twenty months after the operation.
A side from suturing of skin grafting, hang 10–13 threads around the auricle and the same number of threads at a site distant from the skin graft for use as tieovers.
We usually remove the tie-overs 2 weeks after surgery if there are no signs of infection, and after removing the sutures we observe the course on an outpatient basis. Skin grafts usually take favorably as long as excessive pressure is not applied. When skin grafts do not take well in some areas, we apply ointment and observe the course. When signs of infection are observed, the wound should be promptly lavaged. Although very rare, when exposure of the transplanted buttress cartilage cannot be prevented by conservative observation of the course, we try to cover the transplanted buttress cartilage using the skin flap from the postauricular region.
Elevation of the Auricle Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
95
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
Postoperative Management and Complications
References 3 Yoshimura K, AsatoH, Nakatsuka T, Sugawara Y, Park S: Elevation of a constructed auricle using the anteriorly based mastoid fascial flap. Br J Plast Surg 1999;52:530–533.
Norio Fukuda Department of Plastic Surgery, Dokkyo Medical University 880 Kitakobayashi, Mibu-Machi, Shimotsuga-gun Tochigi 320-0293 (Japan) E-Mail [email protected]
96
Fukuda · Fukayama Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 92–96 (DOI: 10.1159/000350622)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:27:36 AM
1 Jahrsdoerfer RA, Yearkley JW, Aguilar EA, Cole RR, Gray LC: Grading system for the selection of patients with congenital aural atresia. Am J Otol 1992; 13: 6– 12. 2 Nagata S: Modification of the stages in total reconstruction of the auricle. IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 1994; 93: 254– 266.
