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Early experience in microtia reconstruction: The first 100 cases
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 452e458
Early experience in microtia reconstruction: The first 100 cases* Walid Sabbagh* Department of Plastic and Reconstructive Surgery, Royal Free Hospital, Pond Street, London NW3 2PF, UK Received 6 June 2010; accepted 27 July 2010
KEYWORDS Microtia; Ear reconstruction
Summary Auricular reconstruction in Microtia is a challenging operation with a steep learning curve. In view its rarity attaining a high standard for new surgeons is extremely difficult. This study analyses the first 100 microtia cases looking at complications, technique, pattern of progress and aesthetic outcome. The author performed 100 autologous ear reconstructions for microtia over a period of 4 years utilizing the two stage technique popularised by Nagata and Firmin. In 11 cases a temroparietal fascial flap was utilised because of either a low hairline or scarring. Follow up ranged from 3 to 36 months. Data was collected prospectively. There were 7 cases of partial skin necrosis, 3 of which healed with conservative management. In early cases deficiencies were seen in the proportions of the reconstructed ear and the quality of definition. Better shape and definition were evident as more surgical experience was gained. This occurred as a result of increased appreciation of the ear proportions and improved framework carving. Although two stages were planned 21 cases required further procedures. The series demonstrates the early learning curve in microtia reconstruction and underlines the importance of appropriate training and case availability in achieving high quality results in autologous ear reconstruction. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Autologous ear reconstruction for Microtia is one of the most challenging operations in Plastic Surgery. The ear cartilage has a complex and intricate three-dimensional shape which is enveloped by very thin skin. To construct a quality auricle
* Presented at the British Association of Plastic Reconstructive and Aesthetic Surgery winter meeting, London, December 2008. * Tel.: þ44 020 7794 0500. E-mail address: [email protected].
dedication, surgical aptitude and artistic ability are required. A number of prominent surgeons worldwide have brought ear reconstruction to new standards of excellence. Tanzer was the first to establish that consistent good results can be achieved with costal cartilage.1 Brent described it as ‘a unique marrying of science and art’ and has attained outstanding results with a four stage technique.2,3 Nagata popularised a two stage technique4e9 demonstrating meticulous approach with an excellent outcome. Firmin reported a large series comparing both techniques 10 and more
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.07.027
Early experience in microtia reconstruction recently described a two stage approach based on an alternative surgical classification.11 Their results have set very high standards for autologous ear reconstruction. New Surgeons who aim to perform ear reconstruction are faced by a number of problems. The relative rarity of microtia means that the case availability will be restricted whilst a steady stream of case is necessary to achieve high quality results. There is a long learning curve12 which could well be at the expense of the patient. Complications and unsatisfactory outcome are extremely difficult to rectify and a poor result is often a disastrous outcome for the patient. The author started performing autologous ear reconstruction in 2005 in an already established centre of referral (Mount Vernon Hospital). This study describes the experience with costal cartilage reconstruction for microtia in the first 4 years of practice. One hundred consecutive cases which were performed in this period are reported. The objective was to assess, complications, evolution of technique, pattern of progress and aesthetic outcome. All patients were treated with the principles of the two stage method. The Nagata technique was applied in the majority of the early cases and the technique described by Firmin was also utilised later on in the series.
Patients and methods A total of 96 patients (100 ears) were operated on over a period of 4 years. The group comprised 55 males and 41 females with mean age of 10 (age 7e36). Unilateral microtia accounted for 92 of the patients and 4 patients had bilateral microtia. In 59 cases the microtia was of the lobular type (Figure 3a and c), 26 cases of the conchal type (Figure 4a), eight cases were classified as atypical and the last seven were severe constricted ears requiring rib cartilage for reconstruction. Eighty seven were categorised as non-complex; these had good quality skin and a high hair line. In the remaining 13 complex cases eight had a low hair line and five had scarring from previous surgery. In the complex cases the temproparietal fascial flap (TPF) was used in 12 cases and tissue expansion in one case.
453 the cartilage adjacent to the wire and the each wire is pulled gently towards the incision so it is as snug as possible although not buried in the cartilage. Figure 1 shows a framework early on in the series compared to a more refined framework carved in the latter half of the series. The tragus was constructed at the same time in most cases. For this the vestigial elastic cartilage already present in the microtia was used early on in the series whilst later it was carved from the rib cartilage and incorporated into the framework.
Non-complex cases The Nagata skin approach (lobe transposition, posterior W shaped flap and a subcutaneous pedicle) was initially applied for the lobular and Conchal type microtia (Figure 2a). Later on, however, more cases were performed using the technique described by Francois Firmin in which the lobe is transposed and fixed maintaining the post-auricular sulcus behind the lobule (type 2a according to Firmin classification) (Figure 2d). Of the 85 lobular and conchal microtia cases 43 were reconstructed with the Nagata technique and 42 with the Firmin technique. When the Nagata technique is utilised then it is not possible to insert a framework which is constructed as a complete ring as illustrated in Figure 1b because of the subcutaneous pedicle. In these cases the tragus is not linked to the root of the helix and its stability is maintained by anchoring sutures to the deeper tissue using 5/0 PDS and if necessary bolster sutures are used for the overlying skin which are removed at two weeks. Two suction drains were inserted in all cases which were attached to vacutainers. In the authors hands there was no obvious cosmetic advantage observed between the two approaches (Figure 2). The Firmin technique was increasingly chosen in the latter part of the series because of its less complex design and execution. It was noted, however, that in four cases using the Firmin technique there was partial skin necrosis in the conchal fossa compared to only 1 case using the Nagata technique. The absence of a subcutaneous pedicle as well as a smaller skin envelope to cover the framework, resulting in more tension, may have contributed to this. Therefore the Nagata approach became the preferred choice for cases where the skin was judged to be tight or the lobule was located relatively high. Also if there was any
Surgical technique Rib harvest The cartilage of ribs six, seven and eight were harvested from the ipsilateral microtia side with preservation of the posterior perchondrium. The ninth rib cartilage was also harvested if deemed necessary for the antihelix. The base of the framework was carved from ribs six and seven whilst the eighth rib was bisected and utilised for the helical rim. The remaining half of the eighth rib or ninth (when harvested) was used for the antihelix. When the antihelix is constructed the author does attempts to create a downward slope to the upper and lower crus to give a more natural appearance. The framework carved is not uniform to all cases and is always based on the shape of the contralateral ear. The framework was constructed and fixed together using Nagata fine stainless steel wires. A minimal incision is made in
Figure 1 Carved frameworks. (a) Framework carved early on in series. (b) Framework in the latter half of the series showing improved proportions and definition of the various anatomical components.
454
Figure 2 (def).
W. Sabbagh
Pre and Post-operative photographs of a lobular microtia with the Nagata approach (aec) and with the Firmin approach
concern regarding the vascularity of the skin lining the conchal fossa/helical root area then the extra skin which is usually trimmed at the end was performed at a later date (Figure 3). For the atypical cases the skin incision was usually positioned anteriorly to remove the vestigial elastic cartilage and insert the framework, similar to the Brent technique. In these cases the lobule had to be carved from the costal cartilage. In the five cases of the severe constricted ear deformity, four were reconstructed using a floating rib cartilage and a postauricular skin flap and in one very severe case a similar approach to conchal microtia was utilised.
Complex cases The TPF flap was used in 12 cases. This was covered by a SSG from the thigh in the first two cases. This was then replaced by a scalp graft which was harvested either by scalpel adjacent to the microtic ear (in low hair line cases) or with a dermatome in the occipital area in scarred cases. The advantage of a scalp graft is that it can be harvested
thicker and has better colour match. Tissue expansion was used in only one case which had shortage of skin because of previous surgery.
Post-operative care All patients had a catheter inserted in the chest wound for post-operative analgesia into which 10 ml of 0.25% Bupivicane was injected up to 4 times a day. The vacutainers were changed every 2 h for the first 24 h and then every 4 h. Physiotherapy was commenced on the first post-operative day. The bandages were removed on the third post-operative day and patients were discharged when they were fully mobile (days 3e5).
The second stage Release of the reconstructed ear was performed 6e12 months following the first stage. A previously stored cartilage block was fixed behind the elevated ear to maintain projection. This
Early experience in microtia reconstruction
455
Figure 3 (aec) Conchal type microtia reconstructed with the Firmin approach. The excess skin was trimmed at a later date so the vascularity of the skin in the conchal fossa and over helical root was not compromised.
was then covered either by a random pattern fascial flap from the mastoid area or a TPF flap which in turn was covered by a scalp SSG. Later on in the series the TPF flap became the first choice because of some problems encountered with the mastoid fascia turnover flap. These included occasional graft loss on the posterior aspect of the ear adjacent to the helical rim and also loss of ear projection usually observed after several months. The latter may be related to a combination of the mastoid fascia suboptimal vascularity resulting in cartilage resorption as well as its contraction. In the complex cases in which a TPF flap was already utilised in the first stage then the deep temporal fascia was used to cover the cartilage block. In 5 cases where the contralateral ear had minimum projection then a fascial tunnel was created behind the ear and a small piece of costal cartilage was inserted.
Results Complications Intra-operative complications In five patients there was a tear in the pleura during rib harvest. This was repaired with 4/0 vicryl. A Chest x-ray was performed in all these patients post-operatively and there were no cases of pneumothorax. Post-operative complications In seven patients there was partial skin necrosis, five in the conchal fossa, one over the antihelix and one over the upper pole. In three of these, conservative management was sufficient. The remaining four required surgical intervention. Two patients were managed by a transposition flap from the cheek which was used to resurface the choncal fossa. In one patient a small random pattern temporal fascia flap was flipped over to cover necrosis in the upper pole. There were no cases of infection. There was one case which developed a haematoma 4 days after discharge. This was drained through a small incision and did not compromise the final result. There was no loss of any TPF flap and no loss of any covering SSG. Long-term there was wire extrusions in seven cases and these were removed in the outpatient setting without further problems. In two patients there was some resorption in the lower end of the helical rim. In both cases bone was included in the carved rib because of insufficient cartilage length. Five
patients complained of mild tenderness in the donor site. Following the second stage 10 patients had significant loss of projection following healing. In eight of these the random pattern flap was used whilst the TPF flap was used in two.
Pattern of progress The most dramatic improvement observed was in the quality of the framework carving which was reflected in the detail of the resulting ear (Figure 1). Changes that contributed to a more aesthetic ear include: 1. 2. 3. 4. 5. 6.
Better definition of the various anatomical components Narrowing of the antihelix Narrowing of the space between helix and antihelix Larger and oval conchal fossa Incorporating a helical root into the framework Improved tragus construction
Also increasing experience resulted in a more uniform thin skin envelope which adapted better to the cartilage framework. With regard to the TPF flap, a wider base improved venous drainage resulting in decreased swelling. It was noted that a thin thigh SSG gave a poor appearance as it had a tendency to contract. Thicker scalp SSG gave a better result especially when the skin was harvested with a scalpel in continuity with the ear.
Total number of operations per microtia case Although the aim was to complete the surgery in two stages, further procedures were required in 21 cases (in addition to the four cases which required local flaps to manage partial skin necrosis described above). These included excisions of skin excess (9 cases) (Figure 3), tragus reconstruction (5 cases), deepening of conchal fossa (TPF patients) (1 case), lobe realignment (3 cases), and re-release because of loss of projection (3 cases). In addition laser for hair on the helical rim was necessary in seven cases.
Aesthetic outcome The aesthetic outcome was categorised into very good, good, fair and poor. These were judged subjectively by the
456
W. Sabbagh
Discussion There have been significant advancements in autologous ear reconstruction over the past two decades. Brent, Nagata and Firmin have all reported outstanding results and encouraged many aspiring surgeons to engage in this highly specialised surgery. In addition to the technical aspect, microtia reconstruction presents other challenges. Limited case availability further compounds a learning curve which was clearly illustrated in this study especially in the carving and assembly of the cartilaginous framework. Complications and/or poor technique result in a situation which is extremely difficult to rectify since the outcome of autologous ear reconstruction is very dependent on high quality non scarred skin. It is therefore very important that ear reconstruction surgeons undergo training in this field and ensure that geographically there will be sufficient case availability before embarking on this surgery. There are a number of techniques now available for microtia reconstruction. For many years the four stage technique advocated by Brent2 was the standard method. The two stage technique described by Nagata4 gained popularity because of the reduction in the number of operation. In addition some reports have suggested some aesthetic advantage.10 The use of the W shaped flap and the subcutaneous pedicle, however, can be challenging to design and in inexperienced hands there is a significant risk of complications and unsatisfactory outcome. Firmin has recently described a new surgical classification 11 in which most cases involve direct transposition of the lobe and utilizing the superior skin only (type 2a). Both Park13 and Pan14 have reported a large series of cases where a tissue expander is inserted in the first stage. In the second stage reconstruction with costal cartilage and release are performed at the same time with a third stage for technical refinements. This technique has not gained popularity because of the potential difficulties that can be encountered with tissue expansion, prolonged treatment course and increased burden of travel for patients who reside far from the treatment centres. In this study the
Figure 4 Pre and post-operative after completion all stages: (a-b) Fair result. Shape is satisfactory; the antihelix, upper and lower crus are thick reflecting the early framework. Also the conchal fossa is narrow. (c-d) Good result showing Improved definition and well formed conchal bowl. There is an uneven transition between antihelix and upper/lower crus. (e-f) Very good result showing superior shape and definition.
author and a non plastic surgeon on the basis of shape, anatomical proportions, thickness and definition. Five cases were graded as poor, 25 fair, 51 good and 19 very good (Figure 4). Table 1 shows the trend in aesthetic outcome over the 4 years. This demonstrates a downward trend in the cases graded fair and an upward trend in the cases graded very good. Overall reconstruction with temproparietal fascia in complex cases received a lower grade.
Table 1 Trend in aesthetic outcome over the 4 years shows a downward trend in the fair category and an upward trend in the very good category
Early experience in microtia reconstruction author began by applying the Nagata design for the skin pocket. Later on in the series more cases were performed using the Firmin approach to the skin. The main reason for this was it is easier to design and apply. The main drawback is that it provides less skin to cover the framework. Because of the tension and lack of subcutenous pedicle this appeared to increase the risk of skin compromise in the conchal fossa. The author thus prefers to apply the Nagata designs in those cases where the skin is judged to be tight or when the lobule is very narrow and high. There was no aesthetic advantage observed when comparing the two techniques. The most dramatic improvement through the series was in the carving of the cartilgenous framework. This was manifested in improvement in the anatomical proportions and attaining much better definition. The carved cartilage was very accurately reflected in the final ear shape and the improvement in aesthetic outcome observed was primarily due to the refinement of the framework. However improved utilisation of the skin (thickness and distribution) was also a significant contributor. It is highly recommended that aspiring ear surgeons practice carving on models before embarking on real live cases. There was a relatively low level of complications in this series. Complications can be minimised by a very cautious and respectful approach to the dissection of the skin pocket. This requires careful and meticulous tissue handling, absolute haemostasis and very precise application of dressing. It is also advisable for new surgeons to be more vigilant about the skin vascularity post-operatively and to inspect the ear on the first post-operative day if there is any concern as the continuous suction can exacerbate the problem. The suction drains may occasionally need to be clamped temporarily to improve the skin blood supply. Approximately 2500 wires were used in the series (average 25 per ear) with extrusion of only seven, a rate of 0.28%. The author feels that wire extrusion is possibly related to an inflammatory episode which may result in some resorption of the cartilage if occurs early prior to vascularisation of the cartilage. A minor alteration in uniformity of framework as at site of extrusions was noted in some cases of wire extrusion that occurred within the first six months. The creation of a post-auricular sulcus and achieving adequate projection (the second stage) presents a challenge to the ear surgeon because of the scar contracture that can occur. The most important step is to secure an accurately carved piece of cartilage behind the reconstructed ear. This then has to be covered by vascularised fascia prior to grafting. The turnover mastoid fascial flap is less invasive than the TPF flap and for that reason it was initially chosen. A number of complications were encountered using the mastoid fascia which includes partial graft loss close to the helical rim and loss of projection. The TPF provided a superior vascularised layer and it became the standard technique later on in the series. One of the main problems with the TPF flap is the alopecia around the scar which can be minimised cutting parallel with the hair follicles. The thicker scalp graft was also aesthetically superior to a full thickness graft and a thigh SSG and contacted less than the latter.
457 The complex cases which were reconstructed with a TPF flap cover received an overall lower aesthetic result. There are a number of steps which can optimise the outcome with a TPF flap reconstruction. These include maintaining a wide base to improve venous drainage and thus minimise flap swelling. The use of an ultra delicate graft in continuity with the local skin gives the best possible colour match and is least likely to contract. It is also important to create a deep conchal fossa to enhance the shape of the ear. This series clearly shows that there is a learning curve to microtia reconstruction. Such a learning curve is unavoidable; however, it is important that its steepness is curtailed. Before undertaking costal cartilage reconstruction surgeons should complete a fellowship in this field to gain an in-depth understanding of the techniques and the principles involved. It is important that these cases are not performed on an occasional basis by interested surgeons as it is unlikely that good results will be achieved. A suboptimal outcome is disastrous to the patient and extremely difficult to rectify. Thus it is recommended that ear reconstruction is only performed where there is a steady stream of cases. This series demonstrates that with the appropriate training and case availability it is possible to attain good results without engaging in a prolonged learning curve at the expense of the patient.
Conflict of interest None.
Funding None.
References 1. Tanzer RC. Microtia- a long term follow up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61:161e6. 2. Brent B. The correction of microtia with autologous cartilage graft: I. The classic deformity. Plast Reconstr Surg 1980;66: 1e12. 3. Brent B. Technichal advances with autogenous rib cartilage graft: personal experience with 1200 cases. Plast Reconstr Surg 1999 Aug;104:319e34. 4. Nagata S. A new method of total reconstruction of the auricle in microtia. Plast Reconstr Surg 1993;92:187e201. 5. Nagata S. Secondary reconstruction for unfavourable microtia results utilizing temproparietal and innonimate fascia flaps. Plast Reconstr Surg 1994;94:254e65. 6. Nagata S. Modification of the stages in total reconstruction of the auricle: part I. Grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93:221e30. 7. Nagata S. Modification of the stages in total reconstruction of the auricle: part II. Grafting the three-dimensional costal cartilage framework for concha-type microtia. Plast Reconstr Surg 1994;93:231e42. 8. Nagata S. Modification of the stages in total reconstruction of the auricle: part III. Grafting the three-dimensional costal cartilage framework for small concha-type microtia. Plast Reconstr Surg 1994;93:243e53.
458 9. Nagata S. Modification of the stages in total reconstruction of the auricle: part IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 1994;93:254e66. 10. Firmin F. Ear reconstruction in cases of typical microtia. personal experience based on 352 microtic ear correction. Scand J Plast Reconstr Surg 1998;32:35e47. 11. Firmin F. La reconstruction auriculaire en cas de microtie. Principes, methods et classification. Ann Chir Plast Esthet 2001;46:447e66.
W. Sabbagh 12. Suutarla S, Rautio J, Klockars T. The learning curve in microtia surgery. Facial Plast Surg 2009; Aug;25:164e8. 13. Park C, Lee TJ, Shin KS, et al. A single stage two flap method of total ear reconstruction. Plast Reconstr Surg 1991;88:404e12. 14. Pan B, Jiang H, Guo D, et al. Microtia: ear reconstruction using tissue expander and autogenous costal cartilage. J Plast Reconstr Aesthet Surg 2008;61(Suppl. 1):S98e103 [Epub 2007 Sep 4].
Early experience in microtia reconstruction: The first 100 cases* Walid Sabbagh* Department of Plastic and Reconstructive Surgery, Royal Free Hospital, Pond Street, London NW3 2PF, UK Received 6 June 2010; accepted 27 July 2010
KEYWORDS Microtia; Ear reconstruction
Summary Auricular reconstruction in Microtia is a challenging operation with a steep learning curve. In view its rarity attaining a high standard for new surgeons is extremely difficult. This study analyses the first 100 microtia cases looking at complications, technique, pattern of progress and aesthetic outcome. The author performed 100 autologous ear reconstructions for microtia over a period of 4 years utilizing the two stage technique popularised by Nagata and Firmin. In 11 cases a temroparietal fascial flap was utilised because of either a low hairline or scarring. Follow up ranged from 3 to 36 months. Data was collected prospectively. There were 7 cases of partial skin necrosis, 3 of which healed with conservative management. In early cases deficiencies were seen in the proportions of the reconstructed ear and the quality of definition. Better shape and definition were evident as more surgical experience was gained. This occurred as a result of increased appreciation of the ear proportions and improved framework carving. Although two stages were planned 21 cases required further procedures. The series demonstrates the early learning curve in microtia reconstruction and underlines the importance of appropriate training and case availability in achieving high quality results in autologous ear reconstruction. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Autologous ear reconstruction for Microtia is one of the most challenging operations in Plastic Surgery. The ear cartilage has a complex and intricate three-dimensional shape which is enveloped by very thin skin. To construct a quality auricle
* Presented at the British Association of Plastic Reconstructive and Aesthetic Surgery winter meeting, London, December 2008. * Tel.: þ44 020 7794 0500. E-mail address: [email protected].
dedication, surgical aptitude and artistic ability are required. A number of prominent surgeons worldwide have brought ear reconstruction to new standards of excellence. Tanzer was the first to establish that consistent good results can be achieved with costal cartilage.1 Brent described it as ‘a unique marrying of science and art’ and has attained outstanding results with a four stage technique.2,3 Nagata popularised a two stage technique4e9 demonstrating meticulous approach with an excellent outcome. Firmin reported a large series comparing both techniques 10 and more
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.07.027
Early experience in microtia reconstruction recently described a two stage approach based on an alternative surgical classification.11 Their results have set very high standards for autologous ear reconstruction. New Surgeons who aim to perform ear reconstruction are faced by a number of problems. The relative rarity of microtia means that the case availability will be restricted whilst a steady stream of case is necessary to achieve high quality results. There is a long learning curve12 which could well be at the expense of the patient. Complications and unsatisfactory outcome are extremely difficult to rectify and a poor result is often a disastrous outcome for the patient. The author started performing autologous ear reconstruction in 2005 in an already established centre of referral (Mount Vernon Hospital). This study describes the experience with costal cartilage reconstruction for microtia in the first 4 years of practice. One hundred consecutive cases which were performed in this period are reported. The objective was to assess, complications, evolution of technique, pattern of progress and aesthetic outcome. All patients were treated with the principles of the two stage method. The Nagata technique was applied in the majority of the early cases and the technique described by Firmin was also utilised later on in the series.
Patients and methods A total of 96 patients (100 ears) were operated on over a period of 4 years. The group comprised 55 males and 41 females with mean age of 10 (age 7e36). Unilateral microtia accounted for 92 of the patients and 4 patients had bilateral microtia. In 59 cases the microtia was of the lobular type (Figure 3a and c), 26 cases of the conchal type (Figure 4a), eight cases were classified as atypical and the last seven were severe constricted ears requiring rib cartilage for reconstruction. Eighty seven were categorised as non-complex; these had good quality skin and a high hair line. In the remaining 13 complex cases eight had a low hair line and five had scarring from previous surgery. In the complex cases the temproparietal fascial flap (TPF) was used in 12 cases and tissue expansion in one case.
453 the cartilage adjacent to the wire and the each wire is pulled gently towards the incision so it is as snug as possible although not buried in the cartilage. Figure 1 shows a framework early on in the series compared to a more refined framework carved in the latter half of the series. The tragus was constructed at the same time in most cases. For this the vestigial elastic cartilage already present in the microtia was used early on in the series whilst later it was carved from the rib cartilage and incorporated into the framework.
Non-complex cases The Nagata skin approach (lobe transposition, posterior W shaped flap and a subcutaneous pedicle) was initially applied for the lobular and Conchal type microtia (Figure 2a). Later on, however, more cases were performed using the technique described by Francois Firmin in which the lobe is transposed and fixed maintaining the post-auricular sulcus behind the lobule (type 2a according to Firmin classification) (Figure 2d). Of the 85 lobular and conchal microtia cases 43 were reconstructed with the Nagata technique and 42 with the Firmin technique. When the Nagata technique is utilised then it is not possible to insert a framework which is constructed as a complete ring as illustrated in Figure 1b because of the subcutaneous pedicle. In these cases the tragus is not linked to the root of the helix and its stability is maintained by anchoring sutures to the deeper tissue using 5/0 PDS and if necessary bolster sutures are used for the overlying skin which are removed at two weeks. Two suction drains were inserted in all cases which were attached to vacutainers. In the authors hands there was no obvious cosmetic advantage observed between the two approaches (Figure 2). The Firmin technique was increasingly chosen in the latter part of the series because of its less complex design and execution. It was noted, however, that in four cases using the Firmin technique there was partial skin necrosis in the conchal fossa compared to only 1 case using the Nagata technique. The absence of a subcutaneous pedicle as well as a smaller skin envelope to cover the framework, resulting in more tension, may have contributed to this. Therefore the Nagata approach became the preferred choice for cases where the skin was judged to be tight or the lobule was located relatively high. Also if there was any
Surgical technique Rib harvest The cartilage of ribs six, seven and eight were harvested from the ipsilateral microtia side with preservation of the posterior perchondrium. The ninth rib cartilage was also harvested if deemed necessary for the antihelix. The base of the framework was carved from ribs six and seven whilst the eighth rib was bisected and utilised for the helical rim. The remaining half of the eighth rib or ninth (when harvested) was used for the antihelix. When the antihelix is constructed the author does attempts to create a downward slope to the upper and lower crus to give a more natural appearance. The framework carved is not uniform to all cases and is always based on the shape of the contralateral ear. The framework was constructed and fixed together using Nagata fine stainless steel wires. A minimal incision is made in
Figure 1 Carved frameworks. (a) Framework carved early on in series. (b) Framework in the latter half of the series showing improved proportions and definition of the various anatomical components.
454
Figure 2 (def).
W. Sabbagh
Pre and Post-operative photographs of a lobular microtia with the Nagata approach (aec) and with the Firmin approach
concern regarding the vascularity of the skin lining the conchal fossa/helical root area then the extra skin which is usually trimmed at the end was performed at a later date (Figure 3). For the atypical cases the skin incision was usually positioned anteriorly to remove the vestigial elastic cartilage and insert the framework, similar to the Brent technique. In these cases the lobule had to be carved from the costal cartilage. In the five cases of the severe constricted ear deformity, four were reconstructed using a floating rib cartilage and a postauricular skin flap and in one very severe case a similar approach to conchal microtia was utilised.
Complex cases The TPF flap was used in 12 cases. This was covered by a SSG from the thigh in the first two cases. This was then replaced by a scalp graft which was harvested either by scalpel adjacent to the microtic ear (in low hair line cases) or with a dermatome in the occipital area in scarred cases. The advantage of a scalp graft is that it can be harvested
thicker and has better colour match. Tissue expansion was used in only one case which had shortage of skin because of previous surgery.
Post-operative care All patients had a catheter inserted in the chest wound for post-operative analgesia into which 10 ml of 0.25% Bupivicane was injected up to 4 times a day. The vacutainers were changed every 2 h for the first 24 h and then every 4 h. Physiotherapy was commenced on the first post-operative day. The bandages were removed on the third post-operative day and patients were discharged when they were fully mobile (days 3e5).
The second stage Release of the reconstructed ear was performed 6e12 months following the first stage. A previously stored cartilage block was fixed behind the elevated ear to maintain projection. This
Early experience in microtia reconstruction
455
Figure 3 (aec) Conchal type microtia reconstructed with the Firmin approach. The excess skin was trimmed at a later date so the vascularity of the skin in the conchal fossa and over helical root was not compromised.
was then covered either by a random pattern fascial flap from the mastoid area or a TPF flap which in turn was covered by a scalp SSG. Later on in the series the TPF flap became the first choice because of some problems encountered with the mastoid fascia turnover flap. These included occasional graft loss on the posterior aspect of the ear adjacent to the helical rim and also loss of ear projection usually observed after several months. The latter may be related to a combination of the mastoid fascia suboptimal vascularity resulting in cartilage resorption as well as its contraction. In the complex cases in which a TPF flap was already utilised in the first stage then the deep temporal fascia was used to cover the cartilage block. In 5 cases where the contralateral ear had minimum projection then a fascial tunnel was created behind the ear and a small piece of costal cartilage was inserted.
Results Complications Intra-operative complications In five patients there was a tear in the pleura during rib harvest. This was repaired with 4/0 vicryl. A Chest x-ray was performed in all these patients post-operatively and there were no cases of pneumothorax. Post-operative complications In seven patients there was partial skin necrosis, five in the conchal fossa, one over the antihelix and one over the upper pole. In three of these, conservative management was sufficient. The remaining four required surgical intervention. Two patients were managed by a transposition flap from the cheek which was used to resurface the choncal fossa. In one patient a small random pattern temporal fascia flap was flipped over to cover necrosis in the upper pole. There were no cases of infection. There was one case which developed a haematoma 4 days after discharge. This was drained through a small incision and did not compromise the final result. There was no loss of any TPF flap and no loss of any covering SSG. Long-term there was wire extrusions in seven cases and these were removed in the outpatient setting without further problems. In two patients there was some resorption in the lower end of the helical rim. In both cases bone was included in the carved rib because of insufficient cartilage length. Five
patients complained of mild tenderness in the donor site. Following the second stage 10 patients had significant loss of projection following healing. In eight of these the random pattern flap was used whilst the TPF flap was used in two.
Pattern of progress The most dramatic improvement observed was in the quality of the framework carving which was reflected in the detail of the resulting ear (Figure 1). Changes that contributed to a more aesthetic ear include: 1. 2. 3. 4. 5. 6.
Better definition of the various anatomical components Narrowing of the antihelix Narrowing of the space between helix and antihelix Larger and oval conchal fossa Incorporating a helical root into the framework Improved tragus construction
Also increasing experience resulted in a more uniform thin skin envelope which adapted better to the cartilage framework. With regard to the TPF flap, a wider base improved venous drainage resulting in decreased swelling. It was noted that a thin thigh SSG gave a poor appearance as it had a tendency to contract. Thicker scalp SSG gave a better result especially when the skin was harvested with a scalpel in continuity with the ear.
Total number of operations per microtia case Although the aim was to complete the surgery in two stages, further procedures were required in 21 cases (in addition to the four cases which required local flaps to manage partial skin necrosis described above). These included excisions of skin excess (9 cases) (Figure 3), tragus reconstruction (5 cases), deepening of conchal fossa (TPF patients) (1 case), lobe realignment (3 cases), and re-release because of loss of projection (3 cases). In addition laser for hair on the helical rim was necessary in seven cases.
Aesthetic outcome The aesthetic outcome was categorised into very good, good, fair and poor. These were judged subjectively by the
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Discussion There have been significant advancements in autologous ear reconstruction over the past two decades. Brent, Nagata and Firmin have all reported outstanding results and encouraged many aspiring surgeons to engage in this highly specialised surgery. In addition to the technical aspect, microtia reconstruction presents other challenges. Limited case availability further compounds a learning curve which was clearly illustrated in this study especially in the carving and assembly of the cartilaginous framework. Complications and/or poor technique result in a situation which is extremely difficult to rectify since the outcome of autologous ear reconstruction is very dependent on high quality non scarred skin. It is therefore very important that ear reconstruction surgeons undergo training in this field and ensure that geographically there will be sufficient case availability before embarking on this surgery. There are a number of techniques now available for microtia reconstruction. For many years the four stage technique advocated by Brent2 was the standard method. The two stage technique described by Nagata4 gained popularity because of the reduction in the number of operation. In addition some reports have suggested some aesthetic advantage.10 The use of the W shaped flap and the subcutaneous pedicle, however, can be challenging to design and in inexperienced hands there is a significant risk of complications and unsatisfactory outcome. Firmin has recently described a new surgical classification 11 in which most cases involve direct transposition of the lobe and utilizing the superior skin only (type 2a). Both Park13 and Pan14 have reported a large series of cases where a tissue expander is inserted in the first stage. In the second stage reconstruction with costal cartilage and release are performed at the same time with a third stage for technical refinements. This technique has not gained popularity because of the potential difficulties that can be encountered with tissue expansion, prolonged treatment course and increased burden of travel for patients who reside far from the treatment centres. In this study the
Figure 4 Pre and post-operative after completion all stages: (a-b) Fair result. Shape is satisfactory; the antihelix, upper and lower crus are thick reflecting the early framework. Also the conchal fossa is narrow. (c-d) Good result showing Improved definition and well formed conchal bowl. There is an uneven transition between antihelix and upper/lower crus. (e-f) Very good result showing superior shape and definition.
author and a non plastic surgeon on the basis of shape, anatomical proportions, thickness and definition. Five cases were graded as poor, 25 fair, 51 good and 19 very good (Figure 4). Table 1 shows the trend in aesthetic outcome over the 4 years. This demonstrates a downward trend in the cases graded fair and an upward trend in the cases graded very good. Overall reconstruction with temproparietal fascia in complex cases received a lower grade.
Table 1 Trend in aesthetic outcome over the 4 years shows a downward trend in the fair category and an upward trend in the very good category
Early experience in microtia reconstruction author began by applying the Nagata design for the skin pocket. Later on in the series more cases were performed using the Firmin approach to the skin. The main reason for this was it is easier to design and apply. The main drawback is that it provides less skin to cover the framework. Because of the tension and lack of subcutenous pedicle this appeared to increase the risk of skin compromise in the conchal fossa. The author thus prefers to apply the Nagata designs in those cases where the skin is judged to be tight or when the lobule is very narrow and high. There was no aesthetic advantage observed when comparing the two techniques. The most dramatic improvement through the series was in the carving of the cartilgenous framework. This was manifested in improvement in the anatomical proportions and attaining much better definition. The carved cartilage was very accurately reflected in the final ear shape and the improvement in aesthetic outcome observed was primarily due to the refinement of the framework. However improved utilisation of the skin (thickness and distribution) was also a significant contributor. It is highly recommended that aspiring ear surgeons practice carving on models before embarking on real live cases. There was a relatively low level of complications in this series. Complications can be minimised by a very cautious and respectful approach to the dissection of the skin pocket. This requires careful and meticulous tissue handling, absolute haemostasis and very precise application of dressing. It is also advisable for new surgeons to be more vigilant about the skin vascularity post-operatively and to inspect the ear on the first post-operative day if there is any concern as the continuous suction can exacerbate the problem. The suction drains may occasionally need to be clamped temporarily to improve the skin blood supply. Approximately 2500 wires were used in the series (average 25 per ear) with extrusion of only seven, a rate of 0.28%. The author feels that wire extrusion is possibly related to an inflammatory episode which may result in some resorption of the cartilage if occurs early prior to vascularisation of the cartilage. A minor alteration in uniformity of framework as at site of extrusions was noted in some cases of wire extrusion that occurred within the first six months. The creation of a post-auricular sulcus and achieving adequate projection (the second stage) presents a challenge to the ear surgeon because of the scar contracture that can occur. The most important step is to secure an accurately carved piece of cartilage behind the reconstructed ear. This then has to be covered by vascularised fascia prior to grafting. The turnover mastoid fascial flap is less invasive than the TPF flap and for that reason it was initially chosen. A number of complications were encountered using the mastoid fascia which includes partial graft loss close to the helical rim and loss of projection. The TPF provided a superior vascularised layer and it became the standard technique later on in the series. One of the main problems with the TPF flap is the alopecia around the scar which can be minimised cutting parallel with the hair follicles. The thicker scalp graft was also aesthetically superior to a full thickness graft and a thigh SSG and contacted less than the latter.
457 The complex cases which were reconstructed with a TPF flap cover received an overall lower aesthetic result. There are a number of steps which can optimise the outcome with a TPF flap reconstruction. These include maintaining a wide base to improve venous drainage and thus minimise flap swelling. The use of an ultra delicate graft in continuity with the local skin gives the best possible colour match and is least likely to contract. It is also important to create a deep conchal fossa to enhance the shape of the ear. This series clearly shows that there is a learning curve to microtia reconstruction. Such a learning curve is unavoidable; however, it is important that its steepness is curtailed. Before undertaking costal cartilage reconstruction surgeons should complete a fellowship in this field to gain an in-depth understanding of the techniques and the principles involved. It is important that these cases are not performed on an occasional basis by interested surgeons as it is unlikely that good results will be achieved. A suboptimal outcome is disastrous to the patient and extremely difficult to rectify. Thus it is recommended that ear reconstruction is only performed where there is a steady stream of cases. This series demonstrates that with the appropriate training and case availability it is possible to attain good results without engaging in a prolonged learning curve at the expense of the patient.
Conflict of interest None.
Funding None.
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458 9. Nagata S. Modification of the stages in total reconstruction of the auricle: part IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 1994;93:254e66. 10. Firmin F. Ear reconstruction in cases of typical microtia. personal experience based on 352 microtic ear correction. Scand J Plast Reconstr Surg 1998;32:35e47. 11. Firmin F. La reconstruction auriculaire en cas de microtie. Principes, methods et classification. Ann Chir Plast Esthet 2001;46:447e66.
W. Sabbagh 12. Suutarla S, Rautio J, Klockars T. The learning curve in microtia surgery. Facial Plast Surg 2009; Aug;25:164e8. 13. Park C, Lee TJ, Shin KS, et al. A single stage two flap method of total ear reconstruction. Plast Reconstr Surg 1991;88:404e12. 14. Pan B, Jiang H, Guo D, et al. Microtia: ear reconstruction using tissue expander and autogenous costal cartilage. J Plast Reconstr Aesthet Surg 2008;61(Suppl. 1):S98e103 [Epub 2007 Sep 4].