- Email: [email protected]
Secondary revisions due to unfavourable results after microtia reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 940e946
Secondary revisions due to unfavourable results after microtia reconstruction Tae Sung Lee, So Young Lim, Jai Kyong Pyon, Goo Hyun Mun, Sa Ik Bang, Kap Sung Oh* Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Ilwon-dong 50, Gangnam-gu, Seoul, 135-710, Republic of Korea Received 24 January 2009; accepted 16 April 2009
KEYWORDS Microtia; Auricular reconstruction; Rib cartilage graft; Secondary revision
Summary Autologous rib cartilage grafting is a basic modality in auricular reconstruction, especially in cases of congenital microtia. However, due to heavy scarring at operative sites, lack of healthy normal tissues and an unfavourable blood circulation status, revision auricular reconstruction has always presented a surgical challenge to reconstructive surgeons. Rib cartilage grafts were used for revision auricular reconstruction in six cases. In all six, previous attempts at auricular reconstruction had failed due to graft or implant infection. Four cases had previously undergone a rib cartilage graft, one Medpor implantation and another osseo-integrated prosthesis implantation. In total, 16 operations were performed on the six cases. Minor complications were noted after two operations, but no major complications, including infections, occurred. All patients were satisfied with their results. Our findings suggest that autologous rib cartilage grafts should be considered for revision auricular reconstructions. Furthermore, tissue expander surgery or the re-use of previously grafted skin may be required to overcome the limitations of revision surgery. However, when meticulously performed, auricular reconstruction with a rib cartilage graft can produce reliable aesthetic results with minimal complications. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Autologous rib cartilage grafts are currently a standard modality for auricular reconstruction and are widely used, especially in patients with congenital microtia.1e6 However, revision surgery after failed auricular reconstruction may be problematic, and in particular, the use of * Corresponding author. Tel.: þ82 2 3410 2235; fax: þ82 2 3410 0036. E-mail address: [email protected] (K.S. Oh).
autologous rib cartilage grafts is limited in secondary revision cases because of issues arising from previous surgery. For example, revision reconstructions must be performed on excessively scarred tissues in the absence of normal healthy tissues, which makes the process more difficult. Furthermore, blood circulation status in the auricular region is also an issue in revision cases.7 Due to these unfavourable factors, auricular reconstructions in secondary revision cases are usually performed using
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.04.016
Secondary microtia reconstruction artificial implants or prosthetics8,9 or by using more complicated methods, such as free flap transfer.10e14 However, these methods are also limited by complications and side effects. In the present study, we were able to obtain satisfactory results using autologous rib cartilage grafts in secondary revision auricular reconstruction cases.
Patients and methods Patient selection During a 2-year period from 2006 to 2007, six patients with a prior operation history of auricular reconstruction were enrolled from among patients who visited our institute. At the time of presentation, all six had undergone several operations at various other institutes for the reconstruction of congenital microtia. However, outcomes were unfavourable and resulted in excessive scar contracture and skin adhesion in the auricular region. Accordingly, secondary revision auricular reconstructions were attempted using autologous rib cartilage.
Surgical technique Superficial temporal fascial flap or tissue expander surgery Tissue expander surgery was performed before autologous rib cartilage grafting in cases with severe scar contracture and a soft-tissue insufficiency. In particular, prior use of temporal fascia was viewed as an indication for tissue expander surgery. Because a superficial temporal fascial flap is usually used to cover exposed cartilage framework during the auricular elevation procedure, expanded adjacent soft tissues were used instead of a temporal fascial flap. In each case, an incision was placed on the previous operative scar, and subcutaneous dissection was performed in the temporal region to insert the tissue expander (LS 80 060, Sebbin Laboratory, Pontoise, France). Expansion was performed using normal saline over a period of 3 months. Autologous rib cartilage grafting In the four cases that had undergone tissue expander insertion, removal of the tissue expander and autologous
941 rib cartilage grafting were performed simultaneously at an average of 104 days after insertion of tissue expander. Rib cartilages were harvested from sides not used previously. The framework base was fabricated using the sixth and seventh rib cartilages. The eighth rib cartilage was used as a framework for the helix and the ninth rib cartilage for the antihelix. After fabrication of the cartilage had been completed, the framework was inserted into a subcutaneous pocket in the supposed auricular region. On the other hand, in cases with a prior skin graft history in the auricular region, grafted skin was turned over and buried subcutaneously with the cartilage framework for re-use during the auricular elevation procedure (Figure 1). Auricular elevation Auricular elevation was performed on average at 134 days after autologous rib cartilage grafting. An incision was placed along the outer border of the cartilage framework, which was then elevated using underlying temporal fascia (Figure 2). Cartilage fragments that were banked in the subcutaneous layer of the chest during the rib cartilage graft procedure were used to support the elevated framework. A superficial temporal fascial flap or expanded adjacent tissue was mobilised to cover the exposed cartilage, and full-thickness skin was also harvested from the inguinal area and grafted over the fascia.
Results Patient ages at operation ranged from 14 to 37 years with an average of 25.7 years. There were three male and three female patients. Four cases had previously received an autologous rib cartilage graft, but grafts had been subsequently removed due to infection. In one case, previous auricular reconstruction was attempted using a porous polyethylene implant (Medpor, Porex Surgical Inc., College Park, Georgia, USA), and in another, auricular reconstruction was performed with an osseo-integrated prosthesis but both were removed as well because of infection (Table 1). Two minor postoperative complications had occurred after the 16 operations performed on the six patients. However, after secondary reconstruction, no
Figure 1 (Left) In patients presented with a previous skin graft, the previously grafted skin was turned over and buried in the subcutaneous layer during the rib cartilage graft operation. (Right) Auricular elevation was performed later using this buried skin; only a minimal amount of new skin graft was needed.
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T.S. Lee et al.
Figure 2 (Left, right) Superficial temporalis fascial flap was elevated to cover the exposed cartilage block during auricular elevation.
major complications, including infections at operative sites, were encountered and all patients were satisfied with their aesthetic results.
Case 1 A 31-year-old male with a history of failed auricular reconstruction with a porous polyethylene implant visited our institute. The implant had been removed earlier because of an infection at the operative site. Initially, tissue expansion was performed in the temporal area, and subsequent revision reconstruction was performed using an autologous rib cartilage graft. However, partial exposure of the grafted cartilage framework occurred, which was fully treated using a local flap during an additional minor operation. No other complication occurred and the auricular elevation procedure was later performed without problem (Figure 3).
Table 1 Case
Case 2 A 27-year-old female attended our institute after prior auricular reconstruction with an osseo-integrated prosthesis. Partial exteriorisation of the osseo-integrated device was noticed, accompanied by signs of chronic inflammation, such as local heating sensation, redness and purulent discharges. The prosthesis was later removed and revision was performed over a series of operations, which included autologous rib cartilage grafting. No postoperative complications were reported (Figure 4).
Case 3 A 14-year-old female, who had undergone previous rib cartilage grafting for microtia reconstruction, visited for revision. The previous graft had been partially removed soon after primary surgery because of infection. Successful
Case summary Age
Sex
Primary reconstruction method
1
31
M
Medpor implant
2
27
F
Osseointegrated prosthesis
3
14
F
Rib cartilage graft
4
23
M
Rib cartilage graft
5
22
F
Rib cartilage graft
6
36
M
Rib cartilage graft
Secondary revision Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation Rib cartilage graft Auricular elevation Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation Rib cartilage graft Auricular elevation Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation
Secondary microtia reconstruction
943
Figure 3 (Left) Preoperative view of a 31-year-old male with a history of failed auricular reconstruction after Medpor implantation. (Centre) After tissue expansion in the temporal area. (Right) Six months after revision auricular reconstruction using an autologous rib cartilage graft.
revision reconstruction was done by autologous rib cartilage grafting followed by auricular elevation surgery (Figure 5).
Case 4 A 23-year-old male with a history of failed auricular reconstruction visited our institute with excessive scaring
and skin tightening in the auricular region. Initially, a tissue expander was inserted in order to expand soft tissues for scar contracture relief. Autologous rib cartilage grafting and auricular elevation were performed sequentially. Subsequently, partial graft loss occurred after auricular elevation, but this healed completely by secondary intention (Figure 6).
Figure 4 (Left) Preoperative view of a 27-year-old female with failed auricular reconstruction based on an osseointegrated prosthesis. (Centre) After tissue expansion in the temporal area. Revision rib cartilage graft was followed. (Right) Three months after auricular elevation surgery.
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T.S. Lee et al.
Figure 5 (Left) Preoperative view of a 14-year-old female with prior auricular reconstruction using a rib cartilage graft. The graft had been partially removed because of infection. (Centre) After revision rib cartilage grafting. (Right) Six months after auricular elevation.
Case 5
Case 6
A 22-year-old female visited our institute due to failed auricular reconstruction by rib cartilage grafting. Reconstruction with an autologous rib cartilage graft was successfully performed without complication (Figure 7).
A 36-year-old male presented at our institute because of an unsightly right ear. During childhood, he had undergone auricular reconstruction with a rib cartilage graft. However, the graft had been almost totally absorbed due to
Figure 6 (Left) Preoperative view of a 23-year-old male with a history of failed auricular reconstruction after rib cartilage grafting. (Centre) After tissue expansion in the temporal area. Revision rib cartilage graft was followed. (Right) Five months after auricular elevation.
Secondary microtia reconstruction
945
Figure 7 (Left) Preoperative view of a 22-year-old female with failed auricular reconstruction by rib cartilage grafting. (Centre) Six months after revision rib cartilage grafting. (Right) Ten months after auricular elevation surgery.
an infection at the operative site. Revisions were performed using a rib cartilage graft (Figure 8).
Discussion Tanzer first introduced the auricular reconstruction method using cartilage frameworks fabricated with rib cartilages in 1959.5,6 This reconstructive method was further modified by Brent and Nagata, and ever since, autologous rib cartilage grafting has been the mainstay of reconstructions of congenital and acquired deformities of the ear.1e4
However, due to the tedious process of harvesting rib cartilages, and possible complications, other reconstructive methods involving porous polyethylene implants or osseointegrated prostheses are usually preferred; despite the fact that these artificial materials have been shown to be inferior to autogenous cartilage frameworks.8,9 Furthermore, artificial implants and prostheses have been previously reported to have notable demerits, such as vulnerability to trauma and infection, skin irritation, the need for replacement due to a short implant life, persistent pain and inferior aesthetic results. In cases with extensive
Figure 8 (Left) Preoperative view of a 36-year-old male with failed rib cartilage graft reconstruction. (Centre). After tissue expansion in the temporal area. (Right) Four months after revision rib cartilage graft surgery.
946 scarring, such as those caused by burns, free pre-fabricated composite forearm flaps have been introduced, but the need for microscopic surgery and poor aesthetic results have limited the application of this method.10,13,14 Free tissue transfers of contralateral temporal or omental flaps have also been used as alternatives to overcome healthy normal tissue shortcomings in the ipsilateral side, but these are also limited by the need for microscopic surgery.11,12 Auricular reconstruction has always presented a surgical challenge to reconstructive surgeons due to the complexity of the auricular structure, and the difficultly of achieving an aesthetically satisfactory result. Along with these difficulties, secondary revision makes the achievement of satisfactory cosmesis immensely more difficult. Accordingly, the reconstructive methods mentioned above, such as those involving artificial implants and free tissue transfer have been considered for secondary reconstruction. Nevertheless, due to the difficulty involved, attempts at secondary auricular reconstruction are frequently abandoned in patients who actually require revision. Factors like an insufficiency of healthy tissues, scar contracture and the risk of infection cause surgeons to hesitate before undertaking a re-operation involving an autologous rib cartilage graft. However, as this study shows, successful reconstruction by ordinary rib cartilage grafting is possible even in cases that have undergone unsuccessful auricular reconstruction. To overcome concerns regarding scarred and tightened tissues we performed tissue expander surgery. Furthermore, no significant complications leading to graft failure or infection were encountered. In patients who had undergone prior skin grafting in the auricular region, grafted skins were buried subcutaneously and re-used during auricular elevation surgery. Consequently, regions requiring additional skin grafting were diminished and normal tissues were spared. In addition, when temporal fascia had been previously used, but could not be re-used, expanded adjacent tissues were found to act as good substitutes. We conclude that autologous rib cartilage grafts should be considered a primary modality for auricular reconstruction in secondary revision cases, but advise that efforts be made to manage problems arising from prior operations.
Conflict of interest None.
T.S. Lee et al.
Funding None.
References 1. Brent B. The correction of microtia with autogenous cartilage grafts: II. Atypical and complex deformities. Plast Reconstr Surg 1980;66:13e21. 2. Brent B. The correction of microtia with autogenous cartilage grafts: I. The classic deformity. Plast Reconstr Surg 1980;66: 1e12. 3. 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. discussion 67e68. 4. 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. discussion 67e68. 5. Tanzer RC. Total reconstruction of the external ear. Plast Reconstr Surg 1959;23:1e15. 6. Tanzer RC. Microtiaea long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61:161e6. 7. Nagata S. Secondary reconstruction for unfavourable microtia results utilizing temporoparietal and innominate fascia flaps. Plast Reconstr Surg 1994;94:254e65. discussion 66e67. 8. Thorne CH, Brecht LE, Bradley JP, et al. Auricular reconstruction: indications for autogenous and prosthetic techniques. Plast Reconstr Surg 2001;107:1241e52. 9. Wilkes GH, Wolfaardt JF. Osseointegrated alloplastic versus autogenous ear reconstruction: criteria for treatment selection. Plast Reconstr Surg 1994;93:967e79. 10. Akin S. Burned ear reconstruction using a prefabricated free radial forearm flap. J Reconstr Microsurg 2001;17: 233e6. 11. Park C, Roh TS, Chi HS. Total ear reconstruction in the devascularized temporoparietal region: II. Use of the omental free flap. Plast Reconstr Surg 2003;111:1391e7. discussion 8e9. 12. Park C, Suk Roh T. Total ear reconstruction in the devascularized temporoparietal region: I. Use of the contralateral temporoparietal fascial free flap. Plast Reconstr Surg 2001;108: 1145e53. 13. Sucur D, Ninkovic M, Markovic S, et al. Reconstruction of an avulsed ear by constructing a composite free flap. Br J Plast Surg 1991;44:153e4. 14. Zhou G, Teng L, Chang HM, et al. Free prepared composite forearm flap transfer for ear reconstruction: three case reports. Microsurgery 1994;15:660e2.
Secondary revisions due to unfavourable results after microtia reconstruction Tae Sung Lee, So Young Lim, Jai Kyong Pyon, Goo Hyun Mun, Sa Ik Bang, Kap Sung Oh* Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Ilwon-dong 50, Gangnam-gu, Seoul, 135-710, Republic of Korea Received 24 January 2009; accepted 16 April 2009
KEYWORDS Microtia; Auricular reconstruction; Rib cartilage graft; Secondary revision
Summary Autologous rib cartilage grafting is a basic modality in auricular reconstruction, especially in cases of congenital microtia. However, due to heavy scarring at operative sites, lack of healthy normal tissues and an unfavourable blood circulation status, revision auricular reconstruction has always presented a surgical challenge to reconstructive surgeons. Rib cartilage grafts were used for revision auricular reconstruction in six cases. In all six, previous attempts at auricular reconstruction had failed due to graft or implant infection. Four cases had previously undergone a rib cartilage graft, one Medpor implantation and another osseo-integrated prosthesis implantation. In total, 16 operations were performed on the six cases. Minor complications were noted after two operations, but no major complications, including infections, occurred. All patients were satisfied with their results. Our findings suggest that autologous rib cartilage grafts should be considered for revision auricular reconstructions. Furthermore, tissue expander surgery or the re-use of previously grafted skin may be required to overcome the limitations of revision surgery. However, when meticulously performed, auricular reconstruction with a rib cartilage graft can produce reliable aesthetic results with minimal complications. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Autologous rib cartilage grafts are currently a standard modality for auricular reconstruction and are widely used, especially in patients with congenital microtia.1e6 However, revision surgery after failed auricular reconstruction may be problematic, and in particular, the use of * Corresponding author. Tel.: þ82 2 3410 2235; fax: þ82 2 3410 0036. E-mail address: [email protected] (K.S. Oh).
autologous rib cartilage grafts is limited in secondary revision cases because of issues arising from previous surgery. For example, revision reconstructions must be performed on excessively scarred tissues in the absence of normal healthy tissues, which makes the process more difficult. Furthermore, blood circulation status in the auricular region is also an issue in revision cases.7 Due to these unfavourable factors, auricular reconstructions in secondary revision cases are usually performed using
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.04.016
Secondary microtia reconstruction artificial implants or prosthetics8,9 or by using more complicated methods, such as free flap transfer.10e14 However, these methods are also limited by complications and side effects. In the present study, we were able to obtain satisfactory results using autologous rib cartilage grafts in secondary revision auricular reconstruction cases.
Patients and methods Patient selection During a 2-year period from 2006 to 2007, six patients with a prior operation history of auricular reconstruction were enrolled from among patients who visited our institute. At the time of presentation, all six had undergone several operations at various other institutes for the reconstruction of congenital microtia. However, outcomes were unfavourable and resulted in excessive scar contracture and skin adhesion in the auricular region. Accordingly, secondary revision auricular reconstructions were attempted using autologous rib cartilage.
Surgical technique Superficial temporal fascial flap or tissue expander surgery Tissue expander surgery was performed before autologous rib cartilage grafting in cases with severe scar contracture and a soft-tissue insufficiency. In particular, prior use of temporal fascia was viewed as an indication for tissue expander surgery. Because a superficial temporal fascial flap is usually used to cover exposed cartilage framework during the auricular elevation procedure, expanded adjacent soft tissues were used instead of a temporal fascial flap. In each case, an incision was placed on the previous operative scar, and subcutaneous dissection was performed in the temporal region to insert the tissue expander (LS 80 060, Sebbin Laboratory, Pontoise, France). Expansion was performed using normal saline over a period of 3 months. Autologous rib cartilage grafting In the four cases that had undergone tissue expander insertion, removal of the tissue expander and autologous
941 rib cartilage grafting were performed simultaneously at an average of 104 days after insertion of tissue expander. Rib cartilages were harvested from sides not used previously. The framework base was fabricated using the sixth and seventh rib cartilages. The eighth rib cartilage was used as a framework for the helix and the ninth rib cartilage for the antihelix. After fabrication of the cartilage had been completed, the framework was inserted into a subcutaneous pocket in the supposed auricular region. On the other hand, in cases with a prior skin graft history in the auricular region, grafted skin was turned over and buried subcutaneously with the cartilage framework for re-use during the auricular elevation procedure (Figure 1). Auricular elevation Auricular elevation was performed on average at 134 days after autologous rib cartilage grafting. An incision was placed along the outer border of the cartilage framework, which was then elevated using underlying temporal fascia (Figure 2). Cartilage fragments that were banked in the subcutaneous layer of the chest during the rib cartilage graft procedure were used to support the elevated framework. A superficial temporal fascial flap or expanded adjacent tissue was mobilised to cover the exposed cartilage, and full-thickness skin was also harvested from the inguinal area and grafted over the fascia.
Results Patient ages at operation ranged from 14 to 37 years with an average of 25.7 years. There were three male and three female patients. Four cases had previously received an autologous rib cartilage graft, but grafts had been subsequently removed due to infection. In one case, previous auricular reconstruction was attempted using a porous polyethylene implant (Medpor, Porex Surgical Inc., College Park, Georgia, USA), and in another, auricular reconstruction was performed with an osseo-integrated prosthesis but both were removed as well because of infection (Table 1). Two minor postoperative complications had occurred after the 16 operations performed on the six patients. However, after secondary reconstruction, no
Figure 1 (Left) In patients presented with a previous skin graft, the previously grafted skin was turned over and buried in the subcutaneous layer during the rib cartilage graft operation. (Right) Auricular elevation was performed later using this buried skin; only a minimal amount of new skin graft was needed.
942
T.S. Lee et al.
Figure 2 (Left, right) Superficial temporalis fascial flap was elevated to cover the exposed cartilage block during auricular elevation.
major complications, including infections at operative sites, were encountered and all patients were satisfied with their aesthetic results.
Case 1 A 31-year-old male with a history of failed auricular reconstruction with a porous polyethylene implant visited our institute. The implant had been removed earlier because of an infection at the operative site. Initially, tissue expansion was performed in the temporal area, and subsequent revision reconstruction was performed using an autologous rib cartilage graft. However, partial exposure of the grafted cartilage framework occurred, which was fully treated using a local flap during an additional minor operation. No other complication occurred and the auricular elevation procedure was later performed without problem (Figure 3).
Table 1 Case
Case 2 A 27-year-old female attended our institute after prior auricular reconstruction with an osseo-integrated prosthesis. Partial exteriorisation of the osseo-integrated device was noticed, accompanied by signs of chronic inflammation, such as local heating sensation, redness and purulent discharges. The prosthesis was later removed and revision was performed over a series of operations, which included autologous rib cartilage grafting. No postoperative complications were reported (Figure 4).
Case 3 A 14-year-old female, who had undergone previous rib cartilage grafting for microtia reconstruction, visited for revision. The previous graft had been partially removed soon after primary surgery because of infection. Successful
Case summary Age
Sex
Primary reconstruction method
1
31
M
Medpor implant
2
27
F
Osseointegrated prosthesis
3
14
F
Rib cartilage graft
4
23
M
Rib cartilage graft
5
22
F
Rib cartilage graft
6
36
M
Rib cartilage graft
Secondary revision Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation Rib cartilage graft Auricular elevation Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation Rib cartilage graft Auricular elevation Tissue expander insertion Tissue expander removal & Rib cartilage graft Auricular elevation
Secondary microtia reconstruction
943
Figure 3 (Left) Preoperative view of a 31-year-old male with a history of failed auricular reconstruction after Medpor implantation. (Centre) After tissue expansion in the temporal area. (Right) Six months after revision auricular reconstruction using an autologous rib cartilage graft.
revision reconstruction was done by autologous rib cartilage grafting followed by auricular elevation surgery (Figure 5).
Case 4 A 23-year-old male with a history of failed auricular reconstruction visited our institute with excessive scaring
and skin tightening in the auricular region. Initially, a tissue expander was inserted in order to expand soft tissues for scar contracture relief. Autologous rib cartilage grafting and auricular elevation were performed sequentially. Subsequently, partial graft loss occurred after auricular elevation, but this healed completely by secondary intention (Figure 6).
Figure 4 (Left) Preoperative view of a 27-year-old female with failed auricular reconstruction based on an osseointegrated prosthesis. (Centre) After tissue expansion in the temporal area. Revision rib cartilage graft was followed. (Right) Three months after auricular elevation surgery.
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T.S. Lee et al.
Figure 5 (Left) Preoperative view of a 14-year-old female with prior auricular reconstruction using a rib cartilage graft. The graft had been partially removed because of infection. (Centre) After revision rib cartilage grafting. (Right) Six months after auricular elevation.
Case 5
Case 6
A 22-year-old female visited our institute due to failed auricular reconstruction by rib cartilage grafting. Reconstruction with an autologous rib cartilage graft was successfully performed without complication (Figure 7).
A 36-year-old male presented at our institute because of an unsightly right ear. During childhood, he had undergone auricular reconstruction with a rib cartilage graft. However, the graft had been almost totally absorbed due to
Figure 6 (Left) Preoperative view of a 23-year-old male with a history of failed auricular reconstruction after rib cartilage grafting. (Centre) After tissue expansion in the temporal area. Revision rib cartilage graft was followed. (Right) Five months after auricular elevation.
Secondary microtia reconstruction
945
Figure 7 (Left) Preoperative view of a 22-year-old female with failed auricular reconstruction by rib cartilage grafting. (Centre) Six months after revision rib cartilage grafting. (Right) Ten months after auricular elevation surgery.
an infection at the operative site. Revisions were performed using a rib cartilage graft (Figure 8).
Discussion Tanzer first introduced the auricular reconstruction method using cartilage frameworks fabricated with rib cartilages in 1959.5,6 This reconstructive method was further modified by Brent and Nagata, and ever since, autologous rib cartilage grafting has been the mainstay of reconstructions of congenital and acquired deformities of the ear.1e4
However, due to the tedious process of harvesting rib cartilages, and possible complications, other reconstructive methods involving porous polyethylene implants or osseointegrated prostheses are usually preferred; despite the fact that these artificial materials have been shown to be inferior to autogenous cartilage frameworks.8,9 Furthermore, artificial implants and prostheses have been previously reported to have notable demerits, such as vulnerability to trauma and infection, skin irritation, the need for replacement due to a short implant life, persistent pain and inferior aesthetic results. In cases with extensive
Figure 8 (Left) Preoperative view of a 36-year-old male with failed rib cartilage graft reconstruction. (Centre). After tissue expansion in the temporal area. (Right) Four months after revision rib cartilage graft surgery.
946 scarring, such as those caused by burns, free pre-fabricated composite forearm flaps have been introduced, but the need for microscopic surgery and poor aesthetic results have limited the application of this method.10,13,14 Free tissue transfers of contralateral temporal or omental flaps have also been used as alternatives to overcome healthy normal tissue shortcomings in the ipsilateral side, but these are also limited by the need for microscopic surgery.11,12 Auricular reconstruction has always presented a surgical challenge to reconstructive surgeons due to the complexity of the auricular structure, and the difficultly of achieving an aesthetically satisfactory result. Along with these difficulties, secondary revision makes the achievement of satisfactory cosmesis immensely more difficult. Accordingly, the reconstructive methods mentioned above, such as those involving artificial implants and free tissue transfer have been considered for secondary reconstruction. Nevertheless, due to the difficulty involved, attempts at secondary auricular reconstruction are frequently abandoned in patients who actually require revision. Factors like an insufficiency of healthy tissues, scar contracture and the risk of infection cause surgeons to hesitate before undertaking a re-operation involving an autologous rib cartilage graft. However, as this study shows, successful reconstruction by ordinary rib cartilage grafting is possible even in cases that have undergone unsuccessful auricular reconstruction. To overcome concerns regarding scarred and tightened tissues we performed tissue expander surgery. Furthermore, no significant complications leading to graft failure or infection were encountered. In patients who had undergone prior skin grafting in the auricular region, grafted skins were buried subcutaneously and re-used during auricular elevation surgery. Consequently, regions requiring additional skin grafting were diminished and normal tissues were spared. In addition, when temporal fascia had been previously used, but could not be re-used, expanded adjacent tissues were found to act as good substitutes. We conclude that autologous rib cartilage grafts should be considered a primary modality for auricular reconstruction in secondary revision cases, but advise that efforts be made to manage problems arising from prior operations.
Conflict of interest None.
T.S. Lee et al.
Funding None.
References 1. Brent B. The correction of microtia with autogenous cartilage grafts: II. Atypical and complex deformities. Plast Reconstr Surg 1980;66:13e21. 2. Brent B. The correction of microtia with autogenous cartilage grafts: I. The classic deformity. Plast Reconstr Surg 1980;66: 1e12. 3. 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. discussion 67e68. 4. 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. discussion 67e68. 5. Tanzer RC. Total reconstruction of the external ear. Plast Reconstr Surg 1959;23:1e15. 6. Tanzer RC. Microtiaea long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61:161e6. 7. Nagata S. Secondary reconstruction for unfavourable microtia results utilizing temporoparietal and innominate fascia flaps. Plast Reconstr Surg 1994;94:254e65. discussion 66e67. 8. Thorne CH, Brecht LE, Bradley JP, et al. Auricular reconstruction: indications for autogenous and prosthetic techniques. Plast Reconstr Surg 2001;107:1241e52. 9. Wilkes GH, Wolfaardt JF. Osseointegrated alloplastic versus autogenous ear reconstruction: criteria for treatment selection. Plast Reconstr Surg 1994;93:967e79. 10. Akin S. Burned ear reconstruction using a prefabricated free radial forearm flap. J Reconstr Microsurg 2001;17: 233e6. 11. Park C, Roh TS, Chi HS. Total ear reconstruction in the devascularized temporoparietal region: II. Use of the omental free flap. Plast Reconstr Surg 2003;111:1391e7. discussion 8e9. 12. Park C, Suk Roh T. Total ear reconstruction in the devascularized temporoparietal region: I. Use of the contralateral temporoparietal fascial free flap. Plast Reconstr Surg 2001;108: 1145e53. 13. Sucur D, Ninkovic M, Markovic S, et al. Reconstruction of an avulsed ear by constructing a composite free flap. Br J Plast Surg 1991;44:153e4. 14. Zhou G, Teng L, Chang HM, et al. Free prepared composite forearm flap transfer for ear reconstruction: three case reports. Microsurgery 1994;15:660e2.