Correction of cryptotia using tissue expansion

The anatomy and surgical correction of cryptotia are reviewed. Another technical procedure using retroauricular tissue expansion is presented. This method allows release of the auricle and construction of the auriculocephalic sulcus without the problems associated with older soft-tissue techniques, e.g., incomplete correction, multiple scars, poor color match of skin grafts, and donor-site morbidity.     

耳后头皮推进瓣急诊即刻修复创伤性耳郭部分缺损的临床效果观察

目的:探讨耳后头皮瓣急诊即刻修复耳郭部分缺损的可行性与临床效果。方法:对2013年1-12月来我院急诊的7例外伤后耳郭部分缺损的患者(均为男性,年龄22-50岁;其中右耳4例,左耳3例)采用耳后头皮推进瓣即刻修复,以耳郭缺损耳后皮肤及头皮皮肤做推进瓣,将断离的耳郭去皮保留软骨与耳郭断端软骨缝合形成软骨支架,推进皮瓣部分卷曲缝合形成耳轮结构修复耳郭缺损。结果:7例耳郭部分缺损均在急诊环境下即刻修复,耳郭大小和形态满意,颅耳角略变小,随访3~6月耳郭形态稳定。结论:耳后头皮推进瓣卷曲缝合可在急诊条件下即刻修复耳郭部分缺损,具有治疗周期短,一次达到较满意外形的优点,对于无条件行二期手术的患者具有较大意义,其远期效果尚有待进一步随访。     

Congenital upper auricular detachment

A rare case of unilateral congenital ear deformity has been presented. The deformity is characterized by detachment and posterior rotation of the right upper auricle in an otherwise grossly normal auricle. We believe that this deformity may be related to defective mesenchymal fusion or accretion between the auricular hillocks of the hyoid and mandibular arches. Satisfactory correction was achieved by auricular repositioning with two triangular flaps.     

Management of the hairline using a local flap in total reconstruction for microtia

In cases of microtia with a low hairline, the manner in which hair is removed from the reconstructed auricle must be taken into consideration. This is one of the most common but difficult problems with reconstruction for microtia. The authors describe a new technique that uses a simple regional flap to resolve this problem. The hair-bearing skin in the estimated auricular region and its covering are removed using a local flap from the hairless mastoid region. This is done in the first stage of auricular reconstruction, the costal cartilage grafting is done in the second stage, and elevation of the auricle is done in the last stage. In 38 auricles of 36 patients who were treated from 1993 to 1995, eight auricles of eight patients were treated with this technique. In all cases, the hairless flap healed well, without vascular stasis or skin necrosis. In addition, no complications from using this technique occurred in the later stages of auricular reconstruction. With this technique, the skin of the flap provides a good texture and color match to the auricle. In addition, the skin of the flap has good elasticity for the cutaneous pocket for cartilage grafting. The harvested area of the flap can be hidden behind the reconstructed auricle. The authors initially wondered whether the marginal scar of the transposed flap's position in the auricle would be conspicuous. However, all of the scar became inconspicuous because it was positioned in the scaphoid fossa.     

Surgical techniques for a deep concha, a pseudomeatus, and high projection in congenital microtia

Some modified surgical techniques are described for constructing a deep conchal cavity and pseudomeatus and obtaining high auricular projection in congenital microtia. At the primary operation, a rather small portion of the microtic vestige is utilized for the lobule by switching, sparing the skin for the concha, with no free skin graft used. For higher projection of the auricle, three-dimensional transposition of a retroinfraauricular flap together with cartilage pieces underneath is applied to the cephaloauricular sulcus. A deep conchal cavity is constructed by further removal of the soft tissue there, transplantation of a cartilage for building a high posterior wall of the concha. The external meatus is successfully imitated by transplantation of a cone-shaped composite graft taken from the cymba of the opposite ear. The retroinfraauricular flap, the reconstruction of a deep concha, and the composite graft technique were successfully used in 55, 16, and 11 ears, respectively.     

A newly defined conchal floor arterial flap for auricular reconstruction

A conchal floor composite flap pedicled by skin of the helical crus has been well described in the literature. Here the flap is elevated based on the supply by an upper auricular branch of the superficial temporal artery. In this article, a newly defined conchal floor arterial flap is proposed. The flap is based on the main stem of the posterior auricular artery and its venae comitantes. Two types of conchal floor arterial flaps were elevated: a proximally based chondral arterial flap and a distally based chondrocutaneous arterial flap. The proximally based flap was used for earlobe reconstruction, whereas the distally based flap was useful in the reconstruction of the upper auricle. Nine congenital auricular malformations were successfully corrected with this newly defined conchal floor flap procedure. This type of flap is easier to elevate, more reliable, and more versatile than the one currently in use.     

Our method of correcting cryptotia

Our technique for the correction of cryptotia using both Z-plasty and the advancement flap is described. The main advantages are the simple design of the skin incision and the possibility of its application to cryptotia other than severe cartilage deformity and extreme lack of skin.     

Conchal transposition flap for postburn ear deformities

Severe thermal injuries to the external ear often lead to extensive loss of peripheral structures such as helix and lobule but frequently spare the more central parts of the ear, even though they may be grossly deformed by scar contracture. The use of spared conchal structures as a transposition flap in combination with remodeling of the residual auricle and release of surrounding scar when indicated has been a useful technique in the reconstruction of a frequently occurring type of postburn ear deformity. Twenty-four ears have been reconstructed in 18 patients over the past 5 years using a conchal transposition flap. The residual concha with its overlying skin can be transposed superiorly, based on a very narrow pedicle in the area of the crus helicis. The raw central area remaining is then resurfaced with a split-thickness skin graft. This technique maximally utilizes the unique remaining auricular elements and can provide a satisfactory reconstruction in selected patients without resorting to more complex and extensive procedures. There have been no significant complications in this series, and patient acceptance of the results has been excellent.     

One-stage reconstruction for defects of the mouth using a sternomastoid myocutaneous flap.

The sternomastoid muscle has 3 blood supplies: the occipital artery superiorly, the superior thyroid artery in the middle, and the thyrocervical trunk below. We report the use of a myocutaneous flap consisting of a "paddle" of skin on the end of a pedicle of sternomastoid muscle--with the latter based either on its superior or inferior blood supply. Fourteen such flaps have been used successfully in 13 consecutive patients for one-stage reconstructions of defects of the oral cavity and oropharynx. Although there was partial epithelial loss of the skin "paddle" in 7 cases, in each case the surviving dermis became resurfaced with epithelium.     

The tumbling concha-cartilage flap for correction of lop ear

This article presents a new surgical method that uses tumbling concha-cartilage flaps to correct lop ears. Through a posterior or anterior auricular skin incision, a rectangular or T-shaped cartilage flap is elevated from the concha and tumbled backward. After passing under the postauricular skin, the flap's tip is fixed to the lidded helix or scapha. The recoiling force of the flap's conchal side enables the lidded portion to be in a normal, erect, anatomic position. The method also increases the vertical height of the ear and creates a normally shaped scapha. Sixteen lop ears were corrected using this procedure, with most of them maintaining natural auricular features. Therefore, this method was considered effective for the correction of moderate lop ear deformity.     

组织透明化三维显示全包埋耳皮肤神经血管网（英文）

目的 结合组织学染色技术和组织透明化策略研究耳部皮肤中神经纤维和血管的空间对应关系。方法 将耳廓前面和后面的皮肤从其中间软骨仔细剥离，然后直接分别用蛋白基因产物9.5 (PGP 9.5)和鬼笔环肽对耳部皮肤的神经纤维和血管进行免疫荧光染色并进行组织透明化处理。随后，以全包埋方式将耳皮肤组织裱贴在载玻片上用于荧光显微镜和共聚焦显微镜观察。结果 本研究显示PGP 9.5阳性神经纤维伴随鬼笔环肽标记的血管一道从耳廓的基部走行到其外围区域形成耳廓的神经血管网。在传统的免疫荧光染色技术基础上，后续的组织透明化技术可以更好地展示耳部皮肤中神经纤维和血管的形态学细节。结论 从方法学的角度来看，组织透明化技术增进了耳部皮肤中免疫荧光标记的可视性，它可能成为有效的技术手段用于解析正常和病理状态下耳部神经血管网的空间结构。     

Free proximal gracilis muscle and its skin paddle compound flap transplantation for complex facial paralysis

Gracilis functioning free-muscle transplantation for the correction of pure facial paralysis has been a preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis, the deficits include facial paralysis along with soft-tissue, mucosa, and/or skin defects. No adequate solution has been proposed. Treatment requests in those patients are not only for facial reanimation but also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning free-muscle transplantation from 1986 to 2002, eight patients (5 percent) presented with complex deficits requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects included an intraoral defect created following contracture release (one patient), infra-auricular radiation dermatitis with contour depression (one patient), temporal depression following a temporalis muscle-fascia transfer (one patient), ear deformity (two patients), and infra-auricular atrophic tissue with contour depression (three patients). A compound flap, consisting of a gracilis muscle with its overlying skin paddle separated into two components, was transferred for simultaneous correction of both problems. The blood supply to the gracilis and to the skin paddle originated from the same source vessel and therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully without complications. Satisfactory results of facial reanimation were recorded in five patients after all stages were completed. The remaining three patients are undergoing physical therapy and waiting for revision of the skin paddle.     

Framework growth after reconstruction for microtia: is it real and what are the implications?

Historically, fashioning an auricle for a patient born with microtia has been one of the most challenging endeavors in the repertoire of reconstructive surgeons. Despite many ideas advanced on types of materials for the auricular framework, the hands-down favorite and today's medium of choice is autogenous costal cartilage. A subject that remains up for discussion, however, is the question of growth potential in these cartilaginous frameworks. Popularization of the surgical technique for auricular reconstruction has led to much bandying about of opinions on this very important question of growth. Although previous reports allude to the probability of an increase in auricular size after reconstruction, this report is the first to document changes in auricular size with measurements taken directly from patients at the time of graft implantation and during subsequent long-term follow-up. The goals of this study are to define the behavior of the autogenous framework after reconstruction of the microtic auricle. This information serves to clarify the issue of proper framework sizing and to make evident the early age at which reconstruction can begin.The records of patients who underwent costal cartilage auricular reconstruction for grade III microtia between 1990 and 1996 were reviewed, and a cohort of 10 patients was chosen for inclusion based on availability for follow-up and lack of any interval modifications of their cartilaginous framework. The average age was 6.7 years, and the average time interval from initial reconstruction to follow-up was 3.2 years. Measurements of the auricular framework height and width were taken at implantation and at time of final follow-up, and measurements were recorded of the normal ears of patients with unilateral microtia. The mean auricular size was examined for significance of interval change using the two-sample Student's t tests, assuming unequal variances.The results revealed an average height increase of 5 mm (10.4 percent) in the study population. Auricular width changes averaged 2.75 mm (7.02 percent). Growth trends revealed a distinct tendency toward increasing auricular framework size over time, with slowing as patients neared adolescence. Comparison of the reconstructed auricle to the normal ear of each patient with unilateral microtia showed that the reconstructed ear paralleled the growth of the normal side, with no statistically significant differences in height or width at follow-up.This is the first report of auricular framework behavior based on patients having direct measurement of their framework initially and in long-term follow-up. This patient sample underscores a clear pattern of growth in the reconstructed auricles paralleling that of the normal ears. The implications of this finding are important in that the initial oversizing of the framework becomes unnecessary. Moreover, the decision as to age at initial reconstruction is not affected by anticipated growth rates.     

Lower auricular malformations: their representation, correction, and embryologic correlation

Seventy-seven lower auricular malformations in 74 patients treated during the last 6 years were analyzed. Sixty cases (77.9 percent) were of malformations involving the earlobe; 54 cases involved the earlobe alone, and 6 cases were of complex deformities involving the earlobe and adjacent helix and/or tragus. Cleft earlobe was the most common lower auricular malformation (49 cases, 63.6 percent); four subtypes and their corrective methods are described. Cases of complex earlobe malformations, corrected by fabricated costal cartilage and expanded skin flap, are presented. A question mark ear (5 cases, 6.5 percent), a malformation with an ectopic anthelical fold (5 cases, 6.5 percent), and a malformation with a lower conchal stria (5 cases, 6.5 percent) are considered to be major lower auricular malformations. An attempt has been made to correlate the presented malformations with the embryologic-fetal development of the auricle. It is suggested that "clefting" ear malformations such as the cleft earlobe, the question mark ear, and the ectopic anthelical fold deformity may provide clues to understanding the embryologic-fetal development of the human auricle. It appears that hillocks 1 and 6 produce the earlobe and that hillock 4 or 5 produces the anthelix or helix.     

Auricular endochondral pseudocysts: diagnosis and management

The auricle can be the site of a variety of cystic lesions, many of which involve either potential spaces between the auricular cartilage and the perichondrium or spaces within the skin and subcutaneous tissues. An auricular endochondral pseudocyst is a fluid collection located within the cartilaginous structure of the auricle. The auricular hematoma and the auricular pseudocyst may represent opposing ends of a continuum of damage and repair of traumatic insults. Whereas the hematoma represents a significant acute traumatic event resulting in cleavage between the perichondrium and the cartilage, the pseudocyst could be the outcome of chronic lower grade trauma. In this instance, the perichondrium not only separates from the cartilage but may be induced to regenerate an outer cartilaginous wall exacting the contour of the separated perichondrium, thus completing a cartilaginous auricular pseudocyst. This firm, cartilaginous outer cyst wall accounts for the increased difficulty in treating pseudocysts and clearly requires a different surgical treatment than for the hematoma. Having reviewed a substantial number of case reports, we recommend incision and drainage of the cavity followed by obliteration of the cavity by curettage, sclerosing agent, and pressure dressing. More invasive techniques should be reserved for an uncommon recurrence after adequate initial treatment.     

Correction of low-set ear: superoposterior mobilization of the ear as a transposition flap pivoted on the ear canal with burring of the superoposterior canal wall

In a number of congenital, developmental, and postoperative conditions, many patients have a difference in the vertical and anteroposterior position of the ears. On correction of this deformity, the most difficult problem is the low and anterior location of the external auditory canal. To overcome this unyielding limitation, the authors perform superoposterior transposition of the low-set ear pivoted on the ear canal after making a new path for the canal by burring of the thick superoposterior canal wall. A mastoid hairline incision is followed by three-quarters circumferential subpericranial dissection around the bony ear canal posteriorly. A preauricular incision is followed by subcutaneous dissection anteriorly. By using the natural deformability of the cartilaginous ear canal, the S-shaped canal can be straightened through a new path made by burring of the thick superoposterior wall. Then the low-set ear can be mobilized superoposteriorly as a transposition flap pivoted on the ear canal with minimal tension by straightening of the canal. The corrected auricular position can be maintained by (1) several permanent sutures between the cavum conchae and the mastoid and deep temporal fascia, (2) a suspensory temporoparietal fascial loop, and (3) a skin support provided by the repair in an elevated position and V-Y-plasty or Z-plasty on the lower pole of the ear. From December of 1997 to October of 1998, three cases with a maximum follow-up of 15 months were examined. Symmetric ear position was achieved and maintained on both frontal and lateral views after the operation in all cases. This new technique for correction of low-set ear produces symmetric ear position in both vertical and anteroposterior dimensions for a long time. In addition, it can be performed with various other surgical procedures safely and simultaneously in a variety of pathologic conditions.     

A single-stage two-flap method of total ear reconstruction

A single-stage two-flap method of total ear reconstruction in congenital microtia is reported. This method was derived from the one-stage reconstruction described by Song and Song. Two flaps defined by vascular basis were elevated on the mastoid area: the superficial skin flap supplied mainly by subcutaneous pedicled arteriole perforators from the posterior auricular artery and the deeper axial-pattern fascial flap including the posterior auricular artery itself. The ear framework, exaggeratedly carved using autologous rib cartilage, could be inserted easily between the two flaps, simultaneously producing the auriculocephalic angle and the conchal wall. Intraoperative expansion of the skin flap and postoperative external ear molding also were performed to create aesthetically pleasing ears.     

Auricular displacement with rhytidectomy.

The auricle is more mobile than generally recognized and is subject to displacement during rhytidectomy. When the auricle is displaced by a rhytidectomy, movement generally occurs in an anteroinferior direction with forward rotation of the inferior pole. This displacement/rotation is often obscured by concurrent elevation of the temporal hairline and insetting errors of the lobule that may appear to be the sole deformities. Using computer assistance, auricular position was compared in before and after photographs of published rhytidectomy results. Auricular displacement of varying degree was found in 62 percent of the analyzed results. Correlation of the presence, direction, and severity of the displacement with the described surgical technique implicates distraction on the periauricular superficial musculoaponeurotic system/platysma and skin at the time of closure as the causative agent. This retrospective photogrammetric study confirms that the auricle can be displaced if direct or indirect tension is placed on it during rhytidectomy.     

Augmentation of transmidline skin perfusion and viability in transverse rectus abdominis myocutaneous (TRAM) flaps in the pig.

The aim of this experiment was to design a clinically relevant TRAM flap in the pig and to use this flap model to study the effectiveness of preoperative ligation of the dominant vascular pedicle in augmentation of muscle and skin capillary blood flow and skin viability in the TRAM flap. This TRAM flap model was based on the deep inferior epigastric vascular pedicle, with the center of the transverse skin paddle attached to the underlying rectus abdominis muscle at the superior end of the muscle and extending bilaterally from its attached muscle. The transverse skin paddle (8 x 30 cm) included a contralateral and ipsilateral random portion of skin. This flap model was based on the deep inferior epigastric rather than the superior epigastric vascular pedicle because the deep inferior epigastric vascular pedicle is the smaller of the two in the pig and augmentation of its blood supply by ligation of the dominant superior epigastric vascular pedicle resembles more closely the clinical situation. It was observed that ligation of the dominant superior epigastric vascular pedicle 14 days prior to raising the TRAM flap significantly (p less than 0.05; n = 5) increased the total muscle and skin capillary blood flow and skin viability in the transverse skin paddle compared with the sham-operated control (n = 5).(ABSTRACT TRUNCATED AT 250 WORDS)     

A new arterial flap from the postauricular surface: its anatomic basis and clinical application

We studied the arterial pattern of the postauricular surface in 16 cadavers and compared them to the results of Doppler probing in the auricles of 15 human volunteers. The dissections revealed that the postauricular surface is mainly supplied by three to five sizable branches from the upper, middle, and lower divisions of the posterior auricular artery, traversing in a rather straight and cephalic direction toward the auricular rim. One or more branches of the middle division are constantly present and distribute over the upper two-thirds of the postauricular surface. These anatomic findings were compatible with the results of the Doppler probing. We have done four auricular reconstructions with postauricular arterial flaps with excellent postoperative results. It is worthwhile to use the postauricular arterial flap in restoring the middle third of the auricle.