An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction.

This article presents an updated review of our experience with 122 temporoparietal fascial flaps, which were used for coverage of fabricated autogenous cartilage frameworks in total auricular reconstructions. Our indications for use of the temporoparietal fascial flap are presented. Partial flap necrosis occurred in 5 cases, total necrosis in 2 of 14 microsurgically transplanted cases, cartilage infection in 2 cases, and paralysis of the frontal branch of facial nerve in 1 case. Prospective observations of vascular anatomy were carried out in the last 93 temporoparietal fascial flaps during flap elevations. Only 59 flaps (63.4 percent) showed a typical pattern, distributed mainly by the superficial temporal artery and vein. Others (36.6 percent) were distributed mainly by various combinations of the posterior auricular artery or vein, occipital artery or vein, diploic vein, and the superficial temporal artery or vein. At the upper margin of the imaginary reconstructed auricle, the mean diameters of the artery and vein were 1.7 mm and 2.2 mm, respectively. There were no significant differences of vascular patterns and their diameters between the temporoparietal fascial flap of microtia sides and of nonmicrotia sides (sides with acquired ear deformities or free-flap donor sides). We are presenting our technical evolution in using the temporoparietal fascial flap for total auricular reconstruction with the goal of reducing surgical complications and improving aesthetic results.     

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.     

Microtia reconstruction: does the cartilage framework grow?

The use of free rib cartilage ear frameworks in unilateral microtia reconstruction has prompted much discussion about their potential for growth. The senior author has reconstructed ear frameworks in 132 microtia patients, most of whom were under 3 years of age when surgery was initiated. Of this group, 29 were assessed for ear growth through comparison of the lead-plate model of the original normal ear to the normal ear growth and the reconstructed ear framework after a period of at least 2 years. Similarly, 14 reconstructed ears were compared to 14 normal ears at least 2 years after reconstruction. The perimeters of tracings made from the original lead plates and of tracings of normal and reconstructed ears were determined by image analysis techniques. The results demonstrated no significant difference in growth between normal ears and reconstructed ear frameworks after an interval of at least 2.5 years. Therefore, the reconstructed ear is growing at a rate similar to that of the normal ear.     

Subfascial expansion and expanded two-flap method for microtia reconstruction

This article presents an improved two-flap method for microtia reconstruction. In the first stage of this method, a tissue expander is inserted in the mastoid region through a subfascial pocket, after which the overlying fascia and skin are expanded simultaneously with saline infusion for about 5 months. In the second stage, the expanded fascial and skin layers are split and prepared as anteriorly based skin and fascial flaps defined by their vascularity. An erect, three-dimensional, contour-accentuated ear framework fabricated with autogenous rib cartilage is inserted between the two flaps. The anteroauricular surface of the framework is draped with the thin, expanded skin, and the postauricular surface is draped with the thin, expanded fascia and overlying grafted skin. In the third stage, remnant auricular cartilage is removed and the crus helicis, tragus, intertragic notch, conchal floor, and a hollow mimicking the external auditory meatus are shaped. In this study, 146 microtias were reconstructed consecutively using the improved two-flap method. The final results were promising--major complications were minimal and most patients showed consistently favorable aesthetic results. This method married a two-flap procedure with a gradual tissue expansion, conveniently exploiting the advantages of both methods, but without the disadvantages.     

A rational approach to nasal reconstruction in leprosy

Destruction of the nasal septum and nasal bones by Mycobacterium leprae and subsequent infection is still seen regularly in leprosy endemic areas. The social stigma associated with this deformity is significant. Many different procedures have been developed to reconstruct the nose. Patients operated on at Anandaban Hospital and the Green Pastures Hospital and Rehabilitation Center between 1986 and 2001 were reviewed. There were 48 patients with an average age of 47 years. Five deformities were mild, 22 were moderate, 13 were severe, and eight were not graded. Bone grafting with nasolabial skin flaps was performed in 14 cases, bone grafting alone was performed in 10 cases, flaps alone were performed in seven cases, and cartilage grafting was performed in 10 cases. In three patients, a prosthesis was inserted, and in three patients a gull-wing forehead flap was performed. Overall, excellent or good cosmetic results were obtained in 83 percent of cases. Grafting with conchal cartilage was associated with the best cosmetic results and had minimal complications. Bone grafting with or without nasolabial flaps was associated with a 50 percent complication rate of infection or graft resorption. In mild to moderate deformities, cartilage grafting is recommended; for more severe deformities, bone grafting with bony fixation and skin flaps is recommended. Perioperative antibiotics must be used, and these procedures should be performed by an experienced surgeon. In very severe cases with skin deficiency, reconstruction with a forehead flap gives good results.     

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.     

Balanced auricular reconstruction in dystopic microtia with the presence of the external auditory canal

This article presents a new repositioning method in dystopic microtia (low-set microtia, anteriorly tilted microtia, or both) with the presence of the external auditory canal. In the case of low-set malformations, the dystopic auricular canal complex was freed from adjacent bony structure, shifted upward, and anchored to the thick periosteum of the suprameatal triangle or the adjacent superior portion of the temporal bone with nonabsorbable sutures. When the auricular vestige was large and dystopia was severe, the complex was shifted with attachment of the temporoparietal fascia on its cranial part. Meanwhile, when the auricular vestige was small and dystopia was mild, the complex was shifted without attachment of the temporoparietal fascia. Then, the ear framework fabricated with autogenous costal cartilage was positioned and wrapped with the temporoparietal fascial flap. In the case of anteriorly tilted malformations, the dystopic complex was freed, shifted posteriorly, and anchored to the periosteum of the suprameatal triangle. Preauricular dead space, resulting from shifting the complex, was obliterated with pieces of costal cartilage. Simultaneously, the ear framework was placed and wrapped with the temporoparietal fascial flap. No skin necrosis of the shifted complexes occurred in any of the cases. In one case, the facial nerve was transected during dissection and reanastomosed. Upward repositioning distances in low-set microtias were between 1 and 3.5 cm. Posteriorly repositioning distances in anteriorly tilted microtias were 2 and 3 cm. Thirteen patients with low-set malformations, two patients with anteriorly tilted malformations, and three patients with low-set and anteriorly tilted malformations underwent reconstructive operations. The new repositioning method is relatively simple, safe, and effective.     

Ear reconstruction after auricular chondritis secondary to ear piercing

The recent fad of high ear piercing in the pinna has led to an increased incidence of auricular chondritis, which leads to dissolution of the cartilage and residual ear deformity. The typical postpiercing chondritis deformity presents as a structural collapse of the superior helical rim, scaphal cartilage, and the adjacent antihelix. The skin envelope is usually preserved, but it may be scarred from the infectious process and from previous drainage incisions. In the present article, the authors present a systematic approach to reconstruction of these acquired ear deformities. Careful assessment of the residual tissue is requisite to planning and appropriate reconstruction. The greater the cartilage loss, the more structural support is required to expand the skin envelope to its normal size and shape. The choice of cartilage donor site is made on the basis of the size of the defect and may include ipsilateral or contralateral conchal cartilage, bilateral conchal cartilage, or costal cartilage. Redraping of the carefully dissected skin and fixation of the flaps to the newly reconstructed cartilaginous framework usually provide sufficient soft-tissue coverage. A temporal-parietal fascial flap is preserved for the rare cases of extensive full-thickness skin loss or badly damaged and scarred auricular skin.     

Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases

Through the author's experience with 1200 cases during a 25-year period, this article presents technical improvements in ear reconstruction and proposes and discusses possible directions for further technical advancement. This article presents the rationale for the author's current methods of managing total ear repair. Throughout the article, the author stresses and demonstrates cartilage-sparing techniques that are designed to minimize the amount of cartilage used in a repair to preserve maximum chest wall integrity. This article also presents the latest method of framework fabrication, showing differences in construction between younger and older patients; a new method that constructs a tragus as an integral part of the framework; a method that maintains ear projection with a scalp-banked cartilage wedge; and a method that solves the always frustrating low hairline by presurgical laser treatment. In addition, the concept of creating autogenous frameworks by tissue engineering is pursued and discussed in practical clinical terms. A survey of 1000 microtia patients indicates that surgically constructed ears remain durable, withstand trauma well, and provide consistent emotional relief and psychological benefits through the repair.     

Autogenous rib cartilage reconstruction of congenital ear defects: report of 110 cases with Brent's technique

The purpose of this study was to confirm the feasibility of Brent's technique, which was adopted for the treatment of the patients in this series. The author reports his experience with the successful treatment of 110 consecutive patients born with unilateral 95 (86.4 percent) and bilateral 15 (13.6 percent) microtia. The main stages of the reconstruction process are described, from the initial consultation to completion of treatment: reconstruction with sculpted rib cartilage graft, lobule transposition, tragus construction, and construction of the retroauricular sulcus. Minor modifications of Brent's technique for the last surgical stage are described. The author stresses use of autogenous rib cartilage as basic reconstruction material and emphasizes meticulous carving and assembling of frameworks, for which a balanced blend of structural firmness and aesthetic smoothness is essential. The author also describes complications and their management; cases of abandonment of treatment before completion; and difficulties encountered for long-term follow-up. Specially encouraging was the low proportion of short- and long-term complications: one case of hematoma (0.91 percent), one case of infection, two cases of partial skin loss (1.82 percent), and three cases of hypertrophic scars (2.73 percent). Older patients were more prone to abandon treatment before completion of all surgical stages (p = 0.000243) in this series, and this tendency occurred more frequently during the author's early experience in treating microtia patients. Despite the difficulty of the task, this series corroborates the versatility and feasibility of the technique in different geographical areas and population groups.     

The application of dermis grafts in deformities of the nose

Dermis grafts were used by themselves or in conjunction with a more rigid material such as cartilage or bone in a series of 220 patients during a period of 18 years. Of these, 182 patients were seen between 6 months and 2 years after operation. The significant problem during the earlier postoperative period was a transient swelling of the recipient site, which was seen in 150 of the 182 patients (82 percent) and which lasted for up to 6 months. It resolved spontaneously in all cases without active treatment in between 3 and 6 months. In the late postoperative period a significant permanent decrease in graft volume with a return to the previous deformity occurred in 9 of 182 patients (5 percent). This paper illustrates the versatility of dermis grafts in dealing with a variety of iatrogenic and accidental traumatic deformities of the nose.     

Indications and use of composite grafts in 100 consecutive secondary and tertiary rhinoplasty patients: introduction of the axial orientation

The fragile alar rims are complex structures whose specialized and supportive skin ensures the competence of the external valves and the patency of the inlets to the nasal airways. A chart review was performed of 100 consecutive secondary or tertiary rhinoplasty patients in whom the author had placed composite grafts before February 1999. Follow-up continued for at least 12 months. In 94 percent of the patients, composite grafts were harvested from the cymba conchae by removing the cartilage with its adherent anterior skin. In 6 percent of the patients, independently indicated alar wedges supplied the grafts. Six patients required secondary procedures to thin the alar rims, but such revisions have not been necessary since primary contouring of the cartilaginous graft component was instituted. Three auricular donor-site complications (one keloid, two thickened graft contours) were successfully revised through office procedures. Prior cosmetic rhinoplasty in a patient with normal alar cartilage anatomy exceeded all other etiologies as the cause of the deformity for which composite grafts were indicated (50 percent). The second most common etiology was deformity from prior rhinoplasty in a patient with alar cartilage malposition (33 percent of patients). Congenital deformities (7 percent of patients), trauma (6 percent), and prior tumor ablation (4 percent) comprised the remaining etiologies. Composite grafts were used most frequently to correct alar notching or asymmetry in rim height (43 percent of patients) or to provide an increase in apparent or real nasal length (28 percent). External valvular incompetence (14 percent of patients), nostril or vestibular stenosis (11 percent), or combined vestibular stenosis and lateral alar wall collapse (4 percent) were less common indications. Most composite grafts were oriented in the coronal plane (parallel to the alar rims). However, nostril or vestibular stenosis was corrected by sagittally placed composite grafts, and a third orientation (axial plane), to the author's knowledge not described previously, was used in patients with combined nostril stenoses and flattening of the alar walls. In this secondary rhinoplasty series, iatrogenic alar rim deformities or stenoses following cosmetic rhinoplasty dominated other causes requiring composite graft reconstruction (83 percent of patients). Of these 83 patients, 39.7 percent had preexisting alar cartilage malpositions, further supporting the importance of making accurate anatomical diagnosis part of every preoperative rhinoplasty plan.     

The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty.

Anterior riberation methods of otoplasty have been criticized because of the risk of anterior hematoma that can cause anterior skin necrosis, scarring, and even cartilage destruction caused by infection. As a result, cartilage-sparing otoplasty such as the Mustardé and Furnas types has been increasingly popular. However, postauricular suture extrusion may result, and recurrence rates of up to 25 percent have been recorded. In this study, cartilage-sparing otoplasty is refined by the addition of a postauricular fascial flap to reduce suture extrusion and recurrence rates. Fifty-one patients underwent otoplasty (45 bilateral, six unilateral). This technique involves the elevation of a fascial flap from the postauricular region. A new antihelical fold is then created by Mustardé sutures, and the conchal bowl is rotated by Furnas-type concha-mastoid sutures. The fascial flap is then advanced to cover the sutures with a supplementary vascularized layer to prevent suture extrusion. In addition, the advancement of the flap acts as a postauricular support to prevent recurrence. A natural-looking antihelical fold and helical rim is created by this technique. There were no hematomas. There was recurrence in eight ears (8 percent) in six patients. Two patients requested further surgery. No patients developed suture extrusion or granuloma. This is a simple and intrinsically safe procedure and does not cause irreparable complications such as anterior scarring or skin necrosis. The postauricular fascial flap seems to prevent suture extrusion. It may also help to reduce recurrence rates to acceptable levels.     

Primary correction of the unilateral cleft nasal deformity

An 18-year experience with the management of the unilateral cleft nasal deformity in 1200 patients is presented. A primary cleft nasal correction was performed at the time of lip repair in infancy; a secondary rhinoplasty was done in adolescence after nasal growth was complete. The technical details of the authors' primary cleft nasal correction are described. Exposure was obtained through the incisions of the rotation-advancement design. The cartilaginous framework was widely undermined from the skin envelope. The nasal lining was released from the piriform aperture, and a new maxillary platform was created on the cleft side by rotating a "muscular roll" underneath the cleft nasal ala. The alar web was then managed by using a mattress suture running from the web cartilage to the facial musculature. In 60 percent of cases, these maneuvers were sufficient to produce symmetrical dome projection and nostril symmetry. In the other 40 percent, characterized by more severe hypoplasia of the cleft lower lateral cartilage, an inverted U infracartilaginous incision and an alar dome supporting suture (Tajima) to the contralateral upper cartilage were used. Residual dorsal hooding of the lower lateral cartilage was most effectively managed with this suture. This primary approach to the cleft nasal deformity permits more balanced growth and development of the ala and domal complex. Some of the psychological trauma of the early school years may be avoided. Also, because of the early repositioning of the cleft nasal cartilages, the deformity addressed at the time of the adult rhinoplasty is less severe and more amenable to an optimal final result.     

Reconstruction of microtia with a contour-accentuated framework and supplemental coverage

A new method of assembling the framework of the ear with overaccentuated auricular contour is presented. In order to achieve the primary objective of the contour-accentuated framework, any shortage of skin coverage resulting from the increased surface area of the framework is supplied by the resurfaced temporoparietal fascial flap. This is done in 7 cases of microtia reconstruction. The procedure is beneficial for restoring clearly defined auricular relief in ear reconstruction.     

Characterization of pediatric microtia cartilage: a reservoir of chondrocytes for auricular reconstruction using tissue engineering strategies

The external ear is composed of elastic cartilage. Microtia is a congenital malformation of the external ear that involves a small reduction in size or a complete absence. The aim of tissue engineering is to regenerate tissues and organs clinically implantable based on the utilization of cells and biomaterials. Remnants from microtia represent a source of cells for auricular reconstruction using tissue engineering. To examine the macromolecular architecture of microtia cartilage and behavior of chondrocytes, in order to enrich the knowledge of this type of cartilage as a cell reservoir. Auricular cartilage remnants were obtained from pediatric patients with microtia undergoing reconstructive procedures. Extracellular matrix composition was characterized using immunofluorescence and histological staining methods. Chondrocytes were isolated and expanded in vitro using a mechanical-enzymatic protocol. Chondrocyte phenotype was analyzed using qualitative PCR. Microtia cartilage preserves structural organization similar to healthy elastic cartilage. Extracellular matrix is composed of typical cartilage proteins such as type II collagen, elastin and proteoglycans. Chondrocytes displayed morphological features similar to chondrocytes derived from healthy cartilage, expressing SOX9, COL2 and ELN, thus preserving chondral phenotype. Cell viability was 94.6 % during in vitro expansion. Elastic cartilage from microtia has similar characteristics, both architectural and biochemical to healthy cartilage. We confirmed the suitability of microtia remnant as a reservoir of chondrocytes with potential to be expanded in vitro, maintaining phenotypical features and viability. Microtia remnants are an accessible source of autologous cells for auricular reconstruction using tissue engineering strategies.     

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.     

Correction of congenital microtia using the tissue expander

We attempted auricular reconstruction using Radovan-type inflatable silicone expanders in six children and one adult, with the complete hypoplastic, the conchal remnant, and constricted type of microtia. Ear frameworks, including the helix, anthelix, concha, and tragus, were prepared using autologous rib cartilage. Based on the surface area of the normal adult auricle, the silicone expander was tentatively shaped and sized into a rotated semiellipse and expanded with 70 cc saline. Auricular reconstruction on the framework was completed at the time of insertion in four of the seven patients, requiring no elevation of the ear. The reconstructed auricle was satisfactory in both color and texture and had nearly normal sensation. Mild complications were noted in three of the seven patients. However, no resorption of the inserted rib cartilage has been observed 14 months to 2 years and 5 months after the operation. Slight shrinkage of the expanded skin was noted in each patient.     

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.     

A practical classification of septonasal deviation and an effective guide to septal surgery

The conventional designation of septal pathology is a deviated septum, and the common treatment of choice is submucous resection of the septum. These limited generic terms leave the surgery open to frequent failure and render the education of this topic suboptimal. During 1224 septal surgeries, we have observed six different categories of septal deviation requiring different surgical treatments. A study was conducted to investigate the frequency of different classes of septal deviation and to develop guidelines for a more successful surgical correction of each category. Ninety-three consecutive patients who underwent septoplasty were carefully evaluated for the type of septal deformity, age, gender, history of trauma, and previous septal surgery. The surgical technique was reviewed for each category of the septal deformity. Of the 93 patients, 71 were women and 22 were men. Ages ranged from 13 to 76, with an average age of 31.5. Most patients exhibited a "septal tilt" deformity (40 percent; 37 of 93) or a C-shape anteroposterior deviation (32 percent; 30 of 93). The other deformities were C-shape cephalocaudal (4 percent; 4 of 93), S-shape anteroposterior (9 percent; 8 of 93), S-shape cephalocaudal (1 percent; 1 of 93), or localized deviations or large spurs (14 percent; 13 of 93). Each of the six categories of septal deviation requires specific management. If a single procedure is selected for all of the septal deformities, disappointing results may ensue.