Total ear reconstruction in the devascularized temporoparietal region: I. Use of the contralateral temporoparietal fascial free flap

Total ear reconstruction by the use of contralateral temporoparietal fascial free flap and autogenous costal cartilage was performed in 16 patients presenting with a devascularized temporoparietal region resulting from trauma or prior surgery. The microsurgical success rate was 87.5 percent (14 of 16 transplants). On evaluation of the final aesthetic result in 11 patients followed up for more than 3 years, nine patients were graded good-to-excellent and two patients exhibited fair-to-poor results. Despite the relatively long operating hours and the comparatively low microsurgical success rate, ear reconstruction by autogenous tissue transplantation has proved to be an encouraging and worthwhile experience. This article presents the clinical cases and discusses the technical details.     

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.     

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.     

Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases.

The purpose of this paper is twofold: to present a sound approach to auricular construction using methods that have evolved through two decades of my personal experience with 600 cases and to discuss pertinent information I have gleaned from a questionnaire sent to my operated patients. This series comprises 546 completed ears in 500 microtia patients (46 bilateral) and 75 completed ears in acquired deformities. Follow-up ranges from 1 to 17 years. Major complications such as infection, hematoma, or skin loss with cartilage exposure occurred in only 1.6 percent of cases and were limited to the perioperative period of 12 days. None have occurred in the last 9 years (481 frameworks). This paper describes the evolution and rationale for my current management of total ear repair and covers preoperative planning, how to fabricate the rib cartilage framework, how to modify the framework for specific deformities, and how to cover the framework, i.e., how to assess and use local skin and vestiges or when to supplement the coverage by recruiting fascial flaps or using tissue expansion. When considering fascial flaps, patient selection was found to be particularly important because of long-term effects on the donor scalp; expansion was found to be most useful intraoperatively. This paper also covers how to manage the hairline, how to stage the surgery, when to combine procedures, and how to manage bilateral microtia in a team approach. The survey revealed that autogenous cartilage frameworks grow, are durable, retain their detail over the years, and withstand trauma well. More than 40 severe traumas occurred in surgically constructed ears, and all healed without incident. Ears constructed in young patients generally grew to keep pace with the opposite normal side; 41.6 percent actually overgrew by several millimeters. Emotional and psychological benefits were universal, and patient satisfaction was high. Among patients who were classified as "severely affected" by the original deformity, 100 percent were pleased with the result. When considered "moderately disturbed" by the microtic defect and operated on by age 14, 95.5 percent of patients were satisfied with the surgical repair; 83.3 percent of adolescents between the ages of 15 and 20 who did not consider themselves "severely affected" by the deformity were pleased with the outcome, and the rest were "undecided."     

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。     

Definitive repair of the unilateral cleft lip nasal deformity

The majority of patients with a unilateral cleft nasal deformity still benefit from additional nasal surgery in their teenage years, despite having undergone a primary nasal repair. However, the secondary nasal deformity of these patients stands in sharp contrast to those of children who have not benefited from primary repair. The authors' algorithm for the definitive correction of these secondary deformities considers the differences in these two patient groups and defines their indications for rib cartilage grafts and their method of using septal and ear cartilage in the repair. Balancing the muscle forces on the septum and alar cartilage is emphasized in both the primary and secondary repair. Both cartilage malposition and hypoplasia of the lower lateral cartilage complex have been identified as factors contributing to the deformity.     

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.     

In vitro redifferentiation of culture-expanded rabbit and human auricular chondrocytes for cartilage reconstruction

To construct an autologous cartilage graft using tissue engineering, cells must be multiplied in vitro; they then lose their cartilage-specific phenotype. The objective of this study was to assess the capacity of multiplied ear chondrocytes to re-express their cartilage phenotype using various culture conditions. Cells were isolated from the cartilage of the ears of three young and three adult rabbits and, after multiplication in monolayer culture, they were seeded in alginate and cultured for 3 weeks in serum-free medium with insulin-like growth factor 1 (IGF-1) and transforming growth factor-beta2 (TGF-beta2) in three different dose combinations. As a control, cells were cultured in 10% fetal calf serum, which was demonstrated in previous experiments to be unable to induce redifferentiation. Chondrocytes from the ears of young, but not adult, rabbits, synthesized significantly more glycosaminoglycan when serum was replaced by insulin-like growth factor-1 and transforming growth factor-beta2. The number of collagen type II-positive cells was increased from 10 percent to 97 percent in young cells and to 33 percent in adult cells. Using human ear cells from 12 patients (aged 7 to 60 years), glycosaminoglycan synthesis could also be stimulated by replacing serum with insulin-like growth factor and transforming growth factor-beta. Although the number of collagen type II-positive cells could be increased under these conditions, it never reached above 10 percent. Data from five patients showed that further optimization of the culture conditions by adding ITS+ and cortisol significantly increased (doubled or tripled) both glycosaminoglycan synthesis and collagen type II expression. In conclusion, this study demonstrates a method to regain cartilage phenotype in multiplied ear cartilage cells. This improves the chances of generating human cartilage grafts for the reconstruction of external ears or the repair of defects of the nasal septum.     

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.     

Oronasal fistula repair with three layers

We present an innovative method for closure of oronasal fistulas involving a three-layer repair, consisting of septal mucosa flap, bone or cartilage graft, and palatal mucosa flap. The septal mucosa flap closes the nasal side of the defect. This is an inferiorly based flap along the nasal floor and consists of septal mucosa from the side opposite the oronasal fistula. A slit is created in the remaining layers of the nasal septum, allowing the flap to be delivered into the defect. When the septal flap is folded down in this fashion, it exposes nasal septal bone and cartilage. The bone and cartilage are harvested and are used to create the middle layer of the three-layer fistula repair. The oral layer of the repair is provided by a palatal mucosa transposition flap. This method allows the bone/cartilage graft to be sandwiched between two vascular layers. We have successfully used the three-layer repair on three patients. All of the oronasal defects were 2 cm in size. All patients are at least 1 year after repair with 100 percent closure; thus, no oronasal leakage. The flaps both septal and palatal resulted in no morbidity once healed. Specifically, the surgically created slit in the nasal septum is well mucosalized and barely discernible. Also, no nasal obstruction occurs from the septal flap on the floor of the nose. We perform the procedure on an outpatient basis. The three-layer repair can be used in adult patients with oronasal fistulas of the middle and posterior hard palate up to 3 cm in size. This technique is not recommended for children.     

Considerations on the use of ear chondrocytes as donor chondrocytes for cartilage tissue engineering

Articular cartilage is often used for research on cartilage tissue engineering. However, ear cartilage is easier to harvest, with less donor-site morbidity. The aim of this study was to evaluate whether adult human ear chondrocytes were capable of producing cartilage after expansion in monolayer culture. Cell yield per gram of cartilage was twice as high for ear than for articular cartilage. Moreover, ear chondrocytes proliferated faster. Cell proliferation could be further stimulated by the use of serum-free medium with Fibroblast Growth Factor 2 (FGF2) in stead of medium with 10% serum. To evaluate chondrogenic capacity, multiplied chondrocytes were suspended in alginate and implanted subcutaneously in athymic mice. After 8 weeks the constructs demonstrated a proteoglycan-rich matrix that contained collagen type II. Constructs of ear chondrocytes showed a faint staining for elastin. Quantitative RT-PCR revealed that expression of collagen type II was 2-fold upregulated whereas expression of collagen type I was 2-fold down regulated in ear chondrocytes expanded in serum-free medium with FGF2 compared to serum-containing medium. Expression of alkaline phosphatase and collagen type X were low indicating the absence of terminal differentiation. We conclude that ear chondrocytes can be used as donor chondrocytes for cartilage tissue engineering. Furthermore, it may proof to be a promising alternative cell source to engineer cartilage for articular repair.     

Involutional entropion: a simple and stable repair

A simple technique for repair of involutional entropion is described. A 4 x 20 mm strip of cartilage is removed from the concha of the ear and placed in the lower lid, deep to the orbicularis muscle. Over the past 6 years, I have performed this procedure on 15 patients. Fourteen patients had an excellent result; one patient required a secondary lateral wedge resection. There have been no recurrences. The tarsal plate of the lower eyelid appears to soften and shrink with advancing age. As the tarsus shrinks, the lid becomes less rigid and the margin tends to roll inward. Creating a neotarsus out of ear cartilage provides a simple and stable repair for involutional entropion because it restores the structural rigidity of the lower lid. The operative procedure is technically simple. Its long-term effectiveness confirms the view, not widely held, that one primary cause of involutional entropion is a shrunken and atrophic tarsal plate.     

Allogeneic Bone Marrow Transplant from MRL/MpJ Super-Healer Mice Does Not Improve Articular Cartilage Repair in the C57Bl/6 Strain

Background

Articular cartilage has been the focus of multiple strategies to improve its regenerative/ repair capacity. The Murphy Roths Large (MRL/MpJ) “super-healer” mouse demonstrates an unusual enhanced regenerative capacity in many tissues and provides an opportunity to further study endogenous cartilage repair. The objective of this study was to test whether the super-healer phenotype could be transferred from MRL/MpJ to non-healer C57Bl/6 mice by allogeneic bone marrow transplant.

Methodology

The healing of 2mm ear punches and full thickness cartilage defects was measured 4 and 8 weeks after injury in control C57Bl/6 and MRL/MpJ “super-healer” mice, and in radiation chimeras reconstituted with bone marrow from the other mouse strain. Healing was assessed using ear hole diameter measurement, a 14 point histological scoring scale for the cartilage defect and an adapted version of the Osteoarthritis Research Society International scale for assessment of osteoarthritis in mouse knee joints.

Principal Findings

Normal and chimeric MRL mice showed significantly better healing of articular cartilage and ear wounds along with less severe signs of osteoarthritis after cartilage injury than the control strain. Contrary to our hypothesis, however, bone marrow transplant from MRL mice did not confer improved healing on the C57Bl/6 chimeras, either in regards to ear wound healing or cartilage repair.

Conclusion and Significance

The elusive cellular basis for the MRL regenerative phenotype still requires additional study and may possibly be dependent on additional cell types external to the bone marrow.     

A method for repair of cryptotia.

The key points in our method of repair of cryptotia are (1) to cover the skin defect on the posterior aspect of the ear after it is dissected from the head, and (2) to repair the cartilaginous deformity. We describe the use of a temporal skin flap for the former. For the latter, we make parallel incisions on the back of the superior crus and transfer a small graft of conchal cartilage there. The conchal cartilage graft "splints" the repaired crus against cicatricial contracture.     

鼻中隔软骨联合耳软骨雕塑鼻尖在假体隆鼻中应用效果

目的:探讨假体隆鼻时应用鼻中隔软骨联合耳软骨雕塑鼻尖的临床效果。方法:选取2013年1月至2014年3月在我院进行隆鼻术的患者98例,按照随机数表法将其分成对照组和实验组,每组49人。对照组患者采用单纯的假体隆鼻,实验组患者采用假体隆鼻并使用鼻中隔软骨联合耳软骨雕塑鼻尖。评价手术的满意程度及手术前后患者的鼻长、鼻尖高度、鼻尖角的变化情况。结果:实验组患者的治疗满意度为91.84%,明显高于对照组的40.82%,差异具有统计学意义(P0.05)。实验组患者术后鼻长、鼻尖高度、鼻尖角均优于手术前(P0.05),且显著优于对照组,差异均有统计学意义(P0.05)。结论:应用鼻中隔软骨联合耳软骨雕塑鼻尖在假体隆鼻中具有良好的应用效果,满意度较高,值得在临床上推广使用。     

An improved one-stage total ear reconstruction procedure

Based on anatomic studies of the postauricular cutaneous circulation, a modified single-stage total ear reconstruction procedure has been presented. The operation consists of using a large, superthin, well-vascularized, and well-innervated skin flap to cover the anterior surface of the auricular framework carved from costal cartilage, the posterior surface of which is covered by a subcutaneous tissue flap and then skin grafted. Improvements in the makeup and carving of the framework have been made and described. This method has been used to treat 15 cases of anotia, all with satisfactory results.     

The mouse short ear skeletal morphogenesis locus is associated with defects in a bone morphogenetic member of the TGF beta superfamily.

The mouse short ear gene is required for normal growth and patterning of skeletal structures, and for repair of bone fractures in adults. We have carried out an extensive chromosome walk in the chromosome region that surrounds this locus. Here we show that the short ear region contains the gene for a TGF beta-related protein called bone morphogenetic protein 5 (Bmp-5). This gene is deleted or rearranged in several independent mutations at the short ear locus. Mice homozygous for large deletions of the Bmp-5 coding region are viable and fertile. Mutations at the short ear locus provide an important new tool for defining the normal functions of BMPs in mammals. The specific skeletal defects seen in short-eared animals, which occur against a background of otherwise normal skeletal structures, suggest that particular aspects of skeletal morphology may be determined by individual members of a family of signaling factors that can induce the formation of cartilage and bone in vivo.     

Tissue engineering: revolution and challenge in auricular cartilage reconstruction

External ear reconstruction for congenital deformity such as microtia or following trauma remains one of the greatest challenges for reconstructive plastic surgeons. The problems faced in reconstructing the intricate ear framework are highly complex. A durable, inert material that is resistant to scar contracture is required. To date, no material, autologous or prosthetic, is available that perfectly mimics the shapely elastic cartilage found in the ear. Current procedure involves autologous costal cartilage that is sculpted to create a framework for the overlying soft tissues. However, this is associated with donor-site morbidity, and few surgeons worldwide are skilled in the techniques required to obtain excellent results. Various alloplastic materials have therefore been used as a framework. However, a degree of immunogenicity and infection and extrusion are inevitable, and results are often disappointing. Tissue-engineered cartilage is an alternative approach but, despite significant progress in this area, many problems remain. These need to be addressed before routine clinical application will become possible. The current tissue-engineered options are fragile and inflexible. The next generation of auricular cartilage engineering is promising, with smart materials to enhance cell growth and integration, and the application of stem cells in a clinical setting. More recently, the authors' team designed the world's first entirely synthetic trachea composed of a novel nanocomposite material seeded with the patient's own stem cells. This was successfully transplanted in a patient at the Karolinska Hospital in Sweden and may translate into a tissue-engineered auricle in the future.     

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.     

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.