Two stage ear/microtia reconstruction using costal cartilage.

BACKGROUND: Reconstruction of Grade III microtia is a challenging entity in maxillofacial esthetic rehabilitation. Several advocacies and philosophies exist in this field. The aim of the manuscript is to present a single South Indian Experience with Ear reconstruction among South Indian Population.
MATERIALS AND METHODS: Retrospective analysis of unilateral Grade III microtia reconstruction was performed. Using a set of predefined inclusion and exclusion criteria, the population was selected. Outcome measures in terms of the ear size, auriculocephalic angle, and the conchal depth were measured in the reconstructed and normal side. Descriptive statistics is presented.
RESULTS: Twenty-four patients formed the study group and had undergone the classical two-stage reconstruction in a similar fashion. The mean ear size in normal side was 65.8 ± 2.8 mm whereas on the reconstructed side, it was 61.3 ± 5.8 mm. The center's technique achieved above 75% similarity as that of the other normal ear. The mean auriculocephalic angle was 44.6 ± 5.2° whereas for the surgically reconstructed ear, it was 41.9 ± 2.6°. Overall, in these patients, we achieved a 79.94% similarity of auriculocephalic angle in the reconstructed ear as compared to the normal auricle. The conchal depth was 19.2 ± 2.1 mm and 16.6 ± 1.9 mm for normal and reconstructed ear, respectively. In terms of conchal depth, the present study group showed an achievement of 82.88% of accuracy even after a prolonged follow-up. DISCUSSION AND
CONCLUSION: The center employs a classic two stage reconstruction with a customized prosthesis that helps to avoid the loss of projection geometry and minimizes adhesion, infection, and early loss of structural stability.

INTRODUCTION

Reconstruction of the human external auricle or pinna is considered very tricky as it is situated in the esthetic zone and has a very complicated three-dimensional structure. It is a unique tissue that has an elastic cartilage scaffold and covered by skin and its appendages. A perfectly contoured reconstruction of ear should have a good shape, adequate protrusion, and reasonably symmetrical as compared to its normal counterpart. In real life situation, most of the reconstructed auricles would be stiff with mismatched projection geometry and thick owing to the skin texture above them. In addition, on closer observation, they would lack the finer nuances and curves of the normal ear.[1234]

In microtia patients, to achieve a near-ideal, auricular reconstruction autogenous cartilages are often used. It requires a mix of science of surgery infused with an artistic element. To facilitate this, several types of reconstruction procedures have been suggested. They range from a single stage surgery to upto four stage surgeries.[356]

Of this, the two stage surgery is the most popularly used and recommended surgery. The basic step requires minimum two surgeries whereas the remaining minor refinements, if and when required do not form the part of the basic surgery. This kind of surgery had shown relatively reliable, stable, and predictable results than other methods. In addition, the economic dimensions and patient comfort levels are far better than other surgical options[7] The aim of the manuscript is to present the author's experience of the auricular reconstruction for microtia and compare the normal and reconstructed auricle.

MATERIALS AND METHODS

This retrospective study was performed from the archival records of the center from January 2006 to December 2013. Only those Grade III microtia (absence of the external ear with a small peanut-like vestige structure and an absence of the external ear canal and ear drum)[7] cases reconstructed with two-stage surgeries and had a follow-up of at least 6 months were included. Only patients of either gender, who have not been previously operated upon were included in the study. Those cases that had involvement in both ears and severe facial asymmetry were excluded from the study. Patients with insufficient details were excluded from the study.

Measurement of the normal and reconstructed ear was routinely noted down in the records, which were collected. Besides the patients specific demographic of age at the time of the first phase of operation, gender, side of ear reconstructed were noted down. To measure the auricle, the following predefined parameters were used.[1] (1) Ear size: It was defined as the length from the lowest part of the ear lobule to the most distant part of the helix. (2) Auriculocephalic angle: It is the angle formed by two imaginary lines that are drawn from (a) root of the helix to lateral edge of helix (b) root of helix to the mastoid plane. (3) Conchal depth: It is defined as the length between the antihelix and the concha. These values are measured in the normal and the reconstructed auricle at the 6th month postoperative visit. Patient without such data were excluded from the study.

Surgical procedure

In this method[7], during the first stage, all available structures which could be salvaged and be used for latter reconstruction are preserved and moved to their normal location.

For the rigid framework, the harvested free costal cartilage was used. Ideally, two or three fragments (usually fifth, seventh, and ninth rib grafts are preferred) are harvested aseptically and atraumatically. The cartilaginous bit of the sixth, seventh, and eighth rib is collected by already measured format. Usually, the sixth and seventh rib ligaments frame the base system, and the eighth costal ligament is utilized to structure the edge or helix of the ear. Then the pieces are carved to natural shapes using templates developed from X-ray sheets.[8]

Utilizing precision surgical tools fundamental ear shape was drawn from the base system, and then the helical edge was cut by diminishing off the piece from the floating eighth rib on its external raised surface to bring about planned wrapping. Final touches and grooves were drawn and carved out. The ear position was checked. The pieces were then carefully arranged, fixed, and implanted in the subcutaneous pockets in the desired area. This is dictated by two factors – hair line and the position of the contralateral ear. Suturing was done, drain placed, and ideal antibiotics and pain killers provided. The patient was refrained from sleeping or placing the head onto hard surfaces for at least 6 weeks. The implant was left in situ for 4–6 months depending on the patient preference and healing tendency.

After this waiting period, auricular elevation was performed as the second stage operation. During this stage, the implanted structure was carefully elevated and secured. This stage is crucial as it is the phase during which the projection of the ear and the delicate intricacies are carved out. As the lifted skin is prone to attach back to the incision, compromising the esthetics, projection geometry, and possibly the skin tone around the incision and attachment, a modified approach has been followed at our center [Figures 1-13].[9] Depth of helical sulcus was excluded because of potential immediate or latter correction. The details thus collected were tabulated and results discussed.

Figure 1

(a) Microtia defect in right ear, (b) Normal appearance of left ear

Figure 13

(a and b) Postoperative appearance after ear reconstruction

(a and b) Costochondral graft harvested

(a) Graft carved to form the ear framework (b) Framework tunneled subcutaneously. Once suction catheter is placed, overlying skin gets adapted to the framework resembling the auricle (c) Postoperative appearance after stage I

(a) Incision marking for elevation (b) Elevation of the framework (c) Insertion of the banked cartilage for retaining the elevation of the framework

(a and b) Required area of skin graft marked and harvested from iliac region (c) Skin graft sutured to recipient site (d) Bolster dressing done

(a-e) Contouring of external auditory meatus and antihelical fold created using bolsters

(a) Preoperative appearance (b) Postoperative appearance after IInd stage reconstruction (c) Postoperative view with well formed ear and splints to define the contours

Microtia defect of the right ear

(a and b) Donor and recipient sites marked, (c) Costochondral graft harvested using template, (d) Graft carved to form the ear framework and tunneled subcutaneously. Once suction catheter is placed, overlying skin gets adapted to the framework resembling the auricle

(a) Postoperative appearance after stage I, (b and c) Elevation of the framework and insertion of the banked cartilage for retaining the elevation

(a-c) Required area of skin graft marked and harvested. Donor site sutured

(a) Skin graft sutured, (b) After suture removal

RESULTS

The age of the patients ranged between 7 and 48 years. In all, there were 28 patients, among whom there was a complete set of data retrievable in 24 patients and who were included in this study.

There were 15 male and 9 female patients (male:female ratio being 5:3), and more patients had microtia in their right ear (right:left ratio being 7:5). The mean follow-up period was 0.75–6.3 years, and averaged 3 years [Table 1]. The cause of the disorder had been a milder version of hemifacial microsomia, Goldenhar syndrome or Treacher-Collins syndrome. Cases with severe midfacial asymmetry were excluded as they could cloud the results of this study. The demographic details of the study population are described in Table 1. The mean age of the patient was 28.35 ± 9.63 with a range of 7–48 years.

Table 1

Demographic factors of the study group

The mean ear size in the normal side was 65.8 ± 2.8 mm whereas on the reconstructed side, it was 61.3 ± 5.8 mm. The center achieved a near normalcy of about 75% similarity as that of the other normal ear. The mean auriculocephalic angle was 44.6 ± 5.2° whereas for the surgically reconstructed ear, it was 41.9 ± 2.6°. Overall, in these patients, we achieved 79.94% similarity of auriculocephalic angle in the reconstructed ear as compared to the normal auricle. The conchal depth was 19.2 ± 2.1 mm and 16.6 ± 1.9 mm for normal and reconstructed ear, respectively. In terms of conchal depth, the present study group showed an achievement of 82.88% of accuracy even after a prolonged follow-up [Table 2].

Table 2

Study parameters in the study group

DISCUSSION

The ideal external auricle reconstruction is expected to have the following: (1) Sufficient projection that is maintained in an unaided fashion without deformation; (2) uncompromised blood circulation in the reconstructed part; (3) shape of the auricle when front or lateral side should not be abnormal; (4) no or minimal hair in upper part of the elevated auricle; (5) fewer surgical procedures.[10] There is no single, ideal surgical procedure that incorporates these ideal principles and expectation. However, for every type of patient depending on the extent of deformity, available tissues, expectation, contralateral normal ear morphology, age and other host factors, the type of the reconstruction has to be chosen wisely.

Several techniques have been suggested by various authors to meet the clinical situation demands of external auricle reconstruction. Steffensen[11] suggested the retroauricular skin transposition flap to cover the sulcus whereas Rueckert et al.[12] employed a tunneling based approach. Fascial flaps were used by Alexander et al.,[13] in which a stable support for maintaining the auriculocephalic angle was not achieved. This is because the soft tissue support is not sufficed to maintain projection geometry on a longer run. In addition, such failures associated with techniques underlined the importance of hard tissue in reconstruction.

Brent[14] suggested the limited elevation of the auricle by accentuating the helical rim while Nagata[10] used the temporoparietal fascial flap to pack a piece of carved cartilage in the shape of colon with which later they recreated a fine firm projection. Ou et al.[15] modified the Nagata technique using a retroauricular fascial flap instead of a temporoparietal fascial flap. Prantl et al. successfully recreated the postauricular sulcus using a rotation type of flap sourced from the neck.[16]

Correct cartilage that is sufficiently elastic yet rigid; not yielding to warping are certain basic trait expected for the technique employed in the center. In addition, the cartilage should be big and tall enough to support the entire framework. Works of Ou et al.[15] and Yoshimura et al.[17] have stressed the same. In addition, they emphasized on securing the cartilage firmly. Our philosophy of reconstruction also relied on strongly securing the cartilage before it is technically buried inside tissues.

Lim et al.[18] was of the opinion that a retroauricular fascial flap is often less reliable than a temporoparietal fascia owing to two reasons: (1) Anatomy identification and (2) later depression owing to the exposure of tissues over mastoid areas. However, we still choose to use the local fascial flap for two reason – skin color and hairline. Appropriate auricular skin color can be achieved only if the skin is from a local site and hairline is another issue. Because of the hair distribution in these areas, a normal local flap only could meet the expectation of the patients.

When a cartilage is used for reconstruction, the degree of auricle projection can be controlled, and the degree of contracture will not be that heavy. The elevated auricle tends to become flat as time passes; we often performed overelevation by 5° than opposite auriculocephalic angle. However, cartilage is vulnerable to infection, so aseptic surgical techniques and wound dressing after elevation must be provided. This could cause early obliteration.[1] However, we employed a unique prosthesis that helped to achieve our ideal reconstruction. The merits of such prosthesis are dealt elsewhere.[9] The success in our present study partially owes its success to this modification. In this aspect of dressing and preservation, several local methods for Indo-Asian ears have been found in literature.[1920]

In the present series, the postoperative complication rate was low and such complications such as pain and swelling were easily corrected. The author was able to reconstruct the competent ear, to maintain the three-dimensional shape and enough projection for a long time, and to give the patients satisfaction. The near normal achievement of the measures could be attributed to the experience; protocol followed and to an extent the customized prosthesis utilized for our patients. The results surpass those cited in the literature.[1782122]

CONCLUSION

The center's experience in correcting microtia has been presented. The procedure was designed for the best time and economic efficiency with only two operations and the results are mostly satisfying. In addition, it is a gradual surgical approach, and it allows easy response to broad situations, which leads to fewer deformities and complications. It is a good strategy for gradual ear reconstruction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.